 Provider News WisconsinApril 2021 Anthem Provider News - WisconsinHaving the common goal of reaching all Latinos in the US, Anthem, Inc., the Beckman Research Institute of City of Hope, the National Hispanic Medical Association, and Pfizer, Inc., announce the launch of Tomando Acción por Nuestra Salud/Taking Action for Our Health, a free interactive bilingual website aimed at eliminating health disparities in the Latino community. The website encourages preventive health screenings for cancer, emotional health, heart health, and prediabetes. It also provides tools to help people care for the emotional health of their families and themselves in the language of their preference.
The interactive website highlights the importance of health screenings, addresses barriers and provides information on access to low and no cost healthcare services in the community. The easy to use website, guides participants through four programs where they can learn about risk factors, take action to get screened, monitor their progress, and share their results with their doctors, health care teams or family and friends to let them know they are taking steps to protect their health and help encourage others to participate as well.
The website is not exclusive for Anthem members. Health care providers are encouraged to share the website with all of their Latino patients.
The website identifies four major targets of undue poor health outcomes for Latinos. In response, Tomando Acción por Nuestra Salud/Taking Action for Our Health strives to help increase cancer screening, screening for depression/anxiety-risk, heart diseases and prediabetes and provides tools to address emotional health. The website includes a 4-part workshop series “Compartiendo el Café y el Chocolate/Coffee and Chocolate” to help people care for the emotional health of their family and themselves. This is a program, specifically for Hispanics, that uses a holistic approach to emotional stability. It builds on cultural strengths to balance four key items—community, body, mind, and spirit.
To access Tomando Acción por Nuestra Salud/Taking Action for Our Health visit:
Taking Action for Our Health.
Healthcare and mental healthcare professionals have a vital role in identifying, treating, and addressing racial trauma and injustice, moving our communities towards racial equity, and improving the health and wellbeing of all Americans.
We can impact the injustice of racism together.
Anthem has partnered with Motivo*, the first HIPAA-compliant digital platform that connects mental health therapists and clinical supervisors, to take on the challenge of facilitating conversations on racial injustice, trauma, and inequality among our providers and associates.
We are hosting Racial Equity forums on a quarterly basis to keep the conversation going. Please register for the next forum, Deconstructing Bias, to learn more about the impact of racism on healthcare and the people we serve, and what we can do about it.
In Pursuit of Racial Equity: Deconstructing Bias
Wednesday, June 9, 2021
4:00 pm – 5:30 pm Eastern / 3:00 pm – 4:30 pm Central
Register today!
Our racial equity forums focus on:
- Exploring how racism takes shape in healthcare.
- Discussing how to identify racism in your practice and how to be an ally to your patients.
- Understanding the impact of prolonged exposure to racism on people of .
- Providing you with actionable resources to put an end to racism in your practice.
Since October 2020, Anthem has sponsored two virtual forums featuring healthcare professionals from Anthem and Motivo: Racial Trauma in America and The Road to Allyship: Playing Your Part in Racial Equity.
We know we are on the right track because the Racial Equity Forum participants say so.
- 90% received meaningful information about the influence that racism and White privilege may have on their perspectives and gained an understanding on what actions they can take to make a difference and be an ally.
- 86% obtained useful information and resources that will enhance their ability to serve patients.
- 75% agreed that the forum helped them understand a different perspective.
- 76% had some of their perspectives and beliefs challenged.
Systematic racism is a part of today’s healthcare system.
- US physicians underestimate the pain level of Black patients 47% of the time vs. 33.5% of the time for White patients (PNAS).
- Black women die from pregnancy or childbirth 243% more often than White women (CDC).
The first step to addressing racism is to recognize its existence, subtle or otherwise.
These conversations can be uncomfortable, but this is how you can do something about racial injustice now.
At Anthem, we are determined to reduce racism in our communities with your support and participation.
*Motivo is an independent company providing a virtual forum on behalf of Anthem.
Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements starred (*) below.
- Important update to provider UM reimbursement penalties and corresponding entry in Provider Manual*
- Designated Specialty Pharmacy Network*
- Updates for specialty pharmacy are available*
- Medical policy and clinical guideline updates*
- Update: Clinical guideline adoption postponed*
- MCG Care Guidelines 25th Edition available*
- Updated guidance on prior authorization requirements for admissions to in-network skilled nursing facilities (SNF) facilities
- Maximizing efficient, high quality COVID-19 screenings*
- New reimbursement policy: Newborn Inpatient Stays for facilities*
In May 2020, the Centers for Disease Control (CDC) released a report that showed a drop in routine childhood vaccinations as a result of COVID-19; a result of stay at home orders and concerns about infection during well-child visits. Both the American Academy of Pediatrics and the CDC recommend the continuation of routine childhood vaccinations during the COVID-19 pandemic, noting they are essential services.
To encourage well-visits and vaccinations, here are some extra steps you can take, if you haven’t already, to make visits as safe as possible for both patients and staff. They include:
- Scheduling sick visits and well-child visits during different times of the day.
- Asking patients to remain outside until it’s time for their appointment to reduce the number of people in waiting rooms.
- Offering sick visits and well-child visits in different locations.
It’s important to identify those children who have missed immunizations and well-child visits to schedule these essential in-person appointments. To help, the CDC has published vaccine catch-up guidance on their website.
Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
Billing codes:
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- One meningococcal vaccine (MCV) injection between 11 to 13 years of age
- One tetanus, diphtheria toxoids and acellular pertussis vaccine (TDAP/TD) between 10 to 13 years of age
- Two or three HPV vaccines between 9 to 13 years of age
Billing Codes:
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
For a complete list of HEDIS® measures, descriptions and coding tips, visit anthem.com.
If you have questions about prior authorizations (PA), you now have a new option to have them answered quickly and easily. With Anthem Chat, providers can have a real-time, online discussion with a PA specialist.
- Faster access to PA provider services experts
- Real-time answers to your questions about PA and live help for submissions, similar to the call experience
- Access to denial information and clinical team for resolution
- The same high level of safety and security you have come to expect with Anthem Blue Cross and Blue Shield (Anthem)
Chat is one example of how Anthem is using digital technology to improve the healthcare experience, with a goal to save you valuable time. To start, access the service through Payer Spaces on Availity.
