 Provider News VirginiaMay 2022 Anthem Provider News - VirginiaThese guidelines are developed to provide helpful information on how to report services to Anthem Blue Cross and Blue Shield (Anthem) for the administration and observation of the drug Spravato®.
Eskatamine is sold under the brand name Spravato® and is indicated for adults with treatment-resistant depression. Based on the prescribing information, patients who have the drug administered in the professional provider’s office should be monitored for 2 hours to assess for complications.
A main component in understanding how to report the administration of this drug is to identify whether the professional provider has purchased the drug for administration or whether the drug has been supplied and reported by a pharmacy. There are specific codes to report for each scenario:
Professional provider purchased and administered
For professional providers that supply, administer, and provide the required observation of Spravato®, one of the following packaged service codes should be billed and should not include separate billing of the drug or the billing of the post-administration observation:
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HCPCS Code
|
Description
|
|
G2082
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Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
|
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G2083
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Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
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Note: When Spravato® is being supplied by the outpatient hospital and administered in an outpatient hospital, the facility should bill G2082 and G2083 in conjunction with revenue center code (RCC) 919 and the drug should not be billed separately. In addition, there should not be a separate professional claim submitted as procedure codes G2082 and G2083 describe both the drug and the professional services.
Pharmacy supplied and professional provider administered
When a pharmacy supplies Spravato® and is reporting this service in a separate claim, the drug should be billed with the HCPCS code, S0013 – Esketamine, nasal spray, 1 mg.
If the provider administering Spravato® did not purchase the drug, then the provider should not report the supply of the drug on their claim, as this will be reported by the pharmacy.
Post-administration observation
When the provider does not bill a packaged service code (listed above), the professional provider may report an Evaluation and Management (E/M) service including the appropriate prolonged services code.
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CPT Codes
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Description
|
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99202 - 99205
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Office or other outpatient visit for the evaluation and management of a new patient
|
|
99212 - 99215
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Office or other outpatient visit for the evaluation and management of an established patient
|
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99417
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Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes
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In accordance with the American Medical Association’s (AMA’s) CPT® Manual, CPT code 99417 should only be billed when reported with CPT codes 99205 and 99215. Medical records must support coding. Please refer to Anthem’s Prolonged Services – Professional Reimbursement Policy for additional information.
The total economic cost of alcohol use disorder has been estimated to be $249 billion according to the Centers for Disease Control and Prevention (CDC),1 $27 billion of which has been accounted for healthcare costs.2 The CDC projects the economic impact to society is about $807 per person, per year.3
Alcohol use disorder also impacts the economy through work force disruptions caused by tardiness, absenteeism, employee turnover and conflict in the workplace. It causes a reduction in potential employees, customer and taxpayer bases.4
According to the CDC, alcohol use was directly tied to 95,000 deaths annually between 2011 and 2015. This was more than all illicit substances combined. The CDC estimates that alcohol-attributed disease resulted in almost 685,000 years of potential life lost for the same period.
This chart shows the years of potential life lost (YPLL) related directly or indirectly to alcohol use disorder:
|
Cause
|
YPLL
|
|
Total YPLL
|
>2.7 million
|
|
100% alcohol attributed disease
|
684,750
|
|
Suicide
|
334,058
|
|
Motor vehicle crashes
|
323,610
|
|
Liver disease
|
202,391
|
|
Heart disease
|
118,021
|
|
Cancer
|
88,729
|
If you need assistance connecting your patients to opioid, substance use or alcohol use disorder treatment, contact your Anthem Blue Cross and Blue Shield health plan.
Many resources are available for health professionals to support hypertension prevention and management and educate others. To support that effort, the Centers for Disease Control and Prevention (CDC)’s Division for Heart Disease and Stroke Prevention has put together these sets of educational materials for health professionals and patients:
- Hypertension Communications Kit: Health professionals can share these social media messages, graphics, and resources to educate their audiences about hypertension.
Visit the Million Hearts® website for more resources designed for health professionals. Million Hearts® is a national initiative co-led by CDC and the Centers for Medicare & Medicaid Services (CMS). Million Hearts® aims to prevent 1 million heart attacks and strokes within five years.
