 Provider News VirginiaFebruary 2021 Anthem Provider News - Virginia Contents State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2021 CAHPS® surveyState & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2021 Interpretation services
The Commonwealth of Virginia House Bill 1057 – Certified Nurse Specialist (CNS), which became effective July 1, 2020, allows CNS providers to be reimbursed directly for Covered Services performed within their scope of license. HB1057 removed the previous limitation that only allowed licensed CNS providers to be reimbursed for covered mental health services.
As a result of this legislation, Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. will now be contracting directly with Certified Nurse Specialists for these additional Covered Services so they may begin billing their services under their own 10-digit National Provider Identifier (NPI). Direct contracting means Certified Nurse Specialists should now bill Anthem directly and the “incident to” guidelines will no longer apply.
This impacts all lines of business:
- Anthem’s PAR/PPO/EPO health plans, including the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP).
- Anthem HealthKeepers commercial plans, including health plans purchased on or off the Health Insurance Marketplace (also known as the exchange).
- Anthem HealthKeepers Plus (Medicaid/FAMIS and the Commonwealth Coordinated Care Plus plans).
- Medicare Advantage health plans.
How Anthem’s credentialing and contracting process will work
We are offering contracts now with the expectation that all CNS providers working in a professional practice setting will begin the credentialing and contracting efforts immediately. This requirement does not apply to CNS providers who work strictly in a facility setting as these services are included in the facility reimbursement.
In most instances, CNS providers will be required to be credentialed through Anthem in Virginia. Therefore, CNS providers must complete the online application process through CAQH. [To contact CAQH, dial 888-599-1771 (Monday -Thursday 7 a.m. – 9 p.m. ET; Friday 7 a.m. - 7 p.m. ET), or visit the CAQH website at http://www.caqh.org/ucd_physician_register.php.]
Contracts may be requested through Availity.com. If you or your organization need guidance on the contracting process through Availity, please contact your Network Manager.
Other than the “provider type” description, the participation agreement will contain the same provisions and obligations as our standard provider agreements. Fee schedule allowances are clearly displayed in the Plan Compensation Attachment section of the contracts. CNS providers may choose between a Primary Care (PCP), Specialist, or Behavioral Health contract. While CNS providers may elect a PCP contract so that appropriate member cost-shares are applied in a PCP practice, members will not be able to select a CNS as a PCP. CNS providers should select the appropriate contract based on the type of services their office provides.
Benefits of direct contracting for CNS providers
This direct contracting and credentialing approach with Certified Nurse Specialists allows us to include these providers in our provider directories, and our members – your patients – can easily search our provider finder tool for CNS providers who participate with members’ health plans.
In addition, direct contracting with Certified Nurse Specialists will allow easier handling of Medicare crossover claims. Medicare crossover claims for services provided by Certified Nurse Specialists to our members with a secondary group coverage policy will process under the participating CNS provider’s record, all without any re-billing by the group under the physician’s NPI.
967-0221-PN-VAAnthem Blue Cross and Blue Shield (Anthem) and our affiliate HealthKeepers, Inc. will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.
We encourage providers who offer telehealth services to utilize the online Provider Maintenance Form to notify us, and we will add a telehealth indicator to your online provider directory profile.
Visit anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.
965-0221-PN-VA Effective for dates of service on and after May 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-0003 Immunoglobulins
- ING-CC-0011 Ocrevus (ocrelizumab)
- ING-CC-0041 Complement Inhibitors
- ING-CC-0048 Spinraza (nusinersen)
- ING-CC-0062 Tumor Necrosis Factor Antagonists
- ING-CC-0063 Stelara (ustekinumab)
- ING-CC-0071 Entyvio (vedolizumab)
- ING-CC-0121 Gazyva (obinutuzumab)
- ING-CC-0174 Kesimpta (ofatumumab)
- ING-CC-0183 Sogroya (somapacitan-beco)
961-0221-PN-VAEffective with dates of service on and after April 1, 2021, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, Anthem Blue Cross and Blue Shield will update our 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.