To access chat: log on to Availity at Availity.com. Select Payer Spaces then select the health plan. Once in Payer Spaces, select the Chat with Payer box from Applications.
The Centers for Medicare & Medicaid Services (CMS) has issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement Application Programming Interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates, that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS has identified Health Level 7® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.
Anthem Blue Cross and Blue Shield (Anthem) Clinical Data Acquisition Group has integrated Admission, Discharge and Transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange can help Anthem:
- Better support members with care coordination and discharge planning, leading to healthier outcomes for our members—your patients.
- Proactively manage care transitions to avoid waste.
- Close care gaps and educate members about appropriate care settings to better manage out-of-pocket expenses.
Anthem would like to digitally exchange HLT ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real time HL7 ADT messaging data, or at least within 24-hours of admission, discharge or transfer, enables Anthem to most effectively manage care transitions.
Contact the Clinical Data and Analytics team to get started today. Email us at ADT_Intake@anthem.com.
Anthem Blue Cross and Blue Shield (Anthem) and Availity are excited to announce the Prior Authorization and Referrals (278) and Inpatient Admission and Discharge Notification (278N) 5010 transactions functionality.
Prior Authorization and Referral Request (278)
Use this transaction to electronically submit authorization and referral requests. You have the option to transmit this transaction in real-time or batch mode, and you will receive confirmation numbers to validate receipt of request.
- An authorization is a review and approval of specific services
- A referral is used to refer a patient to a specialty provider
Hospital Admission Notification (278N)
Use this transaction to electronically submit hospital admission notifications between your facility and health plan. The EDI 278N is the easiest, most efficient way to communicate facility admissions. Just like the 278, you can also transmit in either batch or real-time format which includes the ability to update a previously submitted date.
What are your benefits for using these transactions?
- Streamline administrative tasks and increase productivity
- Reduce administrative costs through automation
- Increase data accuracy by reducing manual errors
- Confirm a notification of admission is on file in the form of a service reference number that is generated upon registration
- Submit notification of discharge
- Accomplish more with less ‒ fewer phone calls, faxes or keying
Getting Started
- If you use a clearinghouse or vendor work with them to ensure they have the capability to exchange these transactions.
- If you use practice management software have your Availity administrator use the following path to enroll:
- My Providers > Enrollment Center > Transaction Enrollment
Useful Documents
- Availity EDI Companion Guide communicates Availity-specific requirements and other information that supplements requirements and information already provided in standard EDI and HIPAA communications.
- Anthem specific companion guide communicates requirements for submitting these transactions. These are located on the company website at – anthem.com/edi
- The Availity Quick Start Guide will assist you with any EDI connection questions you might have.
If you need assistance, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 8 p.m. Eastern Time.
Did you know your Availity administrator for your organization is the key to opening doors to self-service transaction roles such as EDI. A role is a group of job functions, also known as permissions. Each role consists of one or more permissions. Assigning roles is part of the process when you add a new Availity user with the Add User feature.
What EDI roles do I need?
EDI Management – This role consists of the following permissions available under EDI File Management in the Availity menu:
- EDI Reporting Preferences – Specify the EDI batch report files you want users at your organization to receive, along with file formats and other reporting preferences.
- EDI Send and Receive Files – Review EDI batch report files for batch files submitted using Availity's EDI File Management feature. In addition, review payer responses to Availity Web-based claim forms submitted to payers that process claims in batches.
- File Restore – Restore archived EDI files to your ReceiveFiles
Set up EDI Reporting Preferences
Availity's batch EDI processing generates response files for each batch file that you submit. The administrator for an organization can set reporting preferences that specify which response files are generated. In the Availity Portal menu, click Claims & Payments > EDI Reporting Preferences.
Enroll for the Direct Data Entry Transaction
You must be assigned the Claims role to submit professional claims or encounters. If you cannot access the claim form, contact your administrator to assign the Claims role to you. Submit transactions through manual data entry in Availity Portal.
In the Availity Portal menu, click Claims & Payments > Professional Claim/Facility Claim/Dental Claim > Confirm which organization and payer you would like to submit claims for and continue to complete the fields to be directed to the simple and time saving claim form to enter claim information.
Need More Help?
The EDI Connection Services Startup Guide is a helpful resource to help you get started, set up your EDI reporting preferences and submit transactions through manual data entry in Availity Portal.
Contact Availity
- Select Help & Training > Get Trained to display the Availity Learning Center (ALC) in a new browser tab. Search the catalog to locate and enroll in courses. Based on your needs.
- 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:
- Administrator
- Claim Submission
- Electronic Data Interchange (EDI)
- Glossary
- Select Help & Training > Availity Support to:
- Open a ticket to request support
- Get support via Chat
1061-0421-PN-CNT We’re changing!
The Information Center has replaced the Education and Reference Center application in Payer Spaces on the Availity Portal. There you’ll find important policies, forms and helpful resources.
If you’re looking for specific education materials, we invite you to visit the Custom Learning Center in Availity, which was designed to offer education/training content and to be a learning environment. Content previously posted in the Communication & Education tab have now migrated there. Find the Custom Learning Center tool in Payer Spaces > Applications > Access the Custom Learning Center.
Locate the Information Center in Payer Spaces. Depending on your market, the Information Center contains a number of sections:
- Administrative support
- Behavioral health
- Clinical resources
- Medicaid
- Medicare
- Federal Employee Program (FEP)
To view content in both of these valuable tools, visit Payer Spaces today.
Beginning in April 2021, our online directories will identify professional providers who offer telehealth services in their practice.
We encourage providers to utilize the online Provider Maintenance Form to notify us about your telehealth services and we will add a telehealth indicator to your online provider directory profile.
Visit anthem.com to locate the online Provider Maintenance Form. Please contact Provider Services if you have any questions.
Effective for dates of service on and after July 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will increase the reimbursement penalty for failure to comply with the utilization management (UM) program’s prior authorization requirements for services rendered to commercial plan members. Late prior authorizations, and late notices in the case of emergency admissions, are currently subject to a penalty and will be subject to the increase in the penalty.
