It wasn’t too long ago when patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. Thanks to a small, portable device, patients on warfarin can now self-test with a finger prick drop of blood. There is more to self-testing than the ease and convenience, though. Patients are happier. Their quality of life improved because they can keep up with their activities – even travel, without the stress of making and keeping testing appointments.

 

Self-testing: Measurable difference when correct coding is reflected

 

This type of quality care and improved outcomes are making a measurable difference in the lives of our members. We want this success accounted for in the INR clinical quality measure and with your help, we can do it.  Use these codes to reflect INR In-home monitoring when noting the INR results for your patients.

 

 

Value set ID and subgroup	Code	Description
INR HOME MONITORING	CPT CODE 93792	Patient/caregiver training for initiation of home INR monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results.
INR HOME MONITORING	CPT CODE 93793	Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab INR test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed.
INR HOME MONITORING	HCPCS CODE G0248	Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to perform testing and report results.
INR HOME MONITORING	HCPCS CODE G0249	Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include four tests.
INR HOME MONITORING	HCPCS CODE G0250	Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include four tests.

 

INR clinical quality measure:

 

The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.

 

Clinical Quality Measure	Required documentation	CPT, HCPCS, LOINC and CPT Performance Codes	Provider Specialty
INR Monitoring for Individuals on Warfarin*	Adults 18 years of age and older who have had at least one 56- day interval of warfarin therapy and received at least one INR monitoring test during each 56-day interval with active warfarin therapy in the measurement year. Excludes patients who are monitoring INR at home during the treatment period	CPT 85610 - Prothrombin time LOINC 34714-6 INR blood by coagulation assay 6301-6 INR in platelet poor plasma by coagulation assay 38875-1 INR in platelet poor plasma or blood by coagulation assay 46418-0 INR in capillary blood by coagulation assay 52129-4 INR in platelet poor plasma by coagulation - post heparin adsorption Excludes: G0248 - demonstrate use home INR monitoring G0249 - provide test materials and equipment for home INR monitoring G0250 - physician INR test review interpretation and management	No provider type restrictions

 

1231-0721-PN-VA

Many members have both primary and secondary insurance policies, and it’s important to know which policy is primary. We want to make it as easy as possible for you to find out so you can avoid claim denials for not filing the secondary claim within the timely filing guidelines.

 

Before members arrive for their appointments, check the primary insurance carrier using the Eligibility and Benefits app in Availity. Log onto Availity.com, go to payer spaces, select us as the payer and use the Patient Registration tab to run an Eligibility and Benefits Inquiry. If you find that we are the primary payer, confirm that when the member arrives for the appointment. After providing services, submit the member’s claim as usual – you can use Availity for that, too, through the Claims & Payments app.

 

If we are the secondary payer, we will need the explanation of benefits (EOB) from the primary carrier along with the claim submission to determine our payment amount. You can submit the EOB and the claim through Availity using the Claims & Payments app.

 

When a claim is submitted to us as the primary payer, and we are the secondary payer, our claims system will deny the claim because we don’t have the EOB. This can cause a delay in receipt of your payment and can even cause you to miss the timely filing guideline.

 

We want you to have the information you need to know the best way to file your claims. For more information about filing claims, visit Anthem.com/provider/claims-submissions. For help using Availity, log onto Availity.com and select the Help & Training tab.

 

1234-0721-PN-VA

Laboratory Corporation of America® (LabCorp) is the exclusive clinical reference laboratory provider for HealthKeepers, Inc. LabCorp offers a full range of diagnostic and preventive testing options, including non-invasive colorectal cancer screening tests. For members enrolled in health plans offered by HealthKeepers, Inc., physicians should refer all lab services – including preventive healthcare lab services – to LabCorp. By doing so, members are assured of having the highest benefit level and minimum out-of-pocket expense.

 

Laboratory specimens can be collected in the office with LabCorp courier pick-up available throughout Virginia. Members may also bring a LabCorp requisition form (completed by their physician) to any of the more than 50 LabCorp patient service center locations throughout Virginia.

 

For more on LabCorp's patient service center locations, visit anthem.com.

 

If you have questions about LabCorp services, need to set-up a LabCorp account, order supplies, or schedule a pick-up, please call LabCorp at 800-762-0890.

 

For clarification purposes, other lab providers offering non-invasive colorectal cancer screening tests such as Exact Sciences are not participating with HealthKeepers, Inc.

 

If you have questions about our provider network or coverage for your patients, please contact the phone number on the back of the member’s ID card or your local Anthem network manager.

 

1222-0721-PN-VA

In a recent study published by Pediatrics¹, economic hardship, school closing and shutdowns led to sedentary lifestyles and increases in childhood obesity. The research analyzed doctor visits pre-pandemic then during the pandemic period and the increases were dramatic. Overall obesity increased from 13.7% to 15.4%. Increases observed ranged from 1% in children aged 13 to 17 years to 2.6% for those aged 5 to 9 years.

