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October 2016

In this issue Page

NH16006 NHNL1016

Health care reform update Health care reform updates on anthem.com 2

Administrative and policy update Sign-up today for Network eUPDATE – it’s free! 2 Update to claims processing edits and reimbursement policies 3 AOPS retirement coming: transition to Availity Web Portal now 4 Enhancements to AIM clinical appropriateness guidelines for 5

advanced imaging effective February 18, 2017 Reminder: NOC oncology and biologic drugs added to pre-service 5

clinical review recommendation list effective November 1, 2016 Pre-service clinical review changes for specialty pharmacy drugs 6

effective January 1, 2017 Important information about habilitative and rehabilitative services 7 Reminder - Specialty pharmacy level of care clinical reviews begins 7

October 1, 2016 LiveHealth Online Psychology - easy access to therapists and 9

psychologists from the comfort of home Enhanced Personal Health Care: referral providers benefit by 9

improving quality and controlling costs

Medicare update Medicare Supplement members to receive new ID cards November 1 9 Complete Medicare Advantage AIM OptiNet® registration for X-ray, 9

ultrasound or high-tech imaging services Please follow CMS guidelines for Medicare Advantage Part B 10

immunizations claims filing Use JW modifier when submitting claims for discarded drugs 10 Medicare billing requirements for TAVR and TMVR 11 Anthem to conduct periodic audits to ensure CMS requirements met 11 Help ensure Medicare Part D members receive comprehensive 11

medication review Anthem follows CMS guidelines for DME customization 11 Self-administered drugs should not be billed to MA members 12 Precertification requirements updated for 2017 12 Keep up with Medicare news 12

anthem.com Important phone numbers

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In this issue (continued) Page

Behavioral health update Ambulatory detoxification, H0014, added to physician fee 13

schedules effective October 1, 2016 LiveHealth Online Psychology -easy access to therapists and 13

psychologists from the comfort of home

Quality programs update Communicating the importance of childhood vaccinations 13 Clinical practice and preventive health guidelines on anthem.com 14 Care & Cost Finder powered by Castlight to be launched 14 HEDIS Spotlight: Comprehensive Diabetes Care 14 Anthem Whole Health ConnectionSM 15

Pharmacy update Pharmacy information available on anthem.com 16

Medical policy update Medical policy updates available on anthem.com 17

Clinical guidelines update Clinical guideline updates available on anthem.com 21

Health care reform update Health care reform updates on anthem.com Please be sure to check the Health Care Reform Updates and Notifications and Information about Health Insurance Exchanges sections of our website regularly for the latest updates on health care reform and Health Insurance Exchanges.

Administrative and policy update Sign-up today for Network eUPDATE – it’s free! Connecting with us and staying informed is easy, faster and convenient with our Network eUPDATEs. Network eUPDATE is our web tool for sharing vital information with you. It features short topic summaries on late breaking news that impacts providers:

Important website updates System changes Medical policy updates Claims and billing updates

……and much more

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Registration is fast and easy. There is no limit to the number of subscribers who can register for Network eUPDATEs, so you can submit as many email addresses as you like.

Update to claims processing edits and reimbursement policies On October 1, 2016, we will be updating our Anthem Online Provider Services (AOPS) website with the following new and/or revised reimbursement policies. The updates below identify if the article pertains to professional or facility provider billing. Anesthesia Services – professional In our policy dated September 1, 2016, we removed the reference to modifier AD. This modifier is considered informational only. Assistant Surgeon Coding and Assistant Surgeon Services – professional On August 1, 2016, we updated our Assistant Surgery Services Coding Chart effective January 1, 2016, to include the Current Procedural Terminology (CPT®) code range 12001-13151. These codes were inadvertently omitted from the original January 1, 2016 coding list. On September 1, 2016, the Assistant Surgery Services Coding Chart was updated to add new CPT codes effective July 1, 2016--0437T, 0438T, 0440T, 0441T, 0442T, 0444T and 0445T--to the existing codes that are not eligible for reimbursement for assistant at surgery services reported with modifiers 80, 81, 82, or AS. We also updated the effective date on the Assistant Surgeon policy to July 1, 2016 to align with our updated Assistant Surgery Services Coding Chart. Bundled Services and Modifiers 59 and XE, XP, XS, & XU – professional CPT describes code 95957 as digital analysis of electroencephalogram (EEG) (e.g., for epileptic spike analysis). When the service is simply the paperless acquisition and recording of an EEG via computer-based instrumentation, our position is that providers should not report 95957 with EEG testing. Therefore, beginning with dates of service on or after January 1, 2017, code 95957 will be considered incidental to EEG testing codes 95951, 95953, 95954, or 95956 and will not be eligible for separate reimbursement when reported by the same provider on the same date of service. Modifiers will not override the edit. In addition, we consider 95957 incidental to EEG testing codes 95950, 95951, 95953, 95954, 95955 and 95956 when reported on subsequent dates of service. Therefore, beginning with dates of service on or after January 1, 2017, digital EEG analysis procedure code 95957 will not be eligible for reimbursement when reported subsequent to the date of service for EEG testing codes 95950, 95951, 95953, 95954, 95955 and 95956. Modifiers will not override the edit. Taking guidance from CMS, we consider imaging guidance to be incidental to spinal injections. Therefore, beginning with dates of service on or after January 1, 2017, imaging guidance codes 76942, 77003, 77012, and 77021 will not be eligible for separate reimbursement when reported with spinal injection codes 62310-62311 (injection(s), of diagnostic or therapeutic substance(s)) and 62318-62319 (injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s)). Modifiers will not override these edits. In addition, ClaimsXten currently denies imaging guidance code 77002 as mutually exclusive to spinal injection codes 62310-62311 and 62318-62319 but allows modifier override. Beginning with dates of service on or after January 1, 2017, we will no longer allow modifiers to override this denial. Modifiers 59 and XE, XP, XS, & XU – professional Our current bundled services edit denies CPT code 29822 (arthroscopy, shoulder, surgical; debridement, limited) when reported 29806 (arthroscopy, shoulder, surgical; capsulorrhaphy), 29807 (arthroscopy, shoulder, surgical; repair of slap

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lesion), 29821 (arthroscopy, shoulder, surgical; synovectomy, complete), and 29823 (arthroscopy, shoulder, surgical; debridement, extensive) when performed on the same shoulder. We consider this to be correct coding; therefore, beginning with claims processed on or after November 21, 2016, we will update our current edit so that modifiers 59, XE, XP, XS, and XU will not override the denial of 29822 when performed on the same shoulder as arthroscopy surgical codes 29806, 29807, 29821, and 29823. Place of Service – professional As documented in our policy, there are CPT and HCPCS codes that are specific to services provided in the home setting. When such services are provided in a place of service other than the patient’s home, the service is not eligible for reimbursement. Therefore, for claims processed on or after August 22, 2016, our claims editing system, ClaimsXtenTM, was updated to deny those codes that include the home setting in their description when such codes are reported with a place of service other than a home setting (e.g., when 99504 (home visit for mechanical ventilation care) is reported with an in-hospital place of service (21), the service will not be eligible for reimbursement). In addition, as documented in our policy, we consider hearing screening services 92586, 92558, and 92587 to be included under a facility’s reimbursement and not eligible for separate reimbursement. For claims processed on or after August 22, 2016, we updated our claims editing system to deny these hearing screening codes when submitted by a professional provider in an outpatient hospital setting (19 (off campus outpatient hospital) and 22 (on campus outpatient hospital)). Routine Obstetric Services – professional We consider that evaluation and management (E/M) visits are included in the reimbursement for global obstetrical care when reported with a routine maternity diagnosis code. Beginning with dates of service on or after January 1, 2017, we are updating our policy to include ICD-10 code Z36 (encounter for antenatal screening of mother) to our list of diagnoses we consider to be routine maternity diagnoses. In addition, because ICD-10 diagnosis codes were effective for dates of service on or after October 1, 2015, we are removing the ICD-9 codes that are currently listed in our policy. See our policy for further information. Annual reviews – professional The following professional reimbursement policies received an annual review and include minor language revisions; however, there were no changes to the policy position or criteria:

Documentation and Reporting Guidelines for Evaluation and Management Global Surgery Health and Behavior Assessment Intervention Moderate Sedation Overhead Expenses for Office Based Surgical and Diagnostic Testing Standby Services

Anthem Online Provider Services (AOPS) retirement coming: transition to Availity Web Portal now We continue to transition provider tools to the Availity Web Portal, featuring ease of use and broad functionality. Remittance Inquiry and the Professional Fee Schedule Inquiry tool are now available under Payer Spaces on the Availity Web Portal with the appropriate access. Therefore, we are targeting February 2017 to retire AOPS. All provider tools and information will then be available exclusively via the Availity Web Portal. After this date, web portal access to Eligibility, Benefits, Claim Status Inquiry, Remittance Inquiry, Professional Fee Schedule and important proprietary information will be available exclusively through

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Availity, our multi-payer portal solution. Note: This change does not affect the anthem.com public website or electronic transactions submitted via our Enterprise EDI Gateway; you may continue to submit all X12 transactions through your current EDI transmission channels. See something you can’t access, but you need it? Contact your organization’s administrator to request the role you need. To determine who your organization’s administrator is, select “Who controls my access” from your account drop down box located in the upper right corner of the Availity Web Portal’s top menu bar. Do you have all of your tax IDs registered on the Availity Web Portal? If not, now is the time to register. Your organization’s administrator can add additional tax IDs by selecting Maintain Organization from the Admin Dashboard. If your organization is not registered for Availity: Have your organization’s designated administrator go to www.availity.com and select Register. Complete the online registration wizard. The administrator will receive an e-mail from Availity with a temporary password and next steps. Free Training Once you log into the secure portal, you'll have access to many resources to help jumpstart your learning, including free live training, on-demand training, frequently asked questions, and comprehensive help topics. To view the current training resources, access the Help menu on the Availity Web Portal.

Enhancements to AIM clinical appropriateness guidelines for advanced imaging effective February 18, 2017 On February 18, 2017, the following changes to AIM Clinical Appropriateness Guidelines for Radiology and Cardiology will become effective: Oncologic imaging (CT, MRI and PET)

Enhanced criteria around surveillance following completion of therapy for colorectal cancer Updated criteria for appropriate use of imaging studies in the management of prostate cancer and breast cancer New guidelines for appropriate use of multiparametric MRI in the diagnosis of prostate cancer

Breast MRI

Enhanced criteria for appropriateness of MRI in DCIS, atypical ductal hyperplasia, and follow up imaging of BIRADs 3 studies

Abdominal and pelvic imaging (CT and MRI)

Updated criteria for appropriateness of imaging in inflammatory bowel disease Guidelines for follow up of incidental liver lesions utilizing advanced imaging Enhanced criteria for imaging in chronic abdominal pain and nephrolithiasis

Reminder: NOC oncology and biologic drugs to be added to pre-service clinical review recommendation list effective November 1, 2016 This is a reminder that effective November 1, 2016, in partnership with AIM Specialty Health, we will expand pre-service review to include medical necessity of coverage requests for all not otherwise classified “NOC” oncology and biologic drugs.

