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August 2020 Anthem Provider News - Virginia Page 1 of 52
Virginia Provider NewsAugust 2020 Anthem Provider News - Virginia
Products & Programs:
Pharmacy:
Administrative:
Guideline Updates:
Coverage and Clinical Guidelines:
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Appropriate coding helps provide a comprehensive picture ofpatients’ health
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Anthem prior authorization updates for specialty pharmacy areavailable
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Anthem to update formulary lists for Commercial health planpharmacy benefit
7
Voluntary site of care outreach for oncology checkpointinhibitors beginning August 1, 2020
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Anthem clinical criteria updates for specialty pharmacy areavailable
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REMINDER: Company requires National Drug Code forprofessional and facility outpatient claims effective September1, 2020
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Pharmacy information available on anthem.com 12
Anthem electronic attachments: X12 275 5010 13
Migrate your EDI transactions to Availity today 14
Resources to support diverse patients and communities 17
Interactive Care Reviewer: Anthem’s online prior authorizationtool targeting August launch for Federal Employee Program andSeptember launch for Anthem’s Commercial membership
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Anthem’s fall webinar scheduled for November 12; Registersoon
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Medical record standards 22
August 2020 Anthem Provider News - Virginia Page 2 of 52
Reimbursement Policies:
Medicaid:
Medicare:
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO productsunderwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. InMissouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company(HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten byHMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada:Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. In New Hampshire:Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten byMatthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as AnthemBlue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east ofState Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), which underwrites or administers the PPO and indemnity policiesand underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation
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Expansion of AIM Musculoskeletal Program effective November1, 2020
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Coverage Guidelines effective November 1, 2020 26
Injectable substances with related injection services:Professional
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Behavioral health HEDIS® measures messages 28
Provider data update 31
Adolescent well-care visits HEDIS measure 32
Controlling high blood pressure (CBP) 34
Medical drug benefit Clinical Criteria updates 38
New MCG Care Guidelines 24th edition 39
Quarterly pharmacy formulary change notice 40
DMAS specifications for ER physician non-emergent paymentreduction policy
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DMAS specifications for readmission payment reduction policy 45
Keep up with Medicaid news 46
Medical drug benefit Clinical Criteria updates 46
New MCG Care Guidelines 24th edition 47
2020 Medicare risk adjustment provider trainings 48
AIM Musculoskeletal program expansion 50
Keep up with Medicare news 52
August 2020 Anthem Provider News - Virginia Page 3 of 52
(Compcare) underwrites or administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers WellPriority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of AnthemInsurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation. Use of the Anthem websites constitutes your agreement with our Terms of Use.
August 2020 Anthem Provider News - Virginia Page 4 of 52
Appropriate coding helps provide a comprehensive picture ofpatients’ healthPublished: Aug 1, 2020 - Products & Programs
We appreciate the role you play in managing the health of our members. As the physician ofa patient who has coverage compliant with the Affordable Care Act (ACA), you play a vitalrole in accurately documenting the health of the patient to help ensure compliance with ACAprogram reporting requirements. When patients visit your practice, we encourage you todocument ALL of their health conditions, especially chronic diseases. Ensuring thatthe coding on the claim submission is to the greatest level of specificity can helpreduce the number of medical record requests from us in the future. Please ensure that all codes captured in your electronic medical record (EMR) system arealso included on the claim(s), and are not being truncated by your claims softwaremanagement system. For example, some EMR systems may capture up to 12 diagnosiscodes, but the claim system may only have the ability of capturing four. If your claim systemis truncating some of your codes, please work with your vendor/clearing house to ensure allcodes are being submitted. Reminder about ICD-10 coding The ICD-10 coding system serves multiple purposes including identification of diseases,justification of the medical necessity for services provided, tracking morbidity and mortality,and determination of benefits. Additionally, Anthem uses ICD-10 codes submitted on claimsto monitor health care trends, cost, and disease management. Additionally, the Centers forMedicare & Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment programcreated under the ACA to determine the risk score associated with a patient’s health. Using specific ICD-10 diagnosis codes will help convey the true complexity of the conditionsbeing addressed in each visit.
Code the primary diagnosis, condition, problem or other reason for the medical serviceor procedure.
Include any secondary diagnosis codes that are actively being managed.
August 2020 Anthem Provider News - Virginia Page 5 of 52
Include all chronic historical codes, as they must be documented each year pursuant tothe ACA. (Such as an amputee must be coded each and every year even if the visit is notaddressing the amputated limb specifically).
Telehealth visits are an acceptable format for seeing your patients and assessing if theyhave risk adjustable conditions. ICD-10 coding guidelines still apply, so please ensurecoding on a telehealth visit claim is to the highest specificity with all diagnosis codes. Previous Anthem Provider News editions provide telehealth reimbursement guidance tofollow for claims submission. If you are interested in a coding training session specific to risk adjustable conditions, pleasecontact the Commercial Risk Adjustment network education representative:[email protected] 567-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/appropriate-coding-helps-provide-a-comprehensive-picture-of-patients-health-6
Anthem prior authorization updates for specialty pharmacy areavailablePublished: Aug 1, 2020 - Products & Programs / Pharmacy
Quantity limit updates Effective for dates of service on and after November 1, 2020, the following specialtypharmacy codes from current or new clinical criteria documents will be included in ourexisting prior authorization quantity limit review process. Access the Clinical Criteria information. For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., priorauthorization clinical review of these specialty pharmacy drugs will be managed by Anthem.Drugs used for the treatment of Oncology will still require pre-service clinical review by AIMSpecialty Health (AIM), a separate company.
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August 2020 Anthem Provider News - Virginia Page 6 of 52
This applies to members with Preferred Provider Organization (PPO), AnthemHealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans). Clinical Criteria HCPCS or CPT
Code(s)Drug
ING-CC-0044 J1428 Exondys 51
ING-CC-0058 J2354 Bynfezia
ING-CC-0072 J0179 Beovu
ING-CC-0075 Q5119 Ruxience
ING-CC-0152 J1429 Vyondys 53
ING-CC-0153 C9053 Adakveo
* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncologyuse is managed by AIM.
Clinical criteria updates Effective for dates of service on and after November 1, 2020, the following clinical criteriadocument was revised and might result in services that were previously covered but maynow be found to be not medically necessary in our prior authorization review process. Acess the Clinical Criteria information. For Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc., prior authorizationclinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs usedfor the treatment of Oncology will still require pre-service clinical review by AIM SpecialtyHealth (AIM), a separate company.
ING-CC-0003 Immunoglobulins
Updated medical necessity criteria for myasthenia gravis to include specific drug failures andchronic inflammatory demyelinating polyneuropathy to include requirements regardingdisease duration, specific electrodiagnostic criterion, and objective measures forcontinuation.
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August 2020 Anthem Provider News - Virginia Page 7 of 52
Correction to a prior authorization update In the May 2020 edition of Provider News, we published a prior authorization updateregarding clinical criteria ING-CC-0157 on the drug Padcev.
One HCPCS code, J9309, was listed in error. This is not a valid code for the drugPadcev.
One HCPCS code has been added, J9999. This is a valid code for the drug Padcev.
581-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/anthem-prior-authorization-updates-for-specialty-pharmacy-are-available-6
Anthem to update formulary lists for Commercial health planpharmacy benefitPublished: Aug 1, 2020 - Products & Programs / Pharmacy
Effective with dates of service on and after October 1, 2020, and in accordance with theIngenioRx Pharmacy and Therapeutics (P&T) process, Anthem Blue Cross and Blue Shieldwill update our drug lists that support Commercial health plans. Updates include changes todrug tiers and the removal of medications from the formulary. As certain brand and generic drugs will no longer be covered, providers are encouraged todetermine if a covered alternative drug is appropriate for their patients whose currentmedication will no longer be covered. Please note, this update does not apply to the Select Drug List and does not impactMedicaid and Medicare plans. To ensure a smooth member transition and minimize costs, providers should review thesechanges and consider prescribing a drug on formulary or on a lower tier, if appropriate.
