Effective October 14, 2018, Anthem Blue Cross and Blue Shield in Virginia will enforce the requirement to bill the correct modifier and HCPCS for services utilized.  Incorrect billing will be rejected, and claims will be returned to the provider for correction and resubmission.

 

Durable Medical Equipment (DME) may be purchased, rented or rented until the purchase price has been paid. 

 

Correct billing will allow member benefits to be applied correctly to include benefit accumulations for a member’s DME benefits.

The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) which prohibits member cost sharing for defined preventive services for non-grandfathered policies. The appropriate use of modifier 33 will reduce claim adjustments related to preventive services and your corresponding refunds to members.

 

Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.

 

Modifier 33 should be appended to codes represented for services described in the United States Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.

 

The CPT® 2018 Professional Edition manual shares the following information regarding the billing of modifier 33:

 

 “When the primary purpose of the service is the delivery of an evidence based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”

 

Extension for Community Healthcare Outcomes (ECHO)

 

Opioid overdose rates continue to rise. With the support of medication-assisted therapy (MAT) ECHO, you can help save lives. Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website.

 

Benefits of participating include:
 

• Addiction treatment training.

 

• Free continuing education credits.

 

• Opportunity to receive expert input on your (de-identified) patient cases.

 

• Access to a virtual learning community for treatment guidelines, tools and patient resources.

 

• Opportunity to ask questions and get a variety of support from specialists.

 

Quality medication-assisted therapy

 

To help ensure members have access to comprehensive evidence-based care, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are committed to helping network providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.

 

When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with buprenorphine or, in some plans, methadone maintenance treatment in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.

 

For more information

 

For more information about best practices for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use.

 

You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for more information about the ECHO and MAT programs.

In our ongoing efforts to encourage medical and behavioral health integration, Anthem continues to promote early identification and intervention of behavioral health issues through primary care.  Anthem currently reimburses for screening and assessment for behavioral health and substance use through billing the following codes:

 

• G0396/99408 – Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes

 

• G0397/99409 – Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention, greater than 30 minutes

 

• G0442 – Annual alcohol misuse screening, 15 minutes ≤ G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

 

• G0443 – Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

 

• G0444 – Annual depression screening, 15 minutes

 

Anthem also supports behavioral counseling for specific chronic conditions while in the primary care office.  These services include:

 

• G0446 – Annual, face-to-face intensive behavioral therapy for cardiovascular disease, 15 minutes

 

• G0447 – Face-to-face behavioral counseling for obesity, 15 minutes

 

• G0473 – Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

 

In addition, Anthem reimburses for the psychiatric collaborative care codes; procedure codes 99492, 99493, 99494 are used to report these services.  These codes are reportable by primary care providers for their collaboration with a qualified behavioral health provider, such as a psychiatrist, licensed clinical social worker, etc. 

 

Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations.

 

These codes are intended to represent the care and management for patients with behavioral health conditions that often require extensive discussion, information-sharing, and planning between a primary care physician and a behavioral health specialist.  The American Psychiatric Association (APA) has created a training program for primary care on the collaborative care model and the use of these codes.  It can be found at APA Training Module.

Who is Availity?

 

Most of you know Availity as a Web portal or claims clearinghouse.  Availity is also an intelligent EDI Gateway for multiple vendors and will be the EDI connection for Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc.

 

If you currently use a clearinghouse, billing company or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Anthem.

 

How are you submitting EDI transactions today?

 

• If you currently transmit your EDI submissions using a clearinghouse or billing company, you should contact your clearinghouse to confirm your EDI submission path has not changed. If you are notified of any potential impacts with connectivity, workflow or financial, please know there is no cost alternate submission options available with Availity.

 

• If you currently submit directly to Anthem and already have an Availity login for the portal, you can use that same login for your EDI services.

 

• Please visit https://apps.availity.com/web/welcome/#/anthem to learn more.

 

How can you directly transmit EDI submission to Availity?

 

Below are the different ways you can submit direct EDI transactions to Availity:

 

• Submit transaction files through FTP – If you work with a practice management system, health information system, or other automated system that supports an FTP connection, you can securely upload EDI transactions to the Availity FTP site where the electronic transactions are automatically picked up by Availity and submitted to Anthem.

 

• Submit transaction files through the Availity Portal – If you have batch files of EDI transactions that you need to process and you choose not to use the Availity FTP site, you can manually upload the batch files through the Availity Portal.

 

• Submit transactions through manual data entry in the Availity Portal – The Availity Portal makes it easy to submit transactions, such as eligibility and benefits inquiries or claims, by entering data into our user-friendly Web forms. 

 

What are your next steps?

 

• We recommend that you register with Availity for your EDI transmissions and begin migrating your volume by the end of 2018. These include the 837, 835 and 27X (eligibility and claim status) transactions.

 

• Availity will be working directly with your clearinghouse, billing company and your organization if you choose to submit directly.

 

We look forward to delivering a smooth transition to the Availity EDI Gateway. If you have any questions, please contact Availity Client Services at 1-800-Availity (1-800-282-4548) Monday through Friday 8 a.m. to 7:30 p.m. ET. 

 

Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. now use Availity as our designated EDI service. If you currently use a clearinghouse, billing company, or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Anthem.

 

Check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session. During this fast-paced hour, learn how to:

 

• Understand Availity’s EDI Gateway and Clearinghouse workflow for 837, 270/271, 276/277, and 835 electronic transactions.

 

• Use the Availity Portal to manage file transfers, set up EDI reporting preferences, manage your FTP account, and more.

 

• Enroll for and manage 835 ERA delivery with Availity.

 

• Access and navigate the Availity EDI Guide.

 

• and more…..

 

Upcoming Sessions

 

Scheduled upcoming sessions include:

 

• October 29, 2018, 1 p.m. – 2 p.m. ET

 

• November 7, 2018, 11 a.m. – noon ET

Enroll

 

1. Log in to the Availity Portal.

 

2. Select Help and Training > Get Trained.

 

3. In the Availity Learning Center (ALC) Catalog, select Sessions.

 

4. Scroll Your Calendar to find and enroll for a live session.

 

Can’t make it?

 

We’ve got you covered with a recording of a previous live session. In the ALC, search the Catalog by keyword (song) and enroll for the on-demand option.

 

Need Help?

 

Email training@availity.com if you have issues enrolling for a live webinar.

 

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

 

All guidelines are reviewed annually and updated as needed.  The current guidelines are available on our website.  To access the guidelines, go to anthem.com.  Click “Menu” at the top of the screen to display options and select “Providers.”  Next, select “Virginia” from the dropdown listing of states and press “Enter.”  On the Provider Home Page, select the “Health & Wellness” tab and then the “Practice Guidelines” link.

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

 

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

 

Reminder notifications sent via email

 

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

On October 10, 2018, Anthem will offer our final provider education webinar for the year. Designed for our network-participating providers, the webinars address Anthem business updates and billing guidelines that impact your business interactions with us.

 

For your convenience, we offer these informative, hourly sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the last scheduled webinar for 2018 is:

 

• Wednesday, October 10, 2018, from 10 a.m. to 11 a.m. ET

 

Please take time to register today for the webinar using the registration form in the article attachments section on the right.  If you have already registered for the October webinar, please ensure you have received a fax confirmation or a confirmation from an Anthem representative to ensure we’ve received your registration form.  Please contact joyce.lindley@anthem.com if you need to confirm your registration.

Continuing to build on the initial launch of the new public provider pages, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. recently released a brand new, redesigned landing page for Provider Resources. The most recent release also includes a new Communications page with a clear and concise access point for provider newsletters and eUPDATEs, as pictured below.

This October, anthem.com will be introducing exciting changes to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for manuals and an improved, streamlined experience for other communications.

 

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

 

Effective with dates of service on and after November 1, 2018, Anthem Blue Cross and Blue Shield will transition the medical necessity review of all genetic testing services for members enrolled in our PPO health benefit plans to AIM Specialty Health® (AIM), a separate company.  This review will take place as a prior authorization. 

 

SPECIAL NOTE:  For members enrolled in our affiliate HealthKeepers, Inc.'s Anthem HealthKeepers commercial health plans, there are no changes in the medical necessity review of genetic testing services.  Anthem in Virginia will continue to handle the medical necessity review locally for Anthem HealthKeepers members.

 

The coverage guidelines and codes that will be reviewed by Anthem plans managed by AIM for medical necessity include:

 

Coverage Guideline #	Coverage Guideline Title	Codes
GENE.00001	Genetic Testing for Cancer Susceptibility	81404, 81405, 81406, 81437, 81438, 81445, 81450, 81479, 0013U, 0014U, 0056U
GENE.00002	Preimplantation Genetic Diagnosis Testing	89290, 89291
GENE.00003	Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease	81401, 81405, 81406, 83520, 84999, S3852
GENE.00005	BCR-ABL Mutation Analysis	81170, 81401
GENE.00006	Epidermal Growth Factor Receptor (EGFR) Testing	81235, 88365
GENE.00007	Cardiac Ion Channel Genetic Testing	81404, 81405, 81406, 81407, 81408 81413, 81414, S3861
GENE.00009	Gene-Based Tests for Screening, Detection and Management of Prostate Cancer	81313, 81479, 81541, 81551, 81599, 0005U, 0011M, 0047U, 0053U
GENE.00010	Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status	81225, 81226, 81227, 81230, 81231,81232, 81346, 81350, 81355, 81381, 81479, G9143, 0028U, 0029U, 0030U, 0031U, 0032U, 0033U, G9143
GENE.00011	Gene Expression Profiling for Managing Breast Cancer Treatment	81519,81520, 81521, 81599, 84999, S3854,  0045U
GENE.00012	Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent	81200, 81209, 81220, 81221, 81222, 81223, 81224, 81241, 81242, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81269, 81290, 81330, 81361, 81362, 81363, 81364, 81401, 81403, 81404, 81405, 81406, 81412, 81415, 81416, 81417, 81425, 81426, 81427, 81479, S3800, S3841, S3842, S3844, S3845, S3846, S3849, S3853,  0012U
GENE.00016	Gene Expression Profiling for Colorectal Cancer	81525, 81599, 84999
GENE.00017	Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C)	81403, 81405, 81406, 81407, 81408, 81439, 81479, S3865, S3866
GENE.00018	Gene Expression Profiling for Cancers of Unknown Primary Site	81404, 81406, 81540, 81599
GENE.00020	Gene Expression Profile Tests for Multiple Myeloma	81479, 81599
GENE.00021	Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies	81228, 81229, S3870, 81405
GENE.00023	Gene Expression Profiling of Melanomas	81401, 81599, 84999,
GENE.00024	DNA-Based Testing for Adolescent Idiopathic Scoliosis	0004M
GENE.00025	Molecular Profiling for the Evaluation of Malignant Tumors	81425, 81445, 81450, 81455, 81479, 81599, 88363, 0013U, 0014U, 0036U, 0037U, 0048U, 0050U, 0056U, 0057U
GENE.00026	Cell-Free Fetal DNA-Based Prenatal Screening for Fetal Aneuploidy	81420, 81422, 81479, 81507, 81599, 0009M
GENE.00028	Genetic Testing for Colorectal Cancer Susceptibility	81201, 81202, 81203, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81403, 81406, 81435, 81436
GENE.00029	Genetic Testing for Breast and/or Ovarian Cancer Syndrome	81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81432, 81433, 81445, 81455
GENE.00030	Genetic Testing for Endocrine Gland Cancer Susceptibility	81404, 81405, 81445, 81455, 81479, S3840,
GENE.00031	Genetic Testing for PTEN Hamartoma Tumor Syndrome	81321, 81322, 81323
GENE.00033	Genetic Testing for Inherited Peripheral Neuropathies	81324, 81325, 81326, 81403, 81404, 81405, 81406, 81440, 81448, 81479
GENE.00034	SensiGene® Fetal RhD Genotyping Test	81403
GENE.00035	Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome)	81404, 81405, 81445, 81455
GENE.00036	Genetic Testing for Hereditary Pancreatitis	81222, 81223, 81224, 81401, 81404,  81405
GENE.00037	Genetic Testing for Macular Degeneration	81401, 81405, 81408, 81479, 81599
GENE.00038	Genetic Testing for Statin-Induced Myopathy	81328
GENE.00039	Genetic Testing for Frontotemporal Dementia (FTD)	81406, 81479
GENE.00040	Genetic Testing for CHARGE Syndrome	81403, 81407
GENE.00041	Short Tandem Repeat Analysis for Specimen Provenance Testing	81479, 84999, 0007U, 0020U
GENE.00042	Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome	81406
GENE.00043	Genetic Testing of an Individual’s Genome for Inherited Diseases	81200, 81209, 81221, 81222, 81223, 81224, 81241, 81242, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81269, 81290, 81330, 81361, 81362, 81363, 81364, 81400, 81403, 81404, 81405, 81406, 81408 81410, 81411, 81412, 81415, 81416, 81417, 81425, 81426, 81427, 81430, 81431, 81434, 81440, 81442, 81460, 81465, 81470, 81471, 81479, 81599, 81493, 81506, 81599, S3800, S3841, S3842, S3844, S3845, S3846, S3849, S3853, 0012U
GENE.00044	Analysis of PIK3CA Status in Tumor Cells	81404
GENE.00045	Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers	81479, 81599
GENE.00046	Prothrombin G20210A (Factor II) Mutation Testing	81240
GENE.00047	Methylenetetrahydrofolate Reductase Mutation Testing	81291
CG-GENE-01	Janus Kinase 2 (JAK2) V617F Gene Mutation Assay	81270, 81403
CG-GENE-02	Analysis of Kras Status	81275, 81276, 81479, 88363,
CG-GENE-03	BRAF Mutation Analysis	81210, , 81406, 88363
CG GENE 04	Molecular Marker Evaluation of Thyroid Nodules	81545, 81599, 0018U, 0026U

