Virginia Provider News...October 2020 Anthem Provider News - Virginia Page 56 of 59 * Availity, LLC is an independent company providing administrative support services on behalf of

October 2020 Anthem Provider News - Virginia Page 1 of 59

Virginia Provider NewsOctober 2020 Anthem Provider News - Virginia

Products & Programs:

Pharmacy:

Administrative:

Coverage and Clinical Guidelines:

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Anthem Commercial Risk Adjustment Reporting Update: Newguidance on telephone-only service CPT codes for RiskAdjustment Program

4

Anthem updates formulary lists for commercial health planpharmacy benefit

4

FDA approvals and expedited pathways used: New MolecularEntities

5

Anthem prior authorization updates for specialty pharmacy areavailable

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Updated coverage for breast cancer prevention medications 13

Pharmacy information available on anthem.com 14

Anthem Chat: A fast, easy way to have your questionsanswered

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Prior authorization update for commercial business 15

New Blue HPN® network included in plans available foremployee open enrollment fall 2020

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New medical claim attachment webinars: Register today 18

Electronic member ID cards available on the Availity Portal 20

National Accounts 2021 pre-certification list 22

What Matters Most: Improving the patient experience 22

Register today for Anthem’s fall webinar scheduled forNovember 12

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REMINDER: Expansion of AIM Musculoskeletal Programeffective November 1, 2020

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October 2020 Anthem Provider News - Virginia Page 2 of 59

Reimbursement Policies:

Federal Employee Plan (FEP):

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:

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Emergency department reimbursement policy 24

Federal Employee Program® expands specialty pharmacy priorauthorization list

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Coding spotlight: Providers’ guide to coding for behavioralhealth disorders

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Patient360 enhancement for medical providers 34

Prior authorization requirements for E0482 35

Claim payment disputes: Update 36

Social determinants of health support expanding withGroundGame Health

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Provider Chat: A fast, easy way to have your questionsanswered

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Keep up with Medicaid news 40

Social determinants of health support expanding withGroundGame Health

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Update: Notice of changes to the AIM musculoskeletalprogram

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Patient360 enhancement for medical providers 44

Prior authorization requirements for the below codes (EffectiveDecember 1, 2020)

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Prior authorization requirements for the below codes (EffectiveJanuary 1, 2021)

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Provider transparency update 59

Medical drug benefit Clinical Criteria updates 0

Keep up with Medicare news 0

October 2020 Anthem Provider News - Virginia Page 3 of 59

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(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.

October 2020 Anthem Provider News - Virginia Page 4 of 59

Anthem Commercial Risk Adjustment Reporting Update: Newguidance on telephone-only service CPT codes for RiskAdjustment ProgramPublished: Oct 1, 2020 - Products & Programs

As providers, you are committed to providing the best care for your patients – our members. That care may now include telehealth visits. Recognizing the continuing increased need fortelephone and virtual services during the COVID-19 public health emergency, the U.S.Department of Health and Human Services (HHS) has given additional consideration to thetreatment of telephone-only services in the HHS-operated Risk Adjustment Program. HHShas clarified that telephone-only service CPT codes (98966-98968 and 99441-99443) arevalid for the Risk Adjustment Program. Telephone-only visits may benefit your patients whohave not participated in, or felt comfortable using, a telehealth video visit. Thank you foryour continued commitment to assessing your patients’ health and closing possible gaps incare. If you have questions, please contact the Commercial Risk Adjustment Network Education

Representative, [email protected].

658-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/anthem-commercial-risk-adjustment-reporting-update-new-guidance-on-telephone-only-service-cpt-codes-for-risk-adjustment-program

Anthem updates formulary lists for commercial health planpharmacy benefitPublished: Oct 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 Shieldupdated drug lists that support commercial health plans. Updates include changes to drugtiers and the removal of medications from the formulary.

October 2020 Anthem Provider News - Virginia Page 5 of 59

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. Communications to providers and their patientsaffected by the changes went out in early August. 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. View a summary of changes

IngenioRx, Inc. is an independent company providing pharmacy benefit managementservices on behalf of Anthem Blue Cross and Blue Shield. 661-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/anthem-updates-formulary-lists-for-commercial-health-plan-pharmacy-benefit-2

FDA approvals and expedited pathways used: New MolecularEntitiesPublished: Oct 1, 2020 - Products & Programs / Pharmacy

Anthem Blue Cross and Blue Shield (Anthem) reviews the activities of the Food and DrugAdministration’s (FDA) approval of drugs and biologics on a regular basis to understand thepotential effects for both our providers and members. The FDA approves new drugs/biologics using various pathways of approval. Recent studieson the effectiveness of drugs/biologics going through these different FDA pathwaysillustrates the importance of clinicians being aware of the clinical data behind a drug orbiologic approval in making informed decisions. Here is a list of the approval pathways the FDA uses for drugs/biologics:

October 2020 Anthem Provider News - Virginia Page 6 of 59

Standard Review – The Standard review process follows well-established paths tomake sure drugs/biologics are safe and effective when they reach the public. Fromconcept to approval and beyond, FDA performs these steps: reviews research data andinformation about drugs and biologics before they become available to the public; watchesfor problems once drugs and biologics are available to the public; monitors drug/biologicinformation and advertising; and protects drug/biologic quality. Learn more about theStandard Review process.

Fast Track – Fast Track is a process designed to facilitate the development, andexpedite the review of drugs/biologics to treat serious conditions and fill an unmet medicalneed. Learn more about the Fast Track process.

Priority Review – A Priority Review designation means FDA’s goal is to take action onan application within 6 months. Learn more about the Priority Review process.

Breakthrough Therapy – A process designed to expedite the development and reviewof drugs/biologics which may demonstrate substantial improvement over available therapy.Learn more about the Breakthrough Therapy process.

Orphan Review – Orphan Review is the evaluation and development ofdrugs/biologics that demonstrate promise for the diagnosis and/or treatment of rarediseases or conditions. Learn more about the Orphan Review process.

Accelerated Approval – These regulations allowed drugs/biologics for seriousconditions that filled an unmet medical need to be approved based on a surrogateendpoint. Learn more about the Accelerated Approval process.

New Molecular Entities (NMEs) Approvals: January through August 2020

October 2020 Anthem Provider News - Virginia Page 7 of 59

Certain drugs/biologics are classified as new molecular entities (“NMEs”) for purposes ofFDA review. Many of these products contain active ingredients that have not been approvedby FDA previously, either as a single ingredient drug or as part of a combination product;these products frequently provide important new therapies for patients. Anthem reviews the FDA-approved NMEs on a regular basis. To facilitate the decision-making process, we are providing a list of NMEs approved from January to August 2020along with the FDA approval pathway utilized.