August 2020 Anthem Provider News - Virginia Page 8 of 52
View a summary of changes. IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross andBlue Shield.
598-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/anthem-to-update-formulary-lists-for-commercial-health-plan-pharmacy-benefit-6
Voluntary site of care outreach for oncology checkpointinhibitors beginning August 1, 2020Published: Aug 1, 2020 - Products & Programs / Pharmacy
Anthem Blue Cross and Blue Shield (Anthem) is committed to identifying ways to achievebetter health outcomes, lower costs and deliver access to a better health care experience forconsumers. Effective with dates of service on or after August 1, 2020, members with Commercial planscovered by Anthem will be contacted to voluntarily redirect services to home infusion site ofcare from hospital outpatient site of care for certain immuno-oncology drugs (Bavencio®[avelumab]; Imfinzi® [durvalumab]; Keytruda® [pembrolizumab]; Opdivo® [nivolumab;Tecentriq® [atezolizumab]; and Yervoy® [ipilimumab]). Reviews for these oncology drugs willcontinue to be administered by AIM Specialty Health (AIM). The voluntary site of care redirection only applies to these specific drugsadministered in an outpatient hospital setting. This does not apply to requests for thesespecific drugs when administered in a non-hospital setting or as part of an inpatient stay.The redirection also does not apply when Anthem is the secondary payer. Please note, this review does not apply to the following plans: BlueCard , Federal EmployeeProgram (FEP ), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providerscan view prior authorization requirements for Anthem members on the Coverage Guidelines& Clinical UM Guidelines page at anthem.com. Providers should continue to verify eligibility and benefits for all members prior torendering services.
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August 2020 Anthem Provider News - Virginia Page 9 of 52
If you have questions, please call the Provider Service phone number on the back of themember’s ID card. Note: In some plans, “site of service” or another term such as “setting” or “place of service”may be the term used in benefit plans, provider contracts or other materials instead of or inaddition to “site of care” and in some plans, these terms may be used interchangeably. Forsimplicity, we will hereafter use “site of care.” 580-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/voluntary-site-of-care-outreach-for-oncology-checkpoint-inhibitors-beginning-august-1-2020-2
Anthem clinical criteria updates for specialty pharmacy areavailablePublished: Aug 1, 2020 - Products & Programs / Pharmacy
Effective for dates of service on and after November 1, 2020, the following current and newclinical criteria were revised and might result in services that were previously covered butmay now be found to be not medically necessary. For Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc., prior authorizationof these specialty pharmacy drugs will be managed by Anthem. Drugs used for thetreatment of Oncology will still require prior authorization by AIM Specialty Health (AIM), aseparate company. This applies to members with Preferred Provider Organization (PPO),Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans). Access the clinical criteria document information
ING-CC-0002 Colony Stimulating Factor Agents
ING-CC-0003 Immunoglobulins
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August 2020 Anthem Provider News - Virginia Page 10 of 52
ING-CC-0032 Botulinum Toxin
ING-CC-0044 Exondys 51 (eteplirsen)
ING-CC-0098 Doxorubicin Liposome (Doxil, Lipodox)
ING-CC-0099 Abraxane (paclitaxel, protein bound)
NG-CC-0105 Vectibix (panitumumab)
ING-CC-0106 Erbitux (cetuximab)
ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
ING-CC-0124 Keytruda (pembrolizumab)
ING-CC-0128 Tecentriq (atezolizumab)
ING-CC-0153 Adakveo (crizanlizumab)
566-0820-PN-VA
August 2020 Anthem Provider News - Virginia Page 11 of 52
URL: https://providernews.anthem.com/virginia/article/anthem-clinical-criteria-updates-for-specialty-pharmacy-are-available-3
REMINDER: Company requires National Drug Code forprofessional and facility outpatient claims effective September 1,2020Published: Aug 1, 2020 - Products & Programs / Pharmacy
In the June 2020 edition of Provider News, Anthem Blue Cross and Blue Shield (Anthem)notified providers about a new billing requirement to help us determine the correct amount topay on drug claim lines for Commercial professional and facility outpatient claims filed to us. As a reminder, effective for dates of service on and after September 1, 2020, thefollowing information will be required on claims for all categories of drugs except forthose administered in an inpatient facility setting:
1. Applicable HCPCS code or CPT code
1. Number of HCPCS code or CPT code units
1. Valid 11-digit National Drug Code(s) (NDC), including the N4 qualifier
1. Unit of Measurement qualifier (F2, GR, ML, UN, MG)
1. NDC units dispensed (must be greater than 0)
Note: These billing requirements apply to Local Plan and BlueCard® only. This noticeEXCLUDES claims for members enrolled in the Blue Cross and Blue Shield Service BenefitPlan (also called the Federal Employee Program or FEP) and Coordination ofBenefits/secondary claims.
August 2020 Anthem Provider News - Virginia Page 12 of 52
As we shared in the original notification, Anthem will deny any line items on a claimregarding drugs that do not include the above information – effective for dates of service onand after September 1, 2020. Please include the above information on drug claims to helpensure accurate and timely payments. If you have further questions, please contact the telephone number on the back of themember’s ID card. 599-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/reminder-company-requires-national-drug-code-for-professional-and-facility-outpatient-claims-effective-september-1-2020
Pharmacy information available on anthem.comPublished: Aug 1, 2020 - Products & Programs / Pharmacy
For more information on copayment/coinsurance requirements and their applicable drugclasses, drug lists and changes, prior authorization criteria, procedures for genericsubstitution, therapeutic interchange, step therapy or other management methods subject toprescribing decisions, and any other requirements, restrictions, or limitations that apply tousing certain drugs, visit anthem.com/pharmacyinformation. The Commercial Virginia andmarketplace drug lists are posted to the website quarterly (the first of the month for January,April, July and October). To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “SelectDrug Lists.” This drug list is also reviewed and updated regularly as needed. For the Federal Employee Program (FEP), FEP Pharmacy updates and other pharmacyrelated information may be accessed at www.fepblue.org > Pharmacy Benefits. 575-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/pharmacy-information-available-on-anthemcom-71
August 2020 Anthem Provider News - Virginia Page 13 of 52
Anthem electronic attachments: X12 275 5010Published: Aug 1, 2020 - Administrative
Anthem Blue Cross and Blue Shield and Availity Electronic Data Interchange (EDI) areexcited to announce the X12 275 5010 version of electronic attachments transactions forclaims functionality is now available. The X12 275 5010 version of electronic attachments transactions for claims will:
Bring value to you by eliminating the need for mailing paper records.
Provide a transaction audit trail via an electronic acknowledgment – proof ofdelivery/receipt.
Reduce administrative costs associated with manual processing.
Save time waiting for paper correspondents.
This new functionality includes both solicited and unsolicited attachments.
Solicited Attachment - Documentation submitted in response to a specific request.
Unsolicited Attachment - Documentation is known to be needed and submitted at thesame time as the claim.
