 Provider News WisconsinNovember 2022 Anthem Provider News - WisconsinAs a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.
For any needed changes, please update your information by submitting them to us on our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request.
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
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Thank you for doing your part in keeping our provider directories current.
Providers currently submit prior authorization (PA) requests to AIM Specialty Health ®* (AIM) for outpatient diagnostic imaging services. These PA requests are often reviewed based on provider attestation of certain requirements.
As part of our ongoing quality improvement efforts, we want you to know that as of January 1, 2023, some review requests may require documentation to substantiate the attestations that support the clinical appropriateness of the request. This documentation can be uploaded during the intake process.
When requested, providers must submit such documentation from the patient’s medical record. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. Such documentation is limited to what has been asserted via the PA review attestations.
If the request would be denied as not medically necessary, providers can participate in a PA discussion with an AIM physician reviewer.
We’re phasing in clear, concise, and simplified denial descriptions when returning claims status inquiries. The denial descriptions will explain why the claim or claim line was denied and what to do next. We’ve even included details about how to provide us with information digitally to move the claim further along in the claims process.
Continuing to improve
The new denial descriptions will be phased in over the next few months. Based on your feedback, we’re starting with those claims or claim lines that have caused the most confusion. If new denial reasons are added, the descriptions will be expanded as well.
Accessing claim statuses
The Claims Status application on availity.com* enables you to check the status of your claim and submit attachments needed to process your claim, all in one place. To access the Claims Status app, log into availity.com and, from the Claims & Payments tab, select Claims Status. It’s just that fast and easy to check your claim status through Availity Essentials.
If you’re not enrolled in Availity Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity Essentials.
When submitting claims through the Electronic Data Interchange (EDI), a PWK segment indicator tells us you will be submitting supporting documentation for the claim and ensures the documents are attached correctly. The supporting documents are then sent through the Availity Essentials* Attachments Dashboard.
In November, the Attachments Dashboard will have a new look for Anthem Blue Cross and Blue Shield claims
The sooner we receive your claim attachments, the faster your claim can be processed for payment. To meet this expectation, the Attachments Dashboard will begin a seven-calendar day countdown beginning in November. This means that claims will begin processing sooner for those claims with the PWK segment indicator.
If you are unable to meet the seven-calendar day submission deadline, the claim will move from your Attachments Dashboard inbox into your History folder and will be marked as expired. The claim will then deny for additional information based on the PWK segment indicator and move to Claims Status located under the Claims & Payments tab on availity.com. Upload your attachment from Claims Status by using the Submit Attachment button located on your claim.
To learn more about the new claims attachments workflow, visit our Provider Learning Hub or access the on-demand webinar recording, Learn about the new claims attachments workflow, using this link.
Submitting Anthem Blue Cross and Blue Shield claims disputes through Availity Essentials* is the most efficient way to have a claim reconsidered. Easily accessible through the Claims & Payments application, select Claims Status to access the claim. Use the Dispute button to file the appeal and upload supporting document to finalize the submission.
Add multiple claims to one dispute submission
You can submit one dispute and add multiple claims — up to 25 claims — as long as the additional disputed claims are for the same member, provider, and dispute reason. For Commercial member claims, you can begin submitting multiple claims on one dispute beginning in November.
Access acknowledgement, update, and decision letters digitally, too
Access correspondence related to your disputes through the Appeals Dashboard. When you submit multiple claims on one dispute through Availity Essentials, you will receive correspondence related to each individual dispute, so expect a greater number of letters in your Appeals Dashboard. You can easily identify the correspondence related to your multiple dispute submission by looking for the CI-COMM case number.
Availity Essentials appeals training
For detailed instructions about submitting disputes electronically, use this link to access appeals training from Availity Essentials.
New learnings added to the Provider Learning Hub.
Remittance Inquiry App: How to view, print, and save remittance advice
If you’re still using paper remittance to reconcile your claims, imagine the time you’ll save when you access remittance advice digitally through availity.com. This course shares information about how to view, print, and save electronic remittances.
Attachments: How to setup the Medical Attachment role
To submit attachments digitally (medical records, itemized bills, or other documents needed to process your claims), registering your organization in this training is step one. It will help you every step of the way.
Claim Submission: How to submit a claim using direct data entry
For providers who are not submitting their claims through Electronic Data Interchange (EDI), availity.com offers direct data entry for professional and facility claims. Take this course and walk through the process for submitting claims electronically.
Get started today
Access the Provider Learning Hub today using this link or from anthem.com under Important Announcements on the home page.
