In this issue Page. anthem.com. Important phone numbers. February 2018

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1 February 2018 In this issue Page Announcements Anthem continues efforts to transition lines of business to a common claims platform 3 Anthem s provider website has improved look and feel 4 Coverage and clinical guideline update Coverage guidelines effective May 1, Gamunex-C and Octagam are Anthem s clinically equivalent immune globulin agents 8 AIM alerts Enhancements to AIM Diagnostic Imaging Clinical Appropriateness Guidelines 9 Business update Anthem expands partnership with Aspire Health to support palliative care for our members 10 Physician office lab list update effective February 5 11 HEDIS 2018 starts early February 11 Virginia in-network laboratory update regarding Exact Sciences Laboratories 13 Important information about filing home infusion therapy claims 13 Update regarding Shingrix shingles vaccine 14 Misrouted protected health information (PHI) 14 Clinical practice and preventive health guidelines on the Web 14 Facility footnotes Anthem to partner with Advance Health to help prevent member readmissions 15 Health care reform (including health insurance exchange) Refer to anthem.com for information about health care reform 15 ebusiness New functionality Easily update provider demographics with Anthem s online Provider Maintenance Form 16 Receive notifications via our Network eupdate 17 anthem.com Important phone numbers 1 of 26 VAPENABSNL (02/18)

2 In this issue, continued Page Drug/pharmacy update Anthem expands specialty pharmacy prior authorization list 18 Important update to Anthem s drug lists for members enrolled in Anthem s PAR/PPO and Anthem HealthKeepers health plans 19 Pharmacy information available on anthem.com 19 Medicaid information Continuity of care period extended for long-term services and supports 20 Levoleucovorin calcium, elosulfase alfa, histrelin acetate, idursulfase and fulvestrant to require prior authorization 20 Physician office lab list update effective February 5 for Anthem HealthKeepers Plus members 21 Coverage Gudelines update 22 Data collection for 2017 to 2018 Foster Care Focused Study 23 Medicare information Medical policies and clinical guidelines updated 24 Improve member medication regimen 24 Keep up with Medicare news 25 Bulletin board First 2018 Anthem webinar scheduled for April Anthem webinar and registration form 26 February of 26

3 Announcements Anthem continues efforts to transition lines of business to a common claims platform Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. continue to work to consolidate our internal claims processing systems into one common platform as part of our ongoing efforts to streamline business operations. To that end, we continue to use a phase-in approach to transition claims for our multiple lines of business to another claims platform as groups renew beginning January 1, Effective January 1, we will transition claims to a different claims processing platform for the Virginia Private Colleges Consortium who have members enrolled with Anthem and HealthKeepers, Inc. In addition, claims for Anthem employees enrolled in HealthKeepers, Inc. s Anthem HealthKeepers plans will also transition to the new claims platform. Claims for additional groups are scheduled to move beginning July 2018, as these groups renew their benefit coverage with Anthem and HealthKeepers, Inc. As we transition claims for groups from one claims platform to another, you may notice differences in how the claims are processed due to claims editing logic and the use of McKesson s ClaimsXten editing solution software. Please refer to the Virginia Reimbursement Policy section of your Professional or Ancillary Provider contract if you have questions (not applicable to Facility contracts). Eligibility and benefits As a reminder, we encourage you to check Availity our secure Web-based provider tool for the most up-to-date information about members available benefits before you provide services. Or, if you prefer, call the customer service number on the member s ID card to speak with an Anthem representative. Watch for ID card changes and request current ID cards at time of service In 2018, you may see alpha prefix and other changes to members ID cards as we transition claims to a common platform. The alpha prefix for the Virginia Private Colleges Consortium is changing to VPQ for our PPO business and VCQ for our Anthem HealthKeepers business beginning January 1. The alpha prefix is changing to VAW for the group assigned to Anthem s employees when we transition claims to the new platform on January 1. As always, your office, practice or facility should request that members enrolled in our health benefit plans present their most current ID cards at the time of service. Please check the ID cards carefully. When filing claims to Anthem and HealthKeepers, Inc., enter members ID numbers exactly as the numbers appear on the card including the alpha prefix to help speed claims processing and reimbursement. Watch for further updates about our transition efforts in upcoming editions of the Network Update. February of 26

4 Electronic member ID cards Anthem has a mobile app called Anthem Anywhere that allows members to manage their benefits on their smart phones, including electronic copies of their ID cards. Anthem Anywhere mobile app allows members easy access to their ID card even when there is no Internet connection. If presented with an electronic card, you may still obtain a copy of the ID card for your records. Members who choose to use their mobile app will have the option to or fax their ID card from their phone, and providers can view (and print the card if needed) from the Availity Web Portal. Members are still required to have a copy of their card in one format or another, whether hard copy or electronic, in order for services to be rendered. If you have questions about our electronic member ID cards, you can view our Quick Reference Guide online at anthem.com. Select Menu, and under the Support heading, select Providers. Choose Virginia from the drop down list, and Enter. From the Provider Home page, under the Self-Service and Support heading, select the link titled Electronic Member ID Cards Quick Reference Guide. Anthem s provider website has improved look and feel We want you to easily find the information you need when using the Anthem Blue Cross and Blue Shield provider website. On our site now, you will see updates to the provider website to help improve your user experience. These updates initially include a cleaner and more up-to-date look and feel to the provider landing page on with more intuitive navigation to important information. Watch for additional information about our continued improvements to the provider site in future editions of the Network Update provider newsletter. February of 26

