Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:

• File claims
• Check statuses
• Verify eligibility and benefits
• Submit prior authorizations

The Provider Digital Engagement Supplement outlines Anthem Blue Cross (Anthem) provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits - all in one comprehensive resource. Find it on Anthem.com>Providers>Forms & Guides>Digital Tools.

Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit www.anthem.com] and use the Log In button for access to our secure provider portal, or via the Availity EDI website.

Accept digital member ID cards

• Save time by accepting the digital member ID card when presented by the member via their App or email.

Register for EFT to get funds faster

• Electronic Funds Transfer (EFT) eliminate the need for paper checks. Safe, secure and faster, payments are deposited directly to your bank account. Register here.

Eliminate paper remittances

• Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.

When you understand your patients’ health coverage and local health plan networks, you can help maximize your patients’ benefits and boost your own success. Here are some details you should know about new Blue High Performance Network (Blue HPN®) products and the high performance network in California:

Effective January 1, 2021, new health plans built around Anthem’s Blue High Performance Network are live in six California metropolitan service areas,

• San Diego
• Los Angeles
• Riverside
• Santa Clara
• Sacramento
• San Francisco

Blue HPN is a national network designed from our local market expertise, deep data and strong provider relