Tag: #Anthem

Posted in BCBS (Various States), Training, Updates

BCBS Kentucky: prior authorization requirements for admissions to in-network skilled nursing facilities

Posted on by KR2Medical Billing

The following information applies to Kentucky Anthem BCBS local Commercial health plans.

Updated guidance for prior authorization requirements for admissions to in-network skilled nursing facilities (SNFs).

The Updated process applies to hospital inpatient transfers to SNFs only.

NOT TO  transfers from Acute inpatient Rehab, LTAC to SNF, or SNF to SNF.

Note: This updated process does not apply to admissions to out-of-network SNF facilities.

According to Anthem BCBS of Kentucky-effective August 1, 2021, Anthem will allow a 5-day initial length of stay upon notification of an admission to an in-network SNF facility for Kentucky local Commercial members.

  • Facility and physician must be in-network for the member.
  • Anthem will require notification of the SNF admission, which includes sending demographics and verification of benefits via the usual channel.
  • Anthem will approve an initial 5-day length of stay without the need to provide clinical information.
  • SNF providers will need to submit the clinical information within two business days after the admission to aid in our members’ care coordination, discharge planning and member management. Note that prior authorization is still required but we allow the transfer to SNF, and then allow provider to send clinical within 2-days after the admission.
  • Concurrent review will be required starting on day 5 of the SNF stay.
  • Anthem may apply monetary penalties such as a reduction in payment, for failure to provide timely notice of admission.

Anthem BCBS of Kentucky also stated that they will monitor this process through December 31, 2021 and conduct random audits and monitor trends to evaluate its effectiveness.

Looking for more information? The following FAQs will help you answer some of the questions:

1. As a SNF provider, do I need to send information and notification to Anthem as I would normally do for a prior authorization?

Yes, notification is still required. However, you can notify Anthem of the admission and move the member without having to send in clinical information or wait for an approval. It will be important to verify member benefits.

2. When do I need to submit clinical information?

For the initial SNF admission, no later than two business days after the admission and for continued stay, prior to the last covered day.

3. Does this apply to SNF, IP Rehab and LTAC admissions and related transportation (air or ground ambulance)?

This process is only applicable to the initial SNF admission. Follow standard prior authorization process for IP Rehab, LTAC and any related transportation.

4. For the SNF initial authorization of 5 days, will Anthem assign a level of care?

Anthem UM will assign Level of care once the clinical information is received from the SNF.

5. What if a member needs to be admitted for wound care and IV antibiotics?

If a SNF has any concerns about the criteria for admission, they may still do the full prior authorization process.

6. If the physician and/or facility are out-of-network for the member, does this process apply?

No, the facility AND physician both need to be in network. All out-of-network facilities and providers must follow the full prior authorization process.

7. What if I am uncertain if the member is a local commercial member?

This process is applicable to local commercial accounts only.  It does not apply to FEP, National, Medicaid, Medicare, or IHM. If you are uncertain, reach out to the Anthem dedicated nurse for your facility.

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Posted in BCBS (Various States), Training, Updates

BCBS Nevada Medicare Advantage Group Retiree Plans information

Posted on by KR2Medical Billing

Group Retiree Medicare Advantage has two plans PPO and National Access Plus. These plans are offered through Anthem BCBS (Anthem).

Below please find the FAQs regarding these 2 plans:

What does Anthem BCBS Nevada Group Retiree Medicare Advantage PPO and National Access Plus Plans may include?

Group Retiree Medicare Advantage memberships may include the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare and accepts the member’s PPO plan.

Extra services that traditional Medicare does not cover?

The PPO plans also offer benefits that original Medicare doesn’t cover, including an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online* and SilverSneakers®.*

Anthem Medicare Preferred (PPO):

Front of the card
Front of the card

Sample Mediblue Freedom (PPO) Plan cards:

Front of the card
Front of the card

What are the alpha prefixes for Group Retiree Medicare Advantage PPO members?

Do I need to participate in the Medicare Advantage PPO network to see members with the
National Access Plus benefit?
No contract is required. You can still see your current patients and new patients who have one of the following Medicare Advantage PPO plans:
 Anthem Medicare Preferred (PPO)
 Empire MediBlue Freedom (PPO)

What is the payment rate for out-of-network providers who treat Medicare Advantage PPO
members with the National Access Plus benefit? Out-of-network providers are paid Medicare allowable rates for covered services, less the member’s copay, coinsurance, and/or deductible.

Does the member have a higher copay if they see me as an out-of-network provider?The National Access Plus benefit allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. The member’s copay or coinsurance percentage will be the same whether his/her provider is in- or out-of-network. Whether local or nationwide, doctor or hospital, in- or out-of-network — the member’s cost share doesn’t change. If the member is in one of our PPO plans but the plan does not include the National Access Plus benefit, the member could have a higher copay. Please check member eligibility and benefits to verify the cost share.

How does a provider file claims for Medicare Advantage PPO members with or without the National Access Plus benefit?
Providers may submit claims electronically using the electronic payer ID for the Anthem plan in their state or submit a UB-04 or CMS-1500 form to the Anthem plan in their state. Claims should not be filed with original Medicare. You can file a claim:

  1. Online at availity.com.
  2. Via mail by sending it to the medical claims and inquiries filing address on the back of the member’s ID
    card.

I do not participate in the Medicare Advantage PPO network. I am waiting to hear if a PA
request is approved. Should I ask the member to reschedule or postpone the appointment
until I have confirmation that my PA request is approved?
Non-contracted providers are not required to request PA, but we recommend that you do so to ensure we can assist you with any questions or issues. Anthem will work with providers to approve PAs so members do not postpone appointments.

Are referrals required?
No, members are not required to obtain a referral before they see a provider.

For a complete list of FAQs, including Utilization Management/Prior Authorization process information, please click here for a pdf attachment.

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Posted in BCBS Empire NY, Pharmacy (Various Insurance Payers), Training, Updates

Empire BCBS (NY) Specialty Pharmacy Changes updates for 2021

Posted on by KR2Medical Billing

Reminder #1:

  1. Empire BlueCross BlueShield’s (“Empire”) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team.
  2. Oncology drugs will be managed by AIM Specialty Health (AIM), a separate company.

New Clinical Criteria effective December 22, 2020

The following clinical criteria is new.

  • ING-CC-0184 Danyelza (naxitamab-gqgk)

New Clinical Criteria effective June 1, 2021

The following clinical criteria is new.

  • ING-CC-0185 Oxlumo (lumasiran)

Revised Clinical Criteria Effective 12/22/2020:

The following current clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0124 Keytruda (pembrolizumab)

Revised Clinical Criteria effective January 25, 2021

The following current clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0002 Colony Stimulating Factor Agents
  • ING-CC-0015 Infertility and HCG Agents
  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0154 Givlaari (givosiran)

Revised Clinical Criteria effective January 25, 2021

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

  • ING-CC-0079 Strensiq (Asfotase Alfa)
  • ING-CC-0177 Zilretta (triamcinolone acetonide extended-release)

Revised Clinical Criteria effective June 1, 2021

The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0154 Givlaari (givosiran)

Reminder #2:

Effective June 12, 2021, Empire BCBS NY will be implementing coding updates in the claims system for the following clinical criteria listed below which may result in not medically necessary determinations for certain services.

  • ING-CC-0066 Monoclonal Antibodies to Interleukin-6

To view the complete policies, please visit the following links:

  1. Danyelza
  2. Oxlumo
  3. Keytruda
  4. Colony Stimulating Factor Agents
  5. Infertility and HCG Agents
  6. Botulinum Toxin
  7. Givlaari
  8. Strensiq
  9. Zilretta