 Provider News VirginiaNovember 2022 Anthem Provider News - Virginia Contents State & Federal | Anthem Blue Cross and Blue Shield | Medicare Advantage | November 1, 2022 Personalized Match
As a reminder, periodically log into the Availity* Provider Online Reporting tool to make sure you don’t miss any notifications placed for your review. Here is a recap of the tool and instructions on how to sign up and access your notifications.
Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. will notify you by mail of the provider contract amendment, which includes a statewide fee schedule update. The mailing will occur on November 16, 2022, at which time you may also log into Availity to securely access and download a digital copy of your amendment documents using the Provider Online Reporting tool.
Keep in mind that only authorized users in your practice or facility can view the confidential contract amendments using the reporting tool. Your Availity administrator must grant access to the reporting tool if you do not currently have access. For easy reference, we’re again including the information to help you get started with Provider Contract and Fee Schedule Notifications, if needed.
Provider Online Reporting Reference Guide
How to get started
This document will familiarize you with the Provider Online Reporting application found on the Availity at www.availity.com. Using our web-based Provider Online Reporting application, you will be able to access your updated fee schedule.
For Availity Administrators: How to assign access
If your organization is not currently registered for Availity, go to www.availity.com and select Register to complete the online application.
Your Administrator will need to take the following steps to assign access to Provider Online Reporting:
- Assign the user role of Provider Online Reporting to your Availity access.
- Select Payer Spaces in the top menu bar and select the payer tile that corresponds to the market.
- First-time users accessing Payer Spaces will be asked to accept a Terms of Use Agreement. The agreement will appear for users once every 365 days.
- On the Applications tab, select Provider Online Reporting.
- Select Organization and select Submit.
- On the Welcome to Provider Online Reporting page, select Register/Maintain Organization.
- Select Register Tax ID(s) for the applicable program to register the tax IDs.
- A pop-up window will display all tax IDs that need to be registered for the program. Check the box for each tax ID to be registered and select Save.
- You now have successfully completed the tax ID registration. Notice that after the registration has been completed, the status has changed from Register Tax ID(s) to Edit Tax ID(s).
For Users: How to navigate to the report
Accessing reports:
- Log in to availity.com.
- Choose Payer Spaces in the top menu bar.
- Select the payer tile that corresponds to your market.
- Accept the User Agreement (once every 365 days).
- On the Applications tab, select Provider Online Reporting.
- Select Organization and choose Submit.
- Select Report Search, choose the type of report, and then launch your program’s reporting application.
The home page in Provider Online Reporting will open. This page lists all programs for which that organization is eligible.
Use the navigation options on the left-hand side of the page to easily move around within the tool.
The Programs page providers a description about the program your organization is participating in and includes helpful documents related to your program if applicable. Select a program using the dropdown arrow.
 The Report Search page launches the corresponding reporting application to your program. Select the appropriate program from the dropdown menu. 
Helpful tip: Save online Provider Online Reporting as a favorite.
Save Provider Online Reporting as a favorite to be able to access it quickly from the Availity home page:
- Log in to Availity at availity.com.
- Choose Payer Spaces in the top menu bar.
- Select the payer tile that corresponds to your market.
- On the Applications tab, select the heart icon next to Provider Online Reporting so it fills in and turns red.
- Now, Provider Online Reporting will appear at the top under the My Favorites dropdown.
For questions regarding Availity, contact Availity Client Services at 800-282-4548.
If you have questions about Provider Online Reporting, use the Contact Us section of the application.
For other questions, contact your local contract advisor, consultant, or Provider Relations representative.
Providers currently submit prior authorization (PA) requests to AIM Specialty Health ®* (AIM) for outpatient diagnostic imaging services. These PA requests are often reviewed based on provider attestation of certain requirements.
As part of our ongoing quality improvement efforts, we want you to know that as of January 1, 2023, some review requests may require documentation to substantiate the attestations that support the clinical appropriateness of the request. This documentation can be uploaded during the intake process.
When requested, providers must submit such documentation from the patient’s medical record. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. Such documentation is limited to what has been asserted via the PA review attestations.
