 Provider News OhioApril 1, 2025 April 2025 Provider NewsletterOn January 1, 2025, we launched Health Perks, a new incentive program that rewards members for completing select healthcare activities. This program is available for a select number of our plans. Please confirm member eligibility before promoting the program benefits. For more information or to verify eligibility, benefits, or account details, call the number located on the back of the member’s ID card. Limited health plan eligibilityThese are the Health Perks plans eligible for rewards. Plan number | State | Plan | H4346-014-000 | CO | Anthem Dual Advantage (HMO D-SNP) | H2836-006-000 | CT | Anthem Full Dual Advantage (PPO D-SNP) | H5854-008-000 | CT | Anthem Full Dual Advantage 2 (HMO D-SNP) | H5854-013-000 | CT | Anthem Full Dual Advantage Select (HMO D-SNP) | H4036-032-000 | GA | Anthem Full Dual Advantage (PPO D-SNP) | H4036-039-000 | GA | Anthem Dual Advantage (PPO D-SNP) | H5422-018-000 | GA | Anthem Dual Advantage (HMO D-SNP) | H5422-019-000 | GA | Anthem Full Dual Advantage (HMO D-SNP) | H3447-020-000 | IN | Anthem Full Dual Advantage (HMO D-SNP) | H3447-046-000 | IN | Anthem Dual Advantage (HMO D-SNP) | H3447-048-000 | IN | Anthem Full Dual Advantage Aligned (HMO D-SNP) | H3447-055-000 | IN | Anthem Full Dual Advantage Aligned NFLOC (HMO D-SNP) | H9525-007-000 | KY | Anthem Full Dual Advantage (HMO D-SNP) | H9525-016-000 | KY | Anthem Dual Advantage (HMO D-SNP) | H9525-019-000 | KY | Anthem Full Dual Advantage 2 (HMO D-SNP) | H3447-018-000 | MO | Anthem Full Dual Advantage (HMO D-SNP) | H3447-047-000 | MO | Anthem Dual Advantage (HMO D-SNP) | H3447-053-000 | MO | Anthem Full Dual Advantage 2 (HMO D-SNP) | H4346-025-000 | NV | Anthem Full Dual Advantage (HMO D-SNP) | H4346-026-000 | NV | Anthem I Carelon Full Dual Advantage (HMO D-SNP) | H8432-041-000 | NY | Anthem HealthPlus Full Dual Advantage LTSS (HMO D-SNP) | H8432-042-000 | NY | Anthem HealthPlus Full Dual Advantage (HMO D-SNP) | H3655-033-000 | OH | Anthem Full Dual Advantage (HMO D-SNP) | H3655-048-000 | OH | Anthem Dual Advantage (HMO D-SNP) | H3655-049-000 | OH | Anthem Full Dual Advantage 2 (HMO D-SNP) | H2441-001-000 | VA | Wellpoint Dual Advantage 2 (HMO D-SNP) | H9525-003-000 | WI | Anthem Full Dual Advantage (HMO D-SNP) | H9525-012-000 | WI | Anthem Dual Advantage (HMO D-SNP) | H9525-018-000 | WI | Anthem Full Dual Advantage 2 (HMO D-SNP) |
Health Perks rewardsThese are the eligible healthcare activities, member rewards, and claim codes. Healthcare activity | Reward amount | Eligible claim codes | Annual wellness visit/annual physical | $30 | 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, G0438, G0439, G0463, G0468, Z00.00, Z00.01, Z00.8 | Breast cancer screening | $20 | 77061, 77062, 77063, 77065, 77066, 77067 | Colorectal screening | $30 | 4522, 4523, 4525, 4542, 4543, 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398, G0105, G0121, 74261, 74262, 74263, 4524, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45346, 45347, 45349, 45350, G0104 | Fecal occult blood test | $10 | 82270, 82274, G0328, 81528 | Bone density screening | $10 | 8898, 76977, 77078, 77080, 77081, 77085, 77086, BP48ZZ1, BP49ZZ1, BP4GZZ1, BP4HZZ1, BP4LZZ1, BP4MZZ1, BP4NZZ1, BP4PZZ1, BQ00ZZ1, BQ01ZZ1, BQ03ZZ1, BQ04ZZ1, BR00ZZ1, BR07ZZ1, BR09ZZ1, BR0GZZ1, J0897, J1740, J3489, J3110, J3111 | Flu vaccine | $10 | 90630, 90653, 90654, 90656, 90658, 90661, 90662, 90673, 90674, 90682, 90686, 90688, 90689, 90694, 90756, 90660, 90672 |
Claim coverage notes:- For colonoscopies, annual wellness visits, and breast cancer screenings, members will not have out‑of‑pocket costs or a copayment when performed by an in‑network provider:
- Note: A cost share may be applicable for any additional services or tests conducted during the visit for each service listed in the healthcare activity chart above.
- For bone density screenings, Medicare Part B (for doctor visits, outpatient procedures, preventive services, home health services, and DME) covers this test once every 24 months (or more often if medically necessary) when at least one of the following conditions is met:
- Their care provider has determined they are estrogen‑deficient and at risk for osteoporosis based on their medical history and other findings.
- Their X‑rays show possible osteoporosis, osteopenia, or vertebral fractures.
- They are taking prednisone or steroid‑type drugs or are planning to begin this treatment.
- They have been diagnosed with primary hyperparathyroidism.
- They are being monitored to see if their osteoporosis drug therapy is working.
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-075375-24-CPN75369, MULTI-BCBS-CR-078045-25 We receive your enrollment, credentialing, demographic, and practice data directly from the Ohio Department of Medicaid (ODM). To avoid delays with approvals and claims, please verify that your information is current and complete in ODM’s Provider Network Management (PNM) module. It is especially important that your tax ID with ODM matches your Anthem provider contract. Actions needed:- Enroll in ODM’s PNM system:
- Create an Ohio ID at Create OHID Account (ohio.gov).