October 2020 Anthem Provider News - Virginia Page 8 of 59

GenericName

TradeName

StandardReview

FastTrack

PriorityReview

Break-throughTherapy

OrphanReview

AcceleratedApproval

ApprovalDate

October 2020 Anthem Provider News - Virginia Page 9 of 59

IndicationAbametapir Xeglyze X 7/24/2020 Head lice

Amisulpride Barhemys X 2/26/2020 Postoperativenausea andvomiting

Avapritinib Ayvakit X X X X 1/9/2020 PDGFRa exon 18mutantgastrointestinalstromal tumor

Belantamabmafodotin

Blenrep X X X X 8/05/2020 Multiple myeloma

Bempedoic acid Nexletol X 2/21/2020 DyslipidemiaBrexucabtageneautoleucel

Tecartus X X X X 7/24/2020 Mantle celllymphoma

Capmatinib Tabrecta X X X X 5/6/2020 Non-small celllung cancer(NSCLC)

Decitabine/cedazuridine

Inqovi X X 7/07/2020 Myelodysplasticsyndromes

Eptinezumab-jjmr

Vyepti X 2/21/2020 Migraineprevention

Fostemsavir Rukobia X X X 7/02/2020 Humanimmunodeficiencyvirus (HIV)treatment

Inebilizumab Uplizna X X X 6/11/2020 Neuromyelitisoptica spectrumdisorder

Isatuximab Sarclisa X X 3/2/2020 Multiple myelomaLurbinectedin Zepzelca X X X 6/15/2020 NSCLCNifurtimox Lampit X X X 8/06/2020 Chagas diseaseOliceridine Olinvyk X X 8/07/2020 Moderate to

severe acute painOpicapone Ongentys X 4/24/2020 Parkinson’s

diseaseOsilodrostat Isturisa X X 3/6/2020 Cushing’s

diseaseOzanimod Zeposia X 3/25/2020 Multiple sclerosis

October 2020 Anthem Provider News - Virginia Page 10 of 59

Peanut(Arachishypogaea)allergenpowder-dnfp

Palforzia X X X 1/31/2020 Peanut allergy

Pemigatinib Pemazyre X X X X 4/17/2020 CholangiocarcinomaRemimazolam Byfavo X 7/02/2020 Sedation for

proceduresRimegepant Nurtec

ODT X 2/27/2020 Migraine treatment

Risdiplam Evrysdi X X X X 8/07/2020 Spinal muscularatrophy

Ripretinib Qinlock X X X X 5/15/2020 Gastrointestinalstromal tumor

Sacituzumab-hziy

Trodelvy X X X X X 4/22/2020 Triple negativebreast cancer

Selpercatinib Retevmo X X X X 5/8/2020 NSCLC and thyroidcancers

Selumetinib Koselugo X X X X 4/10/2020 Neurofibromatosistype 1

Tafasitamab Monjuvi X X X X X 7/31/2020 Large B-celllymphoma

Tazemetostat Tazverik X X X 1/23/2020 Epithelioid sarcomaTeprotumumab-trbw

Tepezza X X X X 1/21/2020 Thyroid eye disease

Triheptanoin Dojolvi X X X 6/30/2020 Long-chain fattyacid oxidationdisorders

Tucatinib Tukysa X X X X 4/17/2020 Breast cancerViltolarsen Viltepso X X X X 8/12/2020 Duchenne muscular

dystrophy Source: www.fda.gov 650-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/fda-approvals-and-expedited-pathways-used-new-molecular-entities-nmes-2

October 2020 Anthem Provider News - Virginia Page 11 of 59

Anthem prior authorization updates for specialty pharmacy areavailablePublished: Oct 1, 2020 - Products & Programs / Pharmacy

Prior authorization updates Effective for dates of service on and after January 1, 2021, the following specialty pharmacycodes from current or new clinical criteria documents will be included in our priorauthorization review process.

Anthem in Virginia requires that claims for injection services performed in the office settingmust include the applicable HCPCS J-code, Q-code, or S-code, with the correspondingNational Drug Code (NDC), for the injected substance. This requirement is consistent withCenters for Medicare & Medicaid Services (CMS) guidelines. A covered drug will not beeligible for reimbursement when the NDC is not reported on the same claim. 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 and are shown in italics in the table below. This applies to members with Preferred Provider Organization (PPO), HealthKeepers(HMO), POS AdvantageOne, and Act Wise (CDH plans).

®

October 2020 Anthem Provider News - Virginia Page 12 of 59

Clinical Criteria HCPCS orCPT Code(s)

Drug

ING-CC-0170 J3590, C9399 UpliznaING-CC-0172 J3490, J3590,

C9399Viltepso

ING-CC-0173 J3490, J3590 EnspryngING-CC-0174 J3490, J3590,

C9399Kesimpta

ING-CC-0168 J3590, J9999,J3490

Tecartus

*ING-CC-0171 J3490, J3590,J9999

Zepzelca

*ING-CC-0169 J3490, J3590,J9999, C9399

Phesgo

*ING-CC-0175 J9015 Proleukin*ING-CC-0176 J9032 Beleodaq*ING-CC-0178 J9262 Synribo*ING-CC-0177 J3304 ZilrettaING-CC-0015 J3490 Milprosa

VaginalSystem

*ING-CC-0100 C9065 IstodaxING-CC-0038 J3110 Forteo*ING-CC-0002 J3590 Nyvepria

* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncologyuse is managed by AIM. Step therapy updates Effective for dates of service on and after January 1, 2021, the following specialty pharmacycodes from current or new clinical criteria documents will be included in our existingspecialty pharmacy medical step therapy review process. Access the Clinical Criteria information related to Step Therapy.

October 2020 Anthem Provider News - Virginia Page 13 of 59

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 and are shown in italics in the table below. This applies to members with Preferred Provider Organization (PPO), HealthKeepers(HMO), POS AdvantageOne, and Act Wise (CDH plans). Clinical Criteria Status Drug(s) HCPCS

Code(s)*ING-CC-0002 Preferred Neulasta J2505*ING-CC-0002 Preferred Udenyca Q5111*ING-CC-0002 Non-preferred Fulphila Q5108*ING-CC-0002 Non-preferred Ziextenzo Q5120*ING-CC-0002 Non-preferred Nyvepria J3590

* Non-oncology use is managed by Anthem’s medical specialty drug review team. Oncologyuse is managed by AIM. 676-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/anthem-prior-authorization-updates-for-specialty-pharmacy-are-available-7

Updated coverage for breast cancer prevention medicationsPublished: Oct 1, 2020 - Products & Programs / Pharmacy

Beginning October 1, 2020, most of Anthem’s non-grandfathered health plans that complywith the Affordable Care Act (ACA) will cover generic aromatase inhibitors at 100%. Thereis no member cost share for members who are prescribed these drugs for prevention ofbreast cancer and use an in-network pharmacy. Prior authorization will be required. Providers will need to complete a questionnaire and submit to IngenioRx for consideration. Women must be 35 years or older and have no history of breast cancer.

®

October 2020 Anthem Provider News - Virginia Page 14 of 59

This coverage change aligns with the updated USPSTF “B” recommendation regardingBreast Cancer: Medication Use to Reduce Risk. This updated recommendation nowincludes aromatase inhibitors among medications that can reduce risk of breast cancer (inaddition to tamoxifen or raloxifene). The USPSTF recommends that clinicians offer toprescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors,to women who are at increased risk for breast cancer and at low risk for adverse medicationeffects. Providers can contact the provider service number on the back of the member ID card todetermine if a member’s plan includes this benefit. 644-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/updated-coverage-for-breast-cancer-prevention-medications-2

Pharmacy information available on anthem.comPublished: Oct 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. Federal Employee Program (FEP) Pharmacy updates and other pharmacy relatedinformation may be accessed at www.fepblue.org > Pharmacy Benefits. 659-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/pharmacy-information-available-on-anthemcom-76

October 2020 Anthem Provider News - Virginia Page 15 of 59

Anthem Chat: A fast, easy way to have your questions answeredPublished: Oct 1, 2020 - Administrative

If you have questions, you now have a new option to have them answered quickly andeasily. With Anthem Chat, providers can have a real-time, online discussion through a newdigital service, available through Payer Spaces on Availity.

