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

Introducing the Provider Learning Hub

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

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

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

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

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

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

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

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

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

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

The Anthem, Inc. name is changing

Claims reprocessing update for home- and community-based services

Reminder: Provider orientations are available

Disease Management/Population Health program

Clinical Criteria updates

Keep up with Medicaid news: April 2022

• Prior authorization updates for medications billed under the medical benefit
• Medical drug benefit Clinical Criteria updates
• Improving the lives of our members: Social drivers of health
• Medical Policies and Clinical Utilization Management Guidelines update

Urinary tract infection toolkits are on the way

It is CAHPS survey time

Notice of Regulatory Amendment related to Medicaid participating providers and facilities

Reminder: Provider orientations are available

The Behavioral Health Areas of Expertise Profile improves the referral process

Get faster payments with electronic funds transfer

Keep up with Medicaid news: February 2022

• Provider Services Solution (PRSS)
• Enrollment and maintenance changes starting April 2022
• State Memo: December 1, 2021, Behavioral Health Enhancement (BHE) Licensed Services
• State memo: Important changes to emergency services licenses
• Cancer Care Navigator

Botox® update for Anthem HealthKeepers Plus members

Reducing the burden of medical record review and improving health outcomes with HEDIS ECDS reporting

2021 CAHPS Survey results

Submitting prior authorizations is getting easier

Keep up with Medicaid news: January 2022

• Provider orientations and training
• Prior authorization updates for medications billed under the medical benefit effective March 1, 2022
• Prior authorization updates for medications billed under the medical benefit
• AIM Specialty Health Radiation Oncology Clinical Appropriateness Guidelines update
• Change to durable medical equipment wheelchair benefit limits
• HEDIS Guide for retinal exam using fundoscopic photograph

Reimbursement policy update: Drug Screen Testing

HEDIS measures: Follow-up after ED visits for mental illness and alcohol and drug dependency

Healthy Rewards reminder for providers

Updates to AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines

Medical Policies and Clinical Utilization Management Guidelines update

Change to durable medical equipment wheelchair benefit limits

Non-payment remittance advice enhancements

Keep up with Medicaid news: December 2021

• Durable medical equipment prior authorization requirement changes effective December 1, 2021
• Prior authorization requirement changes
• Updates to AIM Specialty Health Cardiology Clinical Appropriateness Guidelines
• Medical drug benefit Clinical Criteria updates
• Important information regarding behavioral health project BRAVO implementation
• Home delivery pharmacy reminder

Electronic data interchange process

Clinical Criteria updates

Unspecified diagnosis reminder

4 things you can do to encourage cancer screenings for your women patients

Keep up with Medicaid news: November 2021

• FAQ: New AIM Specialty Health contact center phone number
• Behavioral therapy assessments
• Change to DME incontinence benefit limits
• Prior authorization updates for specialty pharmacy

Diabetes testing and screening HEDIS measures

Get your payments faster when you sign up for electronic funds transfer

Prior authorization updates for specialty pharmacy

Prior authorization updates for specialty pharmacy

Keep up with Medicaid news: October 2021

• 2021 affirmative statement concerning utilization management decisions
• Medical Policies and Utilization Management Guidelines update
• Generic buprenorphine/naloxone tablets added to Virginia Preferred Drug List

Keep up with Medicaid news - September 2021

Adding 87081 to Physician Office Lab list

Enrollment for Northern Virginia area is open now through August 31, 2021

Closing gaps in care through telehealth

Keep up with Medicaid news

Reimbursement policy: Modifier 90; reference (outside) laboratory and pass-through billing

Attention facilities: Sending admission, discharge and transfer data to HealthKeepers, Inc. results in improved care management for Anthem HealthKeepers Plus patients

Coding spotlight: Mental disorders in childhood