 

 

Beginning October 22, 2018, prior authorization requests for dates of service on or after November 1, 2018, may be submitted to AIM using one of the following ways:

 

• Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.

 

• Access AIM via the Availity Web Portal at availity.com.

 

• Call the AIM Contact Center toll-free number: 866-789-0158, Monday – Friday, 8 a.m. to 5 p.m. ET.

 

For more information about genetic testing prior authorization, visit AIM’s Genetic Test Site. Precertification requirements for Anthem members can be viewed at anthem.com.

 

Please note, this program does not apply to the Federal Employee Program® (FEP®) or HealthKeepers, Inc. health plans.  Anthem in Virginia will continue to handle the medical necessity review of genetic testing services locally for members enrolled in Anthem HealthKeepers commercial health plans.

 

For questions regarding prior authorization requirements, please contact the provider service number on the back of the member ID card.

Beginning with dates of service on and after January 1, 2019, Anthem Blue Cross and Blue Shield will expand precertification requirements to include upper gastrointestinal (GI) endoscopy, also referred to as esophagogastroduodenoscopy (EGD).  AIM Specialty Health® (AIM), a separate company, will administer this EGD review on behalf of Anthem.

 

EGD procedures will be reviewed against clinical guideline CG-MED-59, Upper Gastrointestinal Endoscopy, for clinical appropriateness and to help ensure care aligns with established evidence-based medicine. Please note, procedures performed in an inpatient or observation setting, or on an emergent basis will not be reviewed under CG-MED-59.

 

A complete list of EGD CPT codes requiring precertification is available on the www.aimproviders.com/surgicalprocedures

 

Submit a request for review

 

Starting December 19, 2018, ordering providers may submit precertification requests for dates of service on or after January 1, 2019, to AIM in one of the following ways:

 

• Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.

 

• Access AIM via the Availity Web Portal at availity.com.

 

• Call the AIM Contact Center toll-free number: 866-789-0158, Monday – Friday, 8 a.m. to 5 p.m. ET.

 

Please note, this review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans.

 

Providers can view precertification requirements for Anthem members at Coverage & Clinical UM Guidelines, and Pre-Cert Requirements at the Virginia provider section of anthem.com.  Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

For questions, please contact the Provider Service number on the back of the member ID card.  

 

Anthem Blue Cross and Blue Shield has completed the HEDIS data collection for 2018 and wants to thank all of our provider offices and their staffs who assisted us.  Your collaboration in this process allows us to strive for the best HEDIS results possible.

 

This is year seven for our incentive program to acknowledge some of our providers who either responded in a timely manner or went “Above & Beyond” to help make our HEDIS data collection successful.   Any practices that responded within 5 business days of our initial request or who went out of their way by taking additional steps to help us with data collection were entered in a drawing to receive a gift. We are pleased to announce that our incentive winners are:

 

Virginia HEDIS drawing winners:

 

• John Min – Centreville, Virginia

 

• Fairfax Health Center – Fairfax, Virginia

 

• Health Center for Women & Families – Farmville, Virginia

 

• Richmond Pediatric Associates – Richmond, Virginia

 

• James Ponder – Franklin, Virginia

 

Virginia Above and Beyond Winners:

 

• Central Virginia Health Services – New Canton, Virginia

 

• Overton Wiley Kirchmier Terry – Richmond Virginia

Our HEDIS results reflect the care you provide to our members. Now is the time to review your patients’ records to ensure that they have received their preventative care and/or immunizations before the end of the year.

An overview of our HEDIS rates will be published in the fourth quarter provider newsletter. In addition, more information on HEDIS can be found by visiting the provider portal at: www.anthem.com > Provider > State > Health & Wellness > Quality Improvement and Standards > HEDIS Information.

 

Thanks again to all of our provider offices and their staffs for assisting us in collecting HEDIS data. We look forward to working with you next HEDIS season.

 

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

Effective for dates of service on and after January 28, 2019, the following updates will apply to the AIM Specialty Health© (AIM), a separate company.  This impacts clinical appropriateness guidelines – advanced imaging appropriate use criteria: imaging of the heart.

 

Carotid duplex ultrasound

 

• Criteria removed for evaluation of syncope in patients with suspected extracranial arterial disease.

 

• New criteria address evaluation of TAVR (TAVI) in patients with suspected or established extracranial arterial disease.

