 Provider News WisconsinFebruary 2023 Anthem Provider News - WisconsinThe Department of Health and Human Services (HHS) Notice of Benefit and Payment Parameters for 2023 Final Rule for Marketplace health plans has a Network Adequacy provision regarding telehealth services. As of January 2023, HHS requires health plans to identify and report the in-network providers who offer telehealth services. As a participating provider with Anthem Blue Cross and Blue Shield, if you provide telehealth services, please let us know by submitting your information to us via the online Provider Maintenance Form, which can be found at anthem.com or through Availity Essentials.* We will add a telehealth indicator to your online provider directory profile so our members know you offer this service. If you have questions about submitting your information, please contact Provider Services.
* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. MULTI-BCBS-CM-017258-23-CPN17179 The Consolidated Appropriations Act, implemented in 2021, contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current. We ask that you to review your online provider directory information on a regular basis to ensure it is correct. To access your information, go here. Then, under Provider Overview, select Find Care. Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include: - Add/change an address location.
- Name change.
- Tax ID changes.
- Provider leaving a group or a single location.
- Phone/fax number changes.
- Closing a practice location.
Once you submit the form, we will send you an email acknowledging receipt of your request. MULTI-BCBS-CM-016525-22-CPN16491 We are committed to improving the way we do business with our provider community. Listening to your feedback, we are pleased to announce a new look and feel is coming to Provider News in the first half of 2023, with additional improvements planned throughout the rest of the year. Stay tuned for more updates. WIBCBS-CDCRCM-016129-22-CPN15788 The best way to send supporting documents when disputing, appealing, or sending us additional information about a claim is to use the digital applications available on Availity.com.* Using Availity.com to send attachments, such as medical records or an itemized bill, is: - We’ll receive the documents needed faster than through the mail.
- Less expensive. No need to pull records, copy them, and then mail them. Digital submissions can be uploaded directly to the claim.
- Submitting attachments digitally is the easiest way to send them and the best way for us to receive them.
- More accurate. The information needed to identify the claim is automated, so the risk associated with submitting incorrect information on paper is eliminated.
However, if you choose to send documentation through the mail, it is important that you include at least one of the three following elements; otherwise, we will not be able to match the document to the claim and the correspondence will be returned to you, causing further delays: - Valid claim number
or
- Valid member ID with prefix and correct dates of service
or
- Valid member ID with prefix and billed charges
For a clinical appeal, ensure these elements are included: - Valid claim number
or
- Valid member ID with prefix and correct dates of service
or
- Valid member ID with prefix) and billed charges
or
- Member name, member date of birth, and correct dates of service
or
- Member name, member date of birth, authorization, or reference number
This is important: We cannot match the attachment to the correct claim or member if these elements are not included with your non-digital (fax or mail) submission. The preferred method for submitting supporting documentation is digitally because the documents are attached directly to the claim. This reduces the possibility that incorrect information is included on the paper submission. To attach documents to your claim digitally, go to Availity.com and use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim and use the Submit Attachments button to upload your supporting documentation. For a claim dispute or an appeal, from Availity.com, use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim, use the Dispute button, and upload your supporting documentation. If the Dispute button capability is not available, refer to the provider manual for information about how to file a claim dispute/appeal. If you do send supporting documentation through the mail or fax, you must include the elements noted above. It is preferrable that you include this information on the first page of the correspondence you send to us. If this information is not included on your paper correspondence, we will return the correspondence