 

The study recommended new approaches to Weight Assessment and Counseling. These include recommending virtual activities that promote increased physical activity. Focusing on ways to remain safe and active with outside activities, such as park visits, walks and bike riding were also suggested.

The Centers for Disease Control and Prevention has a great resource, “Ways to promote health with preschoolers.” This fun flyer shows how we can all work together to support a healthy lifestyle. Download a copy.

The HEDIS® measure Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) requires a nutritional evaluation and pro-active guidance as part of a routine health visit.

 

• When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.

 

• When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.

 

• Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.

 

HEDIS® measure WCC looks at the percentage of members, 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:

• Body mass index (BMI) percentile (percentage, not value)
• Counseling for nutrition
• Counseling for physical activity

 

Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.

Code services correctly to measure success.

 

These diagnosis and procedure codes are used to document BMI percentile, weight assessment, and counseling for nutrition and physical activity:

 

 

Description	CPT®	ICD-10-CM	HCPCS
BMI percentile		Z68.51-Z68.54
Counseling for nutrition	97802, 97803, 97804	Z71.3	G0270, G0271, G0447, S9449, S9452, S9470
Counseling for physical activity		Z02.5, Z71.82	G0447, S9451
Codes to identify outpatient visits: CPT — 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456, 99483 HCPCS — G0402, G0438, G0439, G0463, T1015

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

¹ https://pediatrics.aappublications.org/content/147/5/e2021050123?cct=2287#F1

 

American Academy of Pediatrics. American Academy of Pediatrics raises concern about children’s nutrition and physical activity during pandemic. Available at: http://services.aap.org/en/news-room/news-releases/aap/2020/american-academy-of-pediatrics-raises-concern-about-childrens-nutrition-and-physical-activity-during-pandemic/. Accessed December 10, 2020

 

1232-0721-PN-VA

 

For more than a decade, Blue Precision – Anthem Blue Cross and Blue Shield’s physician transparency program – has recognized specialists for meeting or exceeding established quality and cost effectiveness measures.  Thank you to all those physicians participating in our networks and for the care you provide to our members.

 

Anthem is announcing that we have made the decision to retire our Blue Precision program effective December 31, 2021. Blue Precision recognition icons and other program information will be removed from anthem.com and our “Find Care” provider tool by January 1, 2022.

 

Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.  We look forward to working collaboratively with you in other physician programs to provide our members with continued access to affordable and quality healthcare. 

 

1202-0721-PN-VA

New Policy

Modifier 90: Reference (outside) laboratory and pass-through billing

(Effective 10/01/21)

 

Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

 

HealthKeepers, Inc. does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

 

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

 

For additional information, please review the Modifier 90: Reference (outside) laboratory and pass-through billing reimbursement policy at https://mediproviders.anthem.com/va.

 

AVA-NU-0348-21

Please 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 Centers for Medicare & Medicaid Services (CMS) issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7^® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

 

The Clinical Data Acquisition Group for HealthKeepers, Inc. integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps HealthKeepers, Inc.:

 

• Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings.

 

HealthKeepers, Inc. would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with HealthKeepers, Inc. through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables HealthKeepers, Inc. to most effectively manage care transitions.

 

Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started 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.

 

AVA-NU-0356-21

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

Mental disorders among children may cause serious changes in the way children typically learn, behave or handle their emotions, which cause distress and problems getting through the day. Healthcare professionals use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5),¹ to help diagnose mental health disorders in children.

 

The most common mental disorders of childhood and adolescence fall into the following categories:

 

• Anxiety disorders (generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobic disorder)
• Depression
• Posttraumatic stress disorder (PTSD)
• Separation anxiety disorder
• Social anxiety disorder
• Obsessive-compulsive disorder
• Bipolar disorder
• Disruptive behavioral disorders (attention-deficit/hyperactivity disorder ADHD, conduct disorder, and oppositional defiant disorder)
• Eating disorders
• Schizophrenia (less common).

 

Other conditions and concerns that affect children’s learning, behavior and emotions include learning and developmental disabilities, autism, and risk factors like substance use and self-harm.

ICD-10-CM coding

 

• Chapter 5 of the ICD-10-CM code set categorizes mental disorders.
• Codes from chapter 5 are assigned based on the express documentation of the provider’s clinical judgment regarding the patient’s mental or behavioral disorder(s). The codes are not assigned based on symptoms, signs, or abnormal clinical laboratory findings.

 

Affective disorders

 

Major depressive disorder (MDD) is classified in ICD-10-CM as:

 

• F32: Major depressive disorder, single episode
• F33: Major depressive disorder, recurrent

 

When documenting major depressive disorder, keep in mind that proper and specific coding requires clear documentation of the:

• Episode: single versus recurrent.
• Severity: mild, moderate, or severe.
• Psychotic features, when present.
• Status of remission as either partial or full.

