 Provider News OhioNovember 2022 Anthem Provider News - OhioBlue High Performance Network ® (BlueHPN) plans offer access to providers with a record of delivering high-quality, efficient care.
BlueHPN networks launched in 2021 in more than 50 cities and states, including in the Cincinnati, Cleveland-Elyria, and Columbus, Ohio metro areas. The local provider network that supports BlueHPN plans in Ohio is called the Blue Connection network.
Effective January 1, 2023, the local Blue Connection high performance provider network will be expanded to include select providers in the Dayton, Ohio metropolitan area.
BlueHPN is a national network designed from our local market expertise, deep data analytics on cost and quality performance, and strong provider relationships. BlueHPN is aligned with local high‑performance networks across the country. These local networks are then connected to the national chassis to form a national BlueHPN network. Employees of large, national-scale companies across the country have the option to choose a plan with the BlueHPN as their provider network.
The products that access the Blue HPN network include small group, large group, or national account plans. These will be HMO plans or HSA plans with an HMO network. Under these plans, out‑of‑network benefits are limited to emergency or urgent care. Members may be required to select a primary care provider, but PCP referrals are not required for specialty care.
As a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.
For any needed changes, please update your information by submitting them to us on our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request.
Online update options include:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Thank you for doing your part in keeping our provider directories current.
We’re phasing in clear, concise, and simplified denial descriptions when returning claims status inquiries. The denial descriptions will explain why the claim or claim line was denied and what to do next. We’ve even included details about how to provide us with information digitally to move the claim further along in the claims process.
Continuing to improve
The new denial descriptions will be phased in over the next few months. Based on your feedback, we’re starting with those claims or claim lines that have caused the most confusion. If new denial reasons are added, the descriptions will be expanded as well.
Accessing claim statuses
The Claims Status application on availity.com* enables you to check the status of your claim and submit attachments needed to process your claim, all in one place. To access the Claims Status app, log into availity.com and, from the Claims & Payments tab, select Claims Status. It’s just that fast and easy to check your claim status through Availity Essentials.
If you’re not enrolled in Availity Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity Essentials.
Working together to streamline processes through technology is a collaborative effort. We appreciate your feedback as we continue improving to meet your expectations. The enhancements we’ve made to the Availity Essentials* Authorization application make it faster, easier, and more efficient to submit digital authorizations for Anthem Blue Cross and Blue Shield members.
View attachments for authorizations submitted — You can now view the attachments you’ve submitted to support your authorization in the Availity Essentials authorization application.
Servicing and rendering provider — We’ve enhanced the Availity Essentials Authorization Application to enable a group option when selecting the servicing and rendering provider.
View correspondence — Access status and decision letters right from the Authorization Application Dashboard. Letters can also be downloaded or printed if needed.
Enhanced provider status — Out-of-network and in-network provider statuses are now enhanced to return fewer errors associated with provider status.
Expanded search — Search rendering and serving provider by NPI and ZIP code for quicker results.
Procedure code enhancement — Add the procedure code on an outpatient authorization for more accurate submission.
Case update features — You can now update your authorization right from your Authorization Application Dashboard.
Training sessions on the Availity Essentials authorization application are still available
Whether you prefer live training webcasts, on-demand webinar recordings, or a resource guide, we have everything you need to learn more about the Availity Essentials Authorization Application and how to make the most of it. Use this link to access the training option best for you.
The next live webcast is Wednesday, November 9, 2022, at 11 a.m. ET. Register here.
When submitting claims through the Electronic Data Interchange (EDI), a PWK segment indicator tells us you will be submitting supporting documentation for the claim and ensures the documents are attached correctly. The supporting documents are then sent through the Availity Essentials* Attachments Dashboard.
In November, the Attachments Dashboard will have a new look for Anthem Blue Cross and Blue Shield claims
The sooner we receive your claim attachments, the faster your claim can be processed for payment. To meet this expectation, the Attachments Dashboard will begin a seven-calendar day countdown beginning in November. This means that claims will begin processing sooner for those claims with the PWK segment indicator.
If you are unable to meet the seven-calendar day submission deadline, the claim will move from your Attachments Dashboard inbox into your History folder and will be marked as expired. The claim will then deny for additional information based on the PWK segment indicator and move to Claims Status located under the Claims & Payments tab on availity.com. Upload your attachment from Claims Status by using the Submit Attachment button located on your claim.