If the request would be denied as not medically necessary, providers can participate in a PA discussion with an AIM physician reviewer.
Mail is being forwarded to new post office box addresses for one year.
A recent study indicated that several post office boxes are no longer being used by providers. To streamline our internal mail processing, we are retiring these post office boxes and utilizing post office boxes currently being used in the provider location indicated.
While we have not received any incoming mail from these retiring post office boxes in the last 12 months, should mail be received, it will be forwarded for a 12-month period. This change is effective immediately.
No action is required; this is an informational notification.
|
Provider location
|
Retiring PO Box number
|
Replacement PO Box number
|
|
Virginia
|
PO Box 26016
Richmond VA 23260
|
PO Box 27401
Richmond VA 23261
|
|
PO Box 25638
Richmond VA 23260
|
PO Box 27401
Richmond VA 23261
|
Consider using Availity* at availity.com when sharing information with us. Digital submissions are faster and more efficient than mailing. Register with Availity Essentials.
As a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.
For any needed changes, please update your information by submitting the changes to us on our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request.
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
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. Thank you for doing your part in keeping our provider directories current.
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).
HEDIS medical record submission made easier with our remote EMR access service
Let us take on the responsibility to retrieve medical records for the annual HEDIS® hybrid project by signing up for the remote electronic medical record (EMR) access service offered Anthem.
We offer providers the ability to grant access to their EMR system directly to pull the required documentation to aid your office in reaching compliance while reducing the time and costs associated with medical record retrieval.
We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:
- We only access medical records of members pulled into the HEDIS sample using specific demographic data.
- We only retrieve the medical records that have claims evidence related to the HEDIS measures.
- We access the least amount of information needed for use, disclosure, or for the specific medical records request.
- We only save to file and do not physically print any PHI.
Getting started with remote EMR access
Download and complete the registration form, then email it to us at: Centralized_EMR_Team@anthem.com.
FAQ
How does Anthem retrieve your medical records?
We access your EMRs using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.
Is printing access necessary?
Yes. The NCQA audit requires print-to-file access.
Is this process secure?
Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives.
Why does Anthem need full access to the entire medical record?
There are several reasons we need to look at the entire medical record of a member:
- HEDIS measures can include up to a 10-year look back at a member’s information.
- Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
- Compliant data may be documented or housed in a nonstandard format, such as an in‑office lab slip scanned into miscellaneous documents.
What information do I need to submit to use the remote EMR access service?
Complete the registration form that requests the following information:
- Practice/facility demographic information (for example, address, NPI, TIN, etc.)
- EMR system information (for example, type of EMR system, required access forms, access type, etc.)
- List of current providers/locations or a website for accessing this list
Remote Access not an option? We are now offering onsite visits for HEDIS hybrid retrieval. Email us at Centralized_EMR_Team@anthem.com for more information.
We’re phasing in clear, concise, and simplified denial descriptions when returning claims status inquiries. The denial descriptions will explain why the claim or claim line was denied and what to do next. We’ve even included details about how to provide us with information digitally to move the claim further along in the claims process.
Continuing to improve
The new denial descriptions will be phased in over the next few months. Based on your feedback, we’re starting with those claims or claim lines that have caused the most confusion. If new denial reasons are added, the descriptions will be expanded as well.
Accessing claim statuses
The Claims Status application on availity.com* enables you to check the status of your claim and submit attachments needed to process your claim, all in one place. To access the Claims Status app, log into availity.com and, from the Claims & Payments tab, select Claims Status. It’s just that fast and easy to check your claim status through Availity Essentials.
If you’re not enrolled in Availity Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity Essentials.
Working together to streamline processes through technology is a collaborative effort. We appreciate your feedback as we continue improving to meet your expectations. The enhancements we’ve made to the Availity Essentials* Authorization application make it faster, easier, and more efficient to submit digital authorizations for our members.
View attachments for authorizations submitted — You can now view the attachments you’ve submitted to support your authorization in the Availity Essentials authorization application.