 

Myocardial perfusion imaging (MPI), stress echocardiography, cardiac PET, and coronary CT angiography (CCTA)

 

• Clarifications address exercise-induced syncope and exercise-induced dizziness, lightheadedness or near syncope in symptomatic patients with suspected coronary artery disease.

 

MPI, stress echocardiography, cardiac PET

 

• Criteria added to allow annual surveillance of coronary artery disease in patients with established CAD post-cardiac transplant.

 

• Clarified definition of established coronary artery disease when diagnosed by CCTA.

1. More restrictive for patients diagnosed with coronary artery disease by prior coronary angiography, as FFR must be ≤0.8.
2. More permissive for patients diagnosed with coronary artery disease by CCTA with FFR ≤0.8 (patients previously excluded).

 

Resting transthoracic echocardiography (TTE)

 

• New criteria for evaluation of ventricular function in patients who have undergone cardiac transplantation. 

 

Cardiac MRI

• New criteria allows for annual study to quantify cardiac iron load in chronically ill patients with cardiomyopathy who require frequent blood transfusions (e.g., thalassemia).

 

• Removed allowance for annual LV function evaluation when echocardiography is suboptimal.

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM 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: 866-789-0158, Monday – 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 guidelines on AIM’s website.

 

Please note, this program does not apply to the Federal Employee Program (FEP).

Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers Inc. are committed to helping ensure our members receive patient care that is consistent with recognized best practices. To support this goal, beginning with dates of service on and after January 1, 2019, Anthem will expand our cardiovascular program to require precertification for arterial ultrasound, cardiac catheterization, and percutaneous coronary intervention (PCI). The program will be managed by AIM Specialty Health® (AIM), a separate company administering the program on behalf of Anthem.

 

Please note that all Anthem local members who currently require precertification for high-tech imaging and echocardiograms are included in the program. The program does not apply to Federal Employee Program® (FEP).   Additionally, procedures performed in an inpatient setting or on an emergent basis are not included in the program.

 

Arterial ultrasound, cardiac catheterization, and percutaneous coronary intervention (PCI) services will be reviewed using AIM clinical guidelines which are available at aimproviders.com/cardiology/. 

 

Ordering physicians may submit to AIM a precertification request in one of several ways:

 

• Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.

 

• Access AIM via the Availity Web Portal at availity.com.

 

• Call the AIM Contact Center toll-free number: 866-789-0158, Monday–Friday, 8 a.m. – 5 p.m.

 

Anthem recognizes that the necessity for arterial duplex imaging or percutaneous coronary intervention (PCI) may not be identified by providers until their patients have undergone a physiologic study or cardiac catheterization.  We ask that you contact AIM no later than 10 business days after you perform arterial duplex imaging or PCI, but before you submit the claim, to request clinical appropriateness review. The following codes will be reviewed by AIM as part of the program:

 

 

CPT	Description
93922	Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries
93923	Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels
93924	Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing
93925	Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study
93926	Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study
93930	Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study
93931	Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study
93978	Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study
93979	Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study
93880	Duplex scan of extracranial arteries; complete bilateral study
93882	Duplex scan of extracranial arteries; unilateral or limited study
93454	Catheter placement in coronary artery(s) for coronary angiography
93455	Catheter placement in coronary artery(s) for coronary angiography, with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography
93456	Catheter placement in coronary artery(s) for coronary angiography, with right heart catheterization
93457	Catheter placement in coronary artery(s) for coronary angiography, with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization
93458	Catheter placement in coronary artery(s) for coronary angiography, with left heart catheterization including intraprocedural injection(s) for left ventriculography
93459	Catheter placement in coronary artery(s) for coronary angiography, with left heart catheterization including intraprocedural injection(s) for left ventriculography, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography
93460	Catheter placement in coronary artery(s) for coronary angiography, with right and left heart catheterization including intraprocedural injection(s) for left ventriculography
93461	Catheter placement in coronary artery(s) for coronary angiography, with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography
92920	Percutaneous transluminal coronary angioplasty; single major coronary artery or branch
92924	Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or branch
92928	Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch
92933	Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch
92937	Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel
92943	Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel

 

For questions regarding precertification or prior authorization requirements, please contact the provider service number on the back of the member ID card.

 

 

Effective for dates of service on and after January 28, 2019, the following updates will apply to the AIM Specialty Health© (AIM), a separate company, radiation oncology clinical appropriateness guidelines:

 

Breast cancer

• Removed age and tumor size criteria for accelerated whole breast irradiation (AWBI).

 

Rectal cancer

• Modified criteria no longer limits treatment with IMRT for rectal adenocarcinoma.

 

 Pancreatic cancer

 

• Added criteria for SBRT in treating locally advanced or recurrent disease without evidence of distant metastasis.

 

Head and neck cancer

 

• Added criteria to allow IMRT for head and neck lymphomas.

 

• Clarified no IMRT for stage I/II glottic cancer.

 

Lung cancer

 

• Added DVH parameter for cardiac V50.

 

Sarcoma

 

• Removed preoperative and joint sparing requirements for IMRT.

 

Prostate cancer

                             

• Added discussion on hypofractionation.

 

• Added discussion on brachytherapy.

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM 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:  866-789-0158, Monday - 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 guidelines on AIM’s website.

 

Please note, this program does not apply to the Federal Employee Program (FEP) or National Accounts.  

 

Effective for dates of service on and after January 28, 2019, CPT code A7047 (oral interface used with respiratory suction pump) will be removed from the AIM Specialty Health© (AIM), a separate company, sleep disorder management clinical appropriateness guidelines and will no longer apply.

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM 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 Enter toll-free number:  866-789-0158, Monday - 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 guidelines on AIM’s website

 

Please note, this program does not apply to the Federal Employee Program (FEP).

 

Numerous studies have shown that a patient’s primary health care experience and, to some extent their health care outcomes, are largely dependent upon health care provider and patient interactions.   Anthem Bue Cross and Blue Shield offers a new online learning course – What Matters Most: Improving the Patient Experience – to address gaps in and offer approaches to communication with patients.  This curriculum is available at no cost to providers and their clinical staff nationwide and is acceptable for up to one (1) prescribed continuing medical education (CME) credit by the American Academy of Family Physicians.

