Virginia
Provider Communications

Policy Update: Modifiers 25 and 57 (Policy G-06003, effective 04/01/2023)

Keep up with Medicaid news - March 2023

• Updates to Carelon Medical Benefits Management, Inc. Cardiac Clinical Appropriateness Guidelines
• Update: Carelon Medical Benefits Management, Inc. Cardiology Clinical Appropriateness Guidelines CPT Code List
• Carelon Medical Benefits Management, Inc. Radiology Clinical Appropriateness Guidelines CPT code list update
• Clinical Criteria updates
• Prior authorization updates for medications billed under the medical benefit (Carvykti)
• Prior authorization updates for medications billed under the medical benefit (Aduhelm)
• Applied behavior analysis

Keep up with Medicare news - March 2023

• Update: Carelon Medical Benefits Management, Inc. Cardiology Clinical Appropriateness Guidelines CPT Code List in Virginia
• Carelon Medical Benefits Management, Inc.Genetic Testing Clinical Appropriateness Guidelines CPT code list update
• What date to select for inpatient admissions for claims
• Clinical Criteria updates
• New specialty pharmacy medical step therapy requirements
• Updates to Carelon Medical Benefits Management, Inc. Cardiac Clinical Appropriateness Guidelines

Annual planned visits

Controlling High Blood Pressure and Submitting Compliant Readings

Shared savings and transition care management after inpatient discharges

Informational Update Modifier Usage

Introducing the Provider Learning Hub

Name change announcement: myNEXUS will transition to Carelon Post Acute Solutions on March 1, 2023

Keep up with Medicaid news: February 2023

• Prior authorization updates for medications billed under the medical benefit
• Medical Policies and Clinical Utilization Management Guidelines update
• Prior authorization updates for medications billed under the medical benefit
• POS restrictions for BRAVO services
• Direct member medical necessity appeals to HealthKeepers, Inc.
• Patient liability and claims processing

2023 FEP benefit information available online

Introducing the Provider Learning Hub

Keep up with Medicare news - February 2023

• Updates to AIM Specialty Health Rehabilitative and Habilitative Services Clinical Appropriateness Guidelines
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list (FyInetra)
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list (Spevigo, Xenpozyme)
• Specialty pharmacy precertification list expansion (Rolvedon, Stimufend)
• New specialty pharmacy medical step therapy requirements
• Prior authorization requirement changes effective April 1, 2023
• Medical Policies and Clinical Utilization Management Guidelines update

Engagement with your patient counts

Childhood Immunization Status and Lead Screening in Children for HEDIS

Monkeypox and smallpox vaccines: Product code on claims

Attention physicians and lab providers: COVID-19 update regarding reimbursement

Submitting prior authorizations digitally through ICR

Implementation of Cardinal Care

Keep up with Medicaid news: January 2023

• This is Quitting: Helping teens and young adults quit vaping
• HEDIS measure for prenatal and postpartum care
• Prior authorization requirement changes updated effective January 1, 2023
• AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT Code List update
• Change to vaccine age limitations

Keep up with Medicare news: January 2023

• Prior authorization requirement changes
• New specialty pharmacy medical step therapy requirements
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list
• Updates to AIM Specialty Health Radiation Oncology Clinical Appropriateness Guidelines

Federal Employee Program observation conversion for musculoskeletal cases

Update to the Pregnancy Notification Form

Doula services

Keep up with Medicaid news: December 2022

• Medical drug benefit Clinical Criteria updates
• Medical Policies and Clinical Utilization Management Guidelines update
• Prior authorization updates for medications billed under the medical benefit (Releuko, Vabysmo)
• Prior authorization requirement changes effective January 1, 2023

2023 Medicare Advantage service area and benefit updates

Keep up with Medicare news: December 2022

• Medical drug benefit Clinical Criteria updates
• Medical Policies and Clinical Utilization Management Guidelines update

Personal home helper benefit ending

Important information about utilization management

Remote EMR access service for HEDIS

Important information about utilization management

Guidance for coding evaluation and management services for new and established patients

Retraction of policy: Private duty nursing reimbursement

Keep up with Medicaid news: November 2022

• Prior authorization requirement changes effective November 1, 2022
• Medical drug benefit Clinical Criteria updates

Keep up with Medicare news: November 2022

• New specialty pharmacy medical step therapy requirements
• New specialty pharmacy medical step therapy requirements
• Medical drug benefit Clinical Criteria updates

Personalized Match

Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list

Availity Essentials provider chat: A fast, easy way to get your utilization management questions answered for Federal Employee members

Complex Case Management program

Members’ Rights and Responsibilities section

Reimbursement Policy Retraction: Sexually Transmitted Infections Testing – Professional