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Pre-service clinical review will be based on specific medical policy or clinical guideline when available. In instances where a specific policy or guideline is unavailable, clinical guideline CG-DRUG-01, Off-Label Drug and Approved Orphan Drug Use, will be used for HCPCS codes J9999 and J3590. If the drug is not reviewed pre-service, we will conduct a post-service review based on the same clinical criteria and may request records as part of that review. This pre-service clinical review program will apply to our Commercial, local ASO, National Accounts and Medicare Advantage members. Please contact 800-676-BLUE (2583) to verify any pre-service review recommendations or requirements for BlueCard® business. Ordering physicians may submit a request for services on or after November 1, 2016, to AIM through the AIM ProviderPortalSM (available 24/7 to process orders in real-time), through the Availity Web Portal or by calling the AIM call center at 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m.

Pre-service clinical review changes for specialty pharmacy drugs effective January 1, 2017 We will be expanding the list of specialty pharmacy drugs that are a part of the pre-service clinical review process. Listed below are specialty pharmacy codes from new or current medical policies and/ or clinical UM guidelines that will be added to our existing pre-service review process effective January 1, 2017. Pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM®), a separate company administering the program on behalf of Anthem, as applicable. Clinical UM Guideline or Medical Policy Drug Name Drug Code(s)

CG-DRUG-43: Natalizumab (Tysabri®) Natalizumab (Tysabri) J2323

CG-DRUG-49: Doxorubicin Hydrochloride Liposome Injection Lipodox Q2049

CG-DRUG-49: Doxorubicin Hydrochloride Liposome Injection Doxil Q2050

CG-DRUG-50: Paclitaxel, protein-bound (Abraxane®) Abraxane J9264

CG-DRUG-51: Romidepsin (Istodax®) Isotodax J9315

DRUG.00087 Strensiq J3490

DRUG.00088 Tecentriq C9483, J3590, J9999

DRUG.00089 Zinbryta J3490, J3590

DRUG.00091 Naltrexone J3490, J7999

DRUG.00092 Probuphine J3490

DRUG.00093 Kanuma J3490

Ordering physicians can submit a pre-service clinical review request to AIM for these drugs starting January 1, 2017, through one of the following options:

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AIM ProviderPortalSM available 24/7 to process orders in real-time Access AIM’s portal via the Availity Web Portal AIM’s call center - 866-714-1107, 8:00 a.m. – 5:00 p.m.

Requests received by AIM more than two business days after the date of service will not be accepted by AIM. Post service clinical review will be handled by Anthem. These medical policies and/or clinical UM guidelines can be accessed at anthem.com > Providers > New Hampshire > Medical Policy, Clinical UM Guidelines, Pre-Cert Requirements > Medical Policies and Clinical UM Guidelines (for Local Plan Members). Recent changes to Medical Policies can be found under “Recent Updates”.

Important information about billing habilitative and rehabilitative services In compliance with requirements of the Notice of Benefit and Payment Parameters for 2016 issued pursuant to the Affordable Care Act, we will apply separate and distinct benefit limits for habilitative and rehabilitative services for all Anthem individual and small group On-Exchange and Off-Exchange health plans beginning with dates of service on and after January 1, 2017. This means these plans will no longer have a combined visit limit for habilitative and rehabilitative services. Habilitative services help a person keep, learn, or improve skills and functioning for daily living which have not (but normally would have) developed. Rehabilitative services help a person keep, restore, or improve skills and functioning for daily living which have been lost or impaired after an illness or injury, such as a car accident or stroke. Beginning with dates of service on and after January 1, 2017, the appropriate use of the modifier SZ is necessary when billing habilitative services to us for members seeking care in an outpatient facility or professional office setting. The SZ modifier was effective in 2014 and distinguishes between habilitative and rehabilitative services. Appropriate use of the modifier will help reduce claims issues and adjustments related to habilitative services. Please review your current coding practices as it relates to the use of modifier SZ and the billing of habilitative and rehabilitative services.

Reminder - Specialty pharmacy level of care clinical reviews begins October 1, 2016 The June 2016 and August 2016 editions of Network Update shared information about the expansion of the Specialty Pharmacy program to include level of care clinical review for specialty pharmacy infusions and injections. In this edition of Network Update, we are sharing these details again, as a reminder and for easy reference. We are committed to the Institute for Healthcare Improvement (IHI) Triple Aim --- a framework developed by IHI that describes an approach to optimizing health system performance using the following dimensions:

Improving the patient experience of care (including quality and satisfaction); Improving the health of populations; and Reducing the per capita cost of health care.

We recognize that most members prefer to receive their infusion or injection therapy in the physician’s office, ambulatory infusion suite (AIS) or at home by a licensed home infusion therapy (HIT) provider. This is more convenient for the member, may result in lower member financial responsibility and, in many cases, is a clinically appropriate setting.

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There may be clinical circumstances that require a member to receive infusions or injections in a hospital outpatient facility. Therefore, beginning with dates of service on and after October 1, 2016, we will expand the Specialty Pharmacy program to include a review of the requested level of care. A new clinical guideline Level of Care: Specialty Pharmaceuticals CG-DRUG-47 applies to the review process beginning with dates of service on and after October 1, 2016. The expanded program continues to be administered by AIM Specialty Health (AIM), a separate company. Based on the information you provide, AIM reviews the drug for both clinical appropriateness and the level of care against health plan clinical criteria. The level of care review does not apply to requests for the review of drugs prescribed for oncology, hemophilia, or end stage renal disease drug indications. Physician offices that currently administer specialty drugs in the office setting were not impacted by this change. Providers will continue to request authorization for specialty drugs in one of several ways:

Access AIM’s 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: 866-714-1107

For dates of service on and after October 1, 2016: When providers select a hospital-based outpatient facility as the level of care, a list of alternate locations, such as ambulatory infusion suites and home infusion providers, is made available. Medical specialty pharmacy providers are also listed as an alternate option to supply the infusion medication to physician offices who can administer it to the member. (See below to learn how to register as an alternate level of care location.) If an alternate level of care is not selected, providers are prompted to indicate the reason hospital-based level of care is medically necessary. If a request for hospital-based level of care does not meet medical necessity criteria upon review by a physician reviewer, the request will not be approved. We encourage you to discuss with members the alternate level of care options, such as physician office, infusion center or home infusion therapy. The expanded program applies to local Anthem members who have specialty pharmacy services medically managed by AIM Specialty Health. The expanded program does not apply to the following plans: BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, and Federal Employee Program (FEP). For more information, including a list of drugs that are reviewed for level of care, go to www.aimprovider.com/specialtyrx. Register as an alternate level of care location Beginning October 23, 2016, ambulatory infusion suites, home infusion providers, and other eligible provider locations can visit www.aimprovider.com/specialtyrx/optinet to register with AIM to be included as an alternate location for the administration of specialty drugs. Registration will require only three pieces of information—your practice’s place of service type (e.g., ambulatory infusion suite), the drugs your practice administers, and your coverage area. Additionally, providers can access an interactive training module and other helpful registration materials on the site.

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LiveHealth Online Psychology - easy access to therapists and psychologists from the comfort of home Launched in January 2016, LiveHealth Online Psychology is a convenient and easy way for members to connect one on one with a behavioral health provider using their smartphone, tablet or computer. Through two-way video chat, members can interact with a therapist or psychologist, day or night, by appointment. Appointments are available within 4 days or less and the cost is the same as a regular in-person therapy office visit. The therapists available on LiveHealth Online Psychology can treat issues such as anxiety, depression, stress, grief and relationship issues. For new users, it’s as simple as signing up with a name and email address. Originally available to adults, LiveHealth Online Psychology also launched its Teen edition in July, accessible by 10 to 17 year olds. To learn more, visit livehealthonline.com/psychology or call 844-784-8409.

Enhanced Personal Health Care: Referral providers benefit by improving quality and controlling costs A key goal of the Enhanced Personal Health Care Program is to improve quality while controlling health care costs. One of the ways this is done is by giving primary care physicians (PCPs) in the Program quality and cost information about the health care providers (the referral providers) to which the PCPs refer their attributed members. If referral providers are higher quality and/or lower cost, this component of the Program should result in their getting more referrals from PCPs. The converse should be true if referral providers are lower quality and/or higher cost. We will share data on which we relied in making these evaluations upon request, and will discuss it with referral providers including any opportunities for improvement. Any such requests should be directed to nhephc@anthem.com.

Medicare update Medicare Supplement members to receive new ID cards November 1 All Anthem Medicare Supplement Individual members will receive new member ID cards beginning November 1, 2016. The new ID cards will have both a new member ID number as well as a new group ID number. Please obtain a copy of the new member ID cards to file claims for dates of service November 1, 2016 and beyond. Medicare will be notified of these changes for Anthem Medicare crossover claim purposes. If you need to submit a claim that is not reflected as a Medicare crossover claim, please use the correct member ID number beginning November 1, 2016. Please ask our members to present their most current ID cards each time they receive services – especially on or after November 1. This helps ensure appropriate claims routing and processing. Provider offices should carefully review member ID numbers when filing claims. Further information can be found in the spotlight section of the anthem.com at the Answers@Anthem tab at the top of the provider home page.

Complete your Medicare Advantage AIM OptiNet® registration for X-ray, ultrasound or high-tech imaging services All participating providers who provide imaging services must complete registration for AIM’s online registration tool, OptiNet. OptiNet will collect modality-specific data from providers who render X-ray, ultrasound (abdominal/retroperitoneum, gynecological and obstetrical services only at this time), magnetic resonance (MR), computed tomography (CT), nuclear

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medicine (NUC), positron emission tomography (PET) and echocardiograph imaging services. Areas of assessment include facility qualifications, technician and physician qualifications, accreditation, equipment and technical registration. These data will be used to calculate site scores for providers who render imaging services for our individual Medicare Advantage members. All participating providers who provide imaging services, including x-rays and ultrasounds as noted above, must complete the registration. Providers who do not register, who have a score of less than 76 or who do not complete the survey by January 1, 2017 will receive a line-item denial for the technical component of the outpatient diagnostic imaging service only. Facilities billing on a UB-04 will be excluded form line item denials at this time. Learn more: Attend a webinar We continue to offer webinars to help providers complete their OptiNet surveys. Learn how to:

Access the OptiNet Assessment Copy previously completed OptiNet Assessments to your Anthem Medicare Advantage account Complete a new AIM OptiNet registration Interpret and improve your site score

Check Important Medicare Advantage Updates at anthem.com/medicareprovider for additional information, including webinar information.

Please follow CMS guidelines for Medicare Advantage Part B immunizations claims filing We follow the Centers for Medicare & Medicaid Services’ (CMS) Medicare Part B Immunization Billing guidelines. Please use the following forms when filing flu, pneumonia or Hepatitis B claims for Anthem individual and group-sponsored Medicare Advantage members.

Professional claims should be filed on the CMS 1500 form with the appropriate Current Procedural Terminology code and/or Healthcare Common Procedure Coding System (HCPCS) code for the vaccine and administration.

Institutional claims should be filed on the UB04 form with the appropriate revenue codes – Revenue Codes (except Rural Health Clinics and Federally Qualified Health Centers):

0636 – vaccine (and CPT or HCPCS code) 0771 – administration (and HCPCS code)

– Rural Health Clinics and Federally Qualified Health Centers – 052X revenue code series

Please refer to page three of the Medicare Part B Immunization Billing Guide for specifics on institutional billing.

