Working together to improve the health of our members. february 2009 Network Update C O N N e c t i c u t In this issue Page Anthem News The new age of Network Update online debuts April 2009...Cover Administrative and Policy Update 2009 FEP benefit changes... 2 FEP timely claim filing requirement change effective May 1, 2009... 3 Get the information you need about FEP anytime via the IVR... 3 Notify us of all practice changes including acceptance of member status... 5 IVR to accept NPI only beginning February 20... 5 Update to professional claims processing edits and reimbursement policies... 5 Credentialing reminder participation confirmation and effective dates... 6 Locum tenens process... 6 Access to Anthem Online Provider Services (AOPS)... 7 AIM documentation online... 7 CoverMe Foundation fax referral sheet available on anthem.com... 7 BlueCard Update BlueCard IVR now available... 7 EDI Update Electronic remittance advice (ERA)... 8 Programs and Benefits Update Access Blue New England available effective December 1, 2008... 8 Behavioral Health Update Behavioral health providers please review the entire newsletter... 9 FEP behavioral health authorization change effective January 1, 2009... 9 Behavioral health services scope of license... 9 Member s access to behavioral health care... 9 Coordination of care... 9 Pharmacy Update Empire transition to WellPoint NextRx effective January 1, 2009...10 Voluntary predetermination for specialty pharmacy medications...10 Anthem national drug list updates...11 Medical Policy Update Medical policy updates available on anthem.com...12 ANTHEM NEWS The new age of Network Update online debuts April 2009 In the October 2008 issue of Network Update, we advised that we were considering distributing Network Update via electronic means only. Online newsletters help timely information reach you sooner and in a more efficient, environmentally friendly way. We would like to announce that this February 2009 edition of Network Update will be the final issue to be printed and mailed to you via the US Postal Service. Network Update will continue to be available on anthem. com and also via email distribution. You can easily locate the bi-monthly online edition of Network Update by logging on to anthem.com > Providers > Select state > Enter > then scroll to Provider Newsletters. Feel free to download/print the newsletter at your convenience. We encourage you to sign up for email delivery of a link to the newsletter directly in your email mail box. Sign up is quick and easy and is available at anthem.com > Providers > Select state > Enter > Anthem Network Updates Rapid Email Service. Continued on page 2 PCTNW5036A (1/09) CT09001
The new age of Network Update online debuts April 2009 (Continued) Beginning with the April 2009 issue and each issue thereafter, we ll mail you a brief postcard outlining important information, updates and announcements as a reminder to check out the latest edition of Network Update online. If you don t have Internet access and would like a printed copy of Network Update, please contact the Provider Call Center at 800-922-3242. ADMINISTRATIVE AND POLICY UPDATE 2009 FEP benefit changes Following are some of the benefit changes implemented on January 1, 2009 for Federal Employee Program (FEP) members. FEP members can be identified by the R prefix on their member ID number. To view the 2009 FEP Service Benefit Plan brochure that contains a summary of all 2009 FEP benefit changes, visit www.fepblue.org/benefitplans/2009-sbp/sbp2009brochure_english.pdf. Prior approvals required for certain outpatient procedures Providers will be required to obtain prior approval (also known as prior authorization or outpatient precertification) for the outpatient surgical services listed in the chart below. Outpatient Surgery Service Procedure Codes Morbid obesity Correction of accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth. Correction of congenital anomalies CPT: 43644, 43645, 43770, 43771, 43773, 43842, 43843, 43845 43848, 43888 HCPCS: S2083 CPT: 20605, 21010, 21026, 21030 21032, 21034, 21037, 21040, 21044 21047, 21048 21050, 21060, 21070, 21073, 21116, 21240 21243, 21480 21485, 21490, 29800, 29804, 40490, 40500, 40510, 40520, 40525, 40527, 40530, 40650, 40808, 40800 40801, 40804 40806, 40810, 40812, 40814, 40816, 40819, 40820, 40840, 40842 40845, 40830, 40831, 41000, 41005 41010, 41015 41018, 41100, 41105, 41108, 41110, 41112 41116, 41120, 41130, 41150, 41250-41252, 41520, 42000, 42100, 42104, 42106 42107, 42120, 42140, 42145, 42160, 42300 42320, 42330, 42335, 42340 CPT: 33813 33814, 40700 40761, 42200 42225, 50070, 50135, 50405, 61680 61692, 61710, 63250 63252 HCPCS: C8921 This prior approval requirement applies to all physician and facility services for these procedures including preferred, participating provider, and non-participating providers. Providers must contact the FEP precertification unit at 800-860-2156 to obtain prior approval. Claims for services listed above that are not prior authorized will be denied with a request for medical records. Upon receipt of the medical records, we will review the claim for medical necessity. If the claim is determined to not be medically necessary, the service will be denied and will not be billable to the member when rendered by a contracted provider. 2
FEP optional pre-service review program Providers can write to FEP Customer Service to request a pre-service review for certain services. Pre-service review is an optional program that allows providers/members the option to see if a claim will be paid before the service is actually rendered. Pre-service review is available for: High-dollar procedures, such as surgery High-dollar DME Outpatient procedures Services related to a life-threatening condition To request pre-service review, please indicate in writing that you are requesting a pre-service review and include the following information: Description of the service/procedure CPT and/or HCPCS codes Dollar amount Diagnosis codes and supporting clinical documentation Relevant medical information, including test results, to support medical necessity Indicate whether the service is related to a life threatening condition (expedited review) FEP medical review registered nurses and physicians will review your request and respond in a timely manner. Pre-service reviews for services related to a life-threatening illness will be completed within 24 hours. Incomplete requests will be returned with an explanation of the additional information required. Send the pre-service review request to FEP at: Anthem Blue Cross and Blue Shield Federal Employee Program Connecticut Pre Service Review PO Box 37790 Louisville, KY 40233-7790 Reminder: FEP still requires pre certification for planned hospitalizations The pre-service review program is optional and should not be confused with the required prior approval of certain outpatient surgical services as listed previously, nor with FEP s long-standing required pre-certification of planned inpatient admissions. In all circumstances, benefits will be provided only if: 1. The member is enrolled in FEP at the time the service is rendered. 2. The service, procedure, or durable medical equipment (DME) received is the same as the service, procedure, or DME for which benefits were originally requested and approved. FEP timely claim filing requirement change effective May 1, 2009 The terms of providers contracts with us require that providers submit claims for members enrolled in the Federal Employee Program (FEP) within 180 days following the date of service. FEP members can be identified by the R prefix of their identification number. This is a reminder that this provision applies to all claims when FEP is the primary payer. Effective May 1, 2009, we will not accept claims submitted outside of these contractual guidelines. Get the information you need about FEP anytime via the IVR The Federal Employee Program (FEP) interactive voice response (IVR) system is dedicated to providing you with information about FEP eligibility, benefits and claim status. We have included a quick reference guide below to help you quickly navigate the IVR to get the FEP information you need saving you time. Depending on the option selected on the FEP IVR, simply enter your National Provider Identifier (NPI) number or tax identification number, the patient s ID number, date of birth and date of service to retrieve information regarding eligibility, benefits, claim status and authorizations. See chart on page 4 3
1. Contact the Federal Employee Program in Connecticut via the Toll Free telephone number: 800-438-5356 2. Press 2 (if you are calling from a facility), OR Press 3 (if you are calling from a provider s office) 3. Enter your NPI or tax identification number 4. Press 1 to confirm your NPI or Anthem Provider Identification Number is correct, OR if you need to re-enter, Press 2 5. Choose from the following options 6. If you want to: 7. Press 8. Then 9. Then 10. Then 11. Then 12.Then Verify Eligibility 1 1 Key Member ID#; Key Patient DOB; Then Then Verify Physician Benefits 1 2 Press 1 if Member ID# Press 1 if DOB Press 1 Select desired benefit: entered is correct, OR entered is correct OR 1 = Routine Physical Therapy 2 = Medical Office Visit Press 2 to re-enter ID# Press 2 to re-enter 3 = Preventive Child Care if incorrect DOB if incorrect. 4 = Surgical Services 5 = Maternity Benefits Verify Hospital Benefits 1 2 Same as above Same as above Press 2 Select desired benefit: 1 = Inpatient Medical & Surgical 2 = Outpatient Medical 3 = Outpatient Surgical 4 = Maternity Verify Dental Benefits 1 2 Same as above Same as above Press 3 Verify Prescription Benefits 1 2 Same as above Same as above Press 4 Verify Mental Health Benefits 1 2 Same as above Same as above Press 5 Select desired benefit: 1 = Office Visit 2 = Inpatient 3 = Outpatient 4 = Outpatient Partial Hospitalization and Intensive Outpatient Verify Rehab Benefits 1 2 Same as above Same as above Press 6 Select desired benefit: 1 = Physical Therapy 2 = Occupational and Speech Therapy 3 = Cardiac Rehab Check Claims Status 1 3 Same as above Same as above Key Date of Service Verify Check # and 1 3 Same as above Same as above Key Date Press 2 Check Clear Date of Service Request Provider Remittance 1 3 Same as above Same as above Key Date Press 3 of Service Hear Pre-certification Info 2 Obtain Mailing Address for 3 2 Select State: services rendered in Connecticut, Maine or New Hampshire 1 = CT 2 = ME 3 = NH 4
Notify us of all practice changes including acceptance of member status It is very important that all provider demographic information is up to date and accurate. We receive a significant number of claims with a name or address that does not match with our provider files which can result in a claim payment to an incorrect provider. In addition, members frequently utilize the online directories to obtain information regarding the Anthem network of participating providers and having accurate information is essential. Please be sure to notify us of all changes such as: Names (of practice or individual physicians) Providers leaving or joining practices Address Telephone Tax ID Specialty Credentials (such as board certification status or hospital privileges) To notify us of these changes, please use the Provider Maintenance Form located on anthem.com > Provider > Select state > Enter > Answers @ Anthem > Download Common Forms > Provider Maintenance Form. Please note that changes to tax ID numbers also require an IRS Form W9 and new signed contract. Updated primary care provider status Primary care providers: Please be sure to notify us immediately when your practice has any change in your acceptance of new patients status. Whether you are changing your practice status to accept new patients, or to close your practice to new patients, members of our managed care programs refer to the provider website when selecting providers and this information is kept up to date by notification of changes from your practices. Please remember that if you wish to close your practice to new patients, you must do so across all patients, because your provider contract does not permit you to discriminate against patients who are Anthem members. In addition, please notify us of changes to your back-up or covering providers. IVR to accept NPI only beginning February 20 Effective February 20, 2009, providers will be required to enter an NPI when using the Interactive Voice Response (IVR) system for local business. Providers should use the following guide to determine which NPI to enter to retrieve claims data. Enter the 10-digit NPI number that was or will be used for claims processing. For claims where you previously entered the provider s individual legacy (Anthem) ID to retrieve claims data, please enter the provider s type 1 NPI. Claims where a group legacy ID was entered previously, the group s type 2 NPI will be required. Facilities should enter the facility NPI used to process your claim. Providers whose claims are processed at the group level must be sure to use the billing NPI that is associated with the group billed in box 33A of the CMS-1500 claim form. Please note that once the IVR begins to accept only the NPI as the provider ID number, you will not be able to access the following information via the IVR: Any dates of service prior to May 23, 2007 Any claims not billed with an NPI Update to professional claims processing edits and reimbursement policies We will be updating anthem.com with the following new/or revised reimbursement policies on February 1, 2009. These and other reimbursement policies can be found at anthem.com > Providers > Select state > Enter > Anthem Online Provider Services > Forms and Reference Materials, Claim Processing Edits, Reimbursement Policies. Customized edits This policy was updated in December 2008 to remove the posting of customized edits that involve procedure codes deleted since January 1, 2007. In addition the customized edit between 36415 and S9529 has been removed. Always bundled services and supplies This policy received a minor format change to identify which procedures are always bundled and which common procedures are bundled when reported with a more comprehensive procedure. Therefore, the name of this policy was changed to Bundled Services and Supplies. Significant edits The following reimbursement policies were updated in December 2008 to reflect the findings of the data analysis for the 2008 significant edits. After Hours, Emergency, and Miscellaneous E/M Services Bundled Services and Supplies Laboratory Combination Processing LDL Cholesterol Prolonged Services Venipuncture 5
Claims editing overview This policy was revised in December 2008 to indicate the edits that will be implemented with the last phase of ClaimsXten. Global surgery This policy was updated to add a description section and a reformatted policy section. Injection and infusion administration and bundled supplies A reimbursement policy was published to identify some of the materials and supplies considered to be included in the reimbursement for injection and infusion administration. This policy also documents CPT coding guidelines for the code range of (96360-96549) which state that the administration of hydration, injection, infusion, and chemotherapy are not to be reported by a professional provider in a facility setting. CPT is a registered trademark of the American Medical Association. Modifier rules This policy received minor wording changes and was updated to reflect all current modifiers affecting pricing and claims adjudication. Prolonged services This policy was updated to reflect the 2009 CPT coding changes. Assistant surgery The coding section of this policy will be updated for the April website release to include the never edit designations for the new 2009 CPT codes. Coding tip modifier 22 Procedures or services that may be considered significantly complex or complicated due to clinical situations (such as morbid obesity, removal of extensive adhesions/scarring, redo surgery and/or severity of a patient s condition) can be reported with the modifier 22. These procedures/ services may be eligible for additional reimbursement over the provider s maximum allowance. According to the American Medical Association s (AMA) criteria: The submitted documentation must support the substantial additional work and the reason for the additional work such as intensity, time, technical difficulty of the procedure, severity of the patient s condition, and the physical and mental effort required. Therefore, the procedure or service report (such as an operative report) must be submitted with the initial claim