Faster access to provider services for all questions

Real-time answers to your questions about prior authorization, appeals status, claims,benefits, eligibility, and more

A platform that is easy to use making it simpler to receive help

The same high level of safety and security you have come to expect with Anthem

Chat is one example of how Anthem is using digital technology to help improve the healthcare experience, with a goal to save you valuable time. To start, access the service throughPayer Spaces on Availity. Use Provider Chat: Select Payer Spaces, select Anthem, and from Applications selectChat. 684-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/anthem-chat-a-fast-easy-way-to-have-your-questions-answered-2

Prior authorization update for commercial businessPublished: Oct 1, 2020 - Administrative

October 2020 Anthem Provider News - Virginia Page 16 of 59

Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are committed toreducing costs while improving health outcomes. To that end, effective January 1, 2021,Anthem Blue Cross and Blue Shield and HealthKeepers, Inc. will require prior authorizationfor some additional services for our commercial business. NOTE: This excludes Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, theCommonwealth Coordinated Care Plus (Anthem CCC Plus) plan, and the Blue Cross andBlue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). The following codes have been added to require prior authorization with a date of service onor after January 1, 2021:

33477 SURG.0012136465 SURG.0003736466 SURG.0003753447 SURG.00010E0466 CG-DME-47G0277 CG-MED-73

687-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/prior-authorization-update-for-commercial-business-1

New Blue HPN® network included in plans available for employeeopen enrollment fall 2020Published: Oct 1, 2020 - Administrative

As employers across the country host open enrollment periods for their employees, manywill offer a new option this fall: plans built around a Blue High Performance Network (HPN)® Blue HPN® plans offer access to a select set of providers with a record of delivering high-quality, efficient care. Blue HPN networks will go live January 1, 2021, in more than 50 citiesacross the country.

October 2020 Anthem Provider News - Virginia Page 17 of 59

In Virginia, Blue HPN networks will be in place in the Richmond and Washington, D.C-Arlington-Alexandria metro areas. Anthem is offering Virginia national employers Blue HPNplans, and offering large and small group employers in Virginia plans with access to theHPN, referred to as the Blue Connection network. If you are not sure whether your practice is part of the Blue HPN/Blue Connection network,ask your office manager or business office, or contact your Anthem network representative.Blue HPN participation will be displayed in provider profiles in our provider directory January1, 2021. Beginning January 1, you may see patients accessing this network through either a nationalemployer plan, Blue HPN, or large or small group employer EPO plans and HSA plans withEPO network. Under EPO plans, out-of-network benefits are limited to emergency or urgentcare. Members may be required to select a primary care provider (PCP), but PCP referralsare not required for specialty care.

October 2020 Anthem Provider News - Virginia Page 18 of 59

Below is a sample ID card for a member from Virginia enrolled inthe national employer Blue HPN plan. Note the new “Blue HighPerformance Network,” and “Blue Connection” network names,and “HPN” indicator in the suitcase icon.

682-10-20-PN-VA

Article Attachments

URL: https://providernews.anthem.com/virginia/article/new-blue-hpn-network-included-in-plans-available-for-employee-open-enrollment-fall-2020-4

New medical claim attachment webinars: Register todayPublished: Oct 1, 2020 - Administrative

Anthem Blue Cross and Blue Shield providers may now learn how to use Availity'sattachment tools to submit and track supporting documentation electronically by attendingone of the upcoming live webinars hosted by Availity. The attachments application is a multi-payer, multi-workflow feature. It allows inclusion ofmultiple records across a variety of workflows and request types to support differentbusiness processes for payers.

October 2020 Anthem Provider News - Virginia Page 19 of 59

By attending one of the upcoming webinars, attendees will learn both the digital andelectronic processes that include:

How your organization gets set up

Demonstrations of the tools used to submit attachments via Availity Portal

Navigating the Attachments dashboard

View electronic records of your submissions

As part of the session, we will answer questions and provide handouts and a job aid for youto reference later. Register for an upcoming webinar session

1. In Availity Portal, select Help & Training > Get Trained.

1. The Availity Learning Center opens in a new browser tab.

1. Search for and enroll in a session using one of these options.

In the Catalog, search by webinar title or keyword (medattach).Select the Sessions tab to scroll the live session calendar.

October 2020 Anthem Provider News - Virginia Page 20 of 59

1. After you enroll, you will receive emails with instructions to join the session.

October/November webinar dates

Date Day Time10/07/2020 Wednesday 4 p.m. – 5 p.m. ET10/20/2020 Tuesday 11 a.m. – Noon ET11/04/2020 Wednesday 4 p.m. – 5 p.m. ET11/17/2020 Tuesday 2 p.m. – 3 p.m. ET

Where can you find more help? Select Help & Training > Find Help to display Availity Help in a new browser window. Use Contents to display topics. Depending on your needs, consider exploring these topics:

Claim Submission

Attachments (new)

Medical Attachments (legacy)

702-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/new-medical-claim-attachment-webinars-register-today-2

Electronic member ID cards available on the Availity PortalPublished: Oct 1, 2020 - Administrative

October 2020 Anthem Provider News - Virginia Page 21 of 59

Anthem Blue Cross and Blue Shield offers you the ability to have acopy of the member’s ID card without having to physically handlethe member’s card. This easy, low-touch access to view amember’s ID card is available from the Availity Portal. When conducting an eligibility and benefits inquiry for Anthemmembers, simply select View Member ID Card on the Eligibilityand Benefits results page. Note: the Availity Portal requires you toenter the member’s ID number as well as a date of birth or themember’s first and last name into the search options in order tosubmit an eligibility and benefits inquiry.

Images of both the front and back of the member ID card areavailable, allowing you view all of the pertinent information withoutthe need to make a phone call. The images can be saved directlyto your practice management system as PDF files. Another option available is to access members’ digital versions oftheir ID cards, as many members have transitioned to using adigital card instead of a paper card. Members are able to fax oremail a copy of the electronic ID card from their phone/app. We encourage you to integrate these options into your practice orfacility’s workflow now. 677-1020-PN-VA

Article Attachments

URL: https://providernews.anthem.com/virginia/article/electronic-member-id-cards-available-on-the-availity-portal-2

October 2020 Anthem Provider News - Virginia Page 22 of 59

National Accounts 2021 pre-certification listPublished: Oct 1, 2020 - Administrative

The National Accounts 2021 Pre-certification list has been published. Please note, providersshould continue to verify member eligibility and benefits prior to rendering services.660 -1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/national-accounts-2021-pre-certification-list-3

What Matters Most: Improving the patient experiencePublished: Oct 1, 2020 - Administrative

An online course for providers and office staff that addresses gaps in care and offersapproaches to communication with patients. This course is available at no cost and iseligible for one CME credit by the American Academy of Family Physicians. The What Matters Most training can be accessed at: www.patientexptraining.com 653-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/what-matters-most-improving-the-patient-experience-4

Register today for Anthem’s fall webinar scheduled for November12Published: Oct 1, 2020 - Administrative

Don’t miss an opportunity to attend Anthem’s final provider education webinar for the yearon November 12, 2020. Designed for our network-participating providers, the webinaraddresses Anthem business updates and billing guidelines that impact your businessinteractions with us.

October 2020 Anthem Provider News - Virginia Page 23 of 59

For your convenience, we offer these informative, hour-longsessions online to eliminate travel time and help minimizedisruptions to your office or practice. The date for the fall webinaris:

Thursday, November 12, 2020, from 11 a.m. to Noon ET

Please take time to register 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 fax confirmation or aconfirmation from an Anthem representative to note we’ve receivedyour registration form. Contact [email protected] if youneed to confirm your registration. 646-1020-PN-VA

Article Attachments

Anthem Webinarand RegistrationForm 2020.pdfapplication/pdf - 312.88

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URL: https://providernews.anthem.com/virginia/article/register-today-for-anthems-fall-webinar-scheduled-for-november-12

REMINDER: Expansion of AIM Musculoskeletal Program effectiveNovember 1, 2020Published: Oct 1, 2020 - Guideline Updates / Coverage and Clinical Guidelines

As recently communicated in the August 2020 edition of Anthem’s Provider News, AIMSpecialty Health (AIM), a specialty health benefits company, will expand the AIMMusculoskeletal program to perform medical necessity reviews for certain elective surgeriesof the small joints for Anthem members effective November 1, 2020. Replacement andrevision surgeries for procedures such as total joint of ankle, correction of Hallux Valgus,hammertoe repair are included. The AIM Rehab Program follows the Anthem Clinical Guidelines that state the services mustbe delivered by a qualified provider within the scope of their licensure. Qualified providersacting within the scope of their license, including podiatrists, who intend to perform certainelective surgeries of the small joints procedures should request prior authorization for thoseservices through AIM.

