March 2019 Anthem Provider Newsletter - Virginia

Contents

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Anthem’s direct contracting effort for NPs and PAs gets under way in 2019

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Receive email notifications via our Network eUPDATE

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Register today for Anthem webinar on April 10

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Latest updates to EDI Gateway migration

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Explore the updates to the Medical Attachment tool

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

HEDIS® 2019: Controlling High Blood Pressure (CBP)

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Anthem launches additional changes to anthem.com in March

Guideline UpdatesAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Clinical practice and preventive health guidelines available on the Web

Products & ProgramsAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Anthem Commercial Risk Adjustment Program Update: Medical chart collection for ACA members due by March 31, 2019

Products & ProgramsAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Provider transparency update

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Anthem expands specialty pharmacy medical step therapy drug list

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Biosimilars: What are they?

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Clinical criteria updates for specialty pharmacy effective June 1, 2019

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Anthem expands specialty pharmacy prior authorization list

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Clinical criteria updates for specialty pharmacy

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Important update to Anthem’s commercial drug lists

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Some of your patients will begin moving to IngenioRx in Q2 2019

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Introducing a new clinical criteria Web page for injectable, infused or implanted drugs covered under the medical benefit

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Keep up with Medicare news

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Anthem to contract directly with NPs, PAs in 2019

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Clinical criteria updates for specialty pharmacy

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Change to 835 ERA for all D-SNP MA members for 2019

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Dual Eligible Special Needs Plans: Provider training required

State & FederalHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsMarch 1, 2019

Update: Evaluation and management with Modifier 25

State & FederalHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsMarch 1, 2019

Early intervention claims

State & FederalHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsMarch 1, 2019

Direct contracting for nurse practitioners and physician assistants in 2019

State & FederalHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsMarch 1, 2019

Coding Spotlight: Cancer - A provider’s guide to properly code cancers

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Anthem’s direct contracting effort for NPs and PAs gets under way in 2019

In 2019, Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. will launch an effort that will allow us to begin direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs), so they may begin billing their services under their own 10-digit National Provider Identifier (NPI).  This effort will impact all our lines of business:

 

  • Anthem’s PAR/PPO health plans including the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP).

 

  • Anthem HealthKeepers commercial plans including health plans purchased on or off the Health Insurance Marketplace (also known as the exchange).

 

  • Anthem HealthKeepers Plus [Medicaid/FAMIS and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) plans].

 

  • Medicare Advantage health plans.

 

As you may know, Virginia legislation went into effect on July 1, 2018, allowing nurse practitioners who meet certain work history requirements to begin practicing independently.  Licensed NPs and PAs currently can only bill for covered services under the supervision of the employing/supervising participating physician using that physician’s name and NPI number.  Direct contracting means NPs and PAs will be allowed to bill Anthem directly and the “incident to” guidelines will no longer apply.

 

How Anthem’s contracting process will work

 

We expect to begin the contracting effort sometime in the second quarter of 2019 by reaching out to network-participating providers we know currently employ NPs and PAs. Please note that the new participation agreement WILL NOT apply to certified nurse midwives, clinical nurse specialists, or psychiatric/mental health nurse practitioners, as they are contracted under a separate agreement.

 

Other than the provider type description, the participation agreement will contain all of the same provisions and obligations as our standard physician agreements.  The allowance schedule will be the same as the current standard physician allowance for our commercial and Medicaid agreements.  For Medicare Advantage, we will reimburse NP and PA services at 100 percent of the Medicare rate for these provider types.

 

Credentialing process

 

NPs and PAs will be required to be credentialed through Anthem in Virginia.  Therefore, NPs and PAs must complete the online application process through CAQH.  [To contact CAQH, dial 888-599-1771 (Monday -Thursday 7 a.m. – 9 p.m. ET; Friday 7 a.m. - 7 p.m. ET), or visit the CAQH website at http://www.caqh.org/ucd_physician_register.php.]

 

Benefits of direct contracting for NPs and PAs

 

This direct contracting and credentialing approach with NPs and PAs will allow us to include these providers on our provider directories as independent providers, and our members – your patients – can easily search our provider finder tool for NPs and PAs who participate with members’ health plans.

