 Provider News VirginiaOctober 2020 Anthem Provider News - VirginiaIf you have questions, you now have a new option to have them answered quickly and easily. With Anthem Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity.
- Faster access to provider services for all questions
- Real-time answers to your questions about prior authorization, appeals status, claims, benefits, eligibility, and more
- A platform that is easy to use making it simpler to receive help
- The same high level of safety and security you have come to expect with Anthem
Chat is one example of how Anthem is using digital technology to help improve the health care experience, with a goal to save you valuable time. To start, access the service through Payer Spaces on Availity.
Use Provider Chat: Select Payer Spaces, select Anthem, and from Applications select Chat.
684-1020-PN-VAAnthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are committed to reducing costs while improving health outcomes. To that end, effective January 1, 2021, Anthem Blue Cross and Blue Shield and HealthKeepers, Inc. will require prior authorization for some additional services for our commercial business.
NOTE: This excludes Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).
The following codes have been added to require prior authorization with a date of service on or after January 1, 2021:
|
33477
|
SURG.00121
|
|
36465
|
SURG.00037
|
|
36466
|
SURG.00037
|
|
53447
|
SURG.00010
|
|
E0466
|
CG-DME-47
|
|
G0277
|
CG-MED-73
|
687-1020-PN-VAAs employers across the country host open enrollment periods for their employees, many will offer a new option this fall: plans built around a Blue High Performance Network (HPN)® Blue HPN® plans offer access to a select set of providers with a record of delivering high-quality, efficient care. Blue HPN networks will go live January 1, 2021, in more than 50 cities across the country.
In Virginia, Blue HPN networks will be in place in the Richmond and Washington, D.C-Arlington-Alexandria metro areas. Anthem is offering Virginia national employers Blue HPN plans, and offering large and small group employers in Virginia plans with access to the HPN, referred to as the Blue Connection network.
If you are not sure whether your practice is part of the Blue HPN/Blue Connection network, ask your office manager or business office, or contact your Anthem network representative. Blue HPN participation will be displayed in provider profiles in our provider directory January 1, 2021.
Beginning January 1, you may see patients accessing this network through either a national employer plan, Blue HPN, or large or small group employer EPO plans and HSA plans with EPO network. Under EPO plans, out-of-network benefits are limited to emergency or urgent care. Members may be required to select a primary care provider (PCP), but PCP referrals are not required for specialty care.
Below is a sample ID card for a member from Virginia enrolled in the national employer Blue HPN plan. Note the new “Blue High Performance Network,” and “Blue Connection” network names, and “HPN” indicator in the suitcase icon.
682-10-20-PN-VA Anthem Blue Cross and Blue Shield providers may now learn how to use Availity's attachment tools to submit and track supporting documentation electronically by attending one of the upcoming live webinars hosted by Availity.
The attachments application is a multi-payer, multi-workflow feature. It allows inclusion of multiple records across a variety of workflows and request types to support different business processes for payers.
By attending one of the upcoming webinars, attendees will learn both the digital and electronic processes that include:
- How your organization gets set up
- Demonstrations of the tools used to submit attachments via Availity Portal
- Navigating the Attachments dashboard
- View electronic records of your submissions
As part of the session, we will answer questions and provide handouts and a job aid for you to reference later.
Register for an upcoming webinar session
- In Availity Portal, select Help & Training > Get Trained.
- The Availity Learning Center opens in a new browser tab.
- Search for and enroll in a session using one of these options.
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In the Catalog, search by webinar title or keyword (medattach).
|
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Select the Sessions tab to scroll the live session calendar.
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- After you enroll, you will receive emails with instructions to join the session.
October/November webinar dates
|
Date
|
Day
|
Time
|
|
10/07/2020
|
Wednesday
|
4 p.m. – 5 p.m. ET
|
|
10/20/2020
|
Tuesday
|
11 a.m. – Noon ET
|
|
11/04/2020
|
Wednesday
|
4 p.m. – 5 p.m. ET
|
|
11/17/2020
|
Tuesday
|
2 p.m. – 3 p.m. ET
|
Where can you find more help?
Select Help & Training > Find Help to display Availity Help in a new browser window.
Use Contents to display topics.
Depending on your needs, consider exploring these topics:
- Medical Attachments (legacy)
702-1020-PN-VA Anthem Blue Cross and Blue Shield offers you the ability to have a copy of the member’s ID card without having to physically handle the member’s card. This easy, low-touch access to view a member’s ID card is available from the Availity Portal.
When conducting an eligibility and benefits inquiry for Anthem members, simply select View Member ID Card on the Eligibility and Benefits results page. Note: the Availity Portal requires you to enter the member’s ID number as well as a date of birth or the member’s first and last name into the search options in order to submit an eligibility and benefits inquiry.
Images of both the front and back of the member ID card are available, allowing you view all of the pertinent information without the need to make a phone call. The images can be saved directly to your practice management system as PDF files.
Another option available is to access members’ digital versions of their ID cards, as many members have transitioned to using a digital card instead of a paper card. Members are able to fax or email a copy of the electronic ID card from their phone/app.
We encourage you to integrate these options into your practice or facility’s workflow now.
677-1020-PN-VA
An online course for providers and office staff that addresses gaps in care and offers approaches to communication with patients. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians.
The What Matters Most training can be accessed at: www.patientexptraining.com
653-1020-PN-VA
Don’t miss an opportunity to attend Anthem’s final provider education webinar for the year on November 12, 2020. Designed for our network-participating providers, the webinar addresses Anthem business updates and billing guidelines that impact your business interactions with us.