- Once you have an ID, log on to the PNM website (maximus.com).
- Update your data regularly:
- Maintain current credentialing and demographic data in the PNM module.
- Make sure you list all practicing locations on the other service locations tab within the PNM module.
PNM module instructions: If you need live technical assistance, call the ODM Help Desk at 800‑686‑1516 or email IHD@medicaid.ohio.gov. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-079022-25 This guidance applies to Ohio Medicaid only. For additional information please visit: You can also email us at OHMedicaidENCPESupport@anthem.com. Q: Is preapproval required for a member's admittance into an SNF? A: Yes. Effective June 1, 2023, Anthem allows a seven-day initial length of stay upon notification of an admission to an in-network skilled nursing facility (SNF) for members. Facility and physician must be in-network for the member. We require notification of the SNF admission, which includes sending demographics and verification of benefits via the usual channel. Anthem will approve an initial seven-day length of stay without the need to provide clinical information. More information can be found here. For the initial SNF admission, submit the clinical information no later than three business days after the admission. Then, by no later than by day eight of the admission, additional clinical documentation should be submitted for review. Q: Does the floor to SNF process apply to out of-network care providers? A: No, the facility and physician both need to be in network. All out-of-network facilities and care providers must follow the standard PA process. Q: For the SNF initial authorization of seven days, will Anthem assign a level of care? A: Anthem utilization management (UM) will assign a level of care once the PASRR | Department of Developmental Disabilities Form, the Ohio Medicaid Managed Care/MyCare Ohio Nursing Facility Request Form, and clinical information is received from the SNF. Q: How can I check the status of my preapproval request? A: Care providers can check the status of a preapproval by using the Interactive Care Reviewer (ICR) located within Availity Essentials. Q: Does Anthem pay for transportation while in an SNF? A: Charges for inpatient services for facility personnel are not separately reimbursable, and the reimbursement for such is included in the room and board rate. Examples include but are not limited to lactation consultants, dietary consultants, overtime charges, transport fees, nursing functions (including IV or PICC line insertion at bedside), professional therapy functions, including physical, occupational, and speech call back charges, nursing increments, therapy increments, and bedside respiratory and pulmonary function services. Charges for outpatient services for facility personnel are also not separately reimbursable. The reimbursement is included in the payment for the procedure or observation charge. Q: Does Anthem pay a higher rate for skilled nursing care? A: We follow the ODM fee schedule. Q: Does Anthem pay for bed holds? A: Yes, we follow OAC guidelines Rule 5160‑3-16.4 ‑ Ohio Administrative Code | Ohio Laws. Q: How are bed holds requested? A: To request a bed hold, please submit a preapproval request via Availity Essentials through the ICR or fax to 877‑643-0671. Q: What is required when the member’s level of care changes? A: When the level of care changes, the Ohio Medicaid Managed Care/MyCare Ohio Nursing Facility Request Form should be faxed to 877‑643-0671. Q: What is required from the SNF when a member is admitted into the hospital from an SNF? A: Notification from the SNF that a member has been admitted to a hospital can be faxed to 877‑643-0671 or submitted through the ICR on Availity Essentials. If a bed hold is needed, the SNF should submit a preapproval request. Q: What is required from the SNF when a member readmits to the SNF from a hospital? A: If a member returns to the SNF the same day, and there is no level of care change, no new authorization is needed. However, a notification is needed when the member returns before midnight the same day. If a member returns to the SNF more than 24 hours after the hospital admission, past midnight, and no bed hold request, then a new authorization is required. If the SNF knows how long a member will be admitted, they should submit a notification and bed hold request for the specific number of days. If the number of days is unknown a bed hold request can be submitted with no end date. We follow Rule 5160‑3-16.4 ‑ Ohio Administrative Code | Ohio Laws pertaining to bed holds. The hospital admission and discharge summary for a member returning to an SNF is required regardless of length of time away from the SNF. Q: What is needed when a member transitions to long-term care (LTC)/custodial? A: The SNF should submit the Ohio Medicaid Managed Care/MyCare Ohio Nursing Facility Request Form, face sheet with admit date, and letter of intent to remain in LTC from facility via fax 877‑643-0671 or Availity Essentials. If LTC transition occurs prior to the end of SNF approval, notification is required. We will cover 90 days of LTC, and our UM department assists the facility in transitioning the member to traditional Medicaid. Q: What is needed when a member discharges home from an SNF? A: Discharge summary, including discharge date and time, disposition, primary care provider (PCP) information, and follow-up instructions. Q: Will we pay for private rooms? A: Yes. The ODM will begin reimbursing private rooms at qualifying nursing facilities (NFs). Reimbursement for approved private rooms began in January 2025 for claims with dates of service (DOS) that include the effective date of December 18, 2024, and will apply to individuals covered by fee for-service (FFS) Medicaid, Medicaid managed care, and MyCare. Please note: Per ODM guidance, private room reimbursement is capped at $160 million for each state fiscal year (SFY) beginning with SYF 2025: NF_Fact_Sheet_Private_Rooms.pdf Contact usAvaility Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat. For additional support, visit the Contact Us section of our provider website for the appropriate contact. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CDCR-075517-24 The 21st Century Cures Act requires states to implement electronic visit verification (EVV) for all Medicaid home health and personal care services. The EVV program for the Ohio Department of Medicaid (ODM) leverages technology to capture essential data for claims adjudication. Specific requirements can be found in Chapter 5160—32 — Ohio Administrative Code | Ohio Laws. Provider types and specialties subject to EVV requirements should ensure compliance with EVV guidelines.