Measure Up: Controlling High Blood Pressure (CBP) HEDIS® measure
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 based 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 reading:
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CPT II Code
|
Most recent systolic blood pressure
|
|
3074F
|
<130 mm Hg
|
|
3075F
|
130-139 mm Hg
|
|
3077F
|
≥ 140 mm Hg
|
|
CPT II Code
|
Most recent diastolic blood pressure
|
|
3078F
|
<80 mm Hg
|
|
3079F
|
80-89 mm Hg
|
|
3080F
|
≥ 90 mm Hg
|
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
Submitting your updates in a timely manner helps to ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information in our online provider directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Online update options include:
- Add/change an address location
- Name change
- Taxpayer ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. We appreciate your help in keeping our online provider directories current.
The annual PCP access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine.
The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Anthem Blue Cross and Blue Shield’s demographic database, such as incorrect or non-working phone numbers, practitioner moved, retired, or deceased; the practice has resigned their Anthem contract, accepts private pay only or is no longer in practice; as well as, staff refusing to participate in the survey. We ask that you update your office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Anthem’s contract.
Another item captured in the survey is open panel status for new patients. At the office level, we are capturing more closed panel data than is reflected in the provider directory for members. Please keep Anthem abreast of the open/close panel status of your practice.
What does this mean for our members? If the directory indicates “open” and the practitioner is not available for new patients, the member is making multiple calls to select a primary care physician. Their experience is reflected in the annual CAHPS® member survey of Anthem enrollees, which indicated “not open to new patients” as the number one reason throughout Anthem plans for not getting a personal physician.
To be compliant, per the provider manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:
- Urgent – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within twenty-four (24) hours.
- Explanation – These callers are experiencing a non-emergent condition or injury with acute symptoms that require immediate attention (without prior authorization).
- Routine – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within 10 business days.
- Explanation – A regular routine appointment is a non-symptom related visit for existing patients, such as a check-up, including physicals and chronic monitoring.
- Routine follow-up – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within 30 calendar days.
- Explanation – This is for an evaluation of progress or services, including, but not limited to, medication management. This includes new or existing patients.
Note to staff: It is imperative that your office updates any changes to your practice using the online Provider Maintenance Form on anthem.com.
We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access healthcare, but their outcomes as well. The COVID-19 pandemic has reignited public attention about the serious public health risks and consequences of disparities, and the critical need for health equity.
Health equity means everyone has the opportunity to reach their highest level of health, and barriers to doing so must be removed. Health disparities are health differences that are closely linked with social, economic, and/or environmental disadvantage.1 Achieving health equity requires focus on the elimination of barriers and disparities associated with factors such as race, ethnicity, gender, gender identity, religion, socioeconomic status, disability, and even where you live.2 As a result, it is imperative to offer access to care that is tailored to the unique needs of patients, and Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are committed to supporting our providers in this effort.
MyDiversePatients.com is where you can find resources, information, and techniques to help provide individualized care every patient deserves, regardless of their diverse backgrounds. There, you can also find opportunities for free Continuing Medical Education (CME) credit for learning experiences on topics related to cultural competency and disparities. Mydiversepatients.com is free and accessible from any device (desktop computer, laptop, phone, or tablet) with no account or log in required. Scan the QR code below for direct access to mydiversepatients.com.
Stronger Together is a website where you can find free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created in collaboration with national organizations and are available for you to share with your patients and communities. Scan the QR code below for direct access to Stronger Together.
While there is no single, easy answer to address healthcare disparities, the vision of MyDiversePatients.com and Stronger Together is a start to reversing health care inequity one person at a time.
Change Healthcare will transition out of the post-payment hospital bill audit (HBA) program by the end of 2022. Effective immediately, Anthem Blue Cross and Blue Shield’s (Anthem) complex and clinical audit (CCA) team will conduct the HBA program. For a short period of time, Change Healthcare may continue to contact you to finalize any work that is in process, or already scheduled.
