January 2020 Anthem Blue Cross Provider News - California

Contents

AdministrativeCommercialJanuary 1, 2020

Anthem Blue Cross provider directory and provider data updates

AdministrativeCommercialJanuary 1, 2020

The New Year brings new ID cards for many Anthem Blue Cross members

AdministrativeCommercialJanuary 1, 2020

Contracted provider claim escalation process

AdministrativeCommercialJanuary 1, 2020

Provider Education seminars, webinars, workshops and more!

AdministrativeCommercialJanuary 1, 2020

Stay “in the know” at no charge!

AdministrativeCommercialJanuary 1, 2020

Network leasing arrangements

Federal Employee Program (FEP)CommercialJanuary 1, 2020

2020 FEP® Benefit information available online

State & FederalMedicaidJanuary 1, 2020

Medical drug benefit Clinical Criteria updates

State & FederalMedicare AdvantageJanuary 1, 2020

Help protect your patients by providing medical ID protection – best practices

State & FederalMedicare AdvantageJanuary 1, 2020

California 2020 Medicare Advantage plan changes

State & FederalMedicare AdvantageJanuary 1, 2020

Prior authorization requirements for E0784, K0553 and K0554

State & FederalMedicare AdvantageJanuary 1, 2020

Healthcare Quality Patient Assessment form and Patient Assessment form

State & FederalMedicare AdvantageJanuary 1, 2020

Medicare preferred continuous glucose monitors

State & FederalMedicare AdvantageJanuary 1, 2020

Medical drug benefit Clinical Criteria updates

State & FederalMedicare AdvantageJanuary 1, 2020

Pharmacy benefit manager change to IngenioRx

State & FederalMedicare AdvantageJanuary 1, 2020

Medical policies and Clinical Utilization Management Guidelines update

State & FederalMedicaidJanuary 1, 2020

2020 Prenatal ultrasound diagnosis code update

State & FederalMedicaidJanuary 1, 2020

Verifying and updating your provider information

State & FederalMedicaidJanuary 1, 2020

Improving the patient experience

State & FederalMedicaidJanuary 1, 2020

Medical drug benefit Clinical Criteria updates

State & FederalJanuary 1, 2020

Pharmacy benefit manager changes to IngenioRx

State & FederalJanuary 1, 2020

Medical drug benefit Clinical Criteria updates

State & FederalMedicare AdvantageJanuary 1, 2020

Introducing two new Medicare Advantage special needs plans for 2020

State & FederalMedicare AdvantageJanuary 1, 2020

Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ

State & FederalMedicare AdvantageJanuary 1, 2020

Reminder to Medicare Advantage providers

State & FederalMedicare AdvantageJanuary 1, 2020

City of Marietta offers Medicare Advantage option

AdministrativeCommercialJanuary 1, 2020

Anthem Blue Cross provider directory and provider data updates

It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137), requires that Anthem Blue Cross (Anthem) provide our members accurate and up-to-date provider directory data. As a result, Anthem will be conducting ongoing outreaches to all practices to confirm the information we have on file is accurate. Without verification from you that our Provider Directory information is accurate, we will be required to remove your practice from the directories we make available to our members. We appreciate your attention to this matter.

AdministrativeCommercialJanuary 1, 2020

Reminder: Company requires National Drug Code for professional and facility outpatient claims effective January 1, 2020

In a letter dated September 27, 2019, Anthem Blue Cross (Anthem) notified providers about a new billing requirement to help us determine the correct amount to pay on drug claim lines for commercial professional and facility outpatient claims filed to us.  As a reminder, effective for dates of service on or after January 1, 2020, the following information will be required on claims for all categories of drugs except for those administered in an inpatient facility setting:

 

  1. Applicable HCPCS code or CPT code
  2. Number of HCPCS code or CPT code units
  3. Valid 11-digit National Drug Code(s) (NDC), including the N4 qualifier
  4. Unit of Measurement qualifier (F2, GR, ML, UN, MG)
  5. NDC units dispensed (must be greater than 0)

 

Note: These billing requirements apply to Local Plan and BlueCard® only.  The Federal Employee Program® (FEP®) and Coordination of Benefits/Secondary claims are excluded.

 

As we shared in the original notification, Anthem will deny any line items on a claim regarding drugs that do not include the above information – effective for dates of service on or after January 1, 2020.  Please include the above information on drug claims to help ensure accurate and timely payments.

 

If you have specific claims questions, please call the phone number on the back of the member ID card.  Other questions can be directed to our Provider Service staff at 1-800-677-6669.

AdministrativeCommercialJanuary 1, 2020

Upcoming retirement planned for legacy Medical Attachment submission tool

The Medical Attachment tool makes the process of submitting electronic documentation in support of a claim, simple and streamlined. We are now in the final stages of migration from the Medical Attachments link to the Attachments-New option.

What is happening to the current attachment tool?

  • The legacy tool will be retired soon* with access via Attachments-New option available now.
  • The history of the information you have previously submitted is still available on the legacy tool for now*.
  • Read only access to the history is in the final stages*

 

*Look for messaging on the legacy attachment tool for specific dates

 

How to Access solicited Medical Attachments for Your Office

Availity Administrator, complete these steps:

From My Account Dashboard, select Enrollments Center>Medical Attachments Setup, and complete the following sections:

  1. Select Application>choose Medical Attachments Registration
  2. Provider Management>Select Organization from the drop-down. Add NPIs and/or Tax IDs
  3. Assign user access by checking the box in front of the user’s name

 

Using Medical Attachments

Availity User, complete these steps:

  1. Log in to www.availity.com
  2. Select Claims and Payments > Attachments-New >Send Attachment Tab
  3. Complete all required fields of the form
  4. Attach supporting documentation
  5. Submit

               

Need Training?

