 Provider News OhioMarch 1, 2025 March 2025 Provider Newsletter Contents Medical Policy & Clinical Guidelines | Commercial | February 18, 2025 Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements MCG Care Guidelines 29th edition
OHBCBS-CDCRCM-078142-25 , CPN78072 
What are three things everyone should know about you?I am a born Ohioan and have lived in Ohio most of my adult life. Southwestern Ohio is where the majority of my children and now grandchildren live and go to school. I am married to an Air Force Veteran and have been happily married for the past 20 years. Together we have five children and 12 grandchildren. I love traveling to any new destination and enjoying my time with my family. One of my favorite things is having everyone together for a game night or doing something fun with them such as Kings Island, swimming, playing outside, or roller skating. I also love to make gifts for my family and friends. I enjoy sewing, quilting, crocheting, and making personalized gifts for my 12 grandchildren for each holiday. Professionally, I love to develop and invest in a TEAM. We have such an incredible group dedicated to supporting care providers, and I am very proud of our team. Working in healthcare is great for me. We are constantly learning something new and improving the life and health of those we serve. One thing you never leave home without?My purse. It has everything you could ever need — Band‑Aids, nail clippers, extra hand sanitizer, you name it, and I probably have it. It is basically a shoulder suitcase! Who has been most influential in your life?I have had a lot of good influences on my life. Early on I learned how to have a good work ethic from my parents. They both struggled through things in their life but never gave up and showed us that hard work, common sense, and a good work ethic will never let you down. I was also strongly influenced by my maternal grandmother who taught me how to serve others and to be selfless. My husband has always supported me and my decisions while being honest and giving me loving guidance. I also think that I learned a lot by raising my children. Even if you’re not looking for feedback, they give it, and that has helped me grow as a person. I have also been influenced by leaders here within Anthem. We have a wonderful culture that allows us to grow and be our authentic selves. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-076061-25 Effective May 1, 2025, we will delegate some care management (case management and disease management) services to Carelon Health, Inc. This delegation of services will not impact the way we work with members or care providers. There will be no disruptions in service or impact on how you collaborate with care management staff. All contracts, policies, and procedures will remain unchanged. Additionally, all existing phone numbers, emails, websites, and portals will not change. Your patients’ current points of contact, engagement model, level of care, and service will not change. No action is needed from you. Within our communications, you will see the following changes: - A legal disclaimer — In your patients’ plan communication, you will see a footnote referencing the fact that Carelon Health, Inc. is now providing these care management services on behalf of Anthem.
- Signature of care management/staff healthcare professional — While the team providing services will not change, you will see that their signatures may change to reflect Carelon Health, Inc.
Carelon Health, Inc. is a separate company offering care management services on behalf of the health plan. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CDCR-076027-24-CPN74402 Beginning April 1, 2025, we will update our prepayment coding validation review process for outpatient claims to include claims submitted with modifiers 24, 25, 58, 59, 78, 79, E1–E4, F1–F9, TA, LT, RT, LC, LD, RC, LM, RI, XE, XP, XS, and XU. This updated review aligns with published reimbursement policies and National Correct Coding Initiative (NCCI) correct coding guidelines that require proper modifier usage and submission. We will evaluate the use of modifiers in conjunction with the edits they bypass (such as the NCCI). Registered nurses and coders who are clinical analysts will review claims pending validation, along with any related services, to determine whether it is appropriate for the modifier to bypass the edit. If you believe a claim reimbursement decision should be reviewed, please follow the claims payment dispute process outlined in your provider manual, which is available in our provider manual. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-076807-25 Beginning April 1, 2025, claims processed and submitted with pharmaceutical drug procedure codes must be supported by an approved FDA indication or an approved off‑label indication as listed in the CMS-defined list of pharmaceutical compendia. The approved off‑label usage listed in the compendia is determined using evidence‑based criteria from clinical trials and studies. Drug procedure codes that have a prior authorization requirement or medical policy are excluded from this enhancement. If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual and include the portion of the medical record relevant to the drug provided. If you have questions about this notification, contact your contract manager or 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-CM-075142-24 Please be advised that Anthem follows the Ohio Department of Medicaid (ODM) billing guidelines. We require the appropriate rendering practitioner modifier to ensure accurate reimbursement of all behavioral health claims. If the rendering practitioner modifier is incorrect or omitted, the claim may not be accepted or could be reimbursed at an incorrect rate. Providers should ensure the pricing modifier is appended first. For more information on billing guidelines, please refer to the most recent Behavioral Health Provider Reimbursement Manual at medicaid.ohio.gov/resources‑for-providers/bh. If you have any additional questions, please reach out to your provider relationship account management associate or email OhioMedicaidProvider@anthem.com. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-075684-24 For claims processed on or after April 1, 2025, our claim editing system will align with the AMA CPT® Manual and HCPCS Level II Manual correct coding guidelines for billing anatomical modifiers 50, RT, and LT. According to the AMA CPT and HCPCS Level II manuals, the appropriate anatomical modifier must be appended to the appropriate procedure code. These modifiers designate the area or part of the body on which a service is being performed. If you believe a claim reimbursement decision should be reviewed, please follow the claims dispute process outlined in the Provider Manual. If you have questions about this notification, contact your network manager or 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-CM-077346-25 A message from the Ohio Department of Medicaid The Ohio Department of Medicaid (ODM) resumed provider revalidations in June 2023. It is imperative that providers who are due for revalidation take immediate action, as terminations resumed January 23, 2024. All providers are subject to either three- or five-year, time-limited Provider Agreements. Letters are mailed and emailed 120 days, 90 days, and 60 days prior to termination, and a final notice is sent 30 days prior to termination. Providers who do not submit their revalidation could experience a termination at the state level — which would cascade to the managed care entities (MCEs) and cause claim denials as a non-participating provider. Emails will come from OHPNM@maximus.com. Revalidation notices are posted in the Provider Network Management (PNM) module and can be accessed in the Correspondence folder. Providers will also see a Begin Revalidation option in the PNM Enrollment Action Selection 120 days prior to the Medicaid Agreement end date. Providers can locate this under Manage Application > Enrollment Actions within the provider file. Refer to the Quick Reference Guide: Revalidation/Reenrollment (maximus.com) for step-by-step instructions. Providers who need technical assistance can contact ODM’s integrated help desk at 800-686-1516 and follow the prompts for provider enrollment, or providers can email IHD@medicaid.ohio.gov. To learn more about the PNM module and centralized credentialing, visit the PNM & Centralized Credentialing page (ohio.gov) on the Next Generation Program website (ohio.gov). Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-060524-24, OHBCBS-CD-074747-24 At a glance:
- Care providers contracted with us need to verify and update their demographic data every 90 days using the provider data management (PDM) feature in Availity Essentials.
- Updating and attesting data are critical for maintaining accurate service directories for members and noncompliance with these requirements can result in removal from the online provider directory.
- Availity Essentials provides digital applications that enable users to monitor submitted demographic updates in real time, review the history of previously verified data, and manage multiple updates within one spreadsheet via the Upload Roster feature.
What are the requirements for the attestation of demographic data?
We require our contracted care provider partners to attest to their demographic data every 90 days. Maintaining your provider data is critical as it results in improved connection to members seeking care, supports the accuracy of claims processing, and allows for timely reimbursement, while aligning to a bold purpose of improving the health of humanity.
How do I update and attest to my data?
We require the use of the PDM capability available on Availity Essentials to update your provider or facility data. There are two options within Availity Essentials PDM that are available at no cost to care providers:
- Multipayer platform, which includes Directory Verification and Core PDM: allows care providers to make required updates using Directory Verification and changes using Core PDM
- Roster upload: allows care providers to submit multiple updates within one spreadsheet via the Upload Roster feature (The Upload Roster feature is currently only available and shared with the health plan.)
Both the multipayer platform and Roster Upload feature satisfy your 90‑day attestation requirement.
To attest to your provider data:
- Log in to https://Availity.com.
- Navigate to My Providers > Provider Data Management.
- Select the action menu next to the business whose information you want to verify.
- Select Verify Directory Listing.
- Review each set of data for accuracy.
- Once complete, select Submit Verified Profile.
Organizations with no changes since their last submission may see a Quick Verify button that allows for directory verification in one click.
Individuals registered for their TIN within the Availity Manage My Organization application on Availity Essentials will receive periodic automated emails and notifications in the Notification Center on Availity Essentials reminding them when their attestation is due or overdue.
How do I access Availity Essentials and the PDM application?
To access the PDM application, log on to https://Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.