For your convenience, we offer these informative, hour-long sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the fall webinar is:
- Thursday, November 12, 2020, from 11 a.m. to Noon 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 November webinar, please ensure you have received a fax confirmation or a confirmation from an Anthem representative to note we’ve received your registration form. Contact joyce.lindley@anthem.com if you need to confirm your registration.
646-1020-PN-VA As recently communicated in the August 2020 edition of Anthem’s Provider News, AIM Specialty Health® (AIM), a specialty health benefits company, will expand the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints for Anthem members effective November 1, 2020. Replacement and revision surgeries for procedures such as total joint of ankle, correction of Hallux Valgus, hammertoe repair are included.
The AIM Rehab Program follows the Anthem Clinical Guidelines that state the services must be delivered by a qualified provider within the scope of their licensure. Qualified providers acting within the scope of their license, including podiatrists, who intend to perform certain elective surgeries of the small joints procedures should request prior authorization for those services through AIM.
AIM will begin accepting prior authorization requests on October 26, 2020, for dates of service on and after November 1, 2020. Prior authorization requests may be submitted via the AIM ProviderPortal or by calling (866) 789-0158, Monday through Friday.
We value your participation in our networks and look forward to working with you to help improve the health of our members.
649-1020-PN-VAAnthem Blue Cross and Blue Shield (Anthem) is dedicated to delivering better care to our members, providing higher value to our customers, and helping to improve the health of our communities.
In 2013, Anthem implemented the Emergency Department (ED) Reimbursement Policy. The policy is set forth in the Facility Provider Manual, as applicable, and outlines the levels of emergency room services and states that “the highest level evaluation and management (E&M) code for which a claim clinically qualifies will be used to determine the level of reimbursement, as applicable for ED services.” Currently, Anthem is using a post-pay manual review process to determine the level of service by asking for and reviewing the medical records for the emergency room visit.
Anthem to engage a vendor to assess selected claims for E&M services beginning January 1
In an ongoing effort to ensure accurate claims processing and payment and to decrease the amount of medical records being requested for this policy, effective January 1, 2021, Anthem will begin to use a vendor to assess selected claims for evaluation and management services. An automated analytic solution will be used to better ensure that benefit payments are aligned with national industry coding standards. As outlined in the policy, Anthem will adjust the reimbursement to reflect the lower ED E&M classification for those claims that do not meet the higher level criteria.
As always, providers who feel that the level of reimbursement should be reconsidered can file an appeal in accordance with the terms of their contract. Claim appeals require a statement providing the reason the intensity/complexity would require a different level of reimbursement as well as the medical records which should clearly document the facility interventions performed and referenced in that statement.
If you have questions about the amendment process, please contact your Anthem Network Manager. View the Anthem contact list online at anthem.com.
651-1020-PN-VA As providers, you are committed to providing the best care for your patients – our members. That care may now include telehealth visits. Recognizing the continuing increased need for telephone and virtual services during the COVID-19 public health emergency, the U.S. Department of Health and Human Services (HHS) has given additional consideration to the treatment of telephone-only services in the HHS-operated Risk Adjustment Program. HHS has clarified that telephone-only service CPT codes (98966-98968 and 99441-99443) are valid for the Risk Adjustment Program. Telephone-only visits may benefit your patients who have not participated in, or felt comfortable using, a telehealth video visit. Thank you for your continued commitment to assessing your patients’ health and closing possible gaps in care.
If you have questions, please contact the Commercial Risk Adjustment Network Education Representative, Alicia.Estrada@anthem.com.
658-1020-PN-VA
Effective with dates of service on or after January 1, 2021, the following pharmacy codes will be included in the Anthem Federal Employee® (FEP) plans (member IDs beginning with an “R”) prior authorization review process for specific specialty drugs. The prior authorization review includes review of site-of-care criteria for outpatient hospital-based settings. As a result of this change, services provided on and after January 1, 2021, for any of the additional drugs without a prior authorization will be denied.
FEP will continue to review Federal Employee Program medical policy criteria for medical necessity, and Anthem’s clinical guideline, Level of Care: Specialty Pharmaceuticals (CG-MED-83), will be utilized to review site-of-care criteria.
What’s new beginning with dates of service on or after January 1, 2021, for the “new” drugs listed below?
- Prior to administering the drugs in any setting, a prior authorization must be completed in order to evaluate if the drug meets clinical criteria. Anthem FEP will begin accepting prior authorization requests for these specialty drugs on December 14, 2020, for dates of service on and after January 1, 2021. Request prior authorization review by calling the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at (800) 860-2156.
- Outpatient hospital-based settings will require a site-of-care review for medical necessity as part of the prior authorization review. Hospital-based facilities contracted with Anthem for lower drug and administration costs, non-hospital infusion clinics, provider offices, and home infusion providers will not require a site-of-care review.
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A provider toolkit aligned to Anthem’s clinical guideline (CG-Med83) will be provided to providers requiring a site-of-care review, either by fax or e-review. For outpatient hospital settings that do not meet clinical criteria, a dedicated clinical team will work with you to identify alternate lower level of care sites that can safely administer the drug.
|
|
In the event that there are no infusion centers within 30 miles of the member’s place of residence, or there are no home infusion providers able to service the member’s residence, the hospital-based setting will be approved.
|
- If the prior authorization is denied for either the drug not meeting medical necessity or the site of care not meeting medical necessity, providers should follow the disputed claim/service process. To obtain the current process, please contact the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at (800) 860-2156.
- Services provided on or after January 1, 2021, without prior authorization will result in a denial of claims payment.
