 Provider News VirginiaAugust 1, 2021 August 2021 Anthem Provider News - VirginiaAnthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. introduced a more streamlined provider payment dispute process for claims for members enrolled in our Anthem HealthKeepers Plus (Medicaid) and Medicare Advantage benefit plans. Effective August 17, 2021, this claim payment dispute process will now be available for providers to use regarding Anthem’s Commercial lines of business. (Please note that this notice does not apply to the Blue Cross and Blue Shield Service Benefit Plan also called Federal Employee Program® or FEP.®)
Unlike claims status inquiries, clinical appeals, or requests for additional information, provider claim payment disputes occur after a claim is finalized, and providers disagree with the claim payments Anthem has issued. Some examples include claim disputes regarding manual processing errors, contract interpretation, reduced payments, code editing issues, other health insurance denials, eligibility issues, timely filing issues,* and so forth.
By aligning the provider claim dispute process across our lines of business, we’re working to have a more cohesive and efficient approach for providers when:
- Filing a claim payment dispute.
- Sending supporting documentation to Anthem.
- Checking the status of a claim payment dispute.
- Viewing the history of a claim payment dispute.
* We will consider reimbursement of a claim that has been denied due to failure to meet timely filing if you can: 1) provide documentation that the claim was submitted within the timely filing requirements; or 2) demonstrate good cause exists.
How the provider claim payment dispute process works
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For Anthem in Virginia, the provider claim payment dispute process consists of two steps:
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STEP 1
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Claim payment reconsideration: As the first step, the reconsideration represents providers’ initial request for an investigation into the outcome of the claim. Most issues are resolved at the claim payment reconsideration step. Providers may submit the claim dispute via customer service (refer to the phone number on the back of the member’s ID card), in writing or via Availity. However, providers are encouraged to submit all reconsiderations via Availity. Providers are only allowed one claim payment reconsideration per claim.
Anthem will make every effort to resolve the claims payment reconsideration within 30 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 30 additional calendar days. We will mail you a written extension letter before the expiration of the initial 30 calendar days.
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STEP 2
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Claim payment appeal: In this second step, providers who disagree with the outcome of the reconsideration may request an additional review as a claim payment appeal. However, we cannot process an appeal without a reconsideration on file. Providers may submit the claim dispute in writing or via Availity, but providers are encouraged to submit all appeals via Availity.
When submitting a claim payment appeal, please include as much information as you can to help us understand why you think the reconsideration determination was in error. If a claim payment appeal requires clinical expertise, it will be reviewed by appropriate Anthem clinical professionals.
Anthem will make every effort to resolve the claim payment appeal within 60 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 60 additional calendar days. We will mail you a written extension letter before the expiration of the initial 60 calendar days.
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Submitting claim payment disputes in writing
When submitting a claim payment dispute in writing, providers must include the Claim Information/ Adjustment Request 151 Form and submit to:
Anthem Blue Cross and Blue Shield
Provider Payment Disputes
P.O. Box 27401
Richmond, VA 23279
Submitting claim payment disputes via Availity
For step-by-step instructions to submit a claim payment dispute through Availity:
- Log into Availity at availity.com .
- Select Help & Training | Find Help.
- Under Contents, select Overpayments and Appeals.
- Select Dispute a Claim.
Through Availity, you can upload supporting documentation and receive immediate acknowledgement of your submission. You do not need to attach a Claim Information/Adjustment Request 151 Form for Commercial claims or a Claim Payment Appeal Form when using Availity.
Anthem’s review and providers’ other options
Anthem will review the claim payment dispute once received and communicate an outcome in writing or through the Availity Portal. Providers can check the status of a claim payment dispute on the Availity portal at any time.
If a provider still disagrees with the reconsideration, the provider can then choose to submit the claim payment appeal. Once the claim payment appeal is submitted, the decision is final. A claim payment dispute may not be submitted again. Providers can contact their state regulatory agency for additional assistance.
