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Monthly Changes

Our at-a-glance summary of monthly changes to our policies, pre-authorization requirements, Administrative Manual and other programs or initiatives that impact your office are published:

  • Monthly in our bulletin
  • Bi-monthly in our newsletter
  • On this page within two weeks of our newsletter publication

Subscribe to receive newsletters and bulletins via email. View the changes listed by effective date below:

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August, 2018

In addition to the summary of monthly changes below, please also review our monthly Bulletin for recent and upcoming changes to our medical and dental policies, and associated changes to pre-authorization requirements.

Pre-authorization updates

The following codes were added to our pre-authorization lists effective August 1, 2018:

Commercial

  • Spinal Cord and Dorsal Root Ganglion Stimulation (Surgery #45)
    • HCPCS C1767

Medicare

  • Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders (Medicare Medicine #148)
    • 90867-90869

You can submit standard medical pre-authorizations through the Availity Portal.

Our complete pre-authorization lists are available in the Pre-authorization section of our website. Please review the lists for all updates and pre-authorize services accordingly.

Reimbursement policy updates

We review our reimbursement policies on an annual basis. Included below are updates to existing policies and new policies that will be added to our Reimbursement Policy Manual.

To see how a claim will pay, access the Clear Claim Connection tool on the Availity Portal.

Effective August 1, 2018:

  • Inpatient Hospital Readmissions (#111)
    • Added a new definition for planned readmission or leave of absence
    • Added planned readmissions or leaves of absence as an inclusion to the policy
    • Added readmission for pre-delivery obstetrical care as an exclusion to the policy
  • Immunological Cellular Therapies and Gene Therapies (#112)
    • Updated definitions and terminology to be consistent with medical and pharmacy policy updates

Medication policy updates

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. Read more about these changes in the August and October issues of our newsletter.

New medication policies effective August 1, 2018:

  • Cystic fibrosis transmembrane conductance regulator (CFTR) modulators, dru544
  • Erleada, apalutamide, dru546
  • Lutathera, lutetium Lu 177 dotatate, dru545
  • Crysvita, burosumab, dru547
  • Luxtuma, voretigene neparvovec, dru527

Revised medication policies effective August 1, 2018:

  • Alecensa, alectinib, dru450
  • Bosulif, bosutinib, dru285
  • Lynparza, olaparib, dru389
  • Non-Preferred GLP-1-Agonist-containing medications, dru347
  • Non-Preferred SGLT2-Inhibitor-containing medications, dru543
  • Sovaldi, sofosbuvir, dru332
  • Sprycel, dasatinib, dru137
  • Tasigna, nilotinib, dru151
  • Verzenio, abemaciclib, dru533
  • Zykadia, ceritinib, dru354
  • Tecentrig, atezolizumab, dru463
  • Keytruda, pembrolizumab, dru367
  • Trulicity, dulaglutide, dru347

Archived medication policies effective August 1, 2018

  • Canagliflozin (Invokana, Invokamet, Invokamet XR) andempagliflozin (Glyxambi, Jardiance, Synjardy, Synjardy XR), dru508
  • Imatinib-containing products (generic, Gleevec), dru043
  • Ozempic, semaglutide, dru347

Medical policy updates

We publish updates to medical policies, dental policies and Clinical Position Statements in our monthly publication The Bulletin.

We provided 90-day notice in the April and May 2018 issues of The Bulletin about the following medical policies:

  • Cosmetic and Reconstructive Surgery (Surgery #12), effective August 1, 2018
  • Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders (Medicare Medicine #148), effective August 1, 2018

You can read issues of The Bulletin or subscribe to receive an email notification when issues are published on our website. The Medical Policy Manual includes a list of recent updates and archived policies. All policies and Clinical Position Statements are available on our website.

Gap closure deadline approaching

To qualify for the Hierarchical Condition Category (HCC)/chronic diagnosis gap closure performance bonus on our Medicare Quality Incentive Program, you must have 66 percent of your total HCC gaps closed by August 31, 2018.

To ensure that we have the information necessary to count your gaps as closed, please adhere to the following deadlines for each method of gap closure submission:

  • Claims – August 15, 2018
  • Supplemental electronic medical record (EMR) data extract – August 15, 2018
  • Care gap management application (CGMA) – August 31, 2018