Anthem continues to work with Cotiviti as a post-payment DRG validation audit partner. Effective immediately, the Anthem CCA team is assuming a larger role in conducting post-payment DRG validation audits and DRG readmission audits. In addition to receiving requests from Anthem’s CCA team, network-participating providers may continue to receive letters from Cotiviti requesting access to medical records for the purpose of conducting these audits. We will do our best to avoid duplicate medical record requests from Anthem and Cotiviti.
Thank you for your continued efforts to expedite medical record requests.
This notification applies to all lines of business and all markets. If you have questions about this notification, please contact the Provider Services Call Center.
The following guideline was among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on February 17, 2022. Revisions have been made to the coding which may result in services previously considered medically necessary to now be considered NOT medically necessary for dates of service (DOS) on or after August 1, 2022. This guideline impacts all our products – with the exception of 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 services addressed in this guideline will require authorization for all of our HealthKeepers, Inc. products with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan. A pre-determination can be requested for our PPO products. Please note that FEP is excluded from this requirement as well.
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Guideline
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Code(s)
|
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CG-GENE-14
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81176, 81206, 81207, 81208, 81233, 81236, 81310, 81315, 81334, 81347, 81357, 81360
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At Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc., we’re always looking for ways to create value for all our stakeholders. With that in mind, Anthem in Virginia is pleased to announce a new Rehabilitation program. Effective August 1, 2022, for claims with dates of service on and after August 1, we will transition medical necessity review of physical, occupational, and speech therapy services for Anthem in Virginia’s Commercial fully insured members to AIM Specialty Health® (AIM) – a separate company.
The new Rehabilitation program reviews certain treatment plans against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine. Anthem in Virginia will be utilizing the AIM Outpatient Rehabilitative and Habilitative Services clinical guidelines. Any qualified providers acting within the scope of their license who intend to provide therapy services are required to obtain a prior authorization from AIM.
The Rehabilitation program takes into account individual clinical details in order to titrate the number of authorized visits on a request. We measure progress based on condition management and patient outcomes with additional visits approved as clinically appropriate. Prior authorization is not required for members with a primary diagnosis of autism or ages birth to 3rd birthday.
Unlike models that offer a one-size-fits-all approach, the Rehabilitation program reviews based on multiple clinical factors.
For therapy services that are scheduled to begin on or after August 1, 2022, all providers must contact AIM to obtain prior authorization for the following non-emergency modalities:
- Physical therapy
- Occupational therapy
- Speech therapy
Training webinars
To help you prepare for this program, AIM and Anthem in Virginia are hosting a series of live webinar sessions and Q & A only webinar sessions that are designed for providers and office staff who will be requesting prior authorization.
Live Webinar Sessions with Q & A will cover topics such as:
- How the program and prior authorization request process work
- Which members and services will require prior authorization
- Demonstration of the AIM ProviderPortal and how to enter order requests
- Additional resources
- Q & A
We strongly encourage you and your practice to participate, even if you are already familiar with AIM and the ProviderPortal through other health plans or specialty programs.
How to access the webinars
We will be providing links in a separate notice so that you can register to attend upcoming webinars about the AIM transition. Please consider registering to attend at least one training opportunity. Your facilities attendance at an AIM training opportunity is highly encouraged. AIM solution specific training content will be made available to you upon completion of registration and prior to attending a webinar session. Reviewing the material ahead of the training will allow your facility to bring relevant questions to be addressed during the training. Below is a summary of the type of training to be offered along with dates and times. Watch for an upcoming notice with registration information.
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TYPE OF TRAINING
|
DATE AND TIME
|
|
Live Webinar Session with Q & A
|
Tuesday, June 21, 2022
3 p.m. EST
|
|
Live Webinar Session with Q & A
|
Tuesday, July 5, 2022
3 p.m. EST
|
|
Q & A Only Session
|
Tuesday, July 12, 2022
3 p.m. EST
|
|
Q & A Only Session
|
Tuesday, July 26, 2022
3 p.m. EST
|
|
Q & A Only Session
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Thursday, August 11, 2022
2 p.m. EST
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How to submit a request for review
Starting July 18, 2022, providers can begin submitting requests for review or verify order numbers using one of the following methods:
Online
The AIM ProviderPortalSM is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. To register, go to https://aimspecialtyhealth.com/providerportal/. Registration opens July 18, 2022.