Within PDM you also have the ability to:
- Monitor submitted demographic updates in real time with a digital dashboard.
- Review the history of previously verified data.
Why is updating and attesting to my data important?
Our members use Find Care to make informed decisions about their healthcare and find quality doctors and hospitals. Keeping your data up to date ensures members have access to you when they need it the most.
Failure to complete the 90‑day attestation requirement puts your organization at risk of being classified as non‑compliant with the health plan’s policies and procedures and may result in removal from the online provider directory.
What if I’m not registered for Availity Essentials yet?
If you aren’t registered to use Availity Essentials, signing up is easy and secure. There is no cost to register or to use any of the digital applications. Start by going to https://Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one TIN, ensure you have registered all TINs associated with your account.
If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY (282‑4548).
How do I get training on the Availity Essentials PDM tool?
You can learn about and attend one of our training opportunities by visiting here (apps.availity.com):
- For more information on PDM, check out the Quick Start Guide here (apps.availity.com) using your Availity Essentials user ID and password.
- For more information about the Roster Upload process:
- See the Roster Submission Guide on https://Availity.com > Payer Spaces > Select Payer Tile > Resources > Roster Submission Guide using PDM.
- Find training specifically for the Standard Template and Rules of Engagement by listening to our recorded webinar on our provider Learning Hub.
- Take an on‑demand class hosted by Availity Essentials on the Learning Hub to learn about PDM.
What if I’m a behavioral health care provider?
If you are a behavioral health care provider and assigned to Carelon Behavioral Health, Inc., follow the Carelon Behavioral Health process for attestation. Council for Affordable Quality Healthcare (CAQH) care providers should attest, confirm, or update their data through the CAQH website. Non‑CAQH care providers and facilities should attest, confirm, or update their data directly with Carelon Behavioral Health.
Contact us
Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.
For additional support, visit the Contact Us section of our provider website for the appropriate contact. Carelon Behavioral Health is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-078363-25-CPN78193, MULTI-BCBS-CRCM-084128-25-CPN83900 Anthem has a continued mission to leverage digital technology to provide enhanced services for both members and care providers. We encourage the support of care providers in accepting digital ID cards instead of a physical member ID card. As members increasingly use digital ID cards, care providers may need to implement changes in their processes to accept this format. Due to recent enhancements, care providers can bypass the request for cards by accessing Availity.com. If a copy of a physical member identification card is needed, a member can email, fax, or access card details saved in their digital wallet. As a reminder, care providers can also access eligibility and benefit information without the health care identification (HCID). This makes both check-ins and submitting claims easier and faster. Anthem is dedicated to providing digital solutions that transform both care provider and payer interactions. Thank you in advance for your continued partnership and support in empowering our members to use their digital ID cards. With your help, we can continually build towards a future of shared success. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-069066-24, MULTI-BCBS-CM-077976-25
- Effective March 1, 2025, Carelon Medical Benefits Management will begin conducting clinical appropriateness reviews of cardiovascular, musculoskeletal, and surgical procedures.
- New outpatient utilization management also includes fertility procedures and other medical services for select insurance plans.
- Anthem will continue to perform reviews of transportation services.
- Providers are encouraged to use an online portal for service preauthorization, with resources and training available for guidance.
Carelon Medical Benefits Management will begin accepting prior authorization requests on February 24, 2025, for dates of service on or after March 1, 2025.
Members included in the new program
Updates to Carelon Medical Benefits Management programs apply to select local fully insured members and members covered under self‑insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare supplemental, or Federal Employee Program® (FEP®) plans. For more information, please call the phone number on the back of the member ID card.
Pre‑service review requirements
For procedures scheduled to begin on or after March 1, 2025, all care providers need to contact Carelon Medical Benefits Management to obtain a pre‑service review for the services, including, but not limited to, the following non‑emergency modalities. Please refer to the Clinical Guidelines at Anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.
Note: All codes will be reviewed for medical necessity for the requested service and not for site of care.