5 Coverage and clinical guideline update Coverage guidelines effective May 1, 2018 Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will implement the following new and revised coverage guidelines effective May 1, These guidelines impact all our products with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage and the Medicare-Medicaid Plan (Dual Integration product), and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). Furthermore, the guidelines were among those recently approved at the quarterly Medical Policy and Technology Assessment Committee meeting held on November 2, Services related to specialty pharmacy drugs (non-cancer related) require a Medical Necessity review, which includes site-of service criteria, as outlined in the applicable coverage or clinical UM guideline listed below. The guidelines addressed in this edition of the Network Update are: Hyaluronan Injections in Joints Other than the Knee (DRUG.00017) Eteplirsen (Exondys 51 ) (DRUG.00081) SPECIAL NOTE Gemtuzumab Ozogamicin (Mylotarg ) (DRUG.00112) Recombinant Erythropoietin Products (CG-DRUG-05) Antihemophilic Factors and Clotting Factors (CG-DRUG-78) (Previously DRUG.0066) Ambulatory Electroencephalography and Video Electroencephalography (CG-MED-46) The services addressed in ALL the coverage guidelines presented in this section (pages 5 through 8) will require authorization for all of our products offered by HealthKeepers, Inc. with the exception of Anthem HealthKeepers Plus (Medicaid). Other exceptions are Medicare Advantage, the Medicare-Medicaid Plan (Dual Integration product), and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). A pre-determination can be requested for our Anthem PPO products. February of 26

6 Hyaluronan Injections in Joints Other than the Knee (DRUG.00017) Coverage guideline DRUG addresses the use of injections of hyaluronan in joints other than the knee, including osteoarthritis and temporomandibular joint disease. This therapy may also be referred to as viscosupplementation. Effective for dates of service on and after May 1, 2018, intra-articular injections of hyaluronan for the treatment of pain due to reducing and non-reducing disc displacement disease of temporomandibular joint disorders, are considered investigational and not medically necessary. No pre-certification or prior authorization for these agents will be required, but rather reviewed post-service. The following codes will be subject to post-service review under this coverage guideline: Hyaluronic Acid Euflexxa J7323 Hyaluronic Acid Gel-One J7326 Hyaluronic Acid Gel-Syn J7328 Hyaluronic Acid Genvisc J7320 Hyaluronic Acid Hyalgan J7321 Hyaluronic Acid Hymovis J7322 Hyaluronic Acid Monovisc J7327 Hyaluronic Acid Orthovisc J7324 Hyaluronic Acid Supartz J7321 Hyaluronic Acid Synvisc J7325 Hyaluronic Acid Synvisc-One J7325 Eteplirsen (Exondys 51 ) (DRUG.00081) This revised document addresses the antisense oligonucleotide drug, eteplirsen (Exondys 51; Sarepta Therapeutics, Inc., Cambridge, MA); an exon-skipping drug intended for the treatment of Duchenne muscular dystrophy (DMD). Initiation of therapy with eteplirsen is considered medically necessary for the treatment of Duchenne muscular dystrophy when all of the following criteria are met: A. Individual has a confirmed diagnosis of Duchenne muscular dystrophy; and B. Individual must be ambulatory (with or without needing an assistive device, such as a cane or walker); and C. Individual has a genetic mutation that is amenable to exon 51 skipping. Continuation of therapy with eteplirsen, for each 12 month period post initiation of therapy, is considered medically necessary for the treatment of Duchenne muscular dystrophy when all of the following criteria are met: A. The criteria above for initiation of therapy have been met; and February of 26

