In our previous communications, we shared information about using the Authorizations and Referrals application on Availity Essentials to receive digital notifications for your authorization cases and related decision letters, and we introduced the Preference Center for Authorization and Referrals where you can select your preferred method of communication. We are excited to announce that we launched the Preference Center for Authorization and Referrals in April and will start using your preferences there in July.

Here is a quick recap on how to receive digital notifications and set your preferred communication method for the status of your authorization cases.

Use the Authorizations and Referrals application for digital notifications:

• Retrieve cases submitted digitally and non-digitally by your organization through Auth/Referral Inquiry; use the Pin to Dashboard feature to keep these cases on the Auth/Referral Dashboard, saving you from repeating the search in the future.
• Find the most recent statuses of cases submitted by your organization on the Auth/Referral Dashboard — Select View Details in the Actions menu for case details, including decision letters. For pinned cases, select the case card to get the latest status and case details.

Access the Preference Center and set your preferences:

• After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Preference Center application tile.
• Select your organization and then set your communication preference (your default is Digital Access (Default) or if you prefer to receive paper surface mail, you can select Digital + Mail) for Authorization and Referrals:  
  • Adjust the preference for the tax IDs and NPIs of your organization to fit your business needs.
  • You can add more NPIs to your current registration and set the preferred communication mode for the new NPIs under the selected tax IDs.

Manage preferences (Availity administrators)

Availity Administrators can learn more about managing preferences related to Authorization Decision letters. After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Custom Learning Center application, then select the Resources section to view or download the Reference Guide on managing receipt of Authorization Decision letters.

With your help, we can continually build towards a future of shared success.

Anthem has a continued mission to leverage digital technology to provide enhanced services for both members and care providers. We encourage the support of care providers in accepting digital ID cards instead of a physical member ID card. As members increasingly use digital ID cards, care providers may need to implement changes in their processes to accept this format.

Due to recent enhancements, care providers can bypass the request for cards by accessing Availity.com. If a copy of a physical member identification card is needed, a member can email, fax, or access card details saved in their digital wallet. As a reminder, care providers can also access eligibility and benefit information without the health care identification (HCID). This makes both check-ins and submitting claims easier and faster.

Anthem is dedicated to providing digital solutions that transform both care provider and payer interactions. Thank you in advance for your continued partnership and support in empowering our members to use their digital ID cards. With your help, we can continually build towards a future of shared success.

If you and your organization are focused on promoting evidence-based medicine and clinical quality performance, our Alerts Hub clinical notification tool, accessed through Availity Essentials, can help drive your success.

Our clinical notification application, Alerts Hub, offers admission, discharge, and transfer (ADT) notifications for Medicare Advantage and Medicaid members. For those members, Alerts Hub offers a simple way to view a list of patients who have been admitted to the hospital or visited the emergency room.

Discover what users across the country already know.

Alerts Hub offers timely, actionable information to help your organization reach out to patients who can benefit from transitions in care planning or other interventions following inpatient or emergency care.

Viewing and responding to ADT notifications with outreach to patients can help drive your organizations’ clinical quality and cost of care performance in value-based care arrangements —More importantly, it helps drive better outcomes for your patients.

Get started today.

We are committed to finding solutions that help our care provider partners offer quality services to our members. To access Alerts Hub, log on to Availity Essentials, select Payer Spaces, then select Alerts Hub. New users will need to register and set preferences. Registered users will receive daily notification emails with a summary of relevant alerts and a reminder to view details in Alerts Hub. Be sure to check your junk or spam folders if you aren’t receiving messages in your inbox.

Need more help? The Availity Custom Learning Center offers a range of training materials that can help you get up to speed quickly so that you can take advantage of all Alerts Hub has to offer.

Contact us.

Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section of our provider website.

Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Radiology:

• Brain Imaging:
  • Added indications for MRI and amyloid beta PET imaging in Alzheimer disease to address patients considering or receiving lecanemab
• Spine Imaging:
  • Changed Perioperative and Periprocedural Imaging to Postoperative and Postprocedural Imaging; pre-procedure requests should be reviewed based on more specific indication
• Extremity Imaging:
  • Separated criteria for osteomyelitis and septic arthritis into separate indications; US or arthrocentesis as preliminary tests were placed only in the septic arthritis indication
• Vascular Imaging:
  • CTA/MRA Head addition for chronic posterior circulation Stroke/TIA presentations (CTA/MRA neck already allowed, intracranial eval needed for full extent of anatomy)
  • Lower Extremity PAD: Updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with ACR Appropriateness Criteria
  • Suboptimal imaging option downgrades/removals in Brain, Head and Neck, and Abdomen/Pelvis

Cardiovascular:

• Imaging of the Heart:
  • Resting Transthoracic Echocardiography (TTE)
  • Expanded frequency of echocardiographic evaluation in patients on mavacamten for treatment of hypertrophic obstructive cardiomyopathy (HOCM)
  • Expanded criteria for echocardiographic evaluation to allow a single screening for cardiac disease in patients undergoing evaluation for solid organ or hematopoietic cell transplant
• Cardiac Resynchronization Therapy:
  • Exclusion added for Wireless CRT
• Diagnostic Coronary Angiography:
  • Criteria reaffirmed — no changes
• Endovascular Revascularization:
  • Added indication for endovascular venous arterialization of the tibial or peroneal veins
  • Exclusions added for endovenous femoral-popliteal arterial revascularization with transcatheter placement of intravascular stent and intravascular lithotripsy
  • Also exclusion added for atherectomy (clarification)
• Implantable Cardioverter Defibrillators:
  • Transvenous ICD placement
  • Expanded criteria for transvenous ICD to include phospholamban, filamin-C, and lamin A/C cardiomyopathies
• Percutaneous Coronary Intervention:
  • Exclusion added for percutaneous transluminal coronary lithotripsy
• Permanent Implantable Pacemakers:
  • Device replacement
  • Added criteria for permanent implantable pacemaker device replacement
  • Single chamber leadless pacemakers
  • Clarified that criteria for single chamber leadless pacemaker apply to the right ventricle
  • Exclusion added for right atrial single chamber leadless pacemakers
  • Dual chamber leadless pacemakers
  • Exclusion added for dual chamber leadless pacemakers

Genetic Testing:

• Chromosomal Microarray Analysis:
  • Clarified recommendations for Genetic Counseling
  • Clarified requirements for postnatal evaluation of individuals with:
  • Congenital or early onset epilepsy (before age 3 years) without suspected environmental causes
  • Autism spectrum disorder, developmental delay, or intellectual disability with no identifiable cause (idiopathic)
  • Clarified prenatal evaluation of a fetus with a structural fetal anomaly noted on ultrasound
• Pharmacogenomic Testing:
  • Added APOE testing
• Polygenic Risk Scores renamed Predictive and Prognostic Polygenic Testing:
  • Broadened guideline scope to include polygenic expression prognostic testing and multivariable prognostic genetic testing (essentially clarifications), and moved these tests to exclusions as they are considered not medically necessary
  • Retitled guideline to Predictive and Prognostic Polygenic Testing to address this change in scope.
• Somatic Testing of Solid Tumors:
  • Breast Cancer
  • Clarified gene expression profiling is to guide adjuvant therapy for localized Breast Cancer
• Whole Exome and Whole Genome Sequencing:
  • Expanded WES criteria to include congenital or early onset epilepsy (before age 3) without suspected environmental etiology and added other clarifications.
  • Clarified well-delineated genetic syndrome in criterion for multiple anomalies
  • Clarified Genetic Counseling details for WES

MSK:

• Sacroiliac Joint Fusion:
  • New medical necessity criteria for open SI joint fusion
  • As an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum
  • As an adjunct to the medical treatment of sacroiliac joint infection/sepsis (for example, osteomyelitis, pyogenic sacroiliitis)
  • For severe traumatic injuries associated with pelvic ring disruption (for example, pelvic ring fractures, acetabular fracture, spinopelvic dissociation)
  • During multi-segment spinal constructs (for example, correction of deformity in scoliosis or kyphosis surgery) extending to the ilium as part of medically necessary lumbar spine fusion procedures
  • Open SI joint fusion is not medically necessary for poorly defined low back pain and sacral insufficiency fractures.
• Spine Surgery:
  • Lumbar Discectomy, Foraminotomy, and Laminotomy
  • Added exclusion for annular closure device
  • Lumbar Laminectomy
  • Expanded timeframe for imaging lumbar disc herniation (9 months) and lumbar spinal stenosis (12 months)

Radiation Oncology:

• Removed criteria for hyperthermia
• Clarified inclusion criteria of the RTOG 1112 protocol.