By phone
Call AIM Specialty Health toll free at 866-789-0158, Monday through Friday between 8 a.m. and 5 p.m. EST.
For more information:
Online
For resources to help your practice get started with the Rehabilitation Program, go to www.aimproviders.com/rehabilitation/.
AIM provider website helps you learn more about the program and provides access to useful information and tools such as order entry checklists, clinical guidelines, and FAQs.
To learn more about AIM, please visit www.aimspecialtyhealth.com.
By phone
Contact your Anthem in Virginia Provider Relations Department toll free at 800-676-BLUE between 8 a.m. and 6 p.m. EST.
Anthem and HealthKeepers, Inc. value your participation in our network, as well as the services you provide. We look forward to working with you to help improve the health of our members.
Everything you need to know about using CPT II Codes
Preferred providers can receive incentives for using specific CPT II codes when filing claims.
CPT II codes are supplemental tracking codes that are used to measure quality performance. Use these tracking codes to decrease the need for record submissions and chart reviews – minimizing administrative burden on you and your healthcare teams.
FEP preferred providers can receive incentives for using specific CPT II codes, including blood pressure readings. Join us for a CPT II code webinar to learn more about filing CPT II codes to receive incentives.
Join us for a live webinar
Everything you need to know about using CPT II Codes
Tuesday, May 10, 2022
Noon to 1 p.m. ET
Register here
For additional information about the Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com.
In the April 2022 edition of Provider News, we published incorrect information in the heading of the First Prenatal Visit section of the article. We have corrected the information, and the updated article is included below. We apologize for any inconvenience.
The Federal Employee Program (FEP) is introducing a new Quality Reimbursement Program for PPO providers. Coding for CPT II Category Codes for A1c results, blood pressure readings and the first prenatal visit will now be reimbursed at $10 per code.
CPT II codes are supplemental tracking codes that are used to measure quality performance. The use of these tracking codes decreases the need for record submissions and chart reviews, minimizing administrative burden on physicians and other healthcare professionals.
How to use CPT II codes
Use these CPT II codes when submitting a claim. In field 24F on the CMS-1500 claim form, enter the CPT II code along with the amount of $10. In order to receive reimbursement, the exact dollar amount ($10) and the date of service must be entered on the claim along with the appropriate code for the service performed:
Blood Pressure – Receive $10 for the systolic and the diastolic readings:
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3074F
|
|
Most recent systolic blood pressure less than 130 mm Hg
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|
3075F
|
|
Most recent systolic blood pressure 130-139 mm Hg
|
|
3077F
|
|
Most recent systolic blood pressure greater than or equal to 140 mm Hg
|
|
3078F
|
|
Most recent diastolic blood pressure less than 80 mm Hg
|
|
3079F
|
|
Most recent diastolic blood pressure 80-89 mm Hg
|
|
3080F
|
|
Most recent diastolic blood pressure greater than or equal to 90 mm Hg
|
Hemoglobin A1c:
|
3044F
|
Most recent hemoglobin A1c (HbA1c) level less than 7.0%
|
|
3046F
|
Most recent hemoglobin A1c (HbA1c) level greater than 9.0%
|
|
3051F
3052F
|
Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0%
Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0%
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First Prenatal Visit – The first prenatal visit date of service must be on the claim (Field 24A CMS-1500) with the appropriate code:
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0500F
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Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care. Report also date of visit, and in a separate field, the date of the last menstrual period [LMP]) (Prenatal)
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|
0501F
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Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period [LMP] (Note: If reporting 0501F Prenatal flow sheet, it is not necessary to report 0500F Initial prenatal care visit) (Prenatal)
|
|
|
|
For additional information about the Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com.