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October 2020 Anthem Provider News - Virginia Page 24 of 59

AIM will begin accepting prior authorization requests on October 26, 2020, for dates of service on and

after November 1, 2020. Prior authorization requests may be submitted via the AIM ProviderPortal or by

calling (866) 789-0158, Monday through Friday.

We value your participation in our networks and look forward to working with you to helpimprove the health of our members. 649-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/reminder-expansion-of-aim-musculoskeletal-program-effective-november-1-2020-2

Emergency department reimbursement policyPublished: Oct 1, 2020 - Guideline Updates / Reimbursement Policies

Anthem Blue Cross and Blue Shield (Anthem) is dedicated to delivering better care to ourmembers, providing higher value to our customers, and helping to improve the health of ourcommunities. In 2013, Anthem implemented the Emergency Department (ED) Reimbursement Policy. Thepolicy is set forth in the Facility Provider Manual, as applicable, and outlines the levels ofemergency room services and states that “the highest level evaluation and management(E&M) code for which a claim clinically qualifies will be used to determine the level ofreimbursement, as applicable for ED services.” Currently, Anthem is using a post-paymanual review process to determine the level of service by asking for and reviewing themedical records for the emergency room visit. Anthem to engage a vendor to assess selected claims for E&M services beginningJanuary 1

October 2020 Anthem Provider News - Virginia Page 25 of 59

In an ongoing effort to ensure accurate claims processing and payment and to decrease theamount of medical records being requested for this policy, effective January 1, 2021,Anthem will begin to use a vendor to assess selected claims for evaluation and managementservices. An automated analytic solution will be used to better ensure that benefit paymentsare aligned with national industry coding standards. As outlined in the policy, Anthem willadjust the reimbursement to reflect the lower ED E&M classification for those claims that donot meet the higher level criteria. As always, providers who feel that the level of reimbursement should be reconsidered canfile an appeal in accordance with the terms of their contract. Claim appeals require astatement providing the reason the intensity/complexity would require a different level ofreimbursement as well as the medical records which should clearly document the facilityinterventions performed and referenced in that statement. If you have questions about the amendment process, please contact your Anthem NetworkManager. View the Anthem contact list online at anthem.com. 651-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/emergency-department-reimbursement-policy

Federal Employee Program® expands specialty pharmacy priorauthorization listPublished: Oct 1, 2020 - State & Federal / Federal Employee Plan (FEP)

Effective with dates of service on or after January 1, 2021, the following pharmacy codeswill be included in the Anthem Federal Employee® (FEP) plans (member IDs beginning withan “R”) prior authorization review process for specific specialty drugs. The priorauthorization review includes review of site-of-care criteria for outpatient hospital-basedsettings. As a result of this change, services provided on and after January 1, 2021, forany of the additional drugs without a prior authorization will be denied. FEP will continue to review Federal Employee Program medical policy criteria for medicalnecessity, and Anthem’s clinical guideline, Level of Care: Specialty Pharmaceuticals (CG-MED-83), will be utilized to review site-of-care criteria.

October 2020 Anthem Provider News - Virginia Page 26 of 59

What’s new beginning with dates of service on or after January 1, 2021, for the “new”drugs listed below?

Prior to administering the drugs in any setting, a prior authorization must be completedin order to evaluate if the drug meets clinical criteria. Anthem FEP will begin acceptingprior authorization requests for these specialty drugs on December 14, 2020, for dates ofservice on and after January 1, 2021. Request prior authorization review by calling theBlue Cross and Blue Shield Federal Employee Program Service Benefit Plan at (800)860-2156.

Outpatient hospital-based settings will require a site-of-care review for medicalnecessity as part of the prior authorization review. Hospital-based facilities contracted withAnthem for lower drug and administration costs, non-hospital infusion clinics, provideroffices, and home infusion providers will not require a site-of-care review.

A provider toolkit aligned to Anthem’s clinical guideline (CG-Med83) will be providedto providers requiring a site-of-care review, either by fax or e-review. For outpatienthospital settings that do not meet clinical criteria, a dedicated clinical team will workwith you to identify alternate lower level of care sites that can safely administer thedrug.In the event that there are no infusion centers within 30 miles of the member’s placeof residence, or there are no home infusion providers able to service the member’sresidence, the hospital-based setting will be approved.

If the prior authorization is denied for either the drug not meeting medical necessity orthe site of care not meeting medical necessity, providers should follow the disputedclaim/service process. To obtain the current process, please contact the Blue Cross andBlue Shield Federal Employee Program Service Benefit Plan at (800) 860-2156.

Services provided on or after January 1, 2021, without prior authorization will result in adenial of claims payment.

October 2020 Anthem Provider News - Virginia Page 27 of 59

Additional drugs requiring medical necessity and site-of-care review as of January 1,2021:

Drug Code FEP Medical PolicyActemra J3262 5.70.12Aralast J0256 5.45.09Fabrazyme J0180 5.30.35Fasenra J0517 5.45.07Glassia J0257 5.45.09Ilaris J0638 5.70.09Nucala J2182 5.45.07Ocrevus J2350 5.60.28Prolastin J0256 5.45.09Ultomiris J1303 5.85.33Xolair J2357 5.45.02Zemaira J0256 5.45.09

These changes apply to Anthem FEP members (member IDs beginning with an “R”) who arereceiving the specialty drugs listed above through their medical benefits. These changes donot impact the approval process for these specialty drugs obtained throughpharmacy benefits. For more information, such as clinical criteria for specialty drugs andlevel of care, please contact the Blue Cross and Blue Shield Federal Employee ProgramService Benefit Plan at (800) 860-2156. 647-1020-PN-VA

URL: https://providernews.anthem.com/virginia/article/federal-employee-program-expands-specialty-pharmacy-prior-authorization-list-3

Coding spotlight: Providers’ guide to coding for behavioralhealth disordersPublished: Oct 1, 2020 - State & Federal / Medicaid

Please note, this communication applies to Anthem HealthKeepers Plus offered byHealthKeepers, Inc.

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October 2020 Anthem Provider News - Virginia Page 28 of 59

Behavioral health disorders are classified in Chapter 5 of the ICD-10-CM Behavioral health disorders are commonly underreported on claims. Many AnthemHealthKeepers Plus members may have behavioral health disorders that are not properlymanaged. Health care providers can assist by taking detailed histories and codingbehavioral health issues properly on claims. Below are the ICD-10-CM coding guidelines forbehavioral health conditions. When documenting behavioral disorders, the following descriptors apply:

Type: Depressive, manic, or bipolar disorder.

Episode: Single or recurrent.

Status: Partial or full remission; identify most recent episode as manic, depressed, ormixed.

Severity: Mild, moderate, severe, or with psychotic elements.

Schizophrenic related disorders Schizophrenic related disorders are classified in category F20, with a forth characterindicating the type of schizophrenia as follows:

October 2020 Anthem Provider News - Virginia Page 29 of 59

Code DescriptionF20.0 Paranoid schizophreniaF20.1 Disorganized schizophreniaF20.2 Catatonic schizophreniaF20.3 Undifferentiated schizophreniaF20.5 Residual schizophreniaF20.8 Other schizophrenia

This subcategory is further subdivided as follows:· F20.81 Schizophreniform disorder· F20.89 Other schizophrenia

F20.9 Schizophrenia, unspecified Major depressive disorder (MDD) Major depressive disorder (MDD) is classified in ICD-10-CM to categories:

F32.- Major depressive disorder, single episode

F33.- Major depressive disorder, recurrent

Categories F32 and F33 are further subdivided with fourth characters, and sometimes fifthcharacters, to provide information about the current severity of the disorders, as follows:

0 Mild

1 Moderate

2 Severe, without psychotic features

October 2020 Anthem Provider News - Virginia Page 30 of 59

3 Severe with psychotic features

4 In remission

5 In full remission

8 Other

9 Unspecified

Fourth characters 1 through 8 are assigned only when provider documentation of severity isincluded in the medical record. Manic episodes and bipolar disorders The table below outlines the ICD-10-CM classification for bipolar disorders. Manic/maniaalso falls within this code category. The codes in these categories require fourth and/or fifthdigits to identify the severity of the current episode and whether or not psychotic symptomsare involved.