 

Through the use of compelling real-life stories that convey practical strategies for implementing patient care, providers learn how to apply best practices.  Did you know?

 

• Substantial evidence points to a positive association between the patient experience and health outcomes.

 

• Patients with chronic conditions, such as Diabetes, demonstrate greater self-management skills and quality of life when they report positive interactions with their health care providers.

 

• Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician's practice than patients with the highest-quality relationships.*

 

How will this benefit you and your office staff?  You’ll learn tips and techniques to:

 

• Improve communication skills.

 

• Build patient trust and commitment.

 

• Expand your knowledge of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

 

The course can be accessed at www.patientexptraining.com using your smartphone, tablet, or computer.

 

Like you, Anthem is committed to improving the patient experience in all interactions, and we are proud to work collaboratively with our provider network to provide support and tools to reach our goal.

 

Take the course today.


* Source:  Please visit www.patientexptraining.com

 

At the direction of the Virginia General Assembly, Commonwealth of Virginia state employees with COVA Care or COVA HDHP plans are eligible to participate in a new Anthem program beginning October 1, 2018, that will help make their health care shopping experience simpler and more cost efficient. Vitals SmartShopper is a voluntary program that offers monetary incentives to employees, early retirees, COBRA participants, and covered dependents who use more cost-effective sites of care for certain health services. Additional information on this program will be outlined in the coming weeks and shared in upcoming provider newsletter editions.

 

 

HealthKeepers, Inc. has partnered with Availity to become our designated EDI Gateway effective January 1, 2019.

 

What does this mean to you as a provider?

 

All EDI submissions currently received are now available on Availity. Please note, there is no impact to Anthem HealthKeepers Plus provider participation statuses and no impact on how claims adjudicate.

 

Next steps

 

Contact your clearinghouse to validate their transition dates to Availity. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you.  You can submit claims directly through Availity.

 

Register with Availity

 

If you wish to submit directly through Availity for your 837 (claim), 835 (electronic remittance advice) and 27X (claim status and eligibility) transactions, please visit https://www.availity.com to register.

       

We look forward to delivering a smooth transition to the Availity EDI Gateway.

 

If you have any questions please contact Availity Client Services at 1-800-282-4548, Monday to Friday, 8 a.m. to 7:30 p.m. ET. 

 

 

The following information addresses Anthem HealthKeepers Plus programs offered by HealthKeepers, Inc.

 

Extension for Community Health Care Outcomes (ECHO)

 

People are dying of opioid addiction. With the medication assisted treatment, you can help save lives. Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website at https://echo.unm.edu.

 

Benefits of participating include:

 

• Addiction treatment training.

 

• Free continuing education credits.

 

• Opportunity to receive expert input on your (de-identified) patient cases.

 

• Access to a virtual learning community for treatment guidelines, tools and patient resources.

 

• Opportunity to ask questions and get a variety of support from specialists.

 

Quality Medication-Assisted Therapy (MAT)

 

To help ensure members have access to comprehensive evidence-based care, HealthKeepers, Inc. is committed to helping our providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.

 

When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with naltrexone, buprenorphine or, in some plans, methadone in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.

For more information

 

For more information about what is considered best practice for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use.

 

You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for more information about the ECHO and MAT programs.

 

HealthKeepers, Inc. now conducts monthly provider orientations and training sessions for Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) and Medallion 4.0 programs.

 

These orientations and trainings are for both contracted and noncontracted providers, giving new providers information about engaging the Medicaid health plan and presenting existing providers an opportunity to learn about new initiatives.

 

You can find a schedule of the orientations on the provider website at https://mediproviders.anthem.com/va/pages/manuals-directories-training.aspx

Medical Policies update

 

On January 25, 2018, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem HealthKeepers Plus members. These policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the below listing.

 

The Medical Policies were made publicly available on our provider website on the effective date listed. To search for specific policies, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

Please note:

 

• Starting July 1, 2018, AIM Specialty Health®Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.

 

• For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

 

 

Publish date	Medical Policy number	Medical Policy title	New or revised
2/28/2018	DRUG.00116	Vestronidase alfa (Mepsevii™)	New
2/28/2018	DRUG.00046	Ipilimumab (Yervoy®)	Revised
2/28/2018	DRUG.00075	Nivolumab (Opdivo®)	Revised
2/28/2018	DRUG.00077	Monoclonal Antibodies to Interleukin-17A	Revised
2/1/2018	DRUG.00080	Monoclonal Antibodies for the Treatment of Eosinophilic Conditions	Revised
2/28/2018	DRUG.00082	Daratumumab (DARZALEX™)	Revised
2/28/2018	DRUG.00099	Cerliponase Alfa (Brineura™)	Revised
2/28/2018	GENE.00028	Genetic Testing for Colorectal Cancer Susceptibility	Revised
2/1/2018	GENE.00029	Genetic Testing for Breast and/or Ovarian Cancer Syndrome	Revised
2/28/2018	GENE.00035	Genetic Testing for TP53 Mutations	Revised
2/28/2018	MED.00100	Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems	Revised
2/1/2018	SURG.00011	Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
2/1/2018	SURG.00098	Mechanical Embolectomy for Treatment of Acute Stroke	Revised
2/28/2018	SURG.00145	Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)	Revised

 

Clinical Utilization Management Guidelines update

 

On January 25, 2018, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines to Anthem HealthKeepers Plus members. These clinical guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the following listing. This list represents the Clinical UM Guidelines adopted by the medical operations committee for the Government Business Division on March 2, 2018.

 

The clinical guidelines were made publicly available on our provider website on the effective date listed. To search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

 

Please note:

 

• Starting July 1, 2018, AIM Specialty Health®Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.

