UpdateSM October 2020 Recap - Independence ...
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update SM
October 2020 Recap
This publication contains articles previously published on our Provider News Center.
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company, and with Highmark
Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
Inside this edition
Administrative ● U pdates to the list of specialty drugs that
● New Provider Experience Initiative will require precertification
● New! Independence accepting ● Independence to update telemedicine
applications for inaugural Clinical Care coverage in 2021
Innovation Grants ● Independence to decrease clinical
● Required lead time when updating your update frequency for Medicare
provider information Advantage inpatient stays
● Updated policies on musculoskeletal
Health & Wellness services: AIM guidelines for select
● W
ith SilverSneakers®, patients are free interventional pain management and
to move spinal and joint surgical procedures
● Health of America Report: Millennial ● Reminder: The annual Synagis®
health trends in behavioral conditions (palivizumab) distribution program
● Encouraging care for parents and ● Diabetic retinopathy pilot program
guardians of your Keystone HMO CHIP continues
patients: Immunizations ● Avastin® is the preferred product for
treatment of vascular endothelial growth
Medical factor
● C overage changes for select injectable ● Upcoming changes to billing
asthma drugs requirements for deep brain stimulation
● Now in effect: Three drugs added to the ● View up-to-date policy activity on our
Most Cost-Effective Setting Program Medical and Claim Payment Policy
● eviCore Lab Management Program Portal
expanding to Medicare Advantage PEAR portal
members
● C
oming soon to the PEAR portal: PEAR
● Now in effect! Updated Radiation Comprehensive Visit
Therapy Clinical Guidelines
● Updates to the medical benefit Products
specialty drug cost-share list effective ● W
hat’s new for 2021 Medicare
January 1, 2021 Advantage plans
● Independence Administrators to delegate
some precertification to eviCore Quality Management
● Medical necessity criteria for skilled ● O
pt in now to the QIPS program –
and subacute care in a Skilled Nursing measurement year 2021
Facility
COVID-19
For up-to-date information on our response to
COVID-19, please visit our Provider News Center.
For articles specific to your area of interest, look for the appropriate icon:
Professional Facility Ancillary
October 2020 | Partners in Health UpdateSM 2 www.ibx.com/pnc
ADMINISTRATIVE New Provider Experience Initiative Published October 15, 2020 (Read online) Independence is committed to improving the quality of the relationships we have with our participating hospitals, doctors, and other medical professionals that our members trust and rely on. That is why we are pleased to announce the launch of the Provider Experience Initiative. This new initiative is focused on strengthening the partnerships we have with providers in the region. Through the Provider Experience Initiative, we hope to: ● Make it easier for you to work with us by maximizing efficiency, simplifying day-to-day interactions, and streamlining processes for activities such as claims processing, credentialing, utilization management, and benefit eligibility. ● Be a more accessible partner by enhancing bi-directional information sharing, helping you better navigate our organization, and assisting you in making clinical care investments. ● Better align on our shared mission of improving our members’ and your patients’ care by listening closely to your feedback and developing programs that simplify and optimize value-based models of care. Independence is committed to this initiative. We’ve already communicated some of the changes we are making, like introducing a new provider engagement application called PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR portal). This will replace the NaviNet® web portal (NaviNet Open) and make a real difference in how we all collaborate on care. As this type of activity continues, you can expect to see five-minute surveys sent quarterly to help measure your overall experience, new tools and technology that will enhance the way you work and communicate with us, increased support on innovations to improve clinical care, and streamlined processes for inquiries and issue escalation. We look forward to working with you on this important initiative. Learn more For more information, read the press release on the Independence Newsroom. NaviNet® is a registered trademark of NantHealth, an independent company. October 2020 | Partners in Health UpdateSM 3 www.ibx.com/pnc
ADMINISTRATIVE New! Independence accepting applications for inaugural Clinical Care Innovation Grants Published October 16, 2020 (Read online) Independence is introducing an annual Clinical Care Innovation Grant Program (Grant Program) intended to foster new, innovative approaches to care delivery that will ultimately help improve the health and well-being of its members. Health systems and large specialty groups that are in the Independence network and currently enrolled in a value-based care program are encouraged to apply. Five Clinical Care Innovation Grants will be awarded during 2021 with an average of $200,000 per grant. The submissions should be focused on ideas that are: ● New and innovative ● Improve quality and access to health care ● Enhance the patient experience ● Lower health care costs ● Bring patient care closer to home where possible Grant Program submissions are due by December 31, 2020. Each entity is permitted up to three submissions. The submissions will be evaluated internally by an Independence review committee; providers whose submissions are accepted will then be invited to present their idea(s) in January 2021. Winners will be notified by the end of January 2021. Learn more To learn more about the 2021 Grant Program, including specific information on the criteria and submission process, visit the Clinical Care Innovation Grant Program site. You can also read the press release on the Independence Newsroom. October 2020 | Partners in Health UpdateSM 4 www.ibx.com/pnc
ADMINISTRATIVE Required lead time when updating your provider information Published October 20, 2020 (Read online) Independence would like to remind you that submitting changes in a timely manner helps to ensure prompt payment of claims, delivery of critical communications, seamless recredentialing, and accurate listings in our provider directories.* In accordance with your Provider Agreement, the Provider Manual for Participating Professional Providers, and/or Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, as applicable, you are required to notify Independence whenever key provider demographic information changes. Please review our dedicated webpage to review the specific lead-time requirements, exceptions, and/or additional information for: ● Professional providers ● Facility and ancillary providers ● Authorizing signature and W-9 Forms Independence will not be responsible for changes not processed due to lack of proper notice. Failure to provide proper advance written notice to Independence may delay or otherwise affect provider payment. If you have questions related to updating your provider information after reviewing the webpage, please email our Provider Communications team at provider_communications@ibx.com. *Behavioral health providers contracted with Magellan Healthcare, Inc. (Magellan), an independent company, must submit any changes to their practice information to Magellan via their online Provider Data Change form by selecting the “Display/Edit Practice Info” link. Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members October 2020 | Partners in Health UpdateSM 5 www.ibx.com/pnc