 

Remember to document any established causality between multiple mental health conditions. For example:

 

• Suppose the patient has a diagnosis of depression and a diagnosis of anxiety with a causal relationship between the two conditions. In such cases, documentation must establish the relationship by stating depression with, due to, or related to anxiety

 

ICD-10-CM classifies bipolar disorders under the following categories

 

• F30: Manic episode (bipolar disorder, single manic episode, and mixed affective episode)
• F31: Bipolar disorder (manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction)
• F34: Persistent mood affective disorders (cyclothymic disorder and dysthymic disorder)
• F39: Unspecified mood affective disorder (affective psychosis not otherwise specified).

 

Nonpsychotic mental disorders

 

Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders are classified in categories F40 to F48.

 

Anxiety disorders are classified in ICD-10-CM under the following categories:

 

• F40: Phobic anxiety disorders
• F41: Other anxiety disorders
• F42: Obsessive-compulsive disorder.

 

Reactions to stress

 

ICD-10-CM provides category F43 for coding reactions to severe stress and adjustment disorders. Code F43.0, Acute stress reaction, classifies acute reaction to stress, including acute crisis reaction, crisis state, and psychic shock.

 

Posttraumatic stress disorder (PTSD) is classified in ICD-10-CM to subcategory F43.1, with fifth-characters for unspecified, acute, or chronic.

 

Adjustment disorders are classified to subcategory F43.2, with the fifth-character axis being the nature of the reaction, such as anxiety, depression, or other symptoms. For example:

 

• F43:24: Child adopted from a foreign country, suffering from culture shock with conduct disturbance.

 

Behavioral syndromes associated with physiological disturbances and physical factors

 

Categories F50 to F59 are devoted to behavioral syndromes associated with physiological disturbances and physical factors. These codes are not assigned when the conditions are present due to mental disorders classified elsewhere or organic in origin. This grouping includes, for example:

 

• F50.: Eating disorders (such as anorexia nervosa and bulimia nervosa)
• F51.: Sleep disorders, not due to a substance or known physiological condition
• F54*: Psychological and behavioral factors associated with disorders or diseases classified elsewhere
• F59:  Unspecified behavioral syndromes associated with physiological disturbances and physical factors

 

* Code F54 classifies psychological and behavioral factors associated with diseases classified elsewhere. Typical conditions that are often associated with code F54 include asthma and dermatitis.

 

Schizophrenic disorders

 

• Those types of disorders are classified in category F20, with a fourth character indicating the type of schizophrenia.

 

• The codes from category F20 are followed by an excludes one note indicating they should not be reported with codes classifying a brief psychotic disorder (F23) , cyclic schizophrenia (F25.0), schizoaffective disorder (F25-F25.9) and schizophrenic reaction not otherwise specified (NOS) (F23).

 

• Assign code F20.9, Schizophrenia, unspecified, for chronic schizophrenia with acute exacerbation. The existing ICD-10-CM codes for schizophrenia do not differentiate severity or an acute exacerbation (AHA Coding Clinic, Second Quarter 2019, p.32).

 

Attention deficit hyperactivity disorder (ADHD)

 

ICD-10-CM codes for ADHD include:

 

• F90.0: Attention-deficit hyperactivity disorder, predominantly inattentive type.
• F90.1: Attention-deficit hyperactivity disorder, predominantly hyperactive type.
• F90.2: Attention-deficit hyperactivity disorder, combined type.
• F90.8: Attention-deficit hyperactivity disorder, other types.
• F90.9: Attention-deficit hyperactivity disorder, unspecified type.

 

The ADHD diagnosis may not be established at the time of the initial physician office visit. Therefore, it may take two or more visits before the diagnosis is confirmed or ruled out. ICD-10-CM outpatient coding guidelines specify not to assign a diagnosis code when documented as rule out, working diagnosis or other similar terms indicating uncertainty.

 

Instead, the outpatient coding guidelines instruct to code the condition(s) to the highest degree of certainty for that encounter/visit, requiring the use of codes that describe symptoms, signs or another reason for the visit.

 

History codes (categories Z80 to Z87) may be used as secondary codes if the historical condition or family history impacts current care or influences treatment. Personal and family history of ADHD has an impact on the clinical assessment of an individual for this disorder; the ICD-10-CM codes to report the history of ADHD in an individual include:

 

• Z86.59: Personal history of other mental and behavioral disorders.
• Z81.8:   Family history of other mental and behavioral disorders.

 

Psychosocial circumstances

 

ICD-10-CM provides codes for behaviors that are not classified as behavioral disorders, such as:

 

• R41.840:  Attention and concentration deficit
• R45.83:   Excessive crying of child, adolescent, or adult
• R45.87:   Impulsiveness
• R46.81:   Obsessive-compulsive behavior.