- All courses and webcasts are available 24/7 for your convenience.
- Use filtering options to quickly find courses and job aids.
- Use the Favorites folder to save items for easy access later.
- Once registered, no further registration is required.
- On future visits, your preferences are populated eliminating the need for any additional logon information.
Not registered on availity.com? Use this link for registration information or access registration information from the Provider Learning Hub. There is no cost for our providers to use availity.com.
This communication applies to the Commercial, Medicaid, and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem) in Wisconsin.
HEDIS medical record submission made easier with our remote EMR access service
Let us take on the responsibility to retrieve medical records for the annual HEDIS® hybrid project by signing up for the remote electronic medical record (EMR) access service offered Anthem Blue Cross and Blue Shield (Anthem).
We offer providers the ability to grant access to their EMR system directly to pull the required documentation to aid your office in reaching compliance while reducing the time and costs associated with medical record retrieval.
We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:
- We only access medical records of members pulled into the HEDIS sample using specific demographic data.
- We only retrieve the medical records that have claims evidence related to the HEDIS measures.
- We access the least amount of information needed for use, disclosure, or for the specific medical records request.
- We only save to file and do not physically print any PHI.
Getting started with remote EMR access
Download and complete the registration form, then email it to us at: Centralized_EMR_Team@anthem.com.
FAQ
How does Anthem retrieve your medical records?
We access your EMRs using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.
Is printing access necessary?
Yes. The NCQA audit requires print-to-file access.
Is this process secure?
Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives.
Why does Anthem need full access to the entire medical record?
There are several reasons we need to look at the entire medical record of a member:
- HEDIS measures can include up to a 10-year look back at a member’s information.
- Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
- Compliant data may be documented or housed in a nonstandard format, such as an in‑office lab slip scanned into miscellaneous documents.
What information do I need to submit to use the remote EMR access service?
Complete the registration form that requests the following information:
- Practice/facility demographic information (for example, address, NPI, TIN, etc.)
- EMR system information (for example, type of EMR system, required access forms, access type, etc.)
- List of current providers/locations or a website for accessing this list
Remote Access not an option? We are now offering onsite visits for HEDIS hybrid retrieval. Email us at Centralized_EMR_Team@anthem.com for more information.
Material Adverse Change (MAC)
The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on August 11, 2022.
Determine if prior authorization is needed for an Anthem member by going to anthem.com > select “Providers” > under “Claims” > select “Prior Authorization”, then select your state. Or, you may call the prior authorization phone number on the back of the member’s ID card.
These medical policies to not apply to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan, commonly referred to as the Federal Employee Program® (FEP®). To view medical policies and utilization management guidelines applicable to FEP members, please visit fepblue.org > Policies & Guidelines.
Below are the current clinical guidelines and/or medical policies we reviewed and updates that were approved.
* Denotes prior authorization required.
|
Policy/guideline
|
Information
|
Effective date
|
|
*MED.00142 Gene Therapy for Cerebral Adrenoleukodystrophy
|
· Addresses the recent U.S. FDA-approved gene therapy product, elivaldogene autotemcel (Skysona®)
|
2/1/2023
|
|
*MED.00129 Gene Therapy for Spinal Muscular Atrophy
|
· Revised MN criterion to no more than 3 copies of SMN2
|
2/1/2023
|
|
CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
|
· Added thiopurine methyltransferase (TPMT) to scope of document and Clinical Indications MN section
· Existing CPT® code 81335 will be reviewed for MN criteria
|
2/1/2023
|
|
CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment
|
· Added MN statement on decisions on extending adjuvant hormone therapy beyond 5 years in individuals with 1-3 positive lymph nodes
|
2/1/2023
|
|
*DME.00044 Robotic Arm Assistive Devices
Previously titled: Wheelchair Mounted Robotic Arm
|
· Revised title
· Rescoped the Position Statement to also address robotic feeding assistive device
· No specific code for robotic assistive feeding device, E1399 NOC already listed; considered INV&NMN
|
2/1/2023
|
|
*MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
|
· Added MN criteria for essential tremor
