October 2018 Anthem Provider Newsletter - Virginia Page 1 of 43

Virginia Provider NewsOctober 2018 Anthem Provider Newsletter - Virginia

Administrative:

Guideline Updates:

Coverage and Clinical Guidelines:

Products & Programs:

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Anthem launches additional changes to anthem.com inOctober

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Tips for billing CPT modifier 33 5

Anthem fights opioid addiction: Extension for CommunityHealthcare Outcomes and quality medication-assisted therapy

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Integrated medical and behavioral health care services 7

Anthem partners with Availity to serve as our EDI Gateway 8

Availity EDI Gateway webinars scheduled 10

Clinical practice and preventive health guidelines available onthe Web

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Receive email notifications via out Network eUPDATE 12

Anthem webinar scheduled for October 10 13

Update to Durable Medical Equipment – effective October 14,2018

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New precertification requirement for EGD services beginsJanuary 1, 2019

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Prior authorization for genetic testing 15

Coverage Guidelines effective January 1, 2019 19

Coverage guideline informational notice 21

Update to AIM Specialty Health clinical appropriatenessguidelines: Advanced imaging appropriate use criteria forimaging of the heart

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New precertification requirements for certain cardiovasculardiagnostic and interventional services begins January 1, 2019

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October 2018 Anthem Provider Newsletter - Virginia Page 2 of 43

Pharmacy:

Medicaid:

Medicare:

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Update to AIM Specialty Health radiation oncology clinicalappropriateness guidelines

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Update to AIM Specialty Health sleep disorder managementclinical appropriateness guidelines

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Innovative ways to help improve your patients’ experiences andearn CME credits

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State employees eligible to participate in Vitals SmartShopperprogram beginning October 1

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HEDIS® 2018: Provider incentive winners announced 33

Additional drugs added to the specialty pharmacy clinicallyequivalent drug list effective January 1, 2019

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Access patient-specific drug benefit information through EMR 35

Pharmacy information available on anthem.com 36

HealthKeepers, Inc. fights opioid addiction: Extension forCommunity Health Care Outcomes and quality medication-assisted therapy

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Orientations and training sessions offered to all providers 38

Medical Policies and Clinical Utilization Management Guidelinesupdate

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Vaginal birth after cesarean shared decision-making aidavailable

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Prior authorization requirements for Interferon beta-1a 0

Prior authorization requirements for Somatrem 0

EDI Gateway migration 0

What matters most: Improving the patient experience CME 0

Cervical length measurement by transvaginal ultrasound 0

Anthem HealthKeepers Plus member reassignment andcontinuity of care

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Genetic testing prior authorization by ordering physician helpsensure accurate lab payment

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Anthem transitions Medicare Advantage back pain managementand cardiology UM programs from OrthoNet to AIM

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October 2018 Anthem Provider Newsletter - Virginia Page 3 of 43

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO productsunderwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. InMissouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company(HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten byHMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada:Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. In New Hampshire:Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten byMatthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as AnthemBlue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east ofState Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), which underwrites or administers the PPO and indemnity policiesand underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation(Compcare) underwrites or administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers WellPriority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of AnthemInsurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation. Use of the Anthem websites constitutes your agreement with our Terms of Use.

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Please evaluate statin use for Medicare Advantage memberswith diabetes, cardiovascular disease

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Medicare pharmacy and prescriber home starts January 2019 0

Keep up with Medicare news 0

October 2018 Anthem Provider Newsletter - Virginia Page 4 of 43

Anthem launches additional changes to anthem.com in OctoberPublished: Oct 1, 2018 - Administrative

Continuing to build on the initial launch of the new public provider pages, Anthem Blue Crossand Blue Shield and our affiliate HealthKeepers, Inc. recently released a brand new,redesigned landing page for Provider Resources. The most recent release also includes anew Communications page with a clear and concise access point for provider newslettersand eUPDATEs, as pictured below.

This October, anthem.com will be introducing exciting changes to the public provider site.Coming in the next wave of changes, providers can anticipate a new landing page formanuals and an improved, streamlined experience for other communications. We will continue to keep you informed on upcoming changes to the public provider site aswe progress toward streamlining our Web platform and other business processes.

URL: https://providernews.anthem.com/virginia/article/anthem-launches-additional-changes-to-anthemcom-in-october-1

October 2018 Anthem Provider Newsletter - Virginia Page 5 of 43

Tips for billing CPT modifier 33Published: Oct 1, 2018 - Administrative

The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) whichprohibits member cost sharing for defined preventive services for non-grandfatheredpolicies. The appropriate use of modifier 33 will reduce claim adjustments related topreventive services and your corresponding refunds to members. Modifier 33 is applicable to CPT codes representing preventive care services. CPT codesnot appended with modifier 33 will process under the member’s medical or preventivebenefits, based on the diagnosis and CPT codes submitted. Modifier 33 should be appended to codes represented for services described in the UnitedStates Preventive Services Task Force (USPSTF) A and B recommendations, the AdvisoryCommittee on Immunization Practices (ACIP) of the Centers for Disease Control andPrevention (CDC), and certain guidelines for infants, children, adolescents, and womensupported by the Health Resources and Services Administration (HRSA) Guidelines. The CPT® 2018 Professional Edition manual shares the following information regarding thebilling of modifier 33:

“When the primary purpose of the service is the delivery of an evidence basedservice in accordance with a U.S. Preventive Services Task Force A or B rating ineffect and other preventive services identified in preventive mandates (legislative orregulatory), the service may be identified by adding 33 to the procedure. Forseparately reported services specifically identified as preventive, the modifier shouldnot be used.”

URL: https://providernews.anthem.com/virginia/article/tips-for-billing-cpt-modifier-33-4

Anthem fights opioid addiction: Extension for CommunityHealthcare Outcomes and quality medication-assisted therapyPublished: Oct 1, 2018 - Administrative

Extension for Community Healthcare Outcomes (ECHO) Opioid overdose rates continue to rise. With the support of medication-assisted therapy(MAT) ECHO, you can help save lives. Join one of several video tele-consultative ECHOlearning communities nationwide and participate with other clinicians learning about

October 2018 Anthem Provider Newsletter - Virginia Page 6 of 43

medication-assisted treatment for individuals with opioid disorders. For more information,visit the ECHO website. Benefits of participating include:

Addiction treatment training.

Free continuing education credits.

Opportunity to receive expert input on your (de-identified) patient cases.

Access to a virtual learning community for treatment guidelines, tools and patientresources.

Opportunity to ask questions and get a variety of support from specialists.

Quality medication-assisted therapy To help ensure members have access to comprehensive evidence-based care, AnthemBlue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are committed to helpingnetwork providers double the number of members who receive behavioral health services aspart of MAT for opioid addiction. When treating patients with opioid use disorder, it is considered best practice to offer andarrange evidence-based treatment. This usually consists of MAT with buprenorphine or, insome plans, methadone maintenance treatment in combination with behavioral therapies.Behavioral therapies focused on medication adherence and relapse prevention can improveMAT outcomes and improve other social determinants of health, including development ofan enhanced social support network in recovery. For more information For more information about best practices for medication-assisted treatment, please readthe American Society of Addiction Medicine’s National Practice Guideline For the Use ofMedications in the Treatment of Addiction Involving Opioid Use.

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You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for moreinformation about the ECHO and MAT programs.