7 B. Individual remains ambulatory (with or without needing an assistive device, such as a cane or walker). Use of eteplirsen is considered investigational and not medically necessary when the criteria above are not met, and for all other indications. The HCPCS code associated with this revised coverage guideline is J1428. Gemtuzumab Ozogamicin (Mylotarg ) (DRUG.00112) This new coverage guideline addresses gemtuzumab ozogamicin (Mylotarg) (Pfizer, New York, NY), a humanized anti-cd33 monoclonal antibody for the treatment of acute myeloid leukemia (AML) and acute promyelocytic leukemia (APL). Gemtuzumab ozogamicin is considered medically necessary for the treatment of the following indications: A. Newly-diagnosed CD33-positive acute myeloid leukemia (AML) in adults greater than or equal to 18 years of age; or B. Relapsed or refractory CD33-positive AML in adults and in children 2 years and older. Gemtuzumab ozogamicin is considered medically necessary for the treatment of acute promyelocytic leukemia (APL) in high-risk individuals who are ineligible for treatment with anthracycline. Gemtuzumab ozogamicin is considered investigational and not medical necessary when the medically necessary criteria have not been not met, and for all other indications. The HCPCS code associated with this new coverage guideline is J9203. Recombinant Erythropoietin Products (CG-DRUG-05) This revised clinical UM guideline addresses recombinant, or man-made, erythropoietin products. The clinical indications have been revised to consider Darbepoetin Alfa and Epoetin Alfa to be not medically necessary to treat anemia in individuals with cancer receiving myelosuppressive chemotherapy in whom the anemia can be managed by transfusion. The CPT and HCPCS codes associated with this revised clinical UM guideline are J0881, J0882, J0885, J0887, J0888, Q4081, and S9537. Antihemophilic Factors and Clotting Factors (CG-DRUG-78) (Previously DRUG.0066) This clinical UM guideline addresses select hemophilia and clotting factor replacement treatments created from blood products (human plasma-derived) and others that are manufactured (recombinant). The content was previously addressed in DRUG February of 26

8 It has been revised to include criteria for recombinant coagulation factor IX, GlycoPEGylated (Rebinyn ) and Human Fibrinogen (Fibryna). The HCPCS codes associated with this clinical UM guideline are J7198, J7189, J7190, J7182, J7185, J7192, J7209, J7210, J7211, J7205, J727, J7188, J7191, J7183, J7186, J7187, J7179, J7193, J7194, J7195, J7200, J7195, J7201, J720, J7175, J7180, J7181, and J7178. Ambulatory Electroencephalography and Video Electroencephalography (CG-MED-46) This clinical UM guideline addresses ambulatory electroencephalography (EEG) monitoring in the outpatient (for example, home) setting and video EEG in the outpatient, observation or inpatient settings. The scope has been expanded to include outpatient video EEG. Outpatient video EEG testing is considered not medically necessary for all indications. The CPT codes associated with this revised clinical UM guideline are 95950, 95953, 95956, and These coverage guidelines became available for review on our website at after December 27, Gamunex-C and Octagam are Anthem s clinically equivalent immune globulin agents Effective for dates of service on or after May 1, 2018, Gamunex-C and Octagam will be the immune globulin agents of choice over Bivigam, Carimune NF Flebogamma, Gammagard, Gammagard S/D, Gammaplex, and Privigen. Some health plans require the use of clinically equivalent agents. When prescribing a therapy in these categories, please consider using a preferred clinically equivalent agent. Anthem has a process in place to consider requests for continuing members on existing agents. To inquire about this process, please call the provider service number on the back of the member ID card. The following clinical guidelines have been updated to include the requirement of a clinically equivalent agent effective May 1, Clinical Guideline Impacted Agent Clinically Equivalent Agent CG-DRUG-09 Immune Globulin (IG) Therapy Bivigam, Carimune NF, Flebogamma, Gammagard, Gammagard S/D, Gammaplex, Privigen Gamunex-C Octagam February of 26

9 AIM alerts Enhancements to AIM Diagnostic Imaging Clinical Appropriateness Guidelines Beginning with dates of service on and after May 1, 2018, the following enhancements will apply to AIM Diagnostic Imaging Clinical Appropriateness Guidelines: Expanded indications for use of Fractional Flow Reserve (FFR) have been added to the guidelines that incorporate the most recent literature regarding the use of Coronary CT Angiography (CCTA) (with or without FFR) as a first-line test in patients with suspected coronary artery disease. Ordering and servicing providers may submit pre-certification requests to AIM in one of the following ways: Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization. Access AIM via the Availity Web Portal at availity.com Call the AIM Contact Center toll-free number: , Monday -- Friday, 8 a.m. to 5 p.m. ET. For questions related to guidelines, please contact AIM via at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. February of 26

10 Business update Anthem expands partnership with Aspire Health to support palliative care for our members Beginning April 2, 2018, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. will partner with Aspire Health to supply palliative care support services to our fully insured members with advanced illness who are enrolled in our Anthem PAR/PPO and Anthem HealthKeepers health plans. Aspire Health already provides services for members with advanced illness enrolled in our Medicare and Anthem HealthKeepers Plus (Medicaid) health plans and has demonstrated improvement in quality and cost of care savings. Aspire does not replace the care of PCPs and specialists, but provides an extra layer of support with an interdisciplinary team that includes palliative care physicians, palliative care nurse practitioners, registered nurses, social workers, chaplains and patient care coordinators. Specific palliative care services include: Comprehensive assessments including symptoms, spiritual and psychosocial needs Expert symptom management Supporting patients in defining their goals, values and preferences and in advance care planning Empowering patients to execute advance directives 24/7 access to urgent clinical support from an Aspire interdisciplinary team member Securing needed resources Education on palliative services and hospice care services An initial telephonic outreach to identified members will be made by a palliative care professional to determine the appropriate level of palliative services in one of the following three models: 1. Home based visits by Aspire s interdisciplinary team for patients with a high symptom burden, increased risk of hospitalization or other complex issues (available in certain geographic areas) 2. An Aspire palliative care team embedded within an outpatient medical oncology clinic to provide services to targeted patients (available in certain geographic areas) 3. Provision of telephonic/telehealth services and support at routine intervals to patients by palliative trained providers If you are an Anthem contracted network provider, an Aspire Health palliative physician may reach out to your practice to introduce himself or herself in order to establish a physician-to-physician relationship. They may also discuss developing an February of 26

