Anthem Provider Newsletter – Missouri July 2024

This month’s featured articles:

Administrative

• Drugs and biologic
• Timely receipt of other carrier EOBor rejection helps avoid timely filing denials
• Anesthesia modifiers — professional editing update
• Recovery room — facility editing update
• Phoenix Sepsis Criteria for coding and billing pediatric sepsis
• CAA: Maintain your online provider directory information

Digital Solutions

• Admission, discharge, and transfer information is now available for Medicare Advantage members
• Adopting digital member ID cards
• Digital-only authorization case status notification coming to you

Education and Training

• July is Disability Awareness Month
• Important reminder: The correct original claim number must be included if submitting a corrected claim
• Faster notification of EDI corrected claims errors

Policy Updates

• Clinical Criteriaupdates
• Clinical Criteriaupdates — November 2023
• Carelon Medical Benefits Management, Inc. updates

Medical Policy & Clinical Guidelines

• Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
• Medical Policiesand Clinical Guidelines updates for July 2024
• Medical Policiesand Clinical Utilization Management Guidelines update

Prior Authorization

• Carelon Medical Benefits Management, Inc. genetic testing code updates
• Reimbursement policy update: Incident to Services — Professional

Reimbursement Policies

• Reimbursement policy update: Frequency Editing — Professional
• New reimbursement policy: Diagnostic Radiopharmaceuticals and Contrast Materials — Professional and Facility

Federal Employee Program (FEP)

• Antidepressant Medication Management (AMM)

Pharmacy | Commercial

• Specialty pharmacy updates — July 2024
• Anthem expands specialty pharmacy precertification list

Quality Management

• Understanding your role in the Health Outcomes Survey

Medica Connections Monthly Newsletters

General News

• Durations for Carelon prior authorization approvals for MSK, cardiovascular or radiology services
  • Radiology: order numbers are valid from the date entered + 60 calendar days
  • Cardiovascular: order numbers are valid from the date entered + 60 calendar days
  • MSK:
    • Joint and Spine: order numbers are valid from the date entered + 60 calendar days
    • Interventional Pain: order numbers are valid for 10 business days from the date of service
    • Inpatient: order numbers are valid from the date of service + expected length of stay
  • Claim appeals submitted through Availity to result in online responses

Clinical News

• Reminder the most recent updates to Medica’s UM policies, coverage and clinical guidelines will be effective 08/19/2024. Medica post notification of updates at least 60 days in advance on Medica.com.  You can view the updated guidelines online by following this link or you can request printed copies by calling 1-800-458-5512, option 1, then option 8, then ext 2-2355.
  • https://partner.medica.com/providers/policies-and-guidelines

Pharmacy News

• Effective 09/01/2024 Medica will expand step therapy for long-acting GCSF drug class and the full list can be viewed on the newsletter
• Effective 09/01/2024 prior authorization will be required for Imdeltra

Network News

• Effective 09/01/2024 Medica will make annual ancillary fee schedule updates for all products

Tips and Training

• The training session for July is “Setup and billing for EW (Elderly Waiver) and HSS (Housing Stabilization Service Providers)”. The session date is 07/16/2024 and 11:30 am – 1:00 pm CT.
  • Registration can be done here
    • https://partner.medica.com/providers/provider-training

Cigna – EviCore by Evernorth Quick Reference Guide 6.12.24

This guide is designed to assist providers with the precertification process.

Arkansas BCBS – Providers News June 2024

This month’s featured articles:

Arkansas Blue Cross and Blue Shield

• 2024 Spring Provider Workshops
• ABCBS to Match CMS fiscal year for DRG Inpatient Updates
• Bevacizumab for Ophthalmologic Indications
• Billing For Services to Provider Family Members Prohibited
• Claims Incurred During the Credentialing Process
• Corrected Claim Submission and Correcting Claim Rejections/Errors
• Coverage Policy Manual Updates
• Lucet and Carelon’s Post-Service Prepay
• Medical Specialty Prior Authorization Medications
• Meet New Network Development Representative (NDR) Dawn Roberts and JoalyVelasquez
• Metallic Formulary Changes Effective July 1, 2024
• Provider Data Management: New Provider Information Search
• Standard Formulary Changes Effective July 1, 2024
• Timely Filing Review

Federal Employee Program

• Cervical Cancer Screenings
• LBP KX Modifier: Coding for use of imaging for lower back pain diagnosis

Medicare Advantage

• Centers for Medicare and Medicaid Services (CMS) Preclusion List
• CMS Requirement for Provider Certification on National Plan and Provider Enumeration System (NPPES)
• HIPAA and HITECH Reminders
• Reminder on Billing Qualified Medicare Beneficiaries
• Requirements for outpatient observation care

21 st Blue & You Fitness Challenge

Cigna Reimbursement Policy Update – Exams billed with ICD10 Z diagnosis codes 081724

As a result of a recent review, we will administratively deny claims when International Classification of Diseases, 10th Revision, Clinical Modification Z diagnosis codes Z02.0-Z02.6, Z02.71, Z02.79, Z02.82- Z02.83, Z02.89-Z02.9, Z13.9, Z56.1, Z62.21, or Z63.6 are the only codes on the claim. Denials will include administrative appeal rights.