Sleep Disorder Management:

• Expanded definitions and terminology
• Expanded documentation of hypoventilation
• Expanded criteria for home and in-lab sleep studies
• Added contraindication to APAP titration for use of supplemental oxygen
• Removed home sleep apnea testing (HSAT) as an option in medical necessity of MSLT/MWT for suspected narcolepsy
• Management of OSA using Implanted Hypoglossal Nerve Stimulators — Narrowed age range (raised lower limit to 13) for HNS in individuals with Down syndrome and OSA to align with age range suggested by FDA
• Miscellaneous Devices section added: electronic positional therapy and neuromuscular electrical training of the tongue musculature are considered not medically necessary due to lack of high-quality evidence

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following:

• Access Carelon Medical Benefits Management’s provider portal directly at providerportal.com:
• Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Radiology

Brain imaging:

• Added indications for magnetic resonance imaging (MRI) and amyloid beta positron emission tomography (PET) imaging in Alzheimer’s disease to address patients considering or receiving lecanemab

Spine imaging:

• Changed perioperative and periprocedural imaging to postoperative and postprocedural imaging:
  • Pre-procedure requests should be reviewed based on more specific indication.

Extremity imaging:

• Separated criteria for osteomyelitis and septic arthritis into separate indications:
  • US or arthrocentesis as preliminary tests were placed only in the septic arthritis indication.

Vascular imaging:

• Computed tomography angiography (CTA)/magnetic resonance angiography (MRA) head addition for chronic posterior circulation stroke/transient ischemic attack (TIA) presentations (CTA/MRA of the neck is already allowed; an intracranial evaluation is needed for full extent of anatomy).
• Lower extremity peripheral artery disease (PAD): updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with American College of Radiology (ACR) Appropriateness Criteria®
• Suboptimal imaging option downgrades/removals in brain, head, neck, and abdomen/pelvis

Cardiovascular

Imaging of the heart:

• Resting transthoracic echocardiography (TTE)
• Expanded frequency of echocardiographic evaluation in patients on mavacamten for treatment of hypertrophic obstructive cardiomyopathy (HOCM)
• Expanded criteria for echocardiographic evaluation to allow a single screening for cardiac disease in patients undergoing evaluation for solid organ or hematopoietic cell transplant

Cardiac resynchronization therapy:

• Added exclusion for wireless CRT

Diagnostic coronary angiography:

• Criteria reaffirmed — no changes

Endovascular revascularization:

• Added indication for endovascular venous arterialization of the tibial or peroneal veins
• Added exclusions for endovenous femoral-popliteal arterial revascularization with transcatheter placement of intravascular stent and intravascular lithotripsy
• Added exclusion for atherectomy (clarification)

Implantable cardioverter defibrillators (ICD):

• Transvenous ICD placement
• Expanded criteria for transvenous ICD to include phospholamban, filamin-C, and lamin A/C cardiomyopathies

Percutaneous coronary intervention:

• Added exclusion for percutaneous transluminal coronary lithotripsy

Permanent implantable pacemakers:

• Device replacement
• Added criteria for permanent implantable pacemaker device replacement
• Single chamber leadless pacemakers
• Clarified that criteria for single chamber leadless pacemaker apply to the right ventricle
• Added exclusion for right atrial single chamber leadless pacemakers
• Dual chamber leadless pacemakers
• Added exclusion for dual chamber leadless pacemakers

Radiation oncology:

• Removed criteria for hyperthermia
• Clarified inclusion criteria of the radiation therapy oncology (RTOG) 1112 protocol

Sleep disorder management:

• Expanded definitions and terminology
• Expanded documentation of hypoventilation
• Expanded criteria for home and in-lab sleep studies
• Added contraindication to automatic positive airway pressure (APAP) titration for use of supplemental oxygen
• Removed home sleep apnea testing (HSAT) as an option in medical necessity of multiple sleep latency test/maintenance of wakefulness test (MSLT/MWT) for suspected narcolepsy
• Management of obstructive sleep apnea (OSA) using implanted hypoglossal nerve stimulators (HNS): narrowed age range (raised lower limit to 13) for HNS in individuals with Down syndrome and OSA to align with age range suggested by the FDA
• Miscellaneous Devices section added: Electronic positional therapy and neuromuscular electrical training of the tongue musculature are considered not medically necessary due to lack of
  high-quality evidence.

Reminders

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management by doing the following:

• Access Carelon Medical Benefits Management’s ProviderPortal_SM directly at providerportal.com:
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

If you have any questions about this communication, contact Anthem HealthKeepers Plus Provider Services at 800-901-0020.

The following guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on May 9, 2024. Revisions have been made to the coding that may result in services previously considered medically necessary to now be considered not medically necessary for dates of service on or after October 1, 2024.

This guideline impacts all our products except for Anthem HealthKeepers Plus offered by HealthKeepers, Inc., Medicare Advantage, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).

The services addressed in the guideline presented in this document will require authorization for all our products offered by HealthKeepers, Inc., except for the Anthem HealthKeepers Plus plan. Other exceptions are Medicare Advantage and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program^® or FEP^®). A pre-determination can be requested for our Anthem PPO products.

Effective October 1, 2024, Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. will implement the following new and revised Coverage Guidelines. These guidelines impact all our products except for Anthem HealthKeepers Plus, offered by HealthKeepers, Inc.; Medicare Advantage; and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program^® or FEP). These guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on May 9, 2024.

The guidelines addressed in this edition of Provider News are:

• LAB.00016 Fecal Analysis Panels in the Diagnosis of Intestinal Disorders
• RAD.00069 Absolute Quantitation of Myocardial Blood Flow Measurement

Fecal Analysis Panels in the Diagnosis of Intestinal Disorders (LAB.00016)

This revised Coverage Guideline addresses the use of fecal analysis for the diagnosis of intestinal disorders.

Fecal analysis panels are considered investigational and not medically necessary for all indications, including as a diagnostic test for the evaluation of intestinal dysbiosis, irritable bowel syndrome, malabsorption, or small intestinal overgrowth of bacteria.

The CPT^® codes associated with this revised Coverage Guideline are 0430U, 81599, and 89240.

Absolute Quantitation of Myocardial Blood Flow Measurement (RAD.00069)

This new Coverage Guideline addresses the use of absolute quantitation of myocardial blood flow (AQMBF), an imaging technique that can be used during various modalities of cardiac imaging including positron emission tomography (PET), cardiac magnetic resonance imaging (CMR), and single photon emission computed tomography (SPECT) scan imaging.

The use of absolute quantitation of myocardial blood flow testing is considered investigational and not medically necessary for all indications.

The CPT codes associated with this new Coverage Guideline are 78434, 0742T, 0899T, and 0900T.

These Coverage Guidelines are available for review on our website at anthem.com.

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised during Q4 2023. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit anthem.com/medicareprovider > Providers > Provider Resources > Policies, Guidelines & Manuals.

Notes/updates:

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

• MED.00146 - Gene Therapy for Sickle Cell Disease
• Outlines the Medically Necessary and Investigational & Not Medically Necessary criteria for Gene therapy for sickle cell disease
• RAD.00068 - Myocardial Strain Imaging
• Myocardial strain imaging in considered Investigational & Not Medically Necessary for all indications
• SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
• Reformatted Position Statement and added headers
• Reformatted Medically Necessary statements to move target treatment areas into criteria
• Revised Medically Necessary statement for primary dystonia to remove dystonia manifestation types
• Reformatted Medically Necessary statements for DBS for Parkinson’s, primary dystonia, and OCD
• Reformatted Medically Necessary statements for epilepsy
• Revised DBS for epilepsy Medically Necessary statement regarding non-epileptic seizures
• Revised Position Statement to add revision/replacement Medically Necessary and Investigational & Not Medically Necessary statements for DBS, cortical stimulation, and battery
• Revised and reformatted Investigational & Not Medically Necessary statements
• SURG.00097 - Scoliosis Surgery
• Revision to Position Statement formatting
• Added Medically Necessary and Investigational & Not Medically Necessary criteria for revision, replacement, or removal of vertebral body tethering to Position Statement
• SURG.00142 - Genicular Procedures for Treatment of Knee Pain
• Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain
• Revised title
• Added genicular artery embolization to the scope of document
• Revised Position Statement to add genicular artery embolization as Investigational & Not Medically Necessary

• CG-DME-42 - Continuous Glucose Monitoring Devices
• Previously titled: Continuous Glucose Monitoring Devices and External Insulin Infusion Pumps
• Revised title
• Moved content related to external insulin pumps to new document CG-DME-51 and automated insulin delivery systems to new document CG-DME-50
• Revised existing Medically Necessary and Not Medically Necessary statements

• CG-DME-52 - Continuous Passive Motion Devices in the Home Setting
• Use of a continuous passive motion (CPM) device in the home setting is considered Not Medically Necessary for all indications
• CG-MED-94 - Vestibular Function Testing
• Outlines the Medically Necessary and Not Medically Necessary criteria for vestibular function testing
• CG-SURG-09 - Temporomandibular Disorders
• Revised formatting of Medically Necessary statement
• Revised surgical procedures criteria
• Added MIRO Therapy to Not Medically Necessary statement
• CG-SURG-70 - Gastric Electrical Stimulation
• Added Medically Necessary and Not Medically Necessary criteria to Clinical Indications for removal, revision, or replacement of a gastric electrical stimulator

Medical Policies

On November 9, 2023, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect July 1, 2024.

Clinical UM Guidelines

On November 9, 2023, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members on January 4, 2024. These guidelines take effect July 1, 2024.

Effective September 1, 2024, HealthKeepers, Inc. will upgrade to the 28th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive:

• Behavioral Health Care (BHG):
  • The goal length of stay (GLOS) has been changed in two guidelines in the 28th edition of Behavioral Health Care.
• Inpatient & Surgical Care (ISC):
  • The goal length of stay (GLOS) has been changed in a total of 72 Optimal Recovery Guidelines in the 28th edition of Inpatient & Surgical Care. In medical Optimal Recovery Guidelines, the GLOS has been changed in 37 guidelines and the GLOS has been changed in 35 surgical Optimal Recovery Guidelines, in the 28th edition of Inpatient & Surgical Care.
• General Recovery Care (GRG):
  • The benchmark length of stay (BLOS) has been refined in the 28th edition of General Recovery Care.
• Recovery Facility Care (RFC):
  • A total of one guideline has been removed from the 28th edition of Recovery Facility Care.
• Chronic Care (CCG):
  • A total of 10 guidelines have been moved in the 28th edition of Chronic Care.

If you have any questions, please contact the Provider Services number on the back of the member's ID card.

Effective for dates of service on and after September 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

• Access the ProviderPortal_SM for Carelon Medical Benefits Management directly at providerportal.com.
• Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access Availity.com.

If you have any questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

The following services will be added to precertification for the effective dates listed below.

Precertification responsibility
The ordering or rendering provider of service is responsible for completing the prior authorization process. 

HMO plans: Services that require precertification will be denied if rendered without the appropriate prior authorization for in-network providers. HMO members may not have benefits for nonemergency services rendered outside of the network and are subject to review and may be denied. 

PPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement.

EPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement. No out of network benefit is available with the exception of ER/urgent care and authorized services. 

To request precertification with the Virginia Plan
Access Availity (Availity.com). 

For maternity, medical, surgical precertification, call the number listed on the back of the member’s ID card.

For mental health and substance abuse precertification, call 800-755-0851. Professionals are available 24 hours a day, seven days a week.