when the modifier 22 is submitted. In addition, a cover letter or Anthem s Modifier-22 Explanation Form should be included. The Modifier-22 Explanation Form can be found on anthem.com > Provider > Select your state > Enter > Answers@ Anthem > Download Common Forms. The letter or form should contain a brief description of the complexity, intensity, and/or technical difficulty of the procedure in simple medical verbiage and terminology. This should also be reflected in the procedure/services report. The submitted documentation should also note the description of a typical procedure and the normal time to complete the procedure vs. the member s complexities/complications that were encountered during their procedure and the time to complete the procedure. Note: The submission of the procedure/service report with a modifier 22 cover letter or Anthem s Modifier-22 Explanation Form will not guarantee additional reimbursement. If the procedure/service report is not submitted with the claim, the procedure code(s) with modifier 22 will be reimbursed at the provider s fee schedule allowance. Credentialing reminder participation confirmation and effective dates Physicians or providers who have applied for participation should not provide services to members of any Anthem plan or program until such time as he/she receives a formal notification from us that he/she is a participating provider. This notification will specify the effective date of participation and which programs and/or products are included in the participation. Any services provided to Anthem members before the effective date will be considered out-of-network services. This information is available on anthem.com in the online Professional Provider Manual. Choose Provider > Connecticut > Enter > Provider Manuals > Professional > Chapter 18, Page 2. Locum tenens process Locum tenens are allowed to provide services to Anthem members when they meet the plan s administrative guidelines. A locum tenens is a substitute physician who would take over a physician s professional practice when he or she is absent for reasons such as illness, pregnancy, vacation or continuing medical education. The substitute physician generally has no practice of his/her own. Locum tenens are required to submit information to the plan. 6
The participating physician or provider who will be absent must submit a request to us in writing prior to a locum tenens providing medical services to an Anthem member. We will then send the provider a detailed explanation of our locum tenens process along with an application. We will review the completed application and send back approval or denial of the participating provider s request for a substitute physician. If the substitute physician will be covering for more than a six month period, he/she must apply to become a participating physician either as a member of that group or as an individual in order to continue providing in-network medical services to Anthem members, except as otherwise approved by the plan. Access to Anthem Online Provider Services (AOPS) Reminder when completing the initial application or the add/delete a user forms for access to AOPS, please remember to complete all applicable fields. Provide the full name (first and last) of the user If new/first time application, please ensure the application is signed by a corporate officer Check off all applicable boxes that you are looking to obtain access to Use the correct form. If you are adding/deleting users, the person identified on the original application as the administrator should be downloading and completing the add/delete a user form from the AOPS home page. AIM documentation online On November 1, 2008, we implemented a new diagnostic imaging management program called American Imaging Management (AIM). For your convenience we have posted on our website the AIM announcement mailing we sent in early September as well as AIM Quick Tips reference documents. The documents in the September mailing are available at anthem.com > Providers > Select state > Enter > Anthem Online Provider Services > Forms and Reference Materials > Reference Materials > AIM Documentation. The AIM Quick Tips are available at anthem.com > Providers > Select state > Online Provider Tools > Diagnostic Imaging Management Programs. CoverMe Foundation fax referral sheet available on anthem.com The CoverMe Foundation is a non-profit foundation funded by the foundation of Anthem s parent company to improve overall health of citizens in local communities by assisting individuals in identifying healthcare services and accessing healthcare coverage. To refer an individual to the CoverMe Foundation, please use the CoverMe Foundation Fax Referral Sheet available on our website at anthem.com > Provider > Select state > Enter > Answers@Anthem > Download Common Forms > The CoverMe Foundation Fax Referral Sheet. BLUECARD UPDATE BlueCard IVR now available During the 4th quarter of 2008, we implemented a new interactive voice response (IVR) system for our provider service center that services Host members (Blue Cross and Blue Shield members from another state). Providers are now able to inquire about the status of BlueCard claims using the IVR technology. Callers will experience similar IVR functionality options regardless of the member s Home Plan. By using this technology for claim status inquiries, you will help ensure that our provider service representatives will be available for calls that require personal assistance. We are excited about adding this additional tool for servicing provider claims inquiries for BlueCard inquiries. Our call center agents will continue to be available to you for any questions the IVR does not address. 7
