 Provider News VirginiaMarch 2021 Anthem Provider News - VirginiaTo help ensure accuracy and eliminate delays in the adjudication of your claims, the itemized bill must be included with qualifying claim submissions. Submitting an itemized bill for a high dollar claim just got easier for submitting *unsolicited medical attachments.
There is an “itemized bill” submission option under Attachments – New.
- Log in to Availity Portal
- Select Claims & Payments | Attachments – New
- Select Send Attachment
- Under the Request for Information, select No, if you are including the supplemental information/attachment for an 837 claim PWK.
- Provide provider, patient and claim information
- Attach Supporting Documentation and Reason
- Send Attachment(s)
Also, available for you is the option to submit a claim attachment using Availity Portal for *solicited medical attachments.
Submit supporting documentation in response to a formal (solicited) request from the payer.
- Log in to Availity Portal
- Select Claims & Payments | Attachments – New
- Select Send Attachment
- Under the Request for Information, select Yes, if you are responding to a request from the health plan or need to submit documentation for a specific claim number
- Add supporting documentation and Reason
- Submit
As an added bonus, if you attended a previous webinar, we want to share updated information about submitting an EDI 837 batch, which includes a PWK segment in loops 2300/2400. This detail is the linkage between the electronic claim and your supplemental documentation that can be submitted through the Availity portal.
What does this mean for you?
You may now submit attachments electronically (EDI) using the PWK segment to specify that documents are being submitted in support of the claim, and no additional face sheet or coversheet is needed.
Here are the steps:
- Log in to Availity Portal
- Select Claims & Payments I Attachments - New
- From the Inbox tab, select the appropriate claim or open the request in your work queue
- Add files with supporting documentation
- Submit
Get Trained
Attend an Availity hosted webinar to learn more about all capabilities. You can register for an upcoming live webinar hosted by Availity.
or
Log into www.Availity.com and select Help & Training | Get Trained to open the Availity Learning Center in a new tab (it is your dedicated ALC account).
- Search by keyword (Medattach) to find on-demand and live training options.
- Click Enroll to enroll for a course and then go to your Dashboard to access it any time.
Get started today with these wide-ranging capability enhancements to transform your business operations to a quick, secure, paperless and simple process to fulfill medical records requests electronically through Availity.
*Unsolicited Attachment: Documentation submitted without a formal request from the payer
*Solicited Attachment: Documentation submitted in response to a specific request from payer
1017-0321-PN-VA
On May 6, 2021, Anthem will offer a provider education webinar. Designed for our network-participating providers, the webinar addresses Anthem business updates and billing guidelines that impact your business interactions with us.
For your convenience, we offer these informative, hour-long sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the spring webinar is:
- Thursday, May 6, 2021, from 11 a.m. to noon 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 spring webinar, please ensure you have received a fax confirmation or a confirmation from an Anthem representative to check that we’ve received your registration form. Contact stacey.marsh@anthem.com if you need to confirm your registration.
989-0321-PN-VA As of November 1, 2020, AIM Specialty Health® (AIM) began administering the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints using AIM clinical guidelines for Anthem Blue Cross fully insured members and some ASO groups.
Effective March 14, 2021, the AIM Small Joint Surgery Guideline has been updated with the following:
- Clarified requirements for imaging reports.
- Removed radiographic requirement for confirmation of lesser toe deformities.
- Ankle arthrodesis and total ankle arthroplasty added as new indications for revision of failed previous reconstructions.
- Removed total ankle arthroplasty requirements for adjacent joint or inflammatory arthritis.
- Clarified contraindications only apply to total ankle arthroplasty.
Providers should continue to submit pre-authorization requests to AIM using one of the following ways:
- Access AIM ProviderPortalSM 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.
- Call the AIM toll-free number at 866-789-0397, Monday - Friday, 8 a.m. to 5 p.m. ET.
For questions, please contact the provider number on the back of the member ID card.
993-0321-PN-VA
Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. are committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and access to a better healthcare experience for consumers.
Effective with dates of service on or after June 1, 2021, medical necessity review of the site of care is required for the following long-acting colony-stimulating factors for oncology indications for Anthem Commercial plan members:
- Neulasta® & Neulasta Onpro® (pegfilgrastim)
- Fulphila® (pegfilgrastim-jmdb)
- Udenyca® (pegfilgrastim-cbqv)
- Ziextenzo® (pegfilgrastim-bmez)
- Nyvepria™ (pegfilgrastim-apgf)
The review will be administered by AIM Specialty Health® (AIM).
AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, access Anthem in Virginia’s
Coverage Guidelines and Clinical UM Guidelines and type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.
The site of care medical necessity review only applies to administration performed in an outpatient hospital setting. This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Anthem is the secondary payer.
Submit a request for review
Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021, to AIM in one of the following ways:
- Access AIM ProviderPortalSM 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.
- Call the AIM Contact Center toll-free number: 866-789-0397, Monday - Friday, 8 a.m. to 5 p.m. ET.
Please note, this review does not apply to the following plans:
- BlueCard®
- Federal Employee Program® (FEP®)
- Medicaid
- Medicare Advantage
- Medicare Supplemental plans.
Providers can view prior authorization requirements for Anthem members on the Clinical Criteria Page at anthem.com. .
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the member’s ID card.
Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care.” In some plans, these terms may be used interchangeably. For simplicity, we will hereafter use “site of care.”
1019-0321-PN-VA
Prior authorization updates
Effective for dates of service on and after June 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
The Health Plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code (NDC), for the injected substance. This requirement is consistent with the Centers for Medicare & Medicaid Services (CMS) guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.
Please note, inclusion of National Drug Code code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Access the Clinical Criteria information.
For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
*ING-CC-0185
|
J3490
C9399
|
Oxlumo
|
|
**ING-CC-0184
|
J3490
J3590
J9999
|
Danyelza
|
*Non-oncology use is managed by the medical specialty drug review team. Oncology use is managed by AIM.
** Oncology use is managed by AIM.
Prior authorization update – change in effective date
Please note the change in date for the implementation of prior authorization for injectable iron deficiency anemia products.
The effective date has been changed to dates of service on and after May 1, 2021, for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our prior authorization review process. The previous effective date was March 1, 2021.
The Health Plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code, for the injected substance. This requirement is consistent with CMS guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.
Please note, inclusion of National Drug Code code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified code. Access the Clinical Criteria information.
For Anthem Blue Cross and Blue Shield and HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
*ING-CC-0182
|
J1756
|
Venofer
|
|
*ING-CC-0182
|
J2916
|
Ferrlecit
|
|
*ING-CC-0182
|
J1750
|
Infed
|
|
*ING-CC-0182
|
J1439
|
Injectafer
|
|
*ING-CC-0182
|
Q0138
|
Feraheme
|
|
*ING-CC-0182
|
J1437
|
Monoferric
|
* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Step therapy update – change in effective date
Please note the change in the effective date of step therapy for injectable iron deficiency anemia products.
The effective date has been changed to dates of service on and after May 1, 2021, for the following specialty pharmacy codes from current or new clinical criteria documents that will be included in our existing specialty pharmacy medical step therapy review process. The previous effective date was March 1, 2021.
Access the step therapy drug list.
For Anthem Blue Cross and Blue Shield and HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
|
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS Codes
|
|
*ING-CC-0182
|
Preferred
|
Venofer
|
J1756
|
|
*ING-CC-0182
|
Preferred
|
Ferrlecit
|
J2916
|
|
*ING-CC-0182
|
Preferred
|
Infed
|
J1750
|
|
*ING-CC-0182
|
Non-preferred
|
Injectafer
|
J1439
|
|
*ING-CC-0182
|
Non-preferred
|
Feraheme
|
Q0138
|
|
*ING-CC-0182
|
Non-preferred
|
Monoferric
|
J1437
|
* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Prior authorization update – change in code list
In a recent notification, we shared that effective April 1, 2021, the following codes would be included in our prior authorization review process. Please be advised that these codes will NOT be included in our prior authorization process at this time.
Access the Clinical Criteria information.
For Anthem Blue Cross and Blue Shield and HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
*ING-CC-0095
|
J9041
|
Velcade (Bortezomib)
|
|
**ING-CC-0095
|
J9041
|
Velcade (Bortezomib)
|
|
*ING-CC-0095
|
J9044
|
Bortezomib
|
|
**ING-CC-0095
|
J9044
|
Bortezomib
|
|
*ING-CC-0093
|
J9171
|
Docetaxel
|
|
**ING-CC-0093
|
J9171
|
Docetaxel
|
*Non-oncology use is managed by Anthem’s medical specialty drug review team.