 

In addition, direct contracting with NPs and PAs will allow easier handling of Medicare crossover claims.  Medicare crossover claims for services provided by NPs and PAs to our members with a secondary group coverage policy will process under the participating NP or PA record, all without any re-billing by the group under the physician’s NPI.

 

Looking ahead

 

Going forward, we’ll keep you informed of details and the date contracted NPs and PAs can begin billing directly for their services.  Watch for upcoming editions of our provider newsletter for further details.

 

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Receive email notifications via our Network eUPDATE

Our provider newsletter, Network Update, is our primary source for providing important information to health care providers and professionals. Network Update is published monthly and is posted to our website on the Virginia provider section of anthem.com for easy 24/7 access.

 

Note that in addition to this newsletter and our website, we also use our email service – Network eUPDATE – to communicate new information. If you are not yet signed up to receive Network eUPDATEs, we encourage you to enroll now so you’ll be sure to receive all information we will be sending about billing, upcoming changes, coverage guidelines and other pertinent topics.

 

Reminder notifications sent via email

 

When you sign up, you’ll not only receive an email reminder for each newsletter posted online, you’ll  also be notified of other late breaking news and important information you’ll need when providing services and filing claims for our members. It’s easy to sign up – just select Virginia and access the provider home page.  There, you’ll find a link to register for our Network eUPDATE

 

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Register today for Anthem webinar on April 10

On April 10, 2019, Anthem will offer a provider education webinar. Designed for our network-participating providers, the webinars address Anthem business updates and billing guidelines that impact your business interactions with us.

 

For your convenience, we offer these informative, hourly sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the first scheduled webinar for 2019 is:

 

  • Wednesday, April 10, 2019, from 10 a.m. to 11 a.m. ET

 

Please take time to register today for the webinar using the registration form to the right under the “Article Attachments” section. If you have already registered for the April webinar, please check that you have received a fax confirmation or a confirmation from an Anthem representative to ensure we’ve received your registration form.  Please contact stacey.marsh@anthem.com if you need to confirm your registration.

 

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Latest updates to EDI Gateway migration

Anthem Blue Cross and Blue Shield has designated Availity to operate and serve as your electronic data interchange (EDI) entry point or also called the EDI Gateway.  The EDI Gateway is a no-cost option for our providers who choose to submit their own EDI claims to Anthem.  If you prefer to use a clearinghouse or billing company, please work with them directly to ensure connectivity.

 

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway. 

 

Do you already have an Availity User ID and Login? You can use the same login for your Anthem EDI transactions.  

 

  • Log in to the Availity Portal and select Help & Training | Get Trained. In the Availity Learning Center, search the Catalog by key word “SONG” for live and on-demand resources created especially for you.

 

If you wish to become a direct a trading partner with Availity, the setup is easy.

 


Need Assistance?

 

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

835 Electronic Remittance Advice (ERA)

 

Please use Availity to register and manage account changes for ERA.

If you were previously registered to receive ERA, you must register using Availity to manage account changes.

 

Log into the Availity Portal and select My Providers | Enrollments Center | ERA Enrollment to enroll for 835 ERA delivery.

 

Electronic Funds Transfer (EFT)

 

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

 

If you have any questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 7:30 p.m. Eastern Time.

 

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Explore the updates to the Medical Attachment tool

Have you been using the medical attachment tool on the Availity Portal to submit solicited medical records in support of a claim? You will now find these changes that were recently introduced:

 

  • Select the “Attachment – New” option to submit medical records when Anthem has requested additional information to process a claim
  • To send a solicited attachment, now find the “Send Attachment” link on the top, right side of the page
  • Expanded file size – each attachment can be up to 40 MB with a total of 80 MB as the file size limit
  • Ability to submit an itemized bill

 

If you have not tried the Medical Attachment tool to submit electronic documentation in support of a claim, now is the time to give it a try! This tool makes the process of submitting requested medical records simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Anthem) medical record attachments through the Availity Portal.

 

The existing Medical Attachment tool will not be removed from the Availity Portal immediately, but users are encouraged to connect to the ‘Attachment – New’ option for greater capabilities.