To access additional training for this Availity feature: Log in and select Help & Training > Get Trained to open the Availity Learning Center (ALC) Catalog in a new browser tab. Search the Catalog by keyword (attachments) to find training demo and on-demand courses. Select Enroll to enroll for a course and then go to your Dashboard to access it any time.

AdministrativeCommercialJanuary 1, 2020

An exclusive invitation for providers to subscribe to the Anthem Marketplace for Workers’ Compensation

As a current Anthem diagnostic or therapy provider, you should have received your exclusive invitation in December to subscribe to the Anthem Marketplace, powered by Transparent Health Marketplace™ (THM). This revolutionary marketplace is not like a traditional PPO. It’s a connected end-to-end technology platform that incorporates familiar ways of electronically transacting business.

It’s quick, easy and only takes “one click” to connect to new patients!

Subscribing is easy! 
Visit us today at: www.anthemwc.com/oneclick/invite

With several national payor partners signed up and hundreds of providers already subscribed, the platform has experienced triple-digit growth in select California markets. Now, we are launching statewide in California.  We hope you will embrace our movement, love our platform, tell your friends and colleagues, take back control of your practice, and help us lead the transformation of the workers’ compensation system. Are you in?

AdministrativeCommercialJanuary 1, 2020

Let us help you accomplish your 2020 “To do List” early – EDI migration

The new year always gives us an opportunity to set new goals. Starting in 2020, we want to help you check off a few “to do” items. As the Availity migration continues full speed ahead, let’s get you started on your first goals of the year:


Don’t Delay and Transition to Availity today!

All EDI transmissions currently sent or received today via the Anthem Blue Cross (Anthem) EDI Gateway are now available on the Availity EDI Gateway. 

  • 837- Institutional and Professional
  • 837- Dental
  • 835- Electronic Remittance Advice
  • 276/277- Claim Status
  • 270/271- Eligibility Request
  • 275 – Medical Attachments

Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:

  • Migrate your direct connection with Anthem and become a direct submitter with Availity.
  • Use your existing Clearinghouse or Billing Company for your EDI transmissions. (Work with them to ensure connectivity to the Availity EDI Gateway).
  • Use Direct Single Claim entry through the Availity Portal.

 

Availity setup is simple and at no cost for you!

Use this “Welcome” link below to get started today: https://apps.availity.com/web/welcome/#/anthem

 

Learn Something New!

Enroll in one of Availity’s free courses and training demos. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.

Follow these steps to register at www.Availity.com :

  1. Log in to the Availity Portal and select Help & Training | Get Trained to access the Availity Learning Center (ALC).
  2. Select Sessions from the menu under the search catalog field.
  3. Scroll Your Calendar to locate your webinar.
  4. Select View Course and then Enroll. The ALC will email you instructions to attend.

 

If you and your clearinghouse have already migrated, you are a step ahead! If not, take action today to make the transition. For questions contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday - Friday 5 a.m. - 4 p.m. PT.

AdministrativeCommercialJanuary 1, 2020

The New Year brings new ID cards for many Anthem Blue Cross members

Now is the time to ask all of your patients to present their current ID card.  Many members were assigned new identification numbers effective January 1, 2020 and new ID cards were provided digitally or mailed to all affected members in late December 2019. To ensure claims are processed appropriately, here is some helpful information.

Tips for Success: When Anthem Blue Cross (Anthem) members arrive at your office or facility, ask to see their current member identification card at each visit. Many of our members no longer receive a paper card so they will present you with their digital card on their mobile device. Doing so will help you:

  • Identify the member’s product
  • Obtain health plan contact information
  • Speed claims processing


Note:  Claims submitted with an incorrect ID number may be unable to be processed and may be returned for correction and resubmission with the correct ID.
 

 

Tips for Success: When you contact a member about a claim returned for an invalid ID, and they do not recall receiving a new ID card or they misplaced their ID card, please ask the member to confirm their member ID using one of the following options:

 

  • Log in to their member account on anthem.com
  • Use the Anthem mobile APP called Sydney (formerly Anthem Anywhere) to access their electronic ID card
  • Members can fax or email their most current card from Anthem.com or the mobile APP to your office if needed
  • Call their Anthem member services number

AdministrativeCommercialJanuary 1, 2020

Receive and respond to post pay audit medical record requests via Availity beginning February 10, 2020

We are launching the use of Availity’s medical attachment functionality to begin requesting medical records and itemized bill information from providers electronically instead of paper requests.  This change applies only to the process of requesting and receiving medical records; it is not a change to the audit program.  We began transitioning providers to this new process in an active limited launch in October 2019. We will complete the transition by February 10,  2020.