11 individualized mechanism by which to share information regarding patients who have been identified for palliative care services. Aspire will provide updates to your practice on a regular basis to facilitate the best possible co-management of your patient. If you have questions regarding Aspire Health or palliative care, please palliativecareaspirehospice@anthem.com Physician office lab list update effective February 5 As a reminder, the physician office lab (POL) lists include one list for primary care providers (PCPs) and one for specialist care providers (SCPs). These lists include services for office-based tests for members enrolled in Anthem HealthKeepers and Anthem HealthKeepers Plus (Medicaid) health benefit plans offered by Anthem s affiliate HealthKeepers, Inc. PCPs and SCPs who provide these services during an office visit for a covered member can submit claims for these services directly to HealthKeepers, Inc. for reimbursement. Lab tests not shown on these lists are not reimbursable to providers and must be handled by our exclusive arrangement with laboratory provider, LabCorp. In this edition of the Network Update, HealthKeepers, Inc. is announcing that our POL list has been expanded to include CPT [CPT code is defined as infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types.] This change will be effective February 5, For the complete POL list, visit anthem.com and select providers from the menu option. From the provider page, click on Find Resources for Your State and then select Virginia from the listing of states. From Answers@Anthem on the Virginia Provider home page, select the Provider Office Lab Lists link or click provider office lab list. HEDIS 2018 starts early February Anthem Blue Cross and Blue Shield will begin requesting medical records in February via a phone call to your office followed by a fax. The fax will contain: 1. A cover letter with contact information your office can use to contact us if there are any questions; 2. A member list, which includes the member and HEDIS measure(s) the member was selected for; 3. An instruction sheet listing the details for each HEDIS measure. February of 26

12 As a reminder, under the Health Insurance Portability and Accountability Act (HIPAA), releasing protected health information (PHI) for HEDIS data collection is permitted and does not require patient consent or authorization. HEDIS and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities [45 CFR (c) (4)]. For more information, visit HEDIS review is time sensitive, so please submit the requested medical records within five business days. Meeting this timeframe will make your office eligible for a drawing to win a small prize, and the winners will be announced in the Network Update provider newsletter during the third quarter. To return the medical record documentation back to us in the recommended five-day turnaround time, simply choose one of these options: 1. Upload to our secure portal. This is quick and easy. Logon to enter the password included with your HEDIS Member List and select the files to be uploaded. Once uploaded you will receive a confirmation number to retain for your records. OR 2. Send a secure fax to OR 3. Mail to us via the U.S. Postal Service to: Anthem, Inc., 66 E. Wadsworth Park Drive, Suite 110H, Draper, UT Please contact your Anthem network manager to let him or her know if you have a specific person in your organization that we should contact for HEDIS medical records. Federal Employee Program HEDIS medical record request requirements Centauri Health Solutions is the contracted vendor to gather member medical records on behalf of the Blue Cross and Blue Shield Federal Employee Program (also called the Federal Employee Program or FEP). Centauri Health will work with you to obtain records via fax, mail, remote electronic medical record (EMR) access, or onsite scanning/emr download (as necessary). We ask that you please promptly comply within five (5) business days of the record requests. If you have any questions, please contact Catherine Carmichael with Blue Cross Blue Shield Federal Employee Program at or Carol Oravec with Centauri at Thank you in advance for your support of HEDIS. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). February of 26