to you because we are not able to validate the documentation. For information about submitting attachments digitally, use this link to access Availity: Learn about the new claim attachments workflow. * Availity, LLC is an independent company providing administrative support services on behalf of health plan. MULTI-BCBS-CM-016609-22-CPN16477 The following Anthem Blue Cross and Blue Shield (Anthem) Medical Polices and Clinical Guidelines were reviewed on November 10, 2022. To view medical policies and utilization management guidelines, go to anthem.com, select Providers, and then select your state. Under Provider Resources, select Policies, Guidelines & Manuals. To help determine if prior authorization is needed for Anthem members, go to anthem.com, select Providers, and then select your state. Under Claims, select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card. 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®]), visit www.fepblue.org > Policies & Guidelines. Below are the current Clinical Guidelines and/or Medical Policies we reviewed, and updates were approved. * Denotes prior authorization required Policy/guideline | Information | Effective date | *CG-DME-31 Powered Wheeled Mobility Devices | Added NMN statement for powered wheeled mobility devices using computerized systems to assist with functions such as seat elevation and navigation over curbs, stairs, or uneven terrain (for example, the iBOT Personal Mobility Device) for all indications | 5/1/2023 | *CG-GENE-13 Genetic Testing for Inherited Diseases | Incorporated content from CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions, GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies, GENE.00037 Genetic Testing for Macular Degeneration (partial content), GENE.00038 Genetic Testing for Statin-induced Myopathy, and GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD) into this document- Added CPT and HCPCS codes 81324, 81325, 81326, 81328, 81414, S3861, S3865, S3866, and genes to Tier 2 codes from the documents listed above; also some additional genes added to Tier 2 and NOC codes | 12/28/2022 | *CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management | Moved content from CG-GENE-07 BCR-ABL Mutation Analysis and CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility into this document Added CPT and HCPCS codes 81170 and S3840 and additional genes to Tier 2 codes from documents listed above | 12/28/2022 | CG-MED-23 Home Health | Added HCPCS codes G0320, G0321, G0322 for home health services MN when criteria are met | 5/1/2023 | *CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting | Added HCPCS code G0330 for facility billing for dental services requiring anesthesia, replacing NOC code 41899 | 12/28/2022 | *CG-SURG-27 Gender Affirming Surgery | Added ‘Placement of penile or testicular prostheses’ to NMN statement | 5/1/2023 | *CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities | Added HCPCS codes C7531, C7534, C7535 for revascularization of femoral, popliteal arteries, MN when criteria are met | 5/1/2023 | *CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure | Added HCPCS codes C7538, C7539, C7540 when related to cardiac resynchronization therapy, MN when criteria are met | 5/1/2023 | *CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids | Added CPT codes 69729, 69730 for BAHA with magnetic transcutaneous attachment, MN when criteria are met; also descriptor revisions for codes 69716, 69717, 69719 | 5/1/2023 | *CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity | Added new CPT codes 43290, 43291 for intragastric balloon considered INV&NMN; added NOC code 64999 replacing CPT category III codes 0312T-0317T when specified as VBLOC considered INV&NMN; removed CPT code 00797 for associated anesthesia not addressed | 5/1/2023 | DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Added new CPT Category III codes 0766T, 0767T, 0768T, 0769T, 0783T effective for transcutaneous electromagnetic pulse stimulation and transcutaneous auricular neurostimulation, considered INV&NMN | 5/1/2023 | DME.00048 Virtual Reality-Assisted Therapy Systems | Added new CPT Category III codes 0770T, 0771T, 0772T, 0773T, 0774T for services using virtual reality technology, considered INV&NMN | 5/1/2023 | GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | Added new CPT code 81418 for drug metabolism panel, considered INV&NMN | 5/1/2023 | GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy) | Added CPT PLA code 0356U for NavDx test considered INV&NMN | 5/1/2023 | *GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | Moved content from GENE.00037 Genetic Testing for Macular Degeneration and CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions into this document Added chromosome conformation signatures to scope of document and INV&NMN statement | 5/1/2023 | *GENE.00056 Gene Expression Profiling for Bladder Cancer | Added CPT PLA code 0363U for Cxbladder Triage test considered INV&NMN | 5/1/2023 | LAB.00011 Selected Protein Biomarker Algorithmic Assays | Added CPT PLA code 0360U for Nodify CDT test considered INV&NMN | 5/1/2023 | LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer | Added CPT PLA code 0359U for IsoPSA test, considered INV&NMN | 5/1/2023 | LAB.00046 Testing for Biochemical Markers for Alzheimer's Disease | Added CPT PLA codes 0358U for Lumipulse G βAmyloid Ratio and 0361U for Neurofilament Light Chain (NfL) tests, considered INV&NMN | 5/1/2023 | *MED.00130 Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring Previously titled: Surface Electromyography Devices for Seizure Monitoring | Revised title Revised Position Statement by adding electrodermal activity sensor devices Added HCPCS code E1399 NOC, no specific code for electrodermal activity devices considered INV&NMN | 5/1/2023 | *SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | Added HCPCS codes Q4262, Q4263, Q4264 for products considered INV&NMN; also added Q4236 reactivated for Care patch, considered INV&NMN | 5/1/2023 | *SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures | Added chest wall reconstruction with flat chest closure to the list of surgical procedures considered ‘Reconstructive’ following surgery for breast cancer | 5/1/2023 | SURG.00079 Nasal Valve Repair | Added new CPT code 30469 for Vivaer procedure, considered INV&NMN | 5/1/2023 | SURG.00095 Viscocanalostomy and Canaloplasty | Revised descriptors for CPT codes 66174, 66175 | 12/28/2022 | *SURG.00097 Scoliosis Surgery | Added magnetically controlled growing rods to scope of document in INV&NMN statement | 5/1/2023 | SURG.00113 Artificial Retinal Devices | Removed HCPCS codes C1841, C1842 HCPCS update | 12/28/2022 | SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain | Revised descriptors for CPT codes 64415, 64417, 64447 | 12/28/2022 | TRANS.00013 Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation | Added the term “Multivisceral” and the phrase, “including but not limited to treatment of pseudotumor peritonei” to the first INV&NMN statement Removed the third INV&NMN on “all other Multivisceral transplants” | 5/1/2023 | TRANS.00029 Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias | Expanded scope of document to address autologous hematopoietic stem cell mobilization and pheresis for the treatment of genetic diseases as part of the development of an FDA-approved ex vivo gene therapy (for example, betibeglogene autotemcel or elivaldogene autotemcel) Added MN and INV&NMN criteria for Autologous hematopoietic stem cell mobilization and pheresis | 5/1/2023 | THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radio-ablation | Added new CPT Category III codes 0745T, 0746T, 0747T for cardiac radio-ablation services considered INV&NMN: replacing non-specific radiation therapy codes | 5/1/2023 | TRANS.00035 Therapeutic use of Stem Cells, Blood, and Bone Marrow Products | Added CPT Category III code 0748T for injection of stem cell product into perianal peri fistular soft tissue considered INV&NMN | 5/1/2023 |
*Material adverse change
Effective for dates of service on and after April 1, 2023, the following code updates will apply to the AIM Specialty Health®* Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. Percutaneous coronary intervention: CPT® code | Description | C9600 | Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch | C9601 | Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) | C9602 | Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch | C9603 | Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) | C9604 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel | C9605 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) | C9607 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel | C9608 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure) |
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways: - Access AIM’s ProviderPortalSM directly at providerportal.com
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Essentials at availity.com
If you have questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. MULTI-BCBS-CR-013612-22-CPN12754 To view the 2023 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), go to www.fepblue.org > select Tools & Resources > Brochure & Resources. Here, you will find the Service Benefit plan brochure, benefit plan summaries, and Quick Reference Guides on information for year 2023. If you have questions, please contact FEP Customer Service at: CO – 800-852-5957 CT – 800-438-5356 GA – 800-282-2473 IN – 800-382-5520 KY – 800-456-3967 ME – 800-722-0203 MO – 800-392-8043 NV – 800-727-4060 NH – 800-852-3316 NY – 800-522-5566 OH – 800-451-7602 VA – 800-552-6989 WI – 800-242-9635