 

How to Access solicited Medical Attachments for Your Office

  • Availity Administrator, complete these steps:

 

From My Account Dashboard, select Enrollments Center>Medical Attachments Setup, follow the prompts and complete the following sections:

 

  1. Select Application>choose Medical Attachments Registration
  2. Provider Management>Select Organization from the drop-down. Add NPIs and/or Tax IDs (Multiples can be added separated by spaces or semi-colons)
  3. Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name

 

Using Medical Attachments

Availity User, complete these steps:

  1. Log in to www.availity.com
  2. Select Claims and Payments > Attachments-New >Send Attachment Tab
  3. Complete all required fields of the form
  4. Attach supporting documentation
  5. Submit

 

Need Training?

 

To access additional training for this Availity feature:

 

  1. Log in to the Availity Portal at www.availity.com
  2. At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
  3. In the new window a list of available topics will open. Locate and click Medical Attachments
  4. Under the Recordings section, click View Recording

 

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

HEDIS® 2019: Controlling High Blood Pressure (CBP)

One of the measures we report on is the Controlling High Blood Pressure (CBP) measure. This measure focuses on the percentage of members who are 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement year (2018).

 

What’s new for 2019?

 

  • The Controlling High Blood Pressure (CBP) measure is no longer strictly a hybrid measure, which means that we review both medical records and claims. We can now use claims data to confirm both the diagnosis of hypertension as well as the blood pressure reading (CPT II codes).
  • If you submit a claim using CPT II codes to document the blood pressure reading, we can now use that information, eliminating the need to request the medical record from you.
  • Compliant BP is defined as <140/90 mm Hg for all members.
  • Blood pressure readings taken from remote monitoring devices that are electronically submitted directly to the Provider can be utilized for the measure.


What do we need from you?

We need the last two office visit notes from 2018 with the blood pressure documented. Also, if the member was diagnosed with end stage renal disease, renal dialysis, renal transplant or pregnancy in 2018 please send that documentation as well.

 

Common chart deficiencies:

 

  • Recheck elevated blood pressures readings and document all BP readings in the medical record.

 

For more information on HEDIS, visit the Anthem Provider Portal online at Anthem.com. Click on Providers > Click Polices and Guidelines > Select State>Scroll down and click View Med Policies and UM Guideline >Click Health & Wellness > Scroll down to Quality Improvement and Standards> and then scroll down on the page to HEDIS Information.

 

Thank you for your continued cooperation and support of HEDIS.

 

 

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

 

AdministrativeAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Anthem launches additional changes to anthem.com in March

This March, anthem.com will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms, as seen below.

 

This first version of the new Provider Forms will keep growing and evolving in the coming months.

 

anthem.com forms and guides page


We will continue to keep you informed of upcoming changes to the public provider site, as we progress toward streamlining our Web platform and other business processes.

 

 

ATTACHMENTS (available on web): Provider Forms and Guidelines.jpg (jpg - 0.13mb)

Guideline UpdatesAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Clinical practice and preventive health guidelines available on the Web

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

 

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website at anthem.com/provider/Provider Overviews> scroll down and select ‘Find Resources for Virginia’ > Health and Wellness > Practice Guidelines.

Products & ProgramsAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Anthem Commercial Risk Adjustment Program Update: Medical chart collection for ACA members due by March 31, 2019

Each year, Anthem requests your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), in order to document and close the coding gaps. 

 

The CRA Program is specific to our Affordable Care Act (ACA) members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).

 

With our Retrospective Program, we focus on medical chart collection.  We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS).  This particular effort is part of Anthem’s compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership.  The members’ medical record documentation helps support this data requirement.

 

Analytics are performed internally on claims which do not have the ICD10 code for which we suspect a chronic condition.  These medical records will be requested, reviewed, and any additional codes abstracted can be submitted to CMS to increase our risk score values.

 

Anthem network providers -- may be PCPs, specialists, facilities, behavioral health, ancillary, etc. -- may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review.  These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf.  The vendors’ Web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management. 

 

We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2019, at the latest).  While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.

 

Electronic options that may make medical chart collection easier for providers:

  • EMR Interoperability

 

Allscripts (Opt in: signature required)

NextGen (Opt out: auto-enrolled)

Athenahealth (Opt out: auto-enrolled)

MEDENT

 

  • Remote/Direct Anthem access
  • Vendor virtual or onsite visit
  • Secure FTP

 

The goal of these electronic options is to both improve the medical record data extraction and the experience for Anthem’s network-participating hospitals, clinics and physician offices.  If you are interested in this type of set up or any other remote access options, please contact our Commercial Risk Adjustment Network Education Representative for Virginia via her email:  Alicia.Estrada@anthem.com 

 

Thank you for your continued efforts with our CRA Program and expediting these medical chart collection requests.  

