Exciting new changes are on the horizon for the public provider site at anthem.com. These next wave of updates include:

• A new Contact Us page that gives providers easy access to important contact information

• A redesigned Medicare Advantage page with an improved, effortless user experience

• A new Enhanced Personal Health Care (EPHC) page that provides a more prominent and easier access to information that communicates Anthem’s role in transforming health care. (EPHC is a program designed to advance and support a patient-centered approach to care delivery.)

Below is a preview of the new Contact Us and Medicare Advantage page:

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

Note that in addition we also use our email service to communicate new information. If you are not yet signed up to receive our business critical emails, 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 Provider News 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. 

On October 10, 2019, Anthem’s final provider education webinar for the year takes place. 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 fall webinar is:

• Thursday, October 10, 2019, from 11:30 a.m. to 12:30 p.m. ET

Please take time to register today for the webinar using the registration form to the right under the “Article Attachments” section. If you have already registered for the 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.  Contact stacey.marsh@anthem.com if you need to confirm your registration.

This is a one-week observance that gives organizations and providers an opportunity to raise awareness on the appropriate use of antibiotics and reduce the threat of antibiotic resistance. The Centers for Disease Control and Prevention (CDC) has many tools for providers at https://www.cdc.gov/antibiotic-use/week/toolkit.html.  Posters, prescriptions pads, social media posts, patient education pieces, sticker and counter clings, and more can be found on the CDC website.

During U.S. Antibiotic Awareness Week and throughout the year, the CDC promotes Be Antibiotics Aware, an educational effort to raise awareness about the importance of safe antibiotic prescribing and use.  Be Antibiotics Aware has resources to help health care professionals (in outpatient and inpatient settings) educate patients and families about antibiotic use and risks for potential side effects. For more information, visit: https://www.cdc.gov/antibiotic-use/?s_cid=NCEZID-AntibioticUse-005.

The National Accounts 2020 Pre-certification list has been published. Please note, providers should continue to verify member eligibility and benefits prior to rendering services.

As a reminder, Laboratory  Corporation of America (LabCorp) and its subsidiaries – Dianon Systems, Litholink, MedTox, Esoterix Genetic Laboratories and Accupath Diagnostic Laboratories – are the only participating laboratory providers for all Anthem HealthKeepers and Anthem HealthKeepers Plus laboratory testing except for those lab services included on the in-office laboratory list (part of your Provider Agreement).

LabCorp has many conveniently located patient service centers to assist in the collection of members’ lab specimens.  Members can locate and schedule an appointment for their next visit to a LabCorp patient service center via the LabCorp website at www.LabCorp.com under the Find a Lab option, or by calling 888-LabCorp.

LabCorp’s newest patient service center is located at:

1100 N. Shenandoah Ave, Ste. A

Front Royal, VA 22630

Telephone:  540-883-0030

Hours:

Monday – Friday: 7 a.m. – 4 p.m.

Closed for lunch: Noon – 1 p.m.

Drug screens: 8 a.m. – 3 p.m.

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, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and 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 at anthem.com/provider/Provider Overviews> scroll down and select ‘Find Resources for Virginia’ > Health and Wellness > Practice Guidelines.

Continuing our 2019 CRA updates, Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. request your assistance with respect to accurately reporting our members’ health status to the Centers for Medicare & Medicaid Services.

2019 Retrospective Chart Request

Retrospective medical chart collection begins in November, and it is the most significant and largest volume of our requests.  We appreciate your collaboration as we work through the requests and submit to your medical records department in a timely manner.

Electronic options for chart collections

We have four electronic options for chart collections from which to choose:

1. Remote/direct Anthem access;

2. Electronic Medical Record (EMR) Interoperability with four EMR systems;

3. Inovalon virtual visit or onsite;

4. Secure FTP.

Submitting medical charts can be time consuming for your staff.  Using an electronic option can alleviate the constraints on your staff’s resources and time. 

