 Provider News VirginiaFebruary 2022 Anthem Provider News - Virginia Contents Products & Programs | Anthem Blue Cross and Blue Shield | Commercial | February 1, 2022 Cancer Care Navigator
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. We are asking you to review your online provider directory information to help ensure members enrolled in health benefit plans offered by Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. can locate the most current information for in-network providers and facilities.
You can help us ensure your online provider directory information is current by:
- Reviewing your online provider directory information on a regular basis to ensure it is correct. You can check your directory listing on Anthem’s Find Care Consumers, members, brokers, and providers use the Find Care tool to identify in-network physicians and other healthcare providers supporting member health plans. To ensure we have your most current and accurate information, please take a moment to access Find Care. Go to anthem.com, select Providers, then under Provider Overview, choose Find Care.
- Submitting updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:
|
Add/change an address location
|
|
Name change
|
|
Taxpayer identification number changes
|
|
Provider leaving a group or a single location
|
|
Phone/fax number changes
|
|
Closing a practice location
|
Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for Virginia for complete instructions.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is an annual standardized survey conducted starting February 2022 through May2022 to assess consumers’ experience with their provider and health plan. A random sample of your adult or child patients may get the survey. Over half of the questions used for scoring are directly impacted by providers. These questions are:
- When you needed care right way, how often did you get care as soon as you needed?
- How often did you get an appointment for a check-up or routine care as soon as you needed?
- 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?
- How often did your personal doctor seem informed and up to date about the care you got from other doctors or other health providers?
- How would you rate your personal doctor?
- How would you rate the specialist you see most often?
- How would you rate all your health care in the last 6 months?
Interested in how you can improve CAHPS performance? Anthem Blue Cross and Blue Shield offers an online course for providers and office staff designed to learn how to improve communication skills, build patient trust and commitment, and expand your knowledge of the CAHPS survey. The Improving the Patient Experience course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. It can be accessed at: https://www.mydiversepatients.com/le-ptexp.html
National Wear Red Day is a great way to keep heart aware. It is also a great opportunity to have a conversation with your patients about their heart health. The Centers for Disease Control and Prevention (CDC) has information you can share with your patients, including a helpful Know the Facts about Heart Disease flyer that’s free for healthcare professionals.
Controlling high blood pressure, diabetes, extra weight and unhealthy diets are heart disease contributors that you can help your patients recognize. For information about these heart disease risks to share with your patients, use the CDC website for toolkits, flyers and give-a-ways.
Measure up: Controlling high blood pressure (CBP)
Known as the “silent killer,” high blood pressure or hypertension increases the risk of heart disease.
The HEDIS® measure CBP looks at the percentage of patients 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (140/90) in the measurement year. Record all blood pressure readings and the dates they were taken being sure to record the exact reading. Blood pressure readings captured during a telehealth, virtual care, telephone or e-visit should also be recorded.
Measure up: Statin therapy for patients with cardiovascular disease and diabetes (SPC/SPD)
Statins are effective at lowering cholesterol and protecting against a heart attack and stroke. Patients with diabetes also have elevated cardiovascular risk.
- Statin therapy for patients with cardiovascular disease (STC). HEDIS measure assesses males 21-75 years of age and females 40-75 years of age who have clinical atherosclerotic cardiovascular disease and who received and adhered to statin therapy.
- Statin therapy for patients with diabetes (STD) assesses adults 40 to 75 years of age who have diabetes and who do not have clinical ASCVD, who received and adhered to statin therapy.
Adherence to prescribed medication is key to patient care and SPC/SPD measure success.
The Cancer Care Navigator (CCN) program is a comprehensive cancer support solution for oncologists and Anthem Blue Cross and Blue Shield (Anthem) members who are at high risk for complications during treatment. This program is aimed at helping to simplify the complexities of cancer care for members.
Providers are given a single point of contact to connect the practice to the right people at Anthem to help lessen administrative burdens. CCN also gives the practice access to Anthem’s advanced predictive analytics to help identify patients at high risk for complications, in turn allowing providers the opportunity to take preventive action and guide targeted interventions.
Patients are provided with a wealth of support through supplemental services (dietitians, pharmacists, etc.), medication adherence assistance, individualized care plans, and goal setting, as well as after-hours telephonic and digital support.
CCN is the ultimate support service to improve the care experience and quality of life to allow patients time to focus on overall health and well-being. Please feel free to reach out to the CCN team at 1-833-649-0669.
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. 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.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
Please note, inclusion of National Drug Code (NDC) 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, 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.