 

Products & ProgramsAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Provider transparency update

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways this is done is by giving certain providers (“Payment Innovation Providers”) in Anthem’s various Payment Innovation Programs (such as Enhanced Personal Health Care, Bundled Payments, Medical Home programs, etc.) (the “Programs”) quality, utilization and/or cost information about the health care providers (“Referral Providers”) to whom the Payment Innovation Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in their getting more referrals from Payment Innovation Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

 

Providing this type of data, including comparative cost information, to Payment Innovation Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Payment Innovation Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers -- including any opportunities for improvement. For questions or support, please refer to your local market representative or care consultant.

 

 

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Anthem expands specialty pharmacy medical step therapy drug list

The following clinical criteria will be effective June 1, 2019.

 

Colony Stimulating Factor Agents ING-CC-0002

 

Effective for dates of service on and after June 1, 2019, the following specialty pharmacy codes from new or current criteria will be included in our existing specialty pharmacy medical step therapy review process. Zarxio® will be the preferred short-acting colony stimulating factor (CSF) agent over Neupogen®, Granix®, and Nivestym™®.

 

For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., pre-service clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.

 

This applies to members with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).

 

Additional information regarding biosimilar drugs can be found in the reference document called: “Biosimilar Drugs: What are they?” 

 

Access the clinical criteria information.

 

Clinical Criteria

Status

Drug

HCPCS or CPT Code

NDC Code

ING-CC-0002

Preferred Agent

Zarxio®

Q5101

61314-0304-01

61314-0304-10

61314-0312-01

61314-0312-10

61314-0318-01

61314-0318-10

61314-0326-01

61314-0326-10

ING-CC-0002

Non-Preferred Agent

Neupogen®

J1442

55513-0530-01

55513-0530-10

55513-0546-01

55513-0546-10

55513-0924-01

55513-0924-10

55513-0924-91

55513-0209-01

55513-0209-10

55513-0209-91

ING-CC-0002

Non-Preferred Agent

Granix®

J1447

63459-0910-11

63459-0910-12

63459-0910-15

63459-0910-17

63459-0910-36

63459-0912-11

63459-0912-12

63459-0912-15

63459-0912-17

63459-0912-36

ING-CC-0002

Non-Preferred Agent

Nivestym™

Q5110

00069-0291-10

00069-0291-01

00069-0292-01

00069-0292-10

 

 

 

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Biosimilars: What are they?

What are biologics and biosimilars?  Biologics are medicines made from living cells, manufactured in living systems.  The manufacturing process is complex with extensive quality controls because the living systems used to produce biologics can change ever so slightly over time.  A biosimilar of a biologic is similar to a generic version of a conventional drug, but there is a key difference.  By law, a generic must be an exact copy of the original medication, or reference product.  Because of the complexity of the biological medication, it is not possible to exactly replicate biologic reference products.  Therefore, biosimilars must be highly similar in terms of structure and function and lack clinically meaningful difference in terms of safety and efficacy to their reference product.

 

What are some examples of biosimilars?   Only six biosimilars are commercially available in the U.S. as of October 2018. These include Zarxio®, Nivestym™, and Fulphila™, which treat neutropenia; Inflectra® and Renflexis®, which treat inflammatory diseases; and Retacrit™, which treats anemia. Six additional products – treatments for various cancers, as well as additional treatments for inflammatory diseases – have been approved by the FDA but are not yet commercially available.

 

Are biosimilars approved for all the same indications as the reference product?  Biosimilars may be approved for all or some of the indications as the reference product. Some biosimilars may have a subset of indications as the reference product due to patent exclusivity of certain indications.  There is no clinical reason why the biosimilar cannot be used for all indications of the reference product, even though the biosimilar might not share the same indications.

 

What are the potential benefits of biosimilars?  As patents start to expire on the biologic drugs, the rise of biosimilars brings increased competition to the market resulting in potentially lower treatment cost.  We also expect to see innovation evolve with product competition. Examples of differentiating product attributes already seen include individualized anti-drug antibody monitoring and subcutaneous formulations for greater convenience.