URL: https://providernews.anthem.com/virginia/article/anthem-fights-opioid-addiction-extension-for-community-healthcare-outcomes-and-quality-medication-assisted-therapy-1

Integrated medical and behavioral health care servicesPublished: Oct 1, 2018 - Administrative

In our ongoing efforts to encourage medical and behavioral health integration, Anthemcontinues to promote early identification and intervention of behavioral health issues throughprimary care. Anthem currently reimburses for screening and assessment for behavioralhealth and substance use through billing the following codes:

G0396/99408 – Alcohol and/or substance (other than tobacco) abuse structuredassessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes

G0397/99409 – Alcohol and/or substance (other than tobacco) abuse structuredassessment (e.g., AUDIT, DAST), and brief intervention, greater than 30 minutes

G0442 – Annual alcohol misuse screening, 15 minutes ≤ G0443 - Brief face-to-facebehavioral counseling for alcohol misuse, 15 minutes

G0443 – Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

G0444 – Annual depression screening, 15 minutes

Anthem also supports behavioral counseling for specific chronic conditions while in theprimary care office. These services include:

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G0446 – Annual, face-to-face intensive behavioral therapy for cardiovascular disease,15 minutes

G0447 – Face-to-face behavioral counseling for obesity, 15 minutes

G0473 – Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

In addition, Anthem reimburses for the psychiatric collaborative care codes; procedurecodes 99492, 99493, 99494 are used to report these services. These codes are reportableby primary care providers for their collaboration with a qualified behavioral health provider,such as a psychiatrist, licensed clinical social worker, etc. Care is directed by the primary care team and includes structured care management withregular assessments of clinical status using validated tools and modification of treatment asappropriate. The psychiatric consultant provides regular consultations to the primary careteam to review the clinical status and care of patients and to make recommendations. These codes are intended to represent the care and management for patients withbehavioral health conditions that often require extensive discussion, information-sharing,and planning between a primary care physician and a behavioral health specialist. TheAmerican Psychiatric Association (APA) has created a training program for primary care onthe collaborative care model and the use of these codes. It can be found at APA TrainingModule.

URL: https://providernews.anthem.com/virginia/article/integrated-medical-and-behavioral-health-care-services

Anthem partners with Availity to serve as our EDI GatewayPublished: Oct 1, 2018 - Administrative

Who is Availity?

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Most of you know Availity as a Web portal or claims clearinghouse. Availity is also anintelligent EDI Gateway for multiple vendors and will be the EDI connection for Anthem BlueCross and Blue Shield and our affiliate HealthKeepers, Inc. If you currently use a clearinghouse, billing company or if you submit directly, all your EDItransactions will flow through the Availity EDI Gateway to Anthem. How are you submitting EDI transactions today?

If you currently transmit your EDI submissions using a clearinghouse or billingcompany, you should contact your clearinghouse to confirm your EDI submission path hasnot changed. If you are notified of any potential impacts with connectivity, workflow orfinancial, please know there is no cost alternate submission options available with Availity.

If you currently submit directly to Anthem and already have an Availity login for theportal, you can use that same login for your EDI services.

Please visit https://apps.availity.com/web/welcome/#/anthem to learn more.

How can you directly transmit EDI submission to Availity? Below are the different ways you can submit direct EDI transactions to Availity:

Submit transaction files through FTP – If you work with a practice managementsystem, health information system, or other automated system that supports an FTPconnection, you can securely upload EDI transactions to the Availity FTP site where theelectronic transactions are automatically picked up by Availity and submitted to Anthem.

Submit transaction files through the Availity Portal – If you have batch files of EDItransactions that you need to process and you choose not to use the Availity FTP site, youcan manually upload the batch files through the Availity Portal.

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Submit transactions through manual data entry in the Availity Portal – The AvailityPortal makes it easy to submit transactions, such as eligibility and benefits inquiries orclaims, by entering data into our user-friendly Web forms.

What are your next steps?

We recommend that you register with Availity for your EDI transmissions and beginmigrating your volume by the end of 2018. These include the 837, 835 and 27X (eligibilityand claim status) transactions.

Availity will be working directly with your clearinghouse, billing company and yourorganization if you choose to submit directly.

We look forward to delivering a smooth transition to the Availity EDI Gateway. If youhave any questions, please contact Availity Client Services at 1-800-Availity (1-800-282-4548) Monday through Friday 8 a.m. to 7:30 p.m. ET.

URL: https://providernews.anthem.com/virginia/article/anthem-partners-with-availity-to-serve-as-our-edi-gateway

Availity EDI Gateway webinars scheduledPublished: Oct 1, 2018 - Administrative

Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. now use Availity asour designated EDI service. If you currently use a clearinghouse, billing company, or if yousubmit directly, all your EDI transactions will flow through the Availity EDI Gateway toAnthem. Check out this webinar for lots of great information to get you started. At the end of thetraining, you can participate in a live Q&A session. During this fast-paced hour, learn how to:

Understand Availity’s EDI Gateway and Clearinghouse workflow for 837, 270/271,276/277, and 835 electronic transactions.

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Use the Availity Portal to manage file transfers, set up EDI reporting preferences,manage your FTP account, and more.

Enroll for and manage 835 ERA delivery with Availity.

Access and navigate the Availity EDI Guide.

and more…..

Upcoming Sessions Scheduled upcoming sessions include:

October 29, 2018, 1 p.m. – 2 p.m. ET

November 7, 2018, 11 a.m. – noon ET

Enroll Log in to the Availity Portal. Select Help and Training > Get Trained. In the Availity Learning Center (ALC) Catalog, select Sessions. Scroll Your Calendar to find and enroll for a live session. Can’t make it? We’ve got you covered with a recording of a previous live session. In the ALC, search theCatalog by keyword (song) and enroll for the on-demand option.

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Need Help? Email training@availity.com if you have issues enrolling for a live webinar.

URL: https://providernews.anthem.com/virginia/article/availity-edi-gateway-webinars-scheduled-4

Clinical practice and preventive health guidelines available on theWebPublished: Oct 1, 2018 - Administrative

As part of our commitment to provide you with the latest clinical information and educationalmaterials, we have adopted nationally recognized medical, behavioral health and preventivehealth guidelines that are available to providers on our website. The guidelines – which areused for our quality programs – are based on reasonable medical evidence. In addition, theguidelines are reviewed for content accuracy, current primary sources, the newesttechnological advances and recent medical research.

All guidelines are reviewed annually and updated as needed. The current guidelines areavailable on our website. To access the guidelines, go to anthem.com. Click “Menu” at thetop of the screen to display options and select “Providers.” Next, select “Virginia” from thedropdown listing of states and press “Enter.” On the Provider Home Page, select the “Health& Wellness” tab and then the “Practice Guidelines” link.

URL: https://providernews.anthem.com/virginia/article/clinical-practice-and-preventive-health-guidelines-available-on-the-web-4

Receive email notifications via out Network eUPDATEPublished: Oct 1, 2018 - Administrative

Our provider newsletter is our primary source for providing important information to healthcare providers and professionals. The newsletter is published bi-monthly and is posted toour 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 e-mail service –Network eUPDATE – to communicate new information. If you are not yet signed up toreceive Network eUPDATEs, we encourage you to enroll now so you’ll be sure to receive allinformation we will be sending about billing, upcoming changes, coverage guidelines andother pertinent topics.

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Reminder notifications sent via email When you sign up, you’ll not only receive an email reminder for each newsletter postedonline, you’ll also be notified of other late breaking news and important information you’llneed when providing services and filing claims for our members. It’s easy to sign up – justselect Virginia and access the provider home page. There, you’ll find a link to register forour Network eUPDATE.

URL: https://providernews.anthem.com/virginia/article/receive-email-notifications-via-out-network-eupdate

Anthem webinar scheduled for October 10Published: Oct 1, 2018 - Administrative

On October 10, 2018, Anthem will offer our final provider education webinar for the year.Designed for our network-participating providers, the webinars address Anthem businessupdates and billing guidelines that impact your business interactions with us. For your convenience, we offer these informative, hourly sessions online to eliminate traveltime and help minimize disruptions to your office or practice. The date for the last scheduledwebinar for 2018 is:

Wednesday, October 10, 2018, from 10 a.m. to 11 a.m. ET

Please take time to register today for the webinar using the registration form in the articleattachments section on the right. If you have already registered for the October webinar,please ensure you have received a fax confirmation or a confirmation from an Anthemrepresentative to ensure we’ve received your registration form. Please contactjoyce.lindley@anthem.com if you need to confirm your registration.