Failure to comply with Anthem’s prior authorization requirements, and late notice requirements in the case of emergency admissions, will result in a 100% reduction in reimbursement to the provider and facility.
As a reminder, Anthem requires prior authorization prior to the delivery of certain elective services in both the inpatient and outpatient settings. For an emergency admission, prior authorization is not required; however, you must notify Anthem of the admission within the timeframe specified in the Provider Manual or as otherwise required by law.
Failure to give timely notification for emergency admissions will also result in reimbursement penalties of 100% to providers and facilities.
Enforcement of the program requirement will lead to greater consistency in our processes. This notice updates Anthem’s UM program reimbursement penalties and the corresponding sections of the Provider Manual to reflect this change to the reimbursement penalty for non-compliance. These updates will be reflected in the next updated version of the Provider Manual. As a reminder, providers and facilities may not balance bill the member for any such reduction in payment.
Millennials with behavioral health conditions were at twice the risk of having a chronic physical condition.
The study included the analysis of millennials’ medical claims over a five year period. Those with ongoing behavioral health conditions were twice as likely to have a chronic physical condition as their peers without a behavioral health diagnosis.
Behavioral health conditions driving adverse health for millennials
It’s important to follow-up with your patients—millennial, Gen X, Gen Z or baby boomer—who are prescribed antidepressant medications or who have been hospitalized for mental illness or substance use disorders. Not only will patients have better behavioral health outcomes, their physical health could be significantly impacted as well. Follow these HEDIS® measures for additional guidance in closing the gaps in behavioral health conditions for all ages.
A note about telehealth
NCQA now accepts telehealth codes for behavioral health and some physical health measures. The modifiers 95 and GT are defined as telehealth services rendered via interactive audio and video telecommunications system. CPT Codes 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 98960-98962, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99406-99409 and 99495-99496 may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95.
Antidepressant Medication Management (AMM): The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported:
- Effective Acute Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
- Effective Continuation Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).
AMM Billing Codes:
- BH Outpatient CPT: 99078, 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99510 HCPCS: G0155, G0176-G0177, G0409, G0463, H0002, H0004, H0031, H0034-H0037, H0039-H0040, H2000, H2001, H2010-H2011, M0064, T1015
- Emergency Department CPT: 99281-99285 UB Rev: 0450-0452, 0456, 0459, 0981
- Major Depression ICD-10 CM: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9
- Telephone Visits CPT: 98966-98968, 99441-99443
- Telephone Modifier Value Set: 95 GT POS: 02
- Telehealth: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
- Telehealth modifier: 95 or GT
- Telehealth POS: 02
Follow-Up After Hospitalization for Mental Illness (FUH): The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are reported:
- The percentage of discharges for which the member received follow-up within 30 days after discharge.
- The percentage of discharges for which the member received follow-up within 7 days after discharge.
The follow-up visits, within 7 days and 30 days after hospitalization can both be telehealth visits. Telephone visits alone do not meet this criterion.
FUH Billing Codes:
- Follow-Up Visits CPT: 90791-2, 90832-40, 90845, 90847, 90849, 90853, 90875-6, 98960-2, 98966-8, 99078, 99201-5, 99211-5, 99217-23, 99231-3, 99238-9, 99241-5, 99251-5, 99341-5, 99347-50, 99381-7, 99391-7, 99401-4, 99411-2, 99441-3, 99483, 99495-6, 99510 HCPCS: G0155, G0176-7, G0409, G0463, H0002, H0004, H0031, H0034, H0036-7, H0039-40, H2000, H2010-1, H2013-20, M0064, T1015
- Mental Illness Diagnosis Codes ICD-10: F03.9x, F20-F25.xx, F28-F34.xx, F39-F45.xx, F48.xx, F50-F53.xx, F59-F60.xx, F63-F66.xx, F68-F69.xx, F80-F82.xx, F84.xx, F88-F93.xx, F95.xx, F98-F99.xx
- Telehealth visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
- Telehealth modifier: 95 or GT
- Telehealth POS: 02
Follow-Up After Emergency Department Visit for Mental Illness (FUM): The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness. Two rates are reported:
- The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
- The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).
The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.
FUM Billing Codes:
- Outpatient Follow-Up Visits CPT: 90791-2, 90832-4, 90836-40, 90845, 90847, 90849, 90853, 90875-6, 98960-2, 98966-8, 99078, 99201-5, 99211-5, 99217-23, 99231-3, 99238-9, 99241-5, 99251-5, 99341-5, 99347-50, 99381-7, 99391-7, 99401-4, 99411-2, 99441-3, 99483, 99495-6, 99510
- HCPCS: G0155, G0176-7, G0409, G0463, H0002, H0004, H0031, H0034, H0036-7, H0039-40, H2000, H2010-1, H2013-20, M0064, T1015
- Mental Illness Diagnosis Codes ICD-10:9x, F20-25.xx, F28-34. xx, F39-45.xx, F48.xx, F50-53.xx, F59-60.xx, F63-66.xx, F68-69.xx, F80-82.xx, F84.xx, F88-93.xx, F95.xx, F98-99.xx
- Intentional Self-Harm Diagnosis Codes ICD-10 example:92XA
- Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
- Telehealth modifier: 95 or GT
- Telehealth modifier POS: 02
Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA): The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up visit for AOD. Two rates are reported:
- The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
- The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).
The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.
FUA Billing Codes:
- Initiation, Engagement and Treatment Follow-Up Visits CPT: 98960-2, 99078, 99201-5, 99211-5, 99241-5, 99341-50, 99384-7, 99394-7, 99401-4, 99408-9 99411-2, 99483, 99510
- Alcohol Counseling or Other Follow-Up Visits CPT: 99408-9 HCPCS: G0396-7, G0443, H0005, H0007, H0016, H0022, H0050, H2035-6, T1006, T1012 AOD
- Medication Treatment HCPCS: G2067-77, G2080, G2086-7, H0020, H0033, J0570, J0571-5, J2315, Q9991-2, S0109
- Substance Use Disorder Diagnosis Codes ICD-10: F10-16.xx, F18-19.xx
- Telehealth modifier: 95 or GT
- Telephone visits: 98966 - 98968, 99441- 99443
- Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99408-99409, 98960-98962
- Telehealth modifier POS: 02
Follow-Up After High-Intensity Care for Substance Use Disorder (FUI): The percentage of acute inpatient hospitalizations, residential treatment or detoxification visits for a diagnosis of substance use disorder among members 13 years of age and older that result in a follow-up visit or service for substance use disorder. Two rates are reported:
- The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 30 days after the visit or discharge.