We validate claims requiring EVV against data collected in Sandata when adjudicating claims. If a claim is not accepted, please review data collected by Sandata and update claim information where appropriate; we ask that you ensure claim data is accurate before resubmitting.
Discrepancies are currently paid with notifications on the Explanation of Benefits (EOB); however, this will change as follows:
- Beginning June 1, 2025: Claims with the following codes will not be paid if there are discrepancies:
- G0156 — Home Health Aide
- G0151 — Home Health Physical Therapies
- G0152 — Home Health Occupational Therapies
- G0153 — Home Health Speech Language Pathology Therapies
- G0299 — Home Health Nursing RN
- G0300 — Home Health Nursing LPN
- Beginning August 1, 2025: Claims with the following codes will not be paid if there are discrepancies:
- T1000 — RN & LPN Private Duty Nursing
- T1001 — Registered Nurse Assessment
- T1001 with U9 Modifier — Registered Nurse Consultation
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Unique provider types
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Provider type description
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Unique provider specialty
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Provider specialty description
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16
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16 – Other Accredited Home Health Agency
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160
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160 – Other Accredited Home Health Agency
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25
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25 – Non‑Agency Personal Care Aide
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161
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161 – ODM Otherwise Accredited Home Health Agency
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26
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26 – Non‑Agency Home Care Attendant
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250
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250 – ODM Waiver Non‑Agency Personal Care Attendant
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38
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38 – Non‑Agency Nurse – RN or LPN
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260
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260 – ODM Waiver Non‑Agency Home Care Attendant
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45
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45 – Waivered Services Organization
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380
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380 – RN Private Duty Nursing
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50
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50 – Clinic
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381
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381 – PDN/ODM Waiver Registered Nurse
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55
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55 – Waivered Services Individual
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382
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382 – LPN – Private Duty Nursing
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60
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60 – Medicare Certified Home Health Agency
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383
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383 – PDN/ODM Waiver Licensed Practical Nurse
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65
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65 – Clinical Nurse Specialist Individual
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480
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480 – ODA Waiver
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71
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71 – Nurse midwife Individual
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490
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490 – DODD Waiver
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72
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72 – Nurse Practitioner Individual
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492
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492 – DD Waiver and Nursing
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76
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76 – Durable Medical Equipment Supplier
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600
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600 – Medicare Certified Home Health Agency
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83
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83 – Wheelchair Van
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601
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601 – ODM Medicare Certified Home Health Agency
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89
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89 – Non‑State Operated ICF‑MR
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|
|
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96
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96 – Behavioral health paraprofessional
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|
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More information is available on the ODM’s website under Electronic Visit Verification.
EVV Informational sessions:
- March 31, 2025, at 10 a.m. ET
- April 16, 2025, at 1 p.m. ET
To register, go to EVV Webinar. For additional inquiries, email ohmedicaidencpesupport@anthem.com. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-074745-24, OHBCBS-CD-074746-24 At a glance:- The Provider Enrollment and Network Management tool on Availity Essentials offers streamlined data submission and real‑time status tracking.
- Administrators can manage access via Availity Essentials, enabling roles for provider enrollment and network management features.
- Practice profile changes are facilitated electronically through the Provider Data Management application on Availity Essentials.
Coming soon, we will add additional provider specialties and network management functionality to our Provider Enrollment and Network Management application available in Payer Spaces after logging in to Availity Essentials at https://Availity.com. Features of the Provider Enrollment and Network Management application include:- Ability to enroll as a new care provider.
- Ability to request to join our network. After review, a contract can be sent back to you digitally for an electronic signature. This eliminates the need for paper applications or paper contracts.
- A dashboard for the real‑time status of the submitted applications.
- Streamlined complete data submission.
- Additional options to manage your network.
How to use the online Provider Enrollment and Network Management applicationThe online application will guide you throughout the provider enrollment and network management process, providing status updates using My Dashboard within the Provider Enrollment and Network Management application. As a result, you know where you are in the process without having to call or email for a status. Note: For any changes to your practice profile and demographics, use the Provider Data Management (PDM) application on Availity Essentials, which allows you to electronically submit any changes to your practice profile and demographics. Availity Essentials administrators and assistant administrators can access it by going to Availity Essentials > My Providers > Provider Data Management. Anthem Blue Cross and Blue Shield and Anthem Blue Cross and Blue Shield Medicaid are trade names of Community Insurance Company. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CRCM-080090-25 -CPN79727, OHBCBS-CRCM-075219-24-CPN74723 Our goal is to create and source materials to help support care providers understand and address the diverse needs of patients while maintaining professionalism, trust, and respect. Health equity means everyone has the opportunity to reach their highest level of health, and barriers must be removed. How do cultural factors influence a person's approach to illness and healthcare?Culture, including behaviors, language, beliefs, and values, shapes an individual's approach to illness. Experiences, education, and spiritual beliefs also play a role. Patients may perceive illness differently than healthcare providers. Recognizing these differences can improve health outcomes while ignoring them can lead to misunderstandings and non‑compliance. How can we address health disparities?Health disparities refer to differences in health outcomes linked to unequal social, economic, and environmental opportunities.1 Achieving health equity and optimal health outcomes involves eliminating barriers related to race, ethnicity, gender, religion, socioeconomic status, disability, and geographic location.2 Addressing these disparities fosters healthier communities, enhances quality of life, and supports economic growth by creating a more productive and resilient population. It is essential to meet people where they are in their health journeys and provide tailored healthcare access to address patients' unique needs, and we are committed to supporting our providers in this effort. Cultural competency resourcesYou can find cultural competency resources available on our provider website: - Cultural Competency and Patient Engagement:
- A training resource to increase cultural and disability competency to help effectively support the health and healthcare needs of all your patients.
- Caring for Diverse Populations Toolkit:
- A comprehensive resource to help providers and office staff increase effective communication by enhancing knowledge of the values, beliefs, and needs of all patients.