HEALTH & WELLNESS With SilverSneakers®, patients are free to move Published October 5, 2020 (Read online) As restrictions that kept us in our homes are shifting, members health and safety remain our top priority. Movement and physical activity are essential to your patient’s health. SilverSneakers and Independence are here to support member’s physical well-being . Whether that means returning to a fitness location, enjoying a SilverSneakers LIVE class virtually from home, or taking a walk around the neighborhood. When the time is right, here are some tips that your office can provide to our Medicare Advantage members to help them prepare when returning to a participating fitness location: Before the visit: ● Call or check the fitness location’s* website to see if they’ve implemented any new guidelines. ● Ask if there are limited hours or special times for older adults. ● Prepare for a new experience. Equipment may have moved and class schedules† may have changed. During the visit: ● Follow all recommended guidelines. ● Use touchless check-in options when available. ● Wipe down equipment with disinfectant before and after use. Tips to prevent illness1 ● Wash hands often with soap and water for at least 20 seconds. ● Avoid close contact with those who are sick and keep appropriate distance from people outside the home. ● Clean and disinfect frequently touched surfaces daily. Click here for a complete guide to returning to the gym. At-home fitness options If Medicare Advantage members prefer virtual fitness options, SilverSneakers has at-home fitness options available. In addition to visiting physical locations, members can also create an online account to enjoy SilverSneakers On-DemandTM videos, plus classes and workshops through SilverSneakers LIVE. With SilverSneakers, members are free to move with more options than ever. Now is the time to stay active while staying safe. Encourage your Independence Medicare Advantage members to stay active with SilverSneakers. They can check their eligibility and learn more at SilverSneakers.com. 1 Centers for Disease Control and Prevention. “Prevent Getting Sick.” 2020. Available from https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting- sick/index.html *Membership includes SilverSneakers instructor-led group fitness classes. Some locations offer members additional classes. Classes vary by location. † Participating locations (“PL”) not owned or operated by Tivity Health, Inc. or its affiliates. Use of PL facilities and amenities limited to terms and conditions of PL basic membership. Facilities and amenities vary by PL. SilverSneakers is a registered trademark of Tivity Health, Inc. SilverSneakers On-Demand and SilverSneakers LIVE are trademarks of Tivity Health, Inc. © 2020 Tivity Health, Inc. All rights reserved. October 2020 | Partners in Health UpdateSM 6 www.ibx.com/pnc
HEALTH & WELLNESS Health of America Report: Millennial health trends in behavioral conditions Published October 27, 2020 (Read online) A new Blue Cross Blue Shield Association (BCBSA) report, “Millennial Health Trends in Behavioral Conditions”, found that nearly one third of millennials have a behavioral health condition, with significant increases in the prevalence of conditions like major depression (43%), ADHD (39%), and substance use disorder (SUD) (17%) since 2014. The report, part of The Health of America Report® series, analyzed a data sample of 55 million commercially insured Blue Cross® Blue Shield® (BCBS) members who belong to the millennial age group, defined as people ages 22 – 37 in 2018, based on the definition developed by Pew Research Center, and provides an update to the initial report on the Health of Millennials published last year. Report findings Millennials with behavioral health conditions are at nearly two-times the risk of developing chronic physical conditions such as: ● Hypertension (1.9 times) ● Crohn’s disease/ulcerative colitis (1.9 times) ● Type II diabetes (2.1 times) ● Coronary artery disease (2.7 times) The effects of COVID-19 The ongoing COVID-19 pandemic has had a larger negative health impact on the millennial age group compared to their baby boomer peers. According to a recent BCBSA survey, 92% of millennials said the COVID-19 pandemic has had a negative impact on their mental health, compared to 70% among baby boomers. Additionally, 80% of millennials believe that their mental health impacts their physical health, compared to 62% of baby boomers. A May 11, 2020, BCBSA report on behavioral health showed that certain negative behaviors — including alcohol consumption, smoking, vaping, and nonmedical drug use — have risen since the pandemic began. What we’re doing to help Independence is helping members with anxiety and stress related to the COVID-19 pandemic by offering telemedicine coverage for physical health and behavioral health, online cognitive behavior therapy modules, and stress reduction and improved sleep modules on Achieve Well-Being. We also offer a comprehensive COVID-19 Preparedness Tool developed by Quil, a digital health venture of Independence and Comcast. BCBSA is hosting a two-day virtual forum on October 28 and 29, 2020, to share new details and insights into how the health care industry can better support and address the unique health needs of both millennials and those in the caregiving community. Learn more For more information, read the press release on the Independence Newsroom. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. October 2020 | Partners in Health UpdateSM 7 www.ibx.com/pnc
HEALTH & WELLNESS
Encouraging care for parents and guardians of your Keystone
HMO CHIP patients: Immunizations
Published October 28, 2020 (Read online)
Independence is continuing its series of messages for the parents and/or guardians of our Keystone HMO Children’s
Health Insurance Program (Keystone HMO CHIP) members to help families manage their child’s health care. The topics
chosen are based on Healthcare Effectiveness Data and Information Set (HEDIS®) measures. We are sharing these
topics with you to help support compliance with these measures and to encourage families to obtain these important
services.
This month’s message is about the importance of immunizations.
Important information on HEDIS measures
Childhood immunizations
● Tdap/Td: Babies need three doses of Tdap to strengthen their immune system against tetanus, diphtheria and
pertussis. Then, to maintain that protection through early childhood, young children will need two additional booster
shots.
● Measure: At least four DTaP vaccinations (DTaP Administered Value Set) with different dates of service on or before
the child’s second birthday. The CDC recommends doses at the following ages:
− two months of age
− four months of age
− six months of age
− 15 through 18 months of age
− 4 through 6 years of age
Adolescent immunizations
● Combo 2 (Meningococcal, Tdap, HPV): Recommendations for adolescents are as follows:
− HPV. The Centers for Disease Control and Prevention (CDC) says all boys and girls ages 9 to 12 should get two
doses of the HPV vaccine. The shots should be spaced at least six months apart.