The most efficient electronic option is to allow the Anthem medical coder team to have direct connection access to your EMR system (Option 1), so that we may retrieve the records ourselves.  Our team has collaborated with several providers and facilities to have direct access to their EMR systems to collect the charts.  This allows for no vendor interventions and fewer handoffs of the records.  To address compliance concerns, please note that as a health plan, Anthem is a covered entity under the HIPAA Privacy Rule and is bound to protect PHI. 

If you are interested in any of these electronic options, or you would like to grant Anthem medical coders direct access to your EMR system, please contact our Commercial Risk Adjustment Representative who supports Virginia:  Alicia Estrada at Alicia.Estrada@anthem.com

Thank you for your continued efforts with our CRA Program and your help in expediting chart collection requests.

Policy Update

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

(Policy 06-0149, effective 11/30/19)

Currently, HealthKeepers, Inc. includes Early and Periodic Screening, Diagnosis and Treatment (EPSDT) component services in the reimbursement of Anthem HealthKeepers Plus preventive medicine evaluation and management (E&M) visits unless they are appended with Modifier 25 to indicate a significant, separately identifiable E&M service by the same physician on the same date of service.

However, effective November 30, 2019, the following EPSDT component services will be separately reimbursable from preventive medicine E&M visits:

• Hearing screening with or without the use of an audiometer or other electronic device

• Vision screening

For additional information, please review the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) reimbursement policy at https://mediproviders.anthem.com/va.

Category:  Medicare

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

• March 2019 Medical Policies and Clinical Utilization Management Guidelines update

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• Clinical Laboratory Improvement Amendments for Anthem Blue Cross and Blue Shield

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• Additional information about Lowering health risks with no-cost statins

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• Additional information about Assisting your patients in managing the Donut Hole

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• Prior authorization requirements for continuous positive airway

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Category:  Medicare

On January 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will implement a preferred edit on Medicare-eligible continuous glucose monitors (CGMs). Currently, there are two CGM systems covered by CMS under the Medicare Advantage Part D (MAPD) benefit; these are Dexcom and Freestyle Libre. The preferred CGM for Medicare Advantage Part D individual members covered by Anthem will be Freestyle Libre.

This edit will only affect members who are newly receiving a CGM system. Members will need to obtain their CGM system from a retail or mail order pharmacy – not a durable medical equipment (DME) facility.

For Dexcom coverage requests, call:
1-833-293-0661.

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Category:  Medicare

The Aspire Telehealth Palliative Care program provides an additional layer of telephonic support to patients facing a serious illness. The program is focused on:

• Helping patients understand their diagnosis.

• Facilitating conversations with patients and their families around their goals of care.

• Ensuring patients receive care aligned with their goals and values.

The program begins with an initial 30 to 60 minute telephonic assessment by a specially trained Aspire Health social worker. The conversation in this initial call focuses on building rapport and completing a comprehensive assessment. This assessment includes understanding the patient's perception of their illness and current treatment plan. Follow-up calls occur every 2 to 4 weeks, typically lasting 15 to 45 minutes, with the exact frequency based on a patient's individual need. Aspire Health's social workers are supported by a full interdisciplinary team of board-certified palliative care physicians, nurses, and chaplains who provide additional telephonic support to patients and their families as needed.

Patients enrolled in the telehealth program have access to 24/7 on-call support. The average patient is enrolled in the program for 6 to 8 months with some of the key goals being the ability for patients to teach-back their current medical situation, articulate their health and quality-of-life goals, and establish a future care plan through either the completion of advanced care planning documents and/or a transition to hospice when appropriate.

More information is available at www.aspirehealthcare.com or by calling the 24/7 Patient & Referral Hotline at 1-844-232-0500.

* Aspire Health is an independent company providing telephonic palliative care on behalf of Anthem Blue Cross and Blue Shield.