Additional drugs requiring medical necessity and site-of-care review as of January 1, 2021:
|
Drug
|
Code
|
FEP Medical Policy
|
|
Actemra®
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J3262
|
5.70.12
|
|
Aralast®
|
J0256
|
5.45.09
|
|
Fabrazyme®
|
J0180
|
5.30.35
|
|
Fasenra®
|
J0517
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5.45.07
|
|
Glassia®
|
J0257
|
5.45.09
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|
Ilaris®
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J0638
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5.70.09
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Nucala®
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J2182
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5.45.07
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|
Ocrevus®
|
J2350
|
5.60.28
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|
Prolastin®
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J0256
|
5.45.09
|
|
Ultomiris®
|
J1303
|
5.85.33
|
|
Xolair®
|
J2357
|
5.45.02
|
|
Zemaira®
|
J0256
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5.45.09
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These changes apply to Anthem FEP members (member IDs beginning with an “R”) who are receiving the specialty drugs listed above through their medical benefits. These changes do not impact the approval process for these specialty drugs obtained through pharmacy benefits. For more information, such as clinical criteria for specialty drugs and level of care, please contact the Blue Cross and Blue Shield Federal Employee Program Service Benefit Plan at (800) 860-2156.
647-1020-PN-VA Effective with dates of service on and after October 1, 2020, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, Anthem Blue Cross and Blue Shield updated drug lists that support commercial health plans. Updates include changes to drug tiers and the removal of medications from the formulary.
As certain brand and generic drugs will no longer be covered, providers are encouraged to determine if a covered alternative drug is appropriate for their patients whose current medication will no longer be covered. Communications to providers and their patients affected by the changes went out in early August.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes
IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield.
661-1020-PN-VA
Anthem Blue Cross and Blue Shield (Anthem) reviews the activities of the Food and Drug Administration’s (FDA) approval of drugs and biologics on a regular basis to understand the potential effects for both our providers and members.
The FDA approves new drugs/biologics using various pathways of approval. Recent studies on the effectiveness of drugs/biologics going through these different FDA pathways illustrates the importance of clinicians being aware of the clinical data behind a drug or biologic approval in making informed decisions.
Here is a list of the approval pathways the FDA uses for drugs/biologics:
- Standard Review – The Standard review process follows well-established paths to make sure drugs/biologics are safe and effective when they reach the public. From concept to approval and beyond, FDA performs these steps: reviews research data and information about drugs and biologics before they become available to the public; watches for problems once drugs and biologics are available to the public; monitors drug/biologic information and advertising; and protects drug/biologic quality. Learn more about the Standard Review process.
- Fast Track – Fast Track is a process designed to facilitate the development, and expedite the review of drugs/biologics to treat serious conditions and fill an unmet medical need. Learn more about the Fast Track process.
- Orphan Review – Orphan Review is the evaluation and development of drugs/biologics that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. Learn more about the Orphan Review process.
New Molecular Entities (NMEs) Approvals: January through August 2020
Certain drugs/biologics are classified as new molecular entities (“NMEs”) for purposes of FDA review. Many of these products contain active ingredients that have not been approved by FDA previously, either as a single ingredient drug or as part of a combination product; these products frequently provide important new therapies for patients.
Anthem reviews the FDA-approved NMEs on a regular basis. To facilitate the decision-making process, we are providing a list of NMEs approved from January to August 2020 along with the FDA approval pathway utilized.
|
Generic Name
|
Trade Name
|
Standard
Review
|
Fast Track
|
Priority Review
|
Break-through Therapy
|
Orphan Review
|
Accelerated Approval
|
Approval Date
|
Indication
|
|
Abametapir
|
Xeglyze
|
X
|
|
|
|
|
|
7/24/2020
|
Head lice
|
|
Amisulpride
|
Barhemys
|
X
|
|
|
|
|
|
2/26/2020
|
Postoperative nausea and vomiting
|
|
Avapritinib
|
Ayvakit
|
|
X
|
X
|
X
|
X
|
|
1/9/2020
|
