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Frequently Asked Questions


About the Anthem Cancer Care Quality Program

What is the Anthem Cancer Care Quality Program?
The Anthem Cancer Care Quality Program (“Program”) is an innovative quality initiative bringing physician practices evidence-based cancer treatment information that will allow you to compare planned cancer treatment regimens against evidence-based clinical criteria. The Program also identifies certain evidence-based Cancer Treatment Pathways; when in-network providers order a treatment regimen that aligns with an identified Pathway, they may be eligible for enhanced reimbursement.

How does the Anthem Cancer Care Quality Program benefit my practice?
Practices participating in the Program can gain efficiency through:

  • Practices participating in the Program can gain efficiency through:
  • Synchronization with health plan Medical Policy and Clinical Guidelines
  • Identification of Pathway regimens which may be eligible for enhanced reimbursement

How will the Program be administered?
The Anthem Cancer Care Quality Program will be administered by AIM Specialty Health® (AIM) on behalf of your patients’ health plans. Participating in the Program is most easily managed using the AIM ProviderPortalSM, available 24/7, or by calling AIM directly.

Who may participate in the new Cancer Care Quality program and may be eligible to recieve enhanced reimbursement?
Only Participating Providers who are in-network for the member’s benefit plan are eligible to recieve enhanced reimbursement when selecting a Cancer Treatment Pathway regimen.

Are all chemotherapy drugs, including supportive care drugs, managed through the Program?
Providers may enter cancer treatment drugs, including supportive care drugs, into the AIM ProviderPortal.
The system will thereafter identify cancer treatment regimens that match the list of drugs which have been entered.

About Anthem Cancer Treatment Pathways

What do you mean by Cancer Treatment Pathway?
Pathways are widely accepted as a component in managing oncology treatment quality and costs. More specific than guidelines, pathways identify treatments selected based on effectiveness, favorable toxicity profiles, and cost. Over half of practices responding to ASCO’s 2010 National Practice Benchmark report that they regularly use pathways in patient care. Organizations that have implemented pathways have found that survival outcomes are equivalent for patients treated on and off pathway, while treatment costs decrease substantially for patients treated on pathway.

How were the Cancer Treatment Pathways developed?
The goal of the Cancer Care Quality Program is to promote access to quality and affordable cancer care for health plan members. A key component of the Cancer Care Quality Program is the development of the Anthem Cancer Treatment Pathways.

Cancer Treatment Pathways are developed using a rigorous process of evidence-based medicine. In order to be considered as a possible Cancer Treatment Pathway, a cancer treatment regimen must first be recognized by national guidelines as an effective and recommended cancer therapy.

The Pathways are developed starting with the medical evidence and national clinical guidelines, such as NCCN and ASCO guidelines, which also are used for developing Anthem medical policy. The Pathways are then reviewed by an external Advisory committee that consist of geographically diverse physicians who are actively treating patients and work in academic and community oncology groups. The committee uses a process similar to how we evaluate drugs chosen for our drug formularies. The group evaluates the evidence for given treatments and compares outcomes for each – much like a comparative effectiveness review. Then, they compare costs of those regimens with the best outcomes.

How are Anthem’s external Advisors selected?
Our advisors are selected because of their clinical expertise in cancer care. Of the physicians currently serving as advisors for Anthem, some are on the staffs of NCI or NCCN designated cancer centers, including Cleveland Clinic, Columbia, Fred Hutchinson, University of Colorado, and Yale and some are in community practice settings; many serve or have served on national committees for organizations such as NQF, ASCO, FACT, and IOM to improve cancer care.

Does Anthem have a process to manage conflicts of interest for external Advisors?
Anthem is committed to having clinical experts free of commercial bias and conflicts of interest determining which treatment regimens to be included in Pathways. Upon agreeing to serve as advisors for Anthem, advisors must sign a formal Agreement that outlines the responsibilities, including an acknowledgment that advisor has no conflict of interest. Advisors also agree to notify Anthem immediately of the existence of any conflict of interest. Additionally, advisors must sign a new conflict of interest attestation, at least once annually.

The Cancer Treatment Pathways are selected on the basis of:

  • Bladder Cancer
  • Breast Cancer (Neo/Adv, Metastatic, Endocrine)
  • Central Nervous System (CNS)
  • Chronic Myelogenous Leukemia (CML)
  • Colorectal Cancer
  • Diffuse Large B-Cell Lymphoma
  • Follicular Lymphoma and Marginal Zone Lymphoma
  • Gastroesophageal Cancer
  • Head and Neck Cancer
  • Hodgkin’s Lymphoma
  • Kidney Cancer
  • Mantle Cell Lymphoma
  • Melanoma
  • Myeloma
  • Non-Small Cell Lung Cancer
  • Ovarian Cancer
  • Pancreatic Cancer (Adenocarcinoma)
  • Prostate Cancer
  • Small Lymphocytic Lymphoma/Chronic Lymphocytic Leukemia

We will be adding additional Pathways for other common malignancies throughout 2016.
Providers are encouraged to enter regimens for all malignancies into the
AIM ProviderPortal.

Where can I find a copy of the Cancer Treatment Pathways?
The pathways are posted on www.cancercarequalityprogram.com. On this website you can find information, tools and worksheets to assist you in incorporating the Cancer Care Quality Program into your practice.

What if I am treating a patient for whom a Pathway regimen option is not available?
Cancer Treatment Pathways include multiple regimens for different clinical situations. However, if a Pathway regimen is not available for a particular type of cancer or line of therapy, you can select a different regimen. Please note that enhanced reimbursement is only available for designated Cancer Treatment Pathways.