October 2020 Anthem Provider News - Virginia Page 31 of 59

Category Description F30.- Manic episode (includes bipolar

disorder, single manic episode, andmixed affective episode)

Select appropriate fourth andfifth digits to identify theseverity of the current episodeto indicate whether psychoticsymptoms are involved

F31.- Bipolar disorder (includes manic-depressive illness, manic-depressivepsychosis, and manic-depressivereaction)

Select appropriate fourth andfifth digits to specify theseverity of the current episodeand whether the currentepisode is hypomanic, manic,depressed or mixed, and withor without psychotic features.

F34.- Persistent mood [affective] disorders(includes cyclothymic disorder anddysthymic disorder)

Includes, cyclothymic,dysthymic, and other specifiedmood disorders.

F39 Unspecified mood [affective] disorder(includes affective psychosis nototherwise specified)

Include affective psychosiswhen not otherwise specified

Anxiety disorders Anxiety disorders are classified in ICD-10-CM under the following categories:

F40 Phobic anxiety disorders

F41 Other anxiety disorders

F42 Obsessive-compulsive disorder

Dissociative and conversion disorders ICD-10-CM classifies dissociative and conversion disorders to category F44.

October 2020 Anthem Provider News - Virginia Page 32 of 59

Dissociative disorders: Code DescriptionF44.0 Dissociative amnesiaF44.1 Dissociative fugueF44.2 Dissociative stuporF44.81 Dissociative identity disorder

Conversion disorders: Code DescriptionF44.4 Conversion disorder with motor symptom or deficitF44.5 Conversion disorder with seizures or convulsionsF44.6 Conversion disorder with sensory symptom or deficitF44.7 Conversion disorder with mixed symptom presentation

Behavioral syndromes associated with physiological disturbances and physicalfactors Categories F50 through F59 grouping includes the following conditions:Category/code

Description

F50.0- Eating disorders (such as anorexia nervosa and bulimia nervosa)F51.- Sleep disorders not due to a substance or known physiological conditionF52.- Sexual dysfunction not due to a substance or known physiological conditionF53.- Mental and behavioral disorders associated with the puerperium, not

elsewhere classifiedF54 Psychological and behavioral factors associated with disorders or diseases

classified elsewhereF55.- Abuse of non-psychoactive substancesF59 Unspecified behavioral syndromes associated with physiological

disturbances and physical factors Disorders of adult personality and behavior Categories F60 through F69 include disorders of adult personality and behavior:

October 2020 Anthem Provider News - Virginia Page 33 of 59

Categorycode

Description

F60.0- Specific personality disordersF63.- Impulse disordersF64.- Gender identity disordersF65.- ParaphiliasF66.- Other sexual disordersF68.- Other disorders of adult personality and behavior

Psychosocial circumstances and encounters ICD-10-CM provides codes for behaviors that have not yet been classified to behavioraldisorders, but that may contribute to the need for further treatment or study. The table belowshows some examples:Code DescriptionR41.0 Disorientation, unspecifiedR41.82 Altered mental status, unspecifiedR41.840 Attention and concentration deficitR44.3 Hallucinations, unspecifiedR45.83 Excessive crying of child, adolescent or adultR45.84 AnhedoniaR45.86 Emotional liabilityR45.87 ImpulsivenessR46.0 Very low level of personal hygieneR46.2 Strange and inexplicable behaviorR46.81 Obsessive-compulsive behavior

For behavioral health disorders that resolve and do not require continued treatment, it isappropriate to report code Z86.59, Personal history of other mental and behavioraldisorders. 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. Resources:

1. ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2019.

October 2020 Anthem Provider News - Virginia Page 34 of 59

1. ICD-10-CM/PCS Coding. Theory and practice. 2019/2020 Edition. Elsevier.

AVA-NU-0274-20

URL: https://providernews.anthem.com/virginia/article/coding-spotlight-providers-guide-to-coding-for-behavioral-health-disorders

Patient360 enhancement for medical providersPublished: Oct 1, 2020 - State & Federal / Medicaid

Please note, this communication applies to Anthem HealthKeepers Plus offered byHealthKeepers, Inc. Patient360 is a real-time dashboard you can access through the Availity Portal* that givesyou a full 360° view of your Anthem HealthKeepers Plus patients’ health and treatmenthistory and will help you facilitate care coordination. You can drill down to specific items in apatient’s medical record to retrieve demographic information, care summaries, claimsdetails, authorization details, pharmacy information and care management-related activities. What’s new: Medical providers now have the option to include feedback for AnthemHealthKeepers Plus patients who have gaps in care. Your practice can locate these caregaps in the Active Alerts section on the Member Care Summary page of the Patient360application. Once you have completed all the required fields on the Availity Portal to access Patient360you will land on the Member Summary page of the application. To provide feedback, selectthe Clinical Rules Engine (CRE) within the Active Alerts section. This will open the CareGap Alert Feedback Entry window. You can choose the feedback menu option that applies toyour patient’s care gap. Are you using Patient360 for the first time? You can easily access Patient360 on theAvaility Portal.

October 2020 Anthem Provider News - Virginia Page 35 of 59

First, you need to be assigned to a Patient360 role, which your Availity administrators canlocate within the Clinical Roles options. Once you have the Availity role assignment, navigate to Patient360 through the AvailityPortal by selecting the application on Anthem HealthKeepers Plus Payer Spaces or bychoosing the Patient360 link located on the patient’s benefits screen.Do you need a job aid to help you get started? The Patient360 Navigation Overview illustrates the steps to access Patient360 through theAvaility Portal and offers instructions on how to provide feedback for your patients who aredisplaying a Care Gap Alert. This reference is available for you to access online through theCustom Learning Center. STEP INSTRUCTIONS1 From the Availity home page, select Payer Spaces > Anthem HealthKeepers

Plus payer tile > Applications > Custom Learning Center2 Select Resources from the menu located on the upper left corner of the page

(To use the catalog filter to narrow the results, select Payer Spaces from theCategory menu.)

3 Select Download to view and/or print the reference guide 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. * Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

AVA-NU-0275-20

URL: https://providernews.anthem.com/virginia/article/patient360-enhancement-for-medical-providers-9

Prior authorization requirements for E0482Published: Oct 1, 2020 - State & Federal / Medicaid

Effective November 1, 2020, prior authorization (PA) requirements will change for E0482.The medical codes listed below will require PA by HealthKeepers, Inc. for AnthemHealthKeepers Plus members. Federal and state law, as well as state contract language andCenters for Medicare & Medicaid Services guidelines, including definitions and specific

October 2020 Anthem Provider News - Virginia Page 36 of 59

Noncompliance with new requirements may result in denied claims. PA requirements will be added to the following:

E0482 — Cough stimulating device, alternating positive and negative airway pressure

To request PA, you may use one of the following methods:

Web: https://www.availity.com

Fax: 1-800-964-3627

Phone: 1-800-901-0020

Not all PA requirements are listed here. PA requirements are available to contractedproviders by accessing the Provider Self-Service Tool at https://www.availity.com byvisiting https://mediproviders.anthem.com/va > Login.