PDGFRa exon 18 mutant gastrointestinal stromal tumor
|
|
Belantamab mafodotin
|
Blenrep
|
|
|
X
|
X
|
X
|
X
|
8/05/2020
|
Multiple myeloma
|
|
Bempedoic acid
|
Nexletol
|
X
|
|
|
|
|
|
2/21/2020
|
Dyslipidemia
|
|
Brexucabtagene autoleucel
|
Tecartus
|
|
|
X
|
X
|
X
|
X
|
7/24/2020
|
Mantle cell lymphoma
|
|
Capmatinib
|
Tabrecta
|
|
|
X
|
X
|
X
|
X
|
5/6/2020
|
Non-small cell lung cancer (NSCLC)
|
|
Decitabine/ cedazuridine
|
Inqovi
|
|
|
X
|
|
X
|
|
7/07/2020
|
Myelodysplastic syndromes
|
|
Eptinezumab-jjmr
|
Vyepti
|
X
|
|
|
|
|
|
2/21/2020
|
Migraine prevention
|
|
Fostemsavir
|
Rukobia
|
|
X
|
X
|
X
|
|
|
7/02/2020
|
Human immunodeficiency virus (HIV) treatment
|
|
Inebilizumab
|
Uplizna
|
X
|
|
|
X
|
X
|
|
6/11/2020
|
Neuromyelitis optica spectrum disorder
|
|
Isatuximab
|
Sarclisa
|
X
|
|
|
|
X
|
|
3/2/2020
|
Multiple myeloma
|
|
Lurbinectedin
|
Zepzelca
|
|
|
X
|
|
X
|
X
|
6/15/2020
|
NSCLC
|
|
Nifurtimox
|
Lampit
|
|
|
X
|
|
X
|
X
|
8/06/2020
|
Chagas disease
|
|
Oliceridine
|
Olinvyk
|
X
|
X
|
|
|
|
|
8/07/2020
|
Moderate to severe acute pain
|
|
Opicapone
|
Ongentys
|
X
|
|
|
|
|
|
4/24/2020
|
Parkinson’s disease
|
|
Osilodrostat
|
Isturisa
|
X
|
|
|
|
X
|
|
3/6/2020
|
Cushing’s disease
|
|
Ozanimod
|
Zeposia
|
X
|
|
|
|
|
|
3/25/2020
|
Multiple sclerosis
|
|
Peanut (Arachis hypogaea) allergen powder-dnfp
|
Palforzia
|
X
|
X
|
|
X
|
|
|
1/31/2020
|
Peanut allergy
|
|
Pemigatinib
|
Pemazyre
|
|
|
X
|
X
|
X
|
X
|
4/17/2020
|
Cholangiocarcinoma
|
|
Remimazolam
|
Byfavo
|
X
|
|
|
|
|
|
7/02/2020
|
Sedation for procedures
|
|
Rimegepant
|
Nurtec ODT
|
|
|
X
|
|
|
|
2/27/2020
|
Migraine treatment
|
|
Risdiplam
|
Evrysdi
|
|
X
|
X
|
X
|
X
|
|
8/07/2020
|
Spinal muscular atrophy
|
|
Ripretinib
|
Qinlock
|
|
X
|
X
|
X
|
X
|
|
5/15/2020
|
Gastrointestinal stromal tumor
|
|
Sacituzumab-hziy
|
Trodelvy
|
|
X
|
X
|
X
|
X
|
X
|
4/22/2020
|
Triple negative breast cancer
|
|
Selpercatinib
|
Retevmo
|
|
|
X
|
X
|
X
|
X
|
5/8/2020
|
NSCLC and thyroid cancers
|
|
Selumetinib
|
Koselugo
|
|
X
|
X
|
X
|
X
|
|
4/10/2020
|
Neurofibromatosis type 1
|
|
Tafasitamab
|
Monjuvi
|
X
|
X
|
|
X
|
X
|
X
|
7/31/2020
|
Large B-cell lymphoma
|
|
Tazemetostat
|
Tazverik
|
|
|
X
|
|
X
|
X
|
1/23/2020
|
Epithelioid sarcoma
|
|
Teprotumumab-trbw
|
Tepezza
|
|
X
|
X
|
X
|
X
|
|
1/21/2020
|
Thyroid eye disease
|
|
Triheptanoin
|
Dojolvi
|
X
|
X
|
|
|
X
|
|
6/30/2020
|
Long-chain fatty acid oxidation disorders
|
|
Tucatinib
|
Tukysa
|
|
X
|
X
|
X
|
X
|
|
4/17/2020
|
Breast cancer
|
|
Viltolarsen
|
Viltepso
|
|
X
|
X
|
|
X
|
X
|
8/12/2020
|
Duchenne muscular dystrophy
|
Source: www.fda.gov
650-1020-PN-VA Prior authorization updates
Effective for dates of service on and after January 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Anthem in Virginia requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code (NDC), for the injected substance. This requirement is consistent with Centers for Medicare & Medicaid Services (CMS) guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.
Access the Clinical Criteria information.
For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
ING-CC-0170
|
J3590, C9399
|
Uplizna
|
|
ING-CC-0172
|
J3490, J3590, C9399
|
Viltepso
|
|
ING-CC-0173
|
J3490, J3590
|
Enspryng
|
|
ING-CC-0174
|
J3490, J3590, C9399
|
Kesimpta
|
|
ING-CC-0168
|
J3590, J9999, J3490
|
Tecartus
|
|
*ING-CC-0171
|
J3490, J3590, J9999
|
Zepzelca
|
|
*ING-CC-0169
|
J3490, J3590, J9999, C9399
|
Phesgo
|
|
*ING-CC-0175
|
J9015
|
Proleukin
|
|
*ING-CC-0176
|
J9032
|
Beleodaq
|
|
*ING-CC-0178
|
J9262
|
Synribo
|
|
*ING-CC-0177
|
J3304
|
Zilretta
|
|
ING-CC-0015
|
J3490
|
Milprosa Vaginal System
|
|
*ING-CC-0100
|
C9065
|
Istodax
|
|
ING-CC-0038
|
J3110
|
Forteo
|
|
*ING-CC-0002
|
J3590
|
Nyvepria
|
* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncology use is managed by AIM.
Step therapy updates
Effective for dates of service on and after January 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Access the Clinical Criteria information related to Step Therapy.
For Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
|
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS Code(s)
|
|
*ING-CC-0002
|
Preferred
|
Neulasta
|
J2505
|
|
*ING-CC-0002
|
Preferred
|
Udenyca
|
Q5111
|
|
*ING-CC-0002
|
Non-preferred
|
Fulphila
|
Q5108
|
|
*ING-CC-0002
|
Non-preferred
|
Ziextenzo
|
Q5120
|
|
*ING-CC-0002
|
Non-preferred
|
Nyvepria
|
J3590
|
* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncology use is managed by AIM.
676-1020-PN-VA
Beginning October 1, 2020, most of Anthem’s non-grandfathered health plans that comply with the Affordable Care Act (ACA) will cover generic aromatase inhibitors at 100%. There is no member cost share for members who are prescribed these drugs for prevention of breast cancer and use an in-network pharmacy. Prior authorization will be required. Providers will need to complete a questionnaire and submit to IngenioRx for consideration. Women must be 35 years or older and have no history of breast cancer.