 

Resources

 

¹ American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5)

• ICD-10-CM Expert, 2021. Optum
• Coding Clinic. Optum
• Mental illness in children. https://www.webmd.com/anxiety-panic/mental-health-illness-in-children
• Children’s Mental Health https://www.cdc.gov/childrensmentalhealth/symptoms.html

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

AVA-NU-0358-21 

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

What Matters Most: Improving the Patient Experience is an online course for providers and office staff that addresses gaps in care and offers approaches to communication with patients. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians.

 

The What Matters Most training can be accessed at www.patientexptraining.com.

 

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.

 

AVA-NU-0365-21

 

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) by HealthKeepers, Inc.

 

As patient panels grow more diverse and needs become more complex, providers and office staff need more support to help address patients’ needs. HealthKeepers, Inc. wants to help.

Cultural competency resources

Here is an overview of the cultural competency resources available on our provider website.

 

Cultural Competency and Patient Engagement includes:   The impact of culture and cultural competency on healthcare.   A cultural competency continuum, which can help providers assess their level of cultural competency.   Disability competency and information on the Americans with Disabilities Act (ADA).

Caring for Diverse Populations Toolkit includes:   Comprehensive information, tools and resources to support enhanced care for diverse patients and mitigate barriers.   Materials that can be printed and made available for patients in provider offices.   Regulations and standards for cultural and linguistic services.

My Diverse Patients offers:   A comprehensive repository of resources to providers to help support the needs of diverse patients and address disparities.   Courses with free continuing education credit through the American Academy of Family Physicians.   Free accessibility from any device (for example, desktop computer, laptop, phone or tablet), no account or login required.

To access these resources, go to https://providers.anthem.com/va > Manuals, Directories, Training & More > Anthem HealthKeepers Plus Manuals, Directories, Training & Resources.

 

In addition, providers can access Stronger Together, which offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.



Prevalent non-English languages (based on population data)

 

Like you, HealthKeepers, Inc. wants to effectively serve the needs of diverse patients. It’s important for us all to be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the prevalent non-English languages spoken by 5% or 1,000 individuals in Virginia.¹

 

Prevalent non-English languages in VA
Spanish	Arabic

 

Language support services

 

As a reminder, HealthKeepers, Inc. provides language assistance services for our members with limited English proficiency (LEP) or hearing, speech, or visual impairments. Please see the provider manual for details on what is available and how to access resources. In addition, the cultural competency resources shared above provide guidance on communicating and serving diverse populations effectively.

 

¹ Source: American Community Survey, 2019 American Community Survey 1-Year Estimates, Table B16001, generated 10/04/2020.

 

AVA-NU-0369-21

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

You may be surprised to learn that suicide is currently the 10th leading cause of death in the United States. In 2017 alone, there were an estimated 1.4 million suicide attempts by Americans. As staggering as these numbers are, we’d like to focus on what can be done to mitigate these statistics. The front lines in the battle against suicide are prevention and intervention. According to the CDC, suicide prevention should incorporate reducing factors that increase risk and increasing factors that help with resilience and/or coping.

 

Please read through the information below that can be used to both prevent and intervene when it comes to suicide and your Anthem HealthKeepers Plus patients.

Suicide statistics

 

While the following statistics may be distressing, awareness plays a big role in solving this issue:

 

• Nearly 45,000 lives were lost to suicide in 2016.
• Suicide rates went up more than 30% in half of U.S. states since 1999.
• There was a significant rise in suicide rate among youth ages 10 to 14.
• Suicide is the second leading cause of death for people 10 to 34 years of age.
• Men are more likely to use more lethal methods, such as firearms or suffocation, while women are more likely to attempt suicide by poisoning or prescription overdose.
• American Indian/Alaska Native youth and middle-aged persons have the highest rate of suicide.

Risk factors

Understanding who is at risk is vital to suicide prevention/intervention. The following traits are risk indicators:

 

• Depression, other mental disorders or substance use disorder
• Chronic pain
• A prior suicide attempt
• Family history of a mental disorder, substance use or suicide
• Family violence, including physical or sexual abuse
• Having guns or other firearms in the home
• Having recently been released from prison or jail
• Being exposed to others' suicidal behavior, such as that of family members, peers or celebrities

Warning signs

• Talking about wanting to die or to kill oneself
• Looking for a way to kill oneself, such as searching online or buying a gun
• Talking about feeling hopeless or having no reason to live
• Talking about feeling trapped or in unbearable pain
• Talking about being a burden to others
• Increasing the use of alcohol or drugs
• Acting anxious or agitated; behaving recklessly
• Sleeping too little or too much
• Withdrawing or feeling isolated
• Showing rage or talking about seeking revenge
• Displaying extreme mood swings

How to help someone at risk

• Ask the question, “Are you thinking of killing yourself?”
• Keep them safe from harming or endangering themselves.
• Be there and promote a connectedness.
• Help them connect to resources.
• Follow up with your patient after determining they are at risk.