To learn more about the new claims attachments workflow, visit our Provider Learning Hub or access the on-demand webinar recording, Learn about the new claims attachments workflow, using this link.
Submitting Anthem Blue Cross and Blue Shield claims disputes through Availity Essentials* is the most efficient way to have a claim reconsidered. Easily accessible through the Claims & Payments application, select Claims Status to access the claim. Use the Dispute button to file the appeal and upload supporting document to finalize the submission.
Add multiple claims to one dispute submission
You can submit one dispute and add multiple claims — up to 25 claims — as long as the additional disputed claims are for the same member, provider, and dispute reason. For Commercial member claims, you can begin submitting multiple claims on one dispute beginning in November.
Access acknowledgement, update, and decision letters digitally, too
Access correspondence related to your disputes through the Appeals Dashboard. When you submit multiple claims on one dispute through Availity Essentials, you will receive correspondence related to each individual dispute, so expect a greater number of letters in your Appeals Dashboard. You can easily identify the correspondence related to your multiple dispute submission by looking for the CI-COMM case number.
Availity Essentials appeals training
For detailed instructions about submitting disputes electronically, use this link to access appeals training from Availity Essentials.
New learnings added to the Provider Learning Hub.
Remittance Inquiry App: How to view, print, and save remittance advice
If you’re still using paper remittance to reconcile your claims, imagine the time you’ll save when you access remittance advice digitally through availity.com. This course shares information about how to view, print, and save electronic remittances.
Attachments: How to setup the Medical Attachment role
To submit attachments digitally (medical records, itemized bills, or other documents needed to process your claims), registering your organization in this training is step one. It will help you every step of the way.
Claim Submission: How to submit a claim using direct data entry
For providers who are not submitting their claims through Electronic Data Interchange (EDI), availity.com offers direct data entry for professional and facility claims. Take this course and walk through the process for submitting claims electronically.
Get started today
Access the Provider Learning Hub today using this link or from anthem.com under Important Announcements on the home page.
- All courses and webcasts are available 24/7 for your convenience.
- Use filtering options to quickly find courses and job aids.
- Use the Favorites folder to save items for easy access later.
- Once registered, no further registration is required.
- On future visits, your preferences are populated eliminating the need for any additional logon information.
Not registered on availity.com? Use this link for registration information or access registration information from the Provider Learning Hub. There is no cost for our providers to use availity.com.
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).
HEDIS medical record submission made easier with our remote EMR access service
Let us take on the responsibility to retrieve medical records for the annual HEDIS® hybrid project by signing up for the remote electronic medical record (EMR) access service offered Anthem.
We offer providers the ability to grant access to their EMR system directly to pull the required documentation to aid your office in reaching compliance while reducing the time and costs associated with medical record retrieval.
We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:
- We only access medical records of members pulled into the HEDIS sample using specific demographic data.
- We only retrieve the medical records that have claims evidence related to the HEDIS measures.
- We access the least amount of information needed for use, disclosure, or for the specific medical records request.
- We only save to file and do not physically print any PHI.
Getting started with remote EMR access
Download and complete the registration form, then email it to us at: Centralized_EMR_Team@anthem.com.
FAQ
How does Anthem retrieve your medical records?
We access your EMRs using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.
Is printing access necessary?
Yes. The NCQA audit requires print-to-file access.
Is this process secure?
Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives.
Why does Anthem need full access to the entire medical record?
There are several reasons we need to look at the entire medical record of a member:
- HEDIS measures can include up to a 10-year look back at a member’s information.
- Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
- Compliant data may be documented or housed in a nonstandard format, such as an in‑office lab slip scanned into miscellaneous documents.
What information do I need to submit to use the remote EMR access service?
Complete the registration form that requests the following information:
- Practice/facility demographic information (for example, address, NPI, TIN, etc.)
- EMR system information (for example, type of EMR system, required access forms, access type, etc.)
- List of current providers/locations or a website for accessing this list
Remote Access not an option? We are now offering onsite visits for HEDIS hybrid retrieval. Email us at Centralized_EMR_Team@anthem.com for more information.
Notice of Material Amendment/Change to Contract (MAC)
The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on August 11, 2022.
Determine if prior authorization is needed for an Anthem member by going to anthem.com > select “Providers” > under “Claims” > select “Prior Authorization”, then select your state. Or, you may call the prior authorization phone number on the back of the member’s ID card.