· CPT Category III code 0398T for intracranial MRgFUS will be reviewed for MN criteria for diagnosis G25.0 (was considered INV&NMN)
|
2/1/2023
|
|
SURG.00079 Nasal Valve Repair
Previously titled: Nasal Valve Suspension
|
· Revised title
· Revised the Position Statement
· Expanded scope of document to address an absorbable nasal implant and low-dose radiofrequency intranasal tissue remodeling for the treatment of nasal airway obstruction
· Content related to the absorbable nasal implant (Latera) moved from CG-SURG-87 to this document
· Added CPT code 30468 for absorbable nasal implant (Latera), considered INV&NMN (was addressed in CG-SURG-87); no specific code for RF remodeling considered INV&NMN, CPT 30999 NOC already listed
|
2/1/2023
|
|
SURG.00119 Endobronchial Valve Devices
|
· Added a note in the Position Statement addressing individuals unable to perform a 6‑Minute Walk Distance test
· Updated hierarchy formatting in Position Statement
|
2/1/2023
|
|
*SURG.00121 Transcatheter Heart Valve Procedures
|
· Clarified TAVR MN Clinical Indications
· Added MN statement for transcatheter Mitral Edge-to-Edge Repair/transcatheter mitral valve repair using an FDA approved device when criteria met
· Added NMN statement for transcatheter mitral edge-to-edge repair/TMVr for the treatment of primary or secondary (functional) MR when the criteria above are not met
· Revised INV/NMN statement TMVr to address transcatheter mitral edge-to-edge repair for all “other” indications
· CPT codes 33418, 33419 specific to MitraClip mitral valve procedure will be reviewed for MN criteria (were INV&NMN), and added associated ICD-10-PCS code (other mitral valve codes still considered INV&NMN)
|
2/1/2023
|
|
*SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
|
· Added MN criteria for hypoglossal nerve stimulation as a treatment of OSA in individuals with Down syndrome
· Removed examples from the NMN indications
· Hypoglossal nerve stimulation codes will be reviewed for MN criteria for diagnosis codes Q90.0-Q90.9
|
2/1/2023
|
|
*CG-GENE-13 Genetic Testing for Inherited Diseases
|
· Interim update to add genes PIK3CA and CDKL5 to the table of genes in the Discussion section; added existing CPT code 81309 and genes to Tier 2 codes 81405, 81406 (MN criteria)
|
2/1/2023
|
|
*SURG.00150 Leadless Pacemaker
|
· Moving from Post Service Review to Prior Authorization
|
2/1/2023
|
Below are clinical guidelines and/or medical policies that will be moving from Post Service Review to Prior Authorization effective February 1, 2023.
|
Policy/guideline
|
Title
|
Effective date
|
|
CG-LAB-13
|
Skin Nerve Fiber Density Testing
|
2/1/2023
|
|
LAB.00027
|
Selected Blood, Serum and Cellular Allergy and Toxicity Tests
|
2/1/2023
|
|
MED.00099
|
Navigational Bronchoscopy
|
2/1/2023
|
|
SURG.00036
|
Fetal Surgery for Prenatally Diagnosed Malformations
|
2/1/2023
|
|
SURG.00070
|
Photocoagulation of Macular Drusen
|
2/1/2023
|
|
SURG.00082
|
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
|
2/1/2023
|
|
SURG.00116
|
High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
|
2/1/2023
|
|
SURG.00120
|
Internal Rib Fixation Systems
|
2/1/2023
|
This communication applies to the Commercial, Medicaid, and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem) in Wisconsin.
Effective November 6, 2022, Anthem will transition the Clinical Criteria for medical necessity review of perirectal hydrogel spacer to the AIM Specialty Health®* (AIM) Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline.
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 Availity* at availity.com.
For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com.
Additionally, you may access and download a copy of the current and upcoming guidelines here.
Material Adverse Change (MAC)
Correction to reimbursement policy: Place of Service — Facility
In the July edition of Provider News, we announced a new Place of Service — Facility reimbursement policy indicating that evaluation & management (E/M) services and other professional services must be billed on a CMS-1500 claim form and are not reimbursable when billed on a UB-04 claim form (excluding E/M services rendered in an emergency room or urgent care and billed with ER revenue codes).
It has come to our attention that some of the preventive counseling CPT® codes mentioned in the July article were listed incorrectly. The correct preventive counseling CPT codes are 99401–99404, 99411, and 99412, and are not reimbursable when billed in an outpatient setting of a facility effective with dates of service on or after February 1, 2023.
Please note, however, that the revenue codes 960-983 and the E/M services noted in the July edition were listed correctly in the new Place of Service — Facility reimbursement policy and will be effective with dates of service on or after October 1, 2022.
For specific policy details, visit the reimbursement policy page on our provider website.
Material Adverse Change (MAC)
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’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 request prior authorization review for your patients’ continued use of these medications.
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.