New evidence-based practice for healthcare providers

• Healthcare providers can help prevent suicide when they understand the risk factors and use evidence‑based treatments and use evidence-based treatments nad therapies.

 

• The Joint Commission recommends screening all patients in all medical settings for suicide risk using validated, population-, and setting-specific tools.

 

• It is no longer acceptable to contract for safety with patients; you need to remove or ensure safe storage of potentially lethal items.

 

• Familiarize yourself with the social media outlets in order to identify suicidal content and get help for the person posting the message. Websites such as Instagram, Facebook, Snapchat, Tumblr, Twitter, and YouTube have built-in safety tools.

Be familiar with the resources

• National Suicide Prevention Lifeline: 800-273-TALK (8255) — This is a free, 24-hour hotline available to anyone in suicidal crisis or emotional distress. Callers are routed to the closest crisis center within Lifeline’s network of more than 160 centers.

 

• Suicide Prevention Resource Center (SPRC) — SPRC provides technical assistance, training, and materials to assist states, tribes, campuses, organizations, professionals, and stakeholders develop suicide prevention programs, interventions, and policies. SPRC also acts as Secretariat to the National Action Alliance for Suicide Prevention.

 

• National Action Alliance for Suicide Prevention — This is a public/private partnership that advances the National Strategy for Suicide Prevention through the work of nearly 200 organizations.

 

• Behavioral Health Treatment Services Locator — This tool is a directory of mental health and substance use treatment facilities in the United States and United States territories.

 

• Garrett Lee Smith Suicide Prevention Program — The purpose of this program is to support states and tribes with implementing youth suicide prevention and early intervention strategies in schools, educational institutions, juvenile justice systems, substance use programs, mental health programs, foster care systems, and other child- and youth-serving organizations.

 

• Tribal Technical Assistance Center (TTAC) — The TTAC provides culturally relevant, evidence-based, holistic technical assistance to support native communities who seek to address mental and substance use disorders and suicide.

 

Additional resources

• National Action Alliance for Suicide Prevention:  https://theactionalliance.org/ 

 

• National Indian Child Welfare Association: http://icctc.org/August2013/PMM%20Handouts/Youth%20Suicide%20Prevention%20Toolkit.pdf

 

• Indian Health Services Resources: gov/behavioral/index.cfm?module=BH&option=Suicide

 

• Veterans Crisis Line:  https://www.veteranscrisisline.net/ 

 

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.

References:

1. American Foundation for Suicide Prevention (2019). Suicide Statistics. Retrieved from:

https://afsp.org/about-suicide/suicide-statistics.

2. Centers for Disease Control and Prevention (2018). Suicide: Prevention strategies. Retrieved from https://cdc.gov/violenceprevention/suicide/prevention.html.
3. National Institute of Mental Health (2017, May). Mental health information. NIH. Retrieved from

https://nimh.nih.gov/health/index.shtml.

4. Substance Abuse and Mental Health Services Administration (n.d). SAMHSA. Retrieved from gov.
5. Suicide Prevention Lifeline. National Suicide Prevention Lifeline. Retrieved from https://suicidepreventionlifeline.org.

 

AVA-NU-0380-21 

 Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

Summary of change

 

Effective September 1, 2021, prior authorization (PA) requirements will change for the following codes. The medical codes listed below will require PA by HealthKeepers, Inc. for Anthem HealthKeepers Plus members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

 