URL: https://providernews.anthem.com/virginia/article/anthem-webinar-scheduled-for-october-10

October 2018 Anthem Provider Newsletter - Virginia Page 14 of 43

New precertification requirement for EGD services beginsJanuary 1, 2019Published: Oct 1, 2018 - Guideline Updates

Beginning with dates of service on and after January 1, 2019, Anthem Blue Cross and BlueShield will expand precertification requirements to include upper gastrointestinal (GI)endoscopy, also referred to as esophagogastroduodenoscopy (EGD). AIM SpecialtyHealth® (AIM), a separate company, will administer this EGD review on behalf of Anthem. EGD procedures will be reviewed against clinical guideline CG-MED-59, UpperGastrointestinal Endoscopy, for clinical appropriateness and to help ensure care aligns withestablished evidence-based medicine. Please note, procedures performed in an inpatient orobservation setting, or on an emergent basis will not be reviewed under CG-MED-59. A complete list of EGD CPT codes requiring precertification is available on thewww.aimproviders.com/surgicalprocedures Submit a request for review Starting December 19, 2018, ordering providers may submit precertification requests fordates of service on or after January 1, 2019, to AIM in one of the following ways:

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

Access AIM via the Availity Web Portal at availity.com.

Call the AIM Contact Center toll-free number: 866-789-0158, Monday – Friday, 8a.m. to 5 p.m. ET.

Please note, this review does not apply to the following plans: BlueCard®, FederalEmployee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplementalplans. Providers can view precertification requirements for Anthem members at Coverage &Clinical UM Guidelines, and Pre-Cert Requirements at the Virginia provider section ofanthem.com. Providers should continue to verify eligibility and benefits for allmembers prior to rendering services.

October 2018 Anthem Provider Newsletter - Virginia Page 15 of 43

For questions, please contact the Provider Service number on the back of the member IDcard.

URL: https://providernews.anthem.com/virginia/article/new-precertification-requirement-for-egd-services-begins-january-1-2019

Prior authorization for genetic testingPublished: Oct 1, 2018 - Guideline Updates

Effective with dates of service on and after November 1, 2018, Anthem Blue Cross and BlueShield will transition the medical necessity review of all genetic testing services for membersenrolled in our PPO health benefit plans to AIM Specialty Health® (AIM), a separatecompany. This review will take place as a prior authorization. SPECIAL NOTE: For members enrolled in our affiliate HealthKeepers, Inc.'s AnthemHealthKeepers commercial health plans, there are no changes in the medical necessityreview of genetic testing services. Anthem in Virginia will continue to handle the medicalnecessity review locally for Anthem HealthKeepers members. The coverage guidelines and codes that will be reviewed by Anthem plans managed by AIMfor medical necessity include: CoverageGuideline # Coverage Guideline Title Codes

GENE.00001 Genetic Testing for Cancer Susceptibility

81404, 81405, 81406,81437, 81438, 81445,81450, 81479,0013U, 0014U,0056U

GENE.00002 Preimplantation Genetic Diagnosis Testing 89290, 89291

GENE.00003 Genetic Testing and Biochemical Markers forthe Diagnosis of Alzheimer's Disease

81401, 81405, 81406,83520, 84999, S3852

GENE.00005 BCR-ABL Mutation Analysis 81170, 81401

GENE.00006 Epidermal Growth Factor Receptor (EGFR)Testing 81235, 88365

GENE.00007 Cardiac Ion Channel Genetic Testing81404, 81405, 81406,81407, 81408 81413,81414, S3861

GENE.00009 Gene-Based Tests for Screening, Detectionand Management of Prostate Cancer

81313, 81479, 81541,81551, 81599,0005U, 0011M,0047U, 0053U

October 2018 Anthem Provider Newsletter - Virginia Page 16 of 43

GENE.00010 Genotype Testing for Genetic Polymorphismsto Determine Drug-Metabolizer Status

81225, 81226, 81227,81230, 81231,81232,81346, 81350, 81355,81381, 81479,G9143, 0028U,0029U, 0030U,0031U, 0032U,0033U, G9143

GENE.00011 Gene Expression Profiling for ManagingBreast Cancer Treatment

81519,81520, 81521,81599, 84999,S3854, 0045U

GENE.00012 Preconceptional or Prenatal Genetic Testingof a Parent or Prospective Parent

81200, 81209, 81220,81221, 81222, 81223,81224, 81241, 81242,81251, 81252, 81253,81254, 81255, 81256,81257, 81258, 81259,81260, 81269, 81290,81330, 81361, 81362,81363, 81364, 81401,81403, 81404, 81405,81406, 81412, 81415,81416, 81417, 81425,81426, 81427, 81479,S3800, S3841,S3842, S3844,S3845, S3846,S3849, S3853, 0012U

GENE.00016 Gene Expression Profiling for ColorectalCancer 81525, 81599, 84999

GENE.00017Genetic Testing for Diagnosis andManagement of Hereditary Cardiomyopathies(including ARVD/C)

81403, 81405, 81406,81407, 81408, 81439,81479, S3865, S3866

GENE.00018 Gene Expression Profiling for Cancers ofUnknown Primary Site

81404, 81406, 81540,81599

GENE.00020 Gene Expression Profile Tests for MultipleMyeloma 81479, 81599

GENE.00021

Chromosomal Microarray Analysis (CMA) forDevelopmental Delay, Autism SpectrumDisorder, Intellectual Disability (IntellectualDevelopmental Disorder) and CongenitalAnomalies

81228, 81229,S3870, 81405

GENE.00023 Gene Expression Profiling of Melanomas 81401, 81599, 84999,

GENE.00024 DNA-Based Testing for Adolescent IdiopathicScoliosis 0004M

October 2018 Anthem Provider Newsletter - Virginia Page 17 of 43

GENE.00025 Molecular Profiling for the Evaluation ofMalignant Tumors

81425, 81445, 81450,81455, 81479, 81599,88363, 0013U,0014U, 0036U,0037U, 0048U,0050U, 0056U,0057U

GENE.00026 Cell-Free Fetal DNA-Based PrenatalScreening for Fetal Aneuploidy

81420, 81422, 81479,81507, 81599, 0009M

GENE.00028 Genetic Testing for Colorectal CancerSusceptibility

81201, 81202, 81203,81288, 81292, 81293,81294, 81295, 81296,81297, 81298, 81299,81300, 81317, 81318,81319, 81401, 81403,81406, 81435, 81436

GENE.00029 Genetic Testing for Breast and/or OvarianCancer Syndrome

81162, 81211, 81212,81213, 81214, 81215,81216, 81217, 81432,81433, 81445, 81455

GENE.00030 Genetic Testing for Endocrine Gland CancerSusceptibility

81404, 81405, 81445,81455, 81479,S3840,

GENE.00031 Genetic Testing for PTEN Hamartoma TumorSyndrome 81321, 81322, 81323

GENE.00033 Genetic Testing for Inherited PeripheralNeuropathies

81324, 81325, 81326,81403, 81404, 81405,81406, 81440, 81448,81479

GENE.00034 SensiGene® Fetal RhD Genotyping Test 81403

GENE.00035 Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome)

81404, 81405, 81445,81455

GENE.00036 Genetic Testing for Hereditary Pancreatitis 81222, 81223, 81224,81401, 81404, 81405