Important facts regarding this change:

  • This change only affects providers who use Availity and who have opted into using the medical attachment functionality through the permissions in Availity’s enrollment center.
  • The new functionality is for medical record requests for post pay claims for the Payment Integrity Quality Claims Review (provider audit) department only.
  • There will be no duplicate requests (both paper and electronic).
  • In Availity, the request will come into the provider’s Medical Attachment “inbox”
    • The original letter historically sent via paper is accessible through a hyperlink in the Availity system as a pdf electronic copy. The letter content is the same as it was in paper format.
    • Each electronic request letter will have a timeframe for responding to the request. After the timeframe has passed for that letter, you will not be able to respond to that electronic letter.  If you wish to upload medical records after the response time has expired, please refer to the Availity training referenced below.
    • Providers can respond to the request by uploading records in Availity. The attachments are received in almost real time and are delivered electronically to the payer’s systems through secure means - - nothing is stored in Availity.
  • The following are not included or not impacted:
    • Vendor requests for medical records on behalf of the payer.
    • Providers that do not use Availity or have not turned on permissions for Medical Attachments within Availity.
    • The request timing or verbiage in the request letter.
    • At this time, the Program Integrity Special Investigations Unit (SIU) post pay review, but they will be included at a future date.


Resources

Training is available in Availity located here Availity Training on Electronic Medical Records for Program Integrity.


Can I start using the functionality earlier?

Yes.  If you chose to opt in earlier, please ensure you are configured within Availity.  You may  request early access via this email address: dl-Prod-Availity-Provider-Support@anthem.com.

 

For additional information attached is a copy of Frequently Asked Questions 

AdministrativeCommercialJanuary 1, 2020

New Musculoskeletal and Pain Management Solution – effective for select National ASO accounts January 1, 2020

Musculoskeletal care and interventional pain management (MSK) pose substantial challenges for employers as costs rise, the population ages and physician practice patterns vary widely. With disorders affecting one in every two American adults1, the need for evidence-based care and proactive consumer engagement is essential to better managing care and cost.

With that in mind, we are pleased to announce that select National Accounts will utilize the comprehensive Musculoskeletal and Pain Management Solution, administered by AIM Specialty Health. The new MSK program reviews certain spine and joint surgeries, and interventional pain services against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine.

Transition Period

To ensure continuity of care, we will have a 90 day transition of care for members in active treatment for pain management or for members that have received prior approval through the Anthem precertification.  Providers do not need to obtain authorization through AIM portal for services already in progress or where prior authorization has been obtained with Anthem. 

 

Please contact anthem.com or call the number on the back of the member ID card for member eligibility.

 

1 American Academy of Orthopedic Surgeons

AdministrativeCommercialJanuary 1, 2020

Contracted provider claim escalation process

In an effort to better service our contracted providers right the first time, Anthem Blue Cross has improved our provider claim escalation process. Just click, Provider Claim Escalation Process to read, print, download and share the improved process with your office staff.

Our Network Relations Team is available by email at CAContractSupport@anthem.com to answer questions you have about the process.

AdministrativeCommercialJanuary 1, 2020

Provider Education seminars, webinars, workshops and more!

Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. For a complete listing of our workshops, seminars, webinars and job aids, log on to the Anthem Blue Cross website: www.anthem..com/ca. Scroll down the page to Partners in Health > Tools for Providers. In the middle of the page select the box  Find Resources for California. From the Answers@Anthem page, select the link titled Provider Education Seminars and Webinars link.

AdministrativeCommercialJanuary 1, 2020

Easily update provider demographics with the online Provider Maintenance Form

Anthem Blue Cross (Anthem) providers should now submit changes to their practice profile using our online Provider Maintenance Form.  

Online update options include: add an address location, name change, tax ID changes, provider leaving a group or a single location, phone/fax numbers, closing a practice location, etc. Visit the Provider Maintenance Form landing page to review more.

The new online form can be found the redesigned provider site www.anthem.com/ca, select the Providers tab then select Provider Maintenance Form in the sub bullets. In addition, the Provider Maintenance Form can be accessed through the Availity Web Portal by selecting California> Payer Spaces-Anthem Blue Cross> Resources tab >Provider Maintenance Form.

Important information about updating your practice profile:

  • Change request should be submitted using the online Provider Maintenance Form
  • Submit the change request online. No need to print, complete and mail, fax or email demographic updates
  • You will receive an auto-reply e-mail acknowledging receipt of your request and another email when your submission has been processed
  • For change(s) that require submission of an updated IRS Form w-9 or other documentation, attach them to the form prior to submitting
  • Change request should be submitted with advance notice
  • Contractual agreement guidelines may supersede effective date of request

 

You can check your directory listing on the Anthem Blue Cross: “Find a Doctor tool”. The Find a Doctor tool at Anthem is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans. To ensure Anthem has the most current and accurate information, please take a moment to access the Find A Doctor tool (www.anthem.com/ca, select the Providers tab, then select the Find A Doctor in the sub bullets) and review how you and your practice are being displayed.

AdministrativeCommercialJanuary 1, 2020

Stay “in the know” at no charge!

Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before with our Provider News.

                                

Provider News is our web tool for sharing vital information with you. It features short topic summaries and links that let you dig deeper into timely critical business information:

 

  • Important website updates
  • System changes
  • Fee Schedules
  • Medical policy updates
  • Claims and billing updates

……and much more
 

Registration is fast and easy. There is no limit to the number of subscribers who can register for Provider News, so you can submit as many e-mail addresses as you like.

AdministrativeCommercialJanuary 1, 2020

Network leasing arrangements

Anthem Blue Cross (Anthem) has network leasing arrangements with a variety of organizations, which we call Other Payors. Other payors and affiliates use the Anthem network.

Under the terms of your provider agreement, members of other payors and affiliates are treated like Anthem members. As such, they’re entitled to the same Anthem billing considerations, including discounts and freedom from balance billing. You can obtain the Other Payors list on the Availity web portal, at www.Availity.com. From the Availity site, select Home > Anthem California > Education and Reference Center, or email us at CAContractSupport@Anthem.com.