How to send a 275 transaction
August 2020 Anthem Provider News - Virginia Page 14 of 52
Your practice management software or billing service/clearinghouse must have the ability tosend a 275 transaction. We encourage you to have a conversation with them to determinetheir ability to set up the X12 275 attachment transaction capabilities. Where to find help The new EDI batch process, X12 275 5010v Companion Guide, assists with specificattachment requirements and enables providers to electronically submit attachments basedon your business needs.The companion guide can be downloaded at: (Anthem at www.anthem.com/edi) Availity documentation can be found at: www.availity.com Use the “Availity Welcome Application” below to begin the process of connecting to theAvaility EDI Gateway for your Anthem EDI transmissions. EDI Welcome App: https://apps.availity.com/web/welcome/#/ For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) forassistance Monday - Friday 8 a.m. - 7 p.m. ET. 587-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/anthem-electronic-attachments-x12-275-5010-2
Migrate your EDI transactions to Availity todayPublished: Aug 1, 2020 - Administrative
There is no doubt the coronavirus (COVID-19) crisis has taken a toll on all of us. Thepandemic has led to immeasurable challenges, but we are here to help you ease back intobusiness. We want to remind you, as the Availity migration continues, Anthem Blue Crossand Blue Shield will guide you to make it a smooth transition. The Availity EDI migration hasa target closing date of September 15, 2020. Take action today: Availity setup is simple and at no cost for you
August 2020 Anthem Provider News - Virginia Page 15 of 52
Use this “Welcome” link to get started today: https://apps.availity.com/web/welcome/#/ All EDI transmissions currently sent or received today via the Anthem gateway are nowavailable on the Availity EDI gateway.
837 Institutional and Professional
837 Dental
835 Electronic Remittance Advice
276/277 Claim Status
270/271 Eligibility Request
275 Medical Attachments
278 Prior Authorization/Referrals
278N Inpatient Admission and Discharge Notification
Below are the options you can choose from to exchange EDI transmissions with the AvailityEDI Gateway:
Migrate your direct connection with Anthem and become a direct submitter with Availity.
August 2020 Anthem Provider News - Virginia Page 16 of 52
Use your existing clearinghouse or billing company for your EDI transmissions. (Workwith them to ensure connectivity to the Availity EDI Gateway).
Use Direct Single Claim entry through the Availity Portal.
Learn more about Availity by taking courses at no charge Enroll in one of Availity’s free courses and training demos at your convenience. Making theswitch to Availity's EDI Gateway is easy if you have all the resources that you need. Follow these steps to register at www.Availity.com :
1. Log in to the Availity Portal and select Help & Training | Get Trained to access theAvaility Learning Center (ALC).
1. Select Sessions from the menu under the search catalog field.
1. Scroll Your Calendar to locate your webinar.
1. Select View Course and then Enroll. The ALC will email you instructions to attend.
If you and your clearinghouse have already migrated over to Availity, thank you and you area step ahead. If not, start the process now to make the transition before September 15,2020. For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) forassistance Monday - Friday 8 a.m. - 7 p.m. ET.
August 2020 Anthem Provider News - Virginia Page 17 of 52
585-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/migrate-your-edi-transactions-to-availity-today-2
Resources to support diverse patients and communitiesPublished: Aug 1, 2020 - Administrative
We’ve heard it all our lives: To be fair, you should treat everybody the same. But thechallenge is that everybody is not the same – and these differences can lead to criticaldisparities not only in how patients access health care, but their outcomes as well. Thecurrent health crisis illuminates this quite clearly. It is imperative to offer care that is tailoredto the unique needs of patients, and Anthem Blue Cross and Blue Shield is committed tosupporting our providers in this effort. MyDiversePatients.com offers education resources to help you support the needs of yourdiverse patients and address disparities, including:
Free Continuing Medical Education (CME) learning experiences about disparities,potential contributing factors and opportunities for providers to enhance care.
Real life stories about diverse patients and the unique challenges they face.
Tips and techniques for working with diverse patients to promote improvement in healthoutcomes.
Stronger Together offers free resources to support the diverse health needs of all peoplewhere they live, learn, work and play. These resources were created by our parent companyin collaboration with national organizations and are available for you to share with yourpatients and communities.
August 2020 Anthem Provider News - Virginia Page 18 of 52
While there is no single easy answer to the issue of health caredisparities, the vision of MyDiversePatients.com and StrongerTogether is to start reversing these trends…one person at a time. Embrace the knowledge, skills, ideals, strategies, and techniquesto accelerate your journey to becoming your patients’ trustedhealth care partner by visiting these resources today. My Diverse Patients
Stronger Together Health Equity Resources
584-0820-PN-VA
Article Attachments
URL: https://providernews.anthem.com/virginia/article/resources-to-support-diverse-patients-and-communities-2
August 2020 Anthem Provider News - Virginia Page 19 of 52
Interactive Care Reviewer: Anthem’s online prior authorizationtool targeting August launch for Federal Employee Program andSeptember launch for Anthem’s Commercial membershipPublished: Aug 1, 2020 - Administrative
Later this month, on August 15, 2020, you can begin using Interactive Care Reviewer (ICR)to request and check the status of medical and behavioral health inpatient and outpatientauthorizations for members enrolled in the Blue Cross and Blue Shield Service BenefitPlan (commonly referred to as the Federal Employee Program® or FEP).
You will be able to view FEP historical cases submitted through Point of Care prior toAugust 15, 2020, through ICR and Point of Care.
Updates to existing FEP cases will continue through Point of Care until September 30,2020. If there are any services past September 30, 2020, those will be transitioned andcan be updated through ICR.
Next month, we are targeting September 12 to launch ICR to request new authorizations forour members enrolled in Anthem’s Commercial lines of business. (This includesCommercial plans offered by our affiliate, HealthKeepers, Inc.) Look for additionaldetails in upcoming communications, as we begin to make this transition from Point of Careto ICR. ICR is currently available to request prior authorizations for your patients enrolled inMedicare Advantage and Anthem HealthKeepers Plus (Medicaid). Once fully launched, Interactive Care Reviewer will be your exclusive self-service onlineauthorization tool for all new medical and behavioral health prior authorization requests.Using one application for your patients enrolled in all Anthem plans will further streamlineyour authorization workflow process. Access ICR through the Availity Portal Be prepared early and ask your Availity administrator to grant you the required ICR roleassignment now.
August 2020 Anthem Provider News - Virginia Page 20 of 52
Do you create and submit prior authorization requests?Authorization and Referral Request role assignment Do you check the status of the case or results of the authorization request?Authorization and Referral Inquiry role assignment Beginning August 15, follow these steps to navigate to ICR through Availity to requestand check the status of prior authorizations for FEP members
Select Patient Registration from Availity’s home page
Select Authorizations & Referrals
Select Authorizations (for requests) | Select Auth/Referral Inquiry (for inquiries)
Register for our August ICR webinar We offer training every month to familiarize new users with ICR features and navigation ofthe tool. Our next webinar is taking place on August 18.Register Here Additional ICR resources are available through the Custom Learning Center Follow the steps outlined below to access self-paced videos located on the Custom LearningCenter. From Availity’s home page, select Payer Spaces | Anthem tile | Applications |Custom Learning Center
Select Catalog from the menu located on the upper left corner of the Custom LearningCenter screen.
Use the catalog filter and select Interactive Care Reviewer-Online Authorizations orAuthorizations from the Category
August 2020 Anthem Provider News - Virginia Page 21 of 52
Click Apply then enroll for the courses (videos) you want to view.