Servicing and rendering provider — We’ve enhanced the Availity Essentials Authorization Application to enable a group option when selecting the servicing and rendering provider.
View correspondence — Access status and decision letters right from the Authorization Application Dashboard. Letters can also be downloaded or printed if needed.
Enhanced provider status — Out-of-network and in-network provider statuses are now enhanced to return fewer errors associated with provider status.
Expanded search — Search rendering and serving provider by NPI and ZIP code for quicker results.
Procedure code enhancement — Add the procedure code on an outpatient authorization for more accurate submission.
Case update features — You can now update your authorization right from your Authorization Application Dashboard.
Training sessions on the Availity Essentials authorization application are still available
Whether you prefer live training webcasts, on-demand webinar recordings, or a resource guide, we have everything you need to learn more about the Availity Essentials Authorization Application and how to make the most of it. Use this link to access the training option best for you.
The next live webcast is Wednesday, November 9, 2022, at 11 a.m. ET. Register here.
When submitting claims through the Electronic Data Interchange (EDI), a PWK segment indicator tells us you will be submitting supporting documentation for the claim and ensures the documents are attached correctly. The supporting documents are then sent through the Availity Essentials* Attachments Dashboard.
In November, the Attachments Dashboard will have a new look for our claims
The sooner we receive your claim attachments, the faster your claim can be processed for payment. To meet this expectation, the Attachments Dashboard will begin a seven-calendar day countdown beginning in November. This means that claims will begin processing sooner for those claims with the PWK segment indicator.
If you are unable to meet the seven-calendar day submission deadline, the claim will move from your Attachments Dashboard inbox into your History folder and will be marked as expired. The claim will then deny for additional information based on the PWK segment indicator and move to Claims Status located under the Claims & Payments tab on availity.com. Upload your attachment from Claims Status by using the Submit Attachment button located on your claim.
To learn more about the new claims attachments workflow, visit our Provider Learning Hub or access the on-demand webinar recording, Learn about the new claims attachments workflow.
Submitting claims disputes through Availity Essentials* is the most efficient way to have a claim reconsidered. Easily accessible through the Claims & Payments application, select Claims Status to access the claim. Use the Dispute button to file the appeal and upload supporting document to finalize the submission.
Add multiple claims to one dispute submission
You can submit one dispute and add multiple claims — up to 25 claims — as long as the additional disputed claims are for the same member, provider, and dispute reason. For Commercial member claims, you can begin submitting multiple claims on one dispute beginning in November.
Access acknowledgement, update, and decision letters digitally, too
Access correspondence related to your disputes through the Appeals Dashboard. When you submit multiple claims on one dispute through Availity Essentials, you will receive correspondence related to each individual dispute, so expect a greater number of letters in your Appeals Dashboard. You can easily identify the correspondence related to your multiple dispute submission by looking for the CI-COMM case number.
Availity Essentials appeals training
For detailed instructions about submitting disputes electronically, use this link to access appeals training from Availity Essentials.
New learnings added to the Provider Learning Hub.
Remittance Inquiry App: How to view, print, and save remittance advice
If you’re still using paper remittance to reconcile your claims, imagine the time you’ll save when you access remittance advice digitally through availity.com. This course shares information about how to view, print, and save electronic remittances.
Attachments: How to setup the Medical Attachment role
To submit attachments digitally (medical records, itemized bills, or other documents needed to process your claims), registering your organization in this training is step one. It will help you every step of the way.
Claim Submission: How to submit a claim using direct data entry
For providers who are not submitting their claims through Electronic Data Interchange (EDI), availity.com offers direct data entry for professional and facility claims. Take this course and walk through the process for submitting claims electronically.
Get started today
Access the Provider Learning Hub today using this link or from anthem.com under Important Announcements on the home page.
- All courses and webcasts are available 24/7 for your convenience.
- Use filtering options to quickly find courses and job aids.
- Use the Favorites folder to save items for easy access later.
- Once registered, no further registration is required.
- On future visits, your preferences are populated eliminating the need for any additional logon information.
