 Provider News VirginiaMay 2021 Anthem Provider News - VirginiaAll associates who make utilization management decisions are required to adhere to the following principles:
- Utilization management decision making is based only on appropriateness of care and service and existence of coverage.
- We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support, or tend to support denials of benefits.
- Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization, or create barriers to care and service.
1117-0521-PN-VA Our organization is working robustly to establish Anthem Blue Cross and Blue Shield as a digital-first enterprise and to streamline your daily working tasks by using electronic functionalities. In support of the Digital-First Solutions, we are excited to publish two provider bulletins addressing the submission of medical attachments and itemized bills in partnership with Availity.
The objective of the bulletins is to provide a simple guide for you and your staff with step-by-step navigation instructions, and where to find help and training with medical attachments.
The provider bulletins are posted on the Custom Learning Center (CLC) under the Resources tab. Follow these steps to access the helpful documents:
- Availity > Payer Spaces > Select Payer Tile > Applications > Custom Learning Center
- Select Catalog > Resources to locate, view or download the Provider Bulletins
Please encourage your staff who have questions on the process or who are not submitting claim attachments electronically to review these valuable resources for assistance.
1139-0521-PN-VA
In honor of National High Blood Pressure Education Month, the Centers for Disease Control and Prevention (CDC) is offering the WISEWOMAN program: Well-Integrated Screening and Evaluation for WOMen Across the Nation. The aim of this program is to improve the delivery of heart disease and stroke prevention services for underserved women, aged 40-64 years. The program focuses on cardiovascular disease risk factors, specifically improving high blood pressure.1 To learn even more about WISEWOMAN, visit the CDC website.
Resources for your patients
If your patient is one of the tens of millions of American adults who have hypertension, you know encouraging a healthier lifestyle and prescribing the right medications is important to managing the condition. If you would like to provide additional information about high blood pressure to your patients, take advantage of the helpful resources available to healthcare professionals through the CDC. The Hypertension Communications Kit provides blood pressure logs, tip sheets, and more. Hypertension Patient Education Handouts include fact sheets, medication information and dozens of useful tools.
Meeting the HEDIS® measure?
Controlling High Blood Pressure (CBP) assesses adults ages 18-85 with a diagnosis of hypertension and whose blood pressure was properly controlled base on the following criteria
- Adults 18-59 years of age whose blood pressure was <140/90 mm Hg
- Adults 60-85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg
- Adults 60-85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg
Patient claims should include one systolic reading and one diastolic reading2:
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CPT II Code
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Most recent systolic blood pressure
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|
3074F
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<130 mm Hg
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|
3075F
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130-139 mm Hg
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|
3077F
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≥ 140 mm Hg
|
|
CPT II Code
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Most recent diastolic blood pressure
|
|
3078F
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<80 mm Hg
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|
3079F
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80-89 mm Hg
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3080F
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≥ 90 mm Hg
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When charting your patient’s blood pressure readings, in addition to the systolic and diastolic readings, and dates, if the patient has an elevated blood pressure, but does not have hypertension, note the reason for follow-up.
Additional tips for talking to patients
- Continue to educate patients about the risks of hypertension
- Encourage weight loss, regular exercise, and diet
- Advise patients who are smoking to quit
- Talk about chronic stress and ways to cope with it in a healthy way
1https://www.cdc.gov/wisewoman/about.htm
2 https://www.cdc.gov/bloodpressure/index.htm
1134-0521-PN-VA We’ve heard it all our lives: To be fair, you should treat everybody the same. The challenge is that everybody is not the same. These differences can lead to critical disparities not only in how patients access healthcare but the outcomes as well. The current health crisis illuminates this quite clearly. It is imperative to offer care that is tailored to the unique needs of patients, and Anthem Blue Cross and Blue Shield (Anthem) is committed to supporting our providers in this effort.
MyDiversePatients.com offers education resources to help you support the needs of your diverse patients and address disparities, including:
- Free Continuing medical education (CME) learning experiences about disparities, potential contributing factors and opportunities for providers to enhance care.
- Real-life stories about diverse patients and the unique challenges they face.
- Tips and techniques for working with diverse patients to promote improvement in health outcomes.
Stronger Together offers free resources to support the diverse health needs of all people where they live, learn, work and play. Our parent company – in collaboration with national organizations – created these resources that are available for you to share with your patients and communities.
While there is no single easy answer to the issue of healthcare disparities, the vision of MyDiversePatients.com and Stronger Together is to start reversing these trends…one person at a time.
Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted healthcare partner by visiting these resources today.
My Diverse Patients
Stronger Together Health Equity Resources
1132-0521-PN-VA
The Appointment Scheduler application in Availity Payer Spaces is an online appointment-scheduling feature that allows providers to manage appointments with patients that may want to schedule appointments directly. Providers can manage patients’ appointment requests and maintain their appointment availability.
Providers can receive new appointment requests from active members, along with important information like the member’s ID number, contact information and any special health information they want the doctor to know. Providers can modify or deactivate their availability at any time. Availity Users with the role of “Office Staff” can set up physicians in the practice to accept online appointment requests.
Enrollment for Appointment Scheduler is easy. To access Appointment Scheduler in the Availity portal: Availity>Payer Spaces>Select Payer Tile>Applications
Appointment Scheduler features:
- Manage appointment requests and view physician availability
- Configure appointment availability
- Notification of new visit requests on Availity Notification Center and via email
- Members are notified directly via text or email once appointment is confirmed
- Send patient reminders via the Appointment Scheduler application
- Customize office locations and available times, as well as the types of appointments accepted
Visit the Appointment Scheduler application in the Availity portal today.
1120-0521-PN-VA
Often, healthcare costs incurred by Anthem Blue Cross and Blue Shield (Anthem) members are a result of recommendations made by their physicians. As an Anthem participating physician, you have the ability to help reduce your patients’ healthcare costs. Choices, such as where to refer a member for negative pressure wound therapy, can have a significant impact on your patients’ ultimate out-of-pocket liability. We are sharing the following information with you for consideration when referring patients for negative pressure wound therapy.
Our members, your patients, often participate in health benefit plans that may have coinsurance or deductibles. Your patients may experience significant differences in cost depending on which negative pressure wound therapy providers the members are referred to. The following table provides a sample listing of Anthem high quality, low cost national negative pressure wound therapy providers. Referring to these providers will likely lower your patients’ out-of-pocket costs.
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Provider
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Phone Number
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Apria
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1-800-780-1228
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|
Rotech
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1-844-592-5068
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You can find all of Anthem’s participating durable medical equipment (DME) orthotics and prosthetics providers, at “Find Care” – Anthem’s doctor finder and transparency tool – at www.anthem.com.
Anthem is committed to seeking ways to reduce healthcare costs, and your referrals to network- participating providers can help make a difference. We appreciate your partnership in considering the financial impact to your patients – our members – especially during these challenging economic times.
If you have questions, please contact your local network manager or call Provider Services.
1141-0521-PN-VAThe American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care. Known as the “periodicity schedule,” this screenings and assessments guideline provides a comprehensive schedule for each well-child visit, from infancy.
Schedule for well-child visits
The AAP recommends that children should have a total of eight visits before their 30-month birthday (six visits before they are 15 months) with annual visits thereafter. The AAP periodicity schedule aligns with the well-child visits in the first 30 months of life (W30) HEDIS® measure. Ensuring all visits are completed before the child’s 30-month birthday is critical to assuring compliance with these measures.
Complete coverage for well-child visits regardless of when visit is received
Well-child visits (WCV) are covered 100% regardless of when the visit is received. Payment is not dependent on a set schedule, so there is no requirement to wait for a milestone birth month to schedule the well-child visit.
HEDIS® measures W30 and WCV
- Well-child visits in the first 30 months of life (W30)
Description: The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:
|
Well-child visits in the first 15 months. Children who turned 15 months old during the measurement year: six or more well-child visits.
|
|
Well-child visits for age 15 month to 30 months. Children who turned 30 months old during the measurement year: two or more well-child visits.
|
- Child and adolescent well-care visits (WCV)
Description: The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.
1133-0521-PN-VA After receiving your feedback, we expanded our server to meet your need to upload larger files to our digital attachment tool through Availity. You can now upload files up to 100 megabytes, eliminating the need to mail or fax.
Use the attachment tool to upload:
- Medical records
- Itemized bills
- Payment disputes
- Explanation of benefits (EOB)
- General correspondence
- Consent forms
The digital attachment tool file size expansion is just one example of how Anthem is using digital technology to improve the healthcare experience, with a goal to save you valuable time.
Access the attachment tool through www.Availity.com. From the Claims & Payments header, select Attachments – New. For more information about how to set up electronic attachments, use the Getting Started Guide: Select Help & Training>Find Help and then the Attachments topic in Contents. Once logged on, you can also access the Getting Started Guide.