This coverage change aligns with the updated USPSTF “B” recommendation regarding Breast Cancer: Medication Use to Reduce Risk. This updated recommendation now includes aromatase inhibitors among medications that can reduce risk of breast cancer (in addition to tamoxifen or raloxifene). The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects.
Providers can contact the provider service number on the back of the member ID card to determine if a member’s plan includes this benefit.
644-1020-PN-VA For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit anthem.com/pharmacyinformation. The commercial Virginia and marketplace drug lists are posted to the website quarterly (the first of the month for January, April, July and October).
To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
Federal Employee Program (FEP) Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
659-1020-PN-VAState & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | October 1, 2020 Coding spotlight: Providers’ guide to coding for behavioral health disordersPlease note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
Behavioral health disorders are classified in Chapter 5 of the ICD-10-CM
Behavioral health disorders are commonly underreported on claims. Many Anthem HealthKeepers Plus members may have behavioral health disorders that are not properly managed. Health care providers can assist by taking detailed histories and coding behavioral health issues properly on claims. Below are the ICD-10-CM coding guidelines for behavioral health conditions.
When documenting behavioral disorders, the following descriptors apply:
- Type: Depressive, manic, or bipolar disorder.
- Episode: Single or recurrent.
- Status: Partial or full remission; identify most recent episode as manic, depressed, or mixed.
- Severity: Mild, moderate, severe, or with psychotic elements.
Schizophrenic related disorders
Schizophrenic related disorders are classified in category F20, with a forth character indicating the type of schizophrenia as follows:
|
Code
|
Description
|
|
F20.0
|
Paranoid schizophrenia
|
|
F20.1
|
Disorganized schizophrenia
|
|
F20.2
|
Catatonic schizophrenia
|
|
F20.3
|
Undifferentiated schizophrenia
|
|
F20.5
|
Residual schizophrenia
|
|
F20.8
|
Other schizophrenia
This subcategory is further subdivided as follows:
· F20.81 Schizophreniform disorder
· F20.89 Other schizophrenia
|
|
F20.9
|
Schizophrenia, unspecified
|
Major depressive disorder (MDD)
Major depressive disorder (MDD) is classified in ICD-10-CM to categories:
- F32.- Major depressive disorder, single episode
- F33.- Major depressive disorder, recurrent
Categories F32 and F33 are further subdivided with fourth characters, and sometimes fifth characters, to provide information about the current severity of the disorders, as follows:
- 2 Severe, without psychotic features
- 3 Severe with psychotic features
Fourth characters 1 through 8 are assigned only when provider documentation of severity is included in the medical record.
Manic episodes and bipolar disorders
The table below outlines the ICD-10-CM classification for bipolar disorders. Manic/mania also falls within this code category. The codes in these categories require fourth and/or fifth digits to identify the severity of the current episode and whether or not psychotic symptoms are involved.
|
Category
|
Description
|
|
|
F30.-
|
Manic episode (includes bipolar disorder, single manic episode, and mixed affective episode)
|
Select appropriate fourth and fifth digits to identify the severity of the current episode to indicate whether psychotic symptoms are involved
|
|
F31.-
|
Bipolar disorder (includes manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction)
|
Select appropriate fourth and fifth digits to specify the severity of the current episode and whether the current episode is hypomanic, manic, depressed or mixed, and with or without psychotic features.
|
|
F34.-
|
Persistent mood [affective] disorders (includes cyclothymic disorder and dysthymic disorder)
|
Includes, cyclothymic, dysthymic, and other specified mood disorders.
|
|
F39
|
Unspecified mood [affective] disorder (includes affective psychosis not otherwise specified)
|
Include affective psychosis when not otherwise specified
|
Anxiety disorders
Anxiety disorders are classified in ICD-10-CM under the following categories:
- F40 Phobic anxiety disorders
- F41 Other anxiety disorders
- F42 Obsessive-compulsive disorder
Dissociative and conversion disorders
ICD-10-CM classifies dissociative and conversion disorders to category F44.
Dissociative disorders:
|
Code
|
Description
|
|
F44.0
|
Dissociative amnesia
|
|
F44.1
|
Dissociative fugue
|
|
F44.2
|
Dissociative stupor
|
|
F44.81
|
Dissociative identity disorder
|
Conversion disorders:
|
Code
|
Description
|
|
F44.4
|
Conversion disorder with motor symptom or deficit
|
|
F44.5
|
Conversion disorder with seizures or convulsions
|
|
F44.6
|
Conversion disorder with sensory symptom or deficit
|
|
F44.7
|
Conversion disorder with mixed symptom presentation
|
Behavioral syndromes associated with physiological disturbances and physical factors
Categories F50 through F59 grouping includes the following conditions:
|
Category/ code
|
Description
|
|
F50.0-
|
Eating disorders (such as anorexia nervosa and bulimia nervosa)
|
|
F51.-
|
Sleep disorders not due to a substance or known physiological condition
|
|
F52.-
|
Sexual dysfunction not due to a substance or known physiological condition
|
|
F53.-
|
Mental and behavioral disorders associated with the puerperium, not elsewhere classified
|
|
F54
|
Psychological and behavioral factors associated with disorders or diseases classified elsewhere
|
|
F55.-
|
Abuse of non-psychoactive substances
|
|
F59
|
Unspecified behavioral syndromes associated with physiological disturbances and physical factors
|
Disorders of adult personality and behavior
Categories F60 through F69 include disorders of adult personality and behavior:
|
Category code
|
Description
|
|
F60.0-
|
Specific personality disorders
|
|
F63.-
|
Impulse disorders
|
|
F64.-
|
Gender identity disorders
|
|
F65.-
|
Paraphilias
|
|
F66.-
|
Other sexual disorders
|
|
F68.-
|
Other disorders of adult personality and behavior
|
Psychosocial circumstances and encounters
ICD-10-CM provides codes for behaviors that have not yet been classified to behavioral disorders, but that may contribute to the need for further treatment or study. The table below shows some examples:
|
Code
|
Description
|
|
R41.0
|
Disorientation, unspecified
|
|
R41.82
|
Altered mental status, unspecified
|
|
R41.840
|
Attention and concentration deficit
|
|
R44.3
|
Hallucinations, unspecified
|
|
R45.83
|
Excessive crying of child, adolescent or adult
|
|
R45.84
|
Anhedonia
|
|
R45.86
|
Emotional liability
|
|
R45.87
|
Impulsiveness
|
|
R46.0
|
Very low level of personal hygiene
|
|
R46.2
|
Strange and inexplicable behavior
|
|
R46.81
|
Obsessive-compulsive behavior
|
For behavioral health disorders that resolve and do not require continued treatment, it is appropriate to report code Z86.59, Personal history of other mental and behavioral disorders.