− Tdap. Preteens should get one dose, called Tdap, between the ages of 11 and 12 to boost their immunity.
− Meningococcal. Recommended when a child is 11 or 12 with a booster given at 16, or for when a child is 13 – 18 if
they haven’t been previously vaccinated.
● Measure:The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine, one tetanus,
diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV)
vaccine series by their 13th birthday.
How you can help
Ensure each Keystone HMO CHIP patient is kept up to date with his or her immunizations by updating and completing the
appropriate immunizations at each visit.
Stay tuned for more topics regarding care for your Keystone HMO CHIP patients.
October 2020 | Partners in Health UpdateSM 8 www.ibx.com/pncMEDICAL Coverage changes for select injectable asthma drugs Published October 1, 2020 (Read online) Independence is changing how we cover specialty drugs Fasenra® (benralizumab) and Nucala® (mepolizumab). These drugs are U.S. Food & Drug Administration (FDA)-approved to treat severe asthma and are currently covered under the medical benefit. In 2019, these drugs became available as self-administered injections. It is now more appropriate for plans to cover Fasenra and Nucala as a pharmacy benefit. Effective January 1, 2021, for members enrolled in commercial plans, Fasenra and Nucala will only be covered under the pharmacy benefit. What does this mean for your Independence patients? In November, Independence will mail letters to all commercial members who have received these drugs in the past twelve months. The letter will explain how this upcoming change will affect them. For commercial members who will be new to treatment on or after January 1, 2021, these drugs will only be covered under the member’s pharmacy benefit. Independence Medicare Advantage members will not be affected by this change. Next steps In November, we will mail letters to all providers who have prescribed Fasenra or Nucala in the past twelve months to Independence commercial members. These letters will provide detailed information about this change, such as: ● how members who are currently receiving these drugs are affected; ● the process for managing existing authorizations and obtaining new authorizations; ● writing new prescriptions for these drugs so pharmacy benefits managers can fulfill requests; ● medication delivery options – member’s home or provider’s office. Policy update Fasenra and Nucala will be added to Independence Claim Payment Policy #08.00.78ag: Self-Administered Drugs, which will become effective January 1, 2021. To view this policy, visit our Medical and Claim Payment Policy Portal. October 2020 | Partners in Health UpdateSM 9 www.ibx.com/pnc
MEDICAL Now in effect: Three drugs added to the Most Cost-Effective Setting Program Published October 1, 2020 (Read online) Independence seeks to ensure that our members receive injectable/infusion therapy drugs in a setting that is both safe and cost-effective. Since 2012, Independence has been reviewing the most appropriate setting for commercial members to receive certain injectable and infusion therapy drugs eligible for coverage under the medical benefit. As of October 1, 2020, the following drugs were added to our Most Cost-Effective Setting Program: ● Nyvepria™ (pegfilgrastim-apgf) ● Phesgo™ (pertuzumab/trastuzumab/hyaluronidase-zzxf) ● Uplizna™ (inebilizumab-cdon) New requests for these drugs will require review for setting, as well as medical necessity, during the precertification process. Members who have precertification approval to receive these drugs in a hospital outpatient facility may continue treatment in this setting until their current precertification approval expires. At the next precertification review, Independence will evaluate the requested setting and make a coverage determination. Resources Visit our Most Cost-Effective Setting Program webpage for more information, including a downloadable list of all 74 drugs on the program. October 2020 | Partners in Health UpdateSM 10 www.ibx.com/pnc
MEDICAL
eviCore Lab Management Program expanding to Medicare
Advantage members
Published October 1, 2020 (Read online)
Effective January 1, 2021, Independence is expanding its utilization management program for genetic/genomic tests,
certain molecular analyses, and cytogenetic tests for all Independence Medicare Advantage members. We are working
with eviCore healthcare (eviCore), an independent specialty benefit management company, to manage precertification
and/or prepayment coverage reviews for these tests.
Independence implemented this program for commercial members in 2016.
To view the full list of tests that require precertification, you can access the Independence Blue Cross Prior Authorization
Procedure List on eviCore’s website.
Please note that the ordering provider or laboratory is responsible for submitting precertification requests for the
applicable tests. If the precertification request is not approved, the provider or laboratory will be liable for the cost of the
test.
Precertification process
Ordering health care providers must contact eviCore to obtain precertification for certain genetic/genomic tests, including,
but not limited to, the following:*
● BRCA gene testing
● genetic panels and cancer gene expression tests
● genome-wide tests
● pharmacogenomic tests
You can initiate precertification for genetic/genomic tests in one of the following ways:
● NaviNet® web portal (NaviNet Open). Select eviCore from the Authorizations option in the Independence Workflows
menu.
● Telephone. Call eviCore directly at 1-866-686-2649.
Important information for laboratories
When a request for certain genetic/genomic testing is received, laboratories must ensure a precertification is on file before
rendering services. If a precertification is not on file for the member, it is the laboratory’s responsibility to go through the
above precertification process through eviCore.
Prepayment review
All genetic/genomic tests, along with certain molecular analyses and cytogenetic tests, are reviewed by eviCore prior to
final claim adjudication and payment (if applicable). Examples of molecular analyses and cytogenetic tests include, but
are not limited to:*
● flow cytometry
● fluorescent in situ hybridization (FISH)
● immunohistochemistry (IHC)
● karyotyping
● morphometric analyses
continued on the next page
October 2020 | Partners in Health UpdateSM 11 www.ibx.com/pncMEDICAL continued from the previous page Lab management policy Independence is currently creating a Medicare Advantage policy for the eviCore Lab Management Program. Learn more We will communicate more information about this program expansion in the coming months through Partners in Health UpdateSM articles and through the Medical and Claim Payment Policy Portal. *This list of services is subject to change. NaviNet® is a registered trademark of NanHealth, an independent company. October 2020 | Partners in Health UpdateSM 12 www.ibx.com/pnc
MEDICAL
Now in effect! Updated Radiation Therapy Clinical Guidelines
Published October 1, 2020 (Read online)
As of October 1, 2020, eviCore healthcare (eviCore), an independent specialty benefit management company, has
updated its Radiation Therapy Clinical Guidelines for Independence members.
