 Provider News OhioAugust 2023 Provider News Contents
OHBCBS-CDCRCM-030308-23 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Availity, LLC is an independent company providing administrative support services on behalf of the health plan. Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. As the physician of our members who have Affordable Care Act (ACA) health plans, you play a vital role in the success of this initiative and our compliance with ACA requirements. When members visit your practice or office, we encourage you to document all of the members’ health conditions, especially chronic diseases. As a result, there is ongoing documentation to indicate that these conditions are being assessed and managed. Ensuring proper coding on the claim is to the greatest level of specificity can help reduce the number of medical chart requests in the future. Ensure all codes captured in your electronic medical record (EMR) system are included on the claim and not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes. However, a claim system may only have the ability of capturing four. If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being captured. Best practices and documenting guidelines: Use clear terminology.Include a brief statement that updates the status of each diagnosis. For example, use words such as continue, increase, add, name of medication treating the condition, refer to, return to center, follow up, and so on. This informs the coder the condition is current. Include orders for each condition if applicable. For every medication refilled, document a diagnosis and address it in the progress note. Chronic conditions should be evaluated at least once per year. Use the words history of to mean the condition no longer exists. For example: Document the patient has diabetes and hypertension rather than the patient has a history of diabetes and hypertension. Please see forms and guides for a more comprehensive Commercial Risk Adjustment coding brochure.Contact our Commercial Risk Adjustment Network Education representative if you have any questions: For providers in | Commercial Risk Adjustment Network Education representative | California, Colorado, and Nevada | Martha.Bendot@anthem.com | Indiana, Missouri, Wisconsin, Ohio, and Kentucky | Mary.Swanson@anthem.com | New York, Maine, New Hampshire, Connecticut, Georgia, and Virginia | Alicia.Estrada-Hoare@anthem.com |
Thank you for your continued efforts with our Commercial Risk Adjustment Program. MULTI-BCBS-CM-029140-23-CPN28564 Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment. To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form ( CMS-1500) or its electronic equivalent for clinical laboratory services. The CLIA certificate identification number must be submitted in one of the following manners: Claim format and elements | CLIA number location options | Referring provider name and NPI number location options | Servicing laboratory physical location | CMS-1500 (formerly HCFA-1500) | Must be represented in field 23 | Submit the referring provider name and NPI number in fields 17 and 17b, respectively. | Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the servicing address is not equal to the billing provider address. The servicing provider address must match the address associated with the CLIA ID entered in field 23. | HIPAA 5010 837 Professional | Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01 | Submit the referring provider name and NPI number in the 2310A loop, NM1 segment. | Physical address of servicing provider must be represented in the 2310C loop if not equal to the billing provider address and must match the address associated with the CLIA ID submitted in the 2300 loop, REF02. |
To be considered for reimbursement of reference laboratory services, the referring laboratory must be an independent clinical laboratory. Modifier 90 must be submitted to denote the referred laboratory procedure. Per the Centers for Medicare & Medicaid (CMS), an independent clinical laboratory that submits claims in paper format may not combine non-referred or self-performed and referred services on the same CMS-1500 claim form. Thus, when the referring laboratory bills for both non-referred and referred tests, it must submit two separate paper claims: one claim for non-referred tests and the other for referred tests. If submitted electronically, the reference laboratory must be represented in the 2300 or 2400 loop, REF02 element, with qualifier of F4 in REF01. Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form. Laboratory procedures must be rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code, does not have complete servicing provider demographic information and applicable reference laboratory provider demographic information, will be considered incomplete and rejected or denied. If you have questions, please contact your Provider Relationship Management representative. OHBCBS-CD-029254-23-CPN29147 BackgroundICD-10-CM laterality codes are developed to precisely define laterality (for example, left, right, or bilateral). ICD-10-CM guidelines for laterality coding provide that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. Impact to providersProviders should code their claims to the highest level of specificity in accordance with ICD‑10-CM coding guidelines for site and laterality when specified laterality codes exist and to submit the appropriate laterality code in accordance with the condition. Professional claims submitted on a CMS-1500 form or facility claims submitted on CMS-1450 date of service on or after September 1, 2023, that do not reflect the highest level of specificity when the code exists will be denied. Example:- Reported diagnosis: H60.339 (swimmer’s ear, unspecified ear)
- Billed CPT® code or modifier: CPT 69000-RT (drainage external ear, abscess, or hematoma: simple [right side])
- Determination: It is not appropriate to report unspecified diagnosis codes when a more specific (for example, H60.331 swimmer’s ear, right ear) code is available; therefore, the claim line will be denied.
Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT, HCPCS code(s), and modifiers billed. Anthem Blue Cross and Blue Shield will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines. If you have questions about this communication or need assistance, contact your Provider Relationship Management representative, or call Provider Services. OHBCBS-CM-028811-23-CPN26898 Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment. To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent for clinical laboratory services. The CLIA certificate identification number must be submitted in one of the following manners: Claim format and elements | CLIA number location options | Referring provider name and NPI number location options | Servicing laboratory physical location | CMS-1500 (formerly HCFA-1500) | Must be represented in field 23 | Submit the referring provider name and NPI number in fields 17 and 17b, respectively. | Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the servicing address is not equal to the billing provider address. The servicing provider address must match the address associated with the CLIA ID entered in field 23. | HIPAA 5010 837 Professional | Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01 | Submit the referring provider name and NPI number in the 2310A loop, NM1 segment. | Physical address of servicing provider must be represented in the 2310C loop if not equal to the billing provider address and must match the address associated with the CLIA ID submitted in the 2300 loop, REF02. |
To be considered for reimbursement of reference laboratory services, the referring laboratory must be an independent clinical laboratory. Modifier 90 must be submitted to denote the referred laboratory procedure. Per the Centers for Medicare & Medicaid (CMS), an independent clinical laboratory that submits claims in paper format may not combine non-referred or self-performed and referred services on the same CMS-1500 claim form. Thus, when the referring laboratory bills for both non-referred and referred tests, it must submit two separate paper claims: one claim for non-referred tests and the other for referred tests. If submitted electronically, the reference laboratory must be represented in the 2300 or 2400 loop, REF02 element, with qualifier of F4 in REF01. Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form. Laboratory procedures must be rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code, does not have complete servicing provider demographic information and/or applicable reference laboratory provider demographic information, will be considered incomplete and rejected or denied. If you have questions, please contact your Provider Relationship Management representative. 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-CRCM-029658-23-CPN29126, MULTI-BCBS-CRCM-066936-24 To support the health of our members, Anthem Blue Cross and Blue Shield (Anthem) is sending urinary tract infection (UTI) tool kits to select members who were seen in the ER for a UTI. This kit contains: - A water bottle to help your patient stay hydrated.
- UTI test strips with instructions on use if having symptoms. These test strips are available over the counter (OTC).