We will update the Diagnosis Coding Guidelines (R47) reimbursement
policy to reflect this change. This update is effective for dates of
service on or after August 17, 2024.

June 2024 Provider Newsletter – Provider News (anthem.com)

This month’s featured articles:

Administrative

• Availity Essentials single claim submission response reports
• Implant — Facility Editingupdate
• CAA: Review your online provider directory information
• Expansion of Carelon Medical Benefits Management, Inc. programs
• Digital RFAI Availity training

Education and Training

• June is LGBTQIA+ Pride Month
• You are invited: Thriving, not just surviving: navigating challenging times as a clinician
• Introducing advanced eLearning features for MyDiversePatients.com

Policy Updates

• Clinical Criteriaupdates
• Medical Policiesand Clinical Guidelines updates – June 2024
• MCG Care Guidelines 28th edition
• MCG Care Guidelines 28th edition
• Carelon Medical Benefits Management, Inc. genetic testing code updates
• Updates to Carelon Post-Acute Care Clinical Appropriateness Guidelines
• Expansion of Carelon Medical Benefits Management, Inc. programs

Products & Programs

• Addressing medication adherence gaps
• Improving patient outcomes with statin therapy in diabetes
• Pharmacy information available on our provider website

Quality Management

• Enhance patient access to digital health resources
• Improving patient health and digital literacies
• Tips to Improve Adolescent Immunization (IMA) Rates
• New resources to improve your HEDIS^®and CAHPS^® quality rates
• Statin Use in Persons with Cardiovascular Disease (SPC) measure exclusion criteria: HEDIS^®2024 measurement year

June 2024 Provider Newsletter – Provider News (summitcommunitycare.com)

This month’s featured articles:

Administrative

• Availity Essentials single claim submission response reports
• Digital RFAI Availity training

Education and Training

• Rotary to ground educational message
• Thriving, not just surviving: navigating challenging times as a clinician
• June is LGBTQIA+ Pride Month
• Introducing advanced eLearning features for MyDiversePatients.com

Policy Updates

Notice of Material Amendment to Healthcare Contract

• Clinical Criteriaupdates — November 2023

Notice of Material Amendment to Healthcare Contract

• Medical Policiesand Clinical Utilization Management Guidelines update

Products & Programs

Notice of Material Amendment to Healthcare Contract

• Prior authorization updates for medications billed under the medical benefit

Quality Management

• Tips to Improve Adolescent Immunization (IMA) Rates
• New resources to improve your HEDIS^®and CAHPS^® quality rates
• Complex Case Management program
• Members’ Rights and Responsibilitiessection
• Important information about utilization management

Cigna – MA reimbursement policy update – Bilateral Procedure Codes Billed Without the Requested Modifier 081724

As a result of a recent review, we will implement a new reimbursement policy, Modifier SO Bilateral Procedures (MAMS0), to administratively deny bilateral procedure codes when billed without the required modifier, LT (left side), RT (right side) or SO, as appropriate.

Denials will affect the claim line only and include administrative appeal rights. However, a corrected claim should first be submitted for payment. This update is effective for dates of service on or after August 17, 2024.

Cigna – Medical coverage policy update – Folate Testing Billing with CPT 82746 and 82747 081724

As a result of a recent review, we will implement a new medical coverage policy, Serum Folate and Red Blood Cell Folate (0567), for folate testing billed with Current Procedural Terminology (CPT®) codes 82746 and 82747. We will administratively deny CPT code 82746 when billed with a diagnosis code that is not reimbursable. In addition, we will
administratively deny CPT code 82747 regardless of the diagnosis, as it is not reimbursable.

Denials will affect the claim line only and include administrative appeal rights. However, a corrected claim should first be submitted for payment for claims billed with CPT code 82746. This update is effective for dates of service on or after August 17, 2024.

HealthChoice Network News Spring 2024

In this issue

• Provider customer service
• Corrected claims
• Using the provider portal
• Coming soon: submitting medical records with claims
• Direct data entry of claims and group numbers
• Payment methods
• Medicare crossover claims
• Fee schedule updates
• HealthChoice contact information