**Oncology use is managed by AIM.
Prior authorization update – Medical specialty pharmacy update
In an effort to simplify care and support our providers, we have removed the prior authorization requirement for the use of the drugs listed below used to treat ocular conditions, effective May 1, 2021.
|
Drug
|
Code
|
Code description
|
|
*Avastin
|
C9257
J9035
|
intravitreal bevacizumab
|
|
*Mvasi
|
Q5107
|
bevacizumab-awwb
|
|
*Zirabev
|
Q5118
|
bevacizumab-bvzr
|
*Non-oncology use is managed by Anthem’s medical specialty drug review team.
1007-0321-PN-VA
Starting May 1, 2021, Anthem Blue Cross and Blue Shield will implement a new prior authorization for HIV medications to help ensure patients are not receiving therapeutic duplications when taking certain combinations. Providers and members expected to be impacted by this policy will receive advanced notice by mail.
In order for members to continue to receive coverage for the drug combination, providers must submit a separate prior authorization form for each drug and provide the medical necessity rationale for why the drug combination is clinically needed.
Combinations that are considered clinical duplicates are based on drug mechanism of action (MOA) and developed in accordance with the U.S. Department of Health and Human Services HIV Guidelines.
The duplicate therapy policy may trigger as a result of one of the following drug combinations:
|
Duplicate Name
|
Duplicate Description
|
Example
|
|
Integrase stand transfer inhibitors (INSTI)
|
Two drug products each containing a drug with an INSTI mechanism of action.
|
Isentress (raltegravir) and Dovato (dolutegravir/ lamivudine).
|
|
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
|
Two drug products each containing a drug with an NNRTI mechanism of action.
|
Edurant (rilpivirine) and Symfi (efavirenz/lamivudine/TDF).
|
|
Protease inhibitors (PI)
|
Two drug products each containing a drug with a PI mechanism of action.
|
Prezcobix (darunavir/cobicistat) and Reyataz (atazanavir).
|
|
Nucleoside reverse transcriptase inhibitors (NRTI)
|
Two drug products that together result in four NRTI active ingredients.
|
Truvada (emtricitabine/TDF) and Biktarvy (bictegravir/ emtricitabine/TAF).
|
|
Boosters
|
Two drug products that result in a combination of the protease inhibitor boosters, ritonavir and cobicistat.
|
Prezcobix (darunavir/cobicistat) and Kaletra (lopinavir/ritonavir).
|
As a reminder, prior authorizations may be submitted via phone, fax, or online (through www.CoverMyMeds.com). If you have any questions regarding this policy, please contact 1-833-293-0660.
1002-0321-PN-VA
Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.
HealthKeepers, Inc. is committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, HealthKeepers, Inc. has the answers before you ask the questions. With an initial focus on claim-level insights, HealthKeepers, Inc. has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOP.
Access the Claims Status Listing on Payer Spaces from https://mediproviders.anthem.com/va using the Log In button or through the secure provider portal via Availity.* We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.
Claim resolution daily
Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim
status changes, other claims needing resolution are added, and claims are resolved faster.
HealthKeepers, Inc. made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.
Predictive proactive issue resolution and near real-time digital claim denial information is another example of how HealthKeepers, Inc. is using digital technology to improve the healthcare experience. If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVA-NU-0322-20 Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
Effective June 1, 2021, the following new customizations will be implemented:
- Gastrointestinal Bleeding, Upper (W0170, previously ORG M-180) — Customized the Clinical Indications for admission to inpatient care by revising the hemoglobin; systolic blood pressure; pulse; melena; orthostatic hypotension; and BUN criteria.
- Gastrointestinal Bleeding, Upper Observation Care (W0171, previously OCG OC-021) — Customized the Clinical Indications for observation care by revising the systolic blood pressure and hemoglobin criteria and adding melena or hematochezia and suspected history of bleeding.
To access a detailed summary of customizations, select: Customizations to MCG Care Guidelines 24th Edition (path: https://www.anthem.com/provider/policies/clinical-guidelines > Other Criteria > MCG > Customizations to MCG Care Guidelines 24th Edition.)
