June 2020

wwwHealthyBlueSCcom

CoachBlueSC

HealthyBlueSC

fbmeHealthyBlueSC

IN THIS ISSUEAll Providers

Acquisition of Beacon Health Options 2Is prior authorization required

How to begin the PA process 3Do deliveries requireprior authorization 4

Affirmative statement concerning utilization management decisions 4

Chlamydia screening in women (CHL)

5

Corrected claims update 5

Interim billing update Claims payment disputes 6

Pharmacy Hot Tips 7

Acquisition of Beacon Health Options Healthy Blue is a partnership between Amerigroup and BlueChoice HealthPlan of South Carolina to provide Medicaid Plans to residents of South Carolina Amerigrouprsquos parent company Anthem Inc has completed its acquisition of Beach Health Options (Beacon) a large behavioral health organization that serves more the 36 millionpeople across the country Beacon will operate as a wholly owned subsidiary of Anthem

Bringing together our existing solid behavioral health business with Beaconrsquos successful model and support services creates one of the most comprehensive behavioral health networks in the country Itrsquos also an opportunity to offer best-in-class behavioral health capabilities and whole-person care solutions in new and meaningful ways to help people live their best lives

From the standpoint of our customers and providers currentlyitrsquos business as usual

bull Members should continue to call the customer service number on the back of their membership card or access their health planrsquos website for online self-service

bull Providers should continue to use the provider service contact information websites and online self-service websites as part of their agreement with either Healthy Blue or Beacon

bull There will be no immediate changes to the way Healthy Blue or Beacon manage their respective provider networks contracts and fee arrangements Healthy Blue and Beacon provider networks contracts and fee arrangements will remain separate at this time

We know our providers continue to expect more of their health care partner and at Healthy Blue we aim to deliver more in return

For more details please see the press release httpsirantheminccomnews-releasesnews-release-detailsanthem-inc-completes-acquisition-beacon-health-options additional details will be shared in future communications

2

ALL PROVIDERS

wwwHealthyBlueSCcom

CoachBlueSC

HealthyBlueSC

fbmeHealthyBlueSC

IN THIS ISSUEAll Providers

Acquisition of Beacon Health Options 2Is prior authorization required

How to begin the PA process 3Do deliveries requireprior authorization 4

Affirmative statement concerning utilization management decisions 4

Chlamydia screening in women (CHL)

5

Corrected claims update 5

Interim billing update Claims payment disputes 6

Pharmacy Hot Tips 7

Acquisition of Beacon Health Options Healthy Blue is a partnership between Amerigroup and BlueChoice HealthPlan of South Carolina to provide Medicaid Plans to residents of South Carolina Amerigrouprsquos parent company Anthem Inc has completed its acquisition of Beach Health Options (Beacon) a large behavioral health organization that serves more the 36 millionpeople across the country Beacon will operate as a wholly owned subsidiary of Anthem

Bringing together our existing solid behavioral health business with Beaconrsquos successful model and support services creates one of the most comprehensive behavioral health networks in the country Itrsquos also an opportunity to offer best-in-class behavioral health capabilities and whole-person care solutions in new and meaningful ways to help people live their best lives

From the standpoint of our customers and providers currentlyitrsquos business as usual

bull Members should continue to call the customer service number on the back of their membership card or access their health planrsquos website for online self-service

bull Providers should continue to use the provider service contact information websites and online self-service websites as part of their agreement with either Healthy Blue or Beacon

bull There will be no immediate changes to the way Healthy Blue or Beacon manage their respective provider networks contracts and fee arrangements Healthy Blue and Beacon provider networks contracts and fee arrangements will remain separate at this time

We know our providers continue to expect more of their health care partner and at Healthy Blue we aim to deliver more in return

For more details please see the press release httpsirantheminccomnews-releasesnews-release-detailsanthem-inc-completes-acquisition-beacon-health-options additional details will be shared in future communications

2

ALL PROVIDERS

Is prior authorization required How to begin the PA process When trying to obtain an authorization for a service request it is important to start at the beginning to improve the end-to-end process Deciding if a service request requires a prior authorization is one of the first key elements

1 Provider Manual | There are many resources to assist you in deciding if a prior authorization

is needed The Provider Manual is a good place to start It details what is required as well as other importantplan-specificinformation

2 Customer Service Representative | You can also determine if prior authorization is required

by contacting a Customer Service Representative or reaching out to an intake representative