The tables below list our Clinical UM Guidelines and Medical Policies for medical necessity review.
|
|
Fertility
|
CG-MED-68
|
|
Therapeutic Apharesis
|
MED.00101
|
|
Hyperbaric Oxygen Therapy
|
CG-MED-89
|
|
Physiologic Record of Tremor
|
CG-MED-73
|
|
Parenteral Nutrition
|
DME.00011
|
|
Imaging Eval. of Skin Lesions
|
DME.00048
|
|
Virtual Reality-Assisted Therapy Systems
|
MED.00011
|
|
Quantitative Sensory Test
|
MED.00082
|
|
Automated Nerve Conduction
|
MED.00092
|
|
Bioimpedance Spectroscopy
|
MED.00103
|
|
Autonomic Test
|
MED.00105
|
|
Monitor Intraocular Pressure
|
MED.00112
|
|
Seizure Monitoring
|
MED.00118
|
|
Home Visual Field Monitor
|
MED.00130
|
|
Eye Movement Analysis for Dx of Concussion
|
MED.00131
|
|
Colonic Irrigation
|
MED.00137
|
|
Electrical Stim. Tx. for Pain & Other Conditions
|
MED.00141
|
|
Sensory Stim. for Brain Injury
|
MED.00002
|
|
Automated Evacuation of Meibomian Gland
|
MED.00004
|
|
Selected Sleep Testing
|
CG-MED-66
|
|
|
CG-MED-88
|
|
|
CG-SURG-35
|
|
|
LAB.00045
|
|
Program — Cardiovascular
|
|
Carotid Sinus Baroreceptor Stim. Devices
|
CG-SURG-106
|
|
Venous angioplasty w/wo stent placement
|
CG-SURG-119
|
|
Vein embolization tx for pelvic congestion syndrome and varicocele
|
CG-SURG-28
|
|
Tx of varicose veins
|
CG-SURG-76
|
|
Artery stent placement w/wo angioplasty
|
CG-SURG-83
|
|
Embolization proc.
Dialysis circuit proc.
|
CG-SURG-93
|
|
|
RAD.00059
|
|
|
SURG.00062
|
|
|
SURG.00124
|
|
Program — Musculoskeletal
|
|
Peripheral Nerve Blocks for Tx of Neuropathic Pain Implant of Nerve Stim. Devices
|
SURG.00140
|
|
|
SURG.00158
|
|
|
SURG.00112
|
|
Program — Surgical
|
|
Anesthesia for Dental Svcs.
|
SURG.00045
|
|
Skin Related Cosmetic & Reconstructive Services
|
SURG.00112
|
|
Balloon Dilation of Eustachian Tubes
|
SURG.00144
|
|
Functional Endoscopic Sinus Surgery
|
SURG.00129
|
|
Bronchial Thermoplasty
|
ANC.00007
|
|
Balloon Sinus Ostial Dilation
|
CG-MED-41
|
|
Cochlear & Auditory Brainstem Implants
|
CG-MED-79
|
|
Implantable Hearing Aids
|
CG-MED-81
|
|
Surg. Tx for OSA & Snoring
|
CG-SURG-03
|
|
Drug-Eluting Devices to Maintain Sinus Ostial Patency
|
CG-SURG-08
|
|
Minimally Invasive Tx of Posterior Nasal Nerve for Rhinitis
|
CG-SURG-09
|
|
Temporomandibular Disorders
|
CG-SURG-105
|
|
Septoplasty
|
CG-SURG-117
|
|
Nasal Valve Repair
|
CG-SURG-118
|
|
Bariatric Surgery
|
CG-SURG-12
|
|
MRI Guided US Ablation for Non-Oncologic Indications
|
CG-SURG-120
|
|
Uterine Fibroid Ablation
|
CG-SURG-18
|
|
Sacral Nerve Stim. Tx of Neurogenic Bladder secondary to Spinal Cord Injury
|
CG-SURG-24
|
|
Vagus Nerve Stim.