To access these resources, go to the provider website > Resources > Training Academy. Our provider manual also has details about available resources and how to access them. Prevalent non‑English languages (based on population data)Like you, we want to effectively serve the needs of diverse patients. We must all be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the top 15 non‑English languages spoken by 5% or 1,000 individuals in the state.3 Prevalent non‑English languages in Ohio by 5% or 1000 individuals | Spanish | French (including Cajun) | Russian | German | Vietnamese | Hindi | Chinese (including Mandarin, Cantonese) | Ukrainian or other Slavic languages | Urdu | Arabic | Tagalog (including Filipino) | Nepali, Marathi, or other Indic languages | Amharic, Somali, or other Afro‑Asiatic languages | Yiddish, Pennsylvania Dutch, or other West Germanic languages | Yoruba, Twi, Igbo, or other languages of Western Africa |
Language support servicesWe provide free language assistance services for our members with limited English proficiency (LEP) or hearing, speech, or visual impairments. Telephone interpreters During business hours, providers can call Provider Services to connect to an interpreter on behalf of the member. After business hours, call the 24/7 NurseLine on the back of a member ID card. Face‑to‑face interpreters If you would like to request an interpreter, including sign language, on behalf of your patient, please call Provider Services. Three business days are required to schedule services, and 24 business hours are required to cancel. TTY and relay services For members with hearing or speech loss, members may call the TTY line on the back of a member ID card or 711. After business hours, they should call the 24/7 NurseLine. Leverage the knowledge, skills, values, strategies, and techniques available to foster a trusted partnership with your patients. Access these resources today to enhance your shared journey in healthcare. Sources
1 Office of Disease Prevention and Health Promotion. (2022, Feb 6). Health Equity in Healthy People 2030. Retrieved from https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health
2 Elevance Health. (2022, Feb 7). What Are Health Disparities? Retrieved from https://elevancehealth.com/our‑approach‑to‑health/health‑equity/what‑are‑health‑disparities
3 American Community Survey, 2024 American Community Survey 1‑Year Estimates, Table B16001, generated July 2024. Anthem Blue Cross and Blue Shield and Anthem Blue Cross and Blue Shield Medicaid are trade names of Community Insurance Company. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CDCRCM-076862-24-CPN75666 You are invited to participate in our next Provider Advisory Council meeting on May 21, 2025, at noon ET. In the meeting, we will collaborate with our Ohio provider community to discuss trends, identify challenges, and remove barriers to improve the healthcare delivery system. If you are interested in joining, please sign up by visiting the following link: Provider Advisory Council sign-up (chkmkt.com). We look forward to a future of shared success. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-079332-25, OHBCBS-CD-079333-25 We’re excited to introduce two new Payment Integrity trainings available on our Digital Solutions Learning Hub: - Payment Integrity: Emergency Dept Evaluation and Management Services
- Payment Integrity: Outpatient Evaluation and Management Services
With an initial focus on these two key educational initiatives, our purpose is to amplify your billing and coding accuracy. More trainings will be announced throughout the year. Discover what our Digital Solutions Learning Hub has to offer. Anthem Blue Cross and Blue Shield and Anthem Blue Cross and Blue Shield Medicaid are trade names of Community Insurance Company. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CDCRCM-075945-24-CPN75258, OHBCBS-CDCRCM-072257-24-CPN72085, OHBCBS-CDCRCM-077832-25-CPN77515, OHBCBS-CDCRCM-080181-25-CPN79720 When working with diabetic patients, it is essential to consider various factors to help them maintain their health and well‑being. Led by Dr. Daniel Brunner and Dr. Ann Marie Parker, this webinar will focus on adapting standardized guidelines for diabetes treatment and finding ways to overcome potential obstacles. Apply the knowledge you gain from this webinar to improve your organization’s overall quality. Key measures to be highlighted: - Diabetes Care — Blood Sugar Controlled
- Diabetes Care — Eye Exam
- Medication Adherence for Diabetes Medications
- Statins Use in Persons with Diabetes (SUPD)
- Kidney Evaluation for Patients with Diabetes (KED)
| Tuesday, April 8, 2025
Noon Eastern time
|
This session is approved for one American Academy of Family Physicians credit. Register today!* * Registration page opens best in the Google Chrome browser. Anthem Blue Cross and Blue Shield and Anthem Blue Cross and Blue Shield Medicaid are trade names of Community Insurance Company. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CDCRCM-080268-25-CPN79397 The orientation covers everything you need to know to work with us.
Please register at the link below.
We are here for you
If you have any questions, contact Provider Services at 844-912-1226 or send an email to OhioMedicaidProvider@anthem.com.