Anthem requires providers to use our claims payment reconsideration process if providers feel a claim was not processed correctly.
Once providers complete both the Reconsideration and Appeal processes, providers can contact their Provider Experience Consultant for further assistance. However, providers are required to complete both the Reconsideration and Appeal processes before contacting their Provider Experience Representative for further assistance.
Webinars available
To learn more about the claim dispute tool, register for a live webinar:
- Log in to Availity and select Help & Training | Get Trained.
- Select Sessions and go to Your Calendar to locate a webinar.
- Select View Course and then select Enroll.
- The Availity Learning Center will email you with instructions to attend.
As always, providers can refer to the Provider Manual in their provider contracts, as the manual includes additional information about inquiries, the provider claim dispute process, reconsiderations and appeals. As a reminder, the above notice does not impact the Federal Employee Program.
In July, Anthem Blue Cross and Blue Shield advised of the delay in the implementation of our new data management system called Strategic Provider System (SPS), which was first announced in the June 2021 edition of Provider News. We are pleased to advise that SPS will now be implemented in August – replacing our legacy internal provider data management system for Anthem providers. This investment in advanced technology will significantly improve provider data accuracy and transparency, enhancing the overall provider experience. New system features strengthen Anthem’s ability to match submitted claims for more accurate pricing and processing.
System upgrades special notice
Anthem will be implementing SPS upgrades August 6 through August 12. Provider updates submitted during this time will be processed after August 12. We appreciate your patience as we upgrade our systems.
Next Steps: New Provider Data Maintenance coming soon
Beginning September, the second phase of our improvement will be integration with Availity’s Provider Data Management (PDM) functionality, which will roll out in phases. Through this tool, providers can view, maintain, update, and attest that provider demographic information is accurate for Anthem (and other health plans) in one easy-to-use portal. This service will replace Anthem’s Provider Maintenance Form in the coming months. The PDM service also features a simplified quick verification process that enables providers to complete the required verifications online – eliminating the need to fax, email or use separate online forms.
Get ready for the change today
If your organization is not already registered on the Availity Portal, we strongly encourage you to get started right away. Your organization’s designated administrator can go to https://www.availity.com to register and to find other helpful information about using Availity. Availity is Anthem’s secure provider portal platform where providers can enjoy the convenience of digital transactions including prior authorization submission, claims submission, and benefit and eligibility look-up.
IMPORTANT NOTE:
For claims submitted after August 12 without a billing national provider identifier (NPI), Anthem will deny those claims. Submitting claims with complete and correct data is critical to ensure that Anthem is able to process your claims efficiently and accurately. Please submit your full address including your line 2 address (suite number, unit, etc.) when applicable. All data fields on claims are used when building your claim record. Review your billing practices carefully to ensure provider tax identification number (TIN), billing NPI, taxonomy code, and servicing/rendering provider information (if applicable) are submitted in the appropriate fields.
3072F: New language about two-year compliance
The Comprehensive Diabetes Care HEDIS® Measure Retinal Eye Exam (DRE) valuates the percent of adult members ages 18 to 75, with diabetes (type 1 and type 2), who had a retinal eye exam during the measurement year.
Changes to 3072F
The definition for the code 3072F (negative for retinopathy) has been redefined to: Low risk for retinopathy (no evidence of retinopathy in the prior year). This can be particularly confusing because it would not be used at the time of the exam. It would be used the following year, along with the exam coding for the current year, to indicate that retinopathy was not present the previous year.
A simpler coding solution
Using these three codes count toward the DRE measurement if they are billed in the current measurement year, or the prior year. This means you can submit the appropriate code at the time of the exam, and it covers both years:
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2023F
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Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)
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2025F
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7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed: without evidence of retinopathy (DM)
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2033F
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Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed: without evidence of retinopathy (DM)
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For more about diabetic retinopathy, visit CMS.gov or use this link to read more.