EDI UPDATE Electronic remittance advice (ERA) We offer secure electronic delivery of remittance advices, which explain claims in their final status. This is an added benefit to our electronic claim submitters. If you currently receive paper remits, contact EDI Solutions today to enroll for electronic remits. Our ERA data is in the Health Insurance Portability and Accountability Act (HIPAA) compliant format, with nationally recognized HIPAA-compliant remark codes used by Medicare and other payers like Anthem. ERA advantages Administrative savings by reducing handling and processing time Eliminates papers and simplifies processes No waiting for mailed copies File appears in your electronic mailbox the same day as issued Provides electronic tracking of data and file storage Automates and simplifies billing to other payers (coordination of benefits) Additional ERA options increase efficiency We encourage you to contact your electronic vendor and/or clearinghouse to learn more about additional options available for ERA such as: Manual and automated posting options Single easy-to-read, printer friendly format for multiple payers Easy access and storage of payer Explanation of Benefits (EOBs) Automated coordination of benefit claims filing Capability to quickly locate documents for research and customer service Image retrieval, eliminating loss of misfiled documents Support and staff training How to enroll for ERA Complete the Anthem EDI Registration Form, which you can download at anthem.com/edi or request a copy by calling the EDI Help Desk at 800-334-8262. Fax your completed form to our EDI Specialists at 207-822-7333. If you use an EDI vendor and/or clearinghouse, please contact their representative to discuss the electronic remittances. This will ensure that ERA enrollment procedures are followed appropriately with the vendor and with Anthem. EDI Specialists are available to help you, your vendor or clearinghouse with any of the processes mentioned here at the number listed above or by email at edihelpdesk-ne@wellpoint.com or on the EDI website at anthem.com/edi. The Anthem Companion Guide is also available on the EDI website. PROGRAMS AND BENEFITS UPDATE Access Blue New England available effective December 1, 2008 As we announced in the August 2008 issue of Network Update, Access Blue New England became available in Connecticut, Maine and New Hampshire on December 1, 2008. Access Blue New England is a New England Health Plan HMO product that will allow members to receive specialty services from a network provider without a referral from their primary care physician (PCP). Members will be required to select a PCP, but PCP referrals to other New England Health Plan participating providers will not be required for the member to receive his/her highest benefit level. Please note that out of network services are not covered unless specifically authorized by the Plan. To request out-of-network authorization, please contact us at 800-238-2227. All other current pre-certification and prior authorization requirements, claim filing guidelines, claim filing address, etc. for New England Health Plan products will apply. Members enrolled in Access Blue New England will have ID numbers beginning with one of the following prefixes: Connecticut EHF Maine EHG New Hampshire EHH Massachusetts EHJ 8
Following is a sample Access Blue New England ID card image. BEHAVIORAL HEALTH UPDATE Behavioral health providers please review the entire newsletter While the articles in this section are of specific interest to participating behavioral health providers, there are other articles in this publication that apply to or could be of interest to behavioral health providers as well. Please review the entire issue. FEP behavioral health authorization change effective January 1, 2009 As we announced in the December 2008 edition of Network Update, effective January 1, 2009, there are NO pass through visits for behavioral health services under both the Basic and Standard Federal Employee Programs. Please contact FEP Behavioral Health Customer Service at the number on the member s ID card or submit an outpatient treatment report beginning with the first date of service in 2009. Behavioral health services scope of license As a participating behavioral health provider, in accordance with your Anthem Participating Provider Agreement, services rendered to Anthem members must be within the scope of the provider s State of Connecticut license. Diagnoses and procedure codes are reviewed on all Outpatient Treatment Report forms and determinations of the appropriateness of services are based on the rendering provider s licensure. Member s access to behavioral health care Participating providers are required by their participation contract with us to help ensure our members have prompt access to behavioral health care. Following is a reminder of the requirements for access to care: Non-life threatening emergency needs must be seen, or have appropriate coverage directing the member, within 6 hours. When the severity or nature of presenting symptoms is intolerable but not life threatening to the member. Urgent needs must be seen, or have appropriate coverage directing the member, within 48 hours. Urgent calls concern members whose ability to contract for their own safety, or the safety of others may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. Urgent needs have the potential to