 Provider News OhioFebruary 2020 Anthem Provider News - OhioMaterial Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements starred (*) below.
- Clinical Laboratory Improvements Amendments*
- Medical Policy and Clinical Guidelines Updates – February 2020*
- Updates to AIM Advanced Imaging Clinical Appropriateness Guidelines*
- Updates to AIM Musculoskeletal Program Clinical Appropriateness Guidelines*
Other Important Updates
- Medicare and Medicaid News
Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments (CLIA) 1988 federal statute and regulations require additional information to be considered for payment.
Beginning May 1, 2020, a valid CLIA Certificate Identification number is required for reimbursement of clinical laboratory services reported on a CMS-1500 claim form (or its electronic equivalent). The CLIA Certificate Identification number must be submitted in one of the following ways:
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Claim Format and Elements
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CLIA Number Location Options
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Referring Provider Name and National Provider Identifier (NPI) Number Location Options
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CMS-1500
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Must be represented in field 23
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Submit the referring provider name and NPI number in fields 17 and 17b, respectively.
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Electronic transaction 837 Professional; Health Insurance Portability and Accountability Act (HIPAA) Version 5010
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Must be represented in the 2300 loop, REF02 element, with qualifier of “X4” in REF01
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Submit the referring provider name and NPI number in the 2310A loop, NM1 segment.
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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 in order for the procedure to be evaluated to determine eligibility for benefit coverage.
Laboratory procedures are only covered and therefore payable if rendered by an appropriately licensed or certified laboratory. Therefore, any claim that does not contain the CLIA ID will be considered incomplete and rejected beginning May 1, 2020.
If you have additional questions, please call the telephone number on the back of the member’s identification card.
* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements. Anthem Commercial Risk Adjustment (CRA) contracts with Inovalon -- an independent company that provides secure, clinical documentation services -- to help us comply with provisions of the Affordable Care Act (ACA) that require us to assess members’ relative health risk level and report to CMS on those conditions. Your offices have been receiving Inovalon SOAP ( Subjective; Objective; Assessment; and Plan – these are health assessments) packets all year long as part of our risk adjustment cycle, asking for the physicians’ help with completing health assessments for some of their patients who are our members.
Incentives for submitting SOAP’s/Health Assessments
SOAPs submitted as paper are eligible for a $50 incentive; SOAPs submitted electronically through Inovalon’s ePASS system are eligible for a $100 incentive.
Submission Deadline and Important Reminder
While the dates of service for the patient visits must have been by December 31, 2019, the SOAP notes/Health Assessments can be submitted up until February 15, 2020. We will still pay the incentive payments for these submissions through February 15, 2020.
Questions or assistance with SOAPs
Need help with ePASS or have questions? Simply email your inquiry to Inovalon at ePASSsupport@inovalon.com with your name, organization, contact information, and any questions that you might have. Trained representatives are available to assist you. If you prefer to reach Inovalon by phone, please call 1-877-448-8125, Monday - Friday, 8 am - 9 pm ET; Saturday - Sunday, 10 am - 6 pm ET.
If you have any questions regarding our risk adjustment process, please contact our CRA Network Education Representative who supports your area, Mary.Swanson@anthem.com.
Anthem Blue Cross and Blue Shield’s parent company is collaborating with leading organizations on a new school-based initiative called Shine Light on Depression to help tackle the issue of teen depression and suicide in middle and high school youth nationwide. The Shine Light on Depression e-toolkit (e.g., website) will provide school communities with free, ready-to-use tools designed to raise awareness of depression and suicide prevention in a positive, fact-based, and inclusive manner. This approach will help build a community in which there is open discussion and appropriate vocabulary about the subject of depression and places it in the broader context of good mental health. The e-toolkit features customizable classroom lessons to empower educators to lead effective depression awareness programs, family-community workshop materials to help adults and families talk about how to support teens, and teen club resources that empower students to lead activities and help each other by talking and listening. With 24,053 secondary schools in the U.S., the Shine Light on Depression e-toolkit has the potential to impact large numbers of individuals who are at risk of depression and suicide and support schools in meeting state teaching mandates. Visit Shine Light on Depression to learn more.
Shine Light on Depression is a unique collaboration of organizations committed to raising awareness of depression and suicide prevention among young people: American School Health Association, Anthem, Inc., Erika’s Lighthouse, JetBlue Airways Corporation, and the National Parent Teachers Association.
The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on November 7, 2019 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.
Below are new medical policies and/or clinical guidelines.