- The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 7 days after the visit or discharge.
FUI Billing Codes:
- Opioid Abuse and Dependence ICD-10:10; F11.120; F11.121; F11.122; F11.129
- Other Drug Abuse and Dependence ICD-10:10; F12.120; F12.121; F12.122; F12.129
- Alcohol Abuse and Dependence ICD-10:10; F10.120; F10.121; F10.14; F10.150
- Telephone Visits CPT: 98966-98968; 99411-99443
- Online Assessments CPT: 98969-98972; 99421-99423; 99444; 99458
- IET Stand Alone Visits CPT: 98960-98962; 99201-99205; 99211-99215
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
CPT Code E1399 is not an appropriate billable code for CPAP/APAP/BiPAP.
When providers are requesting CPAP/APAP/BIPAP, please do NOT use a NOC code. Use the specific appropriate code for each of these devices.
E1399 will no longer be part of AIM’s Sleep Therapy program as of April 1, 2021 and should not be submitted to AIM for review for CPAP/APAP/BiPAP.
Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Anthem Blue Cross and Blue Shield (Anthem) contracted laboratories and identify the proper CPT codes to use.
Contact your Anthem representative if you need additional information or visit anthem.com/coronavirus/providers.
COVID-19 testing coding guidelines
- For a new or established patient, CPT code 99211 would be appropriate if patient is being seen for no other services besides a specimen collection.
- For a patient assessment in addition to a specimen collection it is appropriate to bill the applicable E&M service, CPT codes 99202-99215. Specimen collection is a component of the E&M service and not separately reimbursable.
- Effective April 1, 2021, CPT codes G2023 and G2024 are appropriate when billed by clinical laboratories only and are not appropriate for provider practices.
Refer patients to anthem.com/coronavirus to find convenient testing locations
If an Anthem member requests a COVID-19 test, you may refer them to anthem.com or the Sydney Health mobile app to find testing locations near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:
- Appointments or walk-ins
- Drive-through service
- Rapid test results
- Antibody testing
- Testing for children
Send swab tests to Anthem-contracted laboratories
When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high value health care.
Consider Antigen testing when rapid test results are needed
Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), e.g. PCR. Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.
Antigen tests can be used to detect current infection, are relatively easy to use, and most can provide point-of-care testing results. The Centers for Disease Control and Prevention (CDC) notes that proper interpretation of antigen test results (and confirmatory testing with NAAT when indicated) is important for accurate clinical management of patients with suspected COVID-19; more information can be found here.
The Center for Disease Control and Prevention (CDC) notes that when molecular tests are unavailable or rapid turnaround time is needed, antigen tests can generally be used for diagnosis of COVID-19.
Antigen tests are typically less sensitive and clinicians should interpret negative results carefully. When symptoms are present or a high clinical suspicion exists, negative antigen tests should be confirmed with a molecular test.
When antigen tests are used in symptomatic patients, positive antigen tests can be interpreted as indicative of SARS-CoV-2 infection and do not usually require follow-up testing.
Consider using COVID-19 and flu combination testing when appropriate
According to the Center of Disease Control and Prevention (CDC), clinicians should consider testing for other causes of respiratory illness, including infections such as influenza, when clinically appropriate.
Please note that the following information applies to Anthem Wisconsin local Commercial health plans.
Anthem is updating guidance on prior authorization requirements for admissions to
in-network skilled nursing facilities (SNFs).
This process applies to hospital inpatient transfers to SNFs only.
It does not apply to transfers from Acute inpatient Rehab, LTAC to SNF, or SNF to SNF).
The goal of this updated guidance is to minimize any delays in the transfer of members to an in-network SNF facility.
- Effective March 1, 2021, Anthem will allow a 5-day initial length of stay upon notification of an admission to an in-network SNF facility for Wisconsin Local Commercial members.
- Facility and physician must be in-network for the membe
- Anthem will require notification of the SNF admission, which includes sending demographics and verification of benefits via the usual channe
- Anthem will approve an initial 5-day length of stay without the need to provide clinical information.
- SNF providers will need to submit the clinical information within two business days after the admission to aid in our members’ care coordination, discharge planning and member management. Note that prior authorization is still required but we allow the transfer to SNF, and then allow provider to send clinical within 2-days after the admission.
- Concurrent review will be required starting on day 5 of the SNF stay.
- Anthem may apply monetary penalties such as a reduction in payment, for failure to provide timely notice of admission.
We will monitor this process through June 30, 2021 and conduct random audits and monitor trends to evaluate its effectiveness
*Note: This process does not apply to admissions to out-of-network SNF facilities.
Frequently Asked Questions (FAQs)
As a SNF provider, do I need to send information and notification to Anthem as I would normally do for a prior authorization?
Yes, notification is still required. However, you can notify Anthem of the admission and move the member without having to send in clinical information or wait for an approval. It will be important to verify member benefits.
When do I need to submit clinical information?
For the initial SNF admission, no later than two business days after the admission and for continued stay, prior to the last covered day.
Does this apply to SNF, IP Rehab and LTAC admissions and related transportation (air or ground ambulance)?
This process is only applicable to the initial SNF admission. Follow standard prior authorization process for IP Rehab, LTAC and any related transportation.
For the SNF initial authorization of 5 days, will Anthem assign a level of care?
Anthem UM will assign Level of care once the clinical information is received from the SNF.
What if a member needs to be admitted for wound care and IV antibiotics?
If a SNF has any concerns about the criteria for admission, they may still do the full prior authorization process.
If the physician and/or facility are out-of-network for the member, does this process apply?
No, the facility AND physician both need to be in network. All out-of-network facilities and providers must follow the full prior authorization process.
What if I am uncertain if the member is a local commercial member?