- Basic instructions on how to use the tool kit and on reasons to seek care.
You might be hearing from your patients who are Anthem members. If you have any questions, please contact Provider Services via the number on the back of the patient’s member ID card. Anthem Blue Cross and Blue Shield provider orientations The Ohio Medicaid Provider Relationship Account Management team will host provider orientations this summer. Our orientation will cover everything you need to know to work with Ohio Medicaid. Dates: - Wednesday, August 9, 2023, 2 p.m.
- Monday, September 18, 2023, 1 p.m.
To register and join us for either of the dates above, go to the following site: https://bit.ly/42rhI39 If you have questions, please contact your Provider Relationship Account Manager or email OhioMedicaidProvider@anthem.com. OHBCBS-CD-023483-23-SRS23250 As you are aware, the federal Consolidated Appropriations Act (CAA) of 2021 contains several provisions applicable to health plans and their providers. One of the provisions is commonly referred to as a Gag Clause provision; specifically, Section 201: Increasing Transparency by Removing Gag Clauses on Price and Quality Information. Commercial health plans are required to attest annually that their provider agreements are in compliance with the Gag Clause provision. Should your provider agreement with Anthem Blue Cross and Blue Shield (Anthem) have language inconsistent with the Gag Clause provision, it is deemed by Anthem as null and void. To memorialize this provision in your provider agreement, we are providing a CAA Gag Clause Regulatory Addendum. Please attach this addendum to your provider agreement with Anthem. Thank you for the care you provide our members — your patients. Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com/provider, then under Provider Overview, choose Find Care. Submit updates and corrections to your directory information by following the instructions on the Provider Maintenance page on our website. Online update options include: - Add/change an address location.
- Name change.
- Provider leaving a group or a single location.
- Phone/fax number changes.
- Closing a practice location.
The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current. As we communicated in July, we will use the Provider Data Management (PDM) application on Availity Essentials* to verify and initiate care provider demographic change requests for all professional and facility care providers.** Going forward, Availity PDM is now the intake application for care providers to submit demographic change requests, including submitting roster uploads. Availity PDM will replace all current intake channels for demographic change requests and roster submissions as of October 1, 2023. If preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups. Take action nowDon’t wait until October to start using the PDM application. Start using it today to take advantage of the benefits of this application and familiarize yourself with the process before the legacy intake channels retire. What features does the Availity PDM application provide?It allows you to: - Update provider demographic information for all assigned payers in one location.
- Attest and manage current provider demographic information.
- Review the history of previously verified data.
Benefits to our care providers using Availity PDMThe Availity PDM application will ensure the following: - Consistently updated data
- Decreased turnaround time for updates
- Compliance with federal and/or state mandates
- Improved data quality through standardization
- Increased provider directory accuracy
- Choice and flexibility to request data updates via the standard PDM experience or by submitting a spreadsheet via a roster upload
Want to submit a roster using Availity PDM?Don’t wait — Start submitting today. Roster Automation is our new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation today:*** - Utilize the Roster Automation Standard Template:
- For your convenience, there is a standard roster Excel document. Find it online here.
- Follow the Roster Automation Rules of Engagement:
- A reference document, Roster Automation Rules of Engagement, is available to ensure error-free submissions, driving accurate and more timely updates through automation. More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide). Find it online here.
- Upload your completed roster via the Availity PDM application.
- Join our live webinar:
- Title of webinar: Roster Automation Template and Rules of Engagement Training
- Date: Monday, August 21, 2023
- Time: 4 to 5 p.m. ET
- Registration link: here
What about the previous methods by which I have been submitting information?While we are in the process of sunsetting our legacy intake channels, we will continue to process submissions received through current intake channels until September 30, 2023. Effective October 1, 2023, all PDM requests, including rosters, must be submitted via Availity PDM. As of this date, all provider demographic change requests, including rosters, will be rejected if submitted through any format/channel other than Availity PDM. Again, if preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups. How to access the Availity PDM applicationLog onto availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts. Availity administrators will automatically be granted access to PDM. Additional staff may be given access to Provider Data Management by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. Training is available:- Learn about and attend one of our training opportunities by visiting here.
- View the Availity PDM quick start guide here.
Not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by logging into availity.com and selecting the Register icon at the top of the home screen, or you can use this link to access the registration page. If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY. Note: For national providers who provide services in multiple markets, California (all lines of business), Colorado (Commercial and Medicare), and Nevada (all lines of business) are not available for Availity PDM until our Strategic Provider System migration. ** Exclusions: - Behavioral health providers assigned to Carelon Behavioral Health, Inc.* will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health.
- Any specific state mandates or requirements for provider demographic updates.
*** If any roster data updates require credentialing, your submission will be routed appropriately for further action. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. Carelon Behavioral Health, Inc. is an independent company providing utilization management services on behalf of the health plan. OHBCBS-CRCM-031758-23-CPN30214 Below are guidelines for a claim’s escalation process, provider payment dispute, and appeals process relating to claim payment. We encourage providers to seek resolution of issues by using the processes outlined below prior to reaching out to your Provider Relationship Account consultant/manager with claim questions. However, if you notice a trend in your claims, please reach out to your Provider Relationship Account consultant/manager right away with claim examples so they can assist you with resolution. More detailed information can be found in our provider manual on our website: Home | Anthem Blue Cross and Blue Shield. If you are not sure who your Provider Relationship Account consultant is, select this link for a complete territory list with their contact information. Anthem Blue Cross and Blue Shield (Anthem) maintains a Claims Payment Systemic Error (CPSE) report. A CPSE is defined as a systematic incident causing claims to adjudicate incorrectly, which could result in underpaying, overpaying, denying, or suspending claims. When this occurs and impacts five or more providers or has the potential to impact five or more providers, Anthem will report CPSE data on our Ohio Medicaid provider website. Before submitting a complaint, please check the plan’s CPSE report for the issue in question. View the CPSE report here. Step one: Self-service toolsThrough our digital self-service options offered on the Availity Essentials* platform, you can access much of the same information you receive when calling Provider Services. Chat with Payer, an application which is accessed through Availity Essentials Payer Spaces, is a digital alternative to making a phone call to get questions answered through a real-time, online discussion. Inquiry types include eligibility, benefits, claims, authorization status, and appeal status. Chat with Payer is available Monday to Friday from 8 a.m. to 6 p.m. ET. Save your chat session inquiry number as a reference. By using Availity Essentials, you can verify member benefits and eligibility, submit claims, view claims status, submit and view prior authorization requests, and more. More information regarding real-time multi-payer capabilities and provider organization registration process of Availity Essentials can be found here. Submit a claim payment dispute or appeal
Required documentation for claims payment disputes and appeals: - Your name, address, phone number, email, and either your NPI or TIN
- The member’s name and their Anthem or Medicaid ID number
- A listing of disputed claims, which should include the claim number and the date(s) of service(s)
- All supporting statements and documentation
- A detailed explanation of the reason for the appeal
Submit a first-level claim payment dispute: This is the provider’s initial request for a review into the outcome of a claim once it is finalized: Submit a second-level claim payment appeal: This is the second step in the claim payment dispute process. If a provider disagrees with the outcome of the claim payment dispute, providers may request a second-level review, also known as a claim payment appeal: Note: We accept both claim payment disputes and appeal requests through our provider website, verbally, and in writing within 12 months from the date of service (DOS) or 60 calendar days from the date on the Explanation of Payment (EOP) (see below for further details on how to submit). We cannot process a claim payment appeal without a dispute on file. For provider post service/retrospective authorizations: If services have been rendered to the member, providers should file the claim with medical documentation as a payment dispute. A detailed explanation as to why a prior authorization was not obtained should be included with the dispute. Please refer to the provider manual for additional information. Step two: Contact Provider ServicesProvider Services can be reached at 844-912-1226: - Representatives are available Monday to Friday from 7 a.m. to 8 p.m. ET:
- If both our self-service tools and a Provider Services representative are unable to provide you with the support you need, you may request to speak with a Provider Services supervisor/escalation agent, and your call will be escalated.