13 Virginia in-network laboratory update regarding Exact Sciences Laboratories Effective October 28, 2017, Exact Sciences Laboratories, LLC is no longer an in-network laboratory for Anthem Blue Cross and Blue Shield in Virginia. Providers should use in-network laboratory providers, such as LabCorp and Quest Diagnostics, for non-invasive colon cancer screening testing for their Anthem patients beginning October 28, Using an in-network laboratory helps patients maximize their laboratory benefits and minimize their out-of-pocket expenses. If you have specific questions regarding non-invasive colon cancer screening testing performed by in-network labs, please see the contact information below. For a complete listing of in-network laboratory providers, use the Find A Doctor tool on our website at LabCorp: LABCORP ( ) or Quest Diagnostics: MY-QUEST ( ) or IMPORTANT NOTE: Providers should continue to use LabCorp for all laboratory services for members enrolled in Anthem HealthKeepers and Anthem HealthKeepers Plus (Medicaid) health plans. Important information about filing home infusion therapy claims To assist in the accurate and timely processing of home infusion therapy (HIT) claims, it is important for HIT providers to file professional HIT claims to the correct Blue Plan. The following information applies to professional HIT claims for all Bluebranded health plans. Professional claims from a HIT provider should be filed to the Blue Plan where the service was rendered (which may be the member s home or equivalent setting). Even if a HIT provider employs traveling health care professionals or renders services in multiple states, professional HIT claims should submitted to the state Blue Plan where the service was rendered. The following example illustrates appropriate filing of a professional HIT claim: HIT Provider A regularly renders services in multiple states and service areas. Provider A renders services to a member using a traveling home health nurse in the member s home. The member s home is located in the service area for Blue Plan XYZ. Provider A submits the professional HIT claim to Blue Plan XYZ, even though Provider A may be located in a different service area than the member s residence. Please note, professional HIT claims that are not submitted to the Blue Plan where the service was rendered may be denied and require the provider to resubmit the claim to the correct Blue Plan. February of 26

14 Update regarding Shingrix shingles vaccine Anthem Blue Cross and Blue Shield and HealthKeepers, Inc. are updating our Affordable Care Act (ACA) preventive care coverage to include Shingrix, the new zoster (shingles) vaccine, based on a new recommendation by the Advisory Committee on Immunization Practices (ACIP). This coverage update is effective for dates of service on and after January 1, 2018, for all Anthem s PAR/PPO and Anthem HealthKeepers (non-medicaid) health plans including plans that are ACA-compliant. Shingrix will pay at 100% with no member cost share for members who use an in-network provider. Providers should continue to verify eligibility and benefits for all health plans prior to rendering services. Shingrix is recommended for the prevention of herpes zoster and related complications for immunocompetent adults age 50 years and older as well as those who may have previously received Zoster Vaccine Live (Zostavax). Misrouted protected health information (PHI) As a reminder, providers and facilities are required to review all member information received from Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. to help ensure no misrouted PHI is included. Misrouted PHI includes information about members that a provider or facility is not currently treating. PHI can be misrouted to providers and facilities by mail, fax or . Providers and facilities are required to immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are providers or facilities permitted to misuse or re-disclose misrouted PHI. If providers or facilities cannot destroy or safeguard misrouted PHI, providers and facilities must contact Anthem s provider services area to report receipt of misrouted PHI. Clinical practice and preventive health guidelines available on the Web As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines that are available to providers on our website. The guidelines which are used for our quality programs are based on reasonable medical evidence. In addition, the guidelines are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. All guidelines are reviewed annually and updated as needed. The current guidelines are available on our website. To access the guidelines, go to anthem.com. Click Menu at the top of the screen to display options and select Providers. From the Provider Page, click on Find Resources for Your State and select Virginia from the listing of states. On the Virginia Provider Home Page, select the Health & Wellness tab and then the Practice Guidelines link. February of 26

15 Facility footnotes Anthem to partner with Advance Health to help prevent member re-admissions Across our membership, Anthem Blue Cross and Blue Shield is working to find solutions to prevent costly re-admissions after in-patient discharge. Commercial individual members have significant chronicity and complexity, complicated by long-standing lack of access to care (particularly in states that did not expand Medicaid). These members often rely on the use of the emergency room for episodic acute care rather than ongoing health management and consistent preventive care. The goal of the re-admission prevention program is to reduce unnecessary readmissions in the individual and small/large group commercial populations. The current re-admission rate is between 9% to11% across these membership groups. After discussions with several vendors, Anthem chose to work with Advance Health a company with a proven record for successful re-admission prevention. Advance Health will use its network of Nurse Practitioners to outreach and perform an in-home visit, with 85% of visits occurring within the first 72 hours after the member is discharged from inpatient care. Advance Health will conduct a single visit, post-discharge which shall include: medicine review, diagnosis and treatment plan, communication and coordination with the member s primary physician or specialist for new orders or needs, caregiver training, among others. These assessments are designed to intervene in the sensitive timeframe where a gap occurs in 45% of re-admissions in the 0-7 days between discharge and follow-up outpatient care. For specific questions or comments, please reach out to your Anthem network manager. Health care reform (including health insurance exchange) Refer to anthem.com for information about health care reform and the exchange Visit anthem.com for updates, as we continue to post information on our dedicated web pages regarding health care reform and the health plans HealthKeepers Inc. is offering on and off the exchange. Click either of these Web pages Health Care Reform or Health Insurance Exchange for more information, and refer back to these pages often. February of 26