 

Will the pharmacist substitute a reference product with the biosimilar if the prescription indicates may substitute?  Although the biosimilar lacks clinically meaningful difference compared to its reference product, it is not automatically substitutable by the pharmacist, unless it is rated as interchangeable.  To date, no biosimilars are considered interchangeable.  The prescription needs to be written for the biosimilar by name.

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Clinical criteria updates for specialty pharmacy effective June 1, 2019

The following clinical criteria will be effective June 1, 2019.

 

Erythropoiesis Stimulating Agents ING-CC-0001

 

Clinical criteria ING-CC-0001 addresses the use of recombinant erythropoietin products, also known as erythropoiesis stimulating agents (ESAs), for the treatment of severe anemia in chronic kidney disease (CKD), HIV, cancer, surgery, and other conditions.

Effective for dates of service on and after June 1, 2019, the use of Procrit®, Epogen®, and Retacrit™ for the treatment of severe anemia in hepatitis C, chronic inflammatory disease, and bone marrow transplant are considered not medically necessary. 

 

H.P. Acthar Gel® (repository corticotropin injection) ING-CC-0004

 

Clinical criteria ING-CC-0004 addresses the use of repository corticotropin injection for the treatment of infantile spasms (West syndrome) and adults with a corticosteroid-responsive condition, including but not limited to acute exacerbations of multiple sclerosis.

Effective for dates of service on and after June 1, 2019, repository corticotropin injections for the treatment of conditions other than infantile spasms (West syndrome) are considered not medically necessary. 

 

Selective Vascular Endothelial Growth Factor (VEGF) Antagonists ING-CC-0072

 

Clinical criteria ING-CC-0072 addresses the use of intravitreal vascular endothelial growth factor (VEGF) antagonists for the treatment of diabetic retinopathy and other retinal disorders associated with neovascularization.

Effective for dates of service on and after June 1, 2019, the use of Eylea® for the treatment of radiation retinopathy is considered not medically necessary. 

 

Access the clinical criteria information.

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Anthem expands specialty pharmacy prior authorization list

Effective for dates of service on and after June 1, 2019, the following specialty pharmacy codes from new clinical criteria or current clinical guideline will be included in our prior authorization review process.


Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

 

For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., pre-service clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.

 

This applies to members with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).

 

The following clinical criteria will be effective June 1, 2019.

 

Clinical Criteria/Guideline

HCPCS or CPT Code

NDC Code

Drug

CG-DRUG-63

J3490

68152-0112-01

68152-0114-01

Khapzory™

ING-CC-0002

Q5110

00069-0291-10

00069-0291-01

00069-0292-01

00069-0292-10

Nivestym™

ING-CC-0002

J3490

68152-0112-01

68152-0114-01

Udenyca™

ING-CC-0003

J1599

68982-0820-01

68982-0820-02

68982-0820-03

68982-0820-04

68982-0820-05

68982-0820-06

68982-0820-81

68982-0820-82

68982-0820-83

68982-0820-84

68982-0820-85

68982-0820-86

Panzyga®

ING-CC-0034

J3590

47783-0644-01

Takhzyro®

ING-CC-0062

J3590

61314-0871-02

61314-0871-06

61314-0876-02

Hyrimoz™

ING-CC-0062

Q5109

00069-0811-01

Ixifi™

ING-CC-0065

J7192

00026-3942-25

00026-3944-25

00026-3946-25

00026-3948-25

00026-4942-01

00026-4944-01

00026-4946-01

00026-4948-01

Jivi®

ING-CC-0074

J8655

69639-0102-01

Akynzeo®

ING-CC-0077

C9399

J3590

68135-0058-90

68135-0673-40

68135-0673-45

68135-0756-20

Palynziq™

ING-CC-0081

J0584

69794-0102-01

69794-0203-01

69794-0304-01

Crysvita®

ING-CC-0082

C9399

J3490

71336-1000-01

Onpattro™

 

Access the clinical criteria information.

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Clinical criteria updates for specialty pharmacy

On December 1, 2018, Anthem introduced the new clinical criteria page for injectable, infused or implanted drugs.

