(Please note that the important message below from Bryony Winn – President, Health Solutions – applies to our Commercial, Medicaid and Medicare Advantage programs from Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc.)

I am pleased to announce that our shareholders voted to approve our parent company's name change from Anthem, Inc. to Elevance Health, Inc. (NYSE Ticker Symbol — ELV) effective June 28, 2022.

 

Here is what you can expect:

A bold new vision for the future of health   We chose the name Elevance Health to better reflect our business as we elevate the importance of whole health and advance health beyond healthcare for consumers, their families, and our shared communities. This new vision fuels our transformation from a traditional health benefits organization to a health company that looks beyond the traditional scope of physical health.

No action is needed by you, and we remain committed to helping you deliver whole-person care for your patients, our customers. Importantly, there is no impact or changes to your contract, reimbursement, or level of support. For your patients, it will not change their plan or coverage or change how they receive their medications. Provider networks will not be changing.

A more holistic approach to health that improves affordability and outcomes   Bringing together a broad portfolio of health plans, including pharmacy, behavioral, clinical, and complex care provider partners, we can deliver integrated, holistic health solutions to meet the increasing needs of our customers and care provider partners. This includes two notable changes: Our healthcare service partners will operate under a new brand called Carelon. This includes Beacon Health Options, AIM Specialty Health®, CareMore, and IngenioRx. You can find us at Carelon.com.   IngenioRx, our pharmacy benefit management partner, will become CarelonRx on January 1, 2023. This name change will not impact your patient’s benefits, coverage, or how their medications are filled. We will communicate detailed information about this change soon.

A simpler brand portfolio that makes it easier to do business with us We have streamlined and simplified the complexity of our health plan and service businesses and reduced the number of brands we have in the market, so our partners and customers clearly understand where we serve, who we serve, and what our brands do.

What does this mean for care providers?

 

We will operate as Anthem Blue Cross or Anthem Blue Cross and Blue Shield in our 14 Blue-licensed markets. Our existing Anthem-branded health plans are not changing and will continue to operate in their current states. There will be no impact to plans, coverage, or level of support.

 

Looking forward together

 

As your partner, we will continue to keep you updated with new information as soon as it becomes available. In the meantime, you can visit us at ElevanceHealth.com or contact your provider representative with any questions.

 

Thank you for joining us on this exciting path forward as we reimagine what is possible for every moment of health.

 

Sincerely,

Bryony Winn

President, Health Solutions

 

VABCBS-CRCM-001869-22-CPN1793

VAHK-CAID-001870-22-CPN1793 June 2022

Current provider directory information helps Anthem Blue Cross and Blue Shield members find the most up-to-date information available. As a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.

 

If changes are needed, please take the time to update your information by submitting updates and corrections to us on our online Provider Maintenance Form. Online update options include:

 

• Adding/changing an address location
• Name change
• Tax ID 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 complete instructions.

 

The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Thank you for doing your part in keeping our provider directories current.

 

MULTI-BCBS-COMM-002040-22

In a recent study published by Pediatrics, 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% in patients 5 to 9 years. Increases from 1% in children aged 13 to 17 to 2.6% for those aged 5 to 9 years were observed.

 

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 called Ways to Promote Health with Preschoolers. This fun flyer shows how we can all work together to support a healthy lifestyle. You can 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 to 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

 

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.

 

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

 

MULTI-BCBS-CM-002326-22-CPN1916

 

The Comprehensive Diabetes Care HEDIS^® measure Retinal Eye Exam (DRE) valuates the percent of adult members ages 18 to 75, with diabetes (type 1 and type 2), who had a retinal eye exam during the measurement year.

Changes to 3072F

 

The definition for the code 3072F (negative for retinopathy) has been redefined to low risk for retinopathy (no evidence of retinopathy in the prior year). This can be particularly confusing because it would not be used at the time of the exam. It would be used the following year, along with the exam coding for the current year, to indicate that retinopathy was not present the previous year.

A simpler coding solution

 

Using these three codes count toward the DRE measurement if they are billed in the current measurement year or the prior year. This means you can submit the appropriate code at the time of the exam, and it covers both years:

 

2023F	Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)
2025F	7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed: without evidence of retinopathy (DM)
2033F	Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed: without evidence of retinopathy (DM)

 

For more about diabetic retinopathy, visit CMS.gov or use this link to read more.