|
CG-SURG-61
|
|
Ablation for Solid Tumors Outside the Liver
|
CG-SURG-71
|
|
Irreversible Electroporation
|
CG-SURG-73
|
|
Corneal Collagen Cross Linking
|
CG-SURG-79
|
|
Intraocular Telescope
|
CG-SURG-81
|
|
Automated Evacuation of Meibomian Gland
|
CG-SURG-82
|
|
Correct Intraocular Lenses
|
CG-SURG-83
|
|
Viscocanalostomy & Canaloplasty
|
CG-SURG-84
|
|
Intraocular Anterior Segment Aqueous Drainage Devices
|
CG-SURG-88
|
|
Extracorporeal Shock Wave Therapy
|
CG-SURG-95
|
|
Implant of Nerve Stim. Devices
|
CG-SURG-96
|
|
Implanted Artificial Iris Devices
|
CG-SURG-99MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal
|
|
Implanted Port Delivery Systems for Ocular Disease
|
MCG: ISC: S-450/450-RRG/5450: Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy
|
|
Implantable Infusion Pumps
|
MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal
|
|
Tx for Urinary & Fecal Incontinence
|
MCG: ISC: S-665/665-RRG: Hysterectomy, Laparoscopic
|
|
Reduction Mammaplasty
|
MCG: ISC: S-775/775-RRG: Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy
|
|
Mastectomy for Gynecomastia
|
MED.00057
|
|
Panniculectomy & Abdominoplasty
|
MED.00103
|
|
Regenerative Cell Therapy & Soft Tissue Augmentation
|
MED.00132
|
|
Products for Wound Healing & Soft Tissue Grafting
|
SURG.00010
|
|
Surg. & Ablative Tx for Chronic Headaches
|
SURG.00011
|
|
Intraoperative Assess. of Surgical Margins During Breast-Conserving Surg.
|
SURG.00061
|
|
Mandibular/Maxillary Surg.
|
SURG.00077
|
|
Blepharoplasty, Repair & Brow Lift
|
SURG.00079
|
|
Internal Rib Fixation Systems
|
SURG.00084
|
|
Prostate Saturation Biopsy
|
SURG.00095
|
|
Focal Laser Ablation for Tx of Prostate Cancer
|
SURG.00096
|
|
Penile Prosthesis Implantation
|
SURG.00107
|
|
Diaphragmatic/Phrenic Nerve Stim. & Pacing Systems
|
SURG.00118
|
|
US Ablation for Oncologic Indications
|
SURG.00120
|
|
Radiofrequency Ablation of Renal Sympathetic Nerves
|
SURG.00126
|
|
Hysterectomy
|
SURG.00132
|
|
Laparoscopic Gynecologic Surgery
|
SURG.00135
|
|
Myomectomy
|
SURG.00139
|
|
Transurethral Destruction, Prostate Tissue
|
SURG.00156
|
|
Nerve Block Therapy for Tx of Headache & Neuralgia
|
SURG.00157
|
|
|
SURG.00159
|
|
|
SURG.00160
|
To determine if prior authorization is needed for a member on or after March 1, 2025, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on http://Availity.com 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.)
Care providers should continue to submit pre‑service review requests to Carelon Medical Benefits Management using the convenient online service provided on the Carelon Medical Benefits Management provider website. The website is available 24 hours a day, seven days a week, and processes requests in real time using Clinical Criteria. To register, go to https://providerportal.com.
For more information
For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:
Cardiovascular Solution | Carelon Insights
Radiology Solution | Carelon Insights
Sleep Solution | Sleep Healthcare | Carelon Insights
Surgical Procedures Solution | Carelon Insights
Radiation Oncology Solution | Carelon Insights
Additional Outpatient Utilization Management
Sign up at provider training for provider training for the additional outpatient UM:
- Wednesday, February 5, 2025, at 12 p.m. ET/11 a.m. CT
- Wednesday, February 12, 2025, at 12 p.m. ET/11 a.m. CT
- Friday, February 21, 2025, at 11 a.m. ET/10 a.m. CT
- Wednesday, February 26, 2025, at 12 p.m. ET/11 a.m. CT
- Wednesday, March 5, 2025, at 12 p.m. ET/11 a.m. CT
Our website, Anthem.com, provides information and tools such as order entry checklists, Clinical Guidelines, and FAQ. You can also contact your provider relationship management representative with any questions.
Through genuine collaboration, we can simplify access to care and help you deliver high‑quality, equitable healthcare.