These medical policies to not apply to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan, commonly referred to as the Federal Employee Program® (FEP®). To view medical policies and utilization management guidelines applicable to FEP members, please visit fepblue.org > Policies & Guidelines.
Below are the current clinical guidelines and/or medical policies we reviewed and updates that were approved.
* Denotes prior authorization required.
|
Policy/guideline
|
Information
|
Effective date
|
|
*MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy
|
· Addresses the recent U.S. FDA-approved gene therapy product, elivaldogene autotemcel (Skysona®)
|
2/1/2023
|
|
*MED.00129 Gene Therapy for Spinal Muscular Atrophy
|
· Revised MN criterion to no more than 3 copies of SMN2
|
2/1/2023
|
|
CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
|
· Added thiopurine methyltransferase (TPMT) to scope of document and Clinical Indications MN section
· Existing CPT® code 81335 will be reviewed for MN criteria
|
2/1/2023
|
|
CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
|
· Added MN statement on decisions on extending adjuvant hormone therapy beyond 5 years in individuals with 1-3 positive lymph nodes
|
2/1/2023
|
|
*DME.00044 Robotic Arm Assistive Devices
Previously titled: Wheelchair Mounted Robotic Arm
|
· Revised title
· Rescoped the Position Statement to also address robotic feeding assistive device
· No specific code for robotic assistive feeding device, E1399 NOC already listed; considered INV&NMN
|
2/1/2023
|
|
*MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
|
· Added MN criteria for essential tremor
· CPT Category III code 0398T for intracranial MRgFUS will be reviewed for MN criteria for diagnosis G25.0 (was considered INV&NMN)
|
2/1/2023
|
|
SURG.00079 Nasal Valve Repair
Previously titled: Nasal Valve Suspension
|
· Revised title
· Revised the Position Statement
· Expanded scope of document to address an absorbable nasal implant and low-dose radiofrequency intranasal tissue remodeling for the treatment of nasal airway obstruction
· Content related to the absorbable nasal implant (Latera) moved from CG-SURG-87 to this document
· Added CPT code 30468 for absorbable nasal implant (Latera), considered INV&NMN (was addressed in CG-SURG-87); no specific code for RF remodeling considered INV&NMN, CPT 30999 NOC already listed
|
2/1/2023
|
|
SURG.00119 Endobronchial Valve Devices
|
· Added a note in the Position Statement addressing individuals unable to perform a 6‑Minute Walk Distance test
· Updated hierarchy formatting in Position Statement
|
2/1/2023
|
|
*SURG.00121 Transcatheter Heart Valve Procedures
|
· Clarified TAVR MN Clinical Indications
· Added MN statement for transcatheter Mitral Edge-to-Edge Repair/transcatheter mitral valve repair using an FDA approved device when criteria met
· Added NMN statement for transcatheter mitral edge-to-edge repair/TMVr for the treatment of primary or secondary (functional) MR when the criteria above are not met
· Revised INV/NMN statement TMVr to address transcatheter mitral edge-to-edge repair for all “other” indications
· CPT codes 33418, 33419 specific to MitraClip mitral valve procedure will be reviewed for MN criteria (were INV&NMN), and added associated ICD-10-PCS code (other mitral valve codes still considered INV&NMN)
|
2/1/2023
|
|
*SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
|
· Added MN criteria for hypoglossal nerve stimulation as a treatment of OSA in individuals with Down syndrome
· Removed examples from the NMN indications
· Hypoglossal nerve stimulation codes will be reviewed for MN criteria for diagnosis codes Q90.0-Q90.9
|
2/1/2023
|
|
*CG-GENE-13 Genetic Testing for Inherited Diseases
|
· Interim update to add genes PIK3CA and CDKL5 to the table of genes in the Discussion section; added existing CPT code 81309 and genes to Tier 2 codes 81405, 81406 (MN criteria)
|
2/1/2023
|
|
*SURG.00150 Leadless Pacemaker
|
· Moving from Post Service Review to Prior Authorization
|
2/1/2023
|
Below are clinical guidelines and/or medical policies that will be moving from Post Service Review to Prior Authorization effective February 1, 2023.
|
Policy/guideline
|
Title
|
Effective date
|
|
CG-LAB-13
|
Skin Nerve Fiber Density Testing
|
2/1/2023
|
|
LAB.00027
|
Selected Blood, Serum and Cellular Allergy and Toxicity Tests
|
2/1/2023
|
|
MED.00099
|
Navigational Bronchoscopy
|
2/1/2023
|
|
SURG.00036
|
Fetal Surgery for Prenatally Diagnosed Malformations
|
2/1/2023
|
|
SURG.00070
|
Photocoagulation of Macular Drusen
|
2/1/2023
|
|
SURG.00082
|
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
|
2/1/2023
|
|
SURG.00116
|
High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
|
2/1/2023
|
|
SURG.00120
|
Internal Rib Fixation Systems
|
2/1/2023
|
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem) in Ohio.