Behavioral HealthCommercialJanuary 1, 2020

Contract compliance with accessibility standards for Emergency Care instructions After Hours Care

As you know, Anthem Blue Cross (Anthem) monitors member access to Behavioral Health care through a number of mechanisms, including provider and member surveys. These surveys are conducted by Anthem Behavioral Health and external entities such as North American Testing Organization (NATO) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program.  In surveying compliance with After Hours standards, participating providers’ offices are called outside of normal business hours to determine if callers are given appropriate emergency instructions, and have a mechanism to reach a provider after regular hours for urgent situations. Members who have received Behavioral Health care within the previous year are also surveyed via mail. The surveys, in addition to monitoring member complaints, help us to identify whether access to care is available to our members after or before normal business hours.

 

The key to our 2019 success is…YOU!

We thank those of you who have already taken steps to comply with the standards. Your efforts make a direct positive impact on the level of service and access to care for our members. We need your continued support and commitment in helping us achieve the best results possible for our 2019 surveys, which are currently being conducted.

In an effort to improve our results for 2019, Anthem is sharing the 2018 results below.

Provider After Hours Survey 2018

Question

Threshold > 85% of providers comply with the standard

Result

(% compliant with standard)

“What would you tell a caller who states he/she is dealing with a life-threatening emergency?” (Compliant Answers: Hang up and Dial 911 or go to the nearest emergency room; go to nearest emergency room; or Hang up and Dial 911)

 

Medical:  92.4%

Behavioral Health:  88.4%

Urgent Request After Hours. “In what time frame can the patient expect to hear from the provider or on-call provider?” Note: Providers are expected to provide a specific timeframe in that a member can expect a return call. If a specific timeframe is not provided, the answer is considered “non-compliant.”

 

Medical:  85.0%

Behavioral Health:  87.8%

 

How Can You Make a Difference?

  • Review Anthem Access Standards under the Legal and Administrative Overview section of your Anthem California Facility and Professional Provider Manual. Make sure your practice policy and procedures comply with the standards.
  • Ensure your After Hours office staff, answering service and/or answering machine message specifically inform callers when their urgent (non-emergent) calls will be returned.
  • Ensure your After Hours office staff, answering service and/or answering machine message directs callers to dial 911 or go to the nearest emergency room if they are experiencing an emergency.

If your office was surveyed in 2018 and found non-compliant with these After Hours requirements, you have received a letter with recommended compliance measures. 

We value your participation in the Anthem commercial Behavioral Health Network, and appreciate your efforts to meet compliance with established access standards. If you have questions, please email our commercial Behavioral Health Provider Relations team at CABHNetworkRelations@anthem.com.

 

Behavioral HealthCommercialJanuary 1, 2020

A note from our Medical Director – J. Moussai, M.D.

Dear colleagues,  welcome to the Anthem Blue Cross Provider News publication.  This is an opportunity to share with you a number of exciting changes that are happening here at Anthem Blue Cross (Anthem). The information can also provide meaningful clinical input that I hope will be pertinent and practical for your daily clinical use.  First, let me introduce myself. I’ve taken over as the Anthem West Region Behavioral Health Medical Director as of October 1, 2019.  Though I’m saddened by the departure of Dr. Friedman, the previous Medical Director, I’m very excited about this new role. Dr. Friedman was instrumental in the past few years in improving Anthem’s Behavioral Health services and strengthening our collaboration with facility and professional providers, and we wish him the best of luck on his next career venture. 

 

Here at Anthem, we’re always striving towards enhancement of our services and products while staying true to our mission. I want to highlight some of the positive additions. One is 'Sydney' the personal health ally, which is a mobile device app providing personalized wellness activities and other beneficial features to our members. The other is the addition of IngenioRx (our mail-order pharmacy service), which has made pharmacy care more accessible, supporting of provider's care decisions and functions as a health advocate. Additionally, we’re excited about the opportunity to expand behavioral health resources with the pending acquisition of Beacon Health and reemphasizing Anthem's commitment to emotional wellness. 

Anthem is committed to enhancing treatment of major depression. The best practice treatment guidelines include consideration for medications, for example, antidepressants, psychotherapy, as well as mindfulness techniques. If started on an antidepressant, it is imperative that the patient continue with their medication for at least six months. Some suggestions to increase adherence would be educate the patient on time-course, potential side effects, and the importance of preventing relapse.  One tool used for screening, diagnosing, monitoring and measuring the severity of depression is the Patient Health Questionnaire (PHQ-9). This self-reported questionnaire only takes a few minutes for a patient to complete and the provider to score.  The PHQ-9, can also be used to monitor response after initiation of treatment and can be re-administered repeatedly. Other rating scales to consider are the Beck Depression Inventory (BDI), Geriatric Depression Scale (GDS), Hamilton Depression Rating Scale (HAM-D), Inventory of Depressive Symptomatology-Systems Review (IDS-SR), Montgomery-Asberg Depression Rating Scale (MADRS), and Quick Inventory of Depressive Symptomatology (QIDS). Also, it is imperative to complete a treatment plan upon initiation of treatment to include a suicide risk assessment. 

I hope that we continue to have ongoing conversations about how to enhance the care of our members. I welcome your suggestions and input about how we can most effectively use the Provider News platform to communicate. Don’t hesitate to provide me with your feedback. Email our Provider Education team at prov.communications@anthem.com and in the subject line enter, BH newsletter. I look forward to continuing our collaborative efforts.