Do Pathways apply to pediatric patients?
The Cancer Care Quality Program only applies to adult oncology patients at this time. However, you are encouraged to enter regimens for all malignancies into the AIM ProviderPortal.

What happens if I do not select a treatment regimen that is designated as a Cancer Treatment Pathway?
If you are an in-network provider for the member’s benefit plan and you do not select a Cancer Treatment Pathway, you will not be eligible for the enhanced S-code reimbursement. The requested treatment regimen will continue to be reviewed through the usual utilization management review process if UM is required and/or adjudicated according to the member’s benefit plan.

How often are the Cancer Treatment Pathways updated?
Cancer Treatment Pathways are reviewed at least quarterly or more frequently, as needed.

Are supportive drugs included in the Pathways?
Supportive care drugs, such as those used to manage side effects of chemotherapy, are not currently included in the Cancer Treatment Pathways. However, the entire cancer treatment drug regimen, including supportive care drugs, should be included in the order request as certain supportive drugs may be included on the list of drugs that require utilization management review against applicable health plan medical policies or clinical guidelines. This list has not changed with the introduction of the Cancer Care Quality Program.

About pharmacy benefits programs

What should I do if the drugs I am ordering require prior authorization/precertification under my patients’ pharmacy benefits?
Please contact the patient’s Pharmacy Benefit Administrator for any necessary Pharmacy Plan authorizations or pre-certifications required.

About AIM Specialty Health and the clinical appropriateness review process

 

What is AIM Specialty Health and what is its role in the Cancer Care Quality Program?
The Cancer Care Quality Program will be administered by AIM Specialty Health on behalf of your patients’ health plans. AIM Specialty Health, a separate company, collaborates with payors to help improve healthcare quality and manage costs for some of today’s complex tests and treatments, promoting patient care that’s appropriate, safe and affordable.

How do I participate in the Cancer Care Quality Program through AIM?
Participating in the Cancer Care Quality Program can be a straightforward process and is most easily managed using the AIM ProviderPortal.
ProviderPortal allows you to open a new order, update an existing order and retrieve your order summary. As an online application, ProviderPortal is available 24/7. Your first step is to register your practice in ProviderPortal, if you are not already registered.

Online:
Get convenient online service via the AIM ProviderPortal (registration required). ProviderPortal is available twenty-four hours a day, seven days a week, processing requests in real-time. Go to https://providerportal.com to register. If you have previously registered for other services managed by AIM (diagnostic imaging, radiation therapy, specialty drugs), there is no need to register again.

By phone:
Call AIM Specialty Health toll-free at the following phone numbers and times:

AIM Contact Center Information:

State AIM Contact Center Phone AIM Contact Center Hours Monday–Friday
California 877-291-0360 7:00 am - 5:00 pm (PT)
Colorado 877-291-0366 8:00 am - 6:00 pm (MT)
Connecticut 866-714-1107 8:00 am - 5:00 pm (ET)
Georgia 800-554-0580 8:30 am - 7:00 pm (ET)
Indiana 877-430-2288 8:00 am - 6:00 pm (ET)
Kentucky 877-430-2288 8:00 am - 6:00 pm (ET)
Maine 866-714-1107 8:00 am - 5:00 pm (ET)
Missouri 877-430-2288 8:00 am - 6:00 pm (ET)
Nevada 877-291-0366 7:00 am - 5:00 pm (PT)
New Hampshire 866-714-1107 8:00 am - 5:00 pm (ET)
New York 877-291-0360 7:00 am - 5:00 pm (ET)
Ohio 877-430-2288 8:00 am - 6:00 pm (ET)
Virginia 866-789-0158 8:00 am - 5:00 pm (ET)
Wisconsin 877-430-2288 8:00 am - 6:00 pm (ET)

How do I use the AIM ProviderPortal to submit my cancer treatment?
A step-by-step tutorial on using the AIM ProviderPortal to submit your regimen can be accessed
online by going to www.cancercarequalityprogram.com

Once I have submitted a request, how long will it take to receive a response from AIM?
Requests that meet criteria receive a response instantly on screen in the AIM ProviderPortal or on the phone with
the AIM contact center.

If I am in-network provider for the member’s benefit plan and I select a Cancer Treatment Pathway, how will I be notified of the enhanced reimbursement?
When selecting a Cancer Treatment Pathway regimen, you must use either the AIM ProviderPortal or phone. In both instances, you will be notified immediately after selecting a Pathway regimen that you are eligible for S-code reimbursement. A separate letter will not be provided. It is recommended that you save the summary page that you receive from the AIM ProviderPortal after completing your initial order in your patients’ chart.

What happens if I do not call AIM or enter information through the AIM ProviderPortal?
If you call the health plan directly, you will be directed to use the AIM ProviderPortal or call the AIM contact center. If you do not provide AIM with the necessary information, you will not be eligible for enhanced reimbursement, even if the treatment regimen is on Pathway. In addition, if any oncology drugs are subject to health plan Medical Policy or Clinical Guidelines and have not been reviewed prospectively, they may be subject to post-service review.

What if I need a longer treatment period than is indicated in the Cancer Treatment Pathway?
The Cancer Treatment Pathway reflects an expected duration of treatment. For a regimen (e.g., adjuvant therapy) of fixed duration, the Pathway enhanced reimbursement is for the duration of all planned cycles of chemotherapy. For a treatment regimen that is indefinite (e.g., planned until disease progression), the Pathway enhanced reimbursement is for 6 months. If treatment continues beyond 6 months, please submit a new treatment regimen request to AIM. Most users will find the most efficient way to track the Pathway time period is to save the summary page that you receive from the AIM ProviderPortal after completing your initial order in your patients’ charts so that the information to report continuation of treatment is easily available.


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