 

• For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

 

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
5/1/2018	CG-DME-42	Nonimplantable Insulin Infusion and Blood Glucose Monitoring Devices	New
5/1/2018	CG-DME-43	High-Frequency Chest Compression Devices for Airway Clearance	New
5/1/2018	CG-DRUG-82	Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension	New
5/1/2018	CG-DRUG-83	Growth Hormone	New
5/1/2018	CG-DRUG-84	Belimumab (Benlysta®)	New
5/1/2018	CG-DRUG-85	Tesamorelin (Egrifta®)	New
5/1/2018	CG-DRUG-86	Ocriplasmin (Jetrea®) Intravitreal Injection Treatment	New
5/1/2018	CG-DRUG-87	Vedolizumab (Entyvio®)	New
5/1/2018	CG-DRUG-88	Dupilumab (Dupixent®)	New
5/1/2018	CG-SURG-70	Gastric Electrical Stimulation	New
5/1/2018	CG-SURG-71	Reduction Mammaplasty	New
5/1/2018	CG-SURG-72	Endothelial Keratoplasty	New
7/1/2018	CG-THER-RAD-03	Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy	New
7/1/2018	CG-THER-RAD-04	Selective Internal Radiation Therapy of Primary or Metastatic Liver Tumors	New
5/1/2018	CG-DRUG-29	Hyaluronan Injections	Revised
2/28/2018	CG-DRUG-50	Paclitaxel, protein bound (Abraxane®)	Revised
2/28/2018	CG-DRUG-59	Testosterone Injectable	Revised
2/28/2018	CG-DRUG-73	Denosumab (Prolia®, Xgeva®)	Revised
2/28/2018	CG-DRUG-78	Antihemophilic Factors and Clotting Factors	Revised
2/28/2018	CG-MED-39	Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry	Revised
2/28/2018	CG-MED-53	Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing	Revised
2/28/2018	CG-SURG-33	Lumbar Fusion and Lumbar Total Disc Arthroplasty	Revised

 

 

Coverage Guidelines and Clinical Utilization Management Guidelines update

 

The Coverage Guidelines and Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were developed or revised to support clinical coding edits. Note, several guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Please share this notice with other members of your practice and office staff.

 

To search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

 

Coverage Guidelines

 

On March 22, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to HealthKeepers, Inc.

 

 

Publish date	Coverage Guidelines number	Coverage Guidelines title	New or revised
3/29/2018	MED.00120	Voretigene neparvovec-rzyl (Luxturna™)	New
4/25/2018	SURG.00151	Balloon Dilation of Eustachian Tube	New
4/25/2018	DME.00009	Vacuum-Assisted Wound Therapy in the Outpatient Setting	Revised
3/29/2018	GENE.00028	Genetic Testing for Colorectal Cancer Susceptibility	Revised
4/25/2018	RAD.00029	CT Colonography (Virtual Colonoscopy) for Colorectal Cancer	Revised
4/25/2018	SURG.00033	Cardioverter Defibrillators	Revised
4/25/2018	SURG.00098	Mechanical Embolectomy for Treatment of Acute Stroke	Revised
4/25/2018	SURG.00121	Transcatheter Heart Valve Procedures	Revised

Clinical UM Guidelines

 

On March 22, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

 

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
6/28/2018	CG-BEH-15	Activity Therapy for Autism Spectrum Disorders and Rett Syndrome	New
6/22/2018	CG-DRUG-89	Implantable and Extended-Release Buprenorphine-Containing Products	New
6/28/2018	CG-DRUG-90	Intravitreal Treatment for Retinal Vascular Conditions	New
6/28/2018	CG-DRUG-91	Intravitreal Corticosteroid Implants	New
6/28/2018	CG-DRUG-92	Alpha-1 Proteinase Inhibitor Therapy	New
6/28/2018	CG-DRUG-93	Sarilumab (Kevzara®)	New
6/28/2018	CG-LAB-13	Skin Nerve Fiber Density Testing	New
6/28/2018	CG-MED-69	Inhaled Nitric Oxide	New
6/28/2018	CG-MED-70	Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule	New
6/28/2018	CG-SURG-73	Balloon Sinus Ostial Dilation	New
6/28/2018	CG-SURG-74	Total Ankle Replacement	New
6/28/2018	CG-SURG-75	Transanal Endoscopic Microsurgical Excision of Rectal Lesions	New
6/28/2018	CG-THER-RAD-07	Intravascular Brachytherapy (Coronary and Noncoronary)	New
4/25/2018	CG-SURG-31	Treatment of Keloids and Scar Revision	Revised
4/25/2018	CG-SURG-49	Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities	Revised

 

Coverage Guidelines

 

Note:

 

• Effective November 1, 2018, MCG Health Care Guidelines® will be used for reviews, to include the use of customizations to certain guidelines and Behavioral Health Care Guidelines (NEW).

 

• Additionally, effective November 1, 2018, AIM Specialty HealthÒ Proton Beam Therapy will be used for clinical reviews.

 

Please share this notice with other members of your practice and office staff.

 

To search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

 

On May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to HealthKeepers, Inc.

 

Publish date	Coverage Guidelines number	Coverage Guidelines title	New or revised
6/6/2018	DRUG.00098	Lutetium Lu 177 dotatate (Lutathera®)	New
6/6/2018	DRUG.00046	Ipilimumab (Yervoy®)	Revised
5/10/2018	DRUG.00047	Brentuximab Vedotin (Adcetris®)	Revised
5/10/2018	DRUG.00053	Carfilzomib (Kyprolis®)	Revised
6/6/2018	DRUG.00071	Pembrolizumab (Keytruda®)	Revised
6/6/2018	DRUG.00075	Nivolumab (Opdivo®)	Revised
5/10/2018	DRUG.00076	Blinatumomab (Blincyto®)	Revised
6/6/2018	DRUG.00111	Monoclonal Antibodies to Interleukin-23	Revised
5/10/2018	SURG.00026	Deep Brain, Cortical and Cerebellar Stimulation	Revised

 

Clinical Utilization Management (UM) Guidelines

 

On May 3, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

 