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVA-NU-0325-20 Please note, this communication applies to Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
The new Anthem HealthKeepers Plus Provider Manual is now live on our provider website. This recently updated provider manual contains everything you need to know about our programs and how we work with you to provide quality care to our members. You can access the provider manual by visiting https://mediproviders.anthem.com/va > Manuals, Directories, Training & More > Anthem HealthKeepers Plus Manuals, Directories, Trainings & Resources > Anthem HealthKeepers Plus Provider Manual.
There were several important updates made this year that we encourage you to review. These include:
- High-dollar inpatient claims review: removed references to Equian — CERiS* is our vendor managing this process.
- Credentialing: added language to confirm compliance with Virginia House Bill 822.
- Interpretation services: notice of changes to face-to-face interpretation services.
- Provider preventable conditions: added language to confirm compliance with 42 CFR and Department of Medical Assistance Services requirements.
While we strive to keep our provider manual current, please be sure to check https://mediproviders.anthem.com/va > News & Announcements for the most up-to-date plan policy information.
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVA-NU-0327-20 Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
Why are these changes necessary?
Changes are meant to simplify code selection criteria, make coding more clinically relevant and to reduce documentation overload for office-based evaluation and management (E/M) services, while continuing to differentiate payment based on complexity of care.
Key elements of major revisions for 2021
- Physicians may choose their documentation based on medical decision making (MDM) or total time (including non-face-to-face services).
- History and exam are still important parts of the notes and may contribute to both time and MDM, but they will no longer be scored for determining the level of the E/M visit.
- MDM criteria has moved away from simply adding up tasks to instead focusing on tasks that affect the management of a patient’s condition.
- Codes 99202 to 99215 were revised.
Changes to time documentation
Time will now be defined as the total time spent by the provider (both face-to-face and time spent on non-face-to-face activities related to this patient’s visit performed on the same day as the visit). This may include the services listed below but should not include time spent on separately billable services (such as X-ray interpretation). Effective January 1, 2021:
- The total time spent must be documented clearly by the provider for the E/M level to be determined by time and does not include ancillary staff time.
- Time will no longer need to be dominated by counseling.
- All time used for leveling the E/M must be on the same day as the face-to-face visit.
Services included in total time
- Preparing for the visit (for example, reviewing test results)
- Obtaining and/or reviewing separately obtained history
- Performing a medically necessary examination and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering tests, medications, prescriptions or procedures after the visit
- Referring and communicating with other health care professionals (when not reported separately)
- Documenting clinical information in the patient’s medical record
- Independently interpreting results (not separately reportable) and communicating results to the patient/family/caregiver
- Care coordination (not separately reportable)
https://mediproviders.anthem.com/va
|
New patient E/M code
|
Typical time (2020)
|
Total time (2021)
|
|
99201
|
10 minutes
|
Code deleted
|
|
99202
|
20 minutes
|
15 to 29 minutes
|
|
99203
|
30 minutes
|
30 to 44 minutes
|
|
99204
|
45 minutes
|
45 to 59 minutes
|
|
99205
|
60 minutes
|
60 to 74 minutes
|
|
Established patient E/M code
|
Typical time (2020)
|
Total time (2021)
|
|
99211
|
5 minutes
|
Time component removed
|
|
99212
|
10 minutes
|
10 to 19 minutes
|
|
99213
|
15 minutes
|
20 to 29 minutes
|
|
99214
|
25 minutes
|
30 to 39 minutes
|
|
99215
|
40 minutes
|
40 to 54 minutes
|
Prolonged office services
2021 changes include addition of a new add-on code (currently labeled 99417) for prolonged office visits when time is used for code level selection, including face-to-face and non-face-to-face provider time of at least 15 additional minutes on the same date of service for level five office visits (99205, 99215).
