Anthem Provider Newsletter – Missouri September 2023

This month’s featured articles:

Administrative

• Update – Enhanced outpatient facility editing for National Correct Coding
• Initiative
• CAA: Have you reviewed your online provider directory information lately?
• Support documentation for Carelon Medical Benefits Management, Inc . prior
• authorization requests
• HCPCS to revenue code alignment
• Help your patients continue their care and navigate Medicaid renewal

Digital Tools

• Improvements to Digital RFAI Attachment filtering and reporting
• Personalized match phase 1: Specialist provider overview
• Simplifying claims attachments: Digital Request for Additional Information
• through Availity.com
• Member search feature enhancement: Search for a patient without using
• member ID in Availity Essentials

Educational and Training

• You’re invited: Thriving, not just surviving: Youth mental health in today’s world
• Policy Updates
• Clinical Criteria updates – May 2023

Medical Policy and Clinical Guidelines

• Medical policies and clinical guidelines updates – September 2023
• Medical policies and clinical guidelines moving to pre-cert
• Medical policies and clinical guidelines updates

Prior Authorization

• Prior authorization requirement changes effective December 1, 2023
• Carelon Medical Benefits Management, Inc. advanced imaging – Imaging of
• the brain CPT code list update

Reimbursement Policies

• Reimbursement policy update: Documentation Standards for Episodes of Care –
• Professional
• Clarification to reimbursement policy update: Prolonged Services – Professional
• Reimbursement policy update: Documentation and Reporting Guidelines for
• Evaluation and Management Services – Professional
• Reimbursement policy update: Place of Service – Facility
• New reimbursement policy: Split Care Surgical Modifiers – Professional

Products and Programs

• Reminder: Review the health reimbursement arrangement and care plan updates in Availity Essentials
• Specialty pharmacy updates – September 2023
• Sublocade® update

Pharmacy

• Specialty pharmacy medical step therapy for hyaluronan injections
• UPDATED: Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list

Quality Management

• Medication reconciliation post inpatient discharge

As a result of a recent review, we will deny respiratory pathogen panel testing as not medically necessary when administered at a frequency greater than either 12 in a 12-month rolling timeframe or one per day.  Denials will affect the claim line only and include medical necessity appeal rights.

This update is effective for dates of service on or after November 12, 2023. We will update the Nucleic Acid Pathogen Testing (0530) medical coverage policy to reflect this change.

Cigna – Medical Coverage Policy Update – Respiratory Pathogen Panel Testing

Cigna – ClaimsXten Update 111223

As a result of a recent review, we will update the Bundled Service ClaimsXten rule to add 22 service codes. This rule administratively denies claims submitted with bundled codes when billed with any other procedure code not indicated as bundled.

Denials will affect the claim line only and include administrative appeal rights. This update is effective for dates of service on or after November 12, 2023.

Cigna has updated their precertification list.  They have removed over 600 codes that previously needed authorization.

Removal of Precertification Codes August 23

Master Precertification Updated List August

The UHC September Virtual Provider Expo is scheduled for September 12, 2023 from 8:30 – 3:00 PM Central Time.  There will be several sessions throughout the day with the option to earn continuing education credits for attending these presentations:

• Coding education
• Smart Edits
• Payment Integrity

You can find more information on this as well as how to register by following the link below.

UHC September Provider Expo

The September edition of the Medica Connections is now available for review by following the attached link.

Sept2023Conn – Final

The following topics are covered in this edition.

General News

• Annual notice: Medica encourages its members to get flu vaccinations
• Reminder: Use electronic prior authorization option for easy submission

Pharmacy News

• Medica to add new UM policies for 5 new medical pharmacy drugs, eff. Nov. 1
• Medica to add 1 new drug UM policy for Mayo Medical Plan, eff. Nov. 1
• Upcoming changes to Medica Part D drug formularies, eff. Sept. 1

Administrative News

• Self-service resources, featuring: Medical pharmacy guidelines
• Provider administrative training webinar for September

Home State Health – Wellcare by Allwell Prior Authorization List 100123

Please click on the above link to access the announcement from Wellcare by Allwell regarding updates to their prior authorization list effective 10/1/2023.

Home State Health Provider News – Babylon Provider Alert

We’d like to update you on some important information regarding our Ambetter Virtual Access members’ telehealth coverage. Babylon Health’s telehealth services are no longer available as of August 7, 2023. Due to this change, you may receive new requests for both virtual and in-person services from Ambetter Virtual Access members as you are currently in our network.

As always, please verify each member’s eligibility, benefits, and
referral requirements before rendering care.

To view the full announcement, click on the link above.

As you know, we took important steps through COVID-19 to deliver timely accommodations to providers and customers, helping to ensure that customers had continued access to COVID-19 diagnostic services, testing, and treatment in safe settings.

How we reimbursed COVID-19 services

As a reminder, we have been reimbursing providers at contracted rates for COVID-19 related services (e.g., vaccine administration, infusion treatments, and testing) only when provider-specific rates were in place for certain COVID-19 services. When no contracted rates were in place, we reimbursed providers for all covered COVID-19 services billed under the medical benefit at the established national Centers for Medicare & Medicaid Services (CMS) rates.

This reimbursement approach was put in place at the onset of the pandemic to ensure that providers received timely, consistent, and reasonable reimbursement.

Updating how we reimburse these services as of August 1, 2023

At the end of the public health emergency period – May 12, 2023 – we communicated that we would continue to follow this reimbursement guidance in the interim while targeting August 1 to pay all providers at contracted rates, including reverting to a default discount for providers who don’t have specifically negotiated rates for COVID-19-related services.

Please note that we are now reimbursing all participating providers at contracted rates for COVID-19-related services beginning with August 1 dates of service (subject to applicable law).

Get the most up-to-date information

Our dedicated COVID-19 provider web page was recently updated to highlight these changes. I encourage you to review this page for the latest information.

Click on the following links to access the current edition of Cigna Network News

Cigna Network News 3rd Quarter 2023