 Provider News WisconsinFebruary 1, 2021 February 2021 Anthem Provider News - WisconsinState & FederalState & Federal | BadgerCare Plus and Medicaid SSI Programs | February 1, 2021 CAHPS® survey
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.
- Prior authorization updates for specialty pharmacy are available – February 2021*
- Medical Policy and Clinical Guideline Updates – February 2021*
- Reimbursement policy update: Emergency Room Transfers – Facility*
- Reimbursement policy update: Treatment Rooms with Office Evaluation and Management Services – Facility*
Anthem will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.
We encourage providers who offer telehealth services to utilize the online Provider Maintenance Form to notify us and we will add a telehealth indicator to your online provider directory profile.
Visit anthem.com to locate the Provider Maintenance Form. Contact Provider Services if you have any questions.
In January we introduced our new Authorization Rules Lookup tool that you can access through Availity Payer Spaces. This new self-service application displays prior authorization rules so you can quickly verify if the outpatient services require prior authorization for members enrolled in Anthem’s commercial plans.
In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:
- Medical Policies and Clinical Guidelines
- Third Party Guidelines, if applicable (such as AIM Specialty Health, IngenioRx)
Steps to access the Authorization Lookup application through Availity Payer Spaces
Access to the tool does not require an Availity role assignment.
- Select Payer Spaces
- Select the Anthem Blue Cross Blue Shield tile from the Payer Spaces menu
- Select the Applications tab
- Select the Authorization Rules Lookup tile
Once you are in the tool you will need to provide the following information to display the service’s prior authorization rules:
- Tax ID
- National Provider Identifier (NPI)
- Member ID and birth date
- Member’s Group number or Contract Code
(This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)
- CPT/HCPCS code
Give this new tool a try and discover how much this will improve the efficiency of your authorization process.
Please note: If a prior authorization is required for outpatient services, you can submit the case through Interactive Care Reviewer Anthem’s online authorization tool which you can also access through the Availity Portal.
The following Anthem Blue Cross and Blue Shield medical polices will require prior authorization for Indiana, Kentucky, Missouri, Ohio and Wisconsin.
NOTE *Precertification required
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Title
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Information
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Effective Date
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* GENE.00055 Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
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• Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered Investigational and not medically necessary (INV&NMN) for all indications.
CPT PLA code 0203U (effective 10/01/2020) will be considered INV&NMN; also listed NOC codes 81479, 81599 considered NMN when specified as this test.
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5/1/2021
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* SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
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• Implantable peripheral nerve stimulation devices are considered INV&NMN for all indications including, but not limited to, treatment of acute and chronic pain
• Moved content addressing implantable devices (temporarily or permanently implanted) from DME.00011 to this new policy with no change in criteria.
Existing nonspecific codes 64555, 64575, 64590, C1767, C1778, C1787, L8679, L8680, L8683 for neurostimulator implantation and devices will be reviewed and considered INV&NMN for description of PNS systems for pain
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5/1/2021
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* CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction
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This document addresses angiographic evaluation for dialysis access circuit dysfunction and treatment for stenotic or thrombosed arterio-venous grafts (AVG) or fistulas (AVF). This document does not address angiographic evaluation as a treatment for venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, or improving venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).
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5/1/2021
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A new facility reimbursement policy titled Emergency Room Transfers will be implemented beginning with dates of service on, or after May 1, 2021. The policy allows reimbursement for one emergency room visit when a patient is transferred between facilities operating under the same agreement, have the same tax identification number (TIN), or is under common ownership. The transferring facility will not be eligible for separate reimbursement.
For more information about this policy, view Anthem’s reimbursement policies online for your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin.
A new facility reimbursement policy titled Treatment Rooms with Office Evaluation and Management Services will be implemented beginning with dates of service on, or after May 1, 2021. Anthem does not allow reimbursement for office evaluation and management services when reported on a CMS 1450 (UB-04) with revenue code 761 (treatment rooms). Modifiers will not override the edit.
For more information about this policy, view Anthem’s reimbursement policies online for your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin.
Effective with dates of service on and after April 1, 2021, and in accordance with the IngenioRx Pharmacy and Therapeutics (P&T) process, Anthem will update its drug lists that support commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes here.
IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem.
Prior authorization updates
Effective for dates of service on and after May 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.
Click here to access the Clinical Criteria information.
Anthem Blue Cross and Blue Shield (Anthem)’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0183
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J3590
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Sogroya
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*ING-CC-0001
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J0886
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Injection, epoetin alfa (Procrit/Epogen)
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*ING-CC-0019
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J3489
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Reclast, Zometa
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* Non-oncology use is managed by Anthem’s medical specialty drug review team.