16 ebusiness New functionality Easily update provider demographics with Anthem s online Provider Maintenance Form Network providers who participate with Anthem Blue Cross and Blue Shield (Anthem) in Virginia and our affiliate HealthKeepers, Inc. should now submit changes to their practice profiles using our new online Provider Maintenance Form. Online update options include: Adding an address location Name changes Tax ID changes Provider leaving a group or a single location, phone/fax numbers, closing a practice location, etc. Visit anthem.com for new online Provider Maintenance Form The new online form can be found on > from the Menu option, select Providers. From the Provider Page, click on Find Resources for Your State and select Virginia from the listing of states>on the Provider Home Page> select the Answers@Anthem tab>provider Forms> Provider Maintenance Form. In addition, the Provider Maintenance Form can be found on the Availity Web Portal by selecting Virginia> Payer Spaces and then select the Anthem Blue Cross Blue Shield tile> Resources tab >Provider Maintenance Form. Important information about updating your practice profile Change requests should be submitted using the online Provider Maintenance Form Submit change requests online. No need to print, complete and mail, fax or demographic updates You will receive an auto-reply , acknowledging receipt of your request and another when your submission has been processed For change(s) that require submission of an updated IRS Form W-9 or other documentation, attach the documents to the form online prior to submitting Change requests should be submitted with advance notice Please note that contractual agreement guidelines may supersede effective date of request February of 26

17 You can check your directory listing on Anthem s Find a Doctor tool. Consumers, members, brokers and providers use Anthem s Find a Doctor tool to identify in-network physicians and other health care providers supporting our member health plans. To help ensure Anthem has the most current and accurate information in our provider directory, please take a moment to access the Find A Doctor tool and review how you and your practice are being displayed. To report discrepancies, please make corrections by completing the Provider Maintenance Form online. Receive notifications via our Network eupdate Our provider newsletter, Network Update, is our primary source for providing important information to health care providers and professionals. Network Update is published bi-monthly and is posted to our website on the Virginia provider section of anthem.com for easy 24/7 access. Note that in addition to this newsletter and our website, we also use our service Network eupdate to communicate new information. If you are not yet signed up to receive Network eupdates, we encourage you to enroll now so you ll be sure to receive all information we will be sending about the Health Insurance Marketplace or commonly called exchanges and other pertinent topics. Reminder notifications sent via When you sign up, you ll not only receive an reminder for each newsletter posted online, you ll also be notified of other late breaking news and important information you ll need when providing services and filing claims for our members. It s easy to sign up just select Virginia and access the provider home page. There, you ll find a link to register for our Network eupdate. February of 26

18 Drug/pharmacy update Anthem expands specialty pharmacy prior authorization list Effective for dates of service on and after May 1, 2018, the following specialty pharmacy codes from new or current coverage or clinical UM guidelines will be included in our existing pre-service review process. The following clinical guidelines or coverage guidelines will be effective May 1, Pre-service clinical review of the following specialty pharmacy drugs will be required through the Oncology Program administered by AIM Specialty Health (AIM), a separate company administering the program on behalf of Anthem. Coverage or Clinical Guideline Code Drug Comments DRUG J9203 Mylotarg New Drug Guideline DRUG J3590, J9999 Aliqopa New Drug Guideline Pre-service clinical review of the following specialty pharmacy drugs, including site-of-service criteria will be managed by Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. Coverage or Clinical Guideline Code Drug Comments CG-DRUG-78 J7195 Rebinyn New Drug to Existing Guideline CG-DRUG-78 J7178 Fibryna New Drug to Existing Guideline CG-DRUG-61 C9016, J3490 Triptodur New Drug to Existing Guideline February of 26

19 Important update to Anthem s drug lists for members enrolled in Anthem s PAR/PPO and Anthem HealthKeepers health plans Effective with dates of service on and after April 1, 2018, and in accordance with Anthem s Pharmacy and Therapeutic (P&T) process, Anthem and our affiliate HealthKeepers, Inc. update our drug lists for members enrolled in our PAR/PPO and Anthem HealthKeepers health plans. Updates may include changes to drug tiers or the removal of a drug. To help ensure a smooth transition and minimize member costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate. Please note, this update does not apply to the Select Drug List and does not impact Medicare and Anthem HealthKeepers Plus (Medicaid) plans. To view a summary of changes, click here. Pharmacy information available on anthem.com For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit anthem.com/pharmacy information. The drug lists for our PAR, PPO and Anthem HealthKeepers lines of business (including marketplace drug lists) are reviewed, and updates are posted to the website quarterly (the first of the month for January, April, July and October). To locate Marketplace Select Formulary (for Affordable Care Act health plans our members purchase on or off the Health Insurance Marketplace or the exchange) and pharmacy information, go to Customer Support, select Virginia, Download Forms and choose Select Drug List. For State-sponsored Business [Anthem HealthKeepers Plus (Medicaid/FAMIS)], visit SSB Pharmacy Information. Effective January 1, 2018, AllianceRX Walgreens Prime is the new specialty pharmacy program for the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). You can view the 2018 Specialty Drug List or call us at for more information. This drug list is also reviewed and updated quarterly. FEP Pharmacy Policy updates have been added to the FEP Medical Policy Manual and may be accessed at > Pharmacy Benefits. February of 26