escalate into an emergency without clinical intervention. Routine office visit must be within 10 business days. Routine calls concern members who present no immediate distress and can wait to schedule an appointment without any adverse outcomes. We use several methods to monitor adherence to these standards. Monitoring is accomplished by a) assessing the availability of appointments via phone calls by our staff or designated vendor to the provider s office; b) analysis of member complaint data and c) analysis of member satisfaction. Providers are expected to make best efforts to meet these access standards for all members. Coordination of care We encourage coordination of care of our members between behavioral health providers as well as with a member s primary care physician. We encourage our behavioral health providers to discuss the importance of coordination of care with your patients and obtain any necessary authorization to initiate the contact. To assist in this process we have created a Coordination of Care template letter which can be found on anthem.com. Visit anthem.com > Provider > Select your state > Anthem Behavioral Health > Behavioral Health Toolkit > then scroll down to Section 7 Forms and Templates. 9
PHARMACY UPDATE Empire transition to WellPoint NextRx effective January 1, 2009 Effective January 1, 2009, Empire Blue Cross Blue Shield transitioned its pharmacy benefits management to WellPoint NextRx. This impacts providers who render services to Empire members. Formulary As of January 1, 2009, the NextRx formulary applies to Empire members drug coverage. Some Empire members currently on prescribed medication therapy may be impacted by changes in their medication s formulary status or tier placement. By tier placement, we mean whether a drug is listed as generic or branded on the formulary or is listed on the formulary at all. While prescription plan benefits remain the same, the change to the NextRx formulary may result in some drugs having higher or lower costs. It is also possible that some drugs may not be covered on the NextRx formulary at all. Empire members who are affected were notified prior to this change and may wish to discuss potential alternatives with you such as generics or drugs on a lower tier. In the event it is medically necessary for a patient to continue to use a drug that was removed from the formulary, they may also request your assistance in filing an exception request. To view the new NextRx formulary, please visit empireblue. com. Click on the Provider/ Facility tab and look under the Spotlight section for information on NextRx. You may also a request a hard copy by calling 800-750-0156. Mail order With the exception of controlled medications, members with existing refills on file with Caremark will have these automatically transferred to NextRx to minimize disruption. To get Empire members started with the NextRx mail service pharmacy, complete a fax-order form and send it to the NextRx mail service pharmacy. A copy of the Prescription Order Form can be found on our website at empireblue.com. Other clinical edits The list of drugs that will require step therapy, dose limitation or dose optimization is also posted on empireblue.com and are also on the new NextRx Formulary. Prior authorization review In addition, changes related to prior authorization and quantity limits may apply. In general, Empire members will be able to continue their medication therapy as currently prescribed after January 1, 2009. Overall, daily dose and quantity limit requirements are expected to have few changes effective January 1, 2009. If a new prescription will be required, impacted Empire members will be notified in advance. The list of drugs that require prior authorization review after January 1, 2009 can be viewed on empireblue.com. WellPoint NextRx prior authorization request forms are also available for download on empireblue.com. Select the Prior Authorization Forms link under the Learn More section of the Provider/Facility site. Or, you may contact the Prior Authorization Review Center by calling 877-824-7370. We will contact Empire members with current prior authorization approvals if this transition requires a change in their authorization approval status. 10
Voluntary predetermination for specialty pharmacy medications Effective March 30, 2009, we will offer a voluntary predetermination for certain specialty pharmacy medications. A predetermination is a voluntary process for those services where pre-certification is not required, and allows the provider to confirm in advance of providing the service whether the service meets medical policy criteria. In addition, when an adverse determination is issued, the member and provider may access available appeal levels prior to delivering the service. Voluntary predetermination will be offered for the following drugs. Please note that all policies are available in the Medical Policy section of anthem.com. Code Drug Name Applicable Policy 90283, 90284, J1561, J1566, J1567, J1568, J1569, J1572, Q4097 IVIG J0129 Orcencia Drug.00040 J0135, J1438, J1745 Humira, Enbrel, Remicade Drug-00013 and CG-Drug-09 Drug.00002 Predetermination fax forms will be available for your use on anthem.com by March 30, 2009. Please contact Anthem Utilization Management for voluntary predetermination of the above specialty pharmacy drugs at 800-238-2227. Predetermination can also be requested via E-review or by faxing us the predetermination form, both available on anthem.com. Anthem national drug list updates The latest National Drug List Updates to the Anthem National Drug List are available on our website. To access the Drug List/Formulary Updates, visit www.wellpointnextrx.com/wps/ portal/wpo/provider/home. J0585 and J0586 Botox & Myobloc Drug.00006, Drug.00032 and Drug.00073 J1440 and J1441 Neupogen Trans.00022 J2278 Prialt Drug.00027 J2357 Xolair Drug.00024 J2503, J2778, J9035 Macugen, Lucentis, Avastin Drug.00028 and Drug.00038 J2505 Neulasta CG-Drug-16 (effective 5/1/09) J7321, J7322, J7323, J7324 Synvisc Drug-00017 J9035 Avastin Drug.00038 and Drug.00028 J9055 Erbitix Drug.00036 J9303 Vectibix Drug.00035 J9355 Herceptin Drug.00039 11