Meeting the measurement for all diabetes care
These exams are also important in evaluating the overall health of diabetic patients, as well as meeting the Comprehensive Diabetes Care HEDIS measure:
- Hemoglobin A1c (HbA1c) testing
- HbA1c poor control (>9.0%)
- HbA1c control (<8.0%)
- Retinal Eye exam performed
- Blood Pressure control (<140/90 mm Hg)
Record your efforts in the member’s medical records for the HbA1c tests and results, retinal eye exam, blood pressure, urine creatinine test and the estimated glomerular filtration rate test. Meeting the mark and closing gaps in care is key to good health outcomes.
Overview
Join us throughout the year in a new Continuing Medical Education (CME) webinar series, as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving STARs ratings.
Program objectives
- Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas.
- Apply the knowledge you gain from the webinars to improve your organization’s quality and STARs ratings.
Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.
REGISTER HERE for our upcoming clinical quality webinars.
We’re making it even easier for you to schedule online appointments through the Appointment Scheduler App on Availity. The Appointment Scheduler App gives you secure access to new appointment requests. You’ll also receive digital access to the member’s ID number, contact information and any special health information.
Appointment Scheduler App features include:
- Manage appointment requests
- Configure appointment availability
- Notification of new visit requests on Availity dashboard
- Members are notified by text or email when appointments are confirmed
Administrators, administrator assistants and users with the role of “office staff” will have access to the Appointment Scheduler App.
To access Appointment Scheduler, log onto Availity.com and select Anthem from Payer Spaces. The Appointment Scheduler App will be located in your Applications menu. To learn more about the new App, go to the Custom Learning Center in Availity and search by the keyword Appointment Scheduler.
Reductions in missed appointments are significant
Telehealth visits are having a significant impact on missed appointments according to a study published in Counselling Psychology Quarterly. Prior to transitioning to telehealth, clinicians in the study “Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice,1” experienced a 14.25% missed appointment rate. After transitioning to telehealth, the missed appointment rate fell to 5.63%.
Rate of missed appointments before and after transitioning to telehealth
The graph below illustrates the changes in the average rate of missed appointments (cancellations and no-show) for each of the eight clinicians in the study between the periods before and after the transition to telehealth.
https://www.tandfonline.com/doi/full/10.1080/09515070.2020.1777390
“While there are a number of limitations to consider regarding this data, [which is further discussed in the study], the statistically significant reduction in missed appointments pre-and-post [digital] transition is striking,” cited in the study report.
Telehealth and telephone visits with members after a behavioral health (BH) inpatient stay meet HEDIS® criteria for the measure: Follow-up after Hospitalization for Mental Illness (FUH). With transportation being one of the barriers to after hospitalization follow-up, telehealth visits could be an ideal solution.2
The FUH HEDIS measure evaluates:
- Members (6 years and older) who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.
Two areas of importance for this HEDIS measure are:
- The percentage of behavioral health inpatient discharges for which the member received follow-up within 7 days after discharge.
- The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.
These two consecutive follow-up appointments are paramount to positive outcomes as well as meeting this HEDIS measure. Telehealth visits can greatly increase the likelihood of keeping follow-up appointments leading to reduced numbers of rehospitalization and more favorable outcomes for these patients. To learn more about the FUH HEDIS measure, visit the NCQA website.
Effective November 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will transition the clinical criteria for medical necessity review of Computed Tomography to detect Coronary Artery Calcification to AIM Imaging of the Heart Clinical Appropriateness Guideline.
As part of this transition of clinical criteria, the following procedures will be subject to prior authorization at AIM:
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CPT code
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Description
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75571
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Computed tomography, heart, without contrast material, with quantitative evaluation of coronary artery calcium
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S8092
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Electron beam CT (also known as ultrafast CT, cine CT)
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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: 866-789-0397, Monday - Friday, 8 a.m. to 5 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.
Anthem Blue Cross and Blue Shield will implement the following clinical guideline effective November 1, 2021, to support the review for parenteral nutrition given in the home setting.