*Material adverse change
Prior authorization clinical review for non-oncology use of specialty pharmacy drugs is managed by Anthem Blue Cross and Blue Shield’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health®* (AIM), a separate company. Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to submit a prior authorization for your patients’ continued use of these medications. Including the National Drug Code (NDC) code on your claim may help expedite claim processing for drugs billed with a Not Otherwise Classified (NOC) code. Reminder: Clinical Criteria name change In January 2023, we changed the name of Clinical Criteria documents from ING-CC-XXXX to CC‑XXXX; however, the content within the documents remains unchanged. Prior authorization updates Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process. Clinical Criteria | Drug | HCPCS or CPT® code(s) | CC-0226*+ | Elahere (mirvetuximab) | J3590, J9999 | CC-0223*+ | Imjudo (tremelimumab-actl) | J3490, J3590, J9999 | CC-0224*+ | Pedmark (sodium thiosulfate injection) | J3490, J9999 | CC-0222*+ | Tecvayli (teclistamab-cqyv) | J3490, J3590, J9999 | CC-0225+ | Tzield (teplizumab-mzwv) | J3490, J3590 | CC-0107*+ | Vegzelma (bevacizumab-adcd) | J3590, J9999 | CC-0072+ | Vegzelma (bevacizumab-adcd) | J3590 |
* Oncology use is managed by AIM. + The applicable Clinical Criteria is attached to this article in PDF format. Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. Step therapy updates Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Access our Clinical Criteria to view the complete information for these step therapy updates. Clinical Criteria CC-0107 currently has a step therapy preferring Avastin and the biosimilar Mvasi. This update is to notify that the new biosimilar Vegzelma will be added to existing step therapy as a non-preferred agent. Clinical Criteria | Status | Drug | HCPCS or CPT code(s) | CC-0107*+ | Non-preferred | Alymsys | C9142, J3490, J3590, J9999 | CC-0107* | Non-preferred | Vegzelma | J3590, J9999 | CC-0107* | Non-preferred | Zirabev | Q5118 | CC-0107* | Preferred | Avastin | J9035 | CC-0107* | Preferred | Mvasi | Q5107 |
* Oncology use is managed by AIM. + The applicable Clinical Criteria is attached to this article in PDF format. Clinical Criteria CC-0072: This is a courtesy notice to notify that there is an expansion in the preferred products in the step therapy for Clinical Criteria CC-0072 Vascular Endothelial Growth Factor inhibitors. Currently, Avastin and Eylea are preferred. Effective April 1, 2023, Byooviz, Cimerli, Lucentis, and Vabysmo will change from non-preferred to preferred product status. Quantity limit updates Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process. Access our Clinical Criteria to view the complete information for these quantity limit updates. Clinical Criteria | Drug | HCPCS or CPT code(s) | CC-0225+ | Tzield (teplizumab-mzwv) | J3490, J3590 | CC-0072+ | Vegzelma (bevacizumab-adcd) | J3590 |
+ The applicable Clinical Criteria is attached to this article in PDF format. * AIM Specialty Health is an independent company providing some utilization review services on behalf of the health plan. MULTI-BCBS-CM-016921-23 In March 2023, AIM Specialty Health®* will transition to Carelon Medical Benefits Management Inc. This transition is a name change only, and there will be no process changes. The new name will not impact the way AIM works with health plans and providers. In March, any operational assets that mention AIM Specialty Health (such as determination letters) will adopt the new Carelon Medical Benefits Management Inc. name. Provider brand transition FAQ | Provider experience focus area | | 1. Will the AIM ProviderPortalSM URL or platform name be changed? | 1. No, the website address will not be impacted; all providers will continue to have access to www.providerportal.com. The AIM logo will be replaced with a Carelon logo. No changes are being made to the case submission process. | 2. Will there be any changes to the AIM Clinical Guidelines URL or content? | 2. Yes, the clinical guidelines site will be automatically redirected to a new Carelon URL, and the branding will be updated to reflect Carelon. | 3. Are any phone number changes planned as part of this transition? | 3. No, inbound phone numbers are not being changed. References to AIM within recorded scripting will be replaced with Carelon Medical Benefits Management