Contracted and noncontracted providers who are unable to access Availity* may call AnthemHealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated CarePlus Provider Services at 1-800-901-0020 for PA requirements. * Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

AVA-NU-0278

URL: https://providernews.anthem.com/virginia/article/prior-authorization-requirements-for-e0482

Claim payment disputes: UpdatePublished: Oct 1, 2020 - State & Federal / Medicaid

October 2020 Anthem Provider News - Virginia Page 37 of 59

Please note, this communication applies to Anthem HealthKeepersPlus offered by HealthKeepers, Inc. In September 2019, HealthKeepers, Inc. sent all providers theattached provider bulletin, outlining and confirming our claimspayment dispute processes. Since then, the AnthemHealthKeepers Plus Provider Relations team has continued toallow providers to submit claims payment issues directly to themafter completing the first level of the claims payment disputeprocess (reconsideration). Effective October 1, 2020, theAnthem HealthKeepers Plus Provider Relations team will nolonger accept claims payment issues directly from providerswho have not completed the second level of the claimspayment dispute process (appeal). In the meantime, the Anthem HealthKeepers Plus ProviderRelations team will work with providers to transition them to thisprocess and educate and train any providers on the process andsupporting tools. All claims issues that have already been acceptedby the Provider Relations team will be worked using the existingprocesses, and the Provider Relations team will notify providers ofthe outcomes.

Please refer to the bulletin in its entirety by selecting thedocument to the right under "Article Attachments."

AVA-NU-0285-20

Article Attachments

AnthemHealthKeepers PlusClaim PaymentDisputes AVA-NU-0285-20.pdfapplication/pdf - 332.45

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URL: https://providernews.anthem.com/virginia/article/claim-payment-disputes-update

Social determinants of health support expanding withGroundGame HealthPublished: Oct 1, 2020 - State & Federal / Medicaid

Please note, this communication applies to Anthem HealthKeepers Plus and Anthem

October 2020 Anthem Provider News - Virginia Page 38 of 59

Effective October 1, 2020, HealthKeepers, Inc. will integrate community health workers(CHWs) used by GroundGame Health (GGH)* into our current care management program.Referrals into the program are completed via provider direct referrals or ad hoc referralsfrom our Case Management team. Provider direct referrals will include members with thefollowing situations:

Identified social determinants of health needs including, but not limited to:

Living environmentTransportationFood insecurity issuesFinancial issuesSocial isolation, etc.

Hospital readmissions

A readmission risk score of more than 24

GGH provides an extra layer of support by using CHWs as an extension of caremanagement to help members navigate the complex health care system. PreferredCommunity Health Partners (PCHP) makes an initial outreach to identified members todetermine the appropriate level of services a member may need, but they do not provide anyclinical services, replace case management from HealthKeepers, Inc., or replace the careand care management provided by PCPs and specialists. Note: There is no requirement thatmembers participate in this program, and members have the opportunity to opt out of theprogram as they choose. A GGH CHW may reach out to your practice to introduce themselves and establish arelationship with the physician(s) at your practice based on referrals received. CHWs mayalso discuss developing a mechanism by which to share information regarding patients whohave been identified for complex care services.

October 2020 Anthem Provider News - Virginia Page 39 of 59

The CHW may also broaden the impact of case management by focusing on action plandevelopments in various ways, such as helping members fill prescriptions, schedulingappointments and arranging rides to the doctor. CHWs can even accompany members toappointments when appropriate and provide connections to meal delivery services that maybe available to them. To learn more about GGH, please visit https://groundgamehealth.org. If you havequestions regarding GGH, CHWs and complex care services, please call 1-866-739-6323 oremail [email protected]. * GroundGame Health is an independent company providing contracting services on behalf of HealthKeepers, Inc.

AVAPEC-2588-20

URL: https://providernews.anthem.com/virginia/article/social-determinants-of-health-support-expanding-with-groundgame-health-1

Provider Chat: A fast, easy way to have your questions answeredPublished: Oct 1, 2020 - State & Federal / Medicaid

Please note, this communication applies to Anthem HealthKeepers Plus offered byHealthKeepers, Inc. You now have a new option to have questions answered quickly and easily. With AnthemHealthKeepers Plus Chat, providers can have a real-time, online discussion through a newdigital service, available through Payer Spaces on Availity.* Provider Chat offers:

Faster access to Provider Services for all questions.

Real-time answers to your questions about prior authorization and appeals status,claims, benefits, eligibility, and more.

An easy to use platform that makes it simple to receive help.

October 2020 Anthem Provider News - Virginia Page 40 of 59

The same high level of safety and security you have come to expect withHealthKeepers, Inc.

Chat is one example of how HealthKeepers, Inc. is using digital technology to improve thehealth care experience, with the goal to save you valuable time. To get started, access theservice through Payer Services on Availity. 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. * Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

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URL: https://providernews.anthem.com/virginia/article/provider-chat-a-fast-easy-way-to-have-your-questions-answered

Keep up with Medicaid newsPublished: Oct 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: Coverage Guidelines and Clinical Utilization Management Guidelines updateAVA-NU-0227-20

URL: https://providernews.anthem.com/virginia/article/keep-up-with-medicaid-news-41

Social determinants of health support expanding withGroundGame HealthPublished: Oct 1, 2020 - State & Federal / Medicare

October 2020 Anthem Provider News - Virginia Page 41 of 59

Effective October 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will integratecommunity health workers (CHWs) used by GroundGame Health (GGH)* into our currentcare management program. Referrals into the program are completed via provider directreferrals or ad hoc referrals from the Anthem Case Management team. Provider directreferrals will include members with the following situations:

Identified social determinants of health needs including, but not limited to:

Living environmentTransportationFood insecurity issuesFinancial issuesSocial isolation, etc.

Hospital readmissions

A readmission risk score of more than 24

GGH provides an extra layer of support by using CHWs as an extension of caremanagement to help members navigate the complex health care system. PCHP makes aninitial outreach to identified members to determine the appropriate level of services amember may need, but they do not provide any clinical services, replace case managementfrom Anthem, or replace the care and care management provided by PCPs and specialists.Note: There is no requirement that members participate in this program, and members havethe opportunity to opt out of the program as they choose. A GGH CHW may reach out to your practice to introduce themselves and establish arelationship with the physician(s) at your practice based on referrals received. CHWs mayalso discuss developing a mechanism by which to share information regarding patients whohave been identified for complex care services.

October 2020 Anthem Provider News - Virginia Page 42 of 59

The CHW may also broaden the impact of case management by focusing on action plandevelopments in various ways, such as helping members fill prescriptions, schedulingappointments and arranging rides to the doctor. CHWs can even accompany members toappointments when appropriate and provide connections to meal delivery services that maybe available to them. To learn more about GGH, please visit https://groundgamehealth.org. If you havequestions regarding GGH, CHWs and complex care services, please call 1-866-739-6323 oremail [email protected]. * GroundGame Health is an independent company providing contracting services on behalf of Anthem Blue Cross and Blue Shield.

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URL: https://providernews.anthem.com/virginia/article/social-determinants-of-health-support-expanding-with-groundgame-health-4

Update: Notice of changes to the AIM musculoskeletal programPublished: Oct 1, 2020 - State & Federal / Medicare

As you know, AIM Specialty Health (AIM)* administers the musculoskeletal program forMedicare Advantage members, which includes the medical necessity review of certainsurgeries of the spine, joints and interventional pain treatment. For certain surgeries, thereview also includes a consideration of the level of care.Effective December 1, 2020, two joint codes (29871 and 29892) will be incorporatedinto the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures.According to the clinical criteria for level of care, which is based on clinical evidence asoutlined in the AIM guideline, it is generally appropriate to perform these two procedures in ahospital outpatient setting. To avoid additional clinical review for these surgeries, providersrequesting prior authorization should either choose hospital observation admission as thesite of service or Hospital Outpatient Department (HOPD).

We will review requests for inpatient admission and will require the provider to substantiatethe medical necessity of the inpatient setting with proper medical documentation thatdemonstrates one of the following:

®

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Current postoperative care requirements are of such an intensity and/or duration thatthey cannot be met in an observation or outpatient surgical setting.