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Category:  Medicare

As previously communicated in our March 2019 edition of Provider News, Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. have launched an effort to begin direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs). This means that NPs and PAs may begin billing their services under their own 10-digit National Provider Identifier (NPI). This effort will impact all of our lines of business:

• Anthem’s PAR/PPO health plans including the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP)

• Anthem HealthKeepers commercial plans including health plans purchased on or off the Health Insurance Marketplace (also known as the exchange)

• Medicaid programs offered under the Anthem HealthKeepers Plus plan:

• FAMIS (CHIP) and Medallion (Medicaid)

• The Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) program for managed long-term services and supports

• Medicare Advantage health plans

Virginia legislation was passed in March 2019 that now requires payers to offer provider contracting opportunities to NPs who meet Anthem’s terms and conditions. This change is effective October 1, 2019. Currently, licensed NPs and PAs can only bill for covered services under the supervision of the employing/supervising participating physician (using that physician’s name and NPI number). Direct contracting means NPs and PAs will be allowed to bill Anthem directly for their services, and the “incident to” guidelines will no longer apply.

Benefits of direct contracting for NPs and PAs

This direct contracting and credentialing approach with NPs and PAs will allow us to include these providers in our provider directories as independent providers, and our members — your patients — can easily search via our Provider Finder tool for NPs and PAs who participate with members’ health plans.

In addition, direct contracting with NPs and PAs will allow easier handling of Medicare crossover claims. Medicare crossover claims for services provided by NPs and PAs to our members with a secondary group coverage policy will process under the participating NP or PA record — all without any rebilling by the group under the physician’s NPI.

How Anthem’s contracting process will work

Credentialing and contracting of NPs and PAs is now under way. Our network managers have begun reaching out to network-participating providers who we know currently employ NPs and PAs. Please note that the new participation agreement will not apply to certified nurse midwives or clinical nurse specialists, as they are contracted under a separate agreement.

Other than the provider type description, the participation agreement contains all of the same provisions and obligations as our standard physician agreements. The allowance schedule will be the same as the current standard physician allowance for our commercial and Medicaid agreements. For Medicare Advantage, we will reimburse NP and PA services at 100% of our Medicare Advantage rate for these provider types.

Contracts and network participation for NPs and PAs will not be effective any sooner than

September 1, 2019. After September 1, the individual provider’s effective date will be the later of the contract signature date or when credentialing is complete.

Credentialing process

NPs and PAs will be required to be credentialed through Anthem in Virginia. Therefore, NPs and PAs must complete the online application process through CAQH. To contact CAQH, dial 1-888-599-1771 (Monday through Thursday 7 a.m. to 9 p.m. ET; Friday 7 a.m. to 7 p.m. ET) or visit the CAQH website at http://www.caqh.org/ucd_physician_register.php

Category:  Medicare

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

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

To view a guideline, visit the provider website at www.anthem.com/medicareprovider.

Notes/updates

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• * DME.00037 — added devices that combine cooling and vibration to the investigational and not medically necessary statement

• * LAB.00027 — added Mediator Release Test to investigational and not medically necessary statement

• * LAB.00033 — clarified investigational and not medically necessary statement to include 4Kscore and AR-V7

• * OR-PR.00003:

• * SURG.00011:

• * SURG.00045:

• * SURG.00121 — added investigational and not medically necessary statement to address use of transcatheter tricuspid valve repair or replacement for all indications

• The following AIM Specialty Health® updates were approved on June 6, 2019:

Medical Policies

On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem).

Clinical UM Guidelines

On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the Medical Operations Committee for Medicare Advantage members on July 5, 2019.

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Category:  Medicare

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment guidelines. Information for each training is outlined below. The Medicare Risk Adjustment Regulatory Compliance team developed the following two provider trainings. This update outlines the training series:

Medicare risk adjustment and documentation guidance (general)

When — offered the first Wednesday of each month from December 5, 2018, to November 6, 2019 at 1 to 2 p.m. Eastern time

Learning objective — This training will provide an overview of Medicare Risk Adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) Model, with guidance on medical record documentation and coding.

Credit — This activity has been reviewed and is acceptable for up to one prescribed credit by the American Academy of Family Physicians.

If you are interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:

https://antheminc.adobeconnect.com/admin/show-event-catalog?folder-id=38826374.