This process is applicable to local commercial accounts only. It does not apply to FEP, National, Medicaid, Medicare, or IHM. If you are uncertain, reach out to the Anthem dedicated nurse for your facility.
Effective July 1, 2021, we will upgrade to the 25th edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC), Recovery Facility Care (RFC), and Behavioral Health Care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.
Goal Length of Stay (GLOS) for Inpatient & Surgical Care (ISC)
|
MCG Code
|
Guideline
|
24th Edition GLOS
|
25th Edition GLOS
|
|
S-152
|
Aortic Coarctation, Angioplasty
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
W0016
|
Cardiac Septal Defect: Atrial, Transcatheter Closure
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
S-445
|
Esophageal Diverticulectomy, Endoscopic
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
S-510
|
Gastrectomy, Partial - Billroth I or II
|
4 or 6 days postoperative
|
5 days postoperative
|
|
S-1305
|
Hernia Repair (Non-Hiatal)
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
S-1200
|
Pancreatectomy
|
5 or 7 days postoperative
|
6 days postoperative
|
|
S-990
|
Pyloroplasty and Vagotomy
|
4 or 6 days postoperative
|
4 days postoperative
|
|
W0097
|
Cervical Laminectomy
|
2 days postoperative
|
Ambulatory or
2 days postoperative
|
|
W0091
|
Lumbar Diskectomy, Foraminotomy, or Laminotomy
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
S-530
|
Removal of Posterior Spinal Instrumentation
|
1 day postoperative
|
Ambulatory or
1 day postoperative
|
|
W0138
|
Shoulder Hemiarthroplasty
|
1 day postoperative
|
Ambulatory or
1 day postoperative
|
|
W0156
|
Spine, Scoliosis, Posterior Instrumentation, Pediatric
|
4 days postoperative
|
3 days postoperative
|
|
S-190
|
Bladder Resection: Cystectomy with Urinary Diversion, Conduit or Continent
|
5 or 6 days postoperative
|
5 days postoperative
|
|
S-970
|
Prostatectomy, Transurethral Resection (TURP)
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
|
S-1172
|
Urethroplasty
|
Ambulatory or 1 day postoperative
|
Ambulatory
|
New Guidelines for Behavioral Health Care (BHC) and Recovery Facility Care (RFC)
|
MCG Code
|
Body System
|
Guideline Title
|
|
B-031-IP
|
Withdrawal Management
|
Withdrawal Management, Adult: Inpatient Care
|
|
B-031-IOP
|
Withdrawal Management
|
Withdrawal Management, Adult: Intensive Outpatient Program
|
|
B-031-AOP
|
Withdrawal Management
|
Withdrawal Management, Adult: Outpatient Care
|
|
B-031-PHP
|
Withdrawal Management
|
Withdrawal Management, Adult: Partial Hospital Program
|
|
B-031-RES
|
Withdrawal Management
|
Withdrawal Management, Adult: Residential Care
|
|
M-5197
|
Cardiology
|
Hypertension
|
|
M-7087
|
Cardiology
|
Peripheral Vascular Disease (PVD)
|
|
M-7095
|
Nephrology
|
Rhabdomyolysis
|
|
M-7100
|
Nephrology
|
Encephalopathy
|
|
M-5545
|
Thoracic Surgery
|
Rib Fracture
|
Anthem Customizations to MCG care guideline 25th Edition
Effective July 1, 2021, the following MCG care guideline 25th edition customizations will be implemented:
Transcranial Magnetic Stimulation, W0174 (previously ORG: B-801-T) - Revised Clinical Indications for Procedure and added the following:
- Need for acute TMS treatment, up to 6 weeks
- Acute treatment course needed as indicated by (a) Initial course of treatment for major depressive disorder (severe), or (b) Relapse of symptoms after remission
- Continuation of acute treatment, up to 6 months
- TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
- Maintenance TMS treatment
- Continuation of acute TMS treatment for longer than 6 months
- TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, Anxiety disorders, Bipolar depression, Neurodevelopmental disorders, Obsessive-compulsive disorder, Peripartum depression, Post-traumatic stress disorder, Substance use disorders, Tourette's syndrome.
To view a detailed summary of customizations, visit the Clinical Guidelines page, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.
For questions, please contact the provider service number on the back of the member's ID card.
This update is for Anthem Blue Cross and Blue Shield in Indiana, Kentucky, Missouri, Ohio and Wisconsin.
We previously announced that clinical guideline CG-Surg-104, Intraoperative Neuromonitoring, would be adopted effective February 1, 2021.
We are postponing adoption of this clinical guideline.
We will announce the new date for adoption once it is available.
The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on February 11, 2021 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.
To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines.
The new Medical Policies listed below have been approved.
Note: *Precertification required
|
Title
|
Information
|
Effective date
|
|
GENE.00056
Gene Expression Profiling for Bladder Cancer
|
• Gene expression profiling for diagnosing, managing and monitoring bladder cancer is considered INV&NMN -- Existing CPT codes 0012M, 0013M (Cxbladder GEP) moved from LAB.00011, still considered INV&NMN; CPT 0016M effective 01/01/2021 for Decipher TURBT® will be considered INV&NMN
|
7/1/2021
|
|
LAB.00038
Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
|
• Cell-free DNA testing is considered INV&NMN as a non-invasive method of determining the risk of rejection in kidney transplant recipients
- Existing code 0118U for Vitacor TRAC will be considered INV&NMN for kidney transplant diagnoses; no specific codes for other tests, listed 81479, 81599 NOC codes
|
7/1/2021
|
|
LAB.00039
Pooled Antibiotic Sensitivity Testing
|
• Pooled antibiotic sensitivity testing is considered INV&NMN in the outpatient setting for all indications
- No specific codes for these tests (eg Guidance® assay for UTI [Pathnostics, Inc.]), considered INV&NMN; listed NOC codes 81479, 87999
|
7/1/2021
|
|
SURG.00159
Focal Laser Ablation for the Treatment of Prostate Cancer
|
• Focal laser ablation is considered INV&NMN for the treatment of prostate cancer
- No specific code for focal laser ablation of prostate for cancer, considered INV&NMN; listed 55899 NOC and associated ICD-10-PCS code; also listed 0655T (will be effective 07/01/2021) considered INV&NMN
|
7/1/2021
|
|
*TRANS.00037
Uterine Transplantation
|
• Uterine transplantation is considered INV&NMN for all uses, including but not limited to the treatment of uterine factor infertility due to nonfunctioning or absent uterus
- No specific CPT code for uterine transplant services, considered INV&NMN; listed 58999 NOC and associated ICD-10-PCS codes, also listed 0664T-0670T (will be effective 07/01/2021) considered INV&NMN
|
7/1/2021
|
The current Medical policies and/or Clinical Guidelines listed below were reviewed and updates were approved.