GENE.00037 Genetic Testing for Macular Degeneration 81401, 81405, 81408,81479, 81599

GENE.00038 Genetic Testing for Statin-Induced Myopathy 81328

GENE.00039 Genetic Testing for Frontotemporal Dementia(FTD) 81406, 81479

GENE.00040 Genetic Testing for CHARGE Syndrome 81403, 81407

GENE.00041 Short Tandem Repeat Analysis for SpecimenProvenance Testing

81479, 84999,0007U, 0020U

GENE.00042

Genetic Testing for Cerebral AutosomalDominant Arteriopathy with SubcorticalInfarcts and Leukoencephalopathy(CADASIL) Syndrome

81406

October 2018 Anthem Provider Newsletter - Virginia Page 18 of 43

GENE.00043 Genetic Testing of an Individual’s Genome forInherited Diseases

81200, 81209, 81221,81222, 81223, 81224,81241, 81242, 81251,81252, 81253, 81254,81255, 81256, 81257,81258, 81259, 81260,81269, 81290, 81330,81361, 81362, 81363,81364, 81400, 81403,81404, 81405, 81406,81408 81410, 81411,81412, 81415, 81416,81417, 81425, 81426,81427, 81430, 81431,81434, 81440, 81442,81460, 81465, 81470,81471, 81479, 81599,81493, 81506, 81599,S3800, S3841,S3842, S3844,S3845, S3846,S3849, S3853,0012U

GENE.00044 Analysis of PIK3CA Status in Tumor Cells 81404

GENE.00045Detection and Quantification of Tumor DNAUsing Next Generation Sequencing inLymphoid Cancers

81479, 81599

GENE.00046 Prothrombin G20210A (Factor II) MutationTesting 81240

GENE.00047 Methylenetetrahydrofolate ReductaseMutation Testing 81291

CG-GENE-01 Janus Kinase 2 (JAK2) V617F GeneMutation Assay 81270, 81403

CG-GENE-02 Analysis of Kras Status 81275, 81276, 81479,88363,

CG-GENE-03 BRAF Mutation Analysis 81210, , 81406,88363

CG GENE 04 Molecular Marker Evaluation of ThyroidNodules

81545, 81599,0018U, 0026U

Beginning October 22, 2018, prior authorization requests for dates of service on or afterNovember 1, 2018, may be submitted to AIM using one of the following ways:

Access AIM ProviderPortalSM directly at providerportal.com. Online access isavailable 24/7 to process orders in real-time, and is the fastest and most convenient way

October 2018 Anthem Provider Newsletter - Virginia Page 19 of 43

to request authorization.

Access AIM via the Availity Web Portal at availity.com.

Call the AIM Contact Center toll-free number: 866-789-0158, Monday – Friday, 8 a.m.to 5 p.m. ET.

For more information about genetic testing prior authorization, visit AIM’s Genetic Test Site.Precertification requirements for Anthem members can be viewed at anthem.com. Please note, this program does not apply to the Federal Employee Program® (FEP®) orHealthKeepers, Inc. health plans. Anthem in Virginia will continue to handle the medicalnecessity review of genetic testing services locally for members enrolled in AnthemHealthKeepers commercial health plans. For questions regarding prior authorization requirements, please contact the provider servicenumber on the back of the member ID card.

URL: https://providernews.anthem.com/virginia/article/prior-authorization-for-genetic-testing

Coverage Guidelines effective January 1, 2019Published: Oct 1, 2018 - Guideline Updates / Coverage and Clinical Guidelines

Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., willimplement the following new and revised coverage guidelines effective January 1, 2019. These guidelines impact all our products – with the exception of Anthem HealthKeepers Plus(Medicaid), the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan, MedicareAdvantage, and the Blue Cross and Blue Shield Service Benefit Plan (also called theFederal Employee Program or FEP). Furthermore, the guidelines were among thoserecently approved at the Medical Policy and Technology Assessment Committee meetingheld on July 26, 2018. SPECIAL NOTES: The services addressed in these coverage guidelines in this section and in the attachmentunder “Article Attachments” on the right will require authorization for all of our productsoffered by HealthKeepers, Inc. with the exception of Anthem HealthKeepers Plus (Medicaid)

October 2018 Anthem Provider Newsletter - Virginia Page 20 of 43

and the Commonwealth Coordinated Care Plus (Anthem CCC Plus). Other exceptions areMedicare Advantage and the Federal Employee Program.

A pre-determination can be requested for our PPO products. Services related to specialty pharmacy drugs (non-cancer related) require a medicalnecessity review, which includes site of care criteria, as outlined in the applicable coverageor clinical UM guideline listed.

The following guidelines are addressed in this October 2018 edition (see also attachmentunder "Article Attachments" on the right):

Cosmetic and Reconstructive Services: Skin Related (ANC.00007)

Chelation Therapy (DRUG.00003)

Ibalizumab-uiyk (TrogarzoTM) (DRUG.00096)

Epidermal Growth Factor Receptor (EGFR) Testing (GENE.00006)

Circulating Tumor DNA Testing for Cancer (Liquid Biopsy) (GENE.00049)

Neuromuscular Stimulation in the Treatment of Muscle Atrophy (CG-DME-03)

Diagnostic Infertility Surgery (CG-SURG-34)

URL: https://providernews.anthem.com/virginia/article/coverage-guidelines-effective-january-1-2019

October 2018 Anthem Provider Newsletter - Virginia Page 21 of 43

Coverage guideline informational noticePublished: Oct 1, 2018 - Guideline Updates / Coverage and Clinical Guidelines

Archived coverage guideline numbers effective September 20, 2018 The following coverage guideline numbers have been archived:

DME.00027 Ultrasound Bone Growth Stimulation [Note: Content of DME.00027 has beentransferred to new clinical UM guideline CG-DME-45.]

DRUG.00006 Botulinum Toxin [Note: Content of DRUG.00006 has been transferred toclinical UM guideline CG-DRUG-103.]

DRUG.00024 Omalizumab (Xolair®) [Note: Content of DRUG.00024 has been transferred tonew clinical UM guideline CG-DRUG-104.]

DRUG.00040 Abatacept (Orencia) [Note: Content of DRUG.00040 has been transferred toclinical UM guideline CG-DRUG-105.]

DRUG.00047 Brentuximab Vedotin (Adcetris®) [Note: Content of DRUG.00047 has beentransferred to new clinical UM guideline CG-DRUG-106.]

DRUG.00058 Pharmacotherapy for Hereditary Angioedema [Note: Content of DRUG.00058has been transferred to new clinical UM guideline CG-DRUG-107.]

DRUG.00064 Enteral Carbidopa and Levodopa Intestinal Gel Suspension [Note: Content ofDRUG.00064 has been transferred to new clinical UM guideline CG-DRUG-108.]

DRUG.00087 Asfotase Alfa (Strensiq™) [Note: Content of DRUG.00087 has beentransferred to new clinical UM guideline CG-DRUG-109.]

DRUG.00091 Naltrexone Implantable Pellets [Note: Content of DRUG.00091 has beentransferred to new clinical UM guideline CG-DRUG-110.]

DRUG.00093 Sebelipase alfa (KANUMA™) [Note: Content of DRUG.00093 has beentransferred to new clinical UM guideline CG-DRUG-111.]

DRUG.00103 Abaloparatide (Tymlos™) [Note: Content of DRUG.00103 has beentransferred to new clinical UM guideline CG-DRUG-112.]

October 2018 Anthem Provider Newsletter - Virginia Page 22 of 43

MED.00005 Hyperbaric Oxygen Therapy (Systemic/Topical) [Note: Content of MED.00005has been transferred to new clinical UM guideline CG-MED-73.]