 

 

 

 

 

 

 

Federal Employee Program (FEP)CommercialJanuary 1, 2020

2020 FEP® Benefit information available online

To view the 2020 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), go to www.fepblue.org >select Benefit Plans>Brochure & Forms.  Here you will find the Service Benefit Plan Brochure and Benefit Plan Summary information for year 2020.  For questions please contact FEP Customer Service at: 1-800-824-9093.

State & FederalMedicaidJanuary 1, 2020

Medical drug benefit Clinical Criteria updates

Category: Medi-Cal Managed Care


This communication applies to the Medicare Advantage and MMP programs for Anthem Blue Cross (Anthem).

 

On August 16, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

State & FederalMedicare AdvantageJanuary 1, 2020

Help protect your patients by providing medical ID protection – best practices

Category: Medicare

Overview
Many of our members have reported that they received unsolicited calls (or emails) from an individual or company offering to provide durable equipment devices, such as back or leg braces, or items such as topical creams at little or no cost. While it may be tempting to want to receive something for free, members should know that there is a cost. 

 

Although our members may not receive a bill for these devices or medications, the items are billed to the insurance companies, costing hundreds or even thousands of dollars each.

 

How does this impact members?

Members should also know that the cost may be more than monetary. Allergic reactions may occur when using medications that are not properly prescribed. Ill-fitting leg or back braces, or equipment that is not specifically intended for the pain experienced by the member, could do more harm than good.

 

This problem is prevalent throughout the country, so all of our members should be aware. Billions of unsolicited telemarketing calls are made each year, many of which are promoting health care services. Calls often spoof local phone numbers or numbers that appear familiar to trick the recipient into accepting the call. 

 

How can I help protect my patients?

While the ultimate purpose of these telemarketing calls is to sell these items, the immediate goal of the person or company placing the call is to obtain valuable personally identifiable information (PII) from the member. Without this personal information, such as a social security number or insurance identification number, selling these devices and medications is much more difficult. Share this information with you patients to help them learn how to protect their PII.

 

You can help protect your patients and their personally identifiable information from scams by reminding them of the following:

  • Don’t fall prey to scams!
  • Take a few moments to review your Explanation of Benefits (EOB) and the services listed.  
  • When receiving robotic (robo) or telemarketing calls:
    • Simply hang up the phone.
    • Beware of threatening or urgent language used by the caller.
    • Do not provide any personally identifiable information such as your social security number or insurance identification number. The caller may imply that they have your information and ask you to provide it to confirm that they have the correct information. Do not provide the information or confirm it if they do happen to have any identification information.

 

  • When receiving emails:
    • Do not open email attachments you weren’t expecting.
    • Check for spelling mistakes and poor grammar.
    • Do not click on the links you are sent. You can type the link into a new browser.
    • Online scams can come from anywhere. Take a few moments to review your EOB and confirm that you received the services listed on the EOB.
  • Additional ways to protect yourself:
    • Shred or destroy obsolete documents that contain medical claims information or EOBs.
    • Do not use social media to share medical treatment information.

 

How to report when you receive what you suspect is a scam call or email:

  1. To file a complaint with the Federal Trade Commission, you can go to: https://ftc.gov/complaint or call 1-877-FTC-HELP.
  2. Members may contact their plan’s Member Services department.

 

505755MUPENMUB

State & FederalMedicare AdvantageJanuary 1, 2020

Healthcare Quality Patient Assessment form and Patient Assessment form

Category: Medicare

Anthem Blue Cross (Anthem) offers the Healthcare Quality Patient Assessment Form (HQPAF)/Patient Assessment Form (PAF). This newsletter focuses on key tips that may help participating providers successfully close out their 2019 HQPAF/PAF.

 

Dates and tips to remember:

  1. Anthem encourages you to review your patient population as soon as possible. You can help patients schedule an in-office visit. These appointments help the patient manage chronic conditions, which impact the health status of the patient.
  2. At the conclusion of each office visit with the patient, providers who are participating in the HQPAF/PAF program are asked to complete and return a HQPAF/PAF. The form should be completed based on information collected during the visit. Participating providers may continue to use the 2019 version of the HQPAF/PAF for encounters taking place on or before December 31, 2019. Anthem will accept the 2019 version of the HQPAF/PAF for 2019 encounters until midnight on January 31, 2020. Important note: HQPAF/PAF for 2019 dates of service that are rejected due to provider error and corrected by the provider may be submitted through March 31, 2020.
  3. If not already submitted, participating providers are required to submit an Account Setup Form (ASF), W9 and a completed direct deposit enrollment by March 31, 2020. Participating providers should call 1-877-751-9207 if they have questions regarding this requirement. Failure by a participating provider to comply with this requirement will result in forfeiture of the provider payment for submitted 2019 HQPAF/PAF program, if applicable.

 

If you have any questions about the PAF or HQPAF programs, please call 1‑877‑751‑9207 from 6:30 a.m. to 4:30 p.m. Pacific time Monday to Friday.

506172MUPENMUB

State & FederalMedicare AdvantageJanuary 1, 2020

Medical drug benefit Clinical Criteria updates

Category: Medicare

On September 19, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Medicare Advantage Clinical Criteria Web Posting September 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

505908MUPENMUB

State & FederalMedicaidJanuary 1, 2020

Coding spotlight – provider’s guide to coding respiratory diseases

Category: Medi-Cal Managed Care


ICD-10-CM coding

Respiratory diseases are classified in categories J00 through J99 in Chapter 10, “Diseases of the Respiratory System” of the ICD-10-CM Official Guidelines for Coding and Reporting.