Medicare risk adjustment, documentation and coding guidance

(condition specific)

When — offered on the fourth Wednesday of every other month from January 23, 2019 to November 27, 2019 from noon to 1 p.m. Eastern time

Learning objective — This is a collaborative learning event with Enhanced Personal Health Care (EPHC) to provide in-depth disease information pertaining to specific conditions including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.

Credit — This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians.

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

Training will cover HCCs most commonly reported in error as identified by CMS: chronic kidney disease (stage 5), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease. Recording will play upon registration.

https://antheminc.cosocloud.com/e4i5k4h7cf3j/event/registration.html.

2. Red Flag HCCs, part two — Register for recording of live session.

Training will cover HCCs most commonly reported in error as identified by CMS: atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, and diabetes with ophthalmologic or unspecified manifestation. Recording will play upon registration.

https://antheminc.cosocloud.com/enfndbyedd5g/event/event_info.html.

3. Opioids and more: substance abuse and dependence — Recording will play upon registration. https://antheminc.cosocloud.com/ekx3tooh22f7/event/registration.html.

4.  Acute, chronic and status conditions — Recording will play upon registration. 
https://antheminc.cosocloud.com/eeq7am1fht49/event/registration.html.

5.  Diabetes mellitus and other metabolic disorders — September 25, 2019 https://antheminc.cosocloud.com/e9l4sxzbd2lq/event/registration.html.

6.  Behavioral health — November 27, 2019 https://antheminc.cosocloud.com/eatxsocnqf6h/event/registration.html.

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Category:  Medicare

Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem Blue Cross and Blue Shield for Medicare Advantage 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 codes:

• 0026U — Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
• 0533T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
• 0534T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
• 0535T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
• 0536T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
• 0546T — Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
• 33270 — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
• 33271 — Insertion of subcutaneous implantable defibrillator electrode
• 77299 — Unlisted procedure, therapeutic radiology clinical treatment planning
• 81205 — BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., Maple syrup urine disease) gene analysis, common variants (e.g., R183P, G278S, E422X)
• 81219 — CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9 
• 81250 — G6PC (glucose-6-phosphatase, catalytic subunit) (e.g., Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (e.g., R83C, Q347X)
• 81302 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis
• 81303 — MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant
• 81304 —  MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants 
• 81331 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81332 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81400 — Molecular pathology procedure, Level 1 (e.g., identification of single germline variant e.g., SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (e.g., medium chain acyl dehydrogenase deficiency)
• 81401 — Molecular pathology procedure, Level 2 (e.g., 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (e.g., acquired imatinib resistance)
• 81402 — Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81402 — Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81407 — Molecular pathology procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (e.g., generalized epilepsy with febrile seizures), full gene sequence
• 81408 — Molecular pathology procedure, Level 9 (e.g., analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (e.g., Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (e.g., neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (e.g., malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (e.g., von Willebrand disease types 1 and 3), full gene sequence
• 97033 — Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
• C9042 — Injection, bendamustine hcl (belrapzo), 1 mg
• C9043 — Injection, levoleucovorin, 1 mg
• C9141 — Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
• D9130 — Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
• D9920 — or management, by report
• J9999 — Not otherwise classified, antineoplastic drugs
• S3850 — Genetic testing for sickle cell anemia

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

• Web: https://www.Availity.com

• Phone: Call the Provider Services number on the back of the member’s ID card for PA requirements.

Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.Availity.com. Contracted and noncontracted providers who are unable to access Availity may call the Provider Services number on the back of the member’s ID card for PA requirements.

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Category:  Medicare

On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutics (P&T) Committee approved changes to Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Q1 web posting. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.

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Please continue to check our website  https://mediproviders.anthem.com for the latest Medicaid information for members enrolled in Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) benefit plans. Here are some topics we’re addressing in this edition:

• Pharmacy benefit manager change to IngenioRx

• MCG Care Guidelines update and customizations

HealthKeepers, Inc. invites you and your staff to a webinar covering important information for:

• Anthem HealthKeepers Plus members.

• Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members.