Effective November 6, 2022, Anthem will transition the Clinical Criteria for medical necessity review of perirectal hydrogel spacer to the AIM Specialty Health®* (AIM) Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline.
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* Portal at availity.com.
For questions related to guidelines, 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 Amendment/Change to Contract (MAC)
In the July edition of Provider News, we announced a Place of Service — Facility reimbursement policy indicating that evaluation & management (E/M) services and other professional services must be billed on a CMS-1500 claim form and are not reimbursable when billed on a UB-04 claim form (excluding E/M services rendered in an emergency room and billed with ER revenue codes).
It has come to our attention that some of the preventive counseling CPT® codes mentioned in the July article were listed incorrectly. The correct preventive counseling CPT codes are 99401–99404, 99411, and 99412, and are not reimbursable when billed in an outpatient setting of a facility effective with dates of service on or after February 1, 2023.
Please note, however, that the revenue codes 960-983 and the E/M services noted in the July edition were listed correctly in the Place of Service — Facility reimbursement policy effective with dates of service on or after October 1, 2022.
For specific policy details, visit the reimbursement policy page on our provider website.
Notice of Material Amendment/Change to Contract (MAC)
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 AIM Specialty Health® (AIM), 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.
Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after February 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)
|
|
ING-CC-0002*
|
Fylnetra (pegfilgrastim-pbbk)
|
J3590
|
|
ING-CC-0002*
|
Rolvedon (eflapegrastim-xnst)
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Stimufend (pegfilgrastim-fpgk)
|
C9399, J3490, J3590
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
|
C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
|
C9399, J3490, J3590
|
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Site of care updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0065
|
Advate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Adynovate (factor vii)
|
J7207
|
|
ING-CC-0065
|
Afstyla (antihemophilic factor (recombinant) single chain))
|
J7210
|
|
ING-CC-0065
|
Alphanate (antihemophilic factor viii)
|
J7186
|
|
ING-CC-0065
|
Eloctate (recombinant antihemophilic factor)
|
J7205
|
|
ING-CC-0065
|
Esperoct (factor viii recombinant, glycopegylated)
|
J7204
|
|
ING-CC-0065
|
factor viii, anti-hemophilic factor (porcine)
|
J7191
|
|
ING-CC-0065
|
Hemlibra (emicizumab-kxwh)
|
J7170
|
|
ING-CC-0065
|
Hemofil M ((factor viii) human plasma-derived)
|
J7190
|
|
ING-CC-0065
|
Humate-P (antihemophilic factor viii)
|
J7187
|
|
ING-CC-0065
|
Jivi (factor viii, recombinant, pegylated-aucl)
|
J7208
|
|
ING-CC-0065
|
Koate DVI ((factor viii) human plasma-derived)
|
J7190
|
|
ING-CC-0065
|
Kogenate-FS (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Kovaltry (factor viii (antihemophilic factor, recombinant))
|
J7211
|
|
ING-CC-0065
|
Novoeight (factor viii (antihemophilic factor, recombinant))
|
J7182
|
|
ING-CC-0065
|
Nuwiq (factor viii (antihemophilic factor, recombinant))
|
J7209
|
|
ING-CC-0065
|
Obizur (antihemophilic factor viii (recombinant))
|
J7188
|
|
ING-CC-0065
|
Recombinate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Vonvendi (von willebrand factor)
|
J7179
|
|
ING-CC-0065
|
Wilate (antihemophilic factor viii)
|
J7183
|
|
ING-CC-0065
|
Xyntha (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0065
|
Xyntha Solofus (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0148
|
AlphaNine SD (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
|
Alprolix (recombinant coagulation factor ix)
|
J7201
|
|
ING-CC-0148
|
Benefix (factor ix recombinant)
|
J7195
|
|
ING-CC-0148
|
Idelvion (factor ix)
|
J7202
|
|
ING-CC-0148
|
Ixinity (factor ix)
|
J7195
|
|
ING-CC-0148
|
Mononine (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
|
Profilnine SD (factor ix complex human)
|
J7194
|
|
ING-CC-0148
|
Rebinyn (glycopegylated)
|
J7203
|
|
ING-CC-0148
|
Rixubis (factor ix recombinant)
|
J7200
|
|
ING-CC-0149
|
Coagadex (factor x)
|
J7175
|
|
ING-CC-0149
|
Corifact (factor xiii concentrate (human))
|
J7180
|
|
ING-CC-0149
|
Feiba (anti-inhibitor coagulant complex)
|
J7198
|
|
ING-CC-0149
|
Fibryga (human fibrinogen)
|
J7177
|
|
ING-CC-0149
|
NovoSeven RT (factor viia recombinant)
|
J7189
|
|
ING-CC-0149
|
RiaSTAP (fibrinogen concentrate)
|
J7178
|
|