When calling one of these representatives please consider the following (1) Do I need an inpatient hospital admission with the procedure(s) needed (2) Is this request for an out-of-network provider facility

If either of these applies to the services then ldquoYESrdquo a prior authorization is required

Ifyoudecidetoreachouttoarepresentativetofind out if an authorization is required please DO NOT ask only about the codes in question Not letting the representative know that an inpatient admission will be needed or if the servicing providerfacility is out of network can potentially cause a denial or delay when submitting your claim for payment

When reaching out to one of our representatives always make sure you have a ldquocomplete inquiryrdquo A complete inquiry consists of telling the representative what codes are needed if an inpatient stay will be needed and if the servicing providerfacility is out of network

3 Utilizing the Provider Manual | Using the Provider Manual and making complete inquiries withrepresentativesarethefirststepsinhelpingtoimprovetheefficiencyofthepriorauthorizationendto end and the claims process Provider Manual link

httpsproviderhealthybluesccomsouth-carolina- providermanuals-and-guides

4 Customer Care Center | 866-757-8286 South Carolina Healthy BlueBlueChoicereg Intake Department 866-902-1689

3

ALL PROVIDERS

When a patient stays past the mandate it is no longer considered a ldquonormalrdquo inpatient delivery In the 2019 Provider Manual on page 74 it states ldquoExcept for emergency admissions we require UM approval for all admissions Routinenormal vaginal or cesarean section deliveries do not require PA in network facilitiesrdquo

1 No authorization is required for the state mandate two days (48 hours) vaginalfour days (96 hours) C-section Day No 1 of that mandate starts on the date of delivery

2 IF the member stays PAST THE STATE MANDATE then an AUTHORIZATION is REQUIRED (as this is no longer considered routine) because the dates of service that go ldquobeyondrdquo the state mandate have to be reviewed for medical necessity 3 A claim could potentially be denied if what is being submitted by the facility is LONGER than the state mandate allows and no review has been done by the nursemedical director

Please remember to send in the Notification of Delivery form and Newborn Notification forms To view the NotificationofDeliveryformandNewbornNotification visit wwwHealthyBlueSCcom andselect Providers

Do Deliveries RequirePrior Authorization For deliveries the key words are routinenormal The normal is the state mandate mdash two days vaginalfour days C-section

Affirmative statement concerningutilization management decisions All Healthy Blue associates who make utilizationmanagement (UM) decisions are required to adhereto the following principles bull UM decision-making is based only on appropriateness of care and service and existence of coverage

bull Wedonotspecificallyrewardpractitionersor other individuals for issuing denials of coverage or care Decisions about hiring promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support or tend to supportdenialsofbenefits

bull Financial incentives for UM decision-makers do not encourage decisions that result in underutilization or create barriers to care and service

4

ALL PROVIDERS

The corrected claims reimbursement policy has been updated Previously

for participating and nonparticipating providers Healthy Blue followedthecorrectedclaimstimelyfilingstandard of 90 days from the date

of the remittance advice

Effective Aug 1 2020 HealthyBlue corrected claims timelyfilingguidelineshavebeen

updated to follow the standardof 12 months from the date

of service for participating andnonparticipating providers

To view the corrected claimsreimbursement policy visitwwwHealthyBlueSCcom

and select Providers(Policy number 16-001)

1 The HEDISreg measure looks at the percentage of women16-24yearsofagewhowereidentified as sexually active and who had at least one test for chlamydia during the measurement year 2 Record Your Efforts Indicate the date the test was performed and the results 3 Exclusions Based on a pregnancy test alone and who meet either of the following bull A pregnancy test and a prescription for isotretinoin on the date of the pregnancy test or the six days after bull A pregnancy test and an X-ray on the date of the pregnancy test or the six days after

Corrected Claims Update

Chlamydia screening in women (CHL)

Description CPTHCPCSLOINC

Chlamydia TestingCPT 87110 87270 8732087490-87492 87810

2020 HEDISreg Benchmarks and Coding Guidelines for Quality Care

5

ALL PROVIDERS

Interim billing updateHealthy Blue does allow for interim billing with the correct bill type Providers should include the list of bill types below Recently we have received questions about interim billing The charts below should help clarify the process bywhichaninterimbillcanbefiled