Independence has delegated the responsibility for utilization management activities for certain radiation therapy services
to eviCore for commercial Independence members. eviCore is now using the updated Radiation Therapy Clinical
Guidelines to determine the medical necessity for these services.
Self-funded groups have the option to opt in therefore, your outcomes may vary by plan.
To access the updated guidelines, go to the Radiation Oncology section of eviCore’s website and type Independence Blue
Cross in the Search field.
Summary of changes
The following outlines changes to the Radiation Therapy Clinical Guidelines as of October 1, 2020:
There are three new guidelines and 13 revised guidelines with changes in the criteria sections. Additional
guidelines have been updated and/or revised, but these changes do not affect the criteria sections.
New guidelines:
1. Radiation Therapy for Skin Cancer – Basal cell and Squamous cell Cancers
2. Radiation Therapy for Skin Cancer – Melanoma
In previous versions, the two new guidelines were combined into one guideline titled “Radiation Therapy
for Skin Cancer.”
3. Xofigo®(Radium-223)
In previous versions, this new guideline was combined into the guideline titled “Radiation Therapy for Bone
Metastases.”
Criteria changes:
1. Image-Guided Radiation Therapy (IGRT) for specific diagnoses
2. Proton Beam Therapy for uveal melanoma
3. Radiation Therapy for Bone Metastases
4. Radiation Therapy for Brain Metastases
5. Radiation Therapy for Breast Cancer
6. Radiation Therapy for Cervical Cancer
7. Radiation Therapy for Non-Small Cell Lung Cancer
8. Radiation Therapy for Pancreatic Cancer
9. Radiation Therapy for Prostate Cancer
Consistent with the updated National Comprehensive Cancer Network (NCCN) Guidelines (March 2020),
eviCore has updated their Guidelines for Prostate Cancer to only consider hypofractionation medically
necessary for the following populations: low risk, intermediate risk, or high risk when not treating pelvic
lymph nodes. The Guidelines will no longer consider conventional fractionation medically necessary for
these populations.
continued on the next page
October 2020 | Partners in Health UpdateSM 13 www.ibx.com/pncMEDICAL
continued from the previous page
10. Radiation Therapy for Skin Cancer – Basal cell and Squamous cell Cancers
This is a new guideline that was part of the Radiation Therapy for Skin Cancer guideline.
11. Radiation Therapy for Skin Cancer – Melanoma
This is a new guideline that was part of the Radiation Therapy for Skin Cancer guideline.
12. Radiation Therapy for Small Cell Lung Cancer
13. Radiation Treatment with Xofigo® (Radium-223)
This is a new guideline that was part of the Radiation Therapy for Bone Metastases guideline.
Policies and guidelines
The following policies include a link to the Radiation Therapy Clinical Guidelines that eviCore uses and a list of procedure
codes effective October 1, 2020:
● Commercial: #09.00.56k: Radiation Therapy Services
● Medicare Advantage: #MA09.020k: Radiation Therapy Services
To view these policies, visit our Medical and Claim Payment Policy Portal.
October 2020 | Partners in Health UpdateSM 14 www.ibx.com/pncMEDICAL Updates to the medical benefit specialty drug cost-share list effective January 1, 2021 Published October 1, 2020 (Read online) Effective January 1, 2021, Independence will update its list of specialty drugs that require member cost-sharing (e.g., copayment, deductible, and coinsurance). Cost-sharing applies to select medical benefit specialty drugs for members who are enrolled in Commercial FLEX products and other select plans. The member’s cost-sharing amount is based on the terms of the member’s benefit contract. In accordance with your Provider Agreement, it is the provider’s responsibility to verify a member’s individual benefits and cost-share requirements. The cost-share list will be expanded to include 202 drugs, with the following additions: ● evinacumab* – Miscellaneous therapeutic agents ● Fensolvi® – Endocrine/metabolic agents ● inclisiran* – Miscellaneous therapeutic agents ● lumasiran* – Miscellaneous therapeutic agents ● Nyvepria™ – Neutropenia ● pegunigalsidase alfa* – Enzyme replacement factors ● sutimlimab* – Miscellaneous therapeutic agents For drugs that are pending approval from the U.S. Food and Drug Administration (FDA), their official brand names may be different than the names listed above. All names were valid at the time of article publication. In addition, the following changes will be made to the list: ● eptacog beta will be changed to Sevenfact®, to reflect its current brand name ● inebilizumab will be changed to Uplizna™, to reflect its current brand name ● Lucentis® will now carry a biosimilar indicator, as a biosimilar to Lucentis is in the FDA pipeline; once approved, this biosimilar will also be subject to cost-share ● Valrox will be changed to Roctavian™, to reflect its current brand name The above-mentioned changes will be available on our website. *Pending approval from the FDA. October 2020 | Partners in Health UpdateSM 15 www.ibx.com/pnc
MEDICAL Independence Administrators to delegate some precertification to eviCore Published October 1, 2020 (Read online) Beginning January 1, 2021, Independence Administrators will delegate precertification for certain services to eviCore healthcare (eviCore), an independent specialty benefit management company. Providers should seek precertification from eviCore for: ● certain genetic/genomic tests (i.e., nucleic acid testing) and certain molecular analyses; ● radiation therapy. Certain genetic/genomic tests and certain molecular analyses Precertification for certain genetic/genomic tests (i.e., nucleic acid testing) and molecular analyses is required through eviCore. The ordering provider is responsible for submitting precertification requests for the applicable tests. Failure to adhere to the precertification process may result in a bill to your patient. When a request for genetic/genomic testing is received, laboratories must ensure a precertification is on file before rendering services. If precertification is not on file for the member, it is the laboratory’s responsibility to submit a request to eviCore. Policy and guidelines For additional information on this utilization management program, please refer to Medical Policy #06.02.52q: eviCore Lab Management Program. We will update the policy on December 1, 2020, to include Independence Administrators. Radiation therapy Precertification for nonemergent outpatient radiation therapy services is required through eviCore. Precertification is not required when radiation therapy is rendered in the inpatient hospital setting. Consistent with the updated NCCN Guidelines, eviCore has updated their Guidelines to consider hypofractionation medically necessary for specific populations. The Guidelines will no longer consider conventional fractionation medically necessary for these indications. A request for precertification for conventional fractionation may require a peer-to-peer call with an eviCore Radiation Oncologist. Policy and guidelines For additional information on this utilization management program, please refer to Medical Policy #09.00.56k: Radiation Therapy Services. Learn more Additional information will be shared as it becomes available. October 2020 | Partners in Health UpdateSM 16 www.ibx.com/pnc