Anticipated postoperative care requirements cannot be met, even initially, in anobservational surgical setting due to the complexity, duration, or extent of the plannedprocedure and/or substantial preoperative patient risk.

On January 1, 2020, CMS removed total hip arthroplasty as well as six spine codes from theinpatient only (IPO) list making these procedures eligible for payment by Medicare in thehospital outpatient setting in addition to the hospital inpatient setting. The two-midnight ruleshould guide providers on the expected reimbursement. The codes that were removed fromthe inpatient only list and are also in the AIM Musculoskeletal program are 27130, 22633,22634, 63265 and 63267. CMS has established a two year grace period (ending December31, 2021) for site of service reviews of these codes in order to facilitate provider transition tocompliance with the two-midnight rule. To this end, it is recommended that providers choose hospital observation or HospitalOutpatient Department (HOPD) during the prior authorization process when clinicallyappropriate to the respective patient. Choosing hospital observation still allows for thesurgery to be performed and recovered in the main hospital, so long as discharge is plannedfor less than two midnights. Alternatively, the provider may choose to perform the procedurein the Hospital Outpatient Department (HOPD). However, the inpatient setting will still beapproved should the provider decide it is the optimal setting for the member. Providers should continue to submit prior authorization requests to AIM using one of thefollowing ways:

Access AIM ProviderPortal directly at http://providerportal.com. Online access isavailable 24/7 to process orders in real-time, and is the fastest and most convenient wayto request authorization.

Access AIM via the Availity Portal* at http://www.availity.com.

SM

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Call the AIM toll-free number at 1-800-714-0400, Monday through Friday 8 a.m. to 8p.m. ET.

If you have questions, please contact the provider number on the back of the member’s IDcard. * AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross andBlue Shield. Availity, LLC is and independent company providing administrative support services on behalf of Anthem Blue Cross andBlue Shield.

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URL: https://providernews.anthem.com/virginia/article/update-notice-of-changes-to-the-aim-musculoskeletal-program-6

Patient360 enhancement for medical providersPublished: Oct 1, 2020 - State & Federal / Medicare

Patient360 is a real-time dashboard you can access through the Availity Portal* that givesyou a full 360° view of your Anthem Blue Cross and Blue Shield (Anthem) patients’ healthand treatment history and will help you facilitate care coordination. You can drill down tospecific items in a patient’s medical record to retrieve demographic information, caresummaries, claims details, authorization details, pharmacy information and caremanagement-related activities. What’s new: Medical providers now have the option to include feedback for Anthem patientswho have gaps in care. Your practice can locate these care gaps in the Active Alerts sectionon the Member Care Summary page of the Patient360 application. Once you have completed all the required fields on the Availity Portal to access Patient360,you will land on the Member Summary page of the application. To provide feedback, selectthe Clinical Rules Engine (CRE) within the Active Alerts section. This will open the CareGap Alert Feedback Entry window. You can choose the feedback menu option that applies toyour patient’s care gap.

October 2020 Anthem Provider News - Virginia Page 45 of 59

Are you using Patient360 for the first time? You can easily access Patient360 on theAvaility Portal. First, you need to be assigned to a Patient360 role, which your Availity administrators canlocate within the Clinical Roles options. Once you have the Availity role assignment, navigate to Patient360 through the AvailityPortal by selecting the application on Anthem Payer Spaces or by choosing the Patient360link located on the patient’s benefits screen. Do you need a job aid to help you get started? The Patient360 Navigation Overview illustrates the steps to access Patient360 through theAvaility Portal and offers instructions on how to provide feedback for your patients who aredisplaying a Care Gap Alert. This reference is available for you to access online through theCustom Learning Center.

From the Availity home page, select Payer Spaces > Anthem payer tile > Applications> Custom Learning Center

Select Resources from the menu located on the upper left corner of the page (To usethe catalog filter to narrow the results, select Payer Spaces from the Category menu.)

Select Download to view and/or print the reference guide

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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URL: https://providernews.anthem.com/virginia/article/patient360-enhancement-for-medical-providers-15

October 2020 Anthem Provider News - Virginia Page 46 of 59

Prior authorization requirements for the below codes (EffectiveDecember 1, 2020)Published: Oct 1, 2020 - State & Federal / Medicare

On December 1, 2020, Anthem Blue Cross and Blue Shield prior authorization (PA)requirements will change for codes below. Federal and state law, as well as state contractlanguage and CMS guidelines, including definitions and specific contractprovisions/exclusions take precedence over these precertification rules and must beconsidered first when determining coverage. Noncompliance with new requirements mayresult in denied claims. Prior authorization requirements will be added for the following codes:

C1764 Event recorder, cardiac (implantable)

E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE,TWO LEAD, LOCALIZED

E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE,FOUR OR MORE LEADS,

E0731 Conductive Garment For Tens

G0460 Autologous platelet rich plasma for chronic wounds/ulcers, includingphlebotomy, centrifugation, and all other preparatory procedures, administration anddressings, per treatment

L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each

October 2020 Anthem Provider News - Virginia Page 47 of 59

L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength

L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each

L3224 Woman's Shoe Oxford Brace

L3225 Man's Shoe Oxford Brace

L3300 Shoe Lift Taper To Metatarsal

L3310 Lift, elevation, heel and sole, neoprene, per in

L3332 Lift, elevation, inside shoe, tapered, up to one-half in

L3334 Lift, elevation, heel, per in

L3340 Heel wedge, SACH

L3350 Shoe Heel Wedge

L3370 Shoe Sole Wedge Between Sole

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L3390 Shoe Outflare Wedge

L3400 Shoe Metatarsal Bar Wedge Ro

L3450 Shoe Heel Sach Cushion Type

L3485 Shoe Heel Pad Removable For

L3540 Ortho Shoe Add Full Sole

L3580 O Shoe Add Instep Velcro Clo

L3610 Transfer of an orthosis from one shoe to another, caliper plate, new

L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing

L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new

L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified

L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf

October 2020 Anthem Provider News - Virginia Page 49 of 59

L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf

L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf

L3762 Elbow orthosis, rigid, without joints, includes soft interface material,prefabricated, off-the-shelf

L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has beentrimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by anindividual with expertise

L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type

L3912 Hand-finger orthosis (HFO), flexion glove with elastic finger control,prefabricated, off-the-shelf

L3913 HFO, without joints, may include soft interface, straps, custom fabricated,includes fitting and adjustment

L3923 Hand finger orthosis, without joints, may include soft interface, straps,prefabricated item that has been trimmed, bent, molded, assembled, or otherwisecustomized to fit a specific patient by an individual with expertise

October 2020 Anthem Provider News - Virginia Page 50 of 59

L3924 Hand finger orthosis, without joints, may include soft interface, straps,prefabricated, off-the-shelf

L3925 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), nontorsion joint/spring, extension/flexion, may include soft interface material, prefabricated,off-the-shelf

L3927 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip),without joint/spring, extension/flexion (for example, static or ring type), may include softinterface material, prefabricated, off-the-shelf

L3999 Upper Limb Orthosis Nos

L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system

L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, singleaxis knee

L5620 Test Socket Below Knee

L5645 Addition to lower extremity, below knee (BK), flexible inner socket, externalframe

L5649 Addition to lower extremity, ischial containment/narrow M-L socket

October 2020 Anthem Provider News - Virginia Page 51 of 59

L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prostheticshoe, each

0232T Injection(s), platelet rich plasma, any site, including image guidance, harvestingand preparation when performed

0397T Endoscopic retrograde cholangiopancreatography (ERCP), with opticalendomicroscopy (List separately in addition to code for primary procedure.)

0421T Transurethral waterjet ablation of prostate, including control of post-operativebleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/ordilation, and internal urethrotomy are included when performed)

0466T Insertion of chest wall respiratory sensor electrode or electrode array, includingconnection to pulse generator (List separately in addition to code for primary procedure.)