Monkeypox resources and recommendations for our care providers

Keep up with Medicaid news: October 2022

• New specialty pharmacy medical step therapy requirements
• Prior authorization updates for medications billed under the medical benefit – effective December 1, 2022
• Prior authorization updates for medications billed under the medical benefit – effective November 1, 2022
• Private duty nursing reimbursement
• Change to DME canes, crutches, and walkers benefit limits
• Change to DME traction equipment

Medicare telehealth services during the Coronavirus (COVID-19) public health emergency FAQ

Courtesy notification of specialty pharmacy medical step therapy updates

Reimbursement policy retraction: Sexually transmitted infections testing - professional

Keep up with Medicare news: October 2022

• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list – J3490, J3590 and J3299
• Consultation codes

OBRA 93 claim filing for Federal Employee Program

Reimbursement policy update - Modifiers 25 and 57: Evaluation and Management with Global Procedures

Enhancing claims attachment processes through digital applications

New specialty pharmacy medical step therapy requirements

Provider Services Solution enrollment for MCO-only providers

Help your pregnant patients quit smoking

Clinical Laboratory Improvement Amendments

Alcohol use disorders linked to chronic diseases

Keep up with Medicaid news: September 2022

• Clinical Criteria updates
• Updates for medication codes billed under the medical benefit
• Nursing facility admissions and LTSS screenings
• July 2022 HCBS rate increase notice

Prior authorization requirement changes effective December 1, 2022

Reimbursement policy update - Modifiers 25 and 57: Evaluation and Management with Global Procedures

Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list

Reminder: AIM prior authorization phone number change for Medicare

Enhancing claims attachment processes through digital applications

Keep up with Medicare news: September 2022

• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list
• Medicare telehealth services during the Coronavirus (COVID-19) public health emergency (PHE) FAQ

HEDIS 2022: Summary of changes from the National Committee for Quality Assurance

Using screening, brief intervention, and referral to treatment to address opioid and substance use disorders

The cost of alcohol use disorder

Prior authorization requirement changes updated effective November 1, 2022

Chlamydia screening

Billing taxonomy code requirements

Service facilitation visit authorization and limit reminder

Treatment involving prescription of opioids

Keep up with Medicaid news: August 2022

• One-time COVID-19 Support Payment for Attendant/Aides

Keep up with Medicare news: August 2022

• MCG care guidelines 26^th edition

Radiology prior authorization review transitioned to AIM; prior authorization required

Prior authorization requirement changes effective August 1, 2022

MCG care guidelines 26th edition

Antibiotic dispensing guidelines

Update use of modifier 25 for billing for visits that include preventive services and problem-oriented evaluation and management services

Change to Department of Medical Assistance Services’ incontinence undergarment benefit limits

Keep up with Medicaid news: July 2022

• Updating member information
• Use of Imaging Studies for Low Back Pain (LBP)
• Remote patient monitoring update
• Prior authorization updates for medications billed under the medical benefit
• Virginia Medicaid language interpretation services

Update use of modifier 25 for billing for visits that include preventive services and problem-oriented evaluation and management services

Cancer Care Navigator

Keep up with Medicare news: July 2022

• New specialty pharmacy medical step therapy requirements

Process change for Federal Employee Program® third-party correspondence requests

Provider notice for COVID-19 testing

Updates to AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines

Medical drug benefit Clinical Criteria updates

Medical Policies and Clinical Utilization Management Guidelines update

Keep up with Medicaid news: June 2022

• Transcranial magnetic stimulation provider communication
• Prior authorization update for select durable medical equipment (DME) items
• MES and DMAS enrollment requirement
• Updates to AIM Specialty Health Sleep Disorder Management Clinical Appropriateness Guidelines
• Prior authorization updates for medications billed under the medical benefit
• Precertification requirement notice

Provider notice for COVID-19 testing

Updates to AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines

Authorizations for post-acute care services for Medicare Advantage individual, Group Retiree Solutions (GRS), and Dual-Eligible Plan members

Medical drug benefit Clinical Criteria updates

Medical Policies and Clinical Utilization Management Guidelines update

Keep up with Medicare news: June 2022

• Updates to AIM Specialty Health Sleep Disorder Management Clinical Appropriateness Guidelines
• New specialty pharmacy medical step therapy requirements
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list
• Updates to AIM Specialty Health Musculoskeletal Clinical Appropriateness Guidelines

Federal Employee Program® AIM radiology prior authorization review reminder

CORRECTION: Save time by using CPT II codes: Introducing FEP® Quality Reimbursement Program for PPO providers

Join us for a FEP® Quality Learning Program live webinar

Screening for alcohol use disorder in high-prevalence demographics

Personal care services prior authorization change

Keep up with Medicaid news: May 2022

• DMAS MEMO: Medicaid Enterprise System
• Prior authorization requirement change for HCPCS code K1022
• New specialty pharmacy medical step therapy requirements