To view the guideline for Home Parenteral Nutrition (CG-MED-89), select CG-MED-89 Home Parenteral Nutrition. To view other guidelines, follow these navigation instructions:
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VISIT www.anthem.com
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SELECT:
· Providers
· Policies, Guidelines & Manuals under Provider Resources
· Virginia if you’ve not already done so for the state
· View Coverage Guidelines & Clinical UM Guidelines
· Either Full list page link or enter a key word or code to search for guideline
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For questions, please contact the provider service number on the back of the member's ID card.
The following guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on May 13, 2021. Revisions have been made to the coding which may result in services previously considered medically necessary to now be considered not medically necessary for dates of service (DOS) on or after November 1, 2021.
These guidelines impact all our products – with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).
The services addressed in these guidelines will require authorization for all of our HealthKeepers, Inc. products – with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage and the Commonwealth Coordinated Care Plus plan. A pre-determination can be requested for our PPO products. Please note that FEP is excluded from this requirement as well.
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Guideline
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Code(s)
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CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
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31237, 31253, 31257, 31259
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CG-SURG-27 Gender Affirming Surgery
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53410, 53420, 53425, 53430
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CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
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20982
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Effective November 1, 2021, in order to help ensure our members’ security, the Blue Cross and Blue Shield Service Benefit Plan also called Federal Employee Program (FEP® ) will be decommissioning the Utilization Management (UM) email address for processing eReviews of service requests – FEPE-Reviews@anthem.com. As an alternative, FEP offers providers a secure online tool – lnteractive Care Reviewer (ICR).
About Interactive Care Reviewer
ICR is Anthem’s innovative UM app that allows providers, in addition to phone or fax, to submit prior authorization requests and to provide clinical documentation (including imaging) to support initial and continued stay reviews. This enables prior authorization requests and clinical information to be transmitted directly to UM staff.
Key features of the tool
- No cost electronic UM solution
- Instant access from any location at any time
- Create a UM preauthorization case and instantly submit it for review
- Attach clinical documents for review – no faxing required
- Check status of any case regardless of the method used to originally submit request
- Complete record of submissions and dispositions – all in one place
- Bi-directional communication
To submit prior authorization service requests through ICR, your organization needs to be registered with Availity and each user needs to be assigned the Authorization and Referral Request role prior to November 1, 2021.
For more information on Anthem ICR, including training resources: https://www.anthem.com/provider/prior-authorization/interactive-care-reviewer/
Register for Availity: https://www.availity.com/provider-portal-registration
Need help registering? View this video: How to Access Availity and Register
As a reminder, in addition to using ICR on the Availity portal, you can submit authorizations to FEP UM by phone or fax:
- FEP UM precertification toll free phone number: 800-860-2156
- FEP UM precertification fax number: 800-732-8318
- FEP UM advance benefit determination fax number: 877-606-3807
Providers treating members covered by Anthem plans will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications (see list below). Reviews for these oncology drugs will continue to be administered by AIM Specialty Health® (AIM).
As part of the online prior authorization process, providers will be asked about the dosage of the medication being requested in pop-up questions:
- Whether or not the recommended dose reduction is acceptable
- If the patient is considered unable to have his or her dose reduced, then a second question will appear asking for the provider’s clinical reasoning.
For prior authorization requests made outside of the online AIM Provider Portal (for example, via phone or fax), the same questions will be asked by the registered nurse or medical director reviewing the request. Since this program is voluntary, the decision made regarding dose reduction will not affect the final decision on the prior authorization.
The dose reduction questions will appear only if the originally requested dose is within 10 percent of the nearest whole vial. This threshold is based on the current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) it is appropriate to consider dose rounding within 10 percent. View the HOPA recommendations.
The voluntary dose reduction program only applies to the specific oncology drugs listed below. Providers can view prior authorization requirements for Anthem members on the Coverage Guidelines & Clinical UM Guidelines page at anthem.com.
