MP/CG Update/Notice - September 2020 Form

In some plans, ”level of care,” “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts, or other materials instead of or in addition to “site of care” and, in some plans, these terms may be used interchangeably.
For simplicity, Anthem will hereafter use “site of care”.

** At the time of this notice, Anthem is in the process of retitling this guideline to use Site of Care in place of Level of Care.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

621-0920-DM-CA, 637-0920-DM-CA

September 1, 2020

{Provider Name} {Address} {City}, {State} {Zip Code}

Re: Site of Care* medical necessity review for numerous surgical procedures beginning December 1, 2020

Dear Provider:

Anthem Blue Cross (Anthem) is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

Effective with dates of service on or after December 1, 2020, members with commercial plans covered by Anthem will require a medical necessity review of the hospital outpatient site of care for numerous surgical procedures. The clinical guideline, Site of Care**: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services, CG- SURG-52, will apply to the review process. AIM Specialty Health® (AIM) will administer the review.

CG-SURG-52 is available at https://www.anthem.com/dam/medpolicies/abc/active/guidelines/gl_pw_c185539.html.

The site of care review will apply to a wide range of surgical procedures, including but not limited to, the following specialty categories:
• Auditory system • Digestive/Gastrointestinal system • Eye/ocular adnexa system • Female genital system • Hemic and lymphatic system • Integumentary system • Male genital system • Musculoskeletal system • Nervous system • Respiratory system • Urinary system

For a complete list of procedures subject to the site of care review, and additional information, such as Frequently Asked Questions, visit aimproviders.com/surgicalprocedures/resources.

AIM will use CG-SURG-52 to evaluate the clinical information in the request and determine if the procedure requested requires a hospital-based outpatient setting. Providers may contact AIM to request a peer-to-peer discussion before or after the review is complete.

The site of care review only applies to procedures performed in an outpatient hospital setting. The site of care review does not apply to procedures performed in a non-hospital setting or as part of an inpatient stay. For inpatient admission, please contact the health plan at the number on the back of the member ID card. Reviews also do not apply when Anthem is the secondary payer.

In some plans, ”level of care,” “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts, or other materials instead of or in addition to “site of care” and, in some plans, these terms may be used interchangeably.
For simplicity, Anthem will hereafter use “site of care”.

** At the time of this notice, Anthem is in the process of retitling this guideline to use Site of Care in place of Level of Care.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

621-0920-DM-CA, 637-0920-DM-CA 2

Submit a request for review to AIM

Starting November 16, 2020 ordering providers may submit prior authorization requests for the Hospital Outpatient site of care for the applicable procedures for dates of service on or after December 1, 2020 to AIM in one of the following ways:
• Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Portal at availity.com
• Call the AIM Contact Center toll-free number: 1-877-291-0360, Monday–Friday, 7:00 a.m.–5:00 p.m. PT

Beginning in November, AIM will offer webinars to provide information on navigating the AIM ProviderPortalSM.
To register for a webinar visit: aimproviders.com/surgical procedures.

This review applies to local fully insured Anthem members and members covered under self-insured (ASO) benefit plans with services medically managed by AIM. This does not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplemental or Federal Employee Program® (FEP®).

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the back of the members’ ID card.
Prior authorization and site of care updates for specialty pharmacy

Prior authorization updates

Effective for dates of service on and after December 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

Please note inclusion of the National Drug Code (NDC) on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Clinical Criteria information is located at www11.anthem.com/ca/pharmacyinformation/clinicalcriteria.html.

Anthem‘s prior authorization clinical review of non-oncology specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications is managed by AIM and are shown in italics in the tables below.

Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0164 C9399, J3490, J9999 Jelmyto (mitomycin gel) ING-CC-0165 C9399, J3490, J3590, J9999 Trodelvy (sacituzumab govitecan) ING-CC-0061 J1950, J3490 Fensolvi (leuprolide acetate) *Non oncology use is managed by the Anthem medical specialty drug review team. Oncology use is managed by AIM.

In some plans, ”level of care,” “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts, or other materials instead of or in addition to “site of care” and, in some plans, these terms may be used interchangeably.
For simplicity, Anthem will hereafter use “site of care”.

** At the time of this notice, Anthem is in the process of retitling this guideline to use Site of Care in place of Level of Care.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

621-0920-DM-CA, 637-0920-DM-CA 3

Site of care updates

Effective for dates of service on and after December 1, 2020, the following specialty pharmacy codes from current clinical criteria documents will be included in our existing prior authorization site of care review process.

The site of care drug list is located at https://www11.anthem.com/provider/noapplication/f0/s0/t0/pw_g369982.pdf

Clinical Criteria HCPCS or CPT Code(s) Drug ING-CC-0153 J0791 Adakveo (crizanlizumab) ING-CC-0139 J3111 Evenity (romosozumab)
ING-CC-0154 J0223 Givlaari (givosiran)
ING-CC-0156 J0896 Reblozyl (luspatercept)
ING-CC-0003 J1558 Xembify (immune globulin) ING-CC-0002 Q5120 Ziextenzo (pegfilgrastim-bmez) Non oncology use is managed by the Anthem medical specialty drug review team. Oncology use is managed by AIM.

We thank you for your continued efforts on behalf of our members and your partnership toward improved access to quality health care for Californians.

Sincerely,

John Yao, MD, MPH, MBA, MPP, FACP Chief Medical Officer