Illustrated reference guides that you can print are located on Custom Learning CenterResources. Select Resources from the menu located on the upper left corner of thescreen. Use the catalog filter and select Authorizations or Interactive Care Reviewer-Online Authorizations from the Category menu. Select Download to view and/or print thereference guide. 593-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/interactive-care-reviewer-anthems-online-prior-authorization-tool-targeting-august-launch-for-federal-employee-program-and-september-launch-anthems-commercial-membership
Anthem’s fall webinar scheduled for November 12; Register soonPublished: Aug 1, 2020 - Administrative
Anthem continues to offer provider education webinars with our fall webinar scheduled forNovember 12, 2020. Designed for our network-participating providers, the webinaraddresses Anthem business updates and billing guidelines that impact your businessinteractions with us. For your convenience, we offer these informative, hour-long sessions online to eliminatetravel time and help minimize disruptions to your office or practice. The date for the fallwebinar is:
Thursday, November 12, 2020, from 11 a.m. to noon ET
August 2020 Anthem Provider News - Virginia Page 22 of 52
Please consider registering today for the webinar using theregistration form to the right under the “Article Attachments”section. If you have already registered for the November webinar,please ensure you have received a confirmation from an Anthemrepresentative to ensure we’ve received your registration form. Contact [email protected] if you need to confirm yourregistration. 557-0820-PN-VA
Article Attachments
Anthem Webinarand RegistrationForm 2020.pdfapplication/pdf - 312.3 KB
URL: https://providernews.anthem.com/virginia/article/anthems-fall-webinar-scheduled-for-november-12-register-soon
Medical record standardsPublished: Aug 1, 2020 - Guideline Updates
Quality health care requires standard documentation requirements to ensure consistency forthe care of our members. These standards are reviewed annually to ensure they align withour current policies. These standards ensure effective medical record documentation andprovide clear and consistent guidelines to ensure that providers maintain records in acurrent, organized, and effective manner. The medical record criteria that are encouraged forour network of independently contracted providers are outlined below.
1. Every page in the medical record contains the patient name or ID number.
1. Allergies/No Known Drug Allergies (NKDA) and adverse reactions are prominentlydisplayed in a consistent location.
1. All presenting symptom entries are legible, signed and dated, including phone entries.Dictated notes should be initialed to signify review. Signature sheet for initials are noted.
1. The important diagnoses are summarized or highlighted.
August 2020 Anthem Provider News - Virginia Page 23 of 52
1. A problem list is maintained and updated for significant illnesses and medicalconditions.
1. A medication list or reasonable substitute is maintained and updated for chronic andongoing medications.
1. History and physical exam documentation identifies appropriate subjective andobjective information pertinent to the patient’s presenting symptoms, and treatment plandocumentation is consistent with findings.
1. Laboratory tests and other studies are ordered, as appropriate, with results noted in themedical record. (The clinical reviewer should see evidence of documentation ofappropriate follow-up recommendations and/or non-compliance to care plan).
1. Documentation of Advance Directive/Living Will/Power of Attorney discussion (includingcopies of any executed documents) in a prominent part of the medical record for adultpatients is encouraged.
1. Documentation of continuity and coordination of care between the PCP, specialtyphysician (including BH specialty) and/or facilities if there is reference to referral or careprovided elsewhere. The clinical review will look for a summary of findings or dischargesummary in the medical record. Examples include progress notes/report from consultants,discharge summary following inpatient care or outpatient surgery, physical therapy reports,and home health nursing/ provider reports.
1. Age appropriate routine preventive services/risk screening is consistently noted, i.e.childhood immunizations, adult immunizations, mammograms, pap tests, etc., or the
August 2020 Anthem Provider News - Virginia Page 24 of 52
refusal by the patient, parent or legal guardian, of such screenings/immunizations in themedical record.
582-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/medical-record-standards-3
Expansion of AIM Musculoskeletal Program effective November1, 2020Published: Aug 1, 2020 - Guideline Updates / Coverage and Clinical Guidelines
Effective November 1, 2020, the AIM Musculoskeletal Program will be expanded to includemedical necessity reviews for certain elective surgeries of the small joints for Anthemmembers. AIM Specialty Health (AIM)* will perform the expanded musculoskeletal programand will review certain lower extremity small joint surgeries for clinical appropriateness of theprocedure and the setting in which the procedure is performed (level of care review). Theclinical guidelines adopted by Anthem and used by AIM to review for medical necessity andlevel of care are located here: AIM Small Joint Surgery Guideline and AIM Level of CareGuidelines for Musculoskeletal Surgery and Procedures. AIM will begin accepting prior authorization requests on October 26, 2020, for dates ofservice on and after November 1, 2020. To determine if prior authorization is needed for anAnthem member, please call the prior authorization phone number located on the back ofthe member’s ID card. Members included in the new program All fully insured and administrative services only (ASO) members currently participating inthe AIM Musculoskeletal Program are included. For ASO groups that currently do notparticipate in the AIM Musculoskeletal Program, the program will be offered to ASOs to addto their members’ benefit packages as of November 1, 2020. Prior authorization requirements
®
August 2020 Anthem Provider News - Virginia Page 25 of 52
For surgeries that are scheduled to begin on or after November 1, 2020, all providers mustcontact AIM to obtain prior authorization for the following non-emergency modalities: Small Joint replacement (including all associated revision surgeries)
Total joint replacement of ankle
Correction of Hallux Valgus
Hammertoe repair
Surgeries performed as part of an inpatient admission are included. How to place a review request:
Online Get fast, convenient online service via the AIM ProviderPortal . ProviderPortal isavailable 24 hours a day, seven days a week, processing requests in real-time using clinicalcriteria. Go to www.aimspecialtyhealth.com/goweb to register. By phone Call AIM Specialty Health toll-free at (866) 789-0158, Monday through Friday, 8:30 a.m. – 7p.m. ET. For more information: Go to www.aimprovider.com/msk for resources to help your practice get started with themusculoskeletal and pain management program. Our special website helps you learn moreand access helpful information and tools such as order entry checklists, clinical guidelinesand FAQs.
SM
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We value your participation in our network and look forward to working with you to helpimprove the health of our members. * A specialty health benefits company, AIM works with leading insurers to improve health care quality and manage costs for today’smost complex and prevalent tests and treatments, helping to promote care that is appropriate, safe and affordable.
571-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/expansion-of-aim-musculoskeletal-program-effective-november-1-2020-4
Coverage Guidelines effective November 1, 2020Published: Aug 1, 2020 - Guideline Updates / Coverage and Clinical Guidelines
Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., willimplement the following new and revised coverage guidelines effective November 1, 2020. These guidelines impact all our products – with the exception of Anthem HealthKeepers Plus(Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCCPlus) plan, and the Blue Cross and Blue Shield Service Benefit Plan (also called the FederalEmployee Program or FEP). Furthermore, the guidelines were among those recentlyapproved at the Medical Policy and Technology Assessment Committee meeting held onMay 14, 2020. The services addressed in these coverage guidelines in this section and in the attachmentunder "Article Attachments" on the right will require authorization for all of ourHealthKeepers, Inc. products with the exception of Anthem HealthKeepers Plus (Medicaid),Medicare Advantage, and the Anthem CCC Plus plan. Please note that FEP is excludedfrom these requirements as well. A pre-determination can be requested for our PPOproducts.
If applicable, services related to specialty pharmacy drugs (non-cancer related) require amedical necessity review, which includes site of care criteria, as outlined in the applicablecoverage or clinical UM guideline.