20 Medicaid information (Anthem HealthKeepers Plus offered by HealthKeepers, Inc.) Continuity of care period extended for long-term services and supports HealthKeepers, Inc. has elected to extend our continuity of care period for all long-term services and supports (LTSS) providers for Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members for an additional 90 calendar days for each respective region. As such, every Anthem CCC Plus provider will enjoy a total of 180 days from each respective regional implementation date without an authorization requirement. For example, no Anthem CCC Plus providers servicing Tidewater members will require authorization for LTSS through January 31, See updated continuity of care periods below: Tidewater: January 31, 2018 Central: March 2, 2018 Western/Charlottesville: March 31, 2018 Roanoke/Alleghany/Southwest: April 30, 2018 Northern/Winchester: May 31, 2018 Finally, due to this extension period for Anthem CCC Plus members, providers do not need to fax requests to extend authorizations until 30 days prior to the termination of the 180-day period for the respective region. Also, if you already have authorizations in place for this period with HealthKeepers, Inc., this extension does not apply to you. Levoleucovorin calcium, elosulfase alfa, histrelin acetate, idursulfase and fulvestrant to require prior authorization Summary of change Effective April 1, 2018, levoleucovorin calcium, elosulfase alfa, histrelin acetate, idursulfase and fulvestrant will require prior authorization (PA) for Anthem HealthKeepers Plus members. Levoleucovorin calcium, elosulfase alfa, histrelin acetate, idursulfase and fulvestrant will require PA, and all requests must be reviewed by HealthKeepers, Inc. for PA dates of service beginning on or after April 1, Please refer to the provider February of 26

21 self-service tool for detailed authorization requirements at > Precertification > Precertification Lookup Tool. Please note: These drugs may not be covered in all states. Providers must review their specific state for coverage because not all drugs in this update will apply to the state in which you participate. Noncompliance with the new requirements may result in denied claims. PA requirements will be added to the following codes: J0641 Injection, levoleucovorin calcium, 0.5 mg J1322 Injection, elosulfase alfa, 1mg J1675 Injection, histrelin acetate, 10 mcg J1743 Injection, idursulfase, 1 mg J9395 Injection, fulvestrant, 25 mg Please use one of the following methods to request PA: Phone: Fax: Web: Federal and state law, as well as state contract language (this includes definitions and specific contract provisions/exclusions) take precedence over these PA rules and must be considered first when determining coverage. Need assistance? If you have questions about this communication or need assistance with any other item, call Provider Services at Physician office lab list update effective February 5 for Anthem HealthKeepers Plus members Earlier in this edition of the Network Update on page 11, we share information about the upcoming change effective February 5, 2018, for the physician office lab list. Again, the physician office lab (POL) lists include one list for primary care providers (PCPs) and one for specialist care providers (SCPs). These lists include services for office-based tests for Anthem HealthKeepers Plus members as well. Please see page 11 of this edition for details. February of 26

22 Coverage Guidelines update On November 15, 2017, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to Anthem HealthKeepers Plus members. These guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the below listing. We made these Coverage Guidelines publicly available on our website on the effective date listed below. Visit to search for specific guidelines. Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Coverage Guideline effective date Guideline number Guideline title Revised or new? 9/27/17 DRUG Inotuzumab ozogamicin (Besponsa ) New 9/27/17 MED Tisagenlecleucel (Kymriah ) New 9/27/17 DRUG Tocilizumab (Actemra ) Revised Clinical Utilization Management Guidelines update On November 15, 2017, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines applicable to Anthem HealthKeepers Plus members. These guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the below listing. The Clinical UM Guidelines on this list represent those adopted by the Medical Operations Committee for the Government Business Division on October 19, We made these guidelines publicly available on the Coverage Guidelines and Clinical UM Guidelines page on the effective date listed below. Visit to search for specific guidelines. Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Effective date Clinical UM Revised Clinical UM Guideline title Guideline number or new? 9/27/17 CG-LAB-11 Screening for Vitamin D Deficiency in Average Risk New Individuals 9/27/17 CG-MED-59 Upper Gastrointestinal Endoscopy for Diagnosis, New Screening or Surveillance 9/27/17 CG-SURG-59 Vena Cava Filter New 9/27/17 CG-DME-31 Wheeled Mobility Devices: Wheelchairs Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) Revised February of 26

