COVID-19

• Information from Anthem for Care Providers about COVID-19

 

Material Changes/Amendments to Contract and/or Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements starred (*) below.

• Anthem prior authorization updates for specialty pharmacy are available – April 2020*
• UPDATE: Notice of changes to the AIM Musculoskeletal Program prior authorization requirements*
• MCG Care Guidelines 24th Edition*

 

Other Important Updates

• Medicare and Medicaid News – COVID-19 Updates

 

For the most up-to-date information from Anthem Blue Cross and Blue Shield about COVID-19, please bookmark/add to favorites Provider News Home and check back often.

At Anthem Blue Cross and Blue Shield (Anthem), we continue to make changes to our public provider website to make it easier for you to find the information you need. The end of Q1 brings a few updates for the site at anthem.com:

• Information has been added to our website regarding Patient-Centered Specialty Care (PCSC) – Anthem’s value-based payment program for cardiology, endocrinology and obstetrics/gynecology providers. You can find this information online as an extension of our broader patient-centered, value-based care program – Enhanced Personal Health Care (EPHC).
• Documents listed on the Prior Authorization page can be conveniently accessed via online links.
• Medicare Advantage will be live in the coming days. You will be able to view updated Medicare Advantage pages on the commercial public sites.”
• Medical Policies (MP) and Clinical Utilization Management Guidelines (CUMG) now display on our newly designed Web pages.

If you have any questions, please contact Michelle Fraser at michelle.fraser@anthem.com or Nick Kizirnis at nick.kirzinis@anthem.com. 

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways is through Anthem’s value-based programs such as Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, and so on – called the “Programs.” Certain providers (“Value-Based Program Providers” also known as “Payment Innovation Providers”) in Anthem’s various value-based programs receive quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value-Based Program Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in the provider getting 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, including comparative cost information, to Value Based Program Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Value Based Program Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, 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.

 

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers, including any opportunities for improvement. For questions or support, please refer to your local Network Representative or Care Consultant.

Anthem completed its acquisition of Beacon Health Options, a large behavioral health organization that serves more than 36 million people across the country. The company will operate as a wholly owned subsidiary of Anthem.

Bringing together our existing solid behavioral health business with Beacon’s successful model and support services creates one of the most comprehensive behavioral health networks in the country. It’s also an opportunity to offer best-in-class behavioral health capabilities and whole person care solutions in new and meaningful ways to help people live their best lives.

From the standpoint of our customers and providers at this time, it’s business as usual:

• Members should continue to call the customer service number on the back of their membership card or access their health plan’s website for online self-service.
• Providers should continue to use the provider service contact information, websites and online self-service portals as part of their agreement with either Anthem or Beacon.
• There will be no immediate changes to the way Anthem or Beacon manage their respective provider networks, contracts and fee arrangements. Anthem and Beacon provider networks, contracts and fee arrangements will remain separate at this time.

We know our providers continue to expect more of their healthcare partner, and at Anthem, we aim to deliver more in return.

For more details, please see the press release.

 

Click here for more information about the COVID-19 Virus Talking Points for Medicare Advantage.

 

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

 

• Coding tip for psychological and neuropsychological testing
• Medical Policies and Clinical Utilization Management Guidelines update
• New Medicare Advantage opioid treatment Program benefit
• Prior authorization requirements: new 2020 codes for coverage and precertification

 

On November 15, 2019, 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 November 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

^{507833MUPENMUB}

 

On December 18, 2019, and December 23, 2019, 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 December 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.*

 

^{* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield.}

 

^{508037MUPENMUB}

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield (Anthem) offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

 

Medicare Risk Adjustment and Documentation Guidance (General)

• When: The trainings will be offered the first Wednesday of each month from 1 p.m. to 2 p.m. ET (from January 8, 2020, to December 2, 2020).
• Learning objective: This onboarding 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.
• Credits: This live activity has been reviewed and is acceptable for up to 1 prescribed credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those 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:

• Medicare Risk Adjustment and Documentation Guidance (General)

 

Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (Condition Specific)

• When: The trainings will be offered on the third Wednesday of every other month from noon to 1 p.m. ET (from January 15, 2020 to November 18, 2020).
• 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 HCC, with guidance on documentation and coding.
• Credits: This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

 

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

 

1. Red Flag HCCs Part 1 (January 15, 2020) — register for a recording of the session: 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, End-Stage Liver Disease).
   - Link: Red Flag Hierarchical Condition Categories (HCCs), part one

 

2. Red Flag HCCs Part 2 (March 18, 2020): 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, Diabetes with Ophthalmologic or Unspecified Manifestation)
   - Link: Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 2

 

3. Neoplasms (May 20, 2020)
   - Link: Neoplasms
   

 

4. Acute, Chronic and Status Conditions (July 15, 2020)
   - Link: Acute, Chronic and Status Conditions

 

5. Diabetes Mellitus and Other Metabolic Disorders (September 16, 2020)
   - Link: Diabetes Mellitus and Other Metabolic Disorders

 

6. TBD - This Medicare risk adjustment webinar will cover the critical topics and updates that surface during the year (November 18, 2020)
   - Link: Topic TBD

 

^{507941MUPENMUB}

 

Click here for more information about the COVID-19 Virus Talking Points.