Guidelines addressed in this edition of Provider News are:
August 2020 Anthem Provider News - Virginia Page 27 of 52
Electrical Stimulation as a Treatment for Pain and OtherConditions: Surface and Percutaneous Devices (DME.00011)
Electronic Positional Devices for the Treatment of ObstructiveSleep Apnea (DME.00042)
Technologies for the Evaluation of Skin Lesions (includingDermatoscopy, Epiluminescence Microscopy, Videomicroscopyand Ultrasonography) (MED.00004)
Electronic Home Visual Field Monitoring (MED.OO131)
Adipose-derived Regenerative Cell Therapy and Soft TissueAugmentation Procedures (MED.OO132)
Ingestion Event Monitors (MED.OO133)
Electrophysiology-Guided Noninvasive Stereotactic CardiacRadioablation (THER-RAD.OO012)
Gene Mutation Testing for Solid Tumor Cancer Susceptibilityand Management (CG-GENE-14)
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Article Attachments
Coverage guidelineseffective November1, 2020.pdfapplication/pdf - 147.96
KB
August 2020 Anthem Provider News - Virginia Page 28 of 52
URL: https://providernews.anthem.com/virginia/article/coverage-guidelines-effective-november-1-2020
Injectable substances with related injection services:ProfessionalPublished: Aug 1, 2020 - Guideline Updates / Reimbursement Policies
Effective with our Professional Provider Contract Amendment dated September 1, 2019,Anthem Blue Cross and Blue Shield (Anthem) updated our Injectable Substances withRelated Injection Services reimbursement policy. There has been much confusion over theclaims editing taking place. When a claim for an injection service is submitted without theapplicable Healthcare Common Procedure Coding System (HCPCS Level II) drug orinjectable substance code for the injected drug or substance, the code for the injectionservice will not be eligible for reimbursement. When submitting a claim for an aspiration service, with or without an injection, be sure toinclude code J3590 (unclassified biologics) with a zero charge to indicate the biologiccontents of the syringe after aspiration, or the service will not be eligible for reimbursement Additionally, if the provider did not supply the injectable substance, the HCPCS level II codeshould be appended with modifier FB to indicate the injectable substance is supplied to theprovider at no charge. For additional information, please reach out to your Anthem network manager. 578-0820-PN-VA
URL: https://providernews.anthem.com/virginia/article/injectable-substances-with-related-injection-services-professional-1
Behavioral health HEDIS® measures messagesPublished: Aug 1, 2020 - State & Federal / Medicaid
Initiation and Engagement of Alcohol and Other Drug Abuse or DependenceTreatment (IET)
August 2020 Anthem Provider News - Virginia Page 29 of 52
More than 20 million Americans age 13 and older are classified as having a substance usedisorder involving alcohol and other drug use (AOD). Treatment has been shown to reduceAOD-associated morbidity and mortality; improve health, productivity and social outcomes;and reduce health spending. Despite these benefits, less than 20% of individuals withsubstance use disorders receive treatment. To ensure these positive outcomes, it’simportant to remember the following for your Anthem HealthKeepers Plus members 13 andolder who are newly diagnosed with a substance use disorder in any level of care:
Ensure that your patient is seen by a mental health practitioner within 14 days forinitiation of AOD treatment. Treatment can be through an inpatient AOD admission,outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, ormedication-assisted treatment (MAT).
Following that visit, at least two additional visits are recommended within 34 days ofthe initial visit.
All visits must be documented with a substance use diagnosis. Follow-up after Emergency Department visit for alcohol and other drug Abuse ordependence (FUA)
Millions of Americans age 13 and older are classified as having a substance use disorderinvolving alcohol and other drug use (AOD). High ED use for individuals with AOD maysignal a lack of access to care or issues with continuity of care. Timely follow-up care forindividuals with AOD who were seen in the ED is associated with a reduction in substanceuse, future ED use, hospital admissions and bed delays. Do the following to ensure the best outcome for your members age 13 and older dischargedfrom an emergency room visit with a primary diagnosis of alcohol or other drug use ordependence: Make sure they are seen by an outpatient provider (any practitioner) and havea principal diagnosis of AOD use. This follow-up visit may occur on the date of discharge. Two rates are reported:
August 2020 Anthem Provider News - Virginia Page 30 of 52
ED visits for which the member received follow-up within 30 days of the ED visit (31total days)
ED visits for which the member received follow-up within seven days of the ED visit(eight total days)
Follow-up is key. Make sure your members are seen within the seven- and 30-day window. Follow-up after Emergency Department Visit for Mental Illness (FUM)
Mental illness can affect people of all ages. In the United States, 18% of adults and 13% to20% of children under 18 years of age experience mental illness. Research suggests thatfollow-up care for people with mental illness is linked to fewer repeat ED visits, improvedphysical and mental function and increased compliance with follow-up instructions. It’s important to remember that your patients ages 6 and older discharged from anemergency department visit with a primary mental health diagnosis must be seen by anoutpatient provider. The visit may occur on the date of discharge. Two rates are reported:
ED visits for which the member received follow-up within 30 days of the ED visit (31total days)
ED visits for which the member received follow-up within seven days of the ED visit(eight total days)
Follow-up is key. Make sure your members are seen within the seven- and 30-day window.If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
August 2020 Anthem Provider News - Virginia Page 31 of 52
AVA-NU-0254-20
URL: https://providernews.anthem.com/virginia/article/behavioral-health-hedis-measures-messages
Provider data updatePublished: Aug 1, 2020 - State & Federal / Medicaid
HealthKeepers, Inc. partners with AIM Specialty Health * (AIM), a leading specialty benefitsmanagement company that provides services for radiology, cardiology, genetic testing,oncology, musculoskeletal, rehabilitation, sleep management, and additional specialtyareas. We require that Anthem HealthKeepers Plus provider demographic information(group or practice name, additional providers added to the group/practice, location) iscurrent and accurate to eliminate provider and member abrasion. In the event the provider's demographic information has not been updated in the AnthemHealthKeepers Plus system, the data will also be missing from the provider data that goes toAIM. Therefore, providers may not be able to locate the requested record in AIM's system.While the provider's information can be manually entered to build a case, the record willappear to be out-of-network, and the case will adjudicate accordingly. Anthem HealthKeepers Plus provider data updates flow to AIM via the provider dataextract, but the data flow does not work in the reverse back to HealthKeepers, Inc. It isimportant that providers make the following changes or updates with HealthKeepers,Inc., not AIM:
Group or practice name
Tax Identification Number (TIN)
National Provider Identifier (NPI)
®
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Address (add/remove location(s), corrections)
Phone numbers
Fax numbers
Any additional changes
If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. * AIM Specialty Health is an independent company providing some utilization review services on behalf of HealthKeepers, Inc.
AVA-NU-0255-20
URL: https://providernews.anthem.com/virginia/article/provider-data-update-3
Adolescent well-care visits HEDIS measurePublished: Aug 1, 2020 - State & Federal / Medicaid
It is believed that behaviors established during childhood or adolescence, such as eatinghabits and physical activity, often extend into adulthood. Well‐care visits provide anopportunity for providers to influence health and development. For members enrolled inAnthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth CoordinatedCare Plus (Anthem CCC Plus), these visits are a critical opportunity for screening andcounseling. The Adolescent Well-Care Visits (AWC) HEDIS measure looks for at least onecomprehensive well‐care visit for members 12 to 21 years of age with a PCP or OB/GYNtype provider.
An adolescent well-care visit should include the following:
®
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A health history – covers past illnesses (or lack of illness), hospitalizations, chronichealth conditions, allergies, and the child’s emotional and social development. It alsoincludes a family history of health problems. The health history highlights any specialconcerns about the adolescent.
Physical developmental history – includes developmental milestones and anassessment of whether the adolescent is developing skills to become a healthy adult.Examples: Tanner score, onset of menstrual cycle, participation in a team sport.
Mental developmental history – includes developmental milestones and assessmentof whether the adolescent is developing skills to become a healthy adult. Examples:making good grades, good circle of friends, seems depressed or detached from familyand/or friends, career development, smoking/ETOH/drug use.
Physical exam – a comprehensive head to toe exam with vital signs; it must consist ofmore than one body system to meet criteria.
Anticipatory guidance – given in anticipation of emerging issues that member mayface; injury and illness prevention, nutrition, promotion of constructive family relationshipsand developing social skills. Preprinted forms or checklists may be used, but thecheck boxes must be checked off or initialed by the provider at the time of the visit.