Note: *Precertification required
|
Title
|
Change
|
Effective date
|
|
*CG-GENE-22
Gene Expression Profiling for Managing Breast Cancer Treatment
|
• Content moved from GENE.00011
• INV&NMN changed to NMN as a result of MP to CUMG transition
• Removed Insight DX test (no longer marketed) and added Insight TNBC type test as NMN
|
4/7/2021
|
|
*CG-GENE-23
Genetic Testing for Heritable Cardiac Conditions
|
• Content moved from GENE.00007 and GENE.00017
• INV&NMN changed to NMN as a result of MP to CUMG transition
• No other change to clinical indications
|
4/7/2021
|
|
*ANC.00008
Cosmetic and Reconstructive Services of the Head and Neck
|
• Removed the word “physical” from the term “physical functional impairment” in Facial Plastic Surgery, Otoplasty, Rhinophyma, Rhinoplasty or Rhinoseptoplasty and Cranial Nerve Procedures position statements
• Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as COS&NMN
- No specific code for implanted auricular prosthesis, added L8699 NOC, considered COS&NMN for specific implants
|
7/1/2020
|
|
*CG-OR-PR-04
Cranial Remodeling Bands and Helmets (Cranial Orthotics)
|
• Removed condition requirement from REC criteria
• Replaced current diagnostic REC criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry
|
7/1/2021
|
|
*CG-SURG-82
Bone-Anchored and Bone Conduction Hearing Aids
|
• Reorganized Clinical Indications section
• Reorganized and clarified bilateral hearing loss MN criteria
• Clarified MN criteria for transcutaneously-worn bone conduction hearing aids for both bilateral and unilateral hearing loss
• Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
• Moved device-specific threshold information to the Discussion section
• Clarified MN criteria for transcutaneously worn and fully- or partially-implantable bone conduction hearing aids for unilateral hearing loss
• Added NMN statement for when MN criteria have not been met
• Clarified NMN statement regarding replacement parts or upgrades
• Added bone conduction hearing aids using an adhesive adapter behind the ear as NMN for all indications
|
7/1/2021
|
|
*CG-GENE-14
Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
|
• Reorganizing genetic testing topics: Moved the content of the following topics into CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
- CG-GENE-02 Analysis of RAS Status
- CG-GENE-03 BRAF Mutation Analysis
- CG-GENE-12 PIK3CA Mutation Testing for Malignant Condition
- CG-GENE-20 Epidermal Growth Factor Receptor [EGFR] Testing)
• Added circulating tumor DNA (ctDNA) to guide targeted cancer therapy in individuals with solid tumor(s) as MN when criteria are met
• Added NMN criteria on circulating tumor DNA (ctDNA) when the medically necessary criteria are not met, including to detect the recurrence of a solid tumor, including ectal cancer, and to test for solid tumor cancer susceptibility
- Content addressing ctDNA involving 4 or fewer genes or gene variants, moved from GENE.00049 Circulating Tumor DNA Panel Testing for Cancer (Liquid Biopsy) and added to this document (CG-GENE-14)
- Content addressing ctDNA involving 5 or more genes or gene variants (gene panel), will continue to be addressed in GENE.00049
- Added PLA code 0229U (Colvera® 2-gene test) considered NMN (moved from GENE.00049, was considered INV&NMN); added specific codes from merged guidelines (PIK3CA 81309, 0155U, 0177U; RAS 81275, 81276, 81311, 0111U; BRAF 81210; EGFR 81235) and genes to Tier 2 codes, with no changes
|
4/1/2021
|
Reveleer is the contracted vendor to gather member medical records on behalf of the Blue Cross and Blue Shield Federal Employee Program. We value the relationship with our providers, and ask that you respond to the detailed requests in support of risk adjustment, HEDIS and other government required activities within the requested timeframe.
Reveleer will work with you to obtain records via fax, mail, remote electronic medical record (EMR) access, or onsite scanning/EMR download (as necessary). We ask that you please promptly comply within five (5) business days of the record requests.
If you have any questions, you can reach a Reveleer representative by calling 855-454-6182 or contact Ify Ifezulike with Blue Cross Blue Shield Federal Employee Program at (202) 626-4839.
Visit Pharmacy Information for Providers on anthem.com 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
- Any other requirements, restrictions, or limitations that apply to using certain drugs
The commercial drug list is posted to the website quarterly (the first of the month for January, April, July and October).
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
To access the Clinical Criteria information please click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
*ING-CC-0027
|
J0897
|
Xgeva
|
* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
Quantity Limit Updates
Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
To access the Clinical Criteria information please click here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
*ING-CC-0027
|
J0897
|
Xgeva
|
* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
In the February 2021 edition of Provider News, we announced updates to the formulary lists for Commercial health plans effective April 1, 2021.
Be advised that this is the link to the correct summary of formulary changes. Please disregard the list published in the February article.
We apologize for any inconvenience this may have caused.
Beginning July 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) is implementing a designated network for select specialty pharmacy medications administered in the outpatient hospital setting, Designated SRx Network. This applies to all Anthem commercial members and claims priced by Anthem for commercial BlueCard program members. This does not apply to Medicare Advantage, Medicaid, Medicare Supplement, or the Federal Employee Program.
Hospitals that are not in our Designated SRx Network will be required to acquire the select specialty pharmacy medications administered in the hospital outpatient setting through CVS Specialty Pharmacy. For dates of service on or after July 1, 2021, the prescribing provider for Anthem commercial members should continue to contact AIM Specialty Health or IngenioRx for prior authorization. During the authorization process, the prescribing provider will be notified of the requirement to utilize CVS Specialty as the dispensing provider for the specialty pharmacy medication when administered in the outpatient hospital setting. The failure to do so will result in claim denials and the member cannot be billed for these specialty medications. Hospitals may continue to submit a claim for administration of the specialty pharmacy medications in the outpatient hospital setting, which will be reimbursed at the current contracted rates.