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-076017-24 The orientation covers working with our Medicaid members, submitting claims, and more. Please register at the link below. We are here for youIf you have any questions, contact Provider Services at 844‑912‑1226 or send an email to OhioMedicaidProvider@anthem.com. A future of shared success requires collaboration. With your help, we can make great strides in healthcare. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-077420-25, OHBCBS-CD-077667-25, OHBCBS-CD-077423-25 We’re excited to introduce two new Payment Integrity trainings available on our Digital Solutions Learning Hub: - Payment Integrity: Emergency Dept Evaluation and Management Services
- Payment Integrity: Outpatient Evaluation and Management Services
With an initial focus on these two key educational initiatives, our purpose is to amplify your billing and coding accuracy. More trainings will be announced throughout the year. Discover what our Digital Solutions Learning Hub has to offer. Anthem Blue Cross and Blue Shield and Anthem Blue Cross and Blue Shield Medicaid are trade names of Community Insurance Company. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CDCRCM-075945-24-CPN75258, OHBCBS-CDCRCM-072257-24-CPN72085, OHBCBS-CDCRCM-077832-25-CPN77515, OHBCBS-CDCRCM-080181-25-CPN79720 Join our on‑demand webinar on improving antibiotic use in the outpatient setting, led by Dr. Emily McDonald, MD, MPH, and Guillermo Sanchez, PA‑C, MPH, MSHS, from the CDC’s Office of Antibiotic Stewardship. The webinar highlights key strategies such as proper diagnosis, adherence to clinical guidelines, and educational interventions. It will also address common misconceptions regarding patient satisfaction and prescribing practices. Additionally, the session will discuss tools and resources, such as HEDIS® quality measures and communication training, available to help clinicians improve their antibiotic stewardship practices. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Program objectives: - Review the epidemiology of outpatient antibiotic use in the U.S.
- Identify high‑priority conditions where antibiotic prescribing can be improved.
- Describe evidence‑based interventions that can improve antibiotic use.
- Address common myths related to antibiotic use.
Visit: Improving Antibiotic Use for Acute Respiratory Infections (This link works best with the Chrome browser.) Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-077493-25-CPN77017 Please join us to learn more about working with us and supporting your patients, our members. Please register at the link below. We are here for youIf you have any questions, contact Provider Services at 844‑912‑1226 or send an email to OhioMedicaidProvider@anthem.com. Through genuine collaboration, we can work to achieve improved outcomes in patients’ mental health. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-077422-25, OHBCBS-CD-077421-25, OHBCBS-CD-077389-25 The orientation covers everything you need to know to work with us.
Please register at the link below.
We are here for you
If you have any questions, contact Provider Services at 844-912-1226 or send an email to OhioMedicaidProvider@anthem.com.
Through genuine collaboration, we can help solve real needs in a sustainable way. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-077388-25 Have questions or want to learn more about what Anthem has to offer our members? Join us for a webinar led by Carmen Hallman, Ohio Medicaid Sales and Marketing Manager. She will review our Value-Added Benefits (VAB) and Social Determinants of Health (SDoH) program. By attending, you will gain knowledge and have additional guides and resources at your fingertips to assist your patients, our members. 
| Tuesday, March 11, 2025 | 1 p.m. ET Virtual presentation |
RegisterSign up for the webinar here (medallia.com). If you have questionsContact your provider relationship management representative or email OhioMedicaidProvider@anthem.com. We look forward to sharing resources and working with you to achieve improved outcomes for members in our communities. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-074295-24, OHBCBS-CD-074296-24, OHBCBS-CD-074297-24 SummaryThe Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
Please share this notice with other members of your practice and office staff. Please note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective Date | Clinical Criteria Number | Clinical Criteria Title | New or Revised | March 24, 2025 | CC-0272 | Aucatzyl (obecabtagene autoleucel) | New | March 24, 2025 | CC-0273 | Vyloy (zolbetuximab-clzb) | New | March 24, 2025 | CC-0223 | Imjudo (tremelimumab-actl) | Revised | March 24, 2025 | CC-0056 | Selected Injectable 5HT3 Antiemetic Agents | Revised | March 24, 2025 | CC-0148 | Agents for Hemophilia B | Revised | March 24, 2025 | CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised | March 24, 2025 | CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised | March 24, 2025 | CC-0124 | Keytruda (pembrolizumab) | Revised | March 24, 2025 | CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised | March 24, 2025 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised | March 24, 2025 | CC-0204 | Tivdak (tisotumab vedotin-tftv) | Revised | March 24, 2025 | CC-0226 | Elahere (mirvetuximab) | Revised | March 24, 2025 | CC-0125 | Opdivo (nivolumab) | Revised | March 24, 2025 | CC-0128 | Tecentriq (atezolizumab) | Revised | March 24, 2025 | CC-0011 | Ocrevus (ocrelizumab)/Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq) | Revised | March 24, 2025 | CC-0173 | Enspryng (satralizumab-mwge) | Revised | March 24, 2025 | CC-0170 | Uplizna (inebilizumab-cdon) | Revised | March 24, 2025 | CC-0199 | Empaveli (pegcetacoplan) | Revised | March 24, 2025 | CC-0041 | Complement Inhibitors | Revised | March 24, 2025 | CC-0071 | Entyvio (vedolizumab) | Revised | March 24, 2025 | CC-0064 | Interleukin-1 Inhibitors | Revised | March 24, 2025 | CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised | March 24, 2025 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised | March 24, 2025 | CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised | March 24, 2025 | CC-0078 | Orencia (abatacept) | Revised | March 24, 2025 | CC-0063 | Ustekinumab Agents | Revised | March 24, 2025 | CC-0062 | Tumor Necrosis Factor Antagonists | Revised | March 24, 2025 | CC-0003 | Immunoglobulins | Revised | March 24, 2025 | CC-0073 | Alpha-1 Proteinase Inhibitor Therapy | Revised | March 24, 2025 | CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised | March 24, 2025 | CC-0029 | Dupixent (dupilumab) | Revised | March 24, 2025 | CC-0105 | Vectibix (panitumumab) | Revised | March 24, 2025 | CC-0095 | Bortezomib (Boruzu, Velcade) | Revised | March 24, 2025 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised | March 24, 2025 | CC-0201 | Rybrevant (amivantamab-vmjw) | Revised | March 24, 2025 | CC-0120 | Kyprolis (carfilzomib) | Revised | March 24, 2025 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised | March 24, 2025 | CC-0255 | Loqtorzi (toripalimab-tpzi) | Revised | March 24, 2025 | CC-0002 | Colony Stimulating Factor Agents | Revised |
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-075809-24-CPN74713 Effective June 1, 2025, Anthem will upgrade to the 29th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive: - Behavioral Health Care (BHG):
- The guidelines for substance‑related disorders have been updated to allow users to identify ASAM citations more easily within MCG content. Benchmarks have been added to the guidelines for Applied Behavioral Analysis, Neuropsychological Testing, Psychological Testing, and Urine Toxicology Testing.
- Inpatient & Surgical Care (ISC):
- Five new observation care guidelines have been added. Also, a new mean arterial pressure (MAP) calculator has been added.
- General Recovery Care (GRG):
- A new Hospital‑at-Home General Recovery Guideline has been added.
- Chronic Care (CCG):
- New guidelines have been added to self‑management and low‑intensity disease management pediatric guidelines.
If you have questions, please contact Provider Services via the number on the back of our member ID card. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-074776-24-CPN74543 Medical Policy & Clinical Guidelines | Commercial | February 18, 2025 Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements MCG Care Guidelines 29th editionEffective June 1, 2025, Anthem will upgrade to the 29th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive: - Behavioral Health Care (BHG):
- The guidelines for substance‑related disorders have been updated to allow users to identify ASAM citations more easily within MCG content. Benchmarks have been added to the guidelines for Applied Behavioral Analysis, Neuropsychological Testing, Psychological Testing, and Urine Toxicology Testing.
- Inpatient & Surgical Care (ISC):
- Five new observation care guidelines have been added. Also, a new mean arterial pressure (MAP) calculator has been added.
- General Recovery Care (GRG):
- A new Hospital‑at-Home General Recovery Guideline has been added.
- Recovery Facility Care (RFC):
- The discharge planning section for Inpatient Rehabilitation Facility guidelines was expanded.
- Chronic Care (CCG):
- New guidelines have been added to self‑management and low‑intensity disease management pediatric guidelines.
If you have questions, please contact Provider Services via the number on the back of our member ID card. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-074752-24-CPN74544 Effective June 1, 2025, Anthem will upgrade to the 29th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive: - Behavioral Health Care (BHG):
- The guidelines for substance‑related disorders have been updated to allow users to identify ASAM citations more easily within MCG content. Benchmarks have been added to the guidelines for Applied Behavioral Analysis, Neuropsychological Testing, Psychological Testing, and Urine Toxicology Testing.
- Inpatient & Surgical Care (ISC):
- Five new observation care guidelines have been added. Also, a new mean arterial pressure (MAP) calculator has been added.
- General Recovery Care (GRG):
- A new Hospital‑at-Home General Recovery Guideline has been added.
- Recovery Facility Care (RFC):
- The discharge planning section for Inpatient Rehabilitation Facility guidelines was expanded.