MEDICAL Medical necessity criteria for skilled and subacute care in a Skilled Nursing Facility Published October 1, 2020 (Read online) Independence will issue medical policies to communicate medical necessity criteria for the admission to and concurrent reviews for skilled and subacute levels of care in a Skilled Nursing Facility (SNF), effective November 1, 2020. The medical policies provide clinical criteria for rehabilitation and nursing services required for both medical necessity and level of care. The new policies were posted as Notifications on September 1, 2020, and will go into effect November 1, 2020: ● Commercial: #02.03.00: Skilled Nursing Facility (SNF): Skilled and Subacute Levels of Care ● Medicare Advantage: #MA02.004: Skilled Nursing Facility (SNF): Skilled and Subacute Levels of Care For more information about Independence policies, News Articles, and Notifications, please visit our Medical and Claim Payment Policy Center. October 2020 | Partners in Health UpdateSM 17 www.ibx.com/pnc
MEDICAL Updates to the list of specialty drugs that will require precertification Published October 2, 2020 (Read online) Effective January 1, 2021, the following specialty drugs, which are eligible for coverage under the medical benefit for Independence commercial and Medicare Advantage HMO and PPO members, will require precertification: ● Neupogen® (filgrastim) – Colony-stimulating factors ● Tecartus™ (brexucabtagene autoleucel) – Chimeric Antigen Receptor Therapy (CAR-T) ● Xiaflex® (collagenase clostridium histolyticum) – Miscellaneous therapeutic agents ● Zepzelca™ (lurbinectedin) – Antineoplastic agents In addition, the following drugs are pending approval from the U.S. Food and Drug Administration (FDA) and will require precertification for Independence members as of the date they receive FDA approval in 2021, or as of January 1, 2021, for any drug approved by the FDA in 2020: ● ciltacabtagene autoleucel – CAR-T ● dostarlimab – Anti-PD-1/PD-L1 ● evinacumab – Miscellaneous therapeutic agents ● idecabtagene vicleucel – CAR-T ● inclisiran – Miscellaneous therapeutic agents ● lumasiran – Miscellaneous therapeutic agents ● pegunigalsidase alfa – Enzyme replacement agents ● ranibizumab biosimilar – Ophthalmic agents. The antineoplastic agent belantamab mafodotin-blmf has been on the precertification list since January 2020; however, it recently received FDA approval and is now branded as Blenrep™. The precertification list will be updated to reflect this new brand name and will include any drug approved by the FDA in 2020. The following drugs will no longer require precertification approval from Independence as of January 1, 2021: ● Fasenra® (benralizumab) – Respiratory agents* ● Halaven® (eribulin mesylate) – Antineoplastic agents ● Jevtana® (cabazitaxel) – Antineoplastic agents ● Nucala® (mepolizumab) – Respiratory agents* ● Sylvant® (siltuximab) – Miscellaneous therapeutic agents *This drug is now available as a self-administered injection. It will no longer be eligible for coverage under the medical benefit for Commercial members, as of January 1, 2021. However, Medicare Advantage members can continue to receive this drug under the medical benefit, pending precertification approval from Independence. Lastly, the drugs Exondys-51® (eteplirsen), Viltepso™ (viltolarsen), and Vyondys-53® (golodirsen) will no longer require precertification approval as of January 1, 2021. These drugs will not be covered because Independence considers them to be experimental/investigational. Learn more In the absence of a published medical policy on any of these newly added drugs, all requests will be subject to review in accordance with the FDA-approved indications and Independence-recognized compendia. These changes will be reflected in an updated precertification requirement list, which will be posted to our website. October 2020 | Partners in Health UpdateSM 18 www.ibx.com/pnc
MEDICAL Independence to update telemedicine coverage in 2021 Published October 2, 2020 (Read online) Independence will update coverage of telemedicine services for members enrolled in commercial plans, effective for dates of service on or after January 1, 2021. This includes updates to eligible services and provider specialties. For more information about telemedicine services, please refer to Independence Medical Policy #00.10.41h: Telemedicine Services (Independence). It was posted as a Notification on October 2, 2020, and will go into effect January 1, 2021. To learn more about Independence policies, News Articles, and Notifications, please visit our Medical and Claim Payment Policy Portal. October 2020 | Partners in Health UpdateSM 19 www.ibx.com/pnc
MEDICAL Independence to decrease clinical update frequency for Medicare Advantage inpatient stays Published October 14, 2020 (Read online) Under diagnosis related group (DRG) reimbursement, hospitals are required to submit regular clinical updates to Independence on members undergoing inpatient care. Beginning November 2, 2020, the frequency of clinical updates needed for Medicare Advantage inpatient stays will change, and hospitals will only need to send Independence clinical updates on day 14 of the member’s inpatient stay and every 14 days thereafter. In some cases, a member’s care may require more frequent updates. These clinical updates help us ensure that the length of a member’s hospitalization is appropriate. They also promote collaboration with hospitals to establish timely discharge plans and case management referrals. While these ongoing reviews are concurrent, Independence will continue to review authorizations on a post-pay basis. Itemized bills and medical records may be requested for this review. October 2020 | Partners in Health UpdateSM 20 www.ibx.com/pnc