Effective August 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by HealthKeepers, Inc. for Anthem HealthKeepers Plus members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

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

• Web: Once logged in to Availity Essentials at Availity.com.
• Fax: 800-964-3627
• Phone: 800-901-0020

Not all PA requirements are listed here. Detailed PA requirements are available to care providers on providers.anthem.com/va on the Resources tab or for contracted care providers by accessing Availity.com. If you have any questions about this communication, contact Anthem HealthKeepers Plus Provider Services at 800-901-0020.

Effective August 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by HealthKeepers, Inc. for Anthem HealthKeepers Plus members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions), take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

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

• Web: Once logged in to Availity Essentials at Availity.com.
• Fax: 800-964-3627
• Phone: 800-901-0020

Not all PA requirements are listed here. Detailed PA requirements are available to providers on providers.anthem.com/va on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 800-901-0020 for assistance with PA requirements.

The National Committee Quality Assurance (NCQA) develops and collects HEDIS^® measurements to set performance and drive improvement in quality-of-care outcomes.

The Federal Employee Program^® (FEP) for Anthem is continuously working to improve clinical quality of care and performance outcomes. To comply with the NCQA standards and improve HEDIS AMM performance rate, FEP takes this opportunity to remind providers to document every service rendered in an accurate, timely manner and use the appropriate ICD-10-CM, CPT^®, and HCPCS codes when billing services rendered for patients who are receiving antidepressant medications. Below is a description of the AMM measure, why it is important, exclusions, and helpful tips (such as medical records documentation and best practices).

HEDIS AMM measure description

This HEDIS measure evaluates the percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported:

• Effective acute phase treatment: the percentage of members who remained on antidepressant medication for at least 85 days (12 weeks)
• Effective continuation phase treatment: the percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

Members with any diagnosis of major depression who are seen in any of the care settings are included in the AMM measure.

Why is the HEDIS AMM measure important?

Major depression is a serious mental illness with a significant burden of symptoms and the most common psychiatric disorder in individuals who die from suicide.¹ Integrating the right antidepressant medication with appropriate behavioral therapy leads to positive benefits and outcomes for members. Compliance with antidepressant medication is an essential component in treatment guidelines for major depression.²

Exclusions

Enrollees who did not have an encounter with a diagnosis of major depression during the 121-day period from 60 days prior to the index prescription start date (IPSD) through the IPSD and the 60 days after the IPSD

Common behavioral health codes used with any diagnosis of major depression that trigger patients into the HEDIS AMM measure are:

Helpful tips

Medical record documentation:

• Diagnosis of major depression
• Date of services
• Date of dispensing
• Evidence of antidepressant medication prescription

Best practices:

• Educate members that most antidepressants take four to six weeks to work.
• Encourage members to continue any prescribed medication even if they feel better. Inform them of the danger of discontinuing suddenly. If they take the medication for less than six months, they are at a higher risk of recurrence.
• Assess members within 30 days from when the prescription is first filled for any side effects and their response to treatment.
• When patients are making a follow-up visit, educate and encourage patients to bring their discharge instructions and medications list to their first appointment.
• Coordinate care between behavioral health and primary care physicians by sharing progress notes and updates.
• Educate members on what to do in an emergency, such as when having suicidal thoughts.
• Focus on member preferences for treatment, allowing the member to take ownership of their health and treatment plan.

Effective August 1, 2024, the following medication codes will require prior authorization.

Please note, inclusion of a National Drug Code (NDC) on your medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative or call Provider Services at 800-901-0020.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Specialty pharmacy updates for Anthem are listed below.

Anthem’s medical specialty drug review team manages prior authorization (PA) clinical review of non-oncology use of specialty pharmacy drugs. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request PA review for your patients’ continued use of these medications.

Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Effective for dates of service on or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our PA review process.

Access our Clinical Criteria to view the complete information for these prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

Note: PA requests for certain medications may require additional documentation to determine medical necessity.

Step therapy updates

Effective for dates of service on or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

Access our Clinical Criteria to view the complete information for these step therapy updates.

Quantity limit updates

Effective for dates of service on or after October 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

Effective for dates of service on and after October 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

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. They must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.