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVA-NU-0274-20 State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | October 1, 2020 Patient360 enhancement for medical providersPlease note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
Patient360 is a real-time dashboard you can access through the Availity Portal* that gives you a full 360° view of your Anthem HealthKeepers Plus patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.
What’s new: Medical providers now have the option to include feedback for Anthem HealthKeepers Plus patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.
Once you have completed all the required fields on the Availity Portal to access Patient360 you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.
Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.
First, you need to be assigned to a Patient360 role, which your Availity administrators can locate within the Clinical Roles options.
Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem HealthKeepers Plus Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.
Do you need a job aid to help you get started?
The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center.
|
STEP
|
INSTRUCTIONS
|
|
1
|
From the Availity home page, select Payer Spaces > Anthem HealthKeepers Plus payer tile > Applications > Custom Learning Center
|
|
2
|
Select Resources from the menu located on the upper left corner of the page
(To use the catalog filter to narrow the results, select Payer Spaces from the Category menu.)
|
|
3
|
Select Download to view and/or print the reference guide
|
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVA-NU-0275-20State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | October 1, 2020 Prior authorization requirements for E0482Effective November 1, 2020, prior authorization (PA) requirements will change for E0482. The medical codes listed below 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:
- E0482 — Cough stimulating device, alternating positive and negative airway pressure
To request PA, you may use one of the following methods:
Not all PA requirements are listed here. PA requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com by visiting https://mediproviders.anthem.com/va > Login.
Contracted and noncontracted providers who are unable to access Availity* may call Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus Provider Services at 1-800-901-0020 for PA requirements.
AVA-NU-0278 State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | October 1, 2020 Claim payment disputes: UpdatePlease note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
In September 2019, HealthKeepers, Inc. sent all providers the attached provider bulletin, outlining and confirming our claims payment dispute processes. Since then, the Anthem HealthKeepers Plus Provider Relations team has continued to allow providers to submit claims payment issues directly to them after completing the first level of the claims payment dispute process (reconsideration). Effective October 1, 2020, the Anthem HealthKeepers Plus Provider Relations team will no longer accept claims payment issues directly from providers who have not completed the second level of the claims payment dispute process (appeal).
In the meantime, the Anthem HealthKeepers Plus Provider Relations team will work with providers to transition them to this process and educate and train any providers on the process and supporting tools. All claims issues that have already been accepted by the Provider Relations team will be worked using the existing processes, and the Provider Relations team will notify providers of the outcomes.
Please refer to the bulletin in its entirety by selecting the document to the right under "Article Attachments."
AVA-NU-0285-20
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | October 1, 2020 Social determinants of health support expanding with GroundGame HealthPlease note, this communication applies to Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Effective October 1, 2020, HealthKeepers, Inc. will integrate community health workers (CHWs) used by GroundGame Health (GGH)* into our current care management program. Referrals into the program are completed via provider direct referrals or ad hoc referrals from our Case Management team. Provider direct referrals will include members with the following situations:
- Identified social determinants of health needs including, but not limited to:
|
Living environment
|
|
Transportation
|
|
Food insecurity issues
|
|
Financial issues
|
|
Social isolation, etc.
|
- A readmission risk score of more than 24
GGH provides an extra layer of support by using CHWs as an extension of care management to help members navigate the complex health care system. Preferred Community Health Partners (PCHP) makes an initial outreach to identified members to determine the appropriate level of services a member may need, but they do not provide any clinical services, replace case management from HealthKeepers, Inc., or replace the care and care management provided by PCPs and specialists. Note: There is no requirement that members participate in this program, and members have the opportunity to opt out of the program as they choose.
A GGH CHW may reach out to your practice to introduce themselves and establish a relationship with the physician(s) at your practice based on referrals received. CHWs may also discuss developing a mechanism by which to share information regarding patients who have been identified for complex care services.
The CHW may also broaden the impact of case management by focusing on action plan developments in various ways, such as helping members fill prescriptions, scheduling appointments and arranging rides to the doctor. CHWs can even accompany members to appointments when appropriate and provide connections to meal delivery services that may be available to them.
To learn more about GGH, please visit https://groundgamehealth.org. If you have questions regarding GGH, CHWs and complex care services, please call 1-866-739-6323 or email physicianreferral@preferredchp.com.
AVAPEC-2588-20 State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | October 1, 2020 Provider Chat: A fast, easy way to have your questions answeredPlease note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
You now have a new option to have questions answered quickly and easily. With Anthem HealthKeepers Plus Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity.* Provider Chat offers:
- Faster access to Provider Services for all questions.
