Changes to our National Precertification List (NPL)
This update applies to both our commercial and Medicare members.

New-to-market drugs that require precertification

• Elrexfio™ (elranatamab-bcmm) - precertification is required effective Nov 10, 2023
• Talvey™ (talquetamab-tgvs) - precertification is required effective Nov 10, 2023

Submitting precertification requests
Be sure to submit precertification requests at least two weeks in advance. To save time, request precertification online. Doing so is fast, secure and simple.

You can submit most requests online through our Availity provider portal.* Or you can use your practice’s Electronic Medical Record (EMR) system if it’s set up for electronic precertification requests. Use our “Search by CPT® code” search function on our precertification lists page to find out if the code requires precertification.**

Learn more about precertification.

Are you asking for precertification on a specialty drug for a commercial or Medicare member? Then submit your request through Novologix®, also available on Availity®. Not registered for Availity? Go to Availity to register and learn more.

We want to remind you that we do not allow additional payment for services or procedures that are integral to the primary service billed. We base many edits on recommendations such as those provided by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA).

Our claim systems edit for these complex claim scenarios to make sure coding and modifier
usage aligns with industry guidelines. When appropriate, we will evaluate and audit for
appropriate use of separate and distinct service modifiers as well as other separately
identifiable evaluation and management modifiers. The result of these manual audits may
differ from the referenced guideline.

Non-Medical Office Visits
This update applies to our commercial members.

We don’t cover office visits that do not treat or diagnose a specific illness, symptom, complaint or injury unless it’s covered under a member’s benefits plan. Some examples of non-covered exams are those needed to:

• Get or keep a job
• Travel
• Go to a school
• Go to a camp
• Join a sport or other recreational activity

Assistant Therapy Services Billing Reductions
This update applies to both our commercial and Medicare businesses.

In the September issue of OLU, we said that, effective December 1, 2023, we will pay eligible services billed by occupational therapy assistants (OTAs) and physical therapist assistants (PTAs) at 85% of allowed. We delayed the policy changes and will begin applying pay percent reductions on March 1, 2024.

To view November's OfficeLink Updates, click here.