Effective for dates of service on and after March 1, 2019, the following new clinical criteria will be included in our clinical criteria review process.  The drugs that require prior authorization will continue to require precertification with Anthem.

Existing precertification requirements have not changed for the specific clinical criteria below.  While there are no material changes, the document number and online location has changed.  Access the clinical criteria information.  The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., pre-service clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.

 

This applies to members with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).

 

Clinical or Coverage Guideline

Clinical Criteria Document Number

Clinical Criteria Name

Drug(s)

HCPCS or CPT Code(s)

CG-DRUG-29

ING-CC-0006

Hyaluronan Injections

Durolane, Euflexxa, Gel-One, Gen-Syn, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/FX, Synvisc/-One, TriVisc, Visco-3

J7318, J7320 , J7321, J7322, J7323, J7324 , J7325, J7326, J7327, J7328, J7329

DRUG.00015

ING-CC-0007

Synagis (palivizumab)

Synagis

90378

DRUG.0031

ING-CC-0008

Testopel (testosterone subcutaneous implant)

Testosterone implant

S0189

DRUG.00074

ING-CC-0009

Lemtrada (alemtuzumab)

Lemtrada

J0202

DRUG.00078

ING-CC-0010

Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors

Praluent, Repatha

J3490 , J3590

DRUG.00095

ING-CC-0011

Ocrevus (ocrelizumab)

Ocrevus

J2350

DRUG.00099

ING-CC-0012

Brineura (cerliponase alfa)

Brineura

J0567

DRUG.00116

ING-CC-0013

Mepsevii (vestronidase alfa)

Mepsevii

J3490

CG-DRUG-03

ING-CC-0014

Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis

Avonex, Plegridy, Rebif, Betaseron, Extavia, Copaxone, Glatopa

J1595, J1826, J1830, J3490, Q3027, Q3028

CG-DRUG-27

ING-CC-0017

Xiaflex (clostridial collagenase histolyticum) injection

Xiaflex

J0775

CG-DRUG-28

ING-CC-0018

Lumizyme (alglucosidase alfa)

Lumizyme

J0221

CG-DRUG-43

ING-CC-0020

Tysabri (natalizumab)

Tysabri

J2323

CG-DRUG-54

ING-CC-0021

Fabrazyme (agalsidase beta)

Fabrazyme

J0180

CG-DRUG-55

ING-CC-0022

Vimizim (elosulfase alfa)

Vimizim

J1322

CG-DRUG-56

ING-CC-0023

Naglazyme (galsulfase)

Naglazyme

J1458

CG-DRUG-57

ING-CC-0024

Elaprase (idursufase)

Elaprase

J1743

CG-DRUG-58

ING-CC-0025

Aldurazyme (laronidase)

Aldurazyme

J1931

CG-DRUG-73

ING-CC-0027

Denosumab agents

Prolia, Xgeva

J0897

CG-DRUG-84

ING-CC-0028

Benlysta (belimumab)

Benlysta

J0490

CG-DRUG-88

ING-CC-0029

Dupixent (dupilumab)

Dupixent

J3490, J3590

CG-DRUG-89

ING-CC-0030

Implantable and ER Buprenorphine Containing Agents

Probuphine, Sublocade

J0570, J3490 , Q9991, Q9992

CG-DRUG-103

ING-CC-0032

Botulinum Toxin

Botox, Xeomin, Dysport, Myobloc

J0585, J0586, J0587 , J0588 , J0585, J0586 , J0587 , J0588

CG-DRUG-104

ING-CC-0033

Xolair (omalizumab)

Xolair

J2357

CG-DRUG-108

ING-CC-0035

Duopa (carbidopa and levodopa enteral suspension)

Duopa

J7340

CG-DRUG-111

ING-CC-0037

Kanuma (sebelipase alfa)

Kanuma

J2840

CG-DRUG-112

ING-CC-0038

Human Parathyroid Hormone Agents

Tymlos

J3490

DRUG.00013

ING-CC-0039

GamaSTAN [(immune globulin (human)]

GamaSTAN. GamaSTAN S/D

J1460, J1560

DRUG.00027

ING-CC-0040

Prialt (ziconotide)

Prialt

J2278

DRUG.00050

ING-CC-0041

Soliris (eculizumab)

Soliris

J1300

DRUG.00077

ING-CC-0042

Monoclonal Antibodies to Interleukin-17

Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab)