For information about setting up for Program Integrity attachments, once logged on to Availity, use this link. You can also access Program Integrity attachment information from the Custom Learning Center: Payer Spaces>Custom Learning Center>Electronic Medical Records.
1140-0521-PN-VA Effective for dates of service on and after May 1, 2021, the following update will apply to the AIM Oncologic Imaging Clinical Appropriateness Guideline as recommended by the
the United States Preventive Service Taskforce Lung Cancer: Screening (USPSTF) statement.
- Expanded low-dose CT screening for ages equal to or greater than 50 and less than or equal to 80 AND 20 or greater pack-year history of cigarette smoking.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s 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.
- Access AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number: 1-866-789-0158; Monday – to Friday, 8 a.m. to 5 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines.
1119-0521-PN-VA
Anthem Blue Cross and Blue Shield (Anthem) and our affiliate HealthKeepers, Inc. are committed to reducing costs while improving health outcomes. To that end, effective August 1, 2021, Anthem and HealthKeepers, Inc. will be implementing CG-SURG-59 Vena Cava Filters for our commercial business.
NOTE: This excludes Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).
The CPT codes associated with this clinical UM guideline are 37191, 37192, and 37193.
The clinical UM guideline is available for review on our website at www.anthem.com.
1129-0521-PN-VA To more appropriately align program intention to support member care coordination and to ensure compliance with regulatory requirements surrounding the program, Anthem Blue Cross and Blue Shield (Anthem) is amending the approach for enhanced reimbursement that accompanies selection of “on-pathway” chemotherapy drug regimens as part of the AIM Oncology/Cancer Care Quality Program.
Effective July 1, 2021, enhanced reimbursements for medical oncologists selecting on-pathway drug regimens as part of the AIM Oncology/Cancer Care Quality Program chemotherapy authorization process will be adjusted for specific regimens.
Impacted regimens include only select oral and hormonal agents for which a monthly in-office visit may not be required. For these impacted regimens, the optional enhanced reimbursement award, billable using S-codes for treatment planning and care coordination management for cancer, will be reduced from a monthly award during each month of treatment to a single award to accompany treatment initiation (S0353).
This will impact all authorizations submitted through the AIM authorization process on or after July 1, 2021, regardless of planned treatment dates.
AIM and Anthem will continuously review the regimen library to ensure S-code award levels remain consistent with program goals regarding care coordination support.
For a list of the specific regimens that will be impacted by these changes, please see the document to the right under "Article Attachments."
Contact your Anthem network manager or your oncology provider engagement liaison for more information.
1118-0521-PN-VA
In the March 2021 edition of Provider News, we advised that we would no longer require prior authorization for the following drugs used to treat ocular conditions effective May 1, 2021. Please be advised that prior authorization will continue to be required for these drugs. We apologize for any inconvenience.
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Drug
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Code
|
Code description
|
|
*Avastin
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C9257
J9035
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intravitreal bevacizumab
|
|
*Mvasi
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Q5107
|
bevacizumab-awwb
|
|
*Zirabev
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Q5118
|
bevacizumab-bvzr
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*Non-oncology use is managed by Anthem’s medical specialty drug review team.
1160-0521-PN-VA Effective for dates of service on and after August 1, 2021, the following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
For Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc., prior authorization of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require prior authorization 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).
Access the clinical criteria document information
- ING-CC-0033 Xolair (omalizumab)
- ING-CC-0043 Monoclonal Antibodies to Interleukin-5
- ING-CC-0119 Yervoy (ipilimumab)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0157 Padcev (enfortumab vedotin)
- ING-CC-0189 Amondys 45 (casimersen)
- ING-CC-0190 Nulibry (fosdenopterin)
1106-0521-PN-VA Prior authorization updates
Effective for dates of service on and after August 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 NDC 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
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HCPCS or CPT Code(s)
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Drug
|
|
**ING-CC-0186
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J3490, J3590, J9999
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Margenza
|
|
*ING-CC-0187
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J3490, J3590, J9999
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Breyanzi
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|
*ING-CC-0188
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J3490, J3590
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Imcivree
|
|
*ING-CC-0189
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J3490, J3590, C9399
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Amondys 45
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|
*ING-CC-0190
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J3490, J3590, C9399
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Nulibry
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|
**ING-CC-0094
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J9304
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Pemfexy
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|
**ING-CC-0075
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J3590, J9999, C9399
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Riabni
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* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
Prior authorization update – change in clinical criteria
Coding Update: Effective August 18, 2020, these unclassified codes, J3490 and J3590, were removed from clinical criteria ING-CC-0072.