Medical decision making (MDM)
Using the new MDM table, medical decision making for office/outpatient visits will be based on meeting (or exceeding) two out of three categories:
|
MDM must meet two out of three elements
|
|
Code
|
Level of MDM
|
Number and complexity of problems addressed
|
Amount and/or complexity of data to be reviewed and
analyzed
|
Risk of complications and/or morbidity or mortality of patient management
|
|
99211
|
N/A
|
N/A
|
N/A
|
N/A
|
|
99202
99212
|
Straightforward
|
Minimal
|
Minimal or none
|
Minimal
|
|
99203
99213
|
Low
|
Low
|
Limited
|
Low
|
|
99204
99214
|
Moderate
|
Moderate
|
Moderate
|
Moderate
|
|
99205
99215
|
High
|
High
|
Extensive
|
High
|
Number and complexity of problems addressed at the encounter
- Straightforward: One self-limited or minor problem
- Low: Two or more self-limited or minor problems; one stable chronic illness, one acute, uncomplicated illness or injury
- Moderate: One or more chronic illnesses with exacerbation, progression or side effects of treatments; two or more stable chronic illnesses; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; one acute complicated injury
- High: One or more chronic illnesses with severe exacerbation, progression or side effects of treatment; one acute or chronic illness or injury that poses a threat to life or bodily function.
Amount and/or complexity of data to be reviewed and analyzed
The 2021 guidelines list three categories for data:
- Tests, documents or independent
- Independent interpretation of tests
- Discussion of management or test
- Straightforward: Minimal or none
- Low (one category required):
- Two tests/documents or independent historian
- Moderate (one category required):
- Three tests, documents and/or independent historian
- Independent interpretation of a test
- Discussion of management or test interpretation
- High (two categories required):
- Three items between documents and independent historian
- Independent interpretation of a test
- Discussion of management or test interpretation
Risk of complications and/or morbidity or mortality of patient management
For the purposes of MDM, level of risk is based upon the consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization:
- Minimal: Rest, gargle, elastic bandages, superficial dressings
- Low: OTC drugs, physical therapy, minor surgery with no identified risk factors, IV fluids without additives
- Moderate: Management of a prescription drug, minor surgery with identified risk factors, decision regarding major surgery without identified risk factors, diagnosis or treatment
- High: Need to discuss higher risk problems that could happen for which physician or other qualified health care professional will watch or
Tips to prepare your practice for E/M office visit changes
- Identify project lead
- Schedule team preparation time
- Update practice protocols
- Consider coding support
- Review business liability coverage
- Guard against fraud/abuse
- Update compliance plan
- Check with your electronic health record (EHR) vendor
- Assess financial impact
- Understand medical liability coverage
Resources:
- CPT® Professional Edition, 2021. AMA
- AMA Elements of Medical Decision Making. https://www.ama-assn.org/system/files/2019-06/cpt-revised- mdm-grid.pdf
- AMA Press Release 2021 CPT code https://www.ama-assn.org/press-center/press-releases/ama-releases- 2021-cpt-code-set
- Major E/M Changes Coming Are you prepared? https://www.aapc.com/evaluation-management/em- codes-changes-2021.aspx
AVA-NU-0331-20
Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
Effective January 1, 2021, for Anthem HealthKeepers Plus members, lab testing for cystic fibrosis procedure codes 81220 to 81224 will be limited to once per lifetime. Labs will only be able to bill lab tests 81220 to 81224 once per member per lifetime.
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVAPEC-2780-20 Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.
Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC are committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem and AMH Health have the answers before you ask the questions. With an initial focus on claim-level insights, Anthem and AMH Health have streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOP.
Access the Claims Status Listing on Payer Spaces from https://www.anthem.com/medicareprovider using the Log In button or through the secure provider portal via Availity.* We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.
Claim resolution daily
Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim
status changes, other claims needing resolution are added, and claims are resolved faster.
Anthem and AMH Health made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.
Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem and AMH Health are using digital technology to improve the healthcare experience. If you have questions, please reach out to your Provider Relations representative.
ABSCRNU-0193-20 516792MUPENMUB Effective June 1, 2021, the following new customizations will be implemented:
- Gastrointestinal Bleeding, Upper (W0170, previously ORG M-180) – Customized the Clinical Indications for admission to inpatient care by revising the hemoglobin; systolic blood pressure; pulse; melena; orthostatic hypotension; and BUN criteria.
- Gastrointestinal Bleeding, Upper Observation Care (W0171, previously OCG OC-021) – Customized the Clinical Indications for observation care by revising the systolic blood pressure and hemoglobin criteria and adding melena or hematochezia and suspected history of bleeding.
To view a detailed summary of customizations, select: Customizations to MCG Care Guidelines 24th Edition (path: https://www.anthem.com/provider/policies/clinical-guidelines > Change state. Scroll down to Other Criteria > Customizations to MCG Care Guidelines 24th Edition.)