Value DescriptionFacility Type

01 Hospital

02 Skilled Nursing

03 Home Health

04 Christian Science Hospital

05 Christian Science Extended Care

06 Intermediate Care

07 Clinic Rural

08 Special Facility

09 Reserved for National Use

Bill Class

1 Inpatient (including Medicare Part A)

2 Inpatient (Medicare Part B only)

3 Outpatient

4 Other (for hospital referenced diagnosticservices or home)

5 Intermediate Care - Level I

6 Intermediate Care - Level II

7 Intermediate Care - Level III

8 Swing Beds

9 Reserved for National Assignment

Frequency Value Descriptions

0 Non-PaymentZero Claim

1 Admit through Discharge Claim

2 Interim mdash First Claim

3 Interim mdash Continuing Claim

4 Interim mdash Last Claim

5 Late Charge(s) Only Claim

6 Adjustment of Prior Claim

7 Replacement of Prior Claim

8 VoidCancel of Payment

9 Reserved for National Assignment

Claimspayment disputesA new form has been created for claims payment disputes and is posted on our website Availity is always your primary source for claims disputes however if you need the paper form go to this linkhttpsproviderhealthybluesccomdocsgppSCHB_Forms_ProviderClaimPaymentDisputeFormpdf

AvailityisanindependentcompanyprovidingasecureportalonbehalfofBlueChoiceHealthPlan

6

ALL PROVIDERS

Your Healthy Blue (BlueChoice HealthPlan Medicaid) patients on nonpreferred products will have their claims rejected at the pharmacy To avoid additional steps or delays at the pharmacy please consider prescribing preferred products whenever possible Preferred Drug List Visit wwwHealthyBlueSCcom and select Providers

Pharmacy Hot Tips

AcneTherapeutic Class Nonpreferred Preferred Products

Acne

MonodoxGeneric name Doxycycline Monohydrate1 DoryxGeneric name Doxycycline Hyclate1

Oracea 40mgGeneric name Doxycycline Monohydrate 40mg1

Doxycycline Monohydrate2 caps 50 mg 75 mg 100 mg 150 mg Doxycycline Monohydrate oral suspension

Tretinoin pumps

Tretinoin gel tubes all strengths except 005 Tretinoin cream tubes all strengths Tretinoin microsphere gel tubes all strengths except 004

Benzaclin Gel and Pump Neuac Gel Generic name ClindamycinBenzoyl Peroxide 1-53

Acanya Gel PumpGeneric name ClindamycinBenzoyl Peroxide 12-253

Onexton Gel Pump

Clindamycinbenzoyl peroxide 12-5Brand name Duac Gel

Clindagel Clindamycin foam lotions ClindamycinTretinoin Gels Clindamycin topical gels and solutions

1Prior authorization is required and requests may be approved in individuals with a diagnosis of inflammatory rosacea2Tablets are not covered3Neither brand nor generic formulations are covered

BlueChoice HealthPlan of South Carolina is an independent licensee of the Blue Cross and Blue Shield AssociationBlueChoice HealthPlan has contracted with Amerigroup Partnership Plan LLC an independent company for services to support administration of Healthy Connections 212116-4-2020

If you have questions about these Hot Tips please call the Customer Care Center at 866-757-8286

ADHDTherapeutic Class Nonpreferred Preferred Products

ADHD

Guanfacine ER1

Generic for IntunivClonidine 12-hour and immediate releaseGeneric for KapvayCatapres

Evekeo Amphetamine mixed salts OPT (tabscaps) Generic for Adderall

Adzenys XR Dextroamphetamineamphetamine ER OPT (caps)Generic for Adderall XR

Vyvanse2 and Zenzedi Dextroamphetamine IRER (tabscaps and solution)Generic for Dexedrine and Procentra

Adhansia XRAptensio XR Daytrana and Desoxyn2

Methylphenidatebull CD caps 10 mg 20 mg 30 mg 40 mg 50 mg and 60 mgbull ER tab 18 mg 27 mg 36 mg and 54 mgbull IR tabs 5 mg 10 mg and 20 mgbull LA cap 10 mg 20 mg 30 mg 40 mg and 60 mgGeneric for Metadate CD Concerta and RitalinRitalin LADexmethylphenidate Dexmethylphenidate ER Generic for FocalinFocalin XR

Quillichew and Quillivant XR suspension

Methylphenidate solution (5 mg5 mL and 10 mg5 mL)Generic for Ritalin

1Neither brand nor generic formulations are covered2 Chemical preferred drug equivalents are not available for Lisdexamfetamine Dimesylate (Vyvanse) or Methamphetamine (Desoxyn)