23 Data collection for 2017 to 2018 Foster Care Focused Study The Department of Medical Assistance Services (DMAS) is preparing to collect data for the 2017 to 2018 Foster Care Focused Study and has contracted with Health Services Advisory Group to conduct this study as an optional External Quality Review activity. Beginning in January 2018, M. Davis and Company (MDAC) will contact selected Anthem HealthKeepers Plus providers to collect medical records. It is critical to the success of the study that providers respond with the requested information as soon as possible. DMAS has the legal authority to request records of Medicaid, FAMIS and FAMIS Plus recipients as delineated in The Code of Virginia, the Federal Register, the Medicaid Provider Participation Agreement and the Medicaid Physician Manual. Obtaining a signed release form from the member is not necessary, and reimbursement to the provider or to vendors photocopying medical records is not offered. If you receive a medical record request, you must send your charts to MDAC prior to the April 6, 2018, deadline. Please do not send charts to MDAC after this date as those records will not be included in the study. If you have any questions about the 2017 to 2018 Foster Care Focused Study, please contact DMAS via at MedallionQualityImprovement@dmas.virginia.gov. Thank you for your cooperation toward the success of this project. February of 26

24 Medicare information (Anthem s Medicare Advantage and Medicare Supplement plans) Medical policies and clinical guidelines updated The Anthem Medical Policy and Technology Assessment Committee (MPTAC) approved additional medical policies. These medical policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only. Visit Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements at anthem.com/medicareprovider to review specific policies. Improve member medication regimen Anthem and the Centers for Medicare & Medicaid Services consider medication review and reconciliation a top priority to help ensure members take their medications safely. Our pharmacists use medication review and reconciliation to help members understand what medications they are taking, why they are taking them, how they should be taking their medication and to answer any questions or concerns they have about their medication regimen. Anthem may contact you to discuss members medications as part of either the Medication Therapy Management (MTM) or the Medication Reconciliation Post Discharge (MRPD) programs: The MTM program starts with a letter welcoming members to participate in a private medication review with one of our pharmacists over the phone. This free service gives members the opportunity to ask questions about the medicines they are taking and to review prescription and over-the-counter drugs to prevent drug reactions, and helps members get the most benefit from their medications at the lowest cost. At the end of the discussion, your patient is encouraged to share a written summary of their medication list and any medication-related concerns with you. Medication Reconciliation Post Discharge is a HEDIS and Centers for Medicare & Medicaid star ratings measure for The MRPD program helps members with their medications after they have been discharged from an inpatient hospital stay. Anthem pharmacists will work with you and the member to identify and correct any medication related problems to reduce the risk of readmission. To complete this measure per HEDIS specifications, it is necessary to include the appropriate documentation in the member s chart. The medication reconciliation post-discharge HEDIS measure medical record documentation must include the following: 1. Date medication reconciliation was performed 2. Notation stating that current medication and discharge medication lists were reviewed February of 26

25 3. Signature of prescribing care provider, clinical pharmacist or registered nurse who performed medication reconciliation 4. If medications were provided at discharge, please include the member s next steps such as: a. Take new medications as prescribed. b. Discontinue all discharge medications. 5. Notation if no medications were prescribed at discharge Keep up with Medicare news Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including: Prior authorization requirements for injectable drugs: Brineura, Tremfya and Zinplava Prior authorization requirements for Part B drugs: Rebinyn, Fibryna and Hemlibra 70224MUPENMUB 12/22/2017 Bulletin board First 2018 Anthem webinar scheduled for April 19 Anthem s 2018 provider education webinars get under way in April. Designed for our network-participating providers, the webinars address Anthem business updates and billing guidelines that impact your business interactions with us. For your convenience, we offer these informative, hourly sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the first webinar is: Thursday, April19, 2018, from 10:30 a.m. to 11:30 a.m. ET Please take time to register today for the webinar using the registration form on the next page. February of 26

26 Anthem webinar and registration form Due to subject matter content, these webinars will be made available only to professional providers, defined as Anthem network-participating providers and their staffs who submit claims using the 837P or CMS-1500 format, and who have the following medical credentials: MD, DO, DC, DPM, LCSW, LCP, LPC, LFMT, CNS, CNM, plus DDS, DMD & OD (nonroutine medical services only). WEBINAR ATTENDEES MUST HAVE INTERNET AND SIMULTANEOUS TELEPHONE ACCESS. THE BELOW INFORMATION IS REQUIRED IN ORDER TO RECEIVE OUR WEBINAR CONNECTIVITY INFORMATION: PROVIDER REQUEST FOR ANTHEM WEBINAR INVITATION Provider/Practice Name: Medical Specialty: Your Provider Type(s) (circle): MD, DO, DC, DPM, LCSW, LCP, LPC, LFMT, CNS, CNM, DDS, OD, or OTHER: Location of main office in Virginia: NPI #: Tax ID #: * Attendee Name: * Address: Phone #: Fax #: IMPORTANT NOTE: If multiple attendees will be viewing the webinar and listening together as a group via a single computer and phone line, we only need one address. However, if multiple attendees will each be viewing and listening from their own work stations, we must have SEPARATE registration forms with each individual s address. Please mark for 2018 WEBINAR if you wish to attend: Thursday, April 19 (10:30 a.m.-11:30 a.m. ET) Anthem Updates PLEASE COMPLETE FORM AND FAX IT TO (804) Anthem Health Plans of Virginia, Inc. trades as Anthem Blue 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 of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. February of 26