Inc. | 4. Will there be any changes for providers who connect with AIM via other means such as Availity Essentials*? | 4. No, access changes are not needed or planned; however, all references to the AIM company name will eventually be updated to Carelon Medical Benefits Management Inc. | 5. Will AIM references on health plan websites and member materials such as ID cards be changed? | 5. Not right away. Providers may continue to see the AIM company name on health plan websites and member ID cards for some time, but it’s expected that these will be changed through scheduled content update cycles. | | Corporate website | 1. Will the AIM corporate website URL be changed? | 1. The corporate website will be moved to www.carelon.com. All links to the ProviderPortal and clinical guideline pages will remain active and will be redirected. | | Provider microsites | 1. Will the AIM provider microsite URLs change? | 1. The provider microsite URLs you use today to access information from AIM will be automatically redirected to new Carelon URLs, and the branding will be updated to reflect Carelon branding. |
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. AIM Specialty Health is an independent company providing some utilization review services on behalf of the health plan. WIBCBS-CDCR-015637-22-CPN15114 In March 2023, AIM Specialty Health®* will transition to Carelon Medical Benefits Management Inc. This transition is a name change only, and there will be no process changes. The new name will not impact the way AIM works with health plans and providers. In March, any operational assets that mention AIM Specialty Health (such as determination letters) will adopt the new Carelon Medical Benefits Management Inc. name Provider brand transition FAQ | Provider experience focus area | | 1. Will the AIM ProviderPortalSM URL or platform name be changed? | 1. No, the website address will not be impacted; all providers will continue to have access to www.providerportal.com. The AIM logo will be replaced with a Carelon logo. No changes are being made to the case submission process. | 2. Will there be any changes to the AIM Clinical Guidelines URL or content? | 2. Yes, the clinical guidelines site will be automatically redirected to a new Carelon URL, and the branding will be updated to reflect Carelon. | 3. Are any phone number changes planned as part of this transition? | 3. No, inbound phone numbers are not being changed. References to AIM within recorded scripting will be replaced with Carelon Medical Benefits Management Inc. | 4. Will there be any changes for providers who connect with AIM via other means such as Availity Essentials*? | 4. No, access changes are not needed or planned; however, all references to the AIM company name will eventually be updated to Carelon Medical Benefits Management Inc. | 5. Will AIM references on health plan websites and member materials such as ID cards be changed? | 5. Not right away. Providers may continue to see the AIM company name on health plan websites and member ID cards for some time, but it’s expected that these will be changed through scheduled content update cycles. | | Corporate website | 1. Will the AIM corporate website URL be changed? | 1. The corporate website will be moved to www.carelon.com. All links to the ProviderPortal and clinical guideline pages will remain active and will be redirected. | | Provider microsites | 1. Will the AIM provider microsite URLs change? | 1. The provider microsite URLs you use today to access information from AIM will be automatically redirected to new Carelon URLs, and the branding will be updated to reflect Carelon branding. |
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. AIM Specialty Health is an independent company providing some utilization review services on behalf of the health plan. WIBCBS-CDCR-015637-22-CPN15114 In June 2022, myNEXUS* announced that it joined the Carelon family of companies. Carelon* is a new healthcare services brand dedicated to solving the industry's most complex challenges. As part of this shift, myNEXUS will begin operating under a new name, Carelon Post Acute Solutions, on March 1, 2023. In March, any documents that mention myNEXUS, such as provider forms or the myNEXUSwebsite (https://www.mynexuscare.com), will begin adopting the new Carelon Post Acute Solutions name. This is a name change only and does not impact the services myNEXUS offers or the way myNEXUS works with providers. Learn more about Carelon and myNEXUS by visiting:
https://www.carelon.com/about-us/businesses/mynexus * myNEXUS/Carelon is an independent company providing post acute care services on behalf of the health plan. MULTI-BCBS-CR-016950-22-CPN16447 |