Please continue to check Provider Communications & Updates on the provider website for the latest BadgerCare Plus information, including:

 

• November 2019 Medical Policies and Clinical Utilization Management Guidelines update
• Personal care prior authorization
• Prior authorization requirements for A6550 and A9278

 

Effective June 1, 2020, prior authorization (PA) requirements will change for the following services to be covered for Anthem Blue Cross and Blue Shield 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:

• 0156U — Copy number (for example, intellectual disability, dysmorphology), sequence analysis
• 0157U — APC (APC regulator of WNT signaling pathway) (for example, familial adenomatosis polyposis [FAP]) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0158U — MLH1 (mutL homolog 1) (for example, hereditary nonpolyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0159U — MSH2 (mutS homolog 2) (for example, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0160U — MSH6 (mutS homolog 6) (for example, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0161U — PMS2 (PMS1 homolog 2, mismatch repair system component) (for example, hereditary nonpolyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0569T — Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis
• 0570T — Transcatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session (list separately in addition to code for primary procedure)
• 0571T — Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed
• 0572T — Insertion of substernal implantable defibrillator electrode
• 0587T — Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 0588T — Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 64624 — Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
• 81277 — Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities
• E0787 — External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing
• E2398 — Wheelchair accessory, dynamic positioning hardware for back
• J0179 — Injection, brolucizumab- dbll, 1 mg

 

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

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-855-558-1443

 

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/wi > Login. Contracted and non-contracted providers who are unable to access Availity* may call Provider Services at 1-855-558-1443 for PA requirements.

On November 15, 2019, 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 November 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.*

 

^{* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield.}

 

On December 18, 2019, and December 23, 2019, 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 December 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

Disease Management programs are designed to assist PCPs and specialists in caring for members with chronic health care needs. Anthem Blue Cross and Blue Shield Medicaid provides members with continuous education on self-management, assistance in connecting to community resources, and coordination of care by a team of highly qualified professionals whose goal is to create a system of seamless health care interventions and communications for members.

 

Who is eligible?

 

Disease Management case managers provide support to members with:

• Behavioral health conditions such as depression, schizophrenia, bipolar disorder and substance use disorder.
• Diabetes.
• Heart conditions such as congestive heart failure, coronary artery disease and hypertension.
• HIV/AIDS.
• Pulmonary conditions such as asthma and chronic obstructive pulmonary disease.

 

Our case managers use member-centric motivational interviewing to identify and address health risks such as tobacco use and obesity to improve condition-specific outcomes. Interventions are rooted in evidence-based clinical practice guidelines from recognized sources. We implement continuous improvement strategies to increase evaluation, management and health outcomes.

 

We welcome your referrals. To refer a member to Disease Management:

• Call 1-888-830-4300 to speak directly to one of our team members.
• Fill out the Disease Management Referral Form located on the provider website and fax it to 1-888-762-3199 or submit electronically via the Availity Portal.

 

Your input and partnership are valued. Once your patient is enrolled, you will be notified by the assigned Disease Management case manager. You can also access your patient’s Disease Management care plan, goals and progress at any time via the Availity Portal through Patient360.

 

We are happy to answer any questions. Our registered nurse case managers are available Monday to Friday from 8:30 a.m. to 5:30 p.m. local time, and our confidential voicemail is available 24 hours a day, 7 days a week.

The HEDIS_® measure, Use of Imaging Studies for Low Back Pain (LBP), analyzes the percentage of patients 18 to 50 years of age during the measurement year with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. The measure is used to determine whether imaging studies are overused to evaluate members with low back pain. The measure is an inverted rate. A higher score indicates appropriate treatment of low back pain.

 

Clinical guidelines for treating patients with acute low back pain recommend against the use of imaging in the absence of red flags (in other words, indications of a serious underlying pathology such as a fracture or tumor). Unnecessary or routine imaging is problematic because it is not associated with improved outcomes and exposes patients to unnecessary harms such as radiation exposure and further unnecessary treatment.

 

Measure exclusions

• Cancer
• Recent trauma
• Intravenous drug abuse
• Neurological impairment
• HIV
• Spinal infection
• Major organ transplant
• Prolonged use of corticosteroids

 

Helpful tips

Hold off on doing imaging for low back pain within the first six weeks, unless red flags are present.

 

Consider alternative treatment options prior to ordering diagnostic imaging studies, such as:

• Nonsteroidal anti-inflammatory drugs.
• Non-pharmacologic treatment, such as heat and massage.
• Exercise to strengthen the core and low back or physical therapy.

 

Other available resources:

• National Committee for Quality Assurance — NCQA.org
• Choosing Wisely — Choosingwisely.org
• American Academy of Family Physicians — AAFP.org