MEDICAL Updated policies on musculoskeletal services: AIM guidelines for select interventional pain management and spinal and joint surgical procedures Published October 14, 2020 (Read online) Effective January 10, 2021, Independence is updating our policies on Musculoskeletal Services to communicate the use of AIM Specialty Health® (AIM) Medical Necessity guidelines for select interventional pain management and spinal and joint surgical procedures with the exception of artificial intervertebral lumbar disc insertion for Independence Commercial and Medicare Advantage members. Previously, we followed our medical policies for all of these services. The current policies on Musculoskeletal Services will remain in place for Independence Administrators. Additionally, effective January 10, 2021, CPT® code 22862 will be considered experimental/investigational, and, therefore, not covered. This code will not be part of the Musculoskeletal Services utilization program with AIM; it will reside in the following new policies: ● Commercial: #11.15.31: Artificial Intervertebral Lumbar Disc Insertion ● Medicare Advantage: #MA11.114: Artificial Intervertebral Lumbar Disc Insertion Learn more For more information, please refer to the following Independence policies, which will be posted as Notifications on October 12, 2020, and will go into effect on January 10, 2021: ● Commercial: − #00.01.66c: Musculoskeletal Services (Independence) − #11.14.19p: Artificial Intervertebral Cervical Disc Insertion (Independence Administrators) − #11.15.31: Artificial Intervertebral Lumber Disc Insertion (Independence and Independence Administrators) ● Medicare Advantage: − #MA00.047c: Musculoskeletal Services − #MA11.114: Artificial Intervertebral Lumbar Disc Insertion To view the Notifications for these policies, visit our Medical and Claim Payment Policy Portal. October 2020 | Partners in Health UpdateSM 21 www.ibx.com/pnc
MEDICAL
Reminder: The annual Synagis® (palivizumab) distribution
program
Published October 14, 2020 (Read online)
The upcoming respiratory syncytial virus (RSV) season runs from November 1, 2020, through March 31, 2021. RSV is
the most common cause of bronchiolitis and pneumonia among children younger than one year. PerformSpecialty®, an
independent company, will be facilitating delivery of the RSV drug Synagis (palivizumab) through the Independence Direct
Ship Drug Program.
Synagis is a humanized monoclonal antibody that provides passive immunity against RSV. It is intended to decrease
the morbidity and mortality associated with RSV lower respiratory tract disease in high-risk infants and children. It is not
effective in the treatment of RSV disease, and it is not approved for this indication.
It is mandatory for all participating providers to order Synagis for Independence members through our Direct Ship Drug
Program. The 2020-2021 Synagis order forms are now available on our Direct Ship Drug Program webpage. Please use
these versions, as forms from previous Synagis seasons will not be accepted.
How to order Synagis for office use
The following guidelines apply when ordering Synagis:
● Providers should go to the Independence Direct Ship Drug Program website to access the order forms. The order
forms are under the Specific Drug Request form section. There are two Synagis order form options:
1. Print form: Office staff are required to write the patient and provider information on the form.
2. Fillable form: Office staff can type information directly onto the form.
Important: There is no online submission option for these forms; they must be printed and faxed to the number on the
form.
● T he form must include sufficient clinical information to meet our Synagis coverage criteria, which are based on current
American Academy of Pediatrics (AAP) recommendations.
● Fax the completed form (print or fillable) to 1-855-851-4056. Be sure to include any necessary documentation to
support the request. Incomplete forms may result in ordering delays.
● Since Independence pays PerformSpecialty directly for the drug, providers neither pay for doses ordered through
PerformSpecialty nor receive reimbursement for the actual pharmaceutical. Providers can still receive payment for the
administration of the drug.
● Synagis will generally be approved for office administration only, unless a patient is receiving home nursing services for
a separate indication.
● Upon approval of the request, Synagis will be shipped to the provider’s office monthly during the RSV season.
Shipping for the 2020-2021 RSV season begins on Monday, November 2, 2020, and continues through Wednesday,
March 31, 2021. Up to five doses (one dose every 30 days) will be shipped per member.
Learn more
Independence provides coverage under the medical benefit for the administration of Synagis for infants and children
during the RSV season, in accordance with the current recommendations from the AAP. These recommendations are
subject to change.
The complete list of coverage criteria for Synagis can be found in the Independence Medical Policy #08.00.22m: Immune
Prophylaxis for Respiratory Syncytial Virus (RSV). To view this policy, visit our Medical and Claim Payment Policy Portal.
If you have questions about Synagis, please call Customer Service at 1-800-ASK-BLUE (1-800-275-2583).
October 2020 | Partners in Health UpdateSM 22 www.ibx.com/pncMEDICAL
Diabetic retinopathy pilot program continues
Published October 15, 2020 (Read online)
Don’t let COVID-19 stop patients from delaying important health screenings! Encourage them to use programs
like our diabetic retinopathy screening pilot.
COVID-19 can be scary for patients but skipping important health screenings can be even scarier. This can be especially
true for those with underlying health issues, like diabetes.
Between 40 and 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy, although
only about half are aware of it.1 Help your patients with Type 1 Adult Diabetes or Type 2 Diabetes stay on top of their eye
health by encouraging them to participate in the diabetic retinopathy screening pilot we have in place with Laboratory
Corporation of America® Holdings (LabCorp) and Wills Eye Hospital.
The diabetic retinopathy screening pilot is currently available at three LabCorp Patient Service Centers in Northeast
Philadelphia:
● 101 East Olney Avenue, Philadelphia, PA 19120 (267-335-4106)
● 15200 Bustleton Avenue, Philadelphia, PA 19116 (215-437-7970)
● 3790 Morrell Avenue, Philadelphia, PA 19114 (267-538-3598)
Learn more
For more information about the pilot program, please visit the LabCorp diabetic retinopathy website.
1
National Eye Institute. Available from: https://nei.nih.gov/health/diabetic/retinopathy.