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Drug Name
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HCPCS Code
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Drug Name
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HCPCS Code
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Abraxane (paclitaxel protein-bound)
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J9264
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Kadcyla (ado-trastuzumab emtansine)
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J9354
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Actimmune (interferon gamma-1B)
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J9216
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Kanjinti (trastuzumab-anns)
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Q5117
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Adcetris (brentuximab vedotin)
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J9042
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Keytruda (pembrolizumab)
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J9271
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Alimta (pemetrexed)
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J9305
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Kyprolis (carfilzomib)
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J9047
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Asparlas (calaspargase pegol-mknl)
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J9118
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Lumoxiti (moxetumomab pasudotox-tdfk)
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J9313
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Avastin (bevacizumab)
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J9035
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Mvasi (bevacizumab-awwb)
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Q5107
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Bendeka (bendamustine)
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J9034
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Mylotarg (gemtuzumab ozogamicin)
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J9203
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Besponsa (inotuzumab ozogamicin)
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J9229
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Neupogen (filgrastim)
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J1442
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Blincyto (blinatumomab)
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J9039
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Ogivri (trastuzumab-dkst)
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Q5114
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Cyramza (ramucirumab)
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J9308
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Oncaspar (pegaspargase)
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J9266
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Darzalex (daratumumab)
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J9145
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Ontruzant (trastuzumab-dttb)
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Q5112
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Doxorubicin liposomal
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Q2050
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Opdivo (nivolumab)
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J9299
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Elzonris (tagraxofusp-erzs)
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J9269
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Padcev (enfortumab vedotin-ejfv)
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J9177
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Empliciti (elotuzumab)
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J9176
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Polivy (polatuzumab vedotin-piiq)
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J9309
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Enhertu (fam-trastuzumab deruxtecan-nxki)
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J9358
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Riabni (rituximab-arrx)
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Q5123
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Erbitux (cetuximab)
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J9055
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Rituxan (rituximab)
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J9312
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Erwinase (asparginase)
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J9019
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Ruxience (rituximab-pvvr)
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Q5119
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Ethyol (amifostine)
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J0207
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Sarclisa (isatuximab-irfc)
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J9227
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Granix (tbo-filgrastim)
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J1447
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Sylvant (siltuximab)
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J2860
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Halaven (eribulin mesylate)
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J9179
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Trazimera (trastuzumab-qyyp)
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Q5116
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Herceptin (trastuzumab)
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J9355
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Treanda (bendamustine)
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J9033
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Herzuma (trastuzumab-pkrb)
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Q5113
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Truxima (rituximab-abbs)
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Q5115
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Imfinzi (durvalumab)
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J9173
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Vectibix (panitumumab)
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J9303
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Istodax (romidepsin)
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J9315
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Yervoy (ipilimumab)
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J9228
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Ixempra (ixabepilone)
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J9207
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Zaltrap (ziv-aflibercept)
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J9400
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Jevtana (cabazitaxel)
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J9043
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Zirabev (bevacizumab-bvzr)
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Q5118
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Note: In some plans “dose reduction to nearest whole vial” or another term “waste reduction” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “dose reduction to nearest whole vial” and in some plans, these terms may be used interchangeably. For simplicity, we will hereafter use “dose reduction (to nearest whole vial).”
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the back of the member’s ID card.
Anthem Blue Cross and Blue Shield (Anthem) is committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.
Effective with dates of service on or after August 1, 2021, providers treating members covered by Anthem Commercial plans may be asked to consider voluntarily reducing the requested dose to avoid vial wastage for select non-oncology specialty medications The dose reduction suggestion will only be made if the originally requested dose is within 10% of the nearest whole vial.
Since this program is voluntary, the decision to participate will not affect the final decision on the prior authorization.
Reviews for these specialty drugs will continue to be administered by IngenioRx®.