- Real-time answers to your questions about prior authorization and appeals status, claims, benefits, eligibility, and more.
- An easy to use platform that makes it simple to receive help.
- The same high level of safety and security you have come to expect with HealthKeepers, Inc.
Chat is one example of how HealthKeepers, Inc. is using digital technology to improve the health care experience, with the goal to save you valuable time. To get started, access the service through Payer Services on Availity.
If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVAPEC-2695-20State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | October 1, 2020 Keep up with Medicaid newsEffective October 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will integrate community health workers (CHWs) used by GroundGame Health (GGH)* into our current care management program. Referrals into the program are completed via provider direct referrals or ad hoc referrals from the Anthem Case Management team. Provider direct referrals will include members with the following situations:
- Identified social determinants of health needs including, but not limited to:
|
Living environment
|
|
Transportation
|
|
Food insecurity issues
|
|
Financial issues
|
|
Social isolation, etc.
|
- A readmission risk score of more than 24
GGH provides an extra layer of support by using CHWs as an extension of care management to help members navigate the complex health care system. PCHP makes an initial outreach to identified members to determine the appropriate level of services a member may need, but they do not provide any clinical services, replace case management from Anthem, or replace the care and care management provided by PCPs and specialists. Note: There is no requirement that members participate in this program, and members have the opportunity to opt out of the program as they choose.
A GGH CHW may reach out to your practice to introduce themselves and establish a relationship with the physician(s) at your practice based on referrals received. CHWs may also discuss developing a mechanism by which to share information regarding patients who have been identified for complex care services.
The CHW may also broaden the impact of case management by focusing on action plan developments in various ways, such as helping members fill prescriptions, scheduling appointments and arranging rides to the doctor. CHWs can even accompany members to appointments when appropriate and provide connections to meal delivery services that may be available to them.
To learn more about GGH, please visit https://groundgamehealth.org. If you have questions regarding GGH, CHWs and complex care services, please call 1-866-739-6323 or email physicianreferral@preferredchp.com.
ABSCARE-0564-20 512479MUPENMUB As you know, AIM Specialty Health® (AIM)* administers the musculoskeletal program for Medicare Advantage members, which includes the medical necessity review of certain surgeries of the spine, joints and interventional pain treatment. For certain surgeries, the review also includes a consideration of the level of care.
Effective December 1, 2020, two joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM guideline, it is generally appropriate to perform these two procedures in a hospital outpatient setting. To avoid additional clinical review for these surgeries, providers requesting prior authorization should either choose hospital observation admission as the site of service or Hospital Outpatient Department (HOPD).
We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:
- Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
- Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.
On January 1, 2020, CMS removed total hip arthroplasty as well as six spine codes from the inpatient only (IPO) list making these procedures eligible for payment by Medicare in the hospital outpatient setting in addition to the hospital inpatient setting. The two-midnight rule should guide providers on the expected reimbursement. The codes that were removed from the inpatient only list and are also in the AIM Musculoskeletal program are 27130, 22633, 22634, 63265 and 63267. CMS has established a two year grace period (ending December 31, 2021) for site of service reviews of these codes in order to facilitate provider transition to compliance with the two-midnight rule.
To this end, it is recommended that providers choose hospital observation or Hospital Outpatient Department (HOPD) during the prior authorization process when clinically appropriate to the respective patient. Choosing hospital observation still allows for the surgery to be performed and recovered in the main hospital, so long as discharge is planned for less than two midnights. Alternatively, the provider may choose to perform the procedure in the Hospital Outpatient Department (HOPD). However, the inpatient setting will still be approved should the provider decide it is the optimal setting for the member.
Providers should continue to submit prior authorization requests to AIM using one of the following ways:
- Access AIM ProviderPortalSM directly at http://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.
- Call the AIM toll-free number at 1-800-714-0400, Monday through Friday 8 a.m. to 8 p.m. ET.
If you have questions, please contact the provider number on the back of the member’s ID card.
ABSCRNU-0163-20 511827MUPENMUBPatient360 is a real-time dashboard you can access through the Availity Portal* that gives you a full 360° view of your Anthem Blue Cross and Blue Shield (Anthem) patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.
What’s new: Medical providers now have the option to include feedback for Anthem patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.
Once you have completed all the required fields on the Availity Portal to access Patient360, you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.
Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.
First, you need to be assigned to a Patient360 role, which your Availity administrators can locate within the Clinical Roles options.
Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.
Do you need a job aid to help you get started?
The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center.
- From the Availity home page, select Payer Spaces > Anthem payer tile > Applications > Custom Learning Center
- Select Resources from the menu located on the upper left corner of the page (To use the catalog filter to narrow the results, select Payer Spaces from the Category menu.)