Quantity limit updates
Effective for dates of service on and after August 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit 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 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 the NDC 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).
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
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Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
*ING-CC-0189
|
J3490. J3590, C9399
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Amondys 45
|
|
*ING-CC-0190
|
J3490, J3590, C9399
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Nulibry
|
* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
1138-0521-PN-VA
Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Anthem Blue Cross and Blue Shield (Anthem)-contracted laboratories and identify the proper CPT® codes to use. Contact your Anthem representative for additional information or visit https://www.anthem.com/medicareprovider.
Refer patients to https://www.anthem.com/coronavirus to find convenient testing locations
If Anthem members request a COVID-19 test, you may refer them to Anthem to find a testing location near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:
- Appointment or walk-in
- Drive-thru service
- Rapid test results
- Antibody testing
- Testing for children
Consider Antigen testing as an option when rapid results are needed
Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), (for example, PCR). Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.
Send swab tests to Anthem-contracted laboratories
When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high-value healthcare.
ABSCRNU-0220-21 517852MUPENMUB Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
We offer webinars on a variety of topics, including medical coding, claims issues, quality measures, healthcare and more. Each live webinar may offer both continuing medical education (CME)/continuing education unit (CMU) credit for attendees. On-demand recordings are also available (with CME credit) for your convenience.
Sign up for a session today.
AVA-NU-0899-21 Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
Effective June 1, 2021, HealthKeepers, Inc. will convert the Enhanced Ambulatory Patient Group (EAPG) platform we use to calculate payment for outpatient facility claims from 3M™ to Optum.* Given that the Optum platform uses 3M’s software, you should not see any changes to your outpatient facility payments.
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020, Anthem CCC Plus Provider Services at 1‑855‑323‑4687 or your Provider Relations representative.
AVA-NU-0363-21 Metabolic monitoring for children and adolescents on antipsychotics (APM)
The metabolic monitoring for children and adolescents on antipsychotics (APM) HEDIS® measure evaluates the percentage of children and adolescents 1 to 17 years of age who had two or more antipsychotic prescriptions and had metabolic testing.
Antipsychotic medications can increase a child’s risk for developing health concerns, including metabolic health complications. The goal of this measure is for members to have metabolic monitoring by having both a blood glucose test (glucose or HbA1c) and LDL-C testing annually.
Record your efforts
- Glucose test or HbA1c test and LDL-C cholesterol test as identified by claim/encounter
- Document results in the member’s medical record
Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications (SSD)
The diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications (SSD) HEDIS measure evaluates members 18 to 64 years of age with schizophrenia, schizoaffective disorder or bipolar disorder, and who were dispensed an antipsychotic medication and had a diabetic screening test during the measurement year.
Diabetes screening is important for anyone with schizophrenia or bipolar disorder. The added risk associated with antipsychotic medications contributes to the need to screen people with schizophrenia for diabetes annually.
Record your efforts
- Glucose test or HbA1c test as identified by claim/encounter
- Document results in the member’s medical record
Helpful tips
- Educate patients and their caregivers on the importance of completing blood work annually.
- If your practice uses electronic medical records (EMRs), have flags or reminders set in the system to alert when a patient is due for screenings.
- Draw labs in your office, if available, or refer members to a participating lab for screenings.
- Follow up on laboratory test results and document in your chart.
- Share EMR data with HealthKeepers, Inc. to capture all coded elements.
Other available resources
- For The Quality Measures Desktop Reference for Medicaid Providers and HEDIS Benchmarks and Coding Guidelines for Quality Care, contact Provider Services.
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-0346-21 Please note, this communication applies to Anthem HealthKeepers Plus and Anthem HealthKeepers Plus,Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
In order to communicate more efficiently with providers, HealthKeepers, Inc. is now sending some bulletins, policy change notifications, prior authorization update information, educational opportunities and more to providers via email. Email is the quickest and most direct way to receive important information from HealthKeepers, Inc.
What do we need from you?
To receive email from HealthKeepers, Inc. (including some sent in lieu of fax or mail), update your email address via the Provider Maintenance Form by visiting www.anthem.com > Providers > Provider Resources > Provider Maintenance. Select Virginia as your state via the button and follow the on-screen instructions.
Note: The Provider Maintenance Form is not supported by Internet Explorer.
Need assistance?
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-0318-20 |