Prior authorization updates
Effective for dates of service on and after May 1, 2022, 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-0204
|
Tivdak
|
J3490, J3590, J9999
|
|
ING-CC-0072
|
Byooviz
|
J3590
|
|
ING-CC-0068
|
Skytrofa
|
J3490
|
* Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after May 1, 2022, 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.
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-0072
|
Non-Preferred
|
Byooviz
|
J3590
|
* Oncology use is managed by AIM.
Quantity limit updates
Effective for dates of service on and after May 1, 2022, 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-0072
|
Byooviz
|
J3590
|
* Oncology use is managed by AIM.
Effective for dates of service on and after May 1, 2022, 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-0001
|
Erythropoiesis Stimulating Agents
|
|
ING-CC-0042
|
Monoclonal Antibodies to Interleukin-17
|
|
ING-CC-0043
|
Monoclonal Antibodies to Interleukin-5
|
|
ING-CC-0049
|
Radicava (edaravone)
|
|
ING-CC-0050
|
Monoclonal Antibodies to Interleukin-23
|
|
ING-CC-0063
|
Stelara (ustekinumab)
|
|
ING-CC-0064
|
Interleukin-1 Inhibitors
|
|
ING-CC-0065
|
Agents for Hemophilia A and von Willebrand Disease
|
|
ING-CC-0066
|
Monoclonal Antibodies to Interleukin-6
|
|
ING-CC-0068
|
Growth Hormone
|
|
ING-CC-0071
|
Entyvio (vedolizumab)
|
|
ING-CC-0148
|
Agents for Hemophilia B
|
|
ING-CC-0149
|
Select Clotting Agents for Bleeding Disorders
|
|
ING-CC-0168
|
Tecartus (brexucabtagene autoleucel)
|
|
ING-CC-0195
|
Abecma (idecabtagene vicleucel)
|
Visit the Drug Lists page on anthem.com 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
- Any other requirements, restrictions, or limitations that apply to using certain drugs
The Commercial and Marketplace drug lists are posted to the website quarterly on the first day of the month in January, April, July and October.
To locate Marketplace formularies 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.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2022 Notice of Regulatory Amendment related to Medicaid participating providers and facilitiesPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
This is to notify all participating Medicaid providers of a new regulatory requirement necessitating a Regulatory Amendment to the Anthem HealthKeepers Plus Provider Agreement and the Anthem HealthKeepers Plus Facility Agreement, as required by the Virginia Department of Medical Assistance Services.
Effective immediately, Section 2.13 of the Virginia HMO Medicaid Participation Attachment to the Anthem HealthKeepers Plus Provider Agreement and Section 2.19 of the Virginia HMO Medicaid Participation Attachment to the Anthem HealthKeepers Plus Facility Agreement shall be changed to read in its entirety as follows:
“RECORD RETENTION, INSPECTION, AND AUDITS: Consistent with Federal managed care regulations 42 CFR 438.3(u), the Provider shall maintain books, records, documents, and other evidence of administrative, medical, and accounting procedures and practices for ten (10) years. In accordance with 12VAC30-120-1730, for Members who are children under age 21 and enrolled in the Tech program, the Provider shall retain records for the greater period of a minimum of ten (10) years or at least six (6) years after the minor has reached 21 years of age. Consistent with Federal managed care regulations 42 CFR § 438.3(h), the Provider shall make the records maintained by the Provider as required by the Department and other regulatory agencies, available to the Department and its agents, designees or contractors or any other authorized representatives of the Commonwealth of Virginia or the United States Government, or their designees or contractors, at such times, places, and in such manner as such entities may reasonably request for the purposes of financial or medical audits, inspections, and examinations, provided that such activities are conducted during the normal business hours of the Provider. The right to audit exists for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later. The Provider further agrees that the Secretary of the U.S. Department of Health and Human Services or his or her designee, the Governor or his or her designee, Comptroller General, and the State Auditor or his or her designee have the right at reasonable times and upon reasonable notice to examine the books, records, and other compilations of data of the Provider and its subcontractors that pertain to: the ability of the Plan to bear the risk of potential financial losses; services performed; or, determinations of amounts payable. The Provider shall make available, for the purposes of record maintenance requirements, its premises, physical facilities and equipment, records relating to its Members, and any additional relevant information that the Department may require, in a manner that meets the Department’s record maintenance requirements. The Provider shall comply with the right of the U.S. Department of Health and Human Services, the Comptroller General, and their designees to inspect, evaluate, and audit records through ten (10) years from the final date of the Contract period or the completion of audit, whichever is later, in accordance with Federal and State requirements.”