981-0221-PN-VA
Prior authorization updates
Effective for dates of service on and after May 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, 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. 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.
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 and are shown in italics in the table below.
This applies 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-0183
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J3590
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Sogroya
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*ING-CC-0001
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J0886
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Injection, epoetin alfa (Procrit/Epogen)
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*ING-CC-0019
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J3489
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Reclast, Zometa
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* Non-oncology use is managed byAnthem’s medical specialty drug review team. Oncology use is managed by AIM.
Quantity Limit Updates
Effective for dates of service on and after May 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Please note, 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. 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.
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 and are shown in italics in the table below.
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-0019
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J3489
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Reclast, Zometa
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979-0221-PN-VA 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 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 (FEP) Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
977-0221-PN-VA State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2021 DMAS 80 notifications: Update to fax numberPlease note, this communication applies to Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
HealthKeepers, Inc. would like to notify Anthem CCC Plus nursing facility and skilled nursing facility (SNF) providers on a change to the fax number for DMAS* 80 notifications. In an effort to streamline this process, effective December 1, 2020, DMAS 80 notifications should be sent to 1-844-430-6803 only.
In addition, we would like to provide some reminders of expectations for submitted DMAS 80 requests. Facilities should be reminded of some common submissions errors we see. Properly completing the DMAS 80 form allows HealthKeepers, Inc. to accurately and promptly complete the necessary steps required. This includes:
- Ensure to check the appropriate box for nursing facility or skilled nursing as appropriate.
- Ensure to check the appropriate box — yes or no — if there is a valid UAI. If the answer is no, please check the appropriate special circumstances. If related to COVID-19, please add a note on the form stating so.
- UAIs should be verified that is has been completed in its entirety and successfully submitted to the ePAS system before marking on the form that there is a valid UAI.
- Submitting DMAS 80s in a timely manner. Requests should be submitted when member is admitted for timely processing.
- The website is only updated for SNF admissions if the member is an Anthem CCC Plus and Medicare Advantage member. All other SNF DMAS 80 forms are for notification only.
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVAC-NU-0001-20State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2021 CAHPS® surveyPlease note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
CAHPS is an annual standardized survey conducted from January to May to assess consumers’ experience with their provider and health plan. A random sample of your adult and child patients may get the survey. Providers directly impact the majority of questions used for scoring.
These questions are:
- When you needed care right way, how often did you get it?
- How often did you get an appointment for a check-up or routine care as soon as you needed it?
- How often was it easy to get the care, tests, or treatment you needed?
- How often did you get an appointment to see a specialist as soon as you needed it?
- How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
- How would you rate your primary care doctor?
- How would you rate the specialist you see most often?
To learn more about CAHPS and how you can improve the patient experience, review the CAHPS Overview training by visiting https://mediproviders.anthem.com/va.
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVA-NU-0312-20
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2021 HEDIS® measurement year 2020: Medicaid summary of changes from NCQAPlease note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
Revised measures:
- The former Well-Child Visits in the First 15 Months of Life (W15) measure was revised to Well‑Child Visits in the First 30 Months of Life (W30). It includes two indicators:
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Well-child visits in the first 15 months — children who turned 15 months during the measurement year with six or more well-child visits
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Well-child visits for ages 15 to 30 months — children who turn 30 months during the measurement year with two or more well-child visits
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- The former Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) and Adolescent Well-Care Visits (AWC) measures have been combined into Child and Adolescent Well-Care Visits (WCV):
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The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year
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Key measure changes:
- Controlling High Blood Pressure (CBP and CDC-CBP)
Telephone visits, e-visits and virtual check-ins are now acceptable settings for blood pressure (BP) readings. Digital BP readings reported by the member are considered numerator compliant.