Meeting the measurement for all diabetes care

 

These exams are also important in evaluating the overall health of diabetic patients, as well as meeting the Comprehensive Diabetes Care HEDIS measure:

 

• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (> 9.0%)
• HbA1c control (< 8.0%)
• Retinal Eye exam performed
• Blood Pressure control (< 140/90 mm Hg)

 

Record your efforts in the member’s medical records for the HbA1c tests and results, retinal eye exam, blood pressure, urine creatinine test, and the estimated glomerular filtration rate test. Meeting the mark and closing gaps in care is key to good health outcomes.

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

 

MULTI-BCBS-COMM-002331-22-CPN1921

This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).

 

In an effort to deliver on Anthem’s purpose to improve the health of humanity, we now have a program for in-home patient care for acute conditions.

 

Anthem’s Hospital in Home program can advise capable, innovative hospital partners in developing their own hospital in home programs. Once implemented, patients can recover in a more comfortable environment, allowing hospitals to keep beds available for patients with more complex needs.

 

Inpatient level of care in the home can be a welcome alternative to traditional hospital settings. Patients may find acute care at home to be more convenient and less stressful, and studies have shown acute care at home can be safe and allow for smoother transition to self-care management after the acute illness. Hospital in Home clinical trials demonstrate a 25% decrease in readmissions and a 50% reduction in time spent in bed.¹

 

Anthem’s Hospital in Home program has a set of minimum requirements that are designed to promote patient safety. These requirements include aspects of the member’s home environment, the clinical scenario, remote monitoring capabilities, and plans for program evaluation.

 

Please contact your Anthem contracting representative to learn more about Anthem’s Hospital in Home program.

 

¹ Levine, D. M., Ouchi, K., Blanchfield, B., Saenz, A., Burke, K., Paz, M., Diamond, K., Pu, C. T., & Schnipper, J. L. (2020). Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Annals of internal medicine, 172(2), 77–85. https://doi.org/10.7326/M19-0600.

 

MULTI-BCBS-CRCM-001819-22-CPN1554

Effective August 1, 2022, Anthem Blue Cross and Blue Shield (Anthem) and our affiliate HealthKeepers, Inc. will transition medical necessity review of physical, occupational, and speech therapy services to AIM Specialty Health® (AIM), a separate company. We announced this change in our May and June 2022 editions of Anthem Provider News.

 

The new rehabilitation program reviews certain treatment plans against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine. Anthem in Virginia will be utilizing the AIM Outpatient Rehabilitative and Habilitative Services clinical guidelines. Any qualified providers acting within the scope of their license who intend to provide therapy services are required to obtain a prior authorization from AIM.

 

Note: Chiropractors performing therapy services are not required to obtain a prior authorization from AIM due to the current American Specialty Health (ASH) chiropractor utilization management program.

 

For therapy services that are scheduled to begin on or after August 1, 2022, all providers must contact AIM to obtain prior authorization for the following non-emergency modalities:

 

• Physical therapy
• Occupational therapy
• Speech therapy

 

For more information

 

The AIM provider website helps you learn more about the program and provides access to useful information and tools such as order entry checklists, clinical guidelines, and FAQs. To learn more about AIM, please visit www.aimspecialtyhealth.com.

 

To help you prepare for this program, Anthem in Virginia and AIM are hosting a series of live webinar sessions and Q&A only webinar sessions that are designed for providers and office staff who will be requesting prior authorization. Please register to attend at least one training opportunity. We highly encourage facilities to attend an AIM training opportunity. AIM solution-specific training content will be made available to you upon completion of registration and prior to attending a webinar session. Reviewing the material ahead of the training will allow your facility to bring relevant questions to be addressed during the training.

               

Type of training	Date and time	Meeting information
Live webinar session with Q&A	Tuesday, July 5, 2022, 3 p.m. Eastern time	Register for July 5 Webinar
Q&A only session	Tuesday, July 12, 2022,   3 p.m. Eastern time	Register for July 12 Webinar
Q&A only session	Tuesday, July 26, 2022,   3 p.m. Eastern time	Register for July 26 Webinar
Q&A only session	Thursday, August 11, 2022,   2 p.m. Eastern time	Register for August 11 Webinar

 

How to submit a request for review

 

Starting July 18, 2022, providers can begin submitting requests for review or verify order numbers using one of the following methods:

 

• Online — The AIM ProviderPortal_SM is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. To register, go to https://aimspecialtyhealth.com/providerportal. Registration opens July 18, 2022.