Online sessions will include information about provider responsibilities, precertification and preauthorization, claims submission, appeals and denials, and common billing errors.

The session dates are listed below. Please follow the link, select the session date of the orientation that you would like to attend from the drop-down list and register.  Please note that if you already registered for a session, you will need to reregister using this updated link.

Link: https://tinyurl.com/Medicaid-Provider-Orientations

All webinars listed are in Eastern time.

If you have any questions regarding upcoming provider orientations, please contact Jamal Matthews in Provider Relations at Jamal.Matthews@anthem.com.

HealthKeepers, Inc. will implement the following clinical guideline effective December 1, 2019, to support the review for unnecessary outpatient pneumatic compression devices (PCDs) postoperative orthopedic procedures for Anthem HealthKeepers Plus members.

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these prior authorization rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Lower Limbs

PCDs are used in clinics or can be purchased or rented for home use for prevention and treatment of a number of conditions. PCD therapy involves the use of an inflatable garment and an electrical pneumatic pump. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. This document only addresses the home use of PCDs postoperative outpatient orthopedic procedures for the prevention of deep vein thrombosis (DVT) of the lower limbs.

Note: This document addresses devices for the prevention of DVT only. Pneumatic devices used in the treatment or prevention of lymphedema, venous insufficiency and therapy for musculoskeletal injuries are not addressed in this document, nor are devices for prevention of DVT postmajor surgical procedures.

Not medically necessary

The home use of PCDs for prevention of thromboembolism of the lower limbs following outpatient orthopedic surgery is considered not medically necessary for all indications.

The Coverage Guidelines and Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. 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 view a guideline, visit https://www11.anthem.com/search.html.

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• *DME.00037 — Added devices that combine cooling and vibration to the Investigational (INV) & not medically necessary (NMN) statement

• *LAB.00027 — Added Mediator Release Test to INV&NMN statement.

• *LAB.00033 — Clarified INV&NMN statement to include 4Kscore and AR-V7

• *OR-PR.00003:

• *SURG.00011:

• *SURG.00045:

• *SURG.00121 — Added INV&NMN statement to address use of transcatheter tricuspid valve repair or replacement for all indications

• The following AIM Specialty Health® updates were approved on June 6, 2019:

Coverage Guidelines

On June 6, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to HealthKeepers, Inc.

Clinical UM Guidelines

On June 6, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. These guidelines were adopted by the medical operations committee for Anthem HealthKeepers Plus members on July 5, 2019.

As previously communicated in our March 2019 edition of Provider News, Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. have launched an effort to begin direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs). This means that NPs and PAs may begin billing their services under their own 10-digit National Provider Identifier (NPI). This effort will impact all of our lines of business:

• Anthem’s PAR/PPO health plans including the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP)

• Anthem HealthKeepers commercial plans including health plans purchased on or off the Health Insurance Marketplace (also known as the exchange)

• Medicaid programs offered under the Anthem HealthKeepers Plus plan:

• FAMIS (CHIP) and Medallion (Medicaid)

• The Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) program for managed long-term services and supports

• Medicare Advantage health plans

Virginia legislation was passed in March 2019 that now requires payers to offer provider contracting opportunities to NPs who meet Anthem’s terms and conditions. This change is effective October 1, 2019.  Currently, licensed NPs and PAs can only bill for covered services under the supervision of the employing/supervising participating physician (using that physician’s name and NPI number). Direct contracting means NPs and PAs will be allowed to bill Anthem directly for their services, and the “incident to” guidelines will no longer apply.

Benefits of direct contracting for NPs and PAs

This direct contracting and credentialing approach with NPs and PAs will allow us to include these providers in our provider directories as independent providers, and our members — your patients — can easily search via our Provider Finder tool for NPs and PAs who participate with members’ health plans.

In addition, direct contracting with NPs and PAs will allow easier handling of Medicare crossover claims. Medicare crossover claims for services provided by NPs and PAs to our members with a secondary group coverage policy will process under the participating NP or PA record — all without any rebilling by the group under the physician’s NPI.