NOTE *Precertification required
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Title
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Information
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Effective Date
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*GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
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• Outlines the Medical Necessity (MN) and Investigational and Not Medically Necessary (INV&NMN) criteria for whole genome sequencing, whole exome sequencing, gene panels, and molecular profiling
• Incorporated whole genome sequencing, whole exome sequencing, gene panel testing, and molecular profiling into single document
• Contains content from all other documents regarding whole genome/whole exome/mitochondrial DNA testing, all panel tests (defined as 5 or more genes, or gene mutation variants, same day, same member, same rendering provider) and molecular profiling:
o GENE.00001 Genetic Testing for Cancer Susceptibility
o GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
o GENE.00025 Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies
o GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility
o GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome
o GENE.00030 Genetic Testing for Endocrine Gland Cancer Susceptibility
o GENE.00035 Genetic Testing for TP53 Mutations
o GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases
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5/1/2020
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The below current Clinical Guidelines and/or Medical policies were reviewed and updates were approved.
NOTE *Precertification required
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Title
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Change
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Effective date
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*CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
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• Content moved from GENE.00001
• INV&NMN changed to NMN as a result of MP to CUMG transition
• Revised title
• Limited scope to gene mutation testing for solid tumor cancer susceptibility and management
• Added criteria for gene mutation testing to guide targeted cancer therapy in individuals with solid tumors
• Removed genetic panel testing from document.
Moved all codes except panel codes to this document with no changes; added codes 81307, 81308, 81403, 81408 and additional genes to other Tier 2 codes to pend for MN criteria; added 81242 as NMN for this indication.
WHOLE GENOME, WHOLE EXOME & GENE PANEL TESTING MOVED TO GENE.00052
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2/5/2020
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*CG-GENE-13 Genetic Testing for Inherited Diseases
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• Content moved from GENE.00012 & GENE.00043
• INV&NMN changed to NMN as a result of MP to CUMG transition
• Title revised
• Removed whole genome, whole exome, and gene panel testing from document
• No other change to clinical indications
Moved all codes except whole genome/exome and panel codes to this document with no changes; added codes 81171, 81172, 81243, 81244 and Tier 2 genes previously addressed in CG-BEH-01 with no change; removed 0136U (not applicable)
WHOLE GENOME, WHOLE EXOME, & GENE PANELS MOVED TO GENE.00052
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2/5/2020
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*CG-GENE-20 Epidermal Growth Factor Receptor (EGFR) Testing
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• Content moved from GENE.00006
• INV&NMN changed to NMN as a result of MP to CUMG transition
• Removed acronym and made minor wording change in Clinical Indications section
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2/5/2020
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*CG-GENE-15 Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis
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• Content moved from GENE.00028
• INV&NMN changed to NMN as a result of MP to CUMG transition
• Revised title
• Removed genetic panel testing from document.
GENE PANEL TESTING MOVED TO GENE.00052
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2/5/2020
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*CG-GENE-16 BRCA Testing for Breast and/or Ovarian Cancer Syndrome
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• Content moved from GENE.00029
• INV&NMN changed to NMN as a result of MP to CUMG transition
• Revised title
• Revised Clinical Indications to include recommendations from the USPSTF
• Added Note to refer to the NCCN testing criteria and BRCA1 or BRCA2 mutation assessment tools listed in the Discussion/General Information section
• Removed gene panel testing from document.
GENE PANEL TESTING MOVED TO GENE.00052
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2/5/2020
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*CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility
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• Content moved from GENE.00030
• INV&NMN changed to NMN as a result of MP to CUMG transition
• Revised title
• Removed gene panel testing from document.
GENE PANEL TESTING MOVED TO GENE.00052
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2/5/2020
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*CG-GENE-18 Genetic Testing for TP53 Mutations
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• Content moved from GENE.00035
• INV&NMN changed to NMN as a result of MP to CUMG transition
• Removed gene panel testing from document
GENE PANEL TESTING MOVED TO GENE.00052
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2/5/2020
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*CG-GENE-19 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
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• Content moved from GENE.00045
• INV&NMN changed to NMN as a result of MP to CUMG transition
• Clarified that “minimal residual disease” is also referred to as “measurable residual disease” in MN criteria
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2/5/2020
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CG-SURG-105 Corneal Collagen Cross-Linking
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• Content moved from MED.00109
• INV&NMN changed to NMN as a result of MP to CUMG transition
• Clarified MN criteria addressing the time of diagnosis of progressive keratoconus ("over 24 consecutive months" changed to "within 24 months")
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2/5/2020
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CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
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• Content moved from RAD.00023
• INV&NMN changed to NMN as a result of MP to CUMG transition
• No other change to clinical indications
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2/5/2020
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*CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
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• Content moved from SURG.00122
• INV&NMN changed to NMN as a result of MP to CUMG transition
• No other change to clinical indications
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2/5/2020
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*SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
Previous title: Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions
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• Revised title
• Revised scope of document to only address benign prostatic hyperplasia (BPH)
• Combined surgical and minimally invasive treatments into one MN section
• Revised MN criteria for transurethral incision of the prostate by adding "prostate volume less the 30 mL
• Added transurethral convective water vapor thermal ablation in individuals with prostate volume less than 80 mL as MN indication
• Added waterjet tissue ablation as MN indication
• Moved transurethral radiofrequency needle ablation from MN to NMN section
• Changed INV&NMN indications to NMN
• Moved placement of prostatic stents from standalone statement to combined NMN statement
• Added 0421T, XV508A4 for AquaBeam waterjet as MN; changed TUIP 52450 and Rezum water vapor 53854 to pend for MN criteria; WIT 53899 (NOC) and RFNA 53852 changed to NMN; scope limited to specific BPH and related diagnosis codes
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5/1/2020
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*SURG.00037 Treatment of Varicose Veins (Lower Extremities)
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• Added the anterior accessory great saphenous vein (AAGSV) as MN for ablation techniques when criteria are met
• Added language to the MN criteria for ablation techniques addressing variant anatomy
• Added limits to retreatment to the MN criteria for all procedures
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5/1/2020
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SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
Previous title: Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
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• Revised title
• Expanded scope to include gastroparesis
• Added gastric peroral endoscopic myotomy or peroral pyloromyotomy as INV&NMN.