Not registered on availity.com? Use this link for registration information or access registration information from the Provider Learning Hub. There is no cost for our providers to use availity.com.
Anthem Blue Cross and Blue Shield (Anthem) in Virginia and our affiliate HealthKeepers, Inc. will implement the following new and revised Coverage Guidelines effective February 1, 2023. These guidelines impact all our products with the exception of Anthem HealthKeepers Plus, Medallion and Anthem CCC Plus offered by HealthKeepers, Inc.; Medicare Advantage; and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).
Special note:
The services addressed in the coverage guideline presented in this document and in the attachment under "Article Attachments" to the right will require authorization for all our products offered by HealthKeepers, Inc., with the exception of the Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus). Other exceptions are Medicare Advantage and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP®). A pre-determination can be requested for our Anthem PPO products.
The guideline addressed in this edition of Provider News is:
- Inhaled Nitric Oxide (CG-MED-69)
This communication applies to Commercial plans offered by Anthem Blue Cross and Blue Shield (Anthem) in Virginia, Medicare Advantage members covered by Anthem, and Anthem HealthKeepers Plus members covered by HealthKeepers, Inc.
Effective November 6, 2022, Anthem will transition the Clinical Criteria for medical necessity review of perirectal hydrogel spacer to the AIM Specialty Health®* (AIM) Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline.
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 https://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 Availity* at availity.com.
For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com.
Additionally, you may access and download a copy of the current and upcoming guidelines.
As you may be aware, the U.S. Preventive Services Task Force (USPSTF) issued updated guidelines recommending screening for colorectal cancer to begin at age 45.1 The USPSTF considers highly sensitive fecal occult blood tests (FOBT) as a good option for colorectal cancer screening. The FDA has approved fecal immunohistochemical testing (FIT, also known as iFOBT) for colorectal cancer screening in average risk patients. When FIT is performed at the recommended intervals, it has similar specificity and sensitivity to stool-based DNA tests.
Labcorp, our Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. exclusive lab provider, has a cost‑effective colorectal cancer screening option that provides high sensitivity and specificity while enabling patient ease, convenience, and satisfaction. You can improve patient compliance for colorectal cancer screening with Labcorp’s FIT kit. Labcorp’s FIT kit provides your patients with everything they need to complete the sample collection at home and mail it back to Labcorp. In addition, the kit is easy to use, requiring no special preparation or direct stool contact.
When you use Labcorp you’ll have:
- Electronic delivery of results to your electronic medical records (EMR) system, making documentation of screening results easier for you and your office staff.
- Patient friendly in-home collections.
- 1% sensitivity and 100% specificity,2 resulting in a high-quality test.
For more information
To obtain FIT kits for your office or for more information, contact your local Labcorp sales representative. You can also visit labcorp.com/cancer/colorectal/providers for additional ordering details.
Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are committed to ongoing transparency in our business relationship with our participating professional healthcare providers. Our reimbursement policies are intended to promote a better understanding of the reimbursement rules and claims editing logic that may impact payment for specific services covered under members’ benefit plans.
As a reminder and beginning with our upcoming amendment, effective March 1, 2023, the Commercial reimbursement policies will be posted online at https://www.anthem.com. If you have questions about the coming changes, please contact your Anthem network manager.
Note:
The provider manual has been historically posted on https://www.anthem.com and will continue to be. However, the provider manual will not be included in contract packages after the upcoming amendment.
Availity Essentials* will also be a source to find the reimbursement policies, provider manual, physician office laboratory listing, and quarterly drug disclosures.
The AIM Rehabilitation Program is effective November 1, 2022.
Recently, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. shared with you our plans to delay the transition of the medical necessity review of physical, occupational and speech therapy services to AIM Specialty Health® (AIM*), a separate company, due to a technical issue related to Anthem’s Commercial members in Virginia. (The transition was originally planned for August 1, 2022.)