Through genuine collaboration, we can help solve real needs in a sustainable way. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-077388-25 The orientation covers working with our Medicaid members, submitting claims, and more. Please register at the link below. We are here for youIf you have any questions, contact Provider Services at 844‑912‑1226 or send an email to OhioMedicaidProvider@anthem.com. A future of shared success requires collaboration. With your help, we can make great strides in healthcare. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-077420-25, OHBCBS-CD-077423-25, OHBCBS-CD-077794-25 Please join us to learn more about working with us and supporting your patients, our members. Please register at the link below. We are here for youIf you have any questions, contact Provider Services at 844‑912‑1226 or send an email to OhioMedicaidProvider@anthem.com. Through genuine collaboration, we can work to achieve improved outcomes in patients’ mental health. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-077422-25, OHBCBS-CD-077421-25, OHBCBS-CD-077389-25 Summary: The Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
Please share this notice with other members of your practice and office staff. Please note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective Date | Clinical Criteria Number | Clinical Criteria Title | New or Revised | March 28, 2025 | CC-0274 | Bizengri (zenocutuzumab-zbco) | New | March 28, 2025 | CC-0275 | Ziihera (zanidatamab-hrii) | New | March 28, 2025 | CC-0276 | Tryngolza (olezarsen) | New | March 28, 2025 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised | March 28, 2025 | CC-0185 | Oxlumo (lumasiran) | Revised | March 28, 2025 | CC-0198 | Relizorb (immobilized lipase) cartridge | Revised | March 28, 2025 | CC-0256 | Rivfloza (nedosiran) | Revised | March 28, 2025 | CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised | March 28, 2025 | CC-0063 | Ustekinumab Agents (Stelara, Selarsdi, Imuldosa, Pyzchiva, Otulfi, Wezlana, Yesintek) | Revised | March 28, 2025 | CC-0058 | Bynfezia Pen, Sandostatin, or Sandostatin LAR (Octreotide) / Octreotide Agents | Revised | March 28, 2025 | CC-0130 | Imfinzi (durvalumab) | Revised | March 28, 2025 | CC-0094 | Pemetrexed | Revised | March 28, 2025 | CC-0003 | Immunoglobulins | Revised |
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-077235-25-CPN76946 Summary: The Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
Please share this notice with other members of your practice and office staff. Please note: - The Clinical Criteria listed below apply only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that have been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised | May 1, 2025 | CC-0272 | Aucatzyl (obecabtagene autoleucel) | New | May 1, 2025 | CC-0273 | Vyloy (zolbetuximab-clzb) | New | May 1, 2025 | CC-0223 | Imjudo (tremelimumab-actl) | Revised | May 1, 2025 | CC-0056 | Selected Injectable 5HT3 Antiemetic Agents | Revised | May 1, 2025 | CC-0124 | Keytruda (pembrolizumab) | Revised | May 1, 2025 | CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised | May 1, 2025 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised | May 1, 2025 | CC-0204 | Tivdak (tisotumab vedotin-tftv) | Revised | May 1, 2025 | CC-0226 | Elahere (mirvetuximab) | Revised | May 1, 2025 | CC-0125 | Opdivo (nivolumab) | Revised | May 1, 2025 | CC-0128 | Tecentriq (atezolizumab) | Revised | May 1, 2025 | CC-0173 | Enspryng (satralizumab-mwge) | Revised | May 1, 2025 | CC-0170 | Uplizna (inebilizumab-cdon) | Revised | May 1, 2025 | CC-0199 | Empaveli (pegcetacoplan) | Revised | May 1, 2025 | CC-0041 | Complement Inhibitors | Revised | May 1, 2025 | CC-0003 | Immunoglobulins | Revised | May 1, 2025 | CC-0073 | Alpha-1 Proteinase Inhibitor Therapy | Revised | May 1, 2025 | CC-0105 | Vectibix (panitumumab) | Revised | May 1, 2025 | CC-0095 | Bortezomib (Boruzu, Velcade) | Revised | May 1, 2025 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised | May 1, 2025 | CC-0201 | Rybrevant (amivantamab-vmjw) | Revised | May 1, 2025 | CC-0120 | Kyprolis (carfilzomib) | Revised | May 1, 2025 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised | May 1, 2025 | CC-0255 | Loqtorzi (toripalimab-tpzi) | Revised |
Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-078011-25 The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. Some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary. Please share this notice with other members of your practice and office staff. To view a guideline, visit the Medical Policy and Clinical UM Guidelines website. Medical PoliciesThe Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect April 12, 2025. Publish date | Medical Policy number | Medical Policy title | New or revised | October 1, 2024 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Revised | October 1, 2024 | DME.00052 | Brain Computer Interface Rehabilitation Devices | New | October 1, 2024 | LAB.00026 | Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions
Previously titled: Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer | Revised | October 1, 2024 | LAB.00051 | Per‑ and Polyfluoroalkyl Substances PFAS Testing | New | October 1, 2024 | MED.00150 | Hepzato Kit™ (melphalan hepatic delivery system) | New | October 1, 2024 | SURG.00032 | Patent Foramen Ovale and Left Atrial Appendage Closure Devices
Previously titled: Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention | Revised | October 1, 2024 | TRANS.00023 | Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias | Revised |
Clinical UM GuidelinesThe MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members. These guidelines take effect April 12, 2025. Publish date | Clinical UM Guideline number | Clinical UM Guideline title | New or revised | October 1, 2024 | CG‑LAB-33 | Carcinoembryonic Antigen Testing | New | October 1, 2024 | CG‑LAB-35 | Cancer Antigen 19‑9 Testing | New | October 1, 2024 | CG‑MED-39 | Bone Mineral Density Testing Measurement | Revised | October 1, 2024 | CG‑SURG-01 | Colonoscopy | Revised | October 1, 2024 | CG‑SURG-122 | Lingual Frenotomy for Ankyloglossia‑Related Feeding Difficulties | New | October 1, 2024 | CG‑SURG-57 | Diagnostic Nasal Endoscopy | Revised |
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-075680-24-CPN74692 The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised during Quarter Three, 2024. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications, or criteria, and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary. Please share this notice with other members of your practice and office staff. To view a guideline, visit the Medical Policies & Clinical UM Guidelines website. Medical PoliciesThe Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect April 28, 2025. Publish date | Medical Policy number | Medical Policy title | Status | 10/1/2024 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Revised | 10/1/2024 | DME.00052 | Brain Computer Interface Rehabilitation Devices | New | 10/1/2024 | LAB.00026 | Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions
Previously titled: Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer | Revised | 10/1/2024 | SURG.00157 | Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis | Reviewed |
Clinical UM GuidelinesThe MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicaid members. These guidelines take effect April 28, 2025. Publish date | Clinical UM Guideline number | Clinical UM Guideline title | Status | 10/1/2024 | CG-DME-48 | Vacuum Assisted Wound Therapy in the Outpatient Setting | Reviewed | 10/1/2024 | CG-LAB-33 | Carcinoembryonic Antigen Testing | New | 10/1/2024 | CG-LAB-35 | Cancer Antigen 19-9 Testing | New |
Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-077801-25 Beginning May 9, save time and speed up care by submitting federal employee program (FEP) behavioral health (BH) preapprovals through Availity Essentials at https://Availity.com. Accessing Availity Essentials for preapproval is easyAsk your organization’s Availity Essentials administrator to ensure you have the Authorization role assignment so you can access the application. Then, log in at https://Availity.com, select Authorizations and Referrals, and navigate to the Patient Registration tab. If you do not already have an Availity Essentials account, you can create one at https://Availity.com. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-079064-25 Effective for dates of service on and after July 1, 2025, the following non-emergency transportation code requires preapproval through Carelon Medical Benefits Management. CPT® code | Description | A0425 | Ground mileage, per statute mile |
As a reminder, ordering and servicing providers may submit preapproval requests to Carelon Medical Benefits Management in one of several ways: - Visit Carelon Medical Benefits Management’s providerportal.com:
- Online access is available 24/7 to process orders in real‑time and is the fastest and most convenient way to request authorization.