Don’t miss an opportunity to perform a well‐child exam. Well-child preventive services counttoward the measure, regardless of the primary intent of the visit (for example, GYN type visitor sick visit), but services that are specific to an acute or chronic condition do not counttowards the measure. If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
August 2020 Anthem Provider News - Virginia Page 34 of 52
Childhood Immunization Status HEDIS measure
Immunizations are essential for disease prevention and are a critical aspect of preventivecare for children. Vaccination coverage must be maintained in order to prevent a resurgenceof vaccine‐preventable diseases. Childhood immunizations are to be completed by a child’ssecond birthday for HEDIS® compliance. If the CDC immunization schedule is followed,immunizations can actually be completed by 18 months of age for Anthem HealthKeepersPlus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (AnthemCCC Plus) members. What is measured for Childhood Immunization Status (CIS)? The percentage of children 2years of age in the measurement year who had the following:
4 – Dtap 3 – IPV (polio)1 – MMR 3 – HiB (haemophilus influenza type B)3 – Hep B 1 – VZV (chicken pox)4 – PCV (pneumococcal) 1 – Hep A2 or 3 – RV (rotavirus) 2 – influenza
Children also need a lead screen (by a capillary or venous blood test) on or before theirsecond birthday. Unfortunately, there has been an increase in the number of parents thatare refusing to vaccinate their children. This is causing a growing concern for the recurrenceof vaccine-preventable diseases. It is imperative to talk with the parents to allay their fearsand dispel any misbeliefs they may have about vaccinations. If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
AVA-NU-0258
URL: https://providernews.anthem.com/virginia/article/adolescent-well-care-visits-hedis-measure
August 2020 Anthem Provider News - Virginia Page 35 of 52
Controlling high blood pressure (CBP)Published: Aug 1, 2020 - State & Federal / Medicaid
This HEDIS measure looks at the percentage of Anthem HealthKeepers Plus membersages 18 to 85 years who have had a diagnosis of hypertension (HTN) and whose bloodpressure (BP) was adequately controlled (< 140/90 mm Hg). Record your efforts: Document blood pressure and diagnosis of hypertension. Members whose BP is adequatelycontrolled include:
Members 18 to 85 years of age who had a diagnosis of HTN and whose BP wasadequately controlled (< 140/90 mm Hg) during the measurement year.
The most recent BP reading during the measurement year on or after the seconddiagnosis of HTN.
If no BP is recorded during the measurement year, assume that the member is “notcontrolled.”
What does not count for this HEDIS measure?
If blood pressure is taken on the same day as a diagnostic test or procedure or for achange in diet or medication regimen.
If blood pressure is taken on or one day before the day of any test or procedure.
Blood pressure taken during an acute inpatient stay or an emergency department visit.
®
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Exclusions:
End stage renal disease
Nephrectomy or kidney transplant
Pregnancy
Nonacute inpatient stay
Members aged 66 to 80 with frailty and advanced illness
Members 81 years old and above with frailty
Helpful tips:
Have your office staff recheck blood pressure for members with initial diagnosis ofhypertension and record readings greater than 140 mm Hg systolic and 90 mm Hgdiastolic during outpatient office visits. Educate your staff to record the recheck inmember’s medical records.
Refer high-risk members to our hypertension programs and other programs foradditional education and support.
August 2020 Anthem Provider News - Virginia Page 37 of 52
Educate members and their spouses, caregivers or guardians about the elements of ahealthy lifestyle such as:
Heart-healthy eating and a low-salt diet.
Smoking cessation and avoiding secondhand smoke.
Adding regular exercise to daily activities.
Home BP monitoring.
Ideal BMI.
The importance of taking all prescribed medications as directed.
Remember to include the applicable Category II reporting code on the claim form tohelp reduce the burden of HEDIS medical record review.
How can we help? We support you in helping members control high blood pressure by:
Providing online Clinical Practice Guidelines on our provider website.
August 2020 Anthem Provider News - Virginia Page 38 of 52
Reaching out to our hypertensive members through our education and supportprograms.
Other available resources:
National Heart, Lung, and Blood Institute
CDC Blood Pressure educational materials
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
AVA-NU-0261-20
URL: https://providernews.anthem.com/virginia/article/controlling-high-blood-pressure-cbp-3
Medical drug benefit Clinical Criteria updatesPublished: Aug 1, 2020 - State & Federal / Medicaid
On November 15, 2019, February 21, 2020, and March 26, 2020, the Pharmacy andTherapeutics (P&T) Committee approved Clinical Criteria applicable to the AnthemHealthKeepers Plus medical drug benefit for HealthKeepers, Inc. Please note, this doesnot affect the prescription drug benefit. These policies were developed, revised orreviewed to support clinical coding edits. The Clinical Criteria is publicly available on the provider websites, and the effective dates willbe reflected in the Clinical Criteria Web Posting March 2020. Visit Clinical Criteria tosearch for specific policies. If you have questions or would like additional information, use this email. AVA-NU-0262-20
August 2020 Anthem Provider News - Virginia Page 39 of 52
URL: https://providernews.anthem.com/virginia/article/medical-drug-benefit-clinical-criteria-updates-45
New MCG Care Guidelines 24th editionPublished: Aug 1, 2020 - State & Federal / Medicaid
Effective August 1, 2020, HealthKeepers, Inc. will use the new acute viral illness guidelinesthat have been added to the 24th edition of the MCG Care Guidelines for AnthemHealthKeepers Plus members. Based on the presenting symptoms or required interventionsdriving the need for treatment or hospitalization, these guidelines are not a substantive ormaterial change to the existing MCG Care Guidelines we use now, such as systemic orinfectious condition, pulmonary disease, or adult or pediatric pneumonia guidelines. Inpatient Surgical Care (ISC):
Viral Illness, Acute – Inpatient Adult (M-280)
Viral Illness, Acute – Inpatient Pediatric (P-280)
Viral Illness, Acute – Observation Care (OC-064)
Recovery Facility Care (RFC):
Viral Illness, Acute – Recovery Facility Care (M-5280)
AVA-NU-0265-20
URL: https://providernews.anthem.com/virginia/article/new-mcg-care-guidelines-24th-edition-4
August 2020 Anthem Provider News - Virginia Page 40 of 52
Quarterly pharmacy formulary change noticePublished: Aug 1, 2020 - State & Federal / Medicaid
The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus andAnthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus)members. Effective July 1, 2020, formulary changes, non-formulary changes and prior authorizationrequirements will apply.