If you wish to be included in the Designated SRx Network by agreeing to the terms/conditions, please contact your Anthem facility contract manager.
The list of specialty pharmacy medications subject to the above will be posted at anthem.com for reference and is subject to change. All specialty pharmacy prior authorization requirements will still apply and are the responsibility of the prescribing provider.
This will have no impact on how members obtain non-specialty pharmacy medications at retail pharmacies or by mail-order.
To access the current Designated Medical Specialty Pharmacy Drug List, visit anthem.com, select Providers, select the state Wisconsin (top right of page), select Forms and Guides (under the Provider Resources column). Scroll down and select Pharmacy in the Category drop down.
On December 18, 2020, and December 22, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following 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.
Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
|
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
|
April 8, 2021
|
ING-CC-0185*
|
Oxlumo (lumasiran)
|
New
|
|
April 8, 2021
|
ING-CC-0184*
|
Danyelza (naxitamab-gqgk)
|
New
|
|
April 8, 2021
|
ING-CC-0154
|
Givlaari (givosiran)
|
Revised
|
|
April 8, 2021
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
Revised
|
|
April 8, 2021
|
ING-CC-0002
|
Colony Stimulating Factor Agents
|
Revised
|
|
April 8, 2021
|
ING-CC-0032*
|
Botulinum Toxin
|
Revised
|
|
April 8, 2021
|
ING-CC-0015
|
Infertility and HCG Agents
|
Revised
|
On June 18, 2020, August 21, 2020, and November 20, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following 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.
Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
|
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
|
March 26, 2021
|
ING-CC-0183*
|
Sogroya (somapacitan-beco)
|
New
|
|
March 26, 2021
|
ING-CC-0148*
|
Agents for Hemophilia B
|
Revised
|
|
March 26, 2021
|
ING-CC-0149*
|
Select Clotting Agents for Bleeding Disorders
|
Revised
|
|
March 26, 2021
|
ING-CC-0065
|
Agents for Hemophilia A and von Willebrand Disease
|
Revised
|
|
March 26, 2021
|
ING-CC-0125
|
Opdivo (nivolumab)
|
Revised
|
|
March 26, 2021
|
ING-CC-0119
|
Yervoy (ipilimumab)
|
Revised
|
|
March 26, 2021
|
ING-CC-0121*
|
Gazyva (obinutuzumab)
|
Revised
|
|
March 26, 2021
|
ING-CC-0048 *
|
Spinraza (nusinersen)
|
Revised
|
|
March 26, 2021
|
ING-CC-0002*
|
Colony Stimulating Factor Agents
|
Revised
|
|
March 26, 2021
|
ING-CC-0034*
|
Hereditary Angioedema Agents
|
Revised
|
|
March 26, 2021
|
ING-CC-0041*
|
Complement Inhibitors
|
Revised
|
|
March 26, 2021
|
ING-CC-0071*
|
Entyvio (vedolizumab)
|
Revised
|
|
March 26, 2021
|
ING-CC-0064*
|
Interleukin-1 Inhibitors
|
Revised
|
|
March 26, 2021
|
ING-CC-0042*
|
Monoclonal Antibodies to Interleukin-17
|
Revised
|
|
March 26, 2021
|
ING-CC-0066*
|
Monoclonal Antibodies to Interleukin-6
|
Revised
|
|
March 26, 2021
|
ING-CC-0050*
|
Monoclonal Antibodies to Interleukin-23
|
Revised
|
|
March 26, 2021
|
ING-CC-0078*
|
Orencia (abatacept)
|
Revised
|
|
March 26, 2021
|
ING-CC-0063*
|
Stelara (ustekinumab)
|
Revised
|
|
March 26, 2021
|
ING-CC-0062*
|
Tumor Necrosis Factor Antagonists
|
Revised
|
|
March 26, 2021
|
ING-CC-0003*
|
Immunoglobulins
|
Revised
|
|
March 26, 2021
|
ING-CC-0039*
|
GamaSTAN [immune globulin (human)]
|
Revised
|
|
March 26, 2021
|
ING-CC-0053
|
Injectable Hydroxyprogesterone for Prevention of Preterm Birth
|
Revised
|
|
March 26, 2021
|
ING-CC-0073*
|
Alpha-1 Proteinase Inhibitor Therapy
|
Revised
|
|
March 26, 2021
|
ING-CC-0075
|
Rituximab Agents for Non-Oncologic Indications
|
Revised
|
|
March 26, 2021
|
ING-CC-0072
|
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
|
Revised
|
|
March 26, 2021
|
ING-CC-0027*
|
Denosumab Agents
|
Revised
|
|
March 26, 2021
|
ING-CC-0019*
|
Zoledronic Acid Agents (Reclast, Zometa)
|
Revised
|
|
March 26, 2021
|
ING-CC-0011*
|
Ocrevus (ocrelizumab)
|
Revised
|
|
March 26, 2021
|
ING-CC-0174*
|
Kesimpta (ofatumumab)
|
Revised
|
Anthem Blue Cross and Blue Shield (Anthem) is committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to better healthcare experiences for consumers.
Effective for dates of service on or after July 1, 2021, providers for our Medicare Advantage plan members covered by Anthem will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications, listed below. Reviews for these oncology drugs will continue to be administered by the reviewing company, either AIM Specialty Health®* or IngenioRx.*
Providers will be asked whether or not they will accept the dose reduction at the initial review point in the prior authorization process. Within the provider portal, a pop-up question will appear related to dose reduction. If the patient is considered unable to have his or her dose reduced, then a second question will appear asking for the provider’s clinical reasoning. For requests made outside of the provider portal (for example, called-in or faxed-in prior authorization requests), the same questions will be asked by the registered nurse or medical director who is reviewing the request. Since this program is voluntary, the decision made regarding dose reduction will not affect the final decision on the prior authorization.