- Access via https://Availity.com.
If you have questions, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com or visit https://guidelines.carelonmedicalbenefitsmanagement.com. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-078792-25-CPN77989 Effective May 1, 2025, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through Availity Essentials or by calling 844‑912‑1226 with additional information, which may include medical records. Prior authorization requirements will be added for the following code(s): Code | Description | 0627T | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level | 0629T | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level | 15155 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less | 15271 | Application Of Skin Substitute Graft to Trunk, Arms, Legs, Total Wound Surface Area Up To 100 Sq Cm; First 25 Sq Cm or Less Wound Surface Area | 15273 | Application Of Skin Substitute Graft to Trunk, Arms, Legs, Total Wound Surface Area Greater Than or Equal To 100 Sq Cm; First 100 Sq Cm Wound Surface Area, Or 1% Of Body Area of infants and children | 15275 | Application Of Skin Substitute Graft to Face, Scalp, Eyelids, Mouth, Neck, Ears, Orbits, Genitalia, Hands, Feet, and/or Multiple Digits, Total Wound Surface Area Up To 100 Sq cm; first 25 sq cm or less wound surface area | 15277 | Application Of Skin Substitute Graft to Face, Scalp, Eyelids, Mouth, Neck, Ears, Orbits, Genitalia, Hands, Feet, and/or Multiple Digits, Total Wound Surface Area Greater Than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | C5271 | Application of low-cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | C5273 | Application of low-cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | C5275 | Application of low-cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | C5277 | Application of low-cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | Q4101 | Apligraf, per square centimeter | Q4106 | Dermagraft, per square centimeter |
To request PA, you may use one of the following methods: - Web: once logged in to Availity Essentials at https://Availity.com
- Fax:
- Physical health: 877‑643‑0672
- Behavioral health: 866‑577‑2183
- Phone: 800‑601‑9935
Not all PA requirements are listed here. Detailed PA requirements are available to providers at https://providers.anthem.com/oh on the Resources tab or for contracted providers by accessing Availity Essentials at https://Availity.com. Providers may also call 844‑912‑1226 for assistance with PA requirements. UM AROW A2025M2993 Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-077341-25 Effective July 1, 2025, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through Availity or by calling Provider Services with additional information which may include medical records.
Prior authorization requirements will be added for the following code(s):
|
Code
|
Description
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|
0108U
|
Gastroenterology (Barrett's esophagus), whole slide‑digital imaging, including morphometric analysis, computer‑assisted quantitative immunolabeling of 9 protein biomarkers (p16, AMACR, p53, CD68, COX‑2, CD45RO, HIF1a, HER‑2, K20) and morphology, formalin‑fixed paraffin‑embedded tissue, algorithm reported as risk of progression to high‑grade dysplasia or cancer
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|
0394U
|
Perfluoroalkyl substances (PFAS) (for example, perfluorooctanoic acid, perfluorooctane sulfonic acid), 16 PFAS compounds by liquid chromatography with tandem mass spectrometry (LC‑MS/MS), plasma or serum, quantitative
|
|
0457U
|
Perfluoroalkyl substances (PFAS) (for example, perfluorooctanoic acid, perfluorooctane sulfonic acid), 9 PFAS compounds by LC‑MS/MS, plasma or serum, quantitative
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|
0479U
|
Tau, phosphorylated, pTau217
|
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0480U
|
Infectious disease (bacteria, viruses, fungi, and parasites), cerebrospinal fluid (CSF), metagenomic next‑generation sequencing (DNA and RNA), bioinformatic analysis, with positive pathogen identification
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0482U
|
Obstetrics (preeclampsia), biochemical assay of soluble fms‑like tyrosine kinase 1 (sFlt‑1) and placental growth factor (PlGF), serum, ratio reported for sFlt‑1/PlGF, with risk of progression for preeclampsia with severe features within 2 weeks
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0490U
|
Oncology (cutaneous or uveal melanoma), circulating tumor cell selection, morphological characterization and enumeration based on differential CD146, high molecular‑weight melanoma‑associated antigen, CD34 and CD45 protein biomarkers, peripheral blood
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0491U
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Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of estrogen receptor (ER) protein biomarker‑expressing cells, peripheral blood
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0492U
|
Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of PD‑L1 protein biomarker‑expressing cells, peripheral blood
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0495U
|
Oncology (prostate), analysis of circulating plasma proteins (tPSA, fPSA, KLK2, PSP94, and GDF15), germline polygenic risk score (60 variants), clinical information (age, family history of prostate cancer, prior negative prostate biopsy), algorithm reported as risk of likelihood of detecting clinically significant prostate cancer
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0503U
|
Neurology (Alzheimer disease), beta amyloid (AB40, AB42, AB42/40 ratio) and tau‑protein (ptau217, np‑tau217, ptau217/np‑tau217 ratio), blood, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC‑MS/MS), algorithm score reported as likelihood of positive or negative for amyloid plaques
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0517U
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Therapeutic drug monitoring, 80 or more psychoactive drugs or substances, LC‑MS/MS, plasma, qualitative and quantitative therapeutic minimally and maximally effective dose of prescribed and non‑prescribed medications