Prior authorization updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0002*
|
Fylnetra (pegfilgrastim-pbbk)
|
J3590
|
|
ING-CC-0002*
|
Rolvedon (eflapegrastim-xnst)
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Stimufend (pegfilgrastim-fpgk)
|
C9399, J3490, J3590
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
|
C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
|
C9399, J3490, J3590
|
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Site of care updates
Effective for dates of service on and after February 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.
Access our Clinical Criteria to view the complete information for these site of care updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0065
|
Advate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Adynovate (factor vii)
|
J7207
|
|
ING-CC-0065
|
Afstyla (antihemophilic factor (recombinant) single chain))
|
J7210
|
|
ING-CC-0065
|
Alphanate (antihemophilic factor viii)
|
J7186
|
|
ING-CC-0065
|
Eloctate (recombinant antihemophilic factor)
|
J7205
|
|
ING-CC-0065
|
Esperoct (factor viii recombinant, glycopegylated)
|
J7204
|
|
ING-CC-0065
|
factor viii, anti-hemophilic factor (porcine)
|
J7191
|
|
ING-CC-0065
|
Hemlibra (emicizumab-kxwh)
|
J7170
|
|
ING-CC-0065
|
Hemofil M ((factor viii) human plasma-derived)
|
J7190
|
|
ING-CC-0065
|
Humate-P (antihemophilic factor viii)
|
J7187
|
|
ING-CC-0065
|
Jivi (factor viii, recombinant, pegylated-aucl)
|
J7208
|
|
ING-CC-0065
|
Koate DVI ((factor viii) human plasma-derived)
|
J7190
|
|
ING-CC-0065
|
Kogenate-FS (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Kovaltry (factor viii (antihemophilic factor, recombinant))
|
J7211
|
|
ING-CC-0065
|
Novoeight (factor viii (antihemophilic factor, recombinant))
|
J7182
|
|
ING-CC-0065
|
Nuwiq (factor viii (antihemophilic factor, recombinant))
|
J7209
|
|
ING-CC-0065
|
Obizur (antihemophilic factor viii (recombinant))
|
J7188
|
|
ING-CC-0065
|
Recombinate (factor viii (antihemophilic factor, recombinant))
|
J7192
|
|
ING-CC-0065
|
Vonvendi (von willebrand factor)
|
J7179
|
|
ING-CC-0065
|
Wilate (antihemophilic factor viii)
|
J7183
|
|
ING-CC-0065
|
Xyntha (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0065
|
Xyntha Solofus (factor viii (antihemophilic factor, recombinant))
|
J7185
|
|
ING-CC-0148
|
AlphaNine SD (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
|
Alprolix (recombinant coagulation factor ix)
|
J7201
|
|
ING-CC-0148
|
Benefix (factor ix recombinant)
|
J7195
|
|
ING-CC-0148
|
Idelvion (factor ix)
|
J7202
|
|
ING-CC-0148
|
Ixinity (factor ix)
|
J7195
|
|
ING-CC-0148
|
Mononine (coagulation factor ix (human))
|
J7193
|
|
ING-CC-0148
|
Profilnine SD (factor ix complex human)
|
J7194
|
|
ING-CC-0148
|
Rebinyn (glycopegylated)
|
J7203
|
|
ING-CC-0148
|
Rixubis (factor ix recombinant)
|
J7200
|
|
ING-CC-0149
|
Coagadex (factor x)
|
J7175
|
|
ING-CC-0149
|
Corifact (factor xiii concentrate (human))
|
J7180
|
|
ING-CC-0149
|
Feiba (anti-inhibitor coagulant complex)
|
J7198
|
|
ING-CC-0149
|
Fibryga (human fibrinogen)
|
J7177
|
|
ING-CC-0149
|
NovoSeven RT (factor viia recombinant)
|
J7189
|
|
ING-CC-0149
|
RiaSTAP (fibrinogen concentrate)
|
J7178
|
|
ING-CC-0149
|
Sevenfact (factor vlla recombinant)
|
J7212
|
|
ING-CC-0149
|
Tretten (coagulation factor xiii a-subunit (recombinant))
|
J7181
|
Step therapy updates
Effective for dates of service on and after February 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.