ING-CC-0149
|
Sevenfact (factor vlla recombinant)
|
J7212
|
|
ING-CC-0149
|
Tretten (coagulation factor xiii a-subunit (recombinant))
|
J7181
|
Step therapy updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Clinical criteria ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long-acting colony stimulating factor Rolvedon will be added to existing step therapy as a non-preferred agents.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0002*
|
Non-preferred
|
Fylnetra
|
J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Rolvedon
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Stimufend
|
C9399, J3490, J3590
|
|
ING-CC-0002
|
Preferred
|
Neulasta
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Neulasta OnPro
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Udenyca
|
Q5111
|
|
ING-CC-0002
|
Non-preferred
|
Fulphila
|
Q5108
|
|
ING-CC-0002
|
Non-preferred
|
Nyvepria
|
Q5122
|
|
ING-CC-0002
|
Non-preferred
|
Ziextenzo
|
Q5120
|
This is a courtesy notice that there is a non-material change in the clinical criteria for Orencia ING-CC-0078. The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s).
Quantity limit updates
Effective for dates of service on and after February 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)
|
|
ING-CC-0017
|
Xiaflex (collagenase clostridium histolyticum)
|
J0775
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0182
|
Feraheme (ferumoxytol)
|
Q0138
|
|
ING-CC-0182
|
Ferrlecit (ferric gluconate)
|
J2916
|
|
ING-CC-0182
|
Infed (iron dextran)
|
J1750
|
|
ING-CC-0182
|
Injectafer (ferric injection)
|
J1439
|
|
ING-CC-0182
|
Monoferric (ferric derisomaltose)
|
J1437
|
|
ING-CC-0182
|
Venofer (iron sucrose)
|
J1756
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
|
C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
|
C9399, J3490, J3590
|
Our Provider Experience team will host multiple pre-go-live provider orientation sessions:
- The general orientation will cover everything you need to know to work with Ohio Medicaid.
- The behavioral health (BH) orientation will cover the specifics of being a BH provider in Ohio. (We highly recommend that BH providers first attend a general orientation session.)
Below are the dates for our provider trainings. Check our provider website at https://providers.anthem.com/oh often to see new training dates as they are identified.
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Session
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Date
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Time (ET)
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General session
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November 3, 2022
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10 to 11 a.m.
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BH session
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November 3, 2022
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3 to 4 p.m.
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|
General session
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November 15, 2022
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10 to 11 a.m.
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BH session
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November 15, 2022
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3 to 4 p.m.
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Please register well in advance of the date you wish to attend to ensure the receipt of your invitation and meeting resources. To register for any of the dates above, go to the following site: https://chkmkt.com/OH-Provider-Training-Registration-Attestation.
If you have questions, please email OhioMedicaidProvider@anthem.com.
Beginning December 1, 2022, Availity* Essentials, the secure multi-payer portal ( availity.com), will allow access to Anthem Blue Cross and Blue Shield (Anthem) digital applications and training resources. Availity Essentials provides access to real-time information and instant responses in a consistent format, regardless of the payer.
If you have been using Availity Essentials for other Anthem plans, you will be able to seamlessly transition to using the portal for Medicaid members during patient check-ins and checkouts.
If you are new to Availity Essentials, register now for secure website access so your organization will be ready to benefit from easy, instant access to health plan information.
Some of the Availity Essentials multi-payer self-service features available for Anthem include:
- Eligibility and benefits including digital ID cards.
- Claims status.
- Claims disputes.
- Medical attachments.
- Authorization status and clinical appeals.