For questions, please contact the provider service number on the back of the member's ID card.
ABSCRNU-0201-20 516850MUPENMUB
Anthem Blue Cross and Blue Shield will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.
We encourage providers who offer telehealth services to use the online Provider Maintenance Form to notify us, and we will add a telehealth indicator to your online provider directory profile.
Visit http://www.anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.
ABSCRNU-0203-20 516908MUPENMUB
Anthem Blue Cross and Blue Shield (Anthem) wants to help ensure Medicare Advantage members receive the DME they are eligible to receive under CMS guidelines as soon as that equipment is needed. When requesting DME for your patients, our members, please include the information below to give our physiatrist and other clinical reviewers a complete picture of your patients’ status and needs. This will help ensure a timely response from Anthem; reduce the need for additional phone calls, faxes, emails and appeals; and deliver the requested DME to your patients as soon as possible.
Manual and power wheelchair repair
- Date of purchase for wheelchair
- Payer of wheelchair
- Make, model and serial number of current chair
- What repairs are needed, and why are they needed?
Manual and power wheelchair replacement
- Date of purchase of wheelchair being replaced
- Payer of current wheelchair being replaced (commercial, traditional Medicare, Medicaid)
- Make, model and serial number of current chair
- Estimate of repairs needed for current wheelchair to be functional
- If current wheelchair cannot be repaired, why not?
- If member’s functional needs have changed, document why current wheelchair is not meeting functional needs (for example, new medical, surgical, neurological event, new injury, etc.)
New manual or power wheelchair requests
- How does member currently complete activities of daily living?
- How does member currently meet mobility needs?
- Does member have a cane, walker, manual wheelchair or power wheelchair? Is it working for them? If no, why not?
- Cognitive status of the member — Are they safe to operate a motorized vehicle independently?
- Need face-to-face physician evaluation for all manual and power wheelchairs
- Need seven element order for power wheelchair (See National Coverage Determination [NCD] 280.3 or Local Coverage Determination [LCD] L33789 below for details.)
- Need physical therapy/occupational therapy/assistive technology practitioner/rehab doctor evaluation for group two/three power wheelchair
- Where does member live (for example, home, dually certified skilled nursing facility [SNF], assisted living facility [ALF), homeless)?
- Does member live in dually certified SNF? If so, is wheelchair paid for by SNF and not by Medicare? (Check QCOR site: https://qcor.cms.gov.)
- Need home assessment completed — Does the home allow the wheelchair to fit into the areas that the member needs to go?
Wheelchair components requests
- Powered elevating leg rests — need physical exam of legs showing swelling of the extremities or knee contracture
- Powered recline — Does the member perform self-catheterization? Does the patient have spasticity?
- Powered tilt — Can the member perform pressure relief? Does the member have pressure ulcers now or a history of pressure ulcers?
Capped wheelchair rentals
- Date of initial approval of wheelchair
- Payer of wheelchair
- Months left to be approved for total of 13 months of capped rental
Helpful CMS links:
E0466 noninvasive home ventilators
- Ensure medical records document:
- Member’s medical history of pulmonary problems.
- How member’s current respiratory needs have been managed (for example, oxygen, CPAP, BIPAP, ventilator).
- Why current management is not sufficient.
- If a continuation is being requested, then provide:
- Date of initial noninvasive ventilation (NIV) approval.
- Which insurer approved the initial NIV approval.
- Doctor’s note/compliance report showing the member is using the ventilator as ordered.
Helpful CMS link:
K0606 lifevest
- Provide physician medical records to support request for lifevest
- Provide documented ECHO report within one month of dates of service requested for both new and continuation requests
- Provide plan of care for future implantation of defibrillator
Helpful CMS link:
E0784 insulin pump
- Results of C-peptide taken at same time as fasting blood glucose; must provide reference range from the lab
- If no C-peptide results, then can submit beta-cell antibody result
Helpful CMS link:
Wound pump
- Date of wound pump application
- Where the wound pump was applied (for example, in hospital, SNF, at home)
- Was it applied on a surgically created wound?