MED.00051 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry [Note:Content of MED.00051 has been transferred to new clinical UM guideline CG-MED-74.] MED.00081 Cognitive Rehabilitation [Note: Content of MED.00081 has been transferred tonew clinical UM guideline CG-REHAB-11.]

MED.00107 Medical and Other Non-Behavioral Health Related Treatments for AutismSpectrum Disorders and Rett Syndrome [Note: Content of MED.00107 has been transferredto new clinical UM guideline CG-MED-75.]

RAD.00019 Magnetic Source Imaging and Magnetoencephalography [Note: Content ofRAD.00019 has been transferred to new clinical UM guideline CG-MED-76.]

RAD.00042 SPECT/CT Fusion Imaging [Note: Content of RAD.00042 has been transferredto new clinical UM guideline CG-MED-77.]

SURG.00014 Cochlear Implants and Auditory Brainstem Implants [Note: Content ofSURG.00014 has been transferred to new clinical UM guideline CG-SURG-81.]

SURG.00020 Bone-Anchored and Bone Conduction Hearing Aids [Note: Content ofSURG.00020 has been transferred to new clinical UM guideline CG-SURG-82.]

SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity [Note:Content of SURG.00024 has been transferred to new clinical UM guideline CG-SURG-83.]

SURG.00049 Mandibular/ Maxillary (Orthognathic) Surgery [Note: Content of SURG.00049has been transferred to new clinical UM guideline CG-SURG-84.]

SURG.00051 Hip Resurfacing [Note: Content of SURG.00051 has been transferred to newclinical UM guideline CG-SURG-85.]

SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease,Aortic Dissection and Aortic Transection [Note: Content of SURG.00054 has beentransferred to new clinical UM guideline CG-SURG-86.]

October 2018 Anthem Provider Newsletter - Virginia Page 23 of 43

SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) andSnoring [Note: Content of SURG.00074 has been transferred to new clinical UM guidelineCG-SURG-87.]

SURG.00085 Mastectomy for Gynecomastia [Note: Content of SURG.00085 has beentransferred to new clinical UM guideline CG-SURG-88.]

SURG.00090 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy forTrigeminal Neuralgia [Note: Content of SURG.00090 has been transferred to new clinicalUM guideline CG-SURG-89.]

TRANS.00018 Donor Lymphocyte Infusion for Hematologic Malignancies after AllogeneicHematopoietic Progenitor Cell Transplantation [Note: Content of TRANS.00018 has beentransferred to new clinical UM guideline CG-TRANS-03.]

URL: https://providernews.anthem.com/virginia/article/coverage-guideline-informational-notice

Update to AIM Specialty Health clinical appropriatenessguidelines: Advanced imaging appropriate use criteria forimaging of the heartPublished: Oct 1, 2018 - Products & Programs

Effective for dates of service on and after January 28, 2019, the following updates will applyto the AIM Specialty Health© (AIM), a separate company. This impacts clinicalappropriateness guidelines – advanced imaging appropriate use criteria: imaging of theheart.

Carotid duplex ultrasound

Criteria removed for evaluation of syncope in patients with suspected extracranialarterial disease.

October 2018 Anthem Provider Newsletter - Virginia Page 24 of 43

New criteria address evaluation of TAVR (TAVI) in patients with suspected orestablished extracranial arterial disease.

Myocardial perfusion imaging (MPI), stress echocardiography, cardiac PET, andcoronary CT angiography (CCTA)

Clarifications address exercise-induced syncope and exercise-induced dizziness,lightheadedness or near syncope in symptomatic patients with suspected coronary arterydisease.

MPI, stress echocardiography, cardiac PET

Criteria added to allow annual surveillance of coronary artery disease in patients withestablished CAD post-cardiac transplant.

Clarified definition of established coronary artery disease when diagnosed by CCTA.

More restrictive for patients diagnosed with coronary artery disease by prior coronaryangiography, as FFR must be ≤0.8.More permissive for patients diagnosed with coronary artery disease by CCTA with FFR ≤0.8(patients previously excluded). Resting transthoracic echocardiography (TTE)

New criteria for evaluation of ventricular function in patients who have undergonecardiac transplantation.

Cardiac MRI

New criteria allows for annual study to quantify cardiac iron load in chronically illpatients with cardiomyopathy who require frequent blood transfusions (e.g., thalassemia).

October 2018 Anthem Provider Newsletter - Virginia Page 25 of 43

Removed allowance for annual LV function evaluation when echocardiography issuboptimal.

As a reminder, ordering and servicing providers may submit prior authorization requests toAIM in one of several ways:

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

Access AIM via the Availity Web Portal at availity.com.

Call the AIM Contact Center toll-free number: 866-789-0158, Monday – Friday, 8 a.m.to 5 p.m. ET.

For questions related to guidelines, please contact AIM via email ataim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copyof the current guidelines on AIM’s website. Please note, this program does not apply to the Federal Employee Program (FEP).

URL: https://providernews.anthem.com/virginia/article/update-to-aim-specialty-healthc-clinical-appropriateness-guidelines-advanced-imaging-appropriate-use-criteria-imaging-of-the-heart-2

New precertification requirements for certain cardiovasculardiagnostic and interventional services begins January 1, 2019Published: Oct 1, 2018 - Products & Programs

Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers Inc. are committed tohelping ensure our members receive patient care that is consistent with recognized best

October 2018 Anthem Provider Newsletter - Virginia Page 26 of 43

practices. To support this goal, beginning with dates of service on and after January 1,2019, Anthem will expand our cardiovascular program to require precertification for arterialultrasound, cardiac catheterization, and percutaneous coronary intervention (PCI). Theprogram will be managed by AIM Specialty Health® (AIM), a separate companyadministering the program on behalf of Anthem. Please note that all Anthem local members who currently require precertification for high-tech imaging and echocardiograms are included in the program. The program does notapply to Federal Employee Program® (FEP). Additionally, procedures performed in aninpatient setting or on an emergent basis are not included in the program. Arterial ultrasound, cardiac catheterization, and percutaneous coronary intervention (PCI)services will be reviewed using AIM clinical guidelines which are available ataimproviders.com/cardiology/. Ordering physicians may submit to AIM a precertification request in one of several ways:

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

Access AIM via the Availity Web Portal at availity.com.

Call the AIM Contact Center toll-free number: 866-789-0158, Monday–Friday, 8 a.m. –5 p.m.

Anthem recognizes that the necessity for arterial duplex imaging or percutaneous coronaryintervention (PCI) may not be identified by providers until their patients have undergone aphysiologic study or cardiac catheterization. We ask that you contact AIM no later than 10business days after you perform arterial duplex imaging or PCI, but before you submit theclaim, to request clinical appropriateness review. The following codes will be reviewed byAIM as part of the program:

CPT Description

93922 Limited bilateral noninvasive physiologic studies of upper or lower extremityarteries

93923 Complete bilateral noninvasive physiologic studies of upper or lower extremity

October 2018 Anthem Provider Newsletter - Virginia Page 27 of 43

arteries,3 ormorelevels

93924 Noninvasive physiologic studies of lower extremity arteries, at rest and followingtreadmill stress testing

93925 Duplex scan of lower extremity arteries or arterial bypass grafts; completebilateral study

93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral orlimited study

93930 Duplex scan of upper extremity arteries or arterial bypass grafts; completebilateral study

93931 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral orlimited study

93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts;complete study

93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts;unilateral or limited study

93880 Duplex scan of extracranial arteries; complete bilateral study 93882 Duplex scan of extracranial arteries; unilateral or limited study93454 Catheter placement in coronary artery(s) for coronary angiography

93455

Catheter placement in coronary artery(s) for coronary angiography, withcatheter placement(s) in bypass graft(s) (internal mammary, free arterial,venous grafts) including intraprocedural injection(s) for bypass graftangiography