The dose reduction questions will appear only if the originally requested dose is within 10% of the nearest whole vial. This threshold is based on current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) that it is appropriate to consider dose rounding within 10%. HOPA recommendations can be found here.
The Voluntary Dose Reduction Program only applies to specific oncology drugs, listed below. Providers can view prior authorization requirements for Anthem members on the Medical Policy and Clinical Utilization Management Guidelines page at anthem.com/medicareprovider.
|
Drug name
|
HCPCS code
|
Drug name
|
HCPCS code
|
|
Abraxane (paclitaxel protein-bound)
|
J9264
|
Istodax (romidepsin)
|
J9315
|
|
Actimmune (interferon gamma-1B)
|
J9216
|
Ixempra (ixabepilone)
|
J9207
|
|
Adcetris (brentuximab vedotin)
|
J9042
|
Jevtana (cabazitaxel)
|
J9043
|
|
Alimta (pemetrexed)
|
J9305
|
Kadcyla (ado-trastuzumab emtansine)
|
J9354
|
|
Asparlas (calaspargase pegol-mknl)
|
J9118
|
Keytruda (pembrolizumab)
|
J9271
|
|
Avastin (bevacizumab)
|
J9035
|
Kyprolis (carfilzomib)
|
J9047
|
|
Bendeka (bendamustine)
|
J9034
|
Lartruvo (olaratumab)
|
J9285
|
|
Besponsa (inotuzumab ozogamicin)
|
J9229
|
Lumoxiti (moxetumomab pasudotox-tdfk)
|
J9313
|
|
Blincyto (blinatumomab)
|
J9039
|
Mylotarg (gemtuzumab ozogamicin)
|
J9203
|
|
Cyramza (ramucirumab)
|
J9308
|
Neupogen (filgrastim)
|
J1442
|
|
Darzalex (daratumumab)
|
J9145
|
Oncaspar (pegaspargase)
|
J9266
|
|
Doxorubicin liposomal
|
Q2050
|
Opdivo (nivolumab)
|
J9299
|
|
Elzonris (tagraxofusp-erzs)
|
J9269
|
Padcev (enfortumab vedotin-ejfv)
|
J9177
|
|
Empliciti (elotuzumab)
|
J9176
|
Polivy (polatuzumab vedotin-piiq)
|
J9309
|
|
Enhertu (fam-trastuzumab deruxtecan-nxki)
|
J9358
|
Rituxan (rituximab)
|
J9312
|
|
Erbitux (cetuximab)
|
J9055
|
Sarclisa (isatuximab-irfc)
|
J9999
|
|
Erwinase (asparginase)
|
J9019
|
Sylvant (siltuximab)
|
J2860
|
|
Ethyol (amifostine)
|
J0207
|
Treanda (bendamustine)
|
J9033
|
|
Granix (tbo-filgrastim)
|
J1447
|
Vectibix (panitumumab)
|
J9303
|
|
Halaven (eribulin mesylate)
|
J9179
|
Yervoy (ipilimumab)
|
J9228
|
|
Herceptin (trastuzumab)
|
J9355
|
Zaltrap (ziv-aflibercept)
|
J9400
|
|
Imfinzi (durvalumab)
|
J9173
|
|
|
Providers should continue to verify eligibility and benefits for all members prior to rendering services.
If you have questions, please call the Provider Service phone number on the back of the member’s ID card.
Note: In some plans, dose reduction to nearest whole vial or waste reduction may be the term used in benefit plans, provider contracts or other materials instead of or in addition to dose reduction to nearest whole vial. In some plans, these terms may be used interchangeably. For simplicity, we have uses dose reduction (to nearest whole vial).
Welcome to the 2021 In-Office Assessment (IOA) program. The IOA program is designed to help providers ensure that all active conditions are continuously being addressed and documented to the highest level of specificity for all Medicare Advantage plan patients of providers participating in the program. This program is designed to help improve all patient quality of care (preventive medicine screening, managing chronic illness and prescription management), as well as care for older adults when generated for a Special Needs Plan member.
If you are interested in learning about the electronic modalities available, please contact your representative or the Optum* Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time.
Success stories
Below are some achievements that Anthem Blue Cross and Blue Shield (Anthem) was able to accomplish with provider groups through the IOA program:
- As a result of leveraging different types of resources offered by the IOA program (for example, technology), providers’ offices were able to see an increase in staff productivity.
- Providers who have taken advantage of the IOA program resources have seen an increase in their documentation and coding accuracy.
COVID-19 update
Anthem knows this is a difficult time for everyone, as the situation continues to evolve each day. Anthem has considered the severity of the situation and is following CDC Guidelines. For the IOA program, all nonessential personal are required to work with provider groups telephonically/electronically until further notice.
Anthem continues to evaluate the situation and guidelines, and will keep you notified of any changes. If you have any questions or concerns about the IOA program and COVID-19 updates, please call the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time.
Dates and tips to remember:
- To review their population as soon as possible, Anthem strongly encourages participating providers to deliver and continually maintain proper care management, as well as care coordination of their patient population. This will further ensure the current and active conditions that impact patient care, treatment and/or management are continually addressed.
- At the conclusion of each office visit with the patient, providers participating in the IOA program are asked to complete and return a patient assessment. The assessment should be completed based on information regarding the patient’s health collected during the office visit. Participating providers may continue to use the 2021 version of the assessment for encounters that take place on or before December 31, 2021; Anthem will accept the 2021 version of the assessment for 2021 encounters until midnight January 31, 2022.
- If not already submitted, participating providers are required to submit an Account Setup Form, W-9 and completed direct deposit enrollment by March 31, 2022. Participating providers should call the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time, if they have any questions regarding this requirement. Failure to comply with this requirement will result in forfeiture of the provider payment for submitted 2021 assessments, if applicable.
Questions
If you have questions about this communication or the IOA program, please contact your representative or the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time.
Beginning in April 2021, our online directories will identify professional providers who offer telehealth services in their practice.
We encourage providers to utilize the online Provider Maintenance Form to notify us about your telehealth services and we will add a telehealth indicator to your online provider directory profile.
Visit anthem.com to locate the online Provider Maintenance Form. Please contact Provider Services if you have any questions.
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