- Select Download to view and/or print the reference guide
ABSCRNU-0164-20 512477MUPENMUB On December 1, 2020, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements will change for codes below. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following codes:
- C1764 Event recorder, cardiac (implantable)
- E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED
- E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS,
- E0731 Conductive Garment For Tens
- G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment
- L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each
- L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength
- L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each
- L3224 Woman's Shoe Oxford Brace
- L3225 Man's Shoe Oxford Brace
- L3300 Shoe Lift Taper To Metatarsal
- L3310 Lift, elevation, heel and sole, neoprene, per in
- L3332 Lift, elevation, inside shoe, tapered, up to one-half in
- L3334 Lift, elevation, heel, per in
- L3370 Shoe Sole Wedge Between Sole
- L3390 Shoe Outflare Wedge
- L3400 Shoe Metatarsal Bar Wedge Ro
- L3450 Shoe Heel Sach Cushion Type
- L3485 Shoe Heel Pad Removable For
- L3540 Ortho Shoe Add Full Sole
- L3580 O Shoe Add Instep Velcro Clo
- L3610 Transfer of an orthosis from one shoe to another, caliper plate, new
- L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing
- L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new
- L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified
- L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
- L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf
- L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf
- L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf
- L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
- L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type
- L3912 Hand-finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the-shelf
- L3913 HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
- L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
- L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-the-shelf
- L3925 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf
- L3927 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/spring, extension/flexion (for example, static or ring type), may include soft interface material, prefabricated, off-the-shelf
- L3999 Upper Limb Orthosis Nos
- L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system
- L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee
- L5620 Test Socket Below Knee
- L5645 Addition to lower extremity, below knee (BK), flexible inner socket, external frame
- L5649 Addition to lower extremity, ischial containment/narrow M-L socket
- L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
- 0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
- 0397T Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure.)
- 0421T Transurethral waterjet ablation of prostate, including control of post-operative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)
- 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure.)
- 0480T Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure.)
- 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation
- 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach
- 33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach
- 33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach
- 33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy)
- 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis
- 33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure)
- 33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed
- 33979 Insertion, Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle
- 33990 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only
- 36514 Therapeutic Apheresis; Plasma Pheresis
- 36522 Photopheresis, Extracorporeal
- 37215 Transcatheter Placement Of Intravascular Stent(S), Cervical Carotid Artery, Percutaneous; With Distal Embolic Protection
- 55874 Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed
- A4224 Supplies for maintenance of insulin infusion catheter, per week
- A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
- A5500 Diabetic Shoe For Density Insert
- A5501 Diabetic Custom Molded Shoe
- A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe
- A5504 Diabetic Shoe With Wedge
- A5505 Diabetic Shoe W/Metatarsal Bar
- A5507 Modification Diabetic Shoe
- A5512 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fah
- A5513 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each
- A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries
- C1722 Cardioverter-defibrillator, single chamber (implantable)
- L5671 Addition to lower extremity, below knee (BK)/above knee (AK) suspension locking mechanism (shuttle, lanyard, or equal), excludes socket insert
- L5673 Addition to lower extremity, below knee/above knee, custom fabricated
- L5679 Addition to lower extremity, below knee/above knee, custom fabricated
- L5700 Replace Socket Below Knee
- L5701 Replace Socket Above Knee
- L5940 Endo Bk Ultra-Light Material
- L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature
- L5981 All lower extremity prostheses, flex-walk system or equal
- L5987 All lower extremity prostheses, shank foot system with vertical loading pylon
- L8699 Prosthetic implant, not otherwise specified
- L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code
Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.anthem.com/medicareprovider > Login. Contracted and noncontracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.
ABSCRNU-0172-20 512805MUPENMUB On January 1, 2021, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements will change for codes below. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following codes:
- 15771 — Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
- 15772 — Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
- 15773 — Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
- 15774 — Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
- 31574 — Laryngoscopy, flexible; with injection(s) for augmentation (for example, percutaneous, transoral), unilateral
- 0378T — Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional
- 0379T — Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional
- C9122 — Mometasone furoate sinus implant, 10 mcg (Sinuva)
- 11950 — Subcutaneous injection of filling material (for example, collagen); 1 cc or less
- 11951 — Subcutaneous injection of filling material (for example, collagen); 1.1 to 5.0 cc
- 11952 — Subcutaneous injection of filling material (for example, collagen); 5.1 to 10.0 cc
- 11954 — Subcutaneous injection of filling material (for example, collagen); over 10.0 cc
- 0565T — Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation
- 0566T — Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral
- C1878 — Material for vocal cord medialization, synthetic (implantable)
- G0429 — Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (for example, as a result of highly active antiretroviral therapy)
- L8607 — Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies
- Q2026 — Injection, Radiesse, 0.1 ml
- Q2028 — Injection, sculptra, 0.5 mg
- 0489T — Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells
- 0490T — Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands
- 0202U — Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
- 17999 — Unlisted procedure, skin, mucous membrane and subcutaneous tissue
- 46999 — Unlisted procedure, anus
Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.anthem.com/provider/medicare-advantage > Login.
Contracted and noncontracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.
ABSCRNU-0170-20 512499MUPENMUB A key goal in our provider transparency initiative is to improve quality while managing health care costs. One of the ways we do that is by offering value-based programs including Freestanding Patient Centered Care (FPCC), Medicare Advantage Enhanced Personal Health Care Essentials and so on (known as the Programs).
Value-based program providers (also known as payment innovation providers) in our programs receive quality, utilization and/or cost data, reports, and information about the health care providers (referral providers) to whom the providers may refer their Anthem Blue Cross and Blue Shield (Anthem) patients. If a referral provider is higher quality and/or lower cost, this component of the Programs should result in the provider receiving more referrals from value-based program providers. The converse should be true if referral providers are lower quality and/or higher cost.
Providing this type of data to value-based program providers (including comparative cost information) helps them make more informed decisions about managing health care costs, maintain/improve quality of care and succeed under the terms of the Programs.
Additionally, employers and group health plans (or their representative/vendors) may also be given data about value-based program providers or referral providers to better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.
Upon request, Anthem will share the data used to make these quality/cost/utilization evaluations and will discuss it with referral providers, including any opportunities for improvement.
If you have questions or need support, contact your local market representative or care consultant.
ABSCRNU-0171-20 512772MUPENMUBOn February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (P&T) Committee approved 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 websites, and the effective dates will be reflected in the [Clinical Criteria Web Posting June 2020]. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
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