- Telehealth updates
NCQA has updated telehealth guidance in 40 HEDIS® measures for HEDIS measurement years 2020 and 2021. The purpose of these changes is to:
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Support increased use of telehealth caused by the pandemic.
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Align with guidance from Centers for Medicare & Medicaid Services and other stakeholders.
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A list of the 40 measures can be found on the NCQA COVID-19 website at www.ncqa.org/covid.
New Medicaid measures:
Kidney Health Evaluation for Patients With Diabetes (KED) — The percentage of members 18 to 85 years of age with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a uACR identified by both a quantitative urine albumin test and a urine creatinine test with service days four or less days apart during the measurement year
Cardiac Rehabilitation (CRE) — The percentage of members 18 years and older who attended cardiac rehabilitation following a qualifying cardiac event, including myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, heart and heart/lung transplantation, or heart valve repair/replacement; four rates are reported:
- Initiation — The percentage of members who attended two or more sessions of cardiac rehabilitation within 30 days after a qualifying event
- Engagement 1 — The percentage of members who attended 12 or more sessions of cardiac rehabilitation within 90 days after a qualifying event
- Engagement 2 — The percentage of members who attended 24 or more sessions of cardiac rehabilitation within 180 days after a qualifying event
- Achievement — The percentage of members who attended 36 or more sessions of cardiac rehabilitation within 180 days after a qualifying event
Retired Medicaid measures:
- Comprehensive Diabetes Care (CDC) retired sub-measures —
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Medical Attention for Nephropathy (retired for Commercial and Medicaid)
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HbA1c control (< 7.0%) for a selected population
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- Adult BMI Assessment (ABA)
- Medication Management for People With Asthma (MMA)
- Children’s and Adolescents’ Access to Primary Care Practitioners (CAP)
Measure change summary:
For a complete summary, go to https://tinyurl.com/NCQA-measures.
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVA-NU-0319-20State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2021 Interpretation servicesPlease note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
Effective January 1, 2021, HealthKeepers, Inc. will no longer offer in-person/face-to-face interpretation services for Anthem HealthKeepers Plus members and will only offer telehealth and voice interpretation services, unless, at the sole discretion of HealthKeepers, Inc., a special situation or circumstance requires in-person interpretation services. For cases that members and/or providers believe in-person interpretation services are necessary, such as members or parents/guardians needing assistance with reviewing and completing required provider documentation, the members or providers must receive prior authorization approval by HealthKeepers, Inc. If there is a unique situation that requires face-to-face interpretation, members or providers may contact our customer service teams to submit the authorization request.
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVA-NU-0323-20
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2021 Medical drug benefit Clinical Criteria updatesPlease note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the Anthem HealthKeepers Plus medical drug benefit for HealthKeepers, Inc. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
AVA-NU-0328-20State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2021 Availity Portal eligibility and benefits provides both additional benefit notes and digital member ID CardsPlease note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
New: Additional benefit detail
Now, you can select Additional Benefit Notes, on the Availity Portal* Eligibility and Benefits results screen to find more descriptive benefit information.
Benefits are listed in alphabetical order, making it easier to search for specific benefits. Capabilities include full benefit descriptions, vendor information associated with the benefit and the option for the provider to print out the benefit information.
Digital member ID cards
The digital member ID card allows easy, low-touch access to view additional information or confirm basic membership details.
When conducting an eligibility and benefits inquiry for Anthem HealthKeepers Plus members, simply select View Member ID Card on the Eligibility and Benefits results page. Note: The Availity Portal requires you to enter the member’s ID number, as well as a date of birth or the member’s first and last name into the search options in order to submit an eligibility and benefits inquiry.
Try both of these valuable tools today.
AVA-NU-0330-20State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2021 Keep up with Medicaid newsOn November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC (AMH Health). These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020 Anthem and Clinical Criteria Web Posting September and October 2020 AMH Health. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
ABSCRNU-0202-20
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