93456 Catheter placement in coronary artery(s) for coronary angiography, with rightheart catheterization

93457

Catheter placement in coronary artery(s) for coronary angiography, withcatheter placement(s) in bypass graft(s) (internal mammary, free arterial,venous grafts) including intraprocedural injection(s) for bypass graftangiography and right heart catheterization

93458Catheter placement in coronary artery(s) for coronary angiography, with leftheart catheterization including intraprocedural injection(s) for leftventriculography

93459

Catheter placement in coronary artery(s) for coronary angiography, with leftheart catheterization including intraprocedural injection(s) for leftventriculography, catheter placement(s) in bypass graft(s) (internal mammary,free arterial, venous grafts) with bypass graft angiography

93460Catheter placement in coronary artery(s) for coronary angiography, with rightand left heart catheterization including intraprocedural injection(s) for leftventriculography

93461

Catheter placement in coronary artery(s) for coronary angiography, with rightand left heart catheterization including intraprocedural injection(s) for leftventriculography, catheter placement(s) in bypass graft(s) (internal mammary,free arterial, venous grafts) with bypass graft angiography

92920 Percutaneous transluminal coronary angioplasty; single major coronary arteryor branch

October 2018 Anthem Provider Newsletter - Virginia Page 28 of 43

92924 Percutaneous transluminal coronary atherectomy, with coronary angioplasty whenperformed; single major coronary artery or branch

92928 Percutaneous transcatheter placement of intracoronary stent(s), with coronaryangioplasty when performed; single major coronary artery or branch

92933 Percutaneous transluminal coronary atherectomy, with intracoronary stent, withcoronary angioplasty when performed; single major coronary artery or branch

92937

Percutaneous transluminal revascularization of or through coronary artery bypassgraft (internal mammary, free arterial, venous), any combination of intracoronarystent, atherectomy and angioplasty, including distal protection when performed;single vessel

92943Percutaneous transluminal revascularization of chronic total occlusion, coronaryartery, coronary artery branch, or coronary artery bypass graft, any combination ofintracoronary stent, atherectomy and angioplasty; single vessel

For questions regarding precertification or prior authorization requirements, please contactthe provider service number on the back of the member ID card.

URL: https://providernews.anthem.com/virginia/article/new-precertification-requirements-for-certain-cardiovascular-diagnostic-and-interventional-services-begins-january-1-2019

Update to AIM Specialty Health radiation oncology clinicalappropriateness guidelinesPublished: Oct 1, 2018 - Products & Programs

Effective for dates of service on and after January 28, 2019, the following updates will applyto the AIM Specialty Health© (AIM), a separate company, radiation oncology clinicalappropriateness guidelines: Breast cancer

Removed age and tumor size criteria for accelerated whole breast irradiation (AWBI).

Rectal cancer

Modified criteria no longer limits treatment with IMRT for rectal adenocarcinoma.

October 2018 Anthem Provider Newsletter - Virginia Page 29 of 43

Pancreatic cancer

Added criteria for SBRT in treating locally advanced or recurrent disease withoutevidence of distant metastasis.

Head and neck cancer

Added criteria to allow IMRT for head and neck lymphomas.

Clarified no IMRT for stage I/II glottic cancer.

Lung cancer

Added DVH parameter for cardiac V50.

Sarcoma

Removed preoperative and joint sparing requirements for IMRT.

Prostate cancer

Added discussion on hypofractionation.

Added discussion on brachytherapy.

As a reminder, ordering and servicing providers may submit prior authorization requests toAIM in one of several ways:

October 2018 Anthem Provider Newsletter - Virginia Page 30 of 43

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

Access AIM via the Availity Web Portal at availity.com.

Call the AIM Contact Center toll-free number: 866-789-0158, Monday - Friday, 8 a.m.to 5 p.m. ET.

For questions related to guidelines, please contact AIM via email ataim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copyof the current guidelines on AIM’s website. Please note, this program does not apply to the Federal Employee Program (FEP) orNational Accounts.

URL: https://providernews.anthem.com/virginia/article/update-to-aim-specialty-healthc-radiation-oncology-clinical-appropriateness-guidelines-3

Update to AIM Specialty Health sleep disorder managementclinical appropriateness guidelinesPublished: Oct 1, 2018 - Products & Programs

Effective for dates of service on and after January 28, 2019, CPT code A7047 (oralinterface used with respiratory suction pump) will be removed from the AIM SpecialtyHealth© (AIM), a separate company, sleep disorder management clinical appropriatenessguidelines and will no longer apply.

As a reminder, ordering and servicing providers may submit prior authorization requests toAIM in one of several ways:

October 2018 Anthem Provider Newsletter - Virginia Page 31 of 43

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

Access AIM via the Availity Web Portal at availity.com.

Call the AIM Contact Enter toll-free number: 866-789-0158, Monday - Friday, 8 a.m. to5 p.m. ET.

For questions related to guidelines, please contact AIM via email ataim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copyof the current guidelines on AIM’s website Please note, this program does not apply to the Federal Employee Program (FEP).

URL: https://providernews.anthem.com/virginia/article/update-to-aim-specialty-healthc-sleep-disorder-management-clinical-appropriateness-guidelines-3

Innovative ways to help improve your patients’ experiences andearn CME creditsPublished: Oct 1, 2018 - Products & Programs

Numerous studies have shown that a patient’s primary health care experience and, to someextent their health care outcomes, are largely dependent upon health care provider andpatient interactions. Anthem Bue Cross and Blue Shield offers a new online learning course– What Matters Most: Improving the Patient Experience – to address gaps in and offerapproaches to communication with patients. This curriculum is available at no cost toproviders and their clinical staff nationwide and is acceptable for up to one (1) prescribedcontinuing medical education (CME) credit by the American Academy of Family Physicians. Through the use of compelling real-life stories that convey practical strategies forimplementing patient care, providers learn how to apply best practices. Did you know?

October 2018 Anthem Provider Newsletter - Virginia Page 32 of 43

Substantial evidence points to a positive association between the patient experienceand health outcomes.

Patients with chronic conditions, such as Diabetes, demonstrate greater self-management skills and quality of life when they report positive interactions with theirhealth care providers.

Patients reporting the poorest-quality relationships with their physicians were threetimes more likely to voluntarily leave the physician's practice than patients with thehighest-quality relationships.*

How will this benefit you and your office staff? You’ll learn tips and techniques to:

Improve communication skills.

Build patient trust and commitment.

Expand your knowledge of the Consumer Assessment of Healthcare Providers andSystems (CAHPS) survey.

The course can be accessed at www.patientexptraining.com using your smartphone,tablet, or computer.

Like you, Anthem is committed to improving the patient experience in all interactions, and weare proud to work collaboratively with our provider network to provide support and tools toreach our goal.

Take the course today.

* Source: Please visit www.patientexptraining.com

October 2018 Anthem Provider Newsletter - Virginia Page 33 of 43

URL: https://providernews.anthem.com/virginia/article/innovative-ways-to-help-improve-your-patients-experiences-and-earn-cme-credits

State employees eligible to participate in Vitals SmartShopperprogram beginning October 1Published: Oct 1, 2018 - Products & Programs

At the direction of the Virginia General Assembly, Commonwealth of Virginia stateemployees with COVA Care or COVA HDHP plans are eligible to participate in a newAnthem program beginning October 1, 2018, that will help make their health care shoppingexperience simpler and more cost efficient. Vitals SmartShopper is a voluntary programthat offers monetary incentives to employees, early retirees, COBRA participants, andcovered dependents who use more cost-effective sites of care for certain health services.Additional information on this program will be outlined in the coming weeks and shared inupcoming provider newsletter editions.