How Anthem’s contracting process will work

Credentialing and contracting of NPs and PAs is now under way. Our network managers have begun reaching out to network-participating providers who we know currently employ NPs and PAs. Please note that the new participation agreement will not apply to certified nurse midwives or clinical nurse specialists, as they are contracted under a separate agreement.

Other than the provider type description, the participation agreement contains all of the same provisions and obligations as our standard physician agreements. The allowance schedule will be the same as the current standard physician allowance for our commercial and Medicaid agreements. For Medicare Advantage, we will reimburse NP and PA services at 100% of our Medicare Advantage rate for these provider types.

Contracts and network participation for NPs and PAs will not be effective any sooner than September 1, 2019. After September 1, the individual provider’s effective date will be the later of the contract signature date or when credentialing is complete.

Credentialing process

The Medical Policies and Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were developed and/or revised by HealthKeepers, Inc. to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. 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 view a guideline, visit https://www11.anthem.com/search.html.

Notes/updates:

• CG-DME-44 — Electric Tumor Treatment Field (TTF) was revised to add the use of enhanced computer treatment planning software (such as NovoTal) as not medically necessary (NMN) in all cases.

• CG-MED-72 — Hyperthermia for Cancer Therapy was revised to clarify medically necessary (MN) and NMN statements addressing frequency of treatment.

• CG-SURG-09 — Temporomandibular Disorders was revised to clarify MN and NMN criteria and removed requirement for FDA approval of prosthetic implants.

• CG-SURG-30 — Tonsillectomy for Children with or without Adenoidectomy was revised to:

• The following AIM Specialty Health® updates took effect on September 28, 2019:  

Advanced Imaging:

Imaging of the Brain
Imaging of the Extremities
Imaging of the Spine

Medical Policies

On March 21, 2019, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem HealthKeepers Plus members.

Clinical UM Guidelines

On March 21, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem HealthKeepers Plus members. These guidelines were adopted by the medical operations committee for members on May 7, 2019.

Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA 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 codes:

• 0026U — Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
• 0533T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
• 0534T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
• 0535T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
• 0536T — Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
• 0546T — Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
• 33270 — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
• 33271 — Insertion of subcutaneous implantable defibrillator electrode
• 77299 — Unlisted procedure, therapeutic radiology clinical treatment planning
• 81205 — BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (for example, Maple syrup urine disease) gene analysis, common variants (for example, R183P, G278S, E422X)
• 81219 — CALR (calreticulin) (for example, myeloproliferative disorders), gene analysis, common variants in exon 9 
• 81250 — G6PC (glucose-6-phosphatase, catalytic subunit) (for example, Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (for example, R83C, Q347X)
• 81302 — MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; full sequence analysis
• 81303 — MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; known familial variant
• 81304 —  MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; duplication/deletion variants 
• 81331 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81332 — SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81400 — Molecular pathology procedure, Level 1 (for example, identification of single germline variant [for example, SNP] by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (for example, medium chain acyl dehydrogenase deficiency)
• 81401 — Molecular pathology procedure, Level 2 (for example, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (for example, acquired imatinib resistance)
• 81402 — Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically using nonsequencing target variant analysis], immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster [I235N, V236E, M238K])
• 81402 — Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically using nonsequencing target variant analysis], immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster [I235N, V236E, M238K])
• 81407 — Molecular pathology procedure, Level 8 (for example, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (for example, generalized epilepsy with febrile seizures), full gene sequence
• 81408 — Molecular pathology procedure, Level 9 (for example, analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (for example, Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (for example, neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (for example, malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (for example, von Willebrand disease types 1 and 3), full gene sequence
• 97033 — Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
• C9042 — Injection, bendamustine hcl (belrapzo), 1 mg
• C9043 — Injection, levoleucovorin, 1 mg
• C9141 — Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
• D9130 — Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
• D9920 — or management, by report
• J9999 — Not otherwise classified, antineoplastic drugs
• S3850 — Genetic testing for sickle cell anemia

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 prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.Availity.com. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 1-800-901-0020 for assistance with PA requirements.