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0518U
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Therapeutic drug monitoring, 90 or more pain and mental health drugs or substances, LC‑MS/MS, plasma, qualitative and quantitative therapeutic minimally effective range of prescribed and non‑prescribed medications
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0519U
|
Therapeutic drug monitoring, medications specific to pain, depression, and anxiety, LC‑MS/MS, plasma, 110 or more drugs or substances, qualitative and quantitative therapeutic minimally effective range of prescribed, non‑prescribed, and illicit medications in circulation
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0915T
|
Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator and dual transvenous electrodes/leads (pacing and defibrillation)
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|
0916T
|
Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator only
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0917T
|
Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; single transvenous lead (pacing or defibrillation) only
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|
0918T
|
Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; dual transvenous leads (pacing and defibrillation) only
|
|
0919T
|
Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); pulse generator only
|
|
0920T
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Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); single transvenous pacing lead only
|
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0921T
|
Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); single transvenous defibrillation lead only
|
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0922T
|
Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); dual (pacing and defibrillation) transvenous leads only
|
|
0923T
|
Removal and replacement of permanent cardiac contractility modulation‑defibrillation pulse generator only
|
|
0924T
|
Repositioning of previously implanted cardiac contractility modulation‑defibrillation transvenous electrode(s)/lead(s), including fluoroscopic guidance and programming of sensing and therapeutic parameters
|
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0925T
|
Relocation of skin pocket for implanted cardiac contractility modulation‑defibrillation pulse generator
|
|
0926T
|
Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation‑defibrillation system
|
|
0927T
|
Interrogation device evaluation (in person) with analysis, review, and report, including connection, recording, and disconnection, per patient encounter, implantable cardiac contractility modulation‑defibrillation system
|
|
0928T
|
Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation‑defibrillation system with interim analysis and report(s) by a physician or other qualified health care professional
|
|
0929T
|
Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation‑defibrillation system, remote data acquisition(s), receipt of transmissions, technician review, technical support, and distribution of results
|
|
0930T
|
Electrophysiologic evaluation of cardiac contractility modulation‑defibrillator leads, including defibrillation‑threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), at time of initial implantation or replacement with testing of cardiac contractility modulation‑defibrillator pulse generator
|
|
0931T
|
Electrophysiologic evaluation of cardiac contractility modulation‑defibrillator leads, including defibrillation‑threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), separate from initial implantation or replacement with testing of cardiac contractility modulation‑defibrillator pulse generator
|
|
0933T
|
Transcatheter implantation of wireless left atrial pressure sensor for long‑term left atrial pressure monitoring, including sensor calibration and deployment, right heart catheterization, transseptal puncture, imaging guidance, and radiological supervision and interpretation
|
|
0934T
|
Remote monitoring of a wireless left atrial pressure sensor for up to 30 days, including data from daily uploads of left atrial pressure recordings, interpretation(s) and trend analysis, with adjustments to the diuretics plan, treatment paradigm thresholds, medications or lifestyle modifications, when performed, and report(s) by a physician or other qualified health care professional
|
|
0935T
|
Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of ureteral sheath(s) and multiple conformable electrodes, contrast injection(s), and fluoroscopy, bilateral
|
|
82542
|
Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase
|
|
83921
|
Organic Acid, Single, Quantitative
|
|
93701
|
Bioimpedance‑derived physiologic cardiovascular analysis
|
|
A2027
|
Matriderm, per square centimeter
|
|
A2028
|
Micromatrix flex, per mg
|
|
A2029
|
Mirotract wound matrix sheet, per cubic centimeter
|
|
A4543
|
Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month
|
|
A4544
|
Electrode for external lower extremity nerve stimulator for restless legs syndrome
|
|
E0738
|
Upper extremity rehabilitation system providing active assistance to facilitate muscle re‑education, includes microprocessor, all components and accessories
|
|
J9248
|
Injection, melphalan (Hepzato), 1 mg
|
|
L5783
|
Addition to lower extremity, user adjustable, mechanical, residual limb volume management system
|
|
L5841
|
Addition, endoskeletal knee‑shin system, polycentric, pneumatic swing, and stance phase control
|