- Measurements of wound
- Progress of wound measurements for continuation request
- Note that per Medicare, wound pumps have a four-month cap — Any requests beyond four months will be denied and must be submitted for an overturn via the appeals process
Helpful CMS link:
Common dressing supply requests
- If requesting more than the Medicare allowable quantity, document why more than the allowable quantity is needed
Helpful CMS links:
Braces
- Physician’s note with physical exam of affected region needing brace
- Imaging of affected area can be submitted to support the need for brace
- Only providing a supplier/vendor note with physical exam is not approvable per Medicare guidelines
Helpful CMS links:
Bone stimulators
- For long bone fracture nonunion, need two X-rays, dated 90 days apart, showing no healing of long bone fracture
- For joint fusion nonunion, need documentation of nonhealing fusion site nine months after joint fusion surgery
- For spinal fusion surgery:
- Documentation of nonhealing fusion site nine months after spinal fusion surgery
- Documentation of spinal fusion surgery at three or more spinal levels
- Documentation of repeat spinal fusion surgery in the same region
Helpful CMS link:
ABSCCRNU-0205-21 516916MUPENMUB The Coverage Guidelines, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Coverage Guidelines and Clinical UM Guidelines below are followed in the absence of Medicare guidance.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit https://www.anthem.com/provider/policies/clinical-guidelines/virginia.
Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- *GENE.00055 – Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
- Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications
- *LAB.00037 – Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
- Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered investigational and not medically necessary for screening, diagnosis or management of irritable bowel syndrome, and for all other indications
- *DME.00011 – Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- Revised scope to only include non-implantable devices and moved content addressing implantable devices to SURG.00158
- Added “non-implantable” to bullet point on percutaneous neuromodulation therapy
- Added percutaneous electrical nerve field stimulation (PENFS) as investigational and not medically necessary for all indications
- *SURG.00062 – Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
- Expanded scope to include percutaneous testicular vein embolization for varicocele and added embolization of the testicular (spermatic) veins as investigational and not medically necessary as a treatment of testicular varicocele
- *CG-LAB-15 – Red Blood Cell Folic Acid Testing
- RBC folic acid testing is considered not medically necessary in all cases
- *CG-LAB-16 – Serum Amylase Testing
- Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions
- *CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules
- Added the Afirma Xpression Atlas as not medically necessary
- SURG.00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
- A new Medical Policy was created from content contained in DME.00011.
- There are no changes to the policy content.
- Publish date is December 16, 2020.
- CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing
- A new Clinical Guideline was created from content contained in GENE.00026.
- There are no changes to the guideline content.
- Publish date is December 16, 2020.
Coverage Guidelines
On November 5, 2020, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect March 8, 2021.
|
Publish date
|
Coverage Guideline number
|
Coverage Guideline title
|
New or revised
|
|
12/16/2020
|
*GENE.00055
|
Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
|
New
|
|
12/16/2020
|
*LAB.00037
|
Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
|
New
|
|
11/12/2020
|
ANC.00009
|
Cosmetic and Reconstructive Services of the Trunk and Groin
|
Revised
|
|
12/16/2020
|
*DME.00011
|
Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
|
Revised
|
|
11/12/2020
|
GENE.00052
|
Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
|
Revised
|
|
11/12/2020
|
MED.00129
|
Gene Therapy for Spinal Muscular Atrophy
|
Revised
|
|
12/16/2020
|
SURG.00011
|
Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
|
Revised
|
|
12/16/2020
|
*SURG.00062
|
Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
|
Revised
|
Clinical UM Guidelines
On November 5, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on November 19, 2020. These guidelines take effect March 8, 2021.
|
Publish date
|
Clinical UM Guideline number
|
Clinical UM Guideline title
|
New or revised
|
|
12/16/2020
|
*CG-LAB-15
|
Red Blood Cell Folic Acid Testing
|
New
|
|
12/16/2020
|
*CG-LAB-16
|
Serum Amylase Testing
|
New
|
|
11/12/2020
|
CG-DME-42
|
Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices
|
Revised
|
|
12/16/2020
|
*CG-GENE-04
|
Molecular Marker Evaluation of Thyroid Nodules
|
Revised
|
|
12/16/2020
|
CG-GENE-18
|
Genetic Testing for TP53 Mutations
|
Revised
|
|
12/16/2020
|
CG-GENE-20
|
Epidermal Growth Factor Receptor (EGFR) Testing
|
Revised
|
|
11/12/2020
|
CG-MED-87
|
Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
|
Revised
|
ABSCRNU-0206-21 517123MUPENMUB |