MEDICAL POLICY UPDATE Medical policy updates available on anthem.com The following new and revised policies were endorsed at the November 20, 2008 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem Blue Cross and Blue Shield medical policies, are available at anthem.com (Providers > Choose your state > Enter > Medical Policies and Clinical UM Guidelines). If you do not have access to the Internet, you may request a hard copy of any updated policy by calling the Provider Call Center at 800-922-3242. Medical Policies Revised Medical Policies Effective 11-20-2008 (The following policies were reviewed and may have additional wording changes or clarifications, but had no significant changes to the policy position or criteria.) ADMIN.00001 Medical Policy Formation ADMIN.00002 Preventive Health Guidelines ADMIN.00004 Definition: Medical Policy ADMIN.00005 Definition: Investigational ADMIN.00007 Immunizations DRUG.00015 Prevention of Respiratory Syncytial Virus Infections TRANS.00008 Liver Transplantation TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation TRANS.00018 Donor Lymphocyte Infusion for Hematology Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation TRANS.00023 High-Dose Chemotherapy with Hematopoietic SCT for Multiple Myeloma and Amyloidosis TRANS.00024 High-Dose Chemotherapy with Hematopoietic Stem Cell Transplantation for the Leukemias and Myelodysplastic Syndrome TRANS.00027 High-Dose Chemotherapy with Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors TRANS.00028 High-Dose Chemotherapy with Hematopoietic SCT for Hodgkin s Disease and non-hodgkin s Lymphoma TRANS.00029 High-Dose Chemotherapy with Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias TRANS.00030 High-Dose Chemotherapy with Hematopoietic SCT for Germ Cell Tumors TRANS.00034 High-Dose Chemotherapy with Hematopoietic SCT for Diabetes Revised Medical Policy Effective 11-20-2008 (The following policies were revised to expand medical necessity indications or criteria.) MED.00064 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation) Archived Medical Policies Effective 01-01-2009 (The following policy was archived) MED.00044 Electrical Impedance Scanning of the Breast SURG.00057 Focused Microwave Phase Array Thermotherapy for Breast Cancer 12
Revised Medical Policies Effective 01-01-2009 (The following policies were revised to expand medical necessity indicators, criteria or add new procedure codes issued 01-01-2009.) DME.00005 Glucose Monitoring and Related Supplies MED.00002 Diagnosis of Sleep Disorder MED.00006 Ophthalmologic Techniques for Evaluation Glaucoma MED.00055 Wearable Cardioverter Defibrillators RAD.00015 Proton Beam Radiation Therapy SURG.00011 Autologous, Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting SURG.00017 Stereotactic Radiosurgery SURG.00044 Breast Ductal Examination and Fluid Cytology Analysis SURG.00071 Percutaneous Techniques for Disc Decompression including Automated Lumbar Discectomy, Laser Discectomy and DISC Nucleoplasty Revised Medical Policies Effective 01-14-2009 (The following policies were revised to expand medical necessity indicators or criteria.) DME.00027 Ultrasonic Bone Growth Stimulation GENE.00004 Janus Kinase 2 (JAK2) Gene Mutation Assay RAD.00004 Peripheral Bone Mineral Density Measurement RAD.00017 Intraoperative Radiation Therapy RAD.00029 CT Colonography (Virtual Colonoscopy) as a Screening or Diagnosis Test for Colorectal Cancer Surg.00033 Implantable Cardioverter Defibrillator (ICD) Revised Medical Policies Effective 01-14-2009 (The following policies were reviewed and had no significant changes to the policy position or criteria.) DRUG.00002 Tumor Necrosis Factor Antagonists DRUG.00034 Insulin Potentiation Therapy DRUG.00035 Panitumumab (Vectibix ) DRUG.00036 Cetuximab (Erbitux ) DRUG.00038 Bevacizumab (Avastin ) for Oncologic Indications GENE.00005 BCR-ABL Mutation Analysis (Qualitative) GENE.00006 Epithelial Growth Factor Receptor (EGFR) Testing in Patients with Non-Small Cell Lung Cancer (NSCLC) MED.00008 Ultraviolet Light, Including Laser Therapy for the Treatment of Skin Disorders MED.00076 Inhaled Nitric Oxide for the Treatment of Respiratory Failure MED.00082 Quantitative Sensory Testing MED.00083 Melanoma Vaccines MED.00085 Antineoplaston Therapy MED.00089 Quantitative Muscle Testing Devices MED.00090 Wireless Capsule for Measuring Gastric Emptying (SmartPill GI Monitoring System ) MED.00095 Anterior Optical Coherence Tomography MED.00096 Low-Frequency Ultrasound Therapy for Wound Management 13