 

Pneumonia

Pneumonia is coded in several ways in ICD-10-CM. Combination codes that account for both pneumonia and the responsible organism are included in Chapter 1, “Certain Infectious And Parasitic Diseases” and Chapter 10, “Diseases of the Respiratory System.” Examples of appropriate codes for pneumonia include:

  • J15.0 — pneumonia due to Klebsiella
  • J15.211 — pneumonia due to Staphylococcus aureus
  • J11.08 + J12.9 — viral pneumonia with influenza.

 

Other types of pneumonia are coded as manifestations of underlying infections classified in chapter 1; two codes are required in such cases. Examples of this dual classification coding include I00 + J17 — pneumonia in rheumatic fever. When the diagnostic statement is pneumonia without any further specification and the organism is not identified, the assigned code is J18.9 — pneumonia, unspecified organism.

 

Influenza

ICD-10-CM classifies influenza as the following categories:

  • J09 — due to certain identified influenza viruses
  • J10 — due to other identified influenza virus
  • J11 — due to unidentified influenza virus.

 

Codes from categories J09 and J10 should be assigned only for confirmed cases of avian flu and other novel influenza A, or for other identified influenza virus.

 

Chronic obstructive pulmonary disease (COPD) and asthma

COPD is a general term used to describe a variety of conditions that result in obstruction of the airway. ICD-10-CM classifies these conditions to category J44, other chronic obstructive pulmonary disease. Category J44 includes the following conditions:

  • Asthma with chronic obstructive pulmonary disease
  • Chronic asthmatic (obstructive) bronchitis
  • Chronic bronchitis with airways obstruction
  • Chronic bronchitis with emphysema
  • Chronic emphysematous bronchitis
  • Chronic obstructive asthma
  • Chronic obstructive bronchitis
  • Chronic obstructive tracheobronchitis

 

Category J44 is further subdivided to specify whether there is an acute lower respiratory infection (J44.0) and whether there is an exacerbation of the condition (J44.1). If applicable, a code from category J45 is assigned to specify the type of asthma. It is appropriate to code both the COPD with acute exacerbation and COPD with a lower respiratory infection. Be specific in the documentation, including the type of infection and the infective agent.

 

For COPD, document severity as either mild, moderate or severe. COPD can occur with or without acute or chronic respiratory failure, so any respiratory failure should be separately noted.

Asthma is classified into category J45; a fourth character indicates the severity as either mild intermittent, mild persistent, moderate persistent, severe persistent, other and unspecified; also, a final character indicates whether the condition is uncomplicated, or whether status asthmaticus or exacerbation is present.

 

Asthma characterized as obstructive or diagnosed in conjunction with COPD is classified to category J44 — other chronic obstructive pulmonary disease. If the specific type of asthma is documented, also use code J45.

 

Signs and symptoms of COPD or asthma that are separately reported when they occur include hypercapnia, hypoxemia, polycythemia, and acute or chronic respiratory failure. Document any dependence on a ventilator or supplemental oxygen.

 

A diagnosis of asthmatic bronchitis without further specification is coded as J45.9 if the diagnosis is stated as exacerbated or acute chronic asthmatic bronchitis, code J44.1 is assigned. A diagnosis of asthmatic bronchitis with COPD or chronic asthmatic bronchitis is coded to J44.9.

Examples of coding for asthma include the following:

  • J45.902 — asthmatic bronchitis with status asthmaticus
  • J44.9 + J45.40 — moderate persistent asthma with COPD.

 

In addition to codes in categories J44 and J45, codes may also be assigned to identify exposure to environmental tobacco smoke (Z77.22), history of tobacco dependence (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17. or tobacco use (Z72.0)

 

HEDIS® quality measures for respiratory conditions

 

Medication Management for People with Asthma (MMA)

This HEDIS measure looks at patients who have been identified as having persistent asthma and have been dispensed appropriate medication on which they remained during the treatment period.

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

Two rates are reported:

  • The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period
  • The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period

 

For patients with asthma, you should:

  • Prescribe controller medication.
  • Educate them on identifying asthma triggers and taking controller medications.
  • Create an asthma action plan (document in the medical record).
  • Remind them to get their controller medication filled regularly.
  • Remind them to continue taking the controller medications even if they are feeling better and free of symptoms.

 

Exclusions:

  • Acute respiratory failure
  • Chronic respiratory conditions due to fumes/vapors
  • COPD
  • Cystic fibrosis
  • Emphysema
  • Other emphysema

 

Asthma Medication Ratio (AMR)

This HEDIS measure looks at patients who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.5 or greater during the measurement year.

 

Helpful tips:

  • For each member, count the units of asthma controller medications dispensed during the measurement year.
  • For each member, count the units of asthma reliever medications dispensed during the measurement year.
  • For each member, sum the units calculated in step 1 and step 2 to determine units of total asthma medications.
  • For each member, calculate the ratio of controller medications to total asthma medications (units of controller medications divided by units of total asthma).

 

Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)

This HEDIS measure looks at members 40 years of age and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis.

 

Helpful tips:

  • Managing chronic conditions takes planning. A pre-visit chart review is a good place to start.
  • Proper diagnosis is needed to ensure members receive appropriate short- and long-term treatment.
  • Both symptomatic and asymptomatic patients suspected of COPD should have spirometry performed to establish airway limitation and severity.