As part of the prior authorization process, providers may be asked the following questions:
- Whether the suggested dose reduction is clinically acceptable
- Clinical reasoning if the dose reduction is not appropriate
Providers can view prior authorization requirements for Anthem members on the Coverage Guidelines & Clinical UM Guidelines page at anthem.com.
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the back of the member’s ID card.
Anthem Blue Cross and Blue Shield (Anthem) is committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.
Effective with dates of service on or after August 1, 2021, providers treating members covered by Anthem Commercial plans may be asked to consider voluntarily using adjusted body weight (AdjBW) dosing compared to actual body weight (ABW) dosing for immune globulin medications. The dose change using AdjBW will only be made if the member’s actual body weight is more than 20% of the ideal body weight (IBW).
Since this program is voluntary, the decision to participate will not affect the final decision on the prior authorization.
Reviews for the immune globulin medications will continue to be administered by IngenioRx® as these will specifically target specialty non-oncology indications.
As part of the prior authorization process, providers may be asked the following questions:
- Whether the suggested use of AdjBW and change in dose is clinically acceptable
- Clinical reasoning if the dose change (using AdjBW) is not appropriate
Providers can view prior authorization requirements for Anthem members on the Coverage Guidelines & Clinical UM Guidelines page at anthem.com.
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the back of the member’s ID card.
Effective for dates of service on and after November 1, 2021, the following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
For Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc., prior authorization of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require prior authorization by AIM Specialty Health® (AIM), a separate company. This applies to members with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
Access the clinical criteria document information.
- ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0128 Tecentriq (atezolizumab)
- ING-CC-0160 Vyepti (eptinezumab)
- ING-CC-0198 Relizorb (immobilized lipase) cartridge
Effective with dates of service on and after October 1, 2021, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, 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.
Prior authorization updates
Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
The Health Plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code (NDC), for the injected substance. This requirement is consistent with CMS guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.
Please note, inclusion of National Drug Code code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Access the Clinical Criteria information.
For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.
This would apply to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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**ING-CC-0196
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J3490, J9999, J3590
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Zynlonta
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**ING-CC-0197
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J3490, J3590, J9999
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Jemperli
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*ING-CC-0199
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J3490, J3590, C9399
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Empaveli
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* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
Quantity limit updates
Effective for dates of service on and after November 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process. The Health Plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code, for the injected substance. This requirement is consistent with CMS guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.
Inclusion of the NDC code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified code.
Access the Clinical Criteria information.
For Anthem Blue Cross and Blue Shield and HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.
This would apply to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0199
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J3490. J3590, C9399
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Empaveli
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* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit anthem.com/pharmacyinformation. The Commercial Virginia and marketplace drug lists are posted to the website quarterly (the first of the month for January, April, July and October).
To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
Federal Employee Program Pharmacy (FEP) updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2021 Adding 87081 to Physician Office Lab listPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Effective June 1, 2021, HealthKeepers, Inc. added CPT® code 87081 to the Physician Office Lab (POL) list for our Anthem HealthKeepers Plus members only.
Providers with the appropriate Clinical Laboratory Improvement Amendments (CLIA) certification to perform this test in their office laboratories may begin performing this test in their office labs effective immediately, and submit claims directly to HealthKeepers, Inc. for payment.
This change is for Anthem HealthKeepers Plus members only, and does not apply to our Commercial, Medicare Advantage, Federal Employee Program, or any other lines of business.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2021 Enrollment for Northern Virginia area is open now through August 31, 2021Please note, this communication applies to Anthem HealthKeepers Plus and Medallion offered by HealthKeepers, Inc.
With enrollment currently open in Northern Virginia, it is now time when your patients can switch to the Anthem HealthKeepers Plus plan. Your patients will still get all the Medicaid benefits they expect, such as doctor visits, prescriptions, and a 24/7 NurseLine at no cost.
However, Anthem HealthKeepers Plus members receive additional benefits, such as:
- Free rides to grocery stores, farmers markets, and food banks.