Clinical criteria ING-CC-0002 currently has a step therapy preferring Neulasta, Neulasta OnPro and the biosimilar Udenyca. This update is to notify that the new biosimilars Fylnetra and Stimufend and the new long-acting colony stimulating factor Rolvedon will be added to existing step therapy as a non-preferred agents.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0002*
|
Non-preferred
|
Fylnetra
|
J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Rolvedon
|
C9399, J3490, J3590
|
|
ING-CC-0002*
|
Non-preferred
|
Stimufend
|
C9399, J3490, J3590
|
|
ING-CC-0002
|
Preferred
|
Neulasta
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Neulasta OnPro
|
J2506
|
|
ING-CC-0002
|
Preferred
|
Udenyca
|
Q5111
|
|
ING-CC-0002
|
Non-preferred
|
Fulphila
|
Q5108
|
|
ING-CC-0002
|
Non-preferred
|
Nyvepria
|
Q5122
|
|
ING-CC-0002
|
Non-preferred
|
Ziextenzo
|
Q5120
|
This is a courtesy notice that there is a non-material change in the clinical criteria for Orencia ING-CC-0078. The criteria document now references ING-CC-0062 Tumor Necrosis Factor Antagonists criteria document for the most current preferred infliximab product(s).
Quantity limit updates
Effective for dates of service on and after February 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)
|
|
ING-CC-0017
|
Xiaflex (collagenase clostridium histolyticum)
|
J0775
|
|
ING-CC-0072
|
Cimerli (ranibizumab-cqrn)
|
J3590
|
|
ING-CC-0182
|
Feraheme (ferumoxytol)
|
Q0138
|
|
ING-CC-0182
|
Ferrlecit (ferric gluconate)
|
J2916
|
|
ING-CC-0182
|
Infed (iron dextran)
|
J1750
|
|
ING-CC-0182
|
Injectafer (ferric injection)
|
J1439
|
|
ING-CC-0182
|
Monoferric (ferric derisomaltose)
|
J1437
|
|
ING-CC-0182
|
Venofer (iron sucrose)
|
J1756
|
|
ING-CC-0220
|
Xenpozyme (olipudase alfa)
|
C9399, J3490, J3590
|
|
ING-CC-0221
|
Spevigo (spesolimab-sbzo)
|
C9399, J3490, J3590
|
According to the American Medical Association (AMA) Current Procedural Terminology ® (CPT) guidelines, a new patient is defined as one who has not received any professional services, i.e. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after December 1, 2022, Anthem Blue Cross and Blue Shield will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.
Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the claims payment dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual or resubmit the claim with an established patient E/M code.
If you have questions about this communication or need assistance with any other item, visit the Contact Us section at the bottom of our provider website (https://providers.anthem.com/wi) for up-to-date contact information or call Provider Services at 855-558-1443.
Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://mediproviders.anthem.com/wi/Pages/manuals-directories-training.aspx.
You can request a free copy of our UM criteria from our Medical Management department. Providers can discuss a UM denial decision with a physician reviewer, by calling us toll free at the numbers listed below. To access UM criteria online, go to https://mediproviders.anthem.com/wi/Pages/manuals-directories-training.aspx.
You can request a peer-to-peer review at 262-523-2425.
We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues.
You can submit precertification requests by:
- Calling us at 855-558-1443.
- Faxing to 800-964-3627.
Have questions about utilization decisions or the UM process?
Call our Clinical team at 855-558-1443, Monday through Friday, from 8 a.m. to 5 p.m. CT.
(Policy G-13001, effective 07/01/22)
In the April edition of Provider News, we announced a policy language update to Inpatient Readmission. To clarify the communication, when a member is readmitted within 30 days, as part of a planned readmission and placed on a leave of absence, the admissions are considered to be one admission, and only one diagnosis-related group (DRG) will be reimbursed.
In addition, effective July 1, 2022, the Inpatient Readmissions policy will not allow separate reimbursement for claims that have been identified as a readmission to the same or different hospital within the same hospital system for the same, similar, or related condition. Also, we will not allow payment for the first admission when a member is readmitted for the same or similar diagnosis.
For additional information, please review the Inpatient Readmissions reimbursement policy at Provider Website.
Alcohol use disorders (AUD) often coexist with, contribute to, or result from many different psychiatric disorders. 1 Because AUD can mimic and complicate many mental health disorders, AUD leads to challenges in diagnoses for psychiatric complaints.
Heavy alcohol use directly affects brain function and may manifest as a broad range of psychiatric symptoms. Common mental health symptoms of AUD include depression and anxiety.
In addition, patients diagnosed with mental health disorders are more likely to use a high amount of mental health services, have difficulties decreasing alcohol consumption, and struggle with suicidal ideation or attempts.