 

Resources:

  • ICD-10-CM Expert for Physicians: the complete official code set. Optum360, LLC. 2019.
  • ICD-10-CM/PCS Coding: theory and practice. 2019/2020 Edition. Elsevier
  • NCQA: HEDIS & performance management: https://www.ncqa.org/hedis/measures

State & FederalMedicaidJanuary 1, 2020

California Smokers’ Helpline launches dedicated quit Vaping line!

Category: Medi-Cal Managed Care

The California Smokers’ Helpline has dedicated a new counseling line to help people quit vaping. The toll-free number is 1-844-8-NO-VAPE (1-844-866-8273). Educational materials are available at www.nobutts.org/quitvaping.

 

For information about cessation services, including telephone counseling, mobile apps, online chat and texting programs, visit www.nobutts.org/free-services.

 

If you have any questions about the new Quit Vaping line or want to learn more about strategies to address vaping with your patients, contact Emily Aughinbaugh, Communications Manager of the California Smokers’ Helpline at elaughinbaugh@ucsd.edu.

State & FederalMedicare AdvantageJanuary 1, 2020

City of San Jose, California moves to Medicare Advantage plan under Anthem Blue Cross

Category: Medicare

Effective January 1, 2020, the City of San Jose, CA will offer an Anthem Medicare Preferred (PPO) and a Senior Secure (HMO) Medicare Advantage plan. 

 

Providers may call Provider Services at 1-833-848-8730 for eligibility, prior authorization (PA) requirements and any questions about the City of San Jose member benefits or coverage.

 

Detailed PA requirements are also available to contracted providers by accessing the provider self-service tool via the Availity Portal.

 

Providers will follow their normal claim filing procedures for City of San Jose member claims.

 

Anthem Medicare Preferred (PPO) plan:

Anthem will provide medical benefits for the City of San Jose retirees through the Local Preferred Provider Organization (LPPO) product under Anthem. The plan includes the National Access Plus benefit, which allows members to receive services from any provider, as long as the provider is eligible to receive payments from Medicare.

 

Non-contracted providers may continue treating City of San Jose members and will be reimbursed at 100% of Medicare’s allowed amount for covered services, less any member cost share. 

 

City of San Jose members’ copay or coinsurance percentage will be the same whether their provider is in- or out-of-network. Locally or nationwide, doctors or hospitals, in- or out-of-network — the member’s cost share doesn’t change.

 

The Medicare Advantage Part D (MAPD) plan offers the same hospital and medical benefits that Medicare covers and also covers additional benefits that Medicare does not, such as an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online® and SilverSneakers®.

 

The prefix on Medicare Advantage PPO ID cards is MBL

 

Senior Secure (HMO) Medicare Advantage plan:

Retirees with Medicare Parts A and B, or Part B only who reside in select California counties are eligible to enroll in the Senior Secure (HMO) Medicare Advantage plan. The MAPD plan offers the same hospital and medical benefits that Medicare covers and also covers additional benefits that Medicare does not, such as an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online® and SilverSneakers®.

 

The prefix on Medicare Advantage HMO ID cards is MHG.

505912CAPENABC

 

State & FederalMedicaidJanuary 1, 2020

2020 Prenatal ultrasound diagnosis code update

Category: Medi-Cal Managed Care


Diagnosis (Dx) codes are effective from October 1, 2019, to September 30, 2020.

Billing date will be effective December 30, 2019.

 

Note: This code list is a guideline only; codes are subject to change without additional notification. Providers are responsible for billing the appropriate CPT® code, modifier and diagnosis combinations.

See the attached table for a list of codes.

State & FederalMedicaidJanuary 1, 2020

Verifying and updating your provider information

Category: Medi-Cal Managed Care


Maintaining accurate provider information is critically important to ensure that our members have timely and accurate access to care. Additionally, Anthem Blue Cross is required by Centers for Medicare & Medicaid Services (CMS) to include accurate information in provider directories for certain key provider data elements. To remain compliant with federal and state requirements, changes must be communicated within 30 days in advance of a change or as soon as possible.

 

Key data elements include physician name, address, phone number, accepting new patient status, hospital affiliations and medical group affiliations.

 

Please notify us by completing the Provider Maintenance Form at https://mediproviders.anthem.com/ca/pages/forms.aspx. Thank you for your help and continued efforts in keeping our records up to date.

State & FederalMedicaidJanuary 1, 2020

Medical drug benefit Clinical Criteria updates

Category: Medi-Cal Managed Care


On September 19, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting September 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

State & FederalJanuary 1, 2020

Pharmacy benefit manager changes to IngenioRx

Category: Cal MediConnect

Earlier this year, we announced the launch of IngenioRx, our new pharmacy benefits manager (PBM). Effective January 1, 2020, IngenioRx will start serving our Anthem Blue Cross members’ prescription drug coverage.

 

With the transition to the new PBM, Anthem Blue Cross Cal MediConnect Plan (Medicare‑Medicaid Plan) members will receive new ID cards containing all the information needed to process claims and access member services. Members will need to use their new ID cards to fill prescriptions beginning January 1, 2020.

 

Transferring prescriptions

Mail order

Members who fill mail order prescriptions will need to fill their prescriptions with IngenioRx beginning January 1, 2020. We will automatically transfer member mail order prescriptions to IngenioRx home delivery pharmacy for members currently using Express Scripts Mail Order Pharmacy. Members will receive further instructions by mail on initiating IngenioRx home delivery pharmacy services.