This is a courtesy reminder that diagnostic imaging services requested on or after November 1, 2021, Anthem Blue Cross and Blue Shield’s Federal Employee Program (FEP) transitioned to AIM Specialty Health® (AIM). These services require prior authorization to determine medical necessity prior to rendering the service for Anthem’s federal employee members.
Your practice can benefit from participation in several ways, including:
- Improving the clinical appropriateness of imaging services through the application of evidence-based guidelines in an efficient and effective review process. Anthem’s Federal Employee Program will be utilizing the FEP Medical Policy to review for medical necessity. In the absence of a controlling FEP Medical Policy, medical necessity determinations will be made using Anthem Coverage Guidelines and/or AIM Clinical Guidelines.
- Maximizing a health plan’s network value through a wide range of solutions including provider assessment tools, cost and quality transparency and reporting.
- Engaging consumers in understanding the range of choices they have in selecting imaging providers and increasing their ability to make informed decisions.
As of November 1, 2021, providers are required to contact AIM prior to rendering the service to obtain pre-service review for the following non-emergency modalities:
- Nuclear imaging, including myocardial perfusion imaging, cardiac blood pool imaging, infarct imaging and positron emission tomography (PET) myocardial imaging
- Computed tomography (CT), including CT angiography, derived fractional flow reserve, structural CT and quantitative evaluation of coronary calcification
- Magnetic resonance imaging (MRI)
- Magnetic resonance angiography (MRA)
- Magnetic resonance spectroscopy (MRS)
- Stress echocardiography (SE)*
- Resting echocardiography (TTE)*
- Transesophageal echocardiography (TEE)*
How to submit a request for review
As a reminder, providers can submit requests for review or can verify order numbers using one of the following methods as a registered AIM portal provider:
- Register by phone: Call AIM Specialty Health toll-free at 866-789-0397, Monday – Friday, 7 a.m. to 7 p.m. CT.
For more information about the Radiology Program and to help your practice get started, go to: http://www.aimprovider.com/radiology.This website can also help you learn more about provider access to useful information and tools such as order entry checklists and clinical guidelines.
Anthem’s Federal Employee Program values your participation in our network, as well as the services you provide. We look forward to working with you to help improve the health of our members.
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company. For Anthem 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®.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code. 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.
Prior authorization updates
Effective for dates of service on and after August 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
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Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0062
|
Yusimry (adalimumab-aqvh)
|
J3590
|
|
ING-CC-0072
|
Vabysmo (faricimab-svoa)
|
J3490, J3590
|
|
ING-CC-0210
|
Enjaymo (sutimlimab-jome)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0211*
|
Kimmtrak (tebentafusp-tebn)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0212
|
Tezspire (tezepelumab-ekko)
|
C9399, J3590
|
|
ING-CC-0213
|
Voxzogo (vosoritide)
|
C9399, J3490
|
*Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after August 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Access our Clinical Criteria to view the complete information for these step therapy updates.
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Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0072
|
Non-Preferred
|
Vabysmo (faricimab-svoa)
|
J3490, J3590
|
Quantity limit updates
Effective for dates of service on and after August 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0062
|
Hulio (adalimumab-fkjp)
|
J3590
|
|
ING-CC-0062
|
Ixifi (infliximab-qbtx)
|
Q5109
|
|
ING-CC-0062
|
Yusimry (adalimumab-aqvh)
|
J3590
|
|
ING-CC-0072
|
Vabysmo (faricimab-svoa)
|
J3490, J3590
|
|
ING-CC-0210
|
Enjaymo (sutimlimab-jome)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0212
|
Tezspire (tezepelumab-ekko)
|
C9399, J3590
|
|
ING-CC-0213
|
Voxzogo (vosoritide)
|
C9399, J3490
|
Effective for dates of service on and after August 1, 2022, 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-0042
|
Monoclonal Antibodies to Interleukin-17
|
|
ING-CC-0050
|
Monoclonal Antibodies to Interleukin-23
|
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
|
ING-CC-0186
|
Margenza (margetuximab-cmkb)
|
|
ING-CC-0209
|
Leqvio (inclisiran)
|
|
ING-CC-0210
|
Enjaymo (sutimlimab-jome)
|
|
ING-CC-0212
|
Tezspire (tezepelumab-ekko)
|
|
ING-CC-0213
|
Voxzogo (vosoritide)
|
Effective March 1, 2022, the following Part B medications from the current Clinical Utilization Management (UM) Guidelines are included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below.
Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.
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Clinical UM Guidelines
|
Preferred drug(s)
|
Nonpreferred drug(s)
|
|
ING-CC-0062
|
Inflectra
Remicade, Infliximab (unbranded)
|
Avsola
Renflexis
|
The National Committee for Quality Assurance (NCQA) has changed, revised, and retired HEDIS® measures for measurement year 2022. Below is a summary of the key changes of which to be aware.
Diabetes measures
NCQA has separated the Comprehensive Diabetes indicators into stand-alone measures:
- Hemoglobin A1c Control for Patients with Diabetes (HBD) (HbA1c Control < 8 and Poor Control HbA1c)
- Eye Exam Performed for Patients with Diabetes (EED)
- Blood Pressure for Patients with Diabetes (BPD)
- Kidney Health Evaluation for Patients with Diabetes (KED)
The process measure Comprehensive Diabetes HbA1c testing was retired as the goal is to move towards more outcome measures.
Race/ethnicity stratification
To address healthcare disparities, the first step is reporting and measuring performance. Given this, NCQA has added race and ethnicity stratifications to the following HEDIS measures:
- Colorectal Cancer Screening (COL)
- Controlling High Blood Pressure (CBP)
- Hemoglobin A1c Control for patients with Diabetes (HBD)
- Prenatal and Post-Partum Care (PPC)
- Child and Adolescent Well Care Visits (WCV)
NCQA plans to expand the race and ethnicity stratifications to additional HEDIS measures over several years to help reduce disparities in care among patient populations. This effort builds on NCQA’s existing work dedicated to the advancing health equity in data and quality measurement.
New measures
Antibiotic Utilization for Respiratory Conditions (AXR): The percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event.
This measure was added given antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse. Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic use. Given this new measure, the Antibiotic Utilization measure has been retired.
Deprescribing of Benzodiazepines in Older Adults (DBO): The percentage of Medicare members 65 years of age and older who were dispensed benzodiazepines and achieved a 20% decrease or greater in benzodiazepine dose during the measurement year.
Guidelines recommend that benzodiazepines be avoided in older adults, and deprescribing benzodiazepines slowly and safely, rather than stopping use immediately. There is an opportunity to promote harm reduction by assessing progress in appropriately reducing benzodiazepine use in the older adult population.
Advanced Care Planning (ACP): The percentage of adults 65 to 80 years of age, with advanced illness, an indication of frailty or who are receiving palliative care, and adults 81 years of age and older, who had advance care planning during the measurement year.
Advance care planning is associated with improved quality of life, this measure will allow an understanding if it is provided to those who are most likely to benefit from it. Given this new measure, the Care for Older Adults measure has been retired.
Measure changes
Use of Imaging Studies for Low Back Pain (LBP): This measure was expanded to the Medicare line-of-business and the upper age limit for this measure was expanded to age 75. Additional exclusions to the measure were also added.
A complete summary of 2022 HEDIS changes and more information, can be found online.
Source: NCQA.org
Anthem Blue Cross and Blue Shield has partnered with Everlywell* to provide at-home lab tests for a subset of our eligible patients. We mail at-home test kits directly to patients’ homes with instructions on how to complete and return the kits. Clinical Laboratory Improvement Amendments-certified labs process the tests, and an independent physician reviews the results.
We provide primary care physicians (PCPs) a list of their patients who receive test kit(s) and send individual results to the patient and their physician. You can help your patients navigate needed testing by encouraging them to complete kits mailed to them. A physician’s recommendation is a significant factor in patient screenings.
A patient may receive up to two at-home test kits:
- Fecal immunochemical test for colorectal cancer screening
- Hemoglobin A1c test to measure average glucose levels over the past two to three months for those with diabetes
How the program works:
- Test kit(s) are automatically mailed to eligible patients, and patient lists are sent to physicians.