We are pleased to announce that the technical issues have been resolved and the prior authorization requirement for the AIM Rehabilitation Program is effective November 1, 2022. The AIM call center re-opened on Monday, October 17, 2022. Providers can now submit requests for review or verify order numbers online via the AIM ProviderPortal® 24/7 or by phone by calling toll free 866-789-0158, Monday through Friday between 8 a.m. and 5 p.m.
At Anthem, we value your business and regret any inconvenience or disruption the delay in transition caused you and your staff.
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. 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, 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.
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 (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.
Prior authorization updates
Effective for dates of service on and after February 1, 2023, 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.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT® code(s)
|
|
ING-CC-0002*
|
Fylnetra (pegfilgrastim-pbbk)
|
J3590
|
|
ING-CC-0002*
|
Rolvedon (eflapegrastim-xnst)
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Stimufend (pegfilgrastim-fpgk)
|
C9399, J3490, J3590
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
|
C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
|
C9399, J3490, J3590
|
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Site of care updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT code(s)
|
|
ING-CC-0065
|
Advate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Adynovate (factor vii)
|
J7207
|
|
ING-CC-0065
|
Afstyla (antihemophilic factor (recombinant) single chain))
|
J7210
|
|
ING-CC-0065
|
Alphanate (antihemophilic factor viii)
|
J7186
|
|
ING-CC-0065
|
Eloctate (recombinant antihemophilic factor)
|
J7205
|
|
ING-CC-0065
|
Esperoct (factor viii recombinant, glycopegylated)
|
J7204
|
|
ING-CC-0065
|
factor viii, anti-hemophilic factor (porcine)
|
J7191
|
|
ING-CC-0065
|
Hemlibra (emicizumab-kxwh)
|
J7170
|
|
ING-CC-0065
|
Hemofil M ((factor viii) human plasma-derived)
|
J7190
|
|
ING-CC-0065
|
Humate-P (antihemophilic factor viii)
|
J7187
|
|
ING-CC-0065
|
Jivi (factor viii, recombinant, pegylated-aucl)
|
J7208
|
|
ING-CC-0065
|
Koate DVI ((factor viii) human plasma-derived)
|
J7190
|
|
ING-CC-0065
|
Kogenate-FS (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Kovaltry (factor viii (antihemophilic factor, recombinant))
|
J7211
|
|
ING-CC-0065
|
Novoeight (factor viii (antihemophilic factor, recombinant))
|
J7182
|
|
ING-CC-0065
|
Nuwiq (factor viii (antihemophilic factor, recombinant))
|
J7209
|
|
ING-CC-0065
|
Obizur (antihemophilic factor viii (recombinant))
|
J7188
|
|
ING-CC-0065
|
Recombinate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Vonvendi (von willebrand factor)
|
J7179
|
|
ING-CC-0065
|
Wilate (antihemophilic factor viii)
|
J7183
|
|
ING-CC-0065
|
Xyntha (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0065
|
Xyntha Solofus (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0148
|
AlphaNine SD (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
|
Alprolix (recombinant coagulation factor ix)
|
J7201
|
|
ING-CC-0148
|
Benefix (factor ix recombinant)
|
J7195
|
|
ING-CC-0148
|
Idelvion (factor ix)
|
J7202
|
|
ING-CC-0148
|
Ixinity (factor ix)
|
J7195
|
|
ING-CC-0148
|
Mononine (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
|
Profilnine SD (factor ix complex human)
|
J7194
|
|
ING-CC-0148
|
Rebinyn (glycopegylated)
|
J7203
|
|
ING-CC-0148
|
Rixubis (factor ix recombinant)
|
J7200
|
|
ING-CC-0149
|
Coagadex (factor x)
|
J7175
|
|
ING-CC-0149
|
Corifact (factor xiii concentrate (human))
|
J7180
|
|
ING-CC-0149
|
Feiba (anti-inhibitor coagulant complex)
|
J7198
|
|
ING-CC-0149
|
Fibryga (human fibrinogen)
|
J7177
|
|
ING-CC-0149
|
NovoSeven RT (factor viia recombinant)
|
J7189
|
|
ING-CC-0149
|
RiaSTAP (fibrinogen concentrate)
|
J7178
|
|
ING-CC-0149
|
Sevenfact (factor vlla recombinant)
|
J7212
|
|
ING-CC-0149
|
Tretten (coagulation factor xiii a-subunit (recombinant))
|
J7181
|
Step therapy updates
Effective for dates of service on and after February 1, 2023, 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.
