Loading...Loading...In addition to the summary of monthly changes below, please also review our monthly Bulletin for recent and upcoming changes to our medical and reimbursement policies, Clinical Position Statements and associated changes to pre-authorization requirements. The Medical Policy Manual includes a list of recent updates and archived policies. Monthly change summaries are added to our website within 10 business days of our newsletter publication.
Review other monthly changes for 2022.
Listed below is a summary of medication policy additions and changes. Links to all medication policies, medication lists and pre-authorization information for our members, including real-time deletions from our pre-authorization lists, are available on our website.
Revised medication policy effective June 14, 2022
Drugs for chronic inflammatory diseases, dru444
Read the August 2022 issue of our newsletter for details.
We are excited to announce our 2022 Commercial Quality Incentive Program (QIP):
- This voluntary program is designed to reward primary care providers (PCPs) who provide timely, evidence-based preventive care to Individual on-exchange patients in 2022.
PCPs will earn a per gap incentive for closing care gaps for the Quality Rating System (QRS) measures included in the program.
Beginning on June 20, 2022, as a participating PCP, you will be able to review identified quality care gaps for Individual on-exchange patients attributed to you as part of your pre-visit planning on our Care Gap Management Application (CGMA) through Novillus LLC.
How to access the CGMA
If you are a current CGMA user for our Medicare QIP, your login will allow you to access both the Medicare and Commercial QIP gap information and no action is required.
If you do not currently have access to the CGMA, send an email to QIPQuestions@regence.com with the following information about the new CGMA user:
- First and last name
- Title
- Phone number
- Email address
- Provider group name
Provider group TIN(s)
Identifying and closing gaps
To identify and close gaps for this program:
- Refer your patient for any procedures or tests that cannot be completed in your office.
- Ensure that your medical record documentation for that visit is complete.
- Submit a claim for the date of service with all appropriate diagnosis and procedure codes that were part of the visit. Most QRS gaps for Individual on-exchange members can only be closed via claim submission.
Note: Controlling High Blood Pressure and Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control can also be closed via supplemental data submission.
On June 20, 2022, you will be able to look up each patient in the CGMA as part of your pre-visit planning. The tool will identify care gaps for Individual on-exchange patients attributed to you to help you schedule any screenings or chronic condition management services.
View incentive measures and learn more in the June, 2022 issue of our newsletter.
You can now use the new Appeals application on Availity Essentials to submit claims appeals.
- The new application streamlines the appeals process, making it faster and easier to submit appeals directly from the Claim Status screen.
- Submit claims appeals with required documentation and receive immediate confirmation of submission.
Review the progress of your appeal and access past appeals in the Appeals dashboard.
Messaging will display if the claim you are disputing does not meet criteria for submission via the application. A messaging guide has been added to our provider website to assist you with alternate appeals options.
Access the new Appeals dashboard on Availity Essentials: Claims & Payments>Appeals.
Note: Pricing disputes are not appeals and should be submitted using our Pricing Dispute Form and dedicated workflow.
Get trained for free
View the training options available by clicking the Help & Training link in the Availity Essentials menu.
The following updates were made to our Administrative Manual on June 1, 2022:
- Provider Appeals
Facility Guidelines
As a reminder, we require the use of the following pneumatic compression device (PCD) HCPCS codes:
- E0650, E0651, E0652: For patients with lymphedema or chronic venous insufficiency
- E0675: For patients with peripheral artery disease (PAD)
E0676: For post-surgical deep vein thrombosis (DVT) prevention (Post-surgical home-use of an intermittent PCD HCPCS E0676 to prevent venous thrombosis is not eligible for reimbursement.)
Please refer to our Pneumatic Compression Device (Administrative #134) commercial and Medicare Advantage reimbursement policies for applicable sleeve codes.
Using unlisted codes (e.g., HCPCS A9900) in place of any of listed codes will result in non-payment.
Important: Reimbursement for a PCD used in a facility or provided by the facility/surgeon (before or after surgery) for post-surgical home use is included in the facility reimbursement and is not separately allowable when billed by the facility or a durable medical equipment (DME) supplier. Allowing a DME supplier to separately bill for this is not appropriate and may result in higher out-of-pocket costs for the member.