Not all PA requirements are listed here. Detailed PA requirements are available on https://www.anthem.com/provider/individual-commercial/medicare-advantage under the Resources tab. Alternatively, contracted providers can access the information at https://Availity.com. Providers may also call Provider Services assistance with PA requirements. UM AROW A2024M2893 Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-076904-25-CPN76474 Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-076777-25 Pharmacy | Commercial | March 27, 2025 Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements Specialty pharmacy updates — April 2025Your patients may be receiving medications listed in the tables below without preapproval. As of July 1, 2025, you may need to request a preapproval review to ensure your patients’ continued use of these medications. Including the National Drug Code (NDC) on your claim will help us process claims more quickly for drugs billed with a not otherwise classified (NOC) code. Preapproval updates Effective for dates of service on or after July 1, 2025, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our preapproval review process. Access our Clinical Criteria to view the complete information for these preapproval updates. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0272 | Aucatzyl (obecabtagene autoleucel) | C9399, J9999 | CC-0274* | Bizengri (zenocutuzumab-zbco) | C9399, J9999 | CC-0041 | Bkemv (eculizumab-aeeb) | Q5139 | CC-0058 | Bynfezia Pen (octreotide acetate) | C9399, J3490 | CC-0041 | Epysgli (eculizumab-aagh) | J3590 | CC-0149 | Hympavzi (marstacimab-hncq) | C9399, J3590 | CC-0063 | Imuldosa (ustekinumab-srlf) | J3590 | CC-0063 | Otulfi (ustekinumab-aauz) | J3590 | CC-0063 | Pyzchiva IV (ustekinumab-ttwe) | Q9997 | CC-0063 | Pyzchiva SC (ustekinumab-ttwe) | Q9996 | CC-0063 | Selarsdi (ustekinumab-aekn) | Q9998 | CC-0128* | Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) | C9399, J9999 | CC-0276 | Tryngolza (olezarsen) | C9399, J3490 | CC-0273* | Vyloy (zolbetuximab-clzb) | C9399, J9999 | CC-0063 | Yesintek (ustekinumab-kfce) | J3590 | CC-0275* | Ziihera (zanidatamab-hrii) | C9399, J9999 |
*Carelon Medical Benefits Management manages oncology use. Note: Preapproval requests for certain medications may require additional documentation to determine medical necessity. Step therapy updates Effective for dates of service on or after July 1, 2025, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our specialty pharmacy medical step therapy review process. Access our Clinical Criteria to view the complete information for these step therapy updates. Clinical Criteria | Status | Drug | HCPCS or CPT code(s) | CC-0063 | Non-preferred | Imuldosa (ustekinumab-srlf) | J3590 | CC-0063 | Non-preferred | Otulfi (ustekinumab-aauz) | J3590 | CC-0063 | Non-preferred | Pyzchiva IV (ustekinumab-ttwe) | Q9997 | CC-0063 | Non-preferred | Pyzchiva SC (ustekinumab-ttwe) | Q9996 | CC-0063 | Non-preferred | Selarsdi (ustekinumab-aekn) | Q9998 | CC-0063 | Non-preferred | Wezlana IV (ustekinumab-auub) | Q5138 | CC-0063 | Non-preferred | Wezlana SC (ustekinumab-auub) | Q5137 | CC-0072 | Non-preferred | Ahzantive (aflibercept-mrbb) | J3590, C9399 | CC-0072 | Non-preferred | Enzeevu (aflibercept-abvz) | J3590, C9399 | CC-0072 | Non-preferred | Opuviz (aflibercept-yszy) | J3590, C9399 | CC-0072 | Non-preferred | Yesafili (aflibercept-jbvf) | J3590, C9399 | CC-0072 | Preferred | Pavblu (aflibercept-ayyh) | J3590, C9399 |
Note: Preapproval requests for certain medications may require additional documentation to determine medical necessity. Quantity limit updates Effective for dates of service on or after July 1, 2025, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process. Access our Clinical Criteria to view the complete information for these quantity limit updates. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0274 | Bizengri (zenocutuzumab-zbco) | C9399, J9999 | CC-0058 | Bynfezia Pen (octreotide acetate) | C9399, J3490 | CC-0063 | Imuldosa (ustekinumab-srlf) | J3590 | CC-0063 | Otulfi (ustekinumab-aauz) | J3590 | CC-0063 | Pyzchiva IV (ustekinumab-ttwe) | Q9997 | CC-0063 | Pyzchiva SC (ustekinumab-ttwe) | Q9996 | CC-0063 | Selarsdi (ustekinumab-aekn) | Q9998 | CC-0276 | Tryngolza (olezarsen) | C9399, J3490 | CC-0063 | Yesintek (ustekinumab-kfce) | J3590 |
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-079579-25-CPN78860 Effective for dates of service on and after July 1, 2025, the specialty Medicare Part B drugs listed below will be included in our preapproval review process. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these preapproval rules and must be considered first when determining coverage. Please follow the new requirements to ensure your claims are accepted. HCPCS or CPT® codes | Medicare Part B drugs | C9399, J9999 | Aucatzyl (obecabtagene autoleucel) | Q5139 | Bkemv (eculizumab-aeeb) | J3590 | Epysqli (eculizumab-aagh) | C9399, J3590 | Hympavzi (marstacimab-hncq) | J3590 | Imuldosa (ustekinumab-srlf) | J3590 | Otulfi (ustekinumab-aauz) | Q9997 | Pyzchiva IV (ustekinumab-ttwe) | Q9998 | Selarsdi (ustekinumab-aekn) | C9399, J9999 | Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) | C9399, J9999 | Vyloy (zolbetuximab-clzb) |
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-077630-25-CPN77426 This article was updated on April 1, 2025 to correct the BioPlus telephone number to 833‑549‑2145. Effective April 1, 2025, and upon member consent, specialty pharmacy prescriptions for our Group Retiree Solutions members currently being dispensed by CarelonRx Specialty Pharmacy will be transferred to BioPlus Specialty Pharmacy (BioPlus). Those of our members who will be affected received a letter in February explaining this transition. Next steps:- If the member provides consent to move to BioPlus, they will receive a phone call from BioPlus to review important information related to their prescriptions.
- If you have Group Retiree Solutions patients who choose to move their prescription, BioPlus will contact you to request new prescriptions, refills, or preapprovals.
- If you have patients who choose not to move their prescription, no action is required.
Benefits of working with BioPlusIf your patients move to BioPlus, you can expect: - Faster approvals — know in two hours whether your patient is accepted for treatment.
- Less paperwork for benefits verification and appeals.
- More help with securing patient financial assistance.
We’re here to helpIf you have questions, contact your provider relationship management representative or call BioPlus directly at 833‑549‑2145. CarelonRx Specialty Pharmacy is an independent company providing pharmacy benefit management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-078432-25-CPN78340 |