Common co-occurring mental health conditions include depressive disorders, anxiety, schizophrenia, and bipolar disorders.
Depressive disorders:2
AUD and depressive disorders are among the most prevalent co-occuring disorders. Depressive disorders are the most common comorbid mental health conditions with AUD. People with AUD are 2 to 3 times more likely to have depression. People with alcohol dependence are more likely to have a depressive disorder than those with alcohol abuse.
Co-occurring AUD and depressive disorders disproportionately affect women, as these disorders are two times more likely to occur in women than in men. Racial and ethnic minorities also encounter systemic disadvantages. For instance, Black and Latino people are significantly less likely to receive integrated mental health and substance use treatment than other races and ethnicities.
Research suggests that AUD is equally as likely to precede depression as well as for depression to precede AUD. In addition, having one increases the risk of having the other. Though the etiology of these disorders is not fully known, studies have identified some evidence of genetic predisposition or dysfunction in reward and stress systems of the brain.
Anxiety:3
Up to half of patients receiving treatment for AUD meet the criteria for one or more anxiety disorders. Data shows that patients with anxiety disorders have poorer outcomes in treatment for alcohol use. Conventional treatment for anxiety (antidepressants and behavioral therapy) do not appear to reduce AUD. This suggests that co-occurring anxiety and AUD benefits from being treated separately but simultaneously.
In addition, patients with an anxiety disorder or AUD experience an increased risk in developing the other disorder. Trauma, chronic stress, and other inheritable traits are associated with the dysfunction in stress‑response systems present in AUD and anxiety disorders.
Schizophrenia:4
The prevalence of schizophrenia is about 1% of the population; however, patients with schizophrenia are at a three times greater risk for AUD. Between 25% to 36% of patients with schizophrenia meet the criteria for AUD. Schizophrenia has a strong genetic risk factor, and a large genome-wide study revealed a significant genetic correlation between schizophrenia and AUD.
There are several theories as to why AUD is so highly prevalent in patients with schizophrenia:
- A combination of neurobiological vulnerability (genetic risk) and environmental vulnerability (poverty, homelessness, trauma, etc.)
- The concept of self-medication, suggesting people with schizophrenia turn to alcohol for relief from their psychiatric symptoms
- Similar to depressive disorders, the hypothesis that both schizophrenia and AUD are related to a dysregulation of the reward system in the brain
Bipolar disorder:5
Bipolar disorder is the most likely psychiatric disorder to have a co‑occurring condition with a substance use disorder (SUD). Estimates for a lifetime co‑occurring bipolar disorder and AUD is between 40% to 70%. These co-occurring disorders are most common in women.
Bipolar disorder occurs in between 1.5% to 5% of the population. Like schizophrenia, bipolar disorder has a shared genetic predisposition with AUD. Heavy alcohol use worsens symptoms of bipolar disorder and can trigger episodes of mania and depression. Conversely, these episodes can lead to increased alcohol consumption. Treatment for bipolar disorder often assists in treatment for co‑occurring AUD. Mood stabilizers used to treat bipolar disorder have been shown to reduce alcohol cravings in patients with bipolar disorder.
Alcohol (and other substances) are likely triggers for the onset of bipolar disorders. In one study, substance use preceded 60% of first manic episodes.6 In juvenile cases, bipolar onset early in life is correlated with AUD development as an adult.
What if I need assistance?
If you need assistance connecting your patients to mental health or AUD treatment, contact Anthem Blue Cross and Blue Shield Provider Services at 855-558-1443.
Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.
Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
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HCPCS or CPT® codes
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Medicare Part B drugs
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C9399, J3490, J3590, J9999
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Opdualag (nivolumab and relatlimab-rmbw)
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C9096
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Releuko (filgrastim-ayow)
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A9699
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Pluvicto (lutetium lu 177 vipivotide tetraxetan)
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Find Care, the doctor finder and transparency tool in the Anthem Blue Cross and Blue Shield (Anthem) online directory, provides Anthem members with the ability to search for in-network providers using the secure member website at www.anthem.com. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetic order, and provider name.
Beginning January 1, 2023, or later, an additional sorting option will be available for members to search by provider performance called Personalized Match. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Provider pairings with the highest overall ranking within the member’s search radius will be displayed first. Members will continue to have the ability to sort based on distance, alphabetic order, and provider name.
- You may review a copy of the Personalized Match methodology which has been posted on Availity* – our secure web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Anthem > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.
- If you have general questions regarding this new sorting option, please submit an inquiry via the web at availity.com.
- If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to availity.com.
Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.
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