0480T Fractional ablative laser fenestration of burn and traumatic scars for functionalimprovement; each additional 100 cm2, or each additional 1% of body surface area ofinfants and children, or part thereof (List separately in addition to code for primaryprocedure.)

33340 Percutaneous transcatheter closure of the left atrial appendage with endocardialimplant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrialangiography, left atrial appendage angiography, when performed, and radiologicalsupervision and interpretation

October 2020 Anthem Provider News - Virginia Page 52 of 59

33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve;percutaneous femoral artery approach

33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; openfemoral artery approach

33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; openaxillary artery approach

33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve;transaortic approach (eg, median sternotomy, mediastinotomy)

33418 Transcatheter mitral valve repair, percutaneous approach, including transseptalpuncture when performed; initial prosthesis

33419 Transcatheter mitral valve repair, percutaneous approach, including transseptalpuncture when performed; additional prosthesis(es) during same session (List separatelyin addition to code for primary procedure)

33477 Transcatheter pulmonary valve implantation, percutaneous approach, includingpre-stenting of the valve delivery site, when performed

33979 Insertion, Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle

October 2020 Anthem Provider News - Virginia Page 53 of 59

33990 Insertion of ventricular assist device, percutaneous including radiologicalsupervision and interpretation; arterial access only

36514 Therapeutic Apheresis; Plasma Pheresis

36522 Photopheresis, Extracorporeal

37215 Transcatheter Placement Of Intravascular Stent(S), Cervical Carotid Artery,Percutaneous; With Distal Embolic Protection

55874 Transperineal placement of biodegradable material, peri-prostatic, single ormultiple injection(s), including image guidance, when performed

A4224 Supplies for maintenance of insulin infusion catheter, per week

A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each

A5500 Diabetic Shoe For Density Insert

A5501 Diabetic Custom Molded Shoe

A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlayshoe or custom molded shoe with roller or rigid rocker bottom, per shoe

October 2020 Anthem Provider News - Virginia Page 54 of 59

A5504 Diabetic Shoe With Wedge

A5505 Diabetic Shoe W/Metatarsal Bar

A5507 Modification Diabetic Shoe

A5512 For diabetics only, multiple density insert, direct formed, molded to foot afterexternal heat source of 230 degrees Fah

A5513 For diabetics only, multiple density insert, custom molded from model ofpatient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16inch material of Shore A 35 durometer (or higher), includes arch filler and other shapingmaterial, custom fabricated, each

A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries

C1722 Cardioverter-defibrillator, single chamber (implantable)

L5671 Addition to lower extremity, below knee (BK)/above knee (AK) suspensionlocking mechanism (shuttle, lanyard, or equal), excludes socket insert

L5673 Addition to lower extremity, below knee/above knee, custom fabricated

October 2020 Anthem Provider News - Virginia Page 55 of 59

L5679 Addition to lower extremity, below knee/above knee, custom fabricated

L5700 Replace Socket Below Knee

L5701 Replace Socket Above Knee

L5940 Endo Bk Ultra-Light Material

L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase activedorsiflexion feature

L5981 All lower extremity prostheses, flex-walk system or equal

L5987 All lower extremity prostheses, shank foot system with vertical loading pylon

L8699 Prosthetic implant, not otherwise specified

L9900 Orthotic and prosthetic supply, accessory, and/or service component of anotherHCPCS L code

Not all prior authorization requirements are listed here. Prior authorization requirements areavailable to contracted providers by accessing the Provider Self-Service Tool atwww.availity.com at https://www.anthem.com/medicareprovider > Login. Contracted andnoncontracted providers who are unable to access Availity* may call the number on the backof the member’s ID card.

October 2020 Anthem Provider News - Virginia Page 56 of 59

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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URL: https://providernews.anthem.com/virginia/article/prior-authorization-requirements-for-the-below-codes-effective-december-1-2020

Prior authorization requirements for the below codes (EffectiveJanuary 1, 2021)Published: Oct 1, 2020 - State & Federal / Medicare

On January 1, 2021, Anthem Blue Cross and Blue Shield prior authorization (PA)requirements will change for codes below. Federal and state law, as well as state contractlanguage and CMS guidelines, including definitions and specific contractprovisions/exclusions take precedence over these precertification rules and must beconsidered first when determining coverage. Noncompliance with new requirements mayresult in denied claims. Prior authorization requirements will be added for the following codes:

15771 — Grafting of autologous fat harvested by liposuction technique to trunk,breasts, scalp, arms, and/or legs; 50 cc or less injectate

15772 — Grafting of autologous fat harvested by liposuction technique to trunk,breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (Listseparately in addition to code for primary procedure.)

15773 — Grafting of autologous fat harvested by liposuction technique to face, eyelids,mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate

October 2020 Anthem Provider News - Virginia Page 57 of 59

15774 — Grafting of autologous fat harvested by liposuction technique to face, eyelids,mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, orpart thereof (List separately in addition to code for primary procedure.)

31574 — Laryngoscopy, flexible; with injection(s) for augmentation (for example,percutaneous, transoral), unilateral

0378T — Visual field assessment, with concurrent real time data analysis andaccessible data storage with patient initiated data transmitted to a remote surveillancecenter for up to 30 days; review and interpretation with report by a physician or otherqualified health care professional

0379T — Visual field assessment, with concurrent real time data analysis andaccessible data storage with patient initiated data transmitted to a remote surveillancecenter for up to 30 days; technical support and patient instructions, surveillance, analysis,and transmission of daily and emergent data reports as prescribed by a physician or otherqualified health care professional

C9122 — Mometasone furoate sinus implant, 10 mcg (Sinuva)

11950 — Subcutaneous injection of filling material (for example, collagen); 1 cc or less

11951 — Subcutaneous injection of filling material (for example, collagen); 1.1 to 5.0cc

11952 — Subcutaneous injection of filling material (for example, collagen); 5.1 to 10.0cc

October 2020 Anthem Provider News - Virginia Page 58 of 59

11954 — Subcutaneous injection of filling material (for example, collagen); over 10.0cc

0565T — Autologous cellular implant derived from adipose tissue for the treatment ofosteoarthritis of the knees; tissue harvesting and cellular implant creation

0566T — Autologous cellular implant derived from adipose tissue for the treatment ofosteoarthritis of the knees; injection of cellular implant into knee joint including ultrasoundguidance, unilateral

C1878 — Material for vocal cord medialization, synthetic (implantable)

G0429 — Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome(LDS) (for example, as a result of highly active antiretroviral therapy)

L8607 — Injectable bulking agent for vocal cord medialization, 0.1 ml, includesshipping and necessary supplies

Q2026 — Injection, Radiesse, 0.1 ml

Q2028 — Injection, sculptra, 0.5 mg

0489T — Autologous adipose-derived regenerative cell therapy for scleroderma in thehands; adipose tissue harvesting, isolation and preparation of harvested cells including

October 2020 Anthem Provider News - Virginia Page 59 of 59

incubation with cell dissociation enzymes, removal of non-viable cells and debris,determination of concentration and dilution of regenerative cells

0490T — Autologous adipose-derived regenerative cell therapy for scleroderma in thehands; multiple injections in one or both hands

0202U — Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratorysyndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, eachpathogen reported as detected or not detected

17999 — Unlisted procedure, skin, mucous membrane and subcutaneous tissue

46999 — Unlisted procedure, anus

Not all prior authorization requirements are listed here. Prior authorization requirements areavailable to contracted providers by accessing the Provider Self-Service Tool atwww.availity.com at https://www.anthem.com/provider/medicare-advantage > Login.

Contracted and noncontracted providers who are unable to access Availity* may call thenumber on the back of the member’s ID card. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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URL: https://providernews.anthem.com/virginia/article/prior-authorization-requirements-for-the-below-codes-2

Provider transparency updatePublished: Oct 1, 2020 - State & Federal / Medicare