- Free general education development (GED) testing.
- A $25 gift card for high school and college students with A’s and B’s.
- Meals delivered to their home after a hospital stay — two meals a day for seven days.
- Free diapers, an umbrella, a stroller, and children’s books.
HealthKeepers, Inc. is excited to announce new Anthem HealthKeepers Plus incentives starting July 1, 2021:
- One eye exam every other year
- Up to $100 for glasses (frames and lenses) or contacts every year
Provide this information to your patients so they can switch to the state’s largest Medicaid plan now.
For more information, your patients can visit https://virginiamanagedcare.com, https://providers.anthem.com/va, or call the Managed Care Helpline at 800-643-2273.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2021 Closing gaps in care through telehealthPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Telehealth is quickly growing into a major part of the healthcare ecosystem, and the COVID-19 pandemic only furthered that acceleration. In fact, the National Committee for Quality Assurance (NCQA) updated their HEDIS® quality measures in response to this recent surge. Aside from offering convenience to patients, telehealth can greatly reduce gaps in care for our Anthem HealthKeepers Plus members.
The pandemic has certainly shed light on many aspects of our society, but one thing is for sure: access to quality care is more important than ever.
Why telehealth matters
Our members have challenges with transportation, childcare, taking time off from work, and other responsibilities, which can make it difficult to get to the office. Telehealth can reduce these barriers by:
- Providing virtual doctor visits completed from the comfort of home.
- Making it easier to access care for patients with mobility issues and/or in rural areas.
- Removing the need to arrange for transportation or childcare.
- Offering appointments conducive to busy schedules.
Telehealth offers improved patient experience and satisfaction, and it also represents a significant reduction in missed appointments or no shows. Telehealth may not be appropriate in all situations, but for routine or follow‑up visits, it may benefit both the patient and provider.
Types of visits ideal for telehealth
Behavioral health:
- Antidepressant Medication Management
- Follow-Up Care for Children Prescribed ADHD Medication
- Follow-Up After Emergency Department Visit for Mental Illness
Primary care and chronic condition management:
- Controlling High Blood Pressure
- Statin Therapy for Patients with Cardiovascular Disease
- Comprehensive Diabetes Care
- Asthma Medication Ratio
Prenatal ─ routine, follow-ups, low-risk pregnancies:
- Well-Child Visits in the First 30 Months of Life
- Child and Adolescent Well Visits
Reimbursement
Be sure to code correctly for telehealth visits. See our HEDIS Telehealth-Eligible Measures Coding bulletin located on the provider website for more information.
Continuing education opportunity
We are offering one continuing medical education (CME) credit/continuing education unit (CEU) for an upcoming training titled Telehealth 2.0 - Building a Sustainable Model on September 9, 2021, at noon ET. An on-demand recording will also be available for your convenience.
Sign up for the session today.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2021 Keep up with Medicaid newsWe want you to have the information you need when filing claims for our Medicare Advantage members so your payments are received quickly and effortlessly. The shingles vaccine and the administration of the vaccine is commonly billed in error under the member’s Medicare Part B medical benefit. The shingles vaccination is a Medicare Part D pharmacy benefit, which requires the member to pay in advance of reimbursement. The member then submits the prescription drug claim form to their Medicare Part D plan for reimbursement.
You can also refer the member to the pharmacy for the vaccine. The claim is usually filed for the member by the pharmacy provider using a clearinghouse platform that enables Medicare Part D claims transactions. Or, if you have access to clearinghouse platforms that enable you to file pharmacy transactions, that is another option for administering the vaccination in your office and for further serving the member.
The Centers for Medicare & Medicaid Services (CMS) has a helpful resource, MLN Fact Sheet: Medicare Part D Vaccines, that offers an all-inclusive look into patient access, vaccine administration, and reimbursement. Use this link to download a copy.
We want you to have all the information you need to know best: More information about filing claims.
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