Proton Pump InhibitorsTherapeutic Class Nonpreferred Preferred Products2

Proton Pump Inhibitors

Zegerid1 Aciphex Dexilant Pantoprazole Brand name Protonix Esomeprazole1 Brand name Nexium Omeprazole1 Brand name Prilosec OmeprazoleSodium Bicarbonate Brand name Omeppi Lansoprazole1 Brand name Prevacid Rabeprazole

OTC Zegerid 20 mg capsule OTC Nexium 24-hr 20 mg capsule OTC Nexium 24-hr 20 mg tablet OTC Esomeprazole DR 20 mg capsule Brand name OTC Nexium OTC Omeprazole Magnesium 206 mg capsule OTC Omeprazole 20 mg tablet Brand name OTC Prilosec OTC Prilosec 20 mg tablet OTC Prilosec 206 mg tablet OTC Lansoprazole 15 mg capsule Brand name OTC Prevacid OTC Prevacid 24-hour 15 mg capsule

1Prescription strength2 OTC products are available with a prescription Quantity limit for proton pump inhibitors = two dosesday for OTC Esomeprazole OTC Omeprazole OTC Lansoprazole OTC Prevacid 24-hours OTC Nexium 24-hours and one doseday for all other PPIs

Chronic PainTherapeutic Class Nonpreferred Preferred Products

Chronic Pain2

Oxycontin Generic oxycodone ER 1 Opana Generic oxymorphone ER1 Exalgo Generic hydromorphone ER1 Avinza and Kadian Generic morphine ER1

Morphine sulfate tablets (15 mg 20 mg 60 mg and 100 mg) Generic for MS Contin Fentanyl patch Generic for Duragesic

1Neither brand nor generic formulations are covered 2Prior authorization for medical necessity is required for preferred products Call 866-231-0847 or fax 800-359-5781

AsthmaTherapeutic Class Nonpreferred Preferred Products

Asthma ndash Controller

Asmanex Pulmicort Aerospan Alvesco ArmonAir RespiClick Azmacort QVAR Redihaler

Arnuity Ellipta Flovent and Budesonide suspension (nebules)

Advair AirDuo RespiClick Symbicort Dulera

Wixela Inhub Generic for Advair Diskus FluticasoneSalmeterol Generic for Advair Diskus Breo Ellipta FluticasoneSalmeterol Generic for AirDuo RespiClick

Asthma ndash Rescue

Proair Proventil HFA Proair RespiClick XopenexGeneric Levalbuterol 1

Ventolin HFA

Albuterol Sulfate HFA Generic for ProAir HFA Albuterol Sulfate HFA Generic for Ventolin HFA Albuterol solution (nebules)

1 Neither brand nor generic formulations are covered

DiabetesTherapeutic Class Nonpreferred Preferred Products

Pen Needles All other manufacturers for pen needlesand insulin syringes BD pen needles and insulin syringes

Insulin2

Short-acting Novolog Humalog Apidra Afrezza FiaspLong-actingLantus Levemir Toujeo Tresiba

Short-actingInsulin Lispro1 AdmelogLong-acting Basalglar Mixes Novolog mix Humalog mix

DPP4-s4

Kombiglyze XR Onglyza Jentadueto Jentadueto XR Tradjenta Kazano Generic name Alogliptin-Metformin3 Nesina Generic name Alogliptin3 Oseni Generic name Alogliptin-Pioglitazon3

Januvia Janumet Janumet XR

GLP-1s4

GLP-1long-acting insulin combo5

Adlyxin Bydureon Byetta Trulicity Tanzeum Xultophy Soliqua Victoza Ozempic

SGLT24

SGLT2DPP-4 combo5

Farxiga Invokava Invokamet Invokanamet XR Xigduo XR Segluromet StreglatroGlyxambi Qtern Steglujan

Jardiance Synjardy Synjardy XR

TZDs4 Actos Actoplus Met Actoplus Met XR Avandia Avandamet Duetact

Pioglitazone Brand name ActosPioglitazone-Metformin Brand name Actoplus MetPioglitazone-Glimepiride Brand name Duetact

1 A1 Effective 11119 Insulin Lispro is preferred2 Insulin quantities are limited to 30 ml30 days3 Neither brand nor generic formulations are covered4 All agents have step therapy through Metformin unless contraindicated TZDs have step therapy through Metformin and one preferred drug within any of the following classes DPP4s GLP-1s SGLT2s5 Combination agents require trial of individual agents and rationale regarding necessity of combination product