These changes are made in accordance with Section 7.1 of the Virginia HMO Medicaid Participation Attachment to the Anthem HealthKeepers Plus Provider Agreement and Section 4.2 of the Virginia HMO Medicaid Participation Attachment to the Anthem HealthKeepers Plus Facility Agreement that states: “Notwithstanding the Amendment provision in the Agreement, this Attachment shall be automatically modified to conform to required changes to Regulatory Requirements related to Medicaid Programs without the necessity of executing written amendments.” Note, no action is required by you. If you are currently participating in the Anthem HealthKeepers Plus network, your Virginia HMO Medicaid Participation Attachment is automatically being updated to include the above provisions. If you are not participating in the Anthem HealthKeepers Plus network and would like to participate, please contact your network manager.
If you have any questions about this communication, please contact your local Provider Network Manager.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2022 Reminder: Provider orientations are availableHealthKeepers, Inc. has started conducting monthly provider orientations and trainings covering information important for Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members.
These orientations/trainings are for all contracted and noncontracted providers. The goal of these orientations/trainings is to aid new providers in engaging with the health plan and give existing providers an opportunity to learn about any new initiatives. You can find a schedule of the orientations along with the registration links by visiting https://providers.anthem.com/va and scrolling down to Provider orientations and training.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | February 1, 2022 The Behavioral Health Areas of Expertise Profile improves the referral processPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
The Behavioral Health Areas of Expertise Profile (BHAEP) is designed to highlight your behavioral health network providers’ services, cultural preferences, race, languages spoken, and other specialties to our members through the enhancement of our online provider directory. The goal is to help our members find the right behavioral health provider to fit their unique needs.
Contracted Medicaid providers are asked to answer a brief online survey on their clinical areas of expertise, demographics, modalities, and accessibility. The data collected provides insight into our behavioral health providers’ capabilities, which assists in member referral, provider network strategy development, and proposal support. Completion of the BHAEP does not affect a provider’s credentialing materials/status or contract.
By capturing this information, we are able to:
- Improve identification of specific services and/or specialties.
- Improve the referral process by better identifying provider capabilities.
- Align with competitors that provide this data in their online provider directories.
Currently, the BHAEP is administered in 18 Medicaid markets. The local health plan completes provider outreach. While data gathered through this tool has proven to be helpful to members, providers, and the health plan, response rates remain low.
View your state’s BHAEP survey here.
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 | February 1, 2022 Get faster payments with electronic funds transferPlease 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 November 1, 2021, EnrollSafe* at https://enrollsafe.payeehub.org replaced Enrollhub® from the Council for Affordable Quality Healthcare, Inc. (CAQH) as the electronic funds transfer (EFT) enrollment website at no cost to Anthem HealthKeepers Plus providers.
EnrollSafe is safe, secure, and available 24-hours a day
Log onto the EnrollSafe enrollment hub at https://enrollsafe.payeehub.org to enroll in EFT. You will be directed through the EnrollSafe secure website to the Registration page, where you will provide the required information to create an account and then Enroll to supply your banking information.
Already enrolled in EFT through CAQH Enrollhub?
If you were previously enrolled in EFT through CAQH Enrollhub, no action is needed unless you are making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, use https://enrollsafe.payeehub.org to update your account.
For more information or additional questions regarding the EnrollSafe Enrollment Hub portal, providers can contact the Support team by calling 877-882-0384, Monday through Friday 9 a.m. to 8 p.m. ET.
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 | February 1, 2022 Keep up with Medicaid news: February 2022Please continue to check our website https://providers.anthem.com/virginia-provider/home for the latest Medicaid information for members enrolled in HealthKeepers, Inc.’s Anthem HealthKeepers Plus and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) benefit plans. Here are the topics we’re addressing in this edition:
 Effective November 1, 2021, EnrollSafe* at https://enrollsafe.payeehub.org replaced Enrollhub® from the Council for Affordable Quality Healthcare, Inc. (CAQH) as the electronic funds transfer (EFT) enrollment website at no cost to Anthem Blue Cross and Blue Shield providers.
EnrollSafe is safe, secure, and available 24-hours a day
Log onto the EnrollSafe enrollment hub at https://enrollsafe.payeehub.org to enroll in EFT. You will be directed through the EnrollSafe secure website to the Registration page, where you will provide the required information to create an account and then Enroll to supply your banking information.
Already enrolled in EFT through CAQH Enrollhub?
If you were previously enrolled in EFT through CAQH Enrollhub, no action is needed unless you are making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, use https://enrollsafe.payeehub.org to update your account.
For more information or additional questions regarding the EnrollSafe Enrollment Hub portal, providers can contact the Support team by calling 877-882-0384, Monday through Friday 9 a.m. to 8 p.m. ET.
|