C9399, J3490, J3590

DRUG.00080

ING-CC-0043

Monoclonal Antibodies to Interleukin-5

Cinqair (reslizumba), Fasenra (benralizumab), Nucala (mepolizumab)

J0517, J2182, J2786

DRUG.00081

ING-CC-0044

Exondys 51 (eteplirsen)

Exondys 51

J1428

DRUG.00086

ING-CC-0045

Increlex (mecasermin)

Increlex

J2170

DRUG.00090

ING-CC-0046

Zinplava (bezlotoxumab)

Zinplava

J0565

DRUG.00096

ING-CC-0047

Trogarzo (ibalizumab-uiyk

Trogarzo

J1746

DRUG.00104

ING-CC-0048

Spinraza (nusinersen)

Spinraza

J2326

DRUG.00108

ING-CC-0049

Radicava (edaravone)

Radicava

J1301

DRUG.00111

ING-CC-0050

Monoclonal Antibodies to Interleukin-23

Ilumya, Tremfya

J1628, J3245

CG-DRUG-08

ING-CC-0051

Enzyme Replacement Therapy for Gaucher Disease

Cerezyme, Elelyso, Vpriv

J1786 , J3060 , J3385

CG-DRUG-44

ING-CC-0057

Krystexxa (pegloticase)

Krystexxa

J2507

CG-DRUG-45

ING-CC-0058

Octreotide Agents

Sandostatin, Sandostatin LAR Depot

J2353 , J2354

CG-DRUG-61

ING-CC-0061

GnRH Analogs for the treatment of non-oncologic indications

Zoladex, Supprelin LA, Lupron Depot/Depot-Ped, Triptodur

C9399, J3490, J1675, J1950, J3315, J3316, J9202 , J9217, J9218 , J9225, J9226 , J3490

CG-DRUG-69

ING-CC-0063

Stelara (ustekinumab)

Stelara

J3357, J3358

CG-DRUG-74

ING-CC-0064

Interleukin-1 Inhibitors

Arcalyst, Ilaris

J2793, J0638

CG-DRUG-93

ING-CC-0066

Monoclonal Antibodies to Interleukin-6

Actemra, Kevzara

J3262, C9399 , J3490 , J3590

CG-DRUG-82

ING-CC-0067

Prostacyclin Infusion and Inhalation Therapy

Flolan, Remodulin, Tyvaso, Veletri, Ventavis

J1325, J3285, J7686, K0455 , Q4074, S0155 , S9347

CG-DRUG-83

ING-CC-0068

Growth hormone

Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive

J2940 , J2941 , Q0515 , S9558

CG-DRUG-85

ING-CC-0069

Egrifta (tesamorelin)

Egrifta

J3490

CG-DRUG-86

ING-CC-0070

Jetrea (ocriplasmin)

Jetrea

J7316

CG-DRUG-87

ING-CC-0071

Entyvio (vedolizumab)

Entyvio

J2503 , C9257, J9035, Q5107 , J2778, J0178

CG-DRUG-92

ING-CC-0073

Alpha-1 Proteinase Inhibitor Therapy

Aralast, Glassia, Prolastin-C, Zemaira

J0256, J0257

CG-DRUG-94

ING-CC-0075

Rituxan (rituximab) for Non-Oncologic Indications

Rituxan

J9311

CG-DRUG-95

ING-CC-0076

Nulojix (belatacept)

Nulojix

J0485

CG-DRUG-105

ING-CC-0078

Orencia (abatacept)

Orencia

J0129

CG-DRUG-109

ING-CC-0079

Strensiq (asfotase alfa)

Strensiq

J3490

 

 

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Important update to Anthem’s commercial drug lists

Effective with dates of service on and after April 1, 2019, and in accordance with Anthem’s Pharmacy and Therapeutic (P&T) process, Anthem Blue Cross and Blue Shield in Virginia will update our commercial drug lists. Updates may include changes to drug tiers or the removal of a drug.

 

To help ensure a smooth transition and minimize member costs, providers should review these changes and consider prescribing a preferred drug to patients currently using a non-preferred drug, if appropriate.

Please note, this update does not apply to the Select Drug List or drugs lists utilized by the Federal Employee Program (FEP).