 

• By phone — Call AIM Specialty Health toll-free at 866-789-0158, Monday through Friday between 8 a.m. and 5 p.m. Eastern time.

 

Anthem and HealthKeepers, Inc. value your participation in our networks, as well as the services you provide. We look forward to working with you to help improve the health of our members.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc.

 

VABCBS-COMM-000018-22

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

 

• New specialty pharmacy medical step therapy requirements

 

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.

 

Practices 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 866-649-0669.

 

MULTI-BCBS-CARE-001242-22

Beginning with claims processed on or after August 1, 2022, Anthem Blue Cross and Blue Shield will implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service (CPT^® codes 99381 to 99397) is billed with a problem-oriented E/M service (CPT codes 99202 to 99215) and appended with Modifier 25 (for example, CPT code 99393 billed with CPT code 99213 to 99225).

 

According to the American Medical Association (AMA) CPT Guidelines, E/M services must be “significant and separately identifiable” in order to appropriately append Modifier 25. Based upon review of the submitted claim information, if the problem-oriented E/M service is determined not to be a significant, separately identifiable service from the preventive service, the problem-oriented E/M service will be bundled with the preventive service.

 

Providers that believe their medical record documentation supports a significant and separately identifiable E/M service should follow the Claims Payment Dispute process (including submission of such with the dispute) as outlined in the provider manual.

 

If you have questions on this program, contact your contract manager or Provider Experience.

 

ABSCRNU-0342-22

Please 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:

 

• Updating member information

 

• Use of Imaging Studies for Low Back Pain (LBP)

 

• Remote patient monitoring update

 

• Prior authorization updates for medications billed under the medical benefit

 

• Virginia Medicaid language interpretation services

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 July 1, 2022, HealthKeepers, Inc. will align the benefit limits for incontinence undergarments with Virginia Department of Medical Assistance Services (DMAS) benefit limits. The list of impacted codes is noted below. This change will affect the current reimbursement policy and related claims processing rules associated with incontinence undergarments.

 

HealthKeepers, Inc. will no longer reimburse for any supply amount that exceeds the DMAS benefit limits for Anthem HealthKeepers Plus members.

 

HealthKeepers, Inc. will only reimburse providers for quantities exceeding DMAS limits when prescribed by a physician, documented on a Certificate of Medical Necessity (CMN), and authorized by HealthKeepers, Inc. HealthKeepers, Inc. follows the same criteria as DMAS in determining all medical necessity approval.

 

We recommend that providers visit the online provider manual to review all authorization, appeals, and reconsideration processes at:

 

https://providers.anthem.com/docs/gpp/VA_CAID_ProviderManual.pdf?v=202105212022.

 

Code	Description	DMAS limit
T4536	Incontinence product, protective underwear/pull-on, reusable, any size	14 per year
T4537	Incontinence product, protective underpad, reusable, bed size	6 per year
T4539	Incontinence product, diaper brief, reusable any size	14 per year
T4540	Incontinence product, protective Under pad, reusable, chair size	6 per year
A4554*	Disposable under pads, All sizes,150 per case	1 case per month
T4541*	Incontinence product, disposable underpad, large	1 case per month
T4542*	Incontinence product, disposable underpad, small	1 case per month

 

* Chux codes (A4554, T4541, T4542) will not be allowed/payable in conjunction with any of the 19 disposable incontinence undergarment codes.