Use JW modifier when submitting claims for discarded drugs Effective January 1, 2017, we will follow CMS’ requirement for contracted and non-contracted providers to:

Use the JW modifier for claims with unused drugs or biologicals from single-use vials or single- use packages that are appropriately discarded (except those provided under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals)

Document the discarded drug or biological in the patient's medical record when submitting claims with unused Part B drugs or biologicals from single use-vials or single-use packages that are appropriately discarded.

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Medicare billing requirements for TAVR and TMVR When an individual or group-sponsored Medicare Advantage (MA) plan participant receives inpatient transcatheter aortic valve replacement (TAVR) or inpatient transcatheter mitral valve replacement (TMVR) surgery, the MA plan is responsible for paying the claim. All other clinical trial related services to Medicare Advantage members must continue to be submitted to Original Medicare for processing. Coding information and additional details can be found at www.anthem.com/medicareprovider under Important Medicare Advantage Updates.

Anthem to conduct periodic audits to ensure CMS requirements are met CMS requires providers to notify every Medicare beneficiary (including Medicare Advantage members) of their discharge appeal rights using the Notice of Medicare Non-Coverage (NOMNC) for skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities, and the Important Message from Medicare About Your Rights (IM) for inpatient hospitals. Providers must obtain the signature of the beneficiary or representative to indicate that the beneficiary/representative received and understood the notice. To help providers meet CMS requirements, we periodically conduct IM and NOMNC audits to proactively identify opportunities for improvement. We make recommendations and work with providers to improve processes and compliance with CMS requirements. Additional details can be found at www.anthem.com/medicareprovider under Important Medicare Advantage Updates.

Help ensure Medicare Part D members receive a comprehensive medication review CMS requires that plans with Medicare Part D benefits offer a comprehensive medication review (CMR) as part of the Medication Therapy Management (MTM) program. A CMR is offered to members who have three or more chronic diseases and who are receiving eight or more maintenance medications. We will contact our qualifying individual and group-sponsored Medicare Part D members to complete the interactive consultation. The CMR consists of a consultation followed by a written medication summary to help educate and support provider recommendations for medication adherence. Please ask these members if they have received a letter or postcard inviting them to participate in a Medication Review. Check Important Medicare Advantage Updates at anthem.com/medicareprovider for additional information.

Anthem follows CMS guidelines for DME customization Our Medicare Advantage programs follow the Centers for Medicare & Medicaid Services (CMS) regulations and guidelines for durable medical equipment (DME). CMS has a high threshold for what it considers a reimbursable customized DME item. We have noticed an increase in authorization requests for customized items, including wheelchairs, and would like to provide this reminder. Items that are measured, assembled, fitted or adapted in consideration of a patient’s body size, weight, disability, period of need, or intended use (i.e., custom fitted items) or have been assembled by a supplier or ordered from a manufacturer who makes available customized features, modification, or components for wheelchairs that are intended for an individual patient’s use in accordance with instructions from the patient’s physician do not meet the definition of customized items. These items are not uniquely constructed or substantially modified and can be grouped with other items for pricing purposes. To learn more please see IOM CMS Publication, 100-04, Chapter 20, Section 30.3.

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Outpatient billing departments and practitioners -- self-administered drugs should not be billed to MA members In accordance with Centers for Medicare & Medicaid Services regulations, Anthem Medicare Advantage plans pay for drugs that usually are considered self-administered by the patient when such drugs are an integral component of a covered procedure or are directly related to a covered procedure. In these situations, the hospital may NOT bill the member for these types of drugs. The drugs, whether coded or uncoded with their charges, must be reported under the appropriate revenue code (cost center under which the hospital accumulates the costs for the drugs). In situations where the member needs a prescription for medication to be used at home following the outpatient treatment, physicians and practitioners are encouraged to give written or electronic prescriptions to members rather than supplying the drug from the hospital pharmacy. Additional details can be found at www.anthem.com/medicareprovider under Important Medicare Advantage Updates.

Precertification requirements updated for 2017 Please refer to your provider agreement, Medicare Advantage HMO & PPO Provider Guidebook/ provider manual and the Medicare Advantage Precertification Guidelines found at the Medical Policy, UM Guidelines and Precertification Requirements link on the provider home page at anthem.com for further information on existing precertification requirements and new precertification requirements for 2017. Non-contracted providers should contact us.

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 New Injectable/Infusible Drugs: Darzalex and Empliciti Prior Authorization Requirements for New Injectable/Infusible Drugs: Istodax, Ixempra, and Taltz Hospital Observation Service Limits June Reimbursement Policy Provider Bulletin Medicare Advantage Reimbursement Policies 2016 Diabetic Supply Coverage for Individual Medicare Advantage Members Providers Must Enroll with Medicare to be able to Prescribe Part D Beginning Feb. 1, 2016 Contact Medicare Part B Specialty Pharmacy before Injections, Infusion Drug Prior Authorization Expire Routine Cervical Cancer Screening Coverage Guidelines Enhancements to AIM Clinical Appropriateness Guidelines for Advanced Imaging Effective November 1, 2016

61516MUPENMUB 08/03/2016

Behavioral health update Behavioral health providers – please review the entire newsletter While the articles in this section are of specific interest to participating behavioral health providers, there are other articles in this publication that apply to or could be of interest to behavioral health providers as well. Please review the entire issue.