Clinical Criteria ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro, and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long‑acting colony stimulating factor Rolvedon will be added to existing step therapy as a non-preferred agents.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT code(s)
|
|
ING-CC-0002*
|
Non-preferred
|
Fylnetra
|
J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Rolvedon
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Stimufend
|
C9399, J3490, J3590
|
|
ING-CC-0002
|
Preferred
|
Neulasta
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Neulasta OnPro
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Udenyca
|
Q5111
|
|
ING-CC-0002
|
Non-preferred
|
Fulphila
|
Q5108
|
|
ING-CC-0002
|
Non-preferred
|
Nyvepria
|
Q5122
|
|
ING-CC-0002
|
Non-preferred
|
Ziextenzo
|
Q5120
|
This is a courtesy notice that there is a non-material change in the Clinical Criteria for Orencia ING-CC-0078. The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s).
Quantity limit updates
Effective for dates of service on and after February 1, 2023, 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-0017
|
Xiaflex (collagenase clostridium histolyticum)
|
J0775
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0182
|
Feraheme (ferumoxytol)
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Q0138
|
|
ING-CC-0182
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Ferrlecit (ferric gluconate)
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J2916
|
|
ING-CC-0182
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Infed (iron dextran)
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J1750
|
|
ING-CC-0182
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Injectafer (ferric injection)
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J1439
|
|
ING-CC-0182
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Monoferric (ferric derisomaltose)
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J1437
|
|
ING-CC-0182
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Venofer (iron sucrose)
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J1756
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
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C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
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C9399, J3490, J3590
|
Effective for dates of service on and after February 1, 2023, the following Clinical Criteria were developed 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 our 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). 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
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ING-CC-0029
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Dupixent (dupilumab)
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ING-CC-0035
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Duopa (carbidopa and levodopa enteral suspension)
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ING-CC-0058
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Byngezia Pen, Sandostatin, or Sandostatin LAR (Octreotide)/ Octreotide Agents
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ING-CC-0142
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Somatuline Depot (lanreotide)
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ING-CC-0176
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Beleodaq (belinostat)
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ING-CC-0188
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Imcivree (setmelanotide)
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State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | November 1, 2022 Important information about utilization managementPlease note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.
Utilization management (UM) decisions for Anthem HealthKeepers Plus members are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://mediproviders.anthem.com/va/Pages/medical.aspx.
You can request a free copy of our UM criteria from our Medical Management department. To access UM criteria online, go to https://mediproviders.anthem.com/va/Pages/medical.aspx. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below.
We are staffed with clinical professionals who coordinate our members’ care. Staff are available during business hours, Monday through Friday, from 8:30 a.m. to 5 p.m., ET, to accept precertification requests. Secured voicemail is available during off-business hours; a clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues.
You can submit precertification requests by:
- Calling:
- o Provider Services: 800-901-0020.
- o Anthem CCC Plus Provider Services: 855-323-4687.
- Faxing to 800-964-3627.
- Visiting Availity* Essentials at availity.com.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | November 1, 2022 Remote EMR access service for HEDISPlease note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.
HEDIS medical record submission made easier with our remote EMR access service
Let us take on the responsibility to retrieve medical records for the annual HEDIS® hybrid project by signing up for the remote electronic medical record (EMR) access service offered by HealthKeepers, Inc.
We offer providers the ability to grant access to their EMR system directly to pull the required documentation to aid your office in reaching compliance while reducing the time and costs associated with medical record retrieval.
We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:
- We only access medical records of members pulled into the HEDIS sample using specific demographic data.
- We only retrieve the medical records that have claims evidence related to the HEDIS measures.
- We access the least amount of information needed for use, disclosure, or for the specific medical records request.
- We only save to file and do not physically print any PHI.