October 2020 | Partners in Health UpdateSM 23 www.ibx.com/pncMEDICAL
Avastin® is the preferred product for treatment of vascular
endothelial growth factor
Published October 26, 2020 (Read online)
As previously communicated in a Partners in Health UpdateSM article, as of January 1, 2020, Avastin and its biosimilars
(i.e., Mvasi™, Zirabev™) are the preferred intravitreal vascular endothelial growth factor (VEGF) products for
Independence commercial and Medicare Advantage members. There are many brands of VEGF antagonists on the
market for the treatment of vascular diseases of the eye, such as Beovu®, Eylea®, Lucentis®, Macugen®, and related
biosimilars. However, there is no reliable evidence of the superiority of any one brand of VEGF antagonists compared to
other brands. Additionally, this article provides clarification regarding the coverage of samples administered by
professional providers.
Coverage criteria
For individuals who meet the medical necessity criteria, use of non-preferred products (which include Beovu, Eylea,
Lucentis, Macugen, and related biosimilars) is considered medically necessary and, therefore, covered in either of the
following instances:
● The individual has a documented contraindication or documented non-response to Avastin and its related biosimilars.
● The non-preferred product was initiated prior to January 1, 2020, and the individual is currently receiving the product
for vascular diseases of the eye.
The use of non-preferred products that do not meet either of these instances is considered not medically necessary and,
therefore, not covered.
For individuals receiving their first course of VEGF antagonists, use of non-preferred products (which include, but are
not limited to, Beovu, Eylea, Lucentis, Macugen, and related biosimilars), is considered not medically necessary and,
therefore, not covered, with the following exceptions because more cost-effective alternatives are available:
● The individual has a documented contraindication or documented non-response to Avastin and its related
biosimilars.
● The non-preferred product was initiated prior to January 1, 2020, and the individual is currently receiving the
product for vascular diseases of the eye.
Please note: Use of non-preferred product samples administered by professional providers does NOT meet
coverage criteria for use of non-preferred products (which include Beovu, Eylea, Lucentis, Macugen, and related
biosimilars).
Additional clinical information demonstrating medical necessity of the desired medication must be submitted by the
requesting prescriber for review.
Learn more
For more information please refer to the following policies:
● Commercial: #08.00.74n: Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and related
biosimilars
● Medicare Advantage: #MA08.073g: Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists
and related biosimilars
These changes are reflected in an updated precertification requirement list, which is posted on our website.
October 2020 | Partners in Health UpdateSM 24 www.ibx.com/pncMEDICAL Upcoming changes to billing requirements for deep brain stimulation Published October 26, 2020 (Read online) Effective January 25, 2021, claims submitted for deep brain stimulation (DBS) with any of the following CPT® codes must include a primary ICD-10 diagnosis code that represents the member’s diagnosis: ● 61850 ● 61860 ● 61863 ● 61864 ● 61867 ● 61868 ● 61886 In accordance with our policy on DBS, this service is considered Medically Necessary for essential tremor, Parkinson’s disease, dystonia, torticollis, or obsessive-compulsive disorder. Claims submitted without an appropriate diagnosis code will not be covered. Updated policies For more information, including a complete list of medical necessity criteria for DBS and the updated billing requirements, please review the following Independence policies, which were posted as Notifications on October 26, 2020, and will go into effect January 25, 2021: ● Commercial: #11.15.20p: Deep Brain Stimulation (DBS) ● Medicare Advantage: #MA11.005d: Deep Brain Stimulation (DBS) To view these policy Notifications, visit the Active Notifications section of our Medical and Claim Payment Policy Portal. CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. October 2020 | Partners in Health UpdateSM 25 www.ibx.com/pnc
MEDICAL
View up-to-date policy activity on our Medical and Claim
Payment Policy Portal
Published October 27, 2020 (Read online)
Changes to Independence medical and claim payment policies for our commercial and Medicare Advantage Benefit
Programs occur in response to industry, medical, and regulatory changes. We encourage you to view the Site Activity
section of our Medical and Claim Payment Policy Portal to stay up to date with changes to our policies.
The Site Activity section is updated in real time as changes are made to the medical and claim payment policies. Topics
include:
● News & Announcements
● Notifications
● New Policies
● Updated Policies
● Reissued Policies
● Coding Updates
To access the Site Activity section, go to our Medical and Claim Payment Policy Portal and select Commercial or
Medicare Advantage under Site Activity to view the monthly changes.
To search for active policies, select either Commercial or Medicare Advantage under Policy Bulletins on the home page.
To access policies from the NaviNet® web portal (NaviNet Open), go to Independence NaviNet Open Plan Central, and
select Medical and Claim Payment Policy Portal under Quick Links in the right-hand column.
Medical codes for services that require precertification
A list of services that require preapproval/precertification from Independence prior to being performed for
our members is available for providers on our Medical and Claim Payment Policy Portal. This list, Services
that require precertification, includes the CPT® and HCPCS codes, where applicable, that correlate with the
services and injectable drugs that are included on our Preapproval/Precertification List.
To access Services that require precertification, select Commercial or Medicare Advantage under Policy
Bulletins on the home page and then Services Requiring Precertification from the left-hand navigation menu.
Links to Services that require precertification have also been added to the Quick Links section on the
right-hand side of this page.
For important policy information related to COVID-19, visit the News & Announcements sections for Commercial and
Medicare Advantage members.
NaviNet® is a registered trademark of NantHealth, an independent company.
CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
October 2020 | Partners in Health UpdateSM 26 www.ibx.com/pncPEAR PORTAL Coming soon to the PEAR portal: PEAR Comprehensive Visit Published October 23, 2020 (Read online) We are excited to announce the launch of another new application in the Provider Engagement, Analytics & Reporting (PEAR) portal: PEAR Comprehensive Visit, launching in 2021.* What is PEAR Comprehensive Visit? PEAR Comprehensive Visit is a new point-of-care application that assists primary care providers with accurate documentation of a member’s visit, assessment, and treatment plan. This will replace the ePASS® tool. Assessments entered in PEAR Comprehensive Visit will be considered official medical records that document the comprehensive elements of a member encounter including vitals, review of systems, diagnoses, quality measures, and social determinants of health. PEAR Comprehensive Visit has been designed to support the familiar format of a SOAP (Subjective, Objective, Assessment, and Plan) note with logic that offers diagnosis and screening considerations to assist in coordinating care. Benefits of PEAR Comprehensive Visit PEAR Comprehensive Visit is designed to: ● Improve accuracy of ICD-10 diagnosis coding ● Manage the continuity of your patient’s annual health status, including documenting both acute and chronic conditions ● Improve quality measures by accurately tracking your patient’s preventative screening status (i.e., Flu vaccine, breast cancer screening, colon cancer screening, etc.) Eligible primary care provider groups can earn an incentive for completing an assessment. Details on the incentive opportunity for 2021 will be shared in the coming months. Office administrators can gain access to the tool to assist in preparing the assessment for the physician’s review and attestation. PEAR Comprehensive Visit is loaded with real-time data, supporting an enhanced user experience with the ability to prepare the assessment prior to the patient’s visit so that the form can be referenced at point of care. Learn more PEAR Comprehensive Visit will be gradually rolled out in 2021. More information on your practice’s PEAR Comprehensive Visit launch date and how to get ready will be shared as it becomes available. For now, continue to use ePASS® and refer to the dedicated PEAR portal page and the PEAR portal FAQ for more information. Stay tuned to Partners in Health UpdateSM for ongoing communications related to the transition to PEAR Comprehensive Visit and announcements of additional PEAR portal tools! *Tandigm providers can continue to access this application through the Tandigm Connect platform. ePASS® is a registered trademark of Inovalon, an independent company. October 2020 | Partners in Health UpdateSM 27 www.ibx.com/pnc
PRODUCTS
What’s new for 2021 Medicare Advantage plans
Published October 5, 2020 (Read online)
Independence continues to offer innovative benefits to our Keystone 65 Basic HMO, Keystone 65 Focus HMO-POS,
Keystone 65 Preferred HMO, Keystone 65 Select HMO, and Personal Choice 65SM Prime Rx PPO members for the 2021
benefit year. With little or no premium increases, these plans offer benefits centered around improving affordability for
members – offering several ways to save on many of their copayments in 2021. Below is a summary of changes to our
existing products.
New! COVID-19 (Coronavirus) member inpatient cost-sharing
Members who are admitted to the hospital due to a COVID-19 diagnosis will have a $0 copayment for the inpatient
hospital stay.
New! Acupuncture services
Routine acupuncture treatment is now available for Medicare Advantage members experiencing one of the following
conditions:
● headache (migraine and tension)
● post-operative nausea and vomiting
● chemo-induced nausea and vomiting
● low back pain
● chronic neck pain
● pain from osteoarthritis of the knee and hip
Over-the-counter – More value!
Keystone 65 Basic Rx HMO, Keystone 65 Rx Focus HMO-POS, and Personal Choice 65 Prime Rx PPO members will
now have a $60 quarterly allowance for eligible over-the-counter (OTC) items. Members will receive an IBX Care Card
that they can use to purchase eligible OTC items in-store at participating retail locations. Members can also purchase
eligible OTC items via catalog for delivery through our dedicated vendor.
Vital Care & Vital Care Plus Programs
The Vital Care Program is available to all eligible Keystone 65 Basic HMO, Keystone 65 Select HMO, and Keystone 65
Preferred HMO members. Keystone 65 Focus HMO-POS plan members residing in Chester, Delaware, and Montgomery
counties in Pennsylvania are also eligible. This program is for members who have been diagnosed with both congestive
heart failure and diabetes. Specific to this program is a reduced copayment for eligible members when visiting their
cardiologist, endocrinologist, or podiatrist.
For Keystone 65 Focus HMO-POS plan members residing in Philadelphia and Bucks counties in Pennsylvania, we offer
the Vital Care Plus Program. Eligible members have the same benefits available to them as members in the Vital Care
Program; however, a lower copayment for pulmonologist visits is also included. In addition, these members have an
extra $20 per quarter added to their OTC benefit allowance and only need to be diagnosed with diabetes – there is no
requirement for the member to have been diagnosed with congestive heart failure.
Eligible members are automatically enrolled into these programs, but they may opt out if they choose to do so.
continued on the next page
October 2020 | Partners in Health UpdateSM 28 www.ibx.com/pncPRODUCTS
continued from the previous page
Dental, vision, and hearing benefits – new and improved!
Dental, vision, and hearing benefits are now included in the benefits package and no longer require an additional
premium.
● Dental benefits include:
− exam/cleaning (every 6 months) and X-rays (Bitewing - once per year, Periapical/Full Mouth X-rays every three
years)
− combined $2,000 allowance per year for comprehensive dental services for HMO and HMO-POS plans†
− combined $1,500 allowance per year for comprehensive dental services for PPO plans
● Vision benefits include:
− routine eye exam every year
− If members purchase glasses (frames and lenses) from Visionworks, they are covered up to $200.
− Members are covered up to $150 per year for contact lenses in lieu of routine eyewear (frames and lenses).
− If members purchase glasses (frames and lenses) outside of the Davis Vision Collection but at a Davis Vision
provider, they are covered up to $150.
● Hearing benefits include:
− routine hearing exam covered once every year
− three hearing aid fittings and evaluations covered every year*
− Keystone 65 Select HMO, Keystone 65 Preferred HMO, and Personal Choice 65 PPO:
▪ $499 copayment per Standard hearing aid per year
▪ $799 copayment per Premium hearing aid per year
− Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, and Personal Choice 65 Prime Rx PPO:
▪ $699 copayment per Standard hearing aid per year
▪ $999 copayment per Premium hearing aid per year
*Members must use a TruHearing provider to use this benefit.
†
Keystone Preferred does not include Comprehensive Dental Services
Learn more
If you have any questions regarding these changes, please call Provider Services at 1-800-ASK-BLUE
(1-800-275-2583).
TruHearing is a registered trademark of TruHearing, Inc., an independent company.
October 2020 | Partners in Health UpdateSM 29 www.ibx.com/pncYou can also read