- Chronic Care (CCG):
- New guidelines have been added to self‑management and low‑intensity disease management pediatric guidelines.
- Ambulatory Care (AC):
- A new Gene and Cellular Therapy section was introduced. A new Specialty Medication guideline has also been added. In addition, new guidance for supporting requests for APAP machines has been added.
- Home Care (HC):
- Updates to Clinical Indications for admission were made.
If you have questions, please contact Provider Services at 844‑912-1226. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-074805-24-CPN74542 The Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
Please share this notice with other members of your practice and office staff. Please note: - The Clinical Criteria listed below apply only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that have been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Clinical Criteria number | Clinical Criteria title | New or revised | March 10, 2025 | CC-0266 | Rytelo (imetelstat) | New | March 10, 2025 | CC-0156 | Reblozyl (luspatercept) | Revised | March 10, 2025 | CC-0244 | Columvi (glofitamab-gxbm) | Revised | March 10, 2025 | CC-0124 | Keytruda (pembrolizumab) | Revised | March 10, 2025 | CC-0104 | Levoleucovorin Agents | Revised | March 10, 2025 | CC-0182 | Iron Agents | Revised | March 10, 2025 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised | March 10, 2025 | CC-0247 | Beyfortus (nirsevimab) | Revised | March 10, 2025 | CC-0082 | Onpattro (patisiran) | Revised | March 10, 2025 | CC-0217 | Amvuttra (vulrisiran) | Revised | March 10, 2025 | CC-0084 | Tegsedi (inotersen) | Revised | March 10, 2025 | CC-0209 | Leqvio (inclisiran) | Revised | March 10, 2025 | CC-0193 | Evkeeza (evinacumab) | Revised | March 10, 2025 | CC-0027 | Denosumab | Revised | March 10, 2025 | CC-0019 | Zoledronic Acid | Revised | March 10, 2025 | CC-0246 | Rystiggo (rozanolixizumab-noli) | Revised | March 10, 2025 | CC-0207 | Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) | Revised | March 10, 2025 | CC-0028 | Benlysta (belimumab) | Revised | March 10, 2025 | CC-0127 | Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Revised | March 10, 2025 | CC-0121 | Gazyva (obinutuzumab) | Revised | March 10, 2025 | CC-0242 | Epkinly (epcoritamab-bysp) | Revised | March 10, 2025 | CC-0130 | Imfinzi (durvalumab) | Revised | March 10, 2025 | CC-0158 | Enhertu (fam-trastuzumab deruxtecan-nxki) | Revised | March 10, 2025 | CC-0048 | Spinraza (nusinersen) | Revised | March 10, 2025 | CC-0003 | Immunoglobulins | Revised | March 10, 2025 | CC-0058 | Sandostatin and Sandostatin LAR (Octreotide) / Octreotide Agents | Revised |
Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-074703-24 What’s changing: Effective January 1, 2025, postal employees began to participate in the Postal Service Health Benefits Program (PSHB), a health benefits program for those under the Federal Employee Program® (FEP). What this means for you as the provider:Postal employees in the PSHB program have a new ID card reflecting new enrollment codes. To ensure correct claim processing, the federal employee ID cards should be validated to confirm the provider has the correct enrollment information. In 2025, federal and USPS employees in the FEP, along with their families, will have the same coverage and benefits as before. The plan options will remain Blue Standard, Blue Basic, and Blue Focus. Only the PSHB ID card and PSHB customer service number (on the back of the card) will be new. Below is an example of the front of the new PSHB card. A stamp symbol in the upper right corner will identify the PSHB enrollment: 
Once the PSHB member is enrolled, they will have a new ID card. The back of the ID card will reflect the toll-free Customer Service and prior authorization numbers for assistance. 
Additional information for all federal employees can be found on the federal employee website at https://fepblue.org. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-075976-24-CPN75169 Effective for dates of service on or after April 1, 2025, the following medication codes will require Preapproval. Please note that the inclusion of a National Drug Code (NDC) 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-0259 | J3490, J3590 | Amtagvi (lifleucel) | CC-0260 | J7353 | Nexobrid (anacaulase‑bcdb) |
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 at 844‑912-1226. Note: Preapproval requests for certain medications may require additional documentation to determine medical necessity. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. OHBCBS-CD-072787-24-CPN72577 |