Getting started with remote EMR access
Download and complete the registration form, then email it to us at: Centralized_EMR_Team@anthem.com.
FAQ
How does HealthKeepers, Inc. retrieve your medical records?
We access your EMRs using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.
Is printing access necessary?
Yes. The NCQA audit requires print-to-file access.
Is this process secure?
Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem HealthKeepers Plus secure network drives.
Why does HealthKeepers, Inc. need full access to the entire medical record?
There are several reasons we need to look at the entire medical record of a member:
- HEDIS measures can include up to a 10-year look back at a member’s information.
- Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
- Compliant data may be documented or housed in a nonstandard format, such as an in‑office lab slip scanned into miscellaneous documents.
What information do I need to submit to use the remote EMR access service?
Complete the registration form that requests the following information:
- Practice/facility demographic information (for example, address, NPI, TIN, etc.)
- EMR system information (for example, type of EMR system, required access forms, access type, etc.)
- List of current providers/locations or a website for accessing this list
Remote Access not an option? We are now offering onsite visits for HEDIS hybrid retrieval. Email us at Centralized_EMR_Team@anthem.com for more information.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | November 1, 2022 Important information about utilization managementPlease note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.
Utilization management (UM) decisions for Anthem HealthKeepers Plus members are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://mediproviders.anthem.com/va/Pages/medical.aspx.
You can request a free copy of our UM criteria from our Medical Management department. To access UM criteria online, go to https://mediproviders.anthem.com/va/Pages/medical.aspx. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below.
We are staffed with clinical professionals who coordinate our members’ care. Staff are available during business hours, Monday through Friday, from 8:30 a.m. to 5 p.m., ET, to accept precertification requests. Secured voicemail is available during off-business hours; a clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues.
You can submit precertification requests by:
- Calling:
- Provider Services: 800-901-0020.
- Anthem CCC Plus Provider Services: 855-323-4687.
- Faxing to 800-964-3627.
- Visiting Availity* Essentials at availity.com.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | November 1, 2022 Guidance for coding evaluation and management services for new and established patientsPlease note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.
According to the American Medical Association (AMA) Current Procedural Terminology® (CPT) guidelines, a new patient is defined as one who has not received any professional services, i.e. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after December 1, 2022, HealthKeepers, Inc. will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.
Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the claims payment dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual or resubmit the claim with an established patient E/M code.
If you have any questions about this communication, call Anthem HealthKeepers Plus., Medallion Provider Services at 800‑901‑0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | November 1, 2022 Retraction of policy: Private duty nursing reimbursementPlease note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.
In the October 2022 edition of Provider News, HealthKeepers, Inc. notified providers in error about a private duty nursing reimbursement policy for members enrolled in Anthem HealthKeepers Plus plan, Medallion, and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan. Please note that the notice should not have been included in the October edition.
We apologize for the error and regret any inconvenience the situation may have caused.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | November 1, 2022 Keep up with Medicaid news: November 2022Please 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:
Find Care, the doctor finder and transparency tool in the Anthem Blue Cross and Blue Shield (Anthem) online directory, provides Anthem members with the ability to search for in-network providers using the secure member website at www.anthem.com. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetic order, and provider name.
Beginning January 1, 2023, or later, an additional sorting option will be available for members to search by provider performance called Personalized Match. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Provider pairings with the highest overall ranking within the member’s search radius will be displayed first. Members will continue to have the ability to sort based on distance, alphabetic order, and provider name.
- You may review a copy of the Personalized Match methodology which has been posted on Availity* – our secure web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Anthem > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.
- If you have general questions regarding this new sorting option, please submit an inquiry via the web at availity.com.
- If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to availity.com.
Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.
Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
|
HCPCS or CPT® codes
|
Medicare Part B drugs
|
|
C9399, J3490, J3590, J9999
|
Opdualag (nivolumab and relatlimab-rmbw)
|
|
C9096
|
Releuko (filgrastim-ayow)
|
|
A9699
|
Pluvicto (lutetium lu 177 vipivotide tetraxetan)
|
|