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
6/6/2018	CG-LAB-12	Testing for Oral and Esophageal Cancer	New
6/6/2018	CG-MED-71	Wound Care in the Home Setting	New
6/28/2018	CG-DME-44	Electric Tumor Treatment Field (TTF)	New
6/28/2018	CG-DRUG-67	Cetuximab (Erbitux®)	New
6/28/2018	CG-DRUG-94	Rituximab (Rituxan®) for Nononcologic Indications	New
6/28/2018	CG-DRUG-95	Belatacept (Nulojix®)	New
6/28/2018	CG-DRUG-96	Ado-trastuzumab emtansine (Kadcyla®)	New
6/28/2018	CG-DRUG-97	Rilonacept (Arcalyst®)	New
6/28/2018	CG-DRUG-98	Bendamustine Hydrochloride	New
6/28/2018	CG-DRUG-99	Elotuzumab (Empliciti™)	New
6/28/2018	CG-DRUG-100	Interferon gamma-1b (Actimmune®)	New
6/28/2018	CG-DRUG-101	Ixabepilone (Ixempra®)	New
6/28/2018	CG-DRUG-102	Olaratumab (Lartruvo™)	New
6/28/2018	CG-MED-72	Hyperthermia for Cancer Therapy	New
6/28/2018	CG-SURG-76	Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty	New
6/28/2018	CG-SURG-77	Refractive Surgery	New
6/28/2018	CG-SURG-78	Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies	New
6/28/2018	CG-SURG-79	Implantable Infusion Pumps	New
6/28/2018	CG-SURG-80	Transcatheter Arterial Chemoembolization and Transcatheter Arterial Embolization for Treating Primary or Metastatic Liver Tumors	New
5/10/2018	CG-DRUG-50	Paclitaxel, protein bound (Abraxane®)	Revised
6/6/2018	CG-DRUG-60	Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications	Revised
6/6/2018	CG-DRUG-62	Fulvestrant (FASLODEX®)	Revised
6/6/2018	CG-DRUG-78	Antihemophilic Factors and Clotting Factors	Revised

 

 

The information in this communication pertains to HealthKeepers, Inc. for Anthem HealthKeepers Plus providers.

 

As part of our commitment to provide you with the latest clinical information and improve member outcomes, we have posted a vaginal birth after cesarean (VBAC) shared decision-making aid to our provider site. This tool has been reviewed and certified by the Washington Health Care Authority* and is available to aid in discussions with your patients regarding their treatment options.

 

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-800-901-0020.

 

 

* The Washington Health Care Authority is recognized as a certifying body by NCQA.

Effective December 1, 2018, prior authorization (PA) requirements will change for injectable/infusible drug Interferon beta-1a to be covered by HealthKeepers, Inc. for Anthem HealthKeepers Plus members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

 

• Interferon beta-1a — injection, 30 mcg (J1826)

 

To request PA, you may use one of the following methods:

 

• Web: https://www.availity.com

 

• Fax: 1-800-964-3627

 

• Phone: 1-800-901-0020

 

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-800-901-0020 for PA requirements.

Effective December 1, 2018, prior authorization (PA) requirements will change for injectable/infusible drug Somatrem to be covered by HealthKeepers, Inc. for Anthem HealthKeepers Plus members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

 

•  Somatrem — injection, 1 mg (J2940)

 

To request PA, you may use one of the following methods:

 

• Web: https://www.availity.com

 

• Fax: 1-800-964-3627

 

• Phone: 1-800-901-0020

 

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-800-901-0020 for PA requirements.

 

 

Are you looking for innovative ways to improve your patients’ experiences?

 

Numerous studies have shown that a patient’s primary health care experience and, to some extent their health care outcomes, are largely dependent upon health care provider and patient interactions. Recently, HealthKeepers, Inc. announced the launch of a new online learning course — What Matters Most: Improving the Patient Experience — to address gaps in and offer approaches to communication with patients. This curriculum is available at no cost to Anthem HealthKeepers Plus providers and their clinical staff.

 

Did you know?

 

• Substantial evidence points to a positive association between the patient experience and health outcomes.

 

• Patients with chronic conditions, such as Diabetes, demonstrate greater self-management skills and quality of life when they report positive interactions with their health care providers.

 

• Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician's practice than patients with the highest-quality relationships.

 

How will this benefit you and your office staff?

 

Through the use of compelling real-life stories that convey practical strategies for implementing patient care, providers learn how to apply best practices. 

 

Through the use of compelling real-life stories that convey practical strategies for implementing patient care, providers learn how to apply best practices. 

 

You’ll learn tips and techniques to:

 

• Improve communication skills.

 

• Build patient trust and commitment.

 

• Expand your knowledge of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey.

 

Get CME credits

 

Providers may apply their completion of the course toward continuing medical education (CME) credit certification. The training has been reviewed and is acceptable for up to one (1) prescribed credit by the American Academy of Family Physicians.*

 

Like you, HealthKeepers, Inc. is committed to improving the patient experience in all interactions, and we are proud to work collaboratively with our provider network to provide support and tools to reach our goal.

 

Please consider taking the course today.

 

SOURCES:

 

What Is Patient Experience? Agency for Healthcare Research and Quality, Rockville, MD. (Content last reviewed March 2017.) http://www.ahrq.gov/cahps/about-cahps/patient-experience/index.html

 

CAHPS®: Assessing Health Care Quality From the Patient's Perspective Agency for Healthcare Research and Quality, Rockville, MD. (Content last reviewed March 2016.)

http://www.ahrq.gov/cahps/about-cahps/cahps-program/cahps_brief.html

 

Physician Communication and Patient Adherence to Treatment: A Meta-analysis Zolnierek, Kelly B. and DiMatteo, M. Robin (2009.) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728700/

 

* This Enduring Material activity, What Matters Most: Improving the Patient Experience, has been reviewed and is acceptable for up to 1.00 Elective credit(s) by the American Academy of Family Physicians. AAFP certification begins April 30, 2018. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

 

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

 

 

In our efforts to improve pregnancy outcomes, including the prevention of preterm birth, HealthKeepers, Inc. previously communicated our endorsement of the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM) guidelines on cervical length (CL) screening and progesterone treatment for Anthem HealthKeepers Plus members.

 

We continue to encourage you to obtain a CL measurement with your patient’s routine prenatal anatomic evaluation ultrasound. For claims submitted on or after January 1, 2019, if a vaginal approach is necessary in addition to an abdominal scan to obtain this measurement, the transvaginal ultrasound will be considered for a multiple procedure reduction.