Code	Description	DMAS Limit
T4521	Adult size disposable incontinence product, brief/diaper, small	180 per month
T4522	Adult size disposable incontinence product, brief/diaper, medium	180 per month
T4523	Adult size disposable incontinence product, brief/diaper, large	180 per month
T4524	Adult size disposable incontinence product, brief/diaper, extra-large, extra absorbent	180 per month
T4525	Adult size disposable incontinence product, protective underwear/pull-on, small	180 per month
T4526	Adult size disposable incontinence product, protective underwear/pull-on, medium	180 per month
T4527	Adult size disposable incontinence product, protective underwear/pull-on, large	180 per month
T4528	Adult size disposable incontinence product, protective underwear/pull-on, extra large	180 per month
T4529	Pediatric sized disposable incontinence product, brief/diaper, small or medium, extra absorbent	180 per month
T4530	Pediatric sized disposable incontinence product, brief/diaper, large or extra-large, extra absorbent	180 per month
T4535	Panty liners, extra absorbent	180 per month
T4531	Pediatric size disposable incontinence product, protective underwear/pull-on, small/medium size, each	180 per month
T4532	Pediatric size disposable incontinence product, protective underwear/pull-on, large size, each	180 per month
T4533	Youth sized disposable incontinence product, brief/diaper	180 per month
T4534	Youth sized disposable incontinence product, protective underwear/pull-on	180 per month
T4535	Disposable liner/shield/guard/pad/undergarment, for incontinence, each	180 per month
T4543	Adult sized disposable incontinence product, protective brief/diaper, above extra large	180 per month
T4544	Adult sized disposable incontinence product, protective underwear/pull-on, above extra large	180 per month
A4335	Incontinence supplies, not otherwise specified	180 per month

 

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.

 

VAHK-CAID-000094-22

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.

 

Beginning with claims processed on or after August 1, 2022, HealthKeepers, Inc. will implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service (CPT^® codes 99381 to 99397) is billed with a problem-oriented E/M service (CPT codes 99202 to 99215) and appended with Modifier 25 (for example, CPT code 99393 billed with CPT code 99213 to 99225).

 

According to the American Medical Association (AMA) CPT Guidelines, E/M services must be “significant and separately identifiable” in order to appropriately append Modifier 25. Based upon review of the submitted claim information, if the problem-oriented E/M service is determined not to be a significant, separately identifiable service from the preventive service, the problem-oriented E/M service will be bundled with the preventive service.

 

Providers that believe their medical record documentation supports a significant and separately identifiable E/M service should follow the Claims Payment Dispute process (including submission of such with the dispute) as outlined in the provider manual.

 

AVA-NU-0580-22

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.

 

Overuse of antibiotics is directly linked to the prevalence of antibiotic resistance. Promoting judicious use of antibiotics is important for reducing the emergence of harmful bacteria that is unresponsive to treatment. The following HEDIS^® measures assess appropriate antibiotic dispensing for pharyngitis, upper respiratory infection, and bronchitis/bronchiolitis.

Appropriate Testing for Pharyngitis (CWP)

 

Pediatric Clinical Practice Guidelines recommend only children with lab‑confirmed group A strep or other bacteria-related ailments be treated with appropriate antibiotics. This measure reports the percentage of episodes for members 3 years of age and older where the member was diagnosed with pharyngitis, prescribed an antibiotic at an outpatient visit, and received a group A strep test. A higher rate indicates better performance (such as appropriate testing).

Appropriate Treatment for Upper Respiratory Infection (URI)

 

This measure calculates the percentage of episodes for members 3 months of age and older with a diagnosis of upper respiratory infection that did not result in an antibiotic dispensing event. Reducing unnecessary use of antibiotics is the goal of this measure. It is reported as an inverted rate. A higher rate indicates appropriate upper respiratory infection treatment (such as the proportion of episodes that did not result in an antibiotic dispensing event).

 

Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)

 

There is considerable evidence that prescribing antibiotics for uncomplicated acute bronchitis is not indicated unless it is associated with a comorbid diagnosis. This measure assesses the percentage of episodes for members ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event. It is reported as an inverted rate. A higher rate indicates appropriate acute bronchitis/bronchiolitis treatment (such as the proportion of episodes that did not result in an antibiotic dispensing event).

 

Helpful tips

 

• When patients present with symptoms of pharyngitis, ensure proper testing (for strep) is performed to avoid the unnecessary prescribing of antibiotics. Record the results of the strep test.
• If prescribing an antibiotic to members with acute bronchitis, be sure to use the diagnosis code for the bacterial infection and/or comorbid condition.
• Educate members on the difference between bacterial and viral infections. Refer to the illness as a common cold, sore throat, or chest cold. Parents and caregivers tend to associate these labels with a less frequent need for antibiotics.
• Write a prescription for symptom relief, such as rest, fluids, cool mist vaporizers, and over‑the‑counter medicine.
• If a patient insists on an antibiotic, consider using delayed prescribing. Refer to the CDC handout for patients titled What is Delayed Prescribing? available at the link below.