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Ambulatory detoxification, H0014, added to physician fee schedules effective October 1, 2016 Effective October 1, 2016, we have added a new code to physician fee schedules. H0014, ambulatory detoxification, may be billed for the induction phase of buprenorphine treatment. Once a member is stabilized on a maintenance dosage of buprenorphine, typically within a few visits, E&M codes may be used for subsequent treatment. We have several options for ancillary psychosocial treatment; please contact our behavioral health department if referrals are needed.

LiveHealth Online Psychology -easy access to therapists and psychologists from the comfort of home Please read this article in the Administrative and policy update section of this newsletter.

Quality programs update Communicating the importance of childhood vaccinations Parents consider healthcare professionals one of the most trusted sources in answering questions and addressing concerns about their child’s health. A recent survey on parents’ attitudes, knowledge, and behaviors regarding vaccines for young children – including vaccine safety and trust – found that 8 out of 10 parents consider pediatric healthcare professionals to be one of their most trusted sources of vaccine information. With so many parents relying on advice about vaccines, a healthcare professional’s recommendation plays a key role in guiding parents’ vaccination decisions. Make sure to address questions or concerns by tailoring responses to the level of detail the parent is looking for. Some parents may be prepared for a fairly high level of detail about vaccines – how they work and the diseases they prevent –while others may be overwhelmed by too much science and may respond better to a personal example of a patient you’ve seen with a vaccine-preventable disease. A strong recommendation from you as a healthcare professional can also make parents feel comfortable with their decision to vaccinate. We are committed to helping close the gap on childhood immunizations. That’s why we are sending a targeted reminder mailing to parents of children from 0 to 2 years old who may have missed an important immunization. It is very important that babies receive all doses of each vaccine, as well as receive each vaccination on time. These reminder letters encourage parents to contact their healthcare provider to verify that their children are up to date on all recommended vaccines and to schedule an appointment to get the immunizations they might have missed. In addition, we provide a colorful schedule of these recommendations created by the CDC that parents can use as a reference. More resources to aid in the communication about vaccine-preventable diseases, vaccines, and vaccine safety are available online at www.cdc.gov/vaccines/conversations.

Clinical practice and preventive health guidelines available on anthem.com 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, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and 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 at anthem.com > Providers > Select state > Health & Wellness > Practice Guidelines.

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Care & Cost Finder powered by Castlight to be launched We are pleased to update you on our strategic collaboration with Castlight Health. As we shared in late 2015, we have come together with Castlight to co-develop a best-in-breed cost and quality transparency solution for Anthem members. The first release will be launched to 27 early adopter clients in October followed by an additional 15 early adopters in January 2017. Both releases focus on large local groups and national clients. Care & Cost Finder will continue to be rolled out to our members through 2018. We will continue to share details and information as we scale Care & Cost Finder to our members.

HEDIS Spotlight: Comprehensive Diabetes Care (CDC) Approximately 29.1 million people (about 1 in 11 people) in the United States have diabetes. In 2012, the American Diabetes Association (ADA) reported that diabetes care cost the US health care system $245 billion. Given the prevalence, associated costs and complexity of this chronic disease, health plans collect data on diabetes monitoring. The Comprehensive Diabetes Care (CDC) measure looks for the percentage of members with diabetes (type 1 and type 2) who had each of the following during the year:

Hemoglobin A1c (HbA1c) testing HbA1c poor control (>9.0%) HbA1c control (<8%) HbA1c control (<7%) Eye exam (retinal) performed Medical attention for nephropathy BP control (<140/90 mm Hg)

Nationally-recognized clinical guidelines recommend that:

HbA1c test at least twice per year; Retinal eye exam by an optometrist or ophthalmologist annually; Nephropathy screening annually; Blood pressure reading at each routine medical visit, not including readings on the same day as a

procedure/diagnostic screening test or an acute inpatient hospital or emergency room visit. Medical chart reviews from the 2016 HEDIS data collection showed the following factors contribute to low CDC rates:

Lack of communication and continuity of care between primary care and specialists Members may have a prescription, but no record of an office visit or lab test/result during the year. Test results may not have been clearly recorded in the member’s medical chart. Tests may not have been done or recommended. Members may not have completed the recommended tests or returned for recommended follow-up visits.

Strategies to improve Comprehensive Diabetes Care rates include:

Establish and maintain a secure office diabetes registry to identify members with diabetes to help track doctor and lab test appointments, results, and specialists.

Clearly document lab/test dates and results in each member’s medical record. Repeat tests for high results, specifically for HbA1c (over 7%) and blood pressure (over 140/90 mm HG).

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Improve communication both within the member’s care team, including among specialists. Work with our members to set goals to improve or maintain their control over their diabetes.

Anthem Whole Health ConnectionSM Anthem Whole Health Connection is a program that enhances clinical care with more data including dental, vision, disability and pharmacy, and creates a bigger picture of member health1. It also consolidates data from primary care physicians, specialists, ancillary providers like eye doctors and dentists, pharmacies and labs. Sophisticated data analytics are applied to the data to deliver relevant, HIPAA compliant member health profiles and actionable insights. The insights are then shared with physicians and care managers to allow for more informed treatment plans and better health outcomes. How it Works

Data Collection – we consolidate all claims and benefit information from all coverage lines (medical, dental, vision, disability, pharmacy and behavioral health) in a central repository.

Analytics – Data is analyzed to deliver condensed, relevant member health profiles and actionable insights via care alerts and proactive care management referrals.

Connect, share and manage – we connect physicians to this data via the Member Medical History Plus (MMH+) tool. Sharing of information allows for more informed treatment plans to manage a member’s condition. The data is further shared with care managers, and ancillary providers such as vision providers.