Read the June, 2022 issue of our provider newsletter for more information.
Effective June 1, 2022, the following codes will be added to our pre-authorization lists.
Commercial and Uniform Medical Plan
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders (#RAD38)
- 0651T, 91110, 91111, 91113
Please review our pre-authorization lists for all updates and pre-authorize services accordingly. You can submit standard medical pre-authorizations through Availity Essentials. Learn more about electric authorizations.
Listed below is a summary of medication policy additions and changes. Links to all medication policies, medication lists and pre-authorization information for our members, including real-time deletions from our pre-authorization lists, are available on our provider website.
New medication policies effective June 1, 2022:
- Besremi, ropeginterferon alfa 2b NJFT, dru703
- Exkivity, mobocertinib, dru686
- Ileal Bile Acid Transporter (IBAT) Inhibitors, dru699
- PCSK9 Inhibitors, dru697
- Rezurock, belumosudil, dru684
- Scemblix, asciminib, dru692
Welireg, belzutifan, dru685
Revised medication policies effective June 1, 2022:
- Brukinsa, zanubrutinib, dru691
- cabozantinib containing medications, dru290
- CDK4/6 Inhibitors for Breast Cancer
- Copiktra, duvelisib, dru573
- High cost medications for dry eye disease, dru472
- Intravitreal Vascular Endothelial Growth Factor (VEGF) Inhibitors (dru621)
- Interleukin-1 Antagonists (dru677)
- Istodax, romidepsin, dru198
- Jakafi, ruxolitinib, dru268
- Medications for pulmonary arterial hypertension, dru633
- metyrosine (generics, Demser), dru405
- Sodium oxybate containing medications, dru093
- Tibsovo, ivosidenib, dru558
Zydelig, idelalisib, dru363
Archived medication policies effective June 1, 2022
- everolimus containing medications, dru178
Sutent, sunitinib, dru128
Read the February and April 2022 issues of our newsletter for details.
Effective June 1, 2022, prior approval will apply to the medications listed below that are covered under the medical benefit for BCBS FEP members for services rendered in Oregon, Utah and Clark County, Washington. This change applies to Standard Option, Basic Option and FEP Blue Focus plans.
- Rituxan (rituximab), Truxima (rituximab-abbs), Ruxience (rituximab-pvvr), and Riabni (rituximab-arrx)
- Breyanzi (lisocabtagene maraleucel)
- Abecma (idecabtagene vicleucel)
- Rituxan Hycela (rituximab and hyaluronidase)
- Sandostatin LAR (octreotide acetate)
- Somatuline Depot (lanreotide)
- Signifor LAR (pasireotide pamoate)
- Eligard/Lupron Depot/Fensolvi (leuprolide acetate), Camcevi (leuprolide mesylate)
- Xolair (omalizumab)
- Fasenra (benralizumab)
- Nucala (mepolizumab)
- Cinqair (reslizumab)
- Cimzia (certolizumab pegol)
- Entyvio (vedolizumab)
- Tysabri (natalizumab)
- Lemtrada (alemtuzumab)
- Ocrevus (ocrelizumab)
- Actemra (tocilizumab)
- Orencia (abatacept)
- Simponi Aria (golimumab)
- Soliris (eculizumab)
- Ultomiris (ravulizumab-cwvz)
Ilumya (tildrakizumab-asmn)
For more information, read the February, 2022 issue of our newsletter.
We publish updates to medical policies in our monthly publication, The Bulletin. You can read issues of The Bulletin or subscribe to receive an email notification when issues are published.
We provided 90 day notice in the March 2022 issue of The Bulletin about the new Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders (#RAD38) medical policy, which is effective June 1, 2022.
We publish updates to reimbursement policies in our monthly publication, The Bulletin. You can read issues of The Bulletin or subscribe to receive an email notification when issues are published.
We provided 90 day notice in the March 2022 issue of The Bulletin about changes to the Cellular and Gene Therapy Products (Medicine #112) reimbursement policy, which are effective June 1, 2022.