- Patients collect samples at home, using instructions provided.
- Patients mail samples to Everlywell in the provided, postage-paid envelope.
- Individual test results are sent to patients and their primary care physician, providing evidence of preventive screening completion.
If you have questions about the at-home testing program, contact your local representative. For additional information about Everlywell, visit everlywell.com.
Please continue to check our website https://providers.anthem.com/virginia-provider/home for the latest Medicaid information for members enrolled in HealthKeepers, Inc.’s Anthem HealthKeepers Plus and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) benefit plans. Here are the topics we’re addressing in this edition:
Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
What is the change?
Effective May 1, 2022, prior authorization will be required for the following service:
- Code: (T1019) Personal care services
Personal care services for members under 21 who do not have the LTSS Waiver but are receiving personal care through the EPSDT benefit require precertification according to Commonwealth Coordinator Care Plus Waiver Services Provider Manual (pg. 8).
Payment is available only for services provided when:
- Individual is present.
- Approved plan of care.
- The services are authorized.
- Qualified provider is providing the services to the individual.
How do I request authorization?
Requests may be submitted by calling Provider Services at 855-323-4687, ext. 1061035152 or faxing the requests to one of the fax lines indicated below. All requests must include clinical documentation showing a medical reason why the member needs to have the service.
Documentation requirements:
- DMAS 7A, or equivalent plan of care, and DMAS 99
- Records of the Department of Education’s last Individual Education Plan (IEP) if a member is receiving or seeking personal care of private duty nursing (PDN) services delivered in a school setting and paid for by Medicaid.
- Recent clinical documentation examples, including hospital or facility discharge summaries, last three physician visit notes (primary or special care), etc.:
- If a reauthorization review, include the most recent two weeks of personal care services progress notes.
- If a new request, examples include hospital or facility discharge summary, last three physician visit notes (primary or special care), etc.
Fax lines
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Early and Periodic Screening Diagnostic Treatment Personal Care Assistance (EPSDT PCA) expedited and new waiver requests
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888-235-8390
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EPSDT PCA standard requests
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844-864-7853
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If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
AVAPEC-3385-22
Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
High-prevalence demographics
The lifetime prevalence of alcohol use disorder (AUD) in the U.S. population is approximately 29.1%. However, only 19.8% of people with AUD receive treatment. Prevalence of AUD is high in white and Indigenous people, younger men (age < 65), unmarried people, and those with low incomes.1
Some 22.8 million people over the age of 12 reported having a substance use disorder (SUD) in 2019; AUD accounted for 63% of this population. An additional 12% presented with AUD and another SUD (excluding nicotine) according to the National Survey on Drug Use and Health (NSDUH).2
AUD and COVID-19
Evidence suggests that alcohol consumption increased during the COVID-19 pandemic. One study found that 60% of respondents reported increased alcohol-intake.3 In 2020, alcohol sales increased by 262% online and 21% in stores, which participants reported was due to increased stress, alcohol availability, and lockdown boredom.4 This increase was most substantial between March to April 2020. The study suggests those most affected by COVID-19 (job loss, friend loss, family loss, and isolation) may be more at risk of AUD.3
AUD co-occurring with mental health conditions
People with a variety of mental health conditions are at increased risk of developing an AUD or have an existing co-occurring AUD.5 While the rates are higher for co-occurring disorders with mental health conditions, there is also a higher risk of greater severity and a worse prognosis for both the mental condition and AUD.
Trauma, including adverse childhood events (ACEs) and post-traumatic stress disorder (PTSD), are often precursors for AUD.6 Traumatic brain injuries (TBI) are also associated with AUD. Alcohol intoxication is one of the strongest predictors of a TBI. In addition, people with a TBI are more likely to abuse alcohol.7
In most co-occurring disorders, the mental health condition preceded the AUD. This indicates that people diagnosed with a mental health condition should be screened for AUD. Preventive work should begin at the onset of symptoms of a mental health condition.5
What if I need assistance?
If you have difficulty connecting patients with AUD to treatment, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
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