Why is it important to connect dental, vision, disability and pharmacy data to population health? It’s important because oral health, eye health and productivity contribute to overall health. The value to your practice

More efficient data collection. The MMH+ supplements the physician’s patient health records with the following information: – Medications and utilization (if not carved out) – Labs – Medical diagnoses (non-sensitive) – Other providers and utilization – Care management status

Earlier detection of medical conditions. For example, a vision exam could be the first indicator of a chronic condition

like diabetes. The vision claim diagnosis of diabetes would populate the MMH+ for viewing by PCPs and care managers.

Proactive care management for improved health outcomes. That same vision claim could trigger a member care alert to the PCP or a referral to Anthem Care Management allowing for proactive outreach to the member by the PCP and care manager.

Reduced cost of care. A recent American Journal of Preventive Medicine study shows that patients with chronic disease or pregnancy who treat their periodontal disease have 6%-74% lower medical costs and hospitalizations2.

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Opportunities for your practice View the MMH+ to complement your electronic health record (EHR) and get a bigger picture of each member’s

health.

Interesting in learning more about the MMH+ advantages? Access our Member Medical History Plus (MMH+) Training document online. Go to anthem.com > Providers > select state > Self Service and Support > Enhanced Personal Health Care Program > Provider Toolkit, Milestone 2: Risk Stratifying Populations, Member Medical History Plus (MMH+) Training. This self-guided presentation introduces Member Medical History Plus, or MMH+, our longitudinal patient record. In addition to basic logon information, this presentation shows the kinds of information available via MMH+, and includes hypothetical scenarios that demonstrate how using MMH+ can help improve patient care. Already have access to MMH+? Log in today and start using it: http://mmhehr.anthem.com/mmhplus Need to request access to MMH+? Please contact your provider relations representative. 1 Anthem Whole Health Connection applies to employer groups that have purchased an Anthem pharmacy, dental, vision or disability plan, in addition to their medical plan. 2 American Journal of Preventive Medicine's Impact of Periodontal Therapy on General Health Study, June 2014

Pharmacy update Pharmacy information available on anthem.com Visit the applicable websites noted below for more information on the following:

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 other requirements, restrictions or limitations that apply to certain drugs

To locate the commercial drug list, go to anthem.com > Customer Support > New Hampshire > Download forms > Anthem Blue Cross and Blue Shield Drug Lists. The commercial drug list is reviewed and updates are posted to the web site quarterly (the first of the month for January, April, July and October). To locate the Marketplace Select Formulary and pharmacy information for health plans offered on the Exchange Marketplace, go to anthem.com > Customer Support > New Hampshire > Download forms > New Hampshire Select Drug List. Website links for the Federal Employee Program formulary Basic and Standard Options are:

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Basic Option: https://www.caremark.com/portal/asset/z6500_drug_list807.pdf Standard Option: https://www.caremark.com/portal/asset/z6500_drug_list.pdf

This drug list is also reviewed and updated regularly as needed.

Medical policy update Medical policy updates are available on anthem.com The following new and revised policies were endorsed at the August 4, 2016 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com > Providers > Select state > Enter > Medical Policies and Clinical UM Guidelines. If you do not have access to the Internet, you may request a hard copy of any updated policy by contacting the Provider Call Center. Please note that the Federal Employee Program® Medical Policy Manual may be accessed at www.fepblue.org > Benefit Plans > Brochures and Forms > Medical Policies. Revised medical policy effective August 1, 2016 (The following policy was revised prior to the August 4, 2016 meeting to expand medical necessity indications or criteria.) Gene.00006 Epidermal Growth Factor Receptor (EGFR) Testing Revised medical policies effective August 18, 2016 (The following policies were revised to expand medical necessity indications or criteria.) BEH.00002 Transcranial Magnetic Stimulation DRUG.00024 Omalizumab (Xolair®) DRUG.00058 Pharmacotherapy for Hereditary Angioedema RAD.00042 SPECT/CT Fusion Imaging SURG.00014 Cochlear Implants and Auditory Brainstem Implants SURG.00020 Bone-Anchored and Bone Conduction Hearing Aids SURG.00055 Cervical Total Disc Arthroplasty SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) SURG.00121 Transcatheter Heart Valve Procedures New medical policy effective August 18, 2016 LAB.00032 Zika Virus Testing Revised medical policies effective October 1, 2016 (The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.) DRUG.00017 Hyaluronan Injections in Joints other than the Knee

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DRUG.00031 Subcutaneous Hormone Replacement Implants DRUG.00057 Canakinumab (Ilaris®) DRUG.00078 Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic

Transection SURG.00122 Venous Angioplasty with or without Stent Placement Revised medical policies effective October 4, 2016 (The following policies were revised to expand medical necessity indications or criteria.) MED.00005 Hyperbaric Oxygen Therapy (Systemic/Topical) MED.00051 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry Revised medical policies effective October 4, 2016 (The following policies were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.) ADMIN.00002 Preventive Health Guidelines ADMIN.00004 Medical Necessity Criteria ADMIN.00005 Investigational Criteria ANC.00006 Biomagnetic Therapy ANC.00007 Cosmetic and Reconstructive Services: Skin Related DME.00004 Electrical Bone Growth Stimulation DME.00009 Vacuum Assisted Wound Therapy in the Outpatient Setting DME.00024 Transtympanic Micropressure for Treatment of Ménière’s Disease DME.00027 Ultrasound Bone Growth Stimulation DME.00030 Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering DME.00037 Cooling Devices and Combined Cooling/Heating Devices DRUG.00002 Tumor Necrosis Factor Antagonists DRUG.00042 Ustekinumab (Stelara®) DRUG.00064 Enteral Carbidopa and Levodopa Intestinal Gel Suspension GENE.00021 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual

Disability (Intellectual Developmental Disorder) and Congenital Anomalies GENE.00022 In Vitro Companion Diagnostic Devices GENE.00040 Genetic Testing for CHARGE Syndrome GENE.00041 Short Tandem Repeat Analysis for Specimen Provenance Testing GENE.00042 Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and

Leukoencephalopathy (CADASIL) Syndrome GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders LAB.00031 Advanced Lipoprotein Testing MED.00055 Wearable Cardioverter Defibrillators MED.00064 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation

or Atrial Flutter (Radiofrequency and Cryoablation) MED.00081 Cognitive Rehabilitation MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders MED.00098 Hyperoxemic Reperfusion Therapy

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MED.00107 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome

MED.00109 Corneal Collagen Cross-Linking MED.00112 Autonomic Testing OR.PR.00005 Upper Extremity Myoelectric Orthoses RAD.00019 Magnetic Source Imaging and Magnetoencephalography RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy) RAD.00035 Coronary Artery Imaging: Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA),

Coronary Magnetic Resonance Angiography (MRA), and Cardiac Magnetic Resonance Imaging (MRI) RAD.00045 Cerebral Perfusion Imaging using Computed Tomography RAD.00046 Cerebral Perfusion Studies using Diffusion and Perfusion Magnetic Resonance Imaging RAD.00063 Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI) SURG.00005 Partial Left Ventriculectomy SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation SURG.00048 Panniculectomy, Abdominoplasty SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery SURG.00051 Hip Resurfacing SURG.00066 Percutaneous Neurolysis for Chronic Neck and Back Pain SURG.00071 Percutaneous and Endoscopic Spinal Surgery SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring SURG.00076 Nerve Graft after Prostatectomy SURG.00077 Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques SURG.00084 Implantable Middle Ear Hearing Aids SURG.00085 Mastectomy for Gynecomastia SURG.00090 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia (TGN SURG.00093 Treatment of Osteochondral Defects SURG.00105 Bicompartmental Knee Arthroplasty SURG.00116 High-Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of

the Anus SURG.00118 Bronchial Thermoplasty SURG.00125 Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain SURG.00126 Irreversible Electroporation (IRE) SURG.00127 Sacroiliac Joint Fusion SURG.00132 Devices for Maintaining Sinus Ostial Patency Following Sinus Surgery SURG.00133 Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy SURG.00134 Interspinous Process Fixation Devices SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization TRANS.00035 Mesenchymal Stem Cell Therapy for Orthopedic Indications New medical policy effective October 4, 2016 (The policy listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.) DRUG.00088 Atezolizumab (Tecentriq™)

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Revised medical policy effective November 1, 2016 (The policy listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.) ADMIN.00007 Immunizations Revised medical policies effective January 1, 2017 (The policies listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.) DRUG.00015 Prevention of Respiratory Syncytial Virus Infections DRUG.00031 Subcutaneous Hormone Replacement Implants DRUG.00078 Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors GENE.00026 Cell-Free Fetal DNA-Based Prenatal Testing LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests MED.00051 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other

Genitourinary Conditions New medical policies effective January 1, 2017 (The policies listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.) DME.00039 Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea DRUG.00087 Asfotase Alfa (Strensiq™) DRUG.00089 Daclizumab (Zinbryta™) DRUG.00091 Naltrexone Implants for the Treatment of Alcohol and Opioid Use Disorders DRUG.00092 Probuphine (buprenorphine implant) DRUG.00093 Sebelipase alfa (KANUMA™) GENE.00046 Prothrombin G20210A (Factor II) Mutation Testing GENE.00047 Methylenetetra-hydrofolate Reductase Mutation Testing RAD.00066 Multiparametric Magnetic Resonance Imaging Fusion Targeted Prostate Biopsy SURG.00144 Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia

Clinical guidelines update Clinical guideline updates are available on anthem.com The following new and revised clinical guidelines were endorsed at the August 4, 2016 Medical Policy & Technology Assessment Committee (MPTAC) meeting. These, and all Anthem medical policies, are available at anthem.com > Providers > Select state > Enter > Medical Policies and Clinical UM Guidelines. If you do not have access to the Internet, you may request a hard copy of any updated policy by contacting the Provider Call Center.

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Revised clinical guideline effective August 18, 2016 (The following guideline was revised to expand the medical necessity indications or criteria.) CG-BEH-02 Adaptive Behavioral Treatment for Autism Spectrum Disorder CG-SURG-27 Sex Reassignment Surgery Revised clinical guidelines effective October 4, 2016 (The following guidelines were revised and had no significant changes to the position or criteria.) CG-BEH-07 Psychological Testing CG-BEH-14 Intensive In-home Behavioral Health Services CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) CG-DRUG-09 Immune Globulin (Ig) Therapy CG-DRUG-11 Infertility Drugs CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar® Gel) CG-DRUG-47 Level of Care: Specialty Pharmaceuticals CG-MED-26 Neonatal Levels of Care CG-MED-31 Skilled Nursing Facility Services CG-MED-46 Ambulatory and Inpatient Video Electroencephalography CG-REHAB-09 Acute Inpatient Rehabilitation CG-SURG-05 Maze Procedure CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury CG-SURG-12 Penile Prosthesis Implantation CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) CG-SURG-38 Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy CG-SURG-44 Coronary Angiography in the Outpatient Setting CG-SURG-48 Elective Percutaneous Coronary Interventions (PCI) Revised clinical guidelines effective January 1, 2017 (The guidelines listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.) CG-BEH-03 Psychiatric Disorder Treatment CG-DRUG-28 Alglucosidase alfa (Lumizyme®, Myozyme®) CG-SURG-27 Sex Reassignment Surgery