• 0203U — Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continuous risk score and classification of inflammatory bowel disease aggressiveness
• 0208U — Oncology (medullary thyroid carcinoma), mRNA, gene expression analysis of 108 genes, utilizing fine needle aspirate, algorithm reported as positive or negative for medullary thyroid carcinoma
• 0230U — Androgen receptor (AR) (for example, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions
• 0231U — Calcium voltage-gated channel subunit alpha 1A (CACNA1A) (for example, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, STR gene expansions, mobile element insertions, and variants in non-uniquely mappable regions
• 0232U — Cystatin B (CSTB) (for example, progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, STR expansions, mobile element insertions, and variants in non-uniquely mappable regions
• 0233U — Frataxin (FXN) (for example, Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, STR expansions, mobile element insertions, and variants in non-uniquely mappable regions
• 0234U — Methyl CpG binding protein 2 (MECP2) (for example, Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
• 0235U — Phosphatase and tensin homolog (PTEN) (for example, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
• 0236U — Survival of motor neuron 1, telomeric (SMN1) and survival of motor neuron 2, centromeric (SMN2) (for example, spinal muscular atrophy) full gene analysis, including small sequence changes in exonic and intronic regions, duplications and deletions, and mobile element insertions
• 0238U — Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
• 0620T — Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed
• 33995 — Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only
• 58999 — Unlisted Proc, Female Genital System (Nonobstetrical)
• 81191 — Neurotrophic receptor tyrosine kinase 1 (NTRK1) (for example, solid tumors) translocation analysis
• 81192 — Neurotrophic receptor tyrosine kinase 2 (NTRK2) (for example, solid tumors) translocation analysis
• 81193 — Neurotrophic receptor tyrosine kinase 3 (NTRK3) (for example, solid tumors) translocation analysis
• 81194 — Neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3 (NTRK) (for example, solid tumors) translocation analysis
• 81279 — Janus kinase 2 (JAK2) (for example, myeloproliferative disorder) targeted sequence analysis (for example, exons 12 and 13)
• 81338 — MPL proto-oncogene, thrombopoietin receptor (MPL) (for example, myeloproliferative disorder) gene analysis; common variants (for example, W515A, W515K, W515L, W515R)
• 81339 — MPL proto-oncogene, thrombopoietin receptor (MPL) (for example, myeloproliferative disorder) gene analysis; sequence analysis, exon 10
• 81351 — Tumor protein 53 (TP53) (for example, Li-Fraumeni syndrome) gene analysis; full gene sequence
• 81352 — Tumor protein 53 (TP53) (for example, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (for example, 4 oncology)
• 81353 — Tumor protein 53 (TP53) (for example, Li-Fraumeni syndrome) gene analysis; known familial variant
• 81546 — Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (for example, benign or suspicious)
• C1787 — Patient programmer, neurostimulator
• C1820 — Generator, neurostimulator (implantable), with rechargeable battery and charging system
• C1883 — Adaptor/extension, pacing lead or neurostimulator lead (implantable)
• G0068 — Professional services for the administration of antiinfective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug administration calendar day in the individual's home, each 15 minutes
• G0069 — Professional services for the administration of subcutaneous immunotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes
• G0070 — Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes
• G0088 — Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual's home, each 15 minutes
• G0089 — Professional services, initial visit, for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes
• G0090 — Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes

To request PA, you may use one of the following methods:

 

• Web: Once logged in to Availity* at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate.
• Fax: 800-964-3627
• Phone: 800-901-0020

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers via the provider website at https://providers.anthem.com/va > Login. Contracted and noncontracted providers who are unable to access the provider website may call Provider Services for assistance with PA requirements at:

 

• Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020.
• Anthem CCC Plus Provider Services at 855‑323‑4687.

 

AVA-NU-0381-21

Please 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 September 1, 2021, prior authorization (PA) requirements will change for 0205U, 0209U, and 0218U. The medical codes listed below will require PA from HealthKeepers, Inc. for our members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

 

Utilization Management Authorization Rule Operations Workgroup item 1327 (UM AROW 1327)

 

• 0205U — ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negative for neovascular age-related macular-degeneration risk associated with zinc supplements
• 0209U — cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities
• 0218U — neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or saliva, identification and characterization of genetic variants

 

To request PA, you may use one of the following methods:

 

• Web: https://providers.anthem.com/va
• Fax: 800-964-3627
• Phone: 800-901-0020

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool through the Availity* Portal at https://www.availity.com or by going to the provider website at https://providers.anthem.com/va > Login. Contracted and noncontracted providers unable to access Availity can call Provider Services for assistance with PA requirements:

 

• Anthem HealthKeepers Plus, Medallion Provider Services: 800‑901‑0020
• Anthem CCC Plus Provider Services: 855‑323‑4687

 

* Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

 

AVA-NU-0382-21

 

 

Please 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 September 1, 2021, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by HealthKeepers, Inc. for our members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

 

Utilization Management Authorization Rule Operations Workgroup item 1837 (UM AROW 1837)

 

• 0045U — oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score
• 0153U — oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s) with information on immune cell involvement
• 0244U — oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin-embedded tumor tissue
• 81404 — molecular pathology procedure level 5
• 81414 — cardiac ion channelopathies (for example, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1
• 81439 — hereditary cardiomyopathy (for example, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy), genomic sequence analysis panel, must include sequencing of at least 5 cardiomyopathy-related genes (for example, DSG2, MYBPC3, MYH7, PKP2, TTN)
• 81518 — oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes
  (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy
• 81519 — oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score
• 81520 — oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score
• 81521 — oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed
  paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis
• 81522 — oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes
  (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score
• S3854 — gene expression profiling panel for use in the management of breast cancer treatment
• S3861 — genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected brugada syndrome
• S3865 — comprehensive gene sequence analysis for hypertrophic cardiomyopathy
• S3866 — genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family

 

To request PA, you may use one of the following methods:

 

• Web: https://providers.anthem.com/va
• Fax: 800-964-3627
• Phone: 800-901-0020

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at https://www.availity.com or on the provider website at https://providers.anthem.com/va > Login. Contracted and noncontracted providers who are unable to access Availity can call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687 for assistance with PA requirements.