URL: https://providernews.anthem.com/virginia/article/state-employees-eligible-to-participate-in-vitals-smartshopper-program-beginning-october-1

HEDIS® 2018: Provider incentive winners announcedPublished: Oct 1, 2018 - Products & Programs

Anthem Blue Cross and Blue Shield has completed the HEDIS data collection for 2018 andwants to thank all of our provider offices and their staffs who assisted us. Your collaborationin this process allows us to strive for the best HEDIS results possible. This is year seven for our incentive program to acknowledge some of our providers whoeither responded in a timely manner or went “Above & Beyond” to help make our HEDISdata collection successful. Any practices that responded within 5 business days of ourinitial request or who went out of their way by taking additional steps to help us with datacollection were entered in a drawing to receive a gift. We are pleased to announce that ourincentive winners are: Virginia HEDIS drawing winners:

John Min – Centreville, Virginia

October 2018 Anthem Provider Newsletter - Virginia Page 34 of 43

Fairfax Health Center – Fairfax, Virginia

Health Center for Women & Families – Farmville, Virginia

Richmond Pediatric Associates – Richmond, Virginia

James Ponder – Franklin, Virginia

Virginia Above and Beyond Winners:

Central Virginia Health Services – New Canton, Virginia

Overton Wiley Kirchmier Terry – Richmond Virginia

Our HEDIS results reflect the care you provide to our members. Now is the time to reviewyour patients’ records to ensure that they have received their preventative care and/orimmunizations before the end of the year.

An overview of our HEDIS rates will be published in the fourth quarter provider newsletter. Inaddition, more information on HEDIS can be found by visiting the provider portal at:www.anthem.com > Provider > State > Health & Wellness > Quality Improvement andStandards > HEDIS Information. Thanks again to all of our provider offices and their staffs for assisting us in collecting HEDISdata. We look forward to working with you next HEDIS season. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

URL: https://providernews.anthem.com/virginia/article/hedis-2018-provider-incentive-winners-announced-12

October 2018 Anthem Provider Newsletter - Virginia Page 35 of 43

Additional drugs added to the specialty pharmacy clinicallyequivalent drug list effective January 1, 2019Published: Oct 1, 2018 - Products & Programs / Pharmacy

Anthem Blue Cross and Blue Shield in Virginia and affiliate HealthKeepers, Inc. will expandour specialty pharmacy clinically equivalent drug list. Effective for dates of service on and after January 1, 2019, the following specialty pharmacycodes from new or current coverage guidelines or clinical utilization management (UM)guidelines will be included in our existing specialty pharmacy clinically equivalent reviewprocess defined by CG-DRUG-64, FDA Approved Biosimilar Products. Clinical UMGuideline Drug HCPCS or CPT Code

CG-DRUG-09

Cuvitru Hizentra HyQvia

J1555 J1559 J1575

URL: https://providernews.anthem.com/virginia/article/additional-drugs-added-to-the-specialty-pharmacy-clinically-equivalent-drug-list-effective-january-1-2019

Access patient-specific drug benefit information through EMRPublished: Oct 1, 2018 - Products & Programs / Pharmacy

Providers can access real-time, patient-specific prescription drug benefit information at thepoint of care. It is part of the e-prescribing process, and is located within a provider’selectronic medical record (EMR) system. This functionality helps providers determine prescription coverage quicker by sharinginformation about patient drug cost, formulary, and coverage alerts such as priorauthorization to sending a prescription to the pharmacy. This information can help providersproactively identify barriers to medication compliance. For example, if a medication is too

October 2018 Anthem Provider Newsletter - Virginia Page 36 of 43

costly for the member, alternatives can be discussed prior to the patient leaving theprovider’s office. Providers can find the following patient-specific prescription benefit information with theirEMR:

Formulary status of selected medication.

Pricing of medication at a retail and mail order pharmacy.

Formulary alternatives.

Coverage alerts, including prior authorization and step therapy.

Providers should contact their IT department or EMR system with questions regardingaccess to real-time prescription drug benefit functionality. Upgrades to EMR software may berequired.

URL: https://providernews.anthem.com/virginia/article/access-patient-specific-drug-benefit-information-through-emr-4

Pharmacy information available on anthem.comPublished: Oct 1, 2018 - Products & Programs / Pharmacy

For more information on copayment/coinsurance requirements and their applicable drugclasses, drug lists and changes, prior authorization criteria, procedures for genericsubstitution, therapeutic interchange, step therapy or other management methods subject toprescribing decisions, and any other requirements, restrictions, or limitations that apply tousing certain drugs, visit anthem.com/pharmacy information. The drug lists for our PAR,PPO and Anthem HealthKeepers lines of business (including marketplace drug lists) arereviewed, and updates are posted to the website quarterly (the first of the month for January,April, July and October). For pharmacy information available on the Web, go to anthem.comand select “Providers” from the top menu (or Providers under the “Partner Login” section can

October 2018 Anthem Provider Newsletter - Virginia Page 37 of 43

be used too) > Select find resources for Virginia > On the Virginia provider home page,select the “Plans & Benefits” tab and scroll down to “Pharmacy Operations.” For State-sponsored Business [Anthem HealthKeepers Plus (Medicaid/FAMIS)], visit SSBPharmacy Information. This drug list is also reviewed and updated regularly as needed. Effective January 1, 2018, AllianceRX Walgreens Prime is the new specialty pharmacyprogram for the Blue Cross and Blue Shield Service Benefit Plan (also called the FederalEmployee Program or FEP). You can view the 2018 Specialty Drug List or call us at 1-888-346-3731 for more information. This drug list is also reviewed and updated quarterly. FEP Pharmacy updates and otherpharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.

URL: https://providernews.anthem.com/virginia/article/pharmacy-information-available-on-anthemcom-13

HealthKeepers, Inc. fights opioid addiction: Extension forCommunity Health Care Outcomes and quality medication-assisted therapyPublished: Oct 1, 2018 - State & Federal / Medicaid

The following information addresses Anthem HealthKeepers Plus programs offered byHealthKeepers, Inc. Extension for Community Health Care Outcomes (ECHO) People are dying of opioid addiction. With the medication assisted treatment, you can helpsave lives. Join one of several video tele-consultative ECHO learning communitiesnationwide and participate with other clinicians learning about medication-assisted treatmentfor individuals with opioid disorders. For more information, visit the ECHO website athttps://echo.unm.edu. Benefits of participating include:

Addiction treatment training.

Free continuing education credits.

October 2018 Anthem Provider Newsletter - Virginia Page 38 of 43

Opportunity to receive expert input on your (de-identified) patient cases.

Access to a virtual learning community for treatment guidelines, tools and patientresources.

Opportunity to ask questions and get a variety of support from specialists.

Quality Medication-Assisted Therapy (MAT) To help ensure members have access to comprehensive evidence-based care,HealthKeepers, Inc. is committed to helping our providers double the number of memberswho receive behavioral health services as part of MAT for opioid addiction. When treating patients with opioid use disorder, it is considered best practice to offer andarrange evidence-based treatment. This usually consists of MAT with naltrexone,buprenorphine or, in some plans, methadone in combination with behavioral therapies.Behavioral therapies focused on medication adherence and relapse prevention can improveMAT outcomes and improve other social determinants of health, including development ofan enhanced social support network in recovery.

For more information For more information about what is considered best practice for medication-assistedtreatment, please read the American Society of Addiction Medicine’s National PracticeGuideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use. You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for moreinformation about the ECHO and MAT programs.