August 2020 Anthem Provider News - Virginia Page 41 of 52
Effective for all members on July 1, 2020Therapeuticclass
Medication Formularystatus
change
Potential alternatives(preferred products)
ADHD AGENTS DYANAVEL XR 2.5MG/ML SUSPENSION
NON-PREFERRED
Vyvansecapsules/chewable
tabletAdderall XR capsulesDextroamphetamine
tabletADHD AGENTS QUILLIVANT XR 25 MG/5
ML SUSPENSIONQUILLICHEW ER 40 MG
CHEW TABLETQUILLICHEW ER 20 MG
CHEW TABLETQUILLICHEW ER 30 MG
CHEW TABLET
NON-PREFERRED
Focalin XR capsulesDaytrana transdermal
patchConcerta tablet
methylphenidate IRcapsules/tablet
ANDROGENS ANDROGEL 1.62%(1.25G)GEL PACKET
NON-PREFERRED
WITH PA
testosterone pump(genric androgel)
PA required
August 2020 Anthem Provider News - Virginia Page 42 of 52
ANTIDIABETICCOMBINATIONS
INVOKAMET 50-500 MGTABLET
INVOKAMET 50-1,000MG TABLET
INVOKAMET 150-500MG TABLET
INVOKAMET 150-1,000MG TABLET
XIGDUO XR 2.5MG-1,000 MG TAB
XIGDUO XR 5 MG-500MG TABLET
XIGDUO XR 5 MG-1,000MG TABLET
XIGDUO XR 10 MG-500MG TABLET
XIGDUO XR 10MG-1,000 MG TAB
PREFERREDWITH MINAGE LIMIT
OF 18 YEARSAND OLDER
N/A
INSULIN HUMALOG JRHUMALOG MIX 50/50
HUMALOG 100/ML VIAL
PREFERRED N/A
INSULIN INSULIN LISPROKWIKPEN
ADMELOG SOLOSTAR
NON-PREFERRED
HUMALOG KWIKINJ 100/ML
INSULIN NOVOLIN N FLEXPEN NON-PREFERRED
HUMULIN NKWIKPEN
INSULIN NOVOLIN 70/30FLEXPEN
NON-PREFERRED
HUMULIN 70/30KWIKPEN
URINARYANTISPASMODICS
SOLIFENACIN 5 MGTABLET
SOLIFENACIN 10 MGTABLET
PREFERRED N/A
URINARYANTISPASMODICS
VESICARE 5 MG TABLETVESICARE
10 MG TABLET
NON-PREFERRED
SOLIFENACIN 5 MGTABLET
SOLIFENACIN 10MG TABLET
August 2020 Anthem Provider News - Virginia Page 43 of 52
Edits effective July 1, 2020No changes in preferred/nonpreferred status revision or addition to UM edit only
Therapeutic class Medication Formulary status changeALLERGENICEXTRACTS
PALFORZIA CAPSULES PA REQUIRED
ANALGESICS - ANTI-INFLAMMATORY
OLUMIANT 1 MGTABLET
OLUMIANT 2 MGTABLET
ADD QTY LIMIT 30 PER 30DAYS
ANALGESICS - ANTI-INFLAMMATORY
OTEZLA 30 MG TABLET ADD QTY LIMIT 60 PER 30DAYS
ANTIRHEUMATICANTIMETABOLITES
OTREXUP INJECTIONSRASUVO INJECTIONS
ADD QTY LIMIT 4 PER 28 DAYS
HISTAMINE H3-RECEPTOR
ANTAGONIST/INVERSEAGONISTS
WAKIX 4.45MG TABLETWAKIX 17.8MG TABLET
PA REQUIRED
INTERLEUKIN-1RECEPTOR
ANTAGONIST
KINERET INJ ADD QTY LIMIT 30 PER 30DAYS
MIGRAINE PRODUCTS REYVOW TABLETUBRELVY TABLET
PA REQUIRED
What action do I need to take? Please review these changes and work with your Anthem HealthKeepers Plus and/orAnthem CCC Plus patients to transition them to formulary alternatives. If you determineformulary alternatives are not clinically appropriate for specific patients, you will need toobtain prior authorization to continue coverage beyond the applicable effective date. What if I need assistance?
August 2020 Anthem Provider News - Virginia Page 44 of 52
We recognize the unique aspects of patients’ cases. If your patients cannot be converted toa formulary alternative, call our Pharmacy department at 1-800-901-0020 (AnthemHealthKeepers Plus members) or 1-855-323-4687 (Anthem CCC Plus members) and followthe voice prompts for pharmacy prior authorization. You can find the Preferred Drug List(formulary) on our provider website at https://mediproviders.anthem.com/va > Pharmacy >Medicaid Common Core Formulary > Common Core Preferred Drug List. If you have any questions about this communication, call our Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. AVA-NU-0266-20
URL: https://providernews.anthem.com/virginia/article/quarterly-pharmacy-formulary-change-notice-5
DMAS specifications for ER physician non-emergent paymentreduction policyPublished: Aug 1, 2020 - State & Federal / Medicaid
In accordance with the Commonwealth of Virginia’s 2020 Appropriation Act, HealthKeepers,Inc. will be implementing the following new reimbursement policy for emergency roompayments, effective July 1, 2020. This policy, together with reimbursement specifications, willalso be added to the Anthem HealthKeepers Plus provider manual. The 2020 Appropriation Act (Chapter 1289) includes the following changes in emergencyroom facility and physician reimbursement. Item 313.AAAAA The Department of Medical Assistance Services shall amend the StatePlan for Medical Assistance Services to allow the pending, reviewing and the reducing offees for avoidable emergency room claims for codes 99282, 99283 and 99284, bothphysician and facility. The department shall utilize the avoidable emergency room diagnosiscode list currently used for Managed Care Organization clinical efficiency rate adjustments.If the emergency room claim is identified as a preventable emergency room diagnosis, thedepartment shall direct the Managed Care Organizations to default to the payment amountfor code 99281, commensurate with the acuity of the visit. The department shall have theauthority to implement this reimbursement change effective July 1, 2020, and prior to thecompletion of any regulatory process undertaken in order to effect such change.
August 2020 Anthem Provider News - Virginia Page 45 of 52
If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. AVA-NU-0268-20
URL: https://providernews.anthem.com/virginia/article/dmas-specifications-for-er-physician-non-emergent-payment-reduction-policy
DMAS specifications for readmission payment reduction policyPublished: Aug 1, 2020 - State & Federal / Medicaid
In accordance with the Commonwealth of Virginia’s 2020 Appropriation Act, HealthKeepers,Inc. will implement the following new reimbursement policy for inpatient readmissions,effective July 1, 2020. This policy, together with reimbursement specifications, will also beadded to the Anthem HealthKeepers Plus provider manual. The 2020 Appropriation Act (Chapter 1289) includes the following change in hospitalreadmission reimbursement. Item 313.BBBBB. The Department of Medical Assistance Services shall amend the StatePlan for Medical Assistance Services under Title XIX to modify the definition of readmissionsto include cases when patients are readmitted to a hospital for the same or a similardiagnosis within 30 days of discharge, excluding planned readmissions, obstetricalreadmissions, admissions to critical access hospitals, or in any case where the patient wasoriginally discharged against medical advice. If the patient is readmitted to the same hospitalfor a potentially preventable readmission then the payment for such cases shall be paid at50 percent of the normal rate, except that a readmission within five days of discharge shallbe considered a continuation of the same stay and shall not be treated as a newcase. Similar diagnoses shall be defined as ICD diagnosis codes possessing the same firstthree digits. The department shall have the authority to implement this reimbursementchange effective July 1, 2020, and prior to the completion of any regulatory processundertaken in order to effect such change. The department shall report quarterly on thenumber of hospital readmissions, the cost, and the primary diagnosis of such readmissionsto the Joint Subcommittee for Health and Human Resources Oversight.
August 2020 Anthem Provider News - Virginia Page 46 of 52
If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. AVA-NU-0269-20
URL: https://providernews.anthem.com/virginia/article/dmas-specifications-for-readmission-payment-reduction-policy
Keep up with Medicaid newsPublished: Aug 1, 2020 - State & Federal / Medicaid
Please continue to check our website https://mediproviders.anthem.com for the latestMedicaid information for members enrolled in HealthKeepers, Inc.’s Anthem HealthKeepersPlus and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) benefit plans. Hereis the topic we’re addressing in this edition: Prior authorization requirements for angiographic evaluation of stenotic or thromboseddialysis circuits AVA-NU-0259-20
URL: https://providernews.anthem.com/virginia/article/keep-up-with-medicaid-news-37
Medical drug benefit Clinical Criteria updatesPublished: Aug 1, 2020 - State & Federal / Medicare
On November 15, 2019, February 21, 2020, and March 26, 2020, the Pharmacy andTherapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drugbenefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised orreviewed to support clinical coding edits. The Clinical Criteria is publicly available on the provider websites, and the effective dates willbe reflected in the Clinical Criteria Web Posting March 2020. Visit Clinical Criteria tosearch for specific policies.