 

*Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

 

AVA-NU-0385-21

 

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

As part of our ongoing quality improvement efforts, HealthKeepers, Inc. is updating our precertification processes for certain specialty medications. Effective August 1, 2021, we may request additional documentation for impacted medications to determine medical necessity.

 

Upon request, providers shall submit documentation from the member’s medical record for each policy question flagged for documentation. A denial may result if documentation does not support medical necessity.

 

Should you have any questions, please refer to the Clinical Criteria policy website for specific medication criteria details.

 

Impacted policy	Impacted medication(s)
ING-CC-0153: Adakveo (crizanlizumab)	Adakveo
ING-CC-0065: Agents for Hemophiilia A and von Willebrand Disease	Advate, Adynovate, Afstyla, Alphanate, Eloctate, Esperoct, Helixate FS, Hemlibra, Hemofil-M, Humate-P, Jivi, Koate-DVI, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Obizur, Recombinate, Wilate, Xyntha
ING-CC-0148: Agents for Hemophilia B	Alphanine SD, Alprolix, Bebulin, Benefix, Idelvion, Ixinity, Mononine, Profilnine SD, Rebinyn, Rixubis
ING-CC-0025: Aldurazyme (laronidase)	Aldurazyme
ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy	Aralast, Glassia, Prolastin-C, Zemaira
ING-CC-0028: Benlysta (belimumab)	Benlysta
ING-CC-0012: Brineura (cerliponase alfa)	Brineura
ING-CC-0137: Cablivi (caplacizumab-yhdp)	Cablivi
ING-CC-0041: Complement Inhibitors	Soliris, Ultomiris
ING-CC-0081: Crysvita (burosumab-twza)	Crysvita
ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)	Duopa
ING-CC-0029: Dupixent (dupilumab)	Dupixent
ING-CC-0069: Egrifta (tesamorelin)	Egrifta
ING-CC-0024: Elaprase (idursufase)	Elaprase
ING-CC-0173: Enspryng (satralizumab-mwge)	Enspryng
ING-CC-0051: Enzyme Replacement Therapy for Gaucher Disease	Cerezyme, Elelyso, Vpriv
ING-CC-0044: Exondys 51 (eteplirsen)	Exondys 51
ING-CC-0021: Fabrazyme (agalsidase beta)	Fabrazyme
ING-CC-0068: Growth hormone	Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive
ING-CC-0034: Hereditary Angioedema Agents	Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro
ING-CC-0188: Imcivree (setmelanotide)	Imcivree
ING-CC-0070: Jetrea (ocriplasmin)	Jetrea
ING-CC-0037: Kanuma (sebelipase alfa)	Kanuma
ING-CC-0057: Krystexxa (pegloticase)	Krystexxa
ING-CC-0018: Lumizyme (alglucosidase alfa)	Lumizyme
ING-CC-0013: Mepsevii (vestronidase alfa)	Mepsevii
ING-CC-0043: Monoclonal Antibodies to Interleukin-5	Cinqair, Fasenra, Nucala
ING-CC-0023: Naglazyme (galsulfase)	Naglazyme
ING-CC-0111: Nplate (romiplostim)	Nplate
ING-CC-0082: Onpattro (patisiran)	Onpattro
ING-CC-0077: Palynziq (pegvaliase-pqpz)	Palynziq
ING-CC-0049: Radicava (edaravone)	Radicava
ING-CC-0156: Reblozyl (luspatercept)	Reblozyl
ING-CC-0159: Scenesse (afamelanotide)	Scenesse
ING-CC-0149: Select Clotting Agents for Bleeding Disorders	Feiba, Novoseven
ING-CC-0079: Strensiq (asfotase alfa)	Strensiq
ING-CC-0008: Subcutaneous Hormonal Implants	Testopel
ING-CC-0084: Tegsedi (inotersen)	Tegsedi
ING-CC-0162: Tepezza (teprotumumab-trbw)	Tepezza
ING-CC-0170: Uplizna (inebilizumab)	Uplizna
ING-CC-0022: Vimizim (elosulfase alfa)	Vimizim
ING-CC-0152: Vyondys 53 (golodirsen)	Vyondys 53
ING-CC-0017: Xiaflex (clostridial collagenase histolyticum) injection	Xiaflex
ING-CC-0033: Xolair (omalizumab)	Xolair

 

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.

 

AVA-NU-0383-21

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

 

Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

 

• Address disparities for vaccine-preventable diseases.

 

• Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.

 

• Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.

 

• Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

 

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

 

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.

If you have 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.

                             

AVA-NU-0384-21

 

 

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following 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.

 

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

 

Please see the explanation/definition for each category of Clinical Criteria below:

 

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

Please share this notice with other members of your practice and office staff.