RAD.00023 RAD.00030 RAD.00033 RAD.00041 RAD.00043 RAD.00047 RAD.00049 SURG.00001 SURG.00008 SURG.00020 SURG.00025 SURG.00050 SURG.00081 SURG.00089 SURG.00093 SURG.00101 SURG.00102 SPECT Scans and Scintimammography Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors (SIR-Spheres and TheraSpheres) Intensity Modulated Radiation Therapy (IMRT) CT Scans with or without Computer Assisted Detection (CAD) for Lung Cancer Screening Neutron Beam Radiotherapy Low Field and Conventional Magnetic Resonance Imaging (MRI) for Screening, Diagnosing and Monitoring Carotid, Vertebral, Intracranial Artery Angioplasty with or without Stent Placement Mechanized Spinal Distraction Therapy for Low Back Pain (VAX-D, DRS, Accu-Spina System, IDD) Bone Anchored Hearing Aids Cryosurgical Ablation of Solid Tumors Outside the Liver Radiofrequency Ablation to Treat Tumors Outside the Liver Total Ankle Replacement Balloon Sinuplasty Treatment of Osteochondral Defects of Knee and Ankle Suprachoroidal Injection of Pharmacologic Agent Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence New Medical Policies Effective 01-14-2009 (These policies are new with no changes in how the services were administered prior to 01-14-2009.) MED.00099 Electromagnetic Navigational Bronchoscopy MED.00100 Diaphragmatic/Phrenic Nerve Stimulation New Medical Policies Effective 05-01-2009 (Some of the policies below might result in services that were previously covered found to be either not medically necessary and/or investigational. These services may presently be denying based on the ADMIN.00006 Medical Policy.) DME.00034 Standing Frames GENE.00014 Analysis of KRAS Mutation in Metastatic Colorectal Cancer RAD.00057 Near-Infrared Imaging as an Aid for the Evaluation of Coronary Artery Plaques (LipiScan Coronary Imaging System) SURG.00107 Prostate Saturation Biopsy SURG.00108 Endothelial Keratoplasty Revised Medical Policies Effective 05-01-2009 (The policies listed below might result in services that were previously covered found to be either not medically necessary and/or investigational.) DRUG.00028 Intravitreal and Periocular Injection Treatments for Age-Related Macular Degeneration MED.00086 Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy SURG.00007 Vagus Nerve Stimulation Therapy SURG.00037 Treatment of Varicose Veins (Lower Extremity) SURG.00065 Locally Ablation Techniques for Treating Primary and Metastatic Liver Malignancies 14
Clinical Guidelines Revised Clinical Guideline Effective 11-20-2008 (The following guideline was revised to expand medical necessity indicators or criteria.) CG.DRUG.09 Intravenous Immune Globulin Therapy (IVIg) Revised Clinical Guidelines Effective 01-14-2009 (The following adopted guidelines were revised and had no significant changes to the policy position or criteria.) CG.DME.09 Continuous Local Delivery of Analgesia to Operative Sites Using an Elastomeric Infusion Pump CG.DME.16 Pressure Reducing Support Surfaces; Group 1 & 2 CG.DME.17 Pressure Reducing Support Surfaces; Group 3 CG.DME.23 Patient Lifts CG.DME.25 Seat Lift Mechanisms CG.DRUG.01 Off-Label Drug and Approved Oprhan Drug Use CG.DRUG.07 Hepatitis C Pegylated Interferon Antiviral Therapy CG.DRUG.12 Biologics for Psoriasis and Psoriatic Arthritis CG.DRUG.13 Hepatitis B Interferon Antiviral Therapy CG.MED.02 Esophageal ph Monitoring CG.OR.PR.01 NeuroControl Freehand Neuroprosthesis CG.RAD.16 Cardiac Radionuclide Imaging CG.SURG.03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift CG.SURG.09 Temporomandibular Joint Dysfunction (TMD), Temporomandibular Joint Syndrome (TMJ), Craniomandibular Disorder (CMD) CG.TRANS.02 Kidney Transplantation Clinical Guideline Effective 05-01-2009 (The following existing Clinical Guideline will be adopted.) CG.DRUG.16 White Blood Cell Growth Factors 15
Network Update is produced bi-monthly by Anthem Blue Cross and Blue Shield s Marketing Communications Department. Editor: JoAnn Boyd 4361 Irwin Simpson Road Mason, OH 45040. Anthem Blue Cross and Blue Shield 370 Bassett Road North Haven, CT 06473 E-mail: joann.boyd@anthem.com. Pass it along! We only send one issue of Network Update to each provider group practice, and a limited number to facilities. Please pass along your copy to other offices/departments, or download this and previous issues from our website, anthem.com. The information in this newsletter is for informational purposes only and should not be construed as treatment protocols or required practice guidelines. Diagnosis, treatment recommendations, and the provision of medical care services for our members and enrollees is the responsibility of physicians and providers. Unless otherwise noted, the information contained in this Network Update applies to Anthem Blue Cross and Blue Shield s commercial plans and programs in Connecticut, including BlueCare Health Plan, Century Preferred, Century Preferred Comp, Century Preferred Direct, Century Preferred HSA, Century 90, State BlueCare, State Preferred, BlueCard, New England Health Plans (formerly HMO New England), FEP, and National Account plans. Unless specifically indicated, this Network Update does not refer to the BlueCare Family Plan (HUSKY A and B) program or MediBlue SM, the Medicare Advantage HMO program. Questions regarding this program should be directed to your BlueCare Family Plan representative. Unless otherwise noted, the information contained in the Behavioral Health Update section in this Network Update applies to services managed by Anthem Behavioral Health. Please note: All policies are subject to the terms, conditions and limitations of the member s plan or program. Network Update February 2009 Working together to improve the health of our members. Important phone numbers Provider Call Center Hours: Monday-Friday, 8:15 a.m.-5 p.m. Professional Providers: 800-922-3242 Institutional Providers: 800-345-2227 EDI Help Desk: 800-334-8262 Anthem Blue Cross and Blue Shield is the trade name for Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.