 

Specialty pharmacy

Members who now fill their specialty drugs with Express Scripts’ Accredo will have a few choices of specialty pharmacy providers. Members may:

  1. Keep Accredo as their specialty pharmacy.
  2. Transfer their specialty pharmacy prescriptions to the new IngenioRx Specialty Pharmacy.
  3. Select another participating specialty pharmacy.

 

Members will receive information by mail about their specialty pharmacy options, including further instructions on initiating IngenioRx specialty pharmacy.

 

Retail pharmacy

It is expected that most members will be able to continue using their current retail pharmacy. In the event a member’s retail pharmacy is not in the new pharmacy network, we will notify the member directly.

 

Controlled substances and compound prescriptions

Prescriptions for controlled substances, currently filled by Express Scripts Mail Order Pharmacy, cannot be transferred to another pharmacy under federal law. Members currently receiving these medications, who will use IngenioRx for their mail order provider, will need a new prescription sent to IngenioRx. Compound prescriptions are also nontransferrable and will require a new prescription.

                                         Please see attached for contact information.

You can confirm whether your patient has transitioned to IngenioRx through the Availity Portal.

Your patient’s PBM information can be located in the Patient Information section of their patient profile as part of the eligibility and benefits inquiry.

 

If you have immediate questions, you can contact the Provider Service phone number on the back of your patient’s member ID card or call the number you normally use for questions.

State & FederalJanuary 1, 2020

Help protect your patients by providing medical ID protection – best practices

Category: Cal MediConnect

Overview

Many of our members have reported that they received unsolicited calls (or emails) from an individual or company offering to provide durable equipment devices, such as back or leg braces, or items such as topical creams at little or no cost. While it may be tempting to want to receive something for free, members should know that there is a cost. 

 

Although our members may not receive a bill for these devices or medications, the items are billed to the insurance companies, costing hundreds or even thousands of dollars each.

 

How does this impact members?

Members should also know that the cost may be more than monetary. Allergic reactions may occur when using medications that are not properly prescribed. Ill-fitting leg or back braces, or equipment that is not specifically intended for the pain experienced by the member, could do more harm than good.

 

This problem is prevalent throughout the country, so all of our members should be aware. Billions of unsolicited telemarketing calls are made each year, many of which are promoting health care services. Calls often spoof local phone numbers or numbers that appear familiar to trick the recipient into accepting the call. 

 

How can I help protect my patients?

While the ultimate purpose of these telemarketing calls is to sell these items, the immediate goal of the person or company placing the call is to obtain valuable personally identifiable information (PII) from the member. Without this personal information, such as a social security number or insurance identification number, selling these devices and medications is much more difficult. Share this information with you patients to help them learn how to protect their PII.

 

You can help protect your patients and their personally identifiable information from scams by reminding them of the following:

  • Don’t fall prey to scams!
  • Take a few moments to review your Explanation of Benefits (EOB) and the services listed.  
  • When receiving robotic (robo) or telemarketing calls:
    • Simply hang up the phone.
    • Beware of threatening or urgent language used by the caller.
    • Do not provide any personally identifiable information such as your social security number or insurance identification number. The caller may imply that they have your information and ask you to provide it to confirm that they have the correct information. Do not provide the information or confirm it if they do happen to have any identification information.
  • When receiving emails:
    • Do not open email attachments you weren’t expecting.
    • Check for spelling mistakes and poor grammar.
    • Do not click on the links you are sent. You can type the link into a new browser.
    • Online scams can come from anywhere. Take a few moments to review your EOB and confirm that you received the services listed on the EOB.
  • Additional ways to protect yourself:
    • Shred or destroy obsolete documents that contain medical claims information or EOBs.
    • Do not use social media to share medical treatment information.

 

How to report when you receive what you suspect is a scam call or email:

  1. To file a complaint with the Federal Trade Commission, you can go to: https://ftc.gov/complaint or call 1-877-FTC-HELP.
  2. Members may contact their plan’s Member Services department.

State & FederalJanuary 1, 2020

Medical drug benefit Clinical Criteria updates

Category: Cal MediConnect

On September 19, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the MMP Clinical Criteria Web Posting September 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

State & FederalMedicare AdvantageJanuary 1, 2020

Introducing two new Medicare Advantage special needs plans for 2020

Category: Medicare

As we continue our efforts to provide high-quality, member-focused health plans for Medicare Advantage beneficiaries, Anthem Blue Cross is offering an Institutional Special Needs Plan (I‑SNP) and a Chronic Special Needs Plan (C-SNP) in 2020. These special needs plans provide members with the benefits of integrated care and case management through a holistic approach while promoting continuity of care and preserving provider choice.

 

More information will be available at the Important Medicare Advantage Updates section of https:// www.anthem.com/ca/medicareprovider.

506285MUPENMUB

 

State & FederalMedicare AdvantageJanuary 1, 2020

Reminder: Medicare claims for secondary payer must be submitted after the 30-day Medicare remittance period

Category: Medicare

Claims will deny when a provider submits a Medicare claim to Anthem Blue Cross (Anthem) as a secondary payer if the claim has been received prior to the 30-day Medicare remittance period. Providers submitting a paper claim for Medicare claims that are filed with Medicare as the first payer must not file with Anthem as the secondary payer until the 30-day remittance period has expired.

 

These claims rejections are a result of improper timely filing by providers. To eliminate claims rejections when Anthem is the secondary payer, submit the claim 30 days after the Medicare Remittance period.

 

For additional information, call the number on the back of the member’s ID card.

505847MUPENMUB