 

Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

  

Effective date	Document number	Clinical Criteria title	New or revised
July 16, 2021	*ING-CC-0195*	Abecma (idecabtagene vicleucel)	New
July 16, 2021	*ING-CC-0191*	Pepaxto (melphalan flufenamide; melflufen)	New
July 16, 2021	*ING-CC-0192*	Cosela (trilaciclib)	New
July 16, 2021	*ING-CC-0193*	Evkeeza (evinacumab)	New
July 16, 2021	*ING-CC-0194*	Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection	New
July 16, 2021	ING-CC-0125	Opdivo (nivolumab)	Revised
July 16, 2021	*ING-CC-0159*	Scenesse (afamelanotide)	Revised
July 16, 2021	ING-CC-0151	Yescarta (axicabtagene ciloleucel)	Revised
July 16, 2021	*ING-CC-0145*	Libtayo (cemiplimab-rwlc)	Revised
July 16, 2021	*ING-CC-0130*	Imfinzi (durvalumab)	Revised
July 16, 2021	ING-CC-0127	Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)	Revised
July 16, 2021	*ING-CC-0075*	Rituximab Agents for Non-Oncologic Indications	Revised

 

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.

AVA-NU-0386-21

Please continue to check our website https://mediproviders.anthem.com 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:

 

Specialty Pharmacy Prior Authorization Retraction Notice

AVA-NU-0370-21

 

Infusion Step Therapy Retraction Notice

AVA-NU-0372-21

 

February 2021 Coverage Guidelines and Clinical Utilization Management Guidelines update

AVA-NU-0377-21

New Policy

Modifier 90: Reference (outside) laboratory and pass-through billing

(Effective 10/01/21)

 

Anthem Blue Cross and Blue Shield does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or the Centers for Medicare & Medicaid Services (CMS) contracts and/or requirements indicate otherwise.

 

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

 

For additional information, please review the Modifier 90: Reference (outside) laboratory and pass-through billing reimbursement policy at www.anthem.com/medicareprovider.

 

ABSCRNU-0212-21                         517554MUPENMUB

The Centers for Medicare & Medicaid Services (CMS) issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7^® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

 

The Clinical Data Acquisition Group for Anthem Blue Cross and Blue Shield (Anthem) integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:

 

• Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.

 

• Proactively manage care transitions to avoid waste.

 

• Close care gaps and educate members about appropriate care settings.

 

Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.

 

Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started today.

 

ABSCRNU-0217-21                 518933MUPENMUB

Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

 

Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

• Address disparities for vaccine-preventable diseases.

 

• Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.

 

• Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.

 

• Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

 

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.

 

ABSCRNU-0228-21                   518911MUPENMUB

On October 1, 2021, prior authorization (PA) requirements will change for A0426 and A0428 covered by Anthem Blue Cross and Blue Shield. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added for the following codes:

 

• A0426 — ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)

 

• A0428 — ambulance service, basic life support, nonemergency transport (BLS)

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at https://www.availity.com or on the provider website at https://www.anthem.com/medicareprovider > Login. Contracted and noncontracted providers unable to access Availity can call the Provider Services located on the back of their patient’s member ID card for PA requirements.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0232-21                   518884MUPENMUB

On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised, or reviewed to support clinical coding edits.

 

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

 

Please see the explanation/definition for each category of Clinical Criteria below:

 

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

Please share this notice with other members of your practice and office staff.

 

Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services. 

 

Effective date	Document number	Clinical Criteria title	New or revised
July 16, 2021	ING-CC-0195*	Abecma (idecabtagene vicleucel)	New
July 16, 2021	ING-CC-0191*	Pepaxto (melphalan flufenamide; melflufen)	New
July 16, 2021	ING-CC-0192*	Cosela (trilaciclib)	New
July 16, 2021	ING-CC-0193*	Evkeeza (evinacumab)	New
July 16, 2021	ING-CC-0194*	Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection	New
July 16, 2021	ING-CC-0125	Opdivo (nivolumab)	Revised
July 16, 2021	ING-CC-0064	Interleukin-1 Inhibitors	Revised
July 16, 2021	ING-CC-0159*	Scenesse (afamelanotide)	Revised
July 16, 2021	ING-CC-0151	Yescarta (axicabtagene ciloleucel)	Revised
July 16, 2021	ING-CC-0145*	Libtayo (cemiplimab-rwlc)	Revised
July 16, 2021	ING-CC-0130*	Imfinzi (durvalumab)	Revised
July 16, 2021	ING-CC-0127	Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)	Revised
July 16, 2021	ING-CC-0075*	Rituximab Agents for Non-Oncologic Indications	Revised

 

ABSCRNU-0233-21                             518931MUPENMUB

Please continue to read news and updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

Prior Authorization Requirement Changes Effective September 1, 2021 – Provider notification for Utilization Management Authorization Rule Operations Workgroup  (UM AROW item 1845)

ABSCRNU-0227-21                   518853MUPENMUB