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If you have questions or would like additional information, use this email. ABSCRNU-0156-20 510564MUPENMUB
URL: https://providernews.anthem.com/virginia/article/medical-drug-benefit-clinical-criteria-updates-46
New MCG Care Guidelines 24th editionPublished: Aug 1, 2020 - State & Federal / Medicare
Effective August 1, 2020, Anthem Blue Cross and Blue Shield will use the new acute viralillness guidelines that have been added to the 24th edition of the MCG Care Guidelines.Based on the presenting symptoms or required interventions driving the need for treatmentor hospitalization, these guidelines are not a substantive or material change to the existingMCG Care Guidelines we use now, such as systemic or infectious condition, pulmonarydisease, or adult or pediatric pneumonia guidelines. Inpatient Surgical Care (ISC):
Viral Illness, Acute – Inpatient Adult (M-280)
Viral Illness, Acute – Inpatient Pediatric (P-280)
Viral Illness, Acute – Observation Care (OC-064)
Recovery Facility Care (RFC):
Viral Illness, Acute – Recovery Facility Care (M-5280)
ABSCRNU-0157-20 511106MUPENMUB
August 2020 Anthem Provider News - Virginia Page 48 of 52
URL: https://providernews.anthem.com/virginia/article/new-mcg-care-guidelines-24th-edition-5
2020 Medicare risk adjustment provider trainingsPublished: Aug 1, 2020 - State & Federal / Medicare
The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross andBlue Shield offers two provider training programs regarding Medicare risk adjustment anddocumentation guidelines. Information for each training is outlined below. Medicare Risk Adjustment and Documentation Guidance (general) When: This training is offered the first Wednesday of each month from 1 p.m. to 2 p.m. ET. Learning objective: This onboarding training will provide an overview of Medicare riskadjustment, including the risk adjustment factor and the hierarchical condition category(HCC) model with guidance on medical record documentation and coding. Credits: This live activity, Medicare Risk Adjustment and Documentation Guidance, fromJanuary 8, 2020, to December 2, 2020, has been reviewed and is acceptable for up to oneprescribed credit(s) by the American Academy of Family Physicians. Physicians shouldclaim only the credit commensurate with the extent of their participation in the activity. For those interested in joining us to learn how providers play a critical role in facilitating therisk adjustment process, register for one of the monthly training sessions at: TrainingRegistration. * Note: Dates may be modified due to holiday scheduling. Medicare Risk Adjustment, Documentation and Coding Guidance (condition specific) When: This training is offered on the third Wednesday of every other month from noon to 1p.m. ET. Learning objective: This training series will provide in-depth disease information pertainingto specific conditions, including an overview of their corresponding hierarchical conditioncategories (HCC), with guidance on documentation and coding.
August 2020 Anthem Provider News - Virginia Page 49 of 52
Credits: This live series activity, Medicare Risk Adjustment Documentation and CodingGuidance, from January 15, 2020, to November 18, 2020, has been reviewed and isacceptable for credit by the American Academy of Family Physicians. Physicians shouldclaim only the credit commensurate with the extent of their participation in the activity. For those interested in joining us for this six-part training series, please see the list of topicsand scheduled training dates below: Session 1: Red Flag HCCs, part one: Training will cover HCCs most commonly reported inerror as identified by CMS, including chronic kidney disease (stage five), ischemic orunspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias,unstable angina and other acute ischemic heart disease, and end-stage liver disease.Recording will play upon registration.2020 Medicare Risk Adjustment Documentation and Coding Guidance: Red FlagHCC's Part 1Password: sDBNERC3 Session 2: Red Flag HCCs, part two: Training will cover HCCs most commonly reported inerror as identified by CMS, including atherosclerosis of the extremities with ulceration organgrene, myasthenia gravis/myoneural disorders and guillain-barre syndrome, drug/alcoholpsychosis, lung and other severe cancers, diabetes with ophthalmologic or unspecifiedmanifestation.Recording will play upon registration.2020 Medicare Risk Adjustment Documentation and Coding Guidance: Red FlagHCC’s Part 2Password: PnPAF4py Session 3: NeoplasmsRecording will play upon registration.2020 Medicare Risk Adjustment Documentation and Coding Guidance: NeoplasmsPassword: PfUWPcs6 Session 4: Acute, Chronic and Status ConditionsRecording link will be provided after October 1, 2020. Session 5: Diabetes Mellitus and Other Metabolic Disorders - September 16, 2020DM and other Endocrine, Nutritional and Metabolic Disorders Session 6: Coinciding Conditions in Risk Adjustment Models - November 18, 2020
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Medicare Risk Adjustment Documentation and Coding Guidance: CoincidingConditions in Risk Adjustment Models ABSCRNU-0158-20 510874MUPENMU
URL: https://providernews.anthem.com/virginia/article/2020-medicare-risk-adjustment-provider-trainings-20
AIM Musculoskeletal program expansionPublished: Aug 1, 2020 - State & Federal / Medicare
Effective November 1, 2020, AIM Specialty Health (AIM)*, a specialty health benefitscompany, will expand the AIM Musculoskeletal program to perform medical necessityreviews for certain elective surgeries of the small joint for Medicare Advantage patients, asfurther outlined below. AIM will follow the Anthem Blue Cross and Blue Shield (Anthem) clinical hierarchy formedical necessity determination. For Medicare Advantage (MA) products AIM makes clinicalappropriateness based on CMS National Coverage Determinations, Local CoverageDeterminations, other coverage guidelines, and instructions issued by CMS and legislativebenefit changes. Where the existing CMS guidance provides insufficient clinical detail, AIMwill determine medical necessity using an objective, evidence-based process. Prior authorization requirements For services scheduled on or after November 1, 2020, providers must contact AIM to obtainprior authorization for the services detailed below. Providers are strongly encouraged toverify they have received a prior authorization before scheduling and performing services. Detailed prior authorization requirements are available to contracted providers by accessingthe Availity Portal* at www.availity.com. Contracted and non-contracted providers may callProvider Services at the phone number on the back of the member’s ID card for priorauthorization requirements or additional questions as needed. Small joint replacement (including all associated revision surgeries)
Total joint replacement of the ankle
®
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Correction of hallux valgus
Hammertoe repair
The expanded musculoskeletal program will review certain lower extremity small jointsurgeries for clinical appropriateness of the procedure and the setting in which theprocedure is performed (Level of Care review). Procedures performed as part of an inpatientadmission are included. The clinical guidelines that have been adopted by Anthem to reviewfor medical necessity and level of care are located at:
AIM Small Joint Surgery Guideline
AIM Level of Care Guidelines for Musculoskeletal Surgery and Procedures
How to place a review request You may place a prior authorization request online via the AIM ProviderPortal . Thisservice is available 24/7 to process requests using Clinical Criteria. Go towww.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday toFriday 7 a.m. to 7 p.m. Central time. For more information For resources to help your practice get started with the musculoskeletal program, go towww.aimprovider.com/msk. This provider website will help you learn more and provide useful information and tools suchas order entry checklists, clinical guidelines, and FAQs. For questions related to guidelines, please contact AIM via email [email protected].
SM
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* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross andBlue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross andBlue Shield.
ABSCRNU-0159-20 511046MUPENEBS
URL: https://providernews.anthem.com/virginia/article/aim-musculoskeletal-program-expansion-4
Keep up with Medicare newsPublished: Aug 1, 2020 - State & Federal / Medicare
Please continue to check Important Medicare Advantage Updates for the latest MedicareAdvantage information, including: Medicare Advantage Submit behavioral health authorizations via our online Interactive CareReviewer toolABSCARE-0488-20 509678MUPENMUB Medicare Advantage Waived copays, deductibles and coinsurance for CCM, complex CCMand TCMABSCRNU-0155-20 510548MUPENMUB Updates to AIM musculoskeletal program clinical appropriateness guidelinesABSCRNU-0149-20 509715MUPENMUB
URL: https://providernews.anthem.com/virginia/article/keep-up-with-medicare-news-153