- Request an External Medical Review
To find additional digital applications exclusive to Anthem, visit Payer Spaces on Availity Essentials. Some of the most frequently used applications are:
- Chat with payer: Start a live chat to get questions answered through a real-time, online discussion.
- Custom Learning Center: Locate job aids and courses illustrating navigation of applications and electronic data interchange (EDI) transactions.
- Patient360: Access member-centric clinical and case management data.
- Precertification Look Up Tool: Verify if outpatient services require prior authorization.
- Provider online reporting: Retrieve Member Panel reports of members assigned to individual providers or groups.
- Remittance inquiry: View, print, and save a copy of your remittance advice.
Not registered with Availity Essentials? Take these steps to get started before December 1, 2022
First, your organization needs to assign an Availity Essentials administrator to initiate registration. To begin the process, the administrator should visit availity.com, select Register, and complete the online form. For more details on registration, visit Learn About Availity Portal Registration. The Portal Registration webpage includes a link with information on live webinars you can join on November 9 and December 7. An instructor will go through the steps necessary to register and get started on Availity Essentials.
As soon as you are registered as an administrator or a user on Availity Essentials, check out the Availity Learning Center (ACL) and begin taking on demand courses.
Availity offers on demand onboarding modules for new administrators and users. To access this Availity training, you need to be registered and have a user ID. These modules are located on the ALC. From the Availity Essentials top navigation bar, select Help & Training | Get Trained. For any course, search by keyword such as administrator onboarding or filter by category to locate the course.
Availity Essentials live training webinars for all providers servicing Anthem members
Join these training events beginning in mid-November. The sessions will cover the digital applications that will be available to use for the health plan. The instructor will demonstrate navigation and features of eligibility and benefits, claims disputes, medical attachments, and more. To enroll for a webinar session, log on to Availity, select Help & Training > Get Trained. The ALC catalog opens in a new browser tab. Enter ohbc in the search field to enroll for these live webinars. Registration for the webinars begins in mid-October.
Do you have questions regarding Availity Essentials registration?
Call Availity Client Services at 800-AVAILITY (800-282-4548). Availity Client Services is available Monday to Friday from 8 a.m. to 8 p.m. Eastern time (excluding holidays) to answer your registration questions.
Find courses and reference guides that will familiarize you with many of our self-service digital tools that you access through the Availity Essentials
Our digital tools are easy to use, and to get started you may need some tips on how to navigate these online applications to get the results you need. The Custom Learning Center has information that will help you get up and running quickly with many of our applications that you access through Payer Spaces. Additionally, you will find both videos and reference guides that will assist you with navigating Interactive Care Reviewer, our online authorization tool.
Follow these steps to access the Custom Learning Center Catalog and Resources
Access to the Custom Learning Center requires Availity Essentials registration. You are required to have your own unique user ID and password.
Login to Availity https://www.availity.com then from the home page, select Payer Spaces | Health plan tile | Applications | Custom Learning Center
The Custom Learning Center opens on the Catalog page where you will find videos and courses.
- You can use the Catalog filter and select a category to narrow your search results
- Click Apply if you select one of the filter categories
- Find the course(s) you want to take and select Enroll. Choose Start to take the course immediately or to save and take later, select Return to Dashboard
Select Resources from the upper left corner of Custom Learning Center to access reference guides
- You can use the Resources filter and select a category to narrow your search results
- Select Download to view and/or print the reference guide
As new online tools become available, we will continue adding job aids to the Custom Learning Center.
Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
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HCPCS or CPT® codes
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Medicare Part B drugs
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C9399, J3490, J3590, J9999
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Opdualag (nivolumab and relatlimab-rmbw)
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C9096
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Releuko (filgrastim-ayow)
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A9699
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Pluvicto (lutetium lu 177 vipivotide tetraxetan)
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Find Care, the doctor finder and transparency tool in the Anthem Blue Cross and Blue Shield (Anthem) online directory, provides Anthem members with the ability to search for in-network providers using the secure member website at www.anthem.com. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetic order, and provider name.
Beginning January 1, 2023, or later, an additional sorting option will be available for members to search by provider performance called Personalized Match. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Provider pairings with the highest overall ranking within the member’s search radius will be displayed first. Members will continue to have the ability to sort based on distance, alphabetic order, and provider name.
- You may review a copy of the Personalized Match methodology which has been posted on Availity* – our secure web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Anthem > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.
- If you have general questions regarding this new sorting option, please submit an inquiry via the web at availity.com.
- If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to availity.com.
Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.
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