 

Resources

• CDC’s Be Antibiotics Aware campaign: https://www.cdc.gov/antibiotic-use/index.html
• CDC handouts for patients: https://www.cdc.gov/antibiotic-use/community/materials-references/index.html

 

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.

 

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

 

AVA-NU-0579-22

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, 2022, we will upgrade to the 26th edition of MCG care guidelines for the following modules: Inpatient/surgical care (ISC). The below tables highlight new guidelines and changes.

 

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

 

Goal length of stay (GLOS) for ISC

 

Guideline	MCG code	25th edition GLOS	26th edition GLOS
*Aortic Valve Replacement, Transcatheter	S-1320 [W0133]	2 days postoperative	1 day postoperative
*Apnea, Neonatal (Non-Preterm Infants)	P-15	3 days	2 days
*Renal Failure, Chronic	M-325	3 days	2 days
*Subarachnoid Hemorrhage, Nonsurgical Treatment	M-79	4 days	3 days
*Craniotomy, Supratentorial	S-410	3 days postoperative	2 days postoperative
*Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF)	S-100	Ambulatory or 1 day postoperative	Ambulatory
*Hip Arthroplasty	S-560 [W0105]	Ambulatory or 2 days postoperative	Ambulatory or 1 day postoperative
*Humerus Fracture, Closed or Open Reduction	S-632	Ambulatory or 1 day postoperative	Ambulatory
*Knee Arthroplasty, Total	S-700 [W0081]	Ambulatory or 2 days postoperative	Ambulatory or 1 day postoperative
*Lumbar Laminectomy	S-830 [W0100]	Ambulatory or 1 day postoperative	Ambulatory
*Nephrectomy	S-870	3 days postoperative	2 days postoperative
*Prostatectomy, Radical	S-960	1 day postoperative	Ambulatory or 1 day postoperative
Dehydration	M-123	1 day	2 days
Esophageal Disease	M-550	1 day	2 days
Gastritis and Duodenitis	M-560	1 day	2 days
Pneumothorax, Neonatal	P-355	2 days	3 days
Seizure	M-327	1 day	2 days
Back Pain	M-63	1 day	2 days

 

New Guidelines ISC

 

Body system	Guideline title	MCG code
Hospital-at-Home	Cellulitis: Hospital-at-Home	M-70-HaH
Hospital-at-Home	Chronic Obstructive Pulmonary Disease: Hospital-at-Home	M-100-HaH
Hospital-at-Home	Heart Failure: Hospital-at-Home	M-190-HaH
Hospital-at-Home	Pneumonia: Hospital-at-Home	M-282-HaH
Hospital-at-Home	Urinary Tract Infection (UTI): Hospital-at-Home	M-300-HaH
Observation Care	Pancreatitis: Observation Care	OC-065
Observation Care	Renal Failure, Acute: Observation Care	OC-066
Observation Care	Stroke: Ischemic: Observation Care	OC-067

 

 Anthem HealthKeepers Plus customizations to MCG care guidelines 26th edition

 

To view a detailed summary of customizations, go to https://www.anthem.com/provider/policies/clinical-guidelines, scroll down to the Other Criteria section, and select Customizations to MCG Care Guidelines 26^th Edition.

 

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-0573-22

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 August 1, 2022, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by HealthKeepers, Inc. 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:

 

• 0214U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O
• 0215U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O
• 81415: Exome (such as unexplained constitutional or heritable disorder or syndrome); sequence analysis
• 81416: Exome (such as unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (such as parents, siblings) (List separately in addition to code for primary procedure)
• 81417: Exome (such as unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (such as updated knowledge or unrelated condition/syndrome)
• L6026: Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device
• L6715: Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement

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

• Availity:* Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then select 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 on the provider website at https://providers.anthem.com/va. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 800-901-0020 for assistance with PA requirements.

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.

 

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

 

AVA-NU-0571-22