• Added CPT 43999 (NOC) and ICD-10-PCS 0D878ZZ for G-POEM, considered INV&NMN
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5/1/2020
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SURG.00097 Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
Previous title: Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
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• Revised title
• Expanded scope of document to include vertebral body tethering
• Added vertebral body tethering as INV&NMN
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5/1/2020
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*New prior authorization requirements for providers may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.
Effective for dates of service on and after May 17, 2020, the following updates will apply to the AIM Advanced Imaging: Vascular Imaging Clinical Appropriateness Guidelines.
Updates by section:
- Aneurysm of the abdominal aorta or iliac arteries
- Added new indication for asymptomatic enlargement by imaging
- Clarified surveillance intervals for stable aneurysms as follows:
- Treated with endografts, annually
- Treated with open surgical repair, every 5 years
- Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified
- Added surveillance indication and interval for surgical bypass grafts
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’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.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 800-554-0580, Monday–Friday, 8:30 a.m.–7:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements. Effective for dates of service on and after May 17, 2020, the following updates will apply to the AIM Musculoskeletal Program: Joint Surgery and Spine Surgery Clinical Appropriateness Guidelines.
Joint Surgery Updates by section:
- Shoulder Arthroplasty
- Added steroid injection for all joints exclusion based on panel recommendation
- Added exclusions for use of xenografts or biologic scaffold for augmentation or bridging reconstruction, use of platelet rich plasma or other biologics and concomitant subacromial decompression
- Removed indication for subacromial impingement with rotator cuff tear
- Hip arthroplasty
- Added exclusion for steroid injection for joint being replaced within the past 6 weeks
- Added labral tear indication
- Knee Arthroscopy and Open Procedures
- Added chondroplasty indication
- Narrowed use of lateral release to lateral compression as a cause for anterior knee pain or chondromalacia patella
- Added a conservative management and advanced osteoarthritis exclusion to patellar compression syndrome section
- Code changes
- Added CPT codes 27425, 27570
Spine Surgery Updates by section:
- No criteria changes
- Code changes only
- Added CPT codes 0200T, 0201T
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’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.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 800-554-0580, Monday–Friday, 8:30 a.m. – 7:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.
Effective with dates of service on and after April 1, 2020, and in accordance with the IngenioRx Pharmacy and Therapeutic (P&T) process, Anthem Blue Cross and Blue Shield (Anthem) will update its drug lists that support commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes here.
IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield. Category: Medicare
CMS requires that all hospitals and critical access hospitals (CAHs) provide written notification and an oral explanation to individuals receiving observation services as outpatients for more than 24 hours.
Hospitals should use the OMB-approved standardized Medicare Outpatient Observation Notice (MOON), form CMS-10611. All hospitals and CAHs are still required to provide this statutorily required notification. The notice and accompanying instructions are available at https://go.cms.gov/391jZH9.
The MOON was developed to inform all Medicare beneficiaries, including Anthem Blue Cross and Blue Shield members, when they are an outpatient receiving observation services, and are not an inpatient of the hospital or CAH. The notice must include the reasons the individual is an outpatient receiving observation services and the implications of receiving outpatient services, such as required Medicare cost-sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility services.
Hospitals and CAHs must deliver the notice no later than 36 hours after observation services are initiated or sooner if the individual is transferred, discharged or admitted.
506979MUPENMUB
Category: Medicare
Effective May 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) has updated the Modifier 62: Co‑Surgeons reimbursement policy to expand the current policy’s language, adding that Anthem does not consider surgeons performing different procedures during the same surgical session as co-surgeons, and Modifier 62 is not required.
Assistant surgeon and/or multiple procedures rules and fee reductions apply if a co-surgeon acts as an assistant in performing additional procedure(s) during the same surgical session.
Please note that assistant surgeon rules do not apply to procedures appropriately billed with Modifier 62.
Please visit www.anthem.com/medicareprovider to view the Modifier 62: Co-Surgeons reimbursement policy for additional information regarding percentages and reimbursement criteria.
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