URL: https://providernews.anthem.com/virginia/article/healthkeepers-inc-fights-opioid-addiction-extension-for-community-health-care-outcomes-and-quality-medication-assisted-therapy

Orientations and training sessions offered to all providersPublished: Oct 1, 2018 - State & Federal / Medicaid

October 2018 Anthem Provider Newsletter - Virginia Page 39 of 43

HealthKeepers, Inc. now conducts monthly provider orientations and training sessions forAnthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus)and Medallion 4.0 programs. These orientations and trainings are for both contracted and noncontracted providers, givingnew providers information about engaging the Medicaid health plan and presenting existingproviders an opportunity to learn about new initiatives. You can find a schedule of the orientations on the provider website athttps://mediproviders.anthem.com/va/pages/manuals-directories-training.aspx

URL: https://providernews.anthem.com/virginia/article/orientations-and-training-sessions-offered-to-all-providers-1

Medical Policies and Clinical Utilization Management GuidelinesupdatePublished: Oct 1, 2018 - State & Federal / Medicaid

Medical Policies update On January 25, 2018, the medical policy and technology assessment committee (MPTAC)approved the following Medical Policies applicable to Anthem HealthKeepers Plus members.These policies were developed or revised to support clinical coding edits. Several policieswere revised to provide clarification only and are not included in the below listing. The Medical Policies were made publicly available on our provider website on the effectivedate listed. To search for specific policies, visithttps://mediproviders.anthem.com/va/Pages/medical.aspx.

Please note:

Starting July 1, 2018, AIM Specialty Health®Cardiology and Radiation OncologyGuidelines are utilized for clinical reviews.

For markets with carved-out pharmacy services, the applicable listings below areinformational only.

October 2018 Anthem Provider Newsletter - Virginia Page 40 of 43

Existing precertification requirements have not changed. Please share this notice withother members of your practice and office staff.

Publishdate

MedicalPolicynumber

Medical Policy titleNew orrevised

2/28/2018 DRUG.00116Vestronidase alfa(Mepsevii™)

New

2/28/2018 DRUG.00046 Ipilimumab (Yervoy®) Revised2/28/2018 DRUG.00075 Nivolumab (Opdivo®) Revised

2/28/2018 DRUG.00077Monoclonal Antibodies toInterleukin-17A

Revised

2/1/2018 DRUG.00080Monoclonal Antibodies forthe Treatment ofEosinophilic Conditions

Revised

2/28/2018 DRUG.00082Daratumumab(DARZALEX™)

Revised

2/28/2018 DRUG.00099Cerliponase Alfa(Brineura™)

Revised

2/28/2018 GENE.00028Genetic Testing forColorectal CancerSusceptibility

Revised

2/1/2018 GENE.00029Genetic Testing for Breastand/or Ovarian CancerSyndrome

Revised

2/28/2018 GENE.00035Genetic Testing for TP53Mutations

Revised

2/28/2018 MED.00100

Diaphragmatic/PhrenicNerve Stimulation andDiaphragm PacingSystems

Revised

2/1/2018 SURG.00011

Allogeneic, Xenographic,Synthetic and CompositeProducts for WoundHealing and Soft TissueGrafting

Revised

2/1/2018 SURG.00098 Mechanical Embolectomy

October 2018 Anthem Provider Newsletter - Virginia Page 41 of 43

for Treatment ofAcute Stroke

Revised

2/28/2018 SURG.00145

MechanicalCirculatory AssistDevices (VentricularAssist Devices,PercutaneousVentricular AssistDevices andArtificial Hearts)

Revised

Clinical Utilization Management Guidelines update On January 25, 2018, the MPTAC approved the following Clinical Utilization Management(UM) Guidelines to Anthem HealthKeepers Plus members. These clinical guidelines weredeveloped or revised to support clinical coding edits. Several guidelines were revised toprovide clarification only and are not included in the following listing. This list represents theClinical UM Guidelines adopted by the medical operations committee for the GovernmentBusiness Division on March 2, 2018. The clinical guidelines were made publicly available on our provider website on the effectivedate listed. To search for specific guidelines, visithttps://mediproviders.anthem.com/va/Pages/medical.aspx. Please note:

Starting July 1, 2018, AIM Specialty Health®Cardiology and Radiation OncologyGuidelines are utilized for clinical reviews.

For markets with carved-out pharmacy services, the applicable listings below areinformational only.

Existing precertification requirements have not changed. Please share this notice withother members of your practice and office staff. Publish

October 2018 Anthem Provider Newsletter - Virginia Page 42 of 43

dateClinical UMGuidelinenumber

Clinical UM Guideline titleNew orrevised

5/1/2018 CG-DME-42Nonimplantable InsulinInfusion and Blood GlucoseMonitoring Devices

New

5/1/2018 CG-DME-43High-Frequency ChestCompression Devices forAirway Clearance

New

5/1/2018 CG-DRUG-82

Prostacyclin Infusion Therapyand Inhalation Therapy forTreatment of PulmonaryArterial Hypertension

New

5/1/2018 CG-DRUG-83 Growth Hormone New5/1/2018 CG-DRUG-84 Belimumab (Benlysta®) New5/1/2018 CG-DRUG-85 Tesamorelin (Egrifta®) New

5/1/2018 CG-DRUG-86Ocriplasmin (Jetrea®)Intravitreal InjectionTreatment

New

5/1/2018 CG-DRUG-87 Vedolizumab (Entyvio®) New5/1/2018 CG-DRUG-88 Dupilumab (Dupixent®) New5/1/2018 CG-SURG-70 Gastric Electrical Stimulation New5/1/2018 CG-SURG-71 Reduction Mammaplasty New5/1/2018 CG-SURG-72 Endothelial Keratoplasty New

7/1/2018CG-THER-RAD-03

Radioimmunotherapy andSomatostatin ReceptorTargeted Radiotherapy

New

7/1/2018CG-THER-RAD-04

Selective Internal RadiationTherapy of Primary orMetastatic Liver Tumors

New

5/1/2018 CG-DRUG-29 Hyaluronan Injections Revised

2/28/2018 CG-DRUG-50Paclitaxel, protein bound(Abraxane®)

Revised

2/28/2018 CG-DRUG-59 Testosterone Injectable Revised

2/28/2018 CG-DRUG-73Denosumab (Prolia®,Xgeva®)

Revised

2/28/2018 CG-DRUG-78Antihemophilic Factors andClotting Factors

Revised

October 2018 Anthem Provider Newsletter - Virginia Page 43 of 43

2/28/2018 CG-MED-39

Central (Hip or Spine) BoneDensity Measurement andScreening for VertebralFractures Using Dual EnergyX-Ray Absorptiometry

Revised

2/28/2018 CG-MED-53Cervical Cancer ScreeningUsing Cytology and HumanPapillomavirus Testing

Revised

2/28/2018 CG-SURG-33Lumbar Fusion and LumbarTotal Disc Arthroplasty

Revised

Coverage Guidelines and Clinical Utilization Management Guidelines update The Coverage Guidelines and Clinical Utilization Management (UM) Guidelines below, whichare applicable to Anthem HealthKeepers Plus members, were developed or revised tosupport clinical coding edits. Note, several guidelines were revised to provide clarificationonly and are not included. Existing precertification requirements have not changed. Formarkets with carved-out pharmacy services, the applicable listings below are informationalonly. Please share this notice with other members of your practice and office staff. To search for specific guidelines, visithttps://mediproviders.anthem.com/va/Pages/medical.aspx.

Coverage Guidelines On March 22, 2018, the Medical Policy and Technology Assessment Committee (MPTAC)approved the following Coverage Guidelines applicable to HealthKeepers, Inc.

Publishdate

CoverageGuidelinesnumber

Coverage Guidelines titleNew orrevised

3/29/2018 MED.00120Voretigene neparvovec-rzyl(Luxturna™)

New

4/25/2018 SURG.00151Balloon Dilation of EustachianTube

New