 

To view a summary of changes, click Summary of Formulary Changes.

PharmacyAnthem Blue Cross and Blue Shield | CommercialMarch 1, 2019

Some of your patients will begin moving to IngenioRx in Q2 2019

In January, Anthem, Inc. announced that it’s accelerating the launch of IngenioRx, its new pharmacy benefits manager (PBM), which will serve members of all Anthem’s affiliated health plans. We will begin moving some members to IngenioRx in Q2, and we will continue the transition, in waves, with the majority of members moving in the latter part of 2019 and Q1 2020.

 

As one of our contracted providers, we wanted to share a few details about what this means for you.

 

  • If your patient has an active prior authorization, that will transfer to IngenioRx.
  • If your patient currently fills home delivery or specialty prescriptions through Express Scripts, prescriptions with at least one refill will be transferred, with the exception of controlled substances and compound drugs, to IngenioRx Home Delivery Pharmacy and IngenioRx Specialty Pharmacy.
  • As your patients transition, new home delivery and specialty prescriptions will need to be sent to IngenioRx.

 

For Providers

THEN

Using ePrescribing

There are no changes, simply select IngenioRx.

Who do not use ePrescribing

You should send your home delivery and specialty prescriptions to IngenioRx.

IngenioRx Home Delivery Pharmacy new prescriptions:

Phone Number: 833-203-1742

Fax number: 800-378-0323

 

IngenioRx Specialty Pharmacy:

Prescriber phone: 833-262-1726

Prescriber fax: 833-263-2871

 

  • If you want to check whether or not a specific patient has moved to IngenioRx, Availity will display the member’s PBM information under the patient information section as part of the eligibility and benefits inquiry.

 

If you have immediate questions, you can contact the Provider Service phone number on the back of your patient’s ID card or call the number you normally use for questions.

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Introducing a new clinical criteria Web page for injectable, infused or implanted drugs covered under the medical benefit

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

 

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

 

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

 

If you have questions or feedback, please use this email link.

 

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Keep up with Medicare news

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Anthem to contract directly with NPs, PAs in 2019

In 2019, Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will begin direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs), so they may begin billing their services under their own 10-digit National Provider Identifier (NPI).  This effort will begin during the second quarter of 2019 and impact all our lines of business, including Medicare Advantage. To learn more, please see Important Medicare Advantage Updates at anthem.com/medicareprovider.

 75743MUPENMUB 01/24/2019

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Clinical criteria updates for specialty pharmacy

The following revised clinical criteria will be effective May 1, 2019. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.

 

Clinical criteria effective date

Clinical criteria number

Clinical criteria

Clinical criteria (new/revised)

May 1, 2019

ING-CC-0001

Erythropoiesis Stimulating Agents

Revised

May 1, 2019

ING-CC-0004

H.P. Acthar Gel®

(repository corticotropin injection)

Revised

May 1, 2019

ING-CC-0072

Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

Revised

 

75743MUPENMUB 01/24/2019

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Change to 835 ERA for all D-SNP MA members for 2019

Anthem updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433. The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:

 

  • Group code patient responsibility (PR) will be assigned.

 

  • Claim adjustment reason codes (CARCs) will include the following:

 

Claim Adjustment Reason Code

Description

1

Deductible amount (professional claim)

2

Coinsurance amount (professional claim)

3

Copay amount (professional and facility claim)

247

Deductible for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)

248

Coinsurance for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)

 

  • Remittance advice remark codes (RARCs) will include the following:

 

Remittance Advice Remark Code

Description

N781

Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.

N782

Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.

N783

Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected copay. This amount may be billed to a subsequent payer.

 

Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.

 

75743MUPENMUB 01/24/2019

State & FederalAnthem Blue Cross and Blue Shield | Medicare AdvantageMarch 1, 2019

Dual Eligible Special Needs Plans: Provider training required

In 2019, Anthem is offering Dual Eligible Special Needs Plans (D-SNPs) to people who are eligible for both Medicare and Medicaid benefits or who are qualified Medicare beneficiaries (QMBs).  D-SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These plans are $0 premium plans.  Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments.  Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.  

 

Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in Q1 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.

 

Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.


For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.

75743MUPENMUB 01/24/2019

 

State & FederalHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsMarch 1, 2019

Policy Update Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service