 

When a routine anatomic evaluation ultrasound (76801, 76802, 76805, 76810) and a transvaginal ultrasound (76817) are billed on the same day by the same provider, the transvaginal ultrasound is considered a part of the multiple procedure payment reduction policy and will be paid at 50% of the applicable fee schedule, and the complete procedure will be paid at the full applicable fee schedule.

 

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services toll free at 1-800-901-0020.

Thank you for being a valued provider.

The Medicaid Medallion 4.0 program is coming to your area soon. As part of this new program, starting in September and October many Anthem Medallion 4.0 Medicaid members will be moved to other health plans. Specifically, the Department of Medical Assistance Services (DMAS) will move:

 

• 6,000 Anthem members in Central Virginia on September 1, 2018 (effective date)

 

• 36,000 Anthem members in Northern Virginia on October 1, 2018 (effective date)

 

Please note that Anthem HealthKeepers Plus members who are switched to a new health plan are entitled to receive 30 days of continuity of care from their current provider practice. This is per DMAS:

1. Anthem HealthKeepers Plus members can call the state’s Managed Care Helpline (Maximus) at 1-800-643-2273 to switch their health plan after they have received their state assignment letter. (See chart on page two for additional details.)
2. Anthem HealthKeepers Plus members also have the option to call and switch health plans 90 days after their effective date.

 

Please do your part by continuing to care for Anthem HealthKeepers Plus members during this transition period, as we hope to have them return to the Anthem HealthKeepers Plus network in the future.

 

If you have questions about this, please contact:

 

• Angie Clayton, Northern Virginia Provider Relations representative:
  • Phone: 1-703-935-6124; email: angelia.clayton@anthem.com

 

• Jerron Dennis, Central Virginia Provider Relations representative:
  • Phone: 1-804-698-9074; email: jerron.dennis@anthem.com

 

Please refer to the attachment under "Article Attachments" on the right for more information about the Medallion 4 mailing process for members calling Maximus.       

 

The AIM Genetic Testing program requires ordering providers to request medical necessity review of all genetic testing services for individual Medicare Advantage members.  Requesting this prior authorization will help ensure that the lab receives timely and accurate payment for these services.

 

Please submit genetic testing prior authorization requests to AIM through one of the following ways:

 

• Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.

 

• Access AIM via the Availity Web Portal at availity.com.

 

• Call the AIM Contact Center toll-free number at 800-714-0040, Monday – Friday, 7 a.m. – 7p.m. CT.

 

For further questions regarding prior authorization requirements, please contact the Provider Services number on the back of your patient’s ID card.

Effective January 1, 2019, Anthem will transition its Medicare back pain management and cardiology programs from OrthoNet LLC to AIM Specialty Health® (AIM), a specialty health benefits company. Anthem has an existing relationship with AIM in the administration of other medical management programs.  Additional information will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider.

 

The Centers for Medicare & Medicaid Services has increased its emphasis on the appropriate use of statins among Medicare Advantage beneficiaries diagnosed with diabetes and cardiovascular disease. Please evaluate whether your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

 

The 2013 American College of Cardiology and the American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults supports the use of moderate-intensity statin therapy in persons with diabetes 40 to 75 years of age to reduce the risks of atherosclerotic cardiovascular disease (ASCVD) events. High-intensity statin therapy is recommended if the patient has an estimated 10-year ASCVD risk ≥7.5 percent. For males 21-75 and females 40-75 years of age with clinical ASCVD, high-intensity statin therapy is recommended unless contraindicated.   These guidelines recommend statin therapy in these scenarios regardless of what patient LDL values are.  Please evaluate if your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

 

Formulary agents are listed below.

 

Moderate-intensity statin therapy (formulary agents)

 

Drug (brand)	Dose
atorvastatin**	10 mg, 20 mg
rosuvastatin*	5 mg, 10 mg
simvastatin**	20 mg, 30 mg, 40 mg
pravastatin**	40 mg, 80 mg
lovastatin**	40 mg

 

 

High-intensity statin therapy (formulary agents)

 

Drug (brand)	Dose
atorvastatin**	40 mg, 80 mg
rosuvastatin*	20 mg, 40 mg

 

*Rosuvastatin (Crestor) is a preferred brand medication on the Medicare formulary. 

 

**Available for a $0 co-pay for most plans in 2018.

 

Per guidance established by the Comprehensive Addiction and Recovery Act of 2016, the Centers for Medicare & Medicaid Services has established provisions to develop a pharmacy and prescriber home program for opioid medications.   Beginning January 1, 2019, Anthem will work with beneficiaries and providers to help to reduce the risk of opioid dependency by streamlining access to opioid medications.  If a beneficiary is exhibiting at-risk opioid medication utilization, the plan sponsor will work with the beneficiary and provider to select a pharmacy home and prescriber home for the beneficiary’s opioid medications.   At risk is defined by CMS as:

1. Cumulative Morphine Milligram Equivalent (MME) > 90mg per day

 

2. Opioid prescribers > than three and opioid dispensing pharmacies > than three

 

3. Or Opioid prescribers > than five regardless the number of pharmacies

 

• Cancer, LTC and Hospice are exempt

 

• Beneficiaries will have the choice of which pharmacy or prescriber to select as their home.

 

• Plan sponsors will request agreement from the provider selected as the home.

 

• At this time, only opioid and benzodiazepine medications will be delegated to a home pharmacy or prescriber.

 

• Both beneficiaries and providers will receive letters to explain what is happening and how it will happen.

 

• Beneficiaries retain the right to request a coverage determination and may choose to change their Home pharmacy or prescriber at any time.

Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information including:

 

Prior authorization requirements for Part B drugs: Nivestym  

 

Prior authorization requirements for high level definitive drug testing 

 

Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila  

 

July Medicare Advantage reimbursement policy  

 

Submit PA medication requests electronically; new phone number for MA prescription PAs 

 

CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019  

 

Inpatient Readmissions   

 

Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective Sept. 1  

 

Introducing the Interactive Care Reviewer