- If a supervisor/escalation agent is unable to assist you immediately, you will receive a call back within two business days. Please record your call reference number.
Step three: Contact Provider Relationship Account consultant/manager:- If our self-service tools, Provider Services, or submitting a claim payment dispute did not resolve the issue to your satisfaction, contact your designated Provider Relationship Account consultant/manager. Your Provider Relationship Account consultant/manager can be found at this link. You can also email the Provider Relationship Account Management team at OhioMedicaidProvider@Anthem.com.
- Providers should use the document below when sending claim issues to their Provider Relationship Account consultant/manager. When an issue is affecting many claims, only five examples are needed for research.
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. OHBCBS-CD-028155-23 ATTACHMENTS (available on web): Copy of Claim Escalation Template (xlsx - 0.02mb) OverviewWe’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes. Engagement Hub objectives:- Learn strategies to help you and your care team improve your performance across a range of clinical areas.
- Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
- Offer care providers a convenient way to earn CME credits at a time that works best for them.
Browse the listing of free CME webinars.* * Sessions in this series are approved for one American Academy of Family Physicians credit each. MULTI-BCBS-CRCM-030986-23-CPN29678 Clinical Criteria updates On August 19, 2022, and March 23, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (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
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
Please share this notice with other providers in 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 policy. 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 | August 6, 2023 | *CC-0235 | Revcovi (elapegademase-lvlr) | New | August 6, 2023 | *CC-0236 | Signifor LAR (pasireotide) | New | August 6, 2023 | CC-0125 | Opdivo (nivolumab) | Revised | August 6, 2023 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised | August 6, 2023 | CC-0038 | Human Parathyroid Hormone Agents | Revised | August 6, 2023 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised | August 6, 2023 | *CC-0197 | Jemperli (dostarlimab-gxly) | Revised | August 6, 2023 | *CC-0119 | Yervoy (ipilimumab) | Revised | August 6, 2023 | CC-0092 | Adcetris (brentuximab vedotin) | Revised | August 6, 2023 | *CC-0065 | Hemophilia A and von Willebrand Disease | Revised | August 6, 2023 | *CC-0034 | Agents for Hereditary Angioedema | Revised | August 6, 2023 | CC-0061 | GnRH Analogs for the Treatment of Non-Oncologic Indications | Revised | August 6, 2023 | CC-0008 | Subcutaneous Hormonal Implants | Revised | August 6, 2023 | CC-0026 | Testosterone, Injectable | Revised |
MULTI-BCBS-CR-027354-23-CPN26411 Medical Policy & Clinical Guidelines | Commercial | July 21, 2023 Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements Updates to Carelon Medical Benefits Management, Inc. Joint Surgery, Small Joint Surgery, and MSK Level of CareClinical Appropriateness Guidelines Effective for dates of service on and after November 5, 2023, the following updates will apply to the Carelon Medical Benefits Management, Inc.* Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services. Joint Surgery updates by sectionMultiple joints:- Loose body — Added indication for removal of loose body from shoulder and for removal of loose body or foreign body from the hip and the knee
- Synovectomy — Added requirement for conservative management; added exclusion for traumatic reactive synovitis in shoulder, hip, and knee; added indications for both limited and extensive synovectomy in the knee
Shoulder:- Rotator cuff repair — Modified diagnostic tests for full thickness rotator cuff tear; removed requirement for conservative management for high-grade partial thickness rotator cuff tear
- Revision rotator cuff repair — Added exclusion for patients with rotator cuff arthropathy
- Labrum repair — Broadened MRI findings to allow for any labral tear other than a Bankart lesion
- Adhesive capsulitis — Extended required conservative management from six weeks to 12 weeks
- Capsulorraphy — Added allowance for capsular redundancy with multidirectional instability; waived conservative management requirement in the setting of traumatic dislocation
- Subacromial decompression/acromioplasty — Added indications for symptomatic is acromial and for symptomatic mechanical impingement due to tumor or malunited fracture
- Shoulder debridement — Extended required conservative management to 12 weeks
- Biceps tenodesis/tenotomy — Broadened criteria to allow when criteria are met for any shoulder procedure, or when patient has an acute proximal biceps tear
- Added exclusion for subacromial balloon spacer and for shoulder resurfacing
Hip:- Added indications for primary partial hip arthroplasty and partial or total hip resurfacing
- Revision total hip arthroplasty — Added indication for elevated cobalt/chromium levels in patients with a metal-on-metal implant
- Acetabuloplasty — Added indications for arthritis, hip instability, and FAIS
- Diagnostic arthroscopy — Added exclusion for non-intra-articular hip procedures
- Femoroacetabular impingement syndrome (FAIS) — Specified requirement for alpha angle greater than 55 degrees for femoroplasty
- Labral tear — Added exclusion for hip arthroscopy for lavage and debridement in advanced osteoarthritis
- Added exclusion for debridement/chondroplasty when done solely for osteoarthritis and for labral repair in untreated severe hip dysplasia
Knee:- Total knee arthroplasty — Added indication for post-traumatic arthritis; added unicompartmental damage to existing indications for partial joint damage
- Unicompartmental knee arthroplasty — Modified requirements related to conservative management and varus/valgus deformities; allow concurrent ACL reconstruction in some scenarios
- Revision knee arthroplasty — Added indication for reconstruction after post knee replacement infection; shortened conservative management requirement to six weeks for revision attributable to prior implants
- Abrasion arthroplasty/microfracture — Aligned with osteochondral grafts criteria regarding the size of defect that can be treated
- Debridement/drainage/lavage (knee) — Reduced conservative management requirement to six weeks for consistency with lysis of adhesions criteria
- Anterolateral ligament reconstruction or extra-articular tenodesis — Added indications
- ACL reconstruction and PCL repair/reconstruction — Excluded patients with advanced knee arthritis (Kellgren-Lawrence 4)
- Added indications for posterolateral corner injury and for collateral/extra-articular ligament injury
- Patellar compression syndrome — Added exclusion for central or medial tracking of the patella
- Medial patellofemoral ligament reconstruction — Waived requirement for conservative management when function is limited due to pain
Osteochondral grafts:- Patient selection requirements — Specified that conservative management duration must be six weeks; waived this requirement when a symptomatic loose body is present
- Osteochondritis dissecans — Added indications for surgical treatment
- Osteochondral allograft transplantation — Decreased the minimum required size of the defect to 1.0 cm2 in the knee and in the talus; removed microfracture for defects in the knee
- Added exclusions for non-standard tissue bank methods and for use of larger allografts as an alternative to traditional total joint replacement
- HCPCS code added: S2118
Small Joint Surgery:- Hallux rigidus procedures; hallux valgus and bunionette procedures; lesser toe deformities — Removed poor wound healing as a contraindication
- Hallux valgus surgery — Add allowance for pre-ulcer (Wagner grade 0 to 1 lesion); added criterion for simple exostectomy/resection medial eminence; separated bunionette surgery indications from hallux valgus surgery
- First MTP joint arthrodesis for hallux valgus — Added indication
- Metatarsal osteotomy — Separated criteria into standalone indication; added exclusion for improved cosmesis
- Ankle arthritis — Added indication for revision total ankle arthroplasty
- Ankle arthroplasty — Removed severe ankle deformity and peripheral neuropathy as contraindications