AllergiesTherapeutic Class Nonpreferred Preferred Products

Allergies

ZyrtecZyrtec D Generic CetirizineCetirizine D1

Xyzal Generic Levocetirizine1

ClarinexGeneric Desloratadine1

FexofenadineFexofenadine-DGeneric for AllegraAllegra DOver-the-counter (OTC) Loratadine LoratadinePseudoephedrine Generic for OTC ClaritinClaritin D

Flonase nasal spray Generic Fluticasone Nasal 1

NasonexGeneric Mometasone1

NasacortGeneric Triamcinolone

OTC Fluticasone Nasal Allergy ReliefOTC Triamcinolone Acetonide Nasal ReliefOTC Rhinocort nasal spray2 OTC Budesonide nasal spray2

Patanol 01 eyedropsGeneric Olopatadine1

Pataday 02 eyedropsGeneric Olopatadine1

Alocril 2 eyedropsAlomide 01 eyedropsBepreve 15 eyedropsEmadine 05 eyedropsLastacaft 025 eyedropsPazeo 07 eyedrops

OTC allergy eyedrops Ketotifen 0025Generic for OTC Zaditor OTC Alaway eyedrops Ketotifen 0025 Epinastine 005 eyedrops Generic for Elestat Azelastine 005 eyedrops Cromolyn 4 eyedrops

1Neither brand nor generic formulations are covered2Effective 1112019 OTC Rhinocort nasal spray and OTC Budesonide nasal spray are preferred products

Topical CorticosteroidPreferred Products

Low potency CreamHydrocortisone 05 creamHydrocortisone 1 creamHydrocortisone 25 creamHydrocortisone-Aloe 1 creamOintmentHydrocortisone 05 ointmentHydrocortisone 1 ointmentHydrocortisone 25 ointmentSolution non-oralScalpicin 1 anti-itch solutionScalp Relief 1 solutionTexacort 25 solution

Medium Potency CreamBetamethasone Valerate 01 creamTriamcinolone 0025 creamTriamcinolone 01 creamTriderm 01 creamMometasone 01 creamFluticasone 0025 creamOintmentTriamcinolone 0025 ointmentTriamcinolone 01 ointmentTrianex 005 ointmentMometasone 01 ointment Fluticasone 0025 ointmentPrednicarbate 01 ointment Solution non-oralMometasone 01 solution

High Potency CreamBetamethasone Dipropionate Augmented 005 creamDiflorasone 005 creamFluocinonide-E 005 cream Triamcinolone 05 creamOintmentAmcinonide 01 ointment Betamethasone Valerate 01 ointmentTriamcinolone 05 ointmentLotionAmcinonide 01 lotionBetamethasone Dipropionate 005 lotion

Very High Potency CreamClobetasol 005 creamClobetasol Emollient 005 creamHalobetasol 005 creamOintmentClobetasol 005 ointmentHalobetasol 005 ointmentGelClobetasol 005 gelSolution non-oralClobetasol 005 solutionCormax 005 solution

Your Healthy Blue patients on nonpreferred products will experience a pharmacy claim rejection To avoid additional steps or delays at the pharmacy please consider proferred products whenever possible

7

ALL PROVIDERS

BlueChoice HealthPlan is an independent licensees of the Blue Cross and Blue Shield Association BlueChoice HealthPlan has contracted withAmerigroup Partnership Plan LLC an independent company for services to support administration of Healthy Connections

Some links in this newsletter lead to third party sites Those organizations are solely responsible for the content and privacy policies on these sites

To report fraud call our confidential Fraud Hotline at 877-725-2702 You may also call the South Carolina Department of Health and Human Services Fraud Hotline at 888-364-3224 or email fraudresscdhhsgov

212315-5-2020

BlueChoice HealthPlan is an independent licensees of the Blue Cross and Blue Shield Association BlueChoice HealthPlan has contracted withAmerigroup Partnership Plan LLC an independent company for services to support administration of Healthy Connections

Some links in this newsletter lead to third party sites Those organizations are solely responsible for the content and privacy policies on these sites

To report fraud call our confidential Fraud Hotline at 877-725-2702 You may also call the South Carolina Department of Health and Human Services Fraud Hotline at 888-364-3224 or email fraudresscdhhsgov

212315-5-2020