Oncology use is managed by AIM.
Quantity Limit Updates
Effective for dates of service on and after May 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.
Click here to access the Clinical Criteria information.
Anthem Blue Cross and Blue Shield (Anthem)’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0019
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J3489
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Reclast, Zometa
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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 web site 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.
New: additional benefit detail
Now, you can select Additional Benefit Notes, on the Availity Portal* Eligibility and Benefits results screen to find more descriptive benefit information.
Benefits are listed in alphabetical order, making it easier to search for specific benefits. Capabilities include full benefit descriptions, vendor information associated with the benefit and the option for the provider to print out the benefit information.
Digital member ID cards
The digital member ID card allows easy, low-touch access to view additional information or confirm basic membership details.
When conducting an eligibility and benefits inquiry for BadgerCare Plus members, simply select View Member ID Card on the Eligibility and Benefits results page. Note: The Availity Portal requires you to enter the member’s ID number, as well as a date of birth or the member’s first and last name into the search options in order to submit an eligibility and benefits inquiry.
Try both of these valuable tools today!
On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email. CAHPS is an annual standardized survey conducted from January to May to assess consumers’ experience with their provider and health plan. A random sample of your adult and child patients may get the survey. Providers directly impact the majority of questions used for scoring.
These questions are:
- When you needed care right way, how often did you get it?
- How often did you get an appointment for a check-up or routine care as soon as you needed it?
- How often was it easy to get the care, tests, or treatment you needed?
- How often did you get an appointment to see a specialist as soon as you needed it?
- How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
- How would you rate your primary care doctor?
- How would you rate the specialist you see most often?
To learn more about CAHPS and how you can improve the patient experience, review the CAHPS Overview training by visiting https://mediproviders.anthem.com/wi.
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Revised measures
- The former Well-Child Visits in the First 15 Months of Life (W15) measure was revised to Well‑Child Visits in the First 30 Months of Life (W30). It includes two indicators:
- Well-child visits in the first 15 months — children who turned 15 months during the measurement year with six or more well-child visits
- Well-child visits for ages 15 to 30 months — children who turn 30 months during the measurement year with two or more well-child visits
- The former Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) and Adolescent Well-Care Visits (AWC) measures have been combined into Child and Adolescent Well-Care Visits (WCV):
- The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year
Key measure changes
- Controlling High Blood Pressure (CBP and CDC-CBP)
Telephone visits, e-visits and virtual check-ins are now acceptable settings for blood pressure (BP) readings. Digital BP readings reported by the member are considered numerator compliant.
- Telehealth updates
NCQA has updated telehealth guidance in 40 HEDIS® measures for HEDIS measurement years 2020 and 2021. The purpose of these changes is to:
- Support increased use of telehealth caused by the pandemic.
- Align with guidance from Centers for Medicare & Medicaid Services and other stakeholders.
A list of the 40 measures can be found on the NCQA COVID-19 website at www.ncqa.org/covid.
New Medicaid measures
Kidney Health Evaluation for Patients With Diabetes (KED) — The percentage of members 18 to 85 years of age with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a uACR identified by both a quantitative urine albumin test and a urine creatinine test with service days four or less days apart during the measurement year
Cardiac Rehabilitation (CRE) — The percentage of members 18 years and older who attended cardiac rehabilitation following a qualifying cardiac event, including myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, heart and heart/lung transplantation, or heart valve repair/replacement; four rates are reported:
- Initiation — The percentage of members who attended two or more sessions of cardiac rehabilitation within 30 days after a qualifying event
- Engagement 1 — The percentage of members who attended 12 or more sessions of cardiac rehabilitation within 90 days after a qualifying event
- Engagement 2 — The percentage of members who attended 24 or more sessions of cardiac rehabilitation within 180 days after a qualifying event
- Achievement — The percentage of members who attended 36 or more sessions of cardiac rehabilitation within 180 days after a qualifying event
Retired Medicaid measures
- Comprehensive Diabetes Care (CDC) retired sub-measures
- Medical Attention for Nephropathy (retired for Commercial and Medicaid)
- HbA1c control (< 7.0%) for a selected population
- Adult BMI Assessment (ABA)
- Medication Management for People With Asthma (MMA)
- Children’s and Adolescents’ Access to Primary Care Practitioners (CAP)
Measure change summary:
For a complete summary, go to https://tinyurl.com/NCQA-measures.
On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC (AMH Health). 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 September and October 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
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