Level of Care for Musculoskeletal Surgery:- Added total or partial primary shoulder arthroplasty to ambulatory surgery center with 23-hour observation to address the addition of hemiarthroplasty and total shoulder arthroplasty
- CPT® codes added to level of care review: 23470 and 23472
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management by: - Accessing Carelon Medical Benefits Management’s ProviderPortalSM directly at 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.
If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-027322-23-CPN26945 As communicated in the July Provider Newsletter, effective October 1, 2023, Carelon Medical Benefits Management, Inc.* a specialty health benefits company, will perform medical necessity reviews for procedures for Anthem Blue Cross and Blue Shield (Anthem) members, as outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable. The expansion will require clinical appropriateness review for pacemakers as part of the Carelon Medical Benefits Management Cardiology program. Due to CPT® code overlap, management of ICD and CRT devices without inclusion of pacemakers creates provider abrasion and operational challenges. The clinical guidelines and medical policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on September 18, 2023, for dates of service October 1, 2023, and after. Members included in the new programAll fully insured, self-funded (ASO), and National members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of August 1, 2023. Members of the following products are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, and Federal Employee Program® (FEP®). Pre-service review requirementsFor procedures that are scheduled to begin on or after October 1, 2023, all providers must contact Carelon Medical Benefits Management to obtain pre-service review for the following non-emergency modalities. Please refer to the clinical guidelines at the links below for more details including code lists. Leadless pacemakers: Medical policy related to the insertion, removal, or replacement of permanent leadless pacemakers. Carelon Medical Benefits Management permanent implantable pacemakers: Clinical appropriateness guideline related to insertion, repair, removal, repositioning, or replacement of permanent implantable pacemakers, pacemaker pulse generators, or electrodes. To determine if prior authorization is needed for a member on or after October 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the Interactive Care Reviewer (ICR) tool on the Availity Essentials* website to pre-certify an outpatient procedure, will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.) Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortalSM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to providers.carelonmedicalbenefitsmanagement.com to register. For more informationGo to providers.carelonmedicalbenefitsmanagement.com/cardiology for resources to help your practice get started with the Cardiology program. Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQs. We value your participation in our network and look forward to working with you to help improve the health of our members. * Carelon Medical Benefits Management, Inc. is an independent company providing administrative support services on behalf of the health plan. Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CM-028688-23- CPN28575 Effective for dates of service on and after November 5, 2023, the following updates will apply to the Carelon Medical Benefits Management, Inc.* Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management Guideline review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services. Joint surgery updates by section:- Multiple joints:
- Loose body — added indication for removal of loose body from shoulder and for removal of loose body or foreign body from the hip and the knee
- Synovectomy — added requirement for conservative management; added exclusion for traumatic reactive synovitis in shoulder, hip, and knee; added indications for both limited and extensive synovectomy in the knee
- Shoulder:
- Rotator cuff repair — modified diagnostic tests for full thickness rotator cuff tear; removed requirement for conservative management for high-grade partial thickness rotator cuff tear
- Revision rotator cuff repair — added exclusion for patients with rotator cuff arthropathy
- Labrum repair — broadened MRI findings to allow for any labral tear other than a Bankart lesion
- Adhesive capsulitis — extended required conservative management from six weeks to 12 weeks
- Capsulorraphy — added allowance for capsular redundancy with multidirectional instability; waived conservative management requirement in the setting of traumatic dislocation
- Subacromial decompression/acromioplasty — added indications for symptomatic os acromiale and for symptomatic mechanical impingement due to tumor or malunited fracture
- Shoulder debridement — extended required conservative management to 12 weeks
- Biceps tenodesis/tenotomy — broadened criteria to allow when criteria are met for any shoulder procedure or when patient has an acute proximal biceps tear
- Added exclusion for subacromial balloon spacer and for shoulder resurfacing
- Hip:
- Added indications for primary partial hip arthroplasty and partial or total hip resurfacing
- Revision total hip arthroplasty — added indication for elevated cobalt/chromium levels in patients with a metal-on-metal implant
- Acetabuloplasty — added indications for arthritis, hip instability, and FAIS
- Diagnostic arthroscopy — added exclusion for non-intra-articular hip procedures
- Femoroacetabular impingement syndrome (FAIS) — specified requirement for alpha angle greater than 55 degrees for femoroplasty
- Labral tear — added exclusion for hip arthroscopy for lavage and debridement in advanced osteoarthritis
- Added exclusion for debridement/chondroplasty when done solely for osteoarthritis and for labral repair in untreated severe hip dysplasia
- Knee:
- Total knee arthroplasty — added indication for post-traumatic arthritis; added unicompartmental damage to existing indications for partial joint damage
- Unicompartmental knee arthroplasty — modified requirements related to conservative management and varus/valgus deformities; allow concurrent anterior cruciate ligament (ACL) reconstruction in some scenarios
- Revision knee arthroplasty — added indication for reconstruction after post knee replacement infection; shortened conservative management requirement to six weeks for revision attributable to prior implants
- Abrasion arthroplasty/microfracture — aligned with osteochondral grafts criteria regarding the size of defect that can be treated
- Debridement/drainage/lavage (knee) — reduced conservative management requirement to six weeks for consistency with lysis of adhesions criteria
- Anterolateral ligament reconstruction or extra-articular tenodesis — added indications
- ACL reconstruction and posterior cruciate ligament (PCL) repair/reconstruction — excluded patients with advanced knee arthritis (Kellgren-Lawrence 4)
- Added indications for posterolateral corner injury and for collateral/extra-articular ligament injury
- Patellar compression syndrome — added exclusion for central or medial tracking of the patella
- Medial patellofemoral ligament reconstruction — waived requirement for conservative management when function is limited due to pain
- Osteochondral grafts:
- Patient selection requirements — specified that conservative management duration must be six weeks; waived this requirement when a symptomatic loose body is present
- Osteochondritis dissecans — added indications for surgical treatment
- Osteochondral allograft transplantation — decreased the minimum required size of the defect to 1.0 cm2 in the knee and in the talus; removed microfracture for defects in the knee
- Added exclusions for non-standard tissue bank methods and for use of larger allografts as an alternative to traditional total joint replacement
Level of care for musculoskeletal (MSK) surgery:- Added “total or partial primary shoulder arthroplasty” to ambulatory surgery center with 23-hour observation to address the addition of hemiarthroplasty and total shoulder arthroplasty
- CPT® codes added to level of care review: 23470 and 23472
As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways: - Access Carelon Medical Benefits Management’s ProviderPortalSM directly at 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.
- Via Availity Essentials* at availity.com.
If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CR-027336-23-CPN26944 Effective November 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield for Medicare 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. Non-compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): Code | Code description | 0377U | Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a lipoprotein profile | 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop | 0380U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and | 0687T | Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session | 0688T | Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report | 0704T | Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment | 0705T | Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hour | 0706T | Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month | 0778T | Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle | A2019 | Kerecis omega3 marigen shield, per square centimeter | A2020 | Ac5 advanced wound system (ac5) | A2021 | Neomatrix, per square centimeter | A4341 | Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each | A4342 | Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each | E1905 | Virtual reality cognitive behavioral therapy device (CBT), including pre-programmed therapy software | Q4265 | Neostim tl, per square centimeter | Q4266 | Neostim membrane, per square centimeter | Q4267 | Neostim dl, per square centimeter | Q4268 | Surgraft ft, per square centimeter | Q4269 | Surgraft xt, per square centimeter | Q4270 | Complete sl, per square centimeter | Q4271 | Complete ft, per square centimeter |
Not all PA requirements are listed here. Detailed PA requirements are available to providers at https://www.anthem.com/provider/news/archives/ > Providers > Claims > Prior Authorization or for contracted providers by accessing Availity.com.* UM AROW 4505
*Availity, LLC is an independent company providing administrative support services on behalf of the health plan. MULTI-BCBS-CR-028190-23-CPN27641 Prior authorization updates for medications billed under the medical benefit New effective dateThis collateral was posted on the provider portal on July 14, 2023, with an August 1, 2023, effective date. The new effective date will begin on October 1, 2023. Prior authorization updatesEffective for dates of service on and after October 1, 2023, the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization. Please note, inclusion of a national drug code on your medical claim is necessary for claims processing. Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below. Clinical Criteria | HCPCS or CPT® code(s) | Drug name | CC-0072 | Q5129 | Vegzelma (bevacizumab-adcd) | CC-0107 | Q5129 | Vegzelma (bevacizumab-adcd) |
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Step therapy updatesEffective for dates of service on and after October 1, 2023, the following specialty pharmacy code from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon prior authorization initiation or renewal in addition to the current medical necessity review of the drugs noted below. Clinical Criteria | Status | Drug(s) | HCPCS codes | CC-0107 | Preferred | Mvasi | Q5107 | CC-0107 | Non-preferred | Avastin | J9035 | CC-0107 | Non-preferred | Alymsys | Q5126 | CC-0107 | Non-preferred | Vegzelma | Q5129 | CC-0107 | Non-preferred | Zirabev | Q5118 |
We look forward to working together to achieve improved outcomes. What if I need assistance?If you have questions about this communication or need assistance with any other item, contact your local Provider Relationship Management representative or call Provider Services at 844-912-1226. OHBCBS-CD-028771-23-CPN28730, OHBCBS-CD-037133-23-CPN37051 Effective September 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield for Ohio Medicaid Managed Care 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. Non-compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): Code | Code description | 81324 | PMP22 (peripheral myelin protein 22) (such as Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis | 81325 | PMP22 (peripheral myelin protein 22) (such as Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis | 81326 | PMP22 (peripheral myelin protein 22) (such as Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant |
To request PA, you may use one of the following methods: - Web: Once logged in to Availity* at availity.com.
- Fax: Physical health 877-643-0672 or 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/ohio-provider/communications/updates on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 844-912-1226 for assistance with PA. UM AROW 4073
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. OHBCBS-CD-027264-23 Effective August 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield for Ohio Medicaid Managed Care members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services (CMS) guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims. Prior authorization requirements will be added for the following code(s): Code | Description | 81309 | PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic subunit alpha) (such as, colorectal and breast cancer) gene analysis, targeted sequence analysis (such as, exons 7, 9, 20) |
To request PA, you may use one of the following methods: - Web: Once logged in to Availity* at availity.com.
- Fax: 877-643-0672 (Physical Health)
- Fax: 866-577-2183 (Behavioral Health)
- Phone: 800-601-9935
Not all PA requirements are listed here. Detailed PA requirements are available to providers on the provider website at https://providers.anthem.com/oh > Log in on the Resources tab or for contracted providers by accessing availity.com. Providers may also call Provider Services at 844-912-1226 for assistance with PA requirements. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan.
UM AROW 3959 OHBCBS-CD-025703-23 Policy Update
Robotic Assisted Surgery(Policy G-10004, effective 11/01/2023) Beginning with dates of service on or after November 1, 2023, Robotic Assisted Surgery reimbursement policy for Anthem Blue Cross and Blue Shield will expand to include CPT® codes for computer-assisted surgical systems. This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure, and are not separately reimbursed. The Related Coding section of the policy has been updated to include the following computer assisted surgical musculoskeletal navigation procedures: - 0054T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (list separately in addition to code for primary procedure)
- 0055T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (list separately in addition to code for primary procedure)
The policy has been renamed to Technology Assisted Surgical Procedures which defines both robotic assisted and computer assisted techniques. For additional information, please review the Technology Assisted Surgical Procedures reimbursement policy at https://providers.anthem.com/oh. OHBCBS-CD-023733-23-CPN22827 InformationalRobotic Assisted Surgery(Policy G-10004, effective 09/01/2023) Effective September 1, 2023, the Robotic Assisted Surgery reimbursement policy with Anthem Blue Cross and Blue Shield will expand to include the computer-assisted surgical systems. This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure and are not separately reimbursed. The policy has been renamed to Technology Assisted Surgical Procedures defines both robotic assisted and computer assisted techniques. For additional information, please review the Technology Assisted Surgical Procedures reimbursement policy at https://www.anthem.com/medicareprovider. MULTI-BCBS-CR-023736-23-CPN22827 Pharmacy | Commercial | August 1, 2023 Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements Specialty pharmacy updates - August 2023Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below. Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.* Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications. Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code. Prior authorization updatesEffective for dates of service on and after November 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process. Access our Clinical Criteria to view the complete information for these prior authorization updates. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0237 | Qalsody (tofersen) | J3490, J3590 | CC-0240* | Zynyz (retifanlimab-dlwr) | J9999 |
* Oncology use is managed by Carelon Medical Benefits Management. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Step therapy updates We are excited to announce the publication of a Medical Step Therapy Drug List. This list serves as an easy to access reference of the preferred and non-preferred products for each of the specialty pharmacy step therapy categories. The link to the pdf document is on the Clinical Criteria homepage. Access our Clinical Criteria to view the Medical Step Therapy Drug List. Quantity limit updatesEffective for dates of service on and after November 1, 2023, 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-0237 | Qalsody (tofersen) | J3490, J3590 | CC-0240 | Zynyz (retifanlimab-dlwr) | J9999 |
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-030324-23-CPN29780 Pharmacy | Commercial | August 1, 2023 Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements Specialty pharmacy updates - August 2023This article originally published with October 1, 2023 effective date in error. This requirement will not go into effect until December 1, 2023. Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below. Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.,* a separate company. Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications. Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code. Prior authorization updatesEffective for dates of service on and after December 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process. Note: On April 6, 2023, the FDA announced its decision to withdraw approval of Makena and generic versions of Makena for reducing the risk of pre-term birth because these drugs are no longer shown to be effective. Access our Clinical Criteria to view the complete information for these site of prior authorization updates. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0238* | hydroxyprogesterone caproate | J1729 |
* Oncology use is managed by Carelon Medical Benefits Management. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. * Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. MULTI-BCBS-CM-027440-23-CPN27209 Effective for dates of service on and after September 1, 2023, the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization. Inclusion of a national drug code on your medical claim is necessary for claims processing. Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below. Clinical Criteria | HCPCS code | Drug name | CC-0072 | Q5124 | Byooviz (ranibizumab-nuna) | CC-0072 | Q5128 | Cimerli (ranibizumab-cqrn) | CC-0002 | Q5130 | Fylnetra (pegfilgrastim-pbbk) | CC-0002 | J1449 | Rolvedon (eflapegrastim-xnst) | CC-0002 | Q5127 | Stimufend (pegfilgrastim-fpgk) |
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Step therapy updatesEffective for dates of service on and after September 1, 2023, the following specialty pharmacy code from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon prior authorization initiation or renewal in addition to the current medical necessity review of the drugs noted below. What if I need assistance?If you have questions about this communication or need assistance with any other item, contact your local Provider Relationship Management representative or call Provider Services at 844-912-1226. Visit the Drug Lists page on our provider website at https://www.anthem.com/ms/pharmacyinformation/home.html for more information about: - Copayment/coinsurance requirements and their applicable drug classes.
- Drug lists and changes.
- Prior authorization criteria.
- Procedures for generic substitution.
- Therapeutic interchange.
- Step therapy or other management methods subject to prescribing decisions.
- Any other requirements, restrictions, or limitations that apply to using certain drugs.
The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October. To locate the exchange, select Formulary and Pharmacy Information, and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed. Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. Did you know?For most conditions, medications need to be taken 80% or more of the time to see an improvement in clinical outcomes such as blood pressure, blood glucose, or cholesterol control. Knowing this, it’s not surprising there is a strong emphasis on medication adherence and proportion of days covered (PDC) for the medication adherence quality measures. Medications are the primary intervention in treating and preventing disease and require patients to take medications long term. Unrecognized non-adherence can lead to dose escalation or additional medication therapy, potentially leading to an increase in adverse events. In addition, not adherence leads to increased medical utilization and morbidity and mortality. Back to the basics: How can we close the adherence gap?- Know which patients are at risk for non-adherence:
- Cognitive Impairment
- Fear of side effects
- Too many medications
- History of non-adherence
- Lack of perceived benefit
- Confusion
- Transportation
- Cost
Consider medication non-adherence as a reason when a patient’s condition is not under control.
- Implement a standardized process to identify patients with non-adherence:
- Ask about adherence at every appointment.
- Incorporate patient questionnaires or targeted questions using open ended questions into existing workflows.
- Analyze non-adherence reporting or claims to identify patients.
- Together with the patient, tailor the solution to the patient’s needs or concerns:
- Simplify the medication regimen.
- Always educate patients on benefits and risks of taking or not taking their medications.
- Leverage real-time prescription benefit to select lower cost and formulary medications during the electronic prescribing process.
- Encourage CarelonRx, Inc.* Mail and prescribe extended day supply to prevent refill gaps, avoid long waits at the pharmacy, and minimize transportation barriers.
* CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan.
References:
- Brown M, Sinsky CA. Medication Adherence. Improve Patient Outcomes and Reduce Costs. American Medical Association Steps Forward. 5 June 2015.https://edhub.ama-assn.org/steps-forward/module/2702595. Accessed 16 May 2023
- Eight reasons patients don’t take their medications. American Medication Association. Feb 22, 2023. Accessed May 17, 2023.https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications
- El Halabi J, Minteer W, Boehmer KR. Identifying and Managing Treatment Nonadherence. Medical Clinics of North America. 2022;106(4):615-626. doi:https://doi.org/10.1016/j.mcna.2022.02.003
- Gooptu A, Taitel M, Laiteerapong N, Press VG. Association between Medication Non-Adherence and Increases in Hypertension and Type 2 Diabetes Medications. Healthcare (Basel). 2021 Jul 31;9(8):976. doi: 10.3390/healthcare9080976..
- Kini V, Ho PM. Interventions to Improve Medication Adherence. JAMA. 2018;320(23):2461. doi: https://doi.org/10.1001/jama.2018.19271
MULTI-BCBS-CR-027442-23-CPN27258 Why it matters:- Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in individuals with diabetes.
- The 2019 ACC/AHA* guidelines recommend statin therapy for primary prevention of ASCVD in patients with diabetes mellitus, aged 40 to 75 years, regardless of estimated 10-year ASCVD risk.
- Statins are generally well-tolerated and safe drugs.
- Benefits of lowering LDL-C with statins far outweigh the likelihood of an adverse effect for most adults at elevated risk for ASCVD and secondary events.
* ACC/AHA- American College of Cardiology and American Heart Association Did you know? - Just over 50% of US adults who would benefit from cholesterol-lowering medications are taking them.
- Reducing LDL-C levels with statins by ~39 mg/dL can reduce heart disease and stroke risk by ~21%
Best practices:- Educate patients on increased risk of cardiovascular disease to understand the benefits of statins.
- Once stable on therapy, prescribe 90-day supply to prevent refill gaps in therapy.
- Consider home delivery through *CarelonRx Mail to avoid long waits at the pharmacy and minimize transportation barriers.
- If statin side effects occur, consider strategies to mitigate them while continuing a statin:
- Lower the dose.
- Intermittent dosing with rosuvastatin may benefit patients with previous statin intolerances.
- Try a brief period of discontinuation, then re-challenge with the same or different statin.
Statin formulary medications Statin therapy intensity | Drug name | Dosage | Low-intensity statin therapy | lovastatin | 20 mg | pravastatin | 10 mg to 20 mg | simvastatin | 10 mg | Moderate-intensity statin therapy | atorvastatin | 10 mg to 20 mg | rosuvastatin | 5 mg to 10 mg | simvastatin | 20 mg to 40 mg | pravastatin | 40 mg to 80 mg | lovastatin | 40 mg | High-intensity statin therapy | atorvastatin | 40 mg to 80 mg | rosuvastatin | 20 mg to 40 mg |
Note: Both pitavastatin (Livalo) 1 to 4 mg and fluvastatin 40 mg BID qualify as moderate-intensity; however, Livalo is non-formulary and fluvastatin is a more expensive agent with member copay (Tier 3 or 4). * CarelonRx, Inc. is an independent company providing pharmacy services on behalf of the health plan.
References:
- American Heart Association: 2021 heart disease and stroke statistics update fact sheet. Accessed 5/8/2023. https://www.heart.org/-/media/PHD-Files-2/Science-News/2/2021-Heart-and-Stroke-Stat-Update/2021_heart_disease_and_stroke_statistics_update_fact_sheet_at_a_glance.pdf
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140(11). doi:https://doi.org/10.1161/cir.0000000000000678
- Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. The Lancet. 2016;388(10059):2532-2561. doi:https://doi.org/10.1016/s0140-6736(16)31357-5
- ElSayed NA, Aleppo G, Aroda VR, et al. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2023. Diabetes Care. 2022;46(Supplement_1):S158-S190. doi:https://doi.org/10.2337/dc23-s010
- Hla D, Jones R, Blumenthal RS, et al. Assessing severity of statin side effects: Fact vs fiction. American College of Cardiology. April 09, 2018. Accessed May 17, 2023. https://www.acc.org/latest-in-cardiology/articles/2018/04/09/13/25/assessing-severity-of-statin-side-effects
- Reston JT, Buelt A, Donahue MP, Neubauer B, Vagichev E, McShea K. Interventions to Improve Statin Tolerance and Adherence in Patients at Risk for Cardiovascular Disease. Annals of Internal Medicine. 2020;173(10):806-812. doi:https://doi.org/10.7326/m20-4680
MULTI-BCBS-CR-026506-23-CPN26142 Anthem Blue Cross and Blue Shield is committed to ensuring all of our members have controlled blood pressure. We’re encouraging you to recheck any elevated readings taken at the start of the appointment and again before the patient leaves, in hopes of obtaining a reading of less than 140/90 mmHg. If the second reading continues to be elevated, have the member return in a few weeks for a blood pressure recheck. We’ve created a guide to help incorporate this practice into your office’s daily workflow with minimal disruption to your day. You can find the Healthy Blood Pressure Recheck Guide here. Please join us in making 2023 our members’ happiest and healthiest year yet! MULTI-BCBS-CR-023986-23-CPN23630 Anthem Blue Cross and Blue Shield is committed to ensuring all of our members have controlled blood pressure. We’re encouraging you to recheck any elevated readings taken at the start of the appointment and again before the patient leaves, in hopes of obtaining a reading of less than 140/90 mmHg. If the second reading continues to be elevated, have the member return in a few weeks for a blood pressure recheck. We’ve created a guide to help incorporate this practice into your office’s daily workflow with minimal disruption to your day. You can find the Healthy Blood Pressure Recheck Guide here. Please join us in making 2023 our members’ happiest and healthiest year yet! MULTI-BCBS-CR-023986-23-CPN23630 Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision-makers to encourage decisions resulting in underutilization. Our Medical Policies and UM Criteria are online at Home | Anthem Blue Cross and Blue Shield, or you can request a free copy of our UM Criteria by contacting the Medical Management department at 844-912-1226 or by emailing Anthem Blue Cross and Blue Shield (Anthem) at ohiomedicaidprovider@anthem.com. Within seven calendar days of the date of denial, providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at 833-308-3035. We are staffed with appropriately qualified UM clinical professionals who are available by telephone from 8 a.m. to 5 p.m. ET, Monday through Friday, (except for the major holidays and two optional closure days, as required by contract) to coordinate our members’ care and render UM decisions for providers. Our UM review staff is available by telephone 24/7 to respond to authorization requests for inpatient admissions. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and being with Anthem when initiating or returning calls regarding UM issues. Please submit prior authorization requests, clinical information, and the member’s discharge date via Availity* at availity.com or fax to: - Inpatient authorization fax numbers:
- 877-643-0671 (Physical health)
- 866-577-2184 (Behavioral health)
- Outpatient authorization fax numbers:
- 877-643-0672 (Physical health)
- 866-577-2183 (Behavioral health)
To expedite your request, use our prior authorization template form located here. Have questions about utilization decisions or the UM process?Call our clinical team at 844-912-1226, Monday through Friday from 7 a.m. to 8 p.m. ET. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. OHBCBS-CD-022724-23-SRS22705 Anthem Blue Cross and Blue Shield (Anthem) is committed to complying with all federal and state laws related to member rights, and we ensure that our employees, contractors, and providers adhere to these laws when providing services to members. In line with our commitment to participating practitioners and members, Anthem has included a Members’ Rights and Responsibilities statement within the provider manual and on the provider website. Delivering quality healthcare requires collaboration and a mutually respectful relationship between patients, their providers, and their healthcare benefit plans. One of the first steps towards achieving this goal is for patients and providers to establish a clear understanding of their respective rights and responsibilities in the delivery of healthcare services. To learn more, please review the information provided in Chapter 5: Member Eligibility/Rights and Responsibilities section of your provider manual, which can be found here: Provider Manual. Or you may review it online here: https://bit.ly/3NUjo1b. OHBCBS-CD-022723-23-SRS22705 Managing illness can be a daunting task for our members. It is not always easy to understand test results, how to obtain essential resources for treatment, or know who to contact with questions and concerns. Anthem Blue Cross and Blue Shield is available to offer assistance in these difficult moments with our Complex Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members, families, PCPs, and caregivers. In addition, the Complex Case Management process uses the experience and expertise of the case management team to educate and empower our members by increasing self-management skills. Our complex case managers can help to find services and resources to assist eligible members with chronic conditions that may involve social drivers of health. Our case managers direct members to community resources and make referrals when possible. The Complex Case Management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare. Members or caregivers can refer themselves or family members by calling the Member Services number located on the back of their ID card. They will be transferred to a team member based on the immediate need. For example, a member newly diagnosed with diabetes will receive assistance from our diabetic complex case manager, who will help them find diabetic resources available in their community. Providers can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals. Members can opt in and opt out of the case management program at any time. You can contact us by email at Condition-Care-Provider-Referrals@anthem.com or by phone at 888-830-4300 Monday through Friday from 8:30 a.m. to 5:30 p.m. ET, except on holidays. OHBCBS-CD-022705-23-SRS22705 Pharmacotherapy Management of COPD Exacerbation HEDIS measure Healthcare Effectiveness Data Information Set (HEDIS®) is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). These are used to drive improvement efforts surrounding best practices. The Pharmacotherapy Management of COPD Exacerbation (PCE) measure assesses chronic obstructive pulmonary disease (COPD) exacerbations for adults 40 years of age and older who had appropriate medication therapy to manage an exacerbation. A COPD exacerbation is defined as an acute inpatient discharge or emergency department visit with a primary discharge diagnosis of COPD. Two rates are reported: - Dispensed a systemic corticosteroid (or there is evidence of an active prescription) within 14 days of the event
- Dispensed a bronchodilator (or there is evidence of an active prescription) within 30 days of the event1
COPD is a debilitating lung condition that affects one in eight Americans age 45 and older. More than 16 million Americans have been diagnosed with COPD, and millions more have it without knowing. 2 COPD exacerbations make up a significant portion of the costs associated with the disease. Appropriate prescribing of medication following exacerbation can prevent future flare-ups, improve health outcomes, and reduce the healthcare burden of COPD.3 Who has COPD?4Prevalence by ethnicity | 12% American Indians and Alaska Natives | 7% Non-Hispanic Blacks | 7% Whites | 4% Hispanics | 3% Native Hawaiian/Pacific Islander | 2% Asians |
COPD action plan A COPD action plan is a personalized patient tool that includes the important steps to help manage COPD. It allows patients to track how they are doing and note any concerns to discuss with their provider. It addresses medications, exercise, diet, and avoidance of triggers, such as tobacco products and other inhaled irritants. The plan should be discussed at each visit and updated as needed.5 HEDIS helpful tips:- Schedule a follow-up appointment after discharge and confirm that the patient has the appropriate medications.
- Reconcile patients’ medications with those prescribed at discharge when you receive the discharge summary.
- Ask the patient if they have any barriers that prevent them from filling their prescriptions.
- Assure patients with COPD are up to date on their vaccinations, including flu, pneumococcal, and COVID-19.
- Provide a COPD action plan for the patient, including daily medications, trigger avoidance, and what to do when flare-ups do occur:
Resources: - NCQA. Pharmacotherapy Management of COPD Exacerbation. Pharmacotherapy Management of COPD Exacerbation - NCQA
- National Heart, Lung and Blood Institute. COPD National Action Plan. https://tinyurl.com/4sphb6fy
- Pasquale, M.K., S.X. Sun, F. Song, H.J. Hartnett, and S.A. Stemkowski. Impact of exacerbations on health care cost and resource utilization in chronic obstructive pulmonary disease patients with chronic bronchitis from a predominantly Medicare population. International Journal of COPD 7:757-64. doi: 10.2147/COPD.S36997. https://tinyurl.com/yma3yt7r
- Chronic Obstructive Pulmonary Disease and Smoking Status— United States, 2017, Morbidity and Mortality Weekly Report (MMWR),68(24), pp. 533-538 (June 21, 2019), Centers for Disease Control and Prevention (CDC).
- American Lung Association. COPD Action Plan & Management Tools. American Lung Association COPD Action Plan & Management Tools
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). OHBCBS-CDCRCM-026835-23-CPN26072 The problemIn 2021, there were 2855 cases of congenital syphilis reported for a rate of 77.9 per 100,000 live births. From 2012 to 2021, the number of cases of congenital syphilis increased 754.8% (334 to 2855 cases), concurrent with a 676.2% increase (2.1 to 16.3 per 100,000 lives) in the rate of primary and secondary syphilis among women aged 15 to 44 years.1 Maternal syphilis is associated with a 21% increased risk for stillbirth, 6% increased risk for preterm delivery, and 9% increased risk for neonatal death.2 Optimal treatment of syphilis during pregnancy is estimated to reduce the risk of congenital syphilis by 98%, stillbirth by 82%, preterm birth by 64%, and neonatal mortality by 80%.3 Syphilis is treatable and curable with penicillin. One in two newborn syphilis cases in the United States occur due to gaps in testing and treatment during prenatal care.3 Congenital syphilis: missed prevention opportunities1
You can make a difference — screen appropriately2 and treat early4!Universal screening: All pregnant women at their first prenatal visit. Treat immediately. High risk screening: Twice in third trimester (28 weeks and at delivery). Ask, document, rescreen: - History of sex with multiple partners
- Sex in conjunction with drug use or transactional sex
- No prenatal care or late entry
- Methamphetamine or heroin use
- Unstable housing or homelessness
- Incarceration of the woman or her partner
- Prior syphilis diagnosis
High prevalence screening: Twice in third trimester (28 weeks and at delivery) for pregnant women who live in communities with high rates of syphilis. For more information, visit https://gis.cdc.gov/grasp/nchhstpatlas/maps.html. Do you know the law in your state? Check your state health department website for updated recommendations. Do you practice in a high prevalence area? Universal screening in the third trimester and at birth are recommended. 1 Centers for Disease Control and Prevention. 2021.Sexually Transmitted Disease Surveillance, 2021 (cdc.gov)cdc.gov/std/statistics/2021/default.htm.
2 Adhikari, Emily H. MD. Syphilis in Pregnancy. Obstetrics & Gynecology 135(5): p1121-1135, May 2020.
3 U.S. Department of Health and Human Services. 2020. Sexually Transmitted Infections National Strategic Plan for the United States: 2021–2025. Washington, DC.
4 Centers for Disease Control and Prevention. 2021.Syphilis - STI Treatment Guidelines (cdc.gov)cdc.gov/std/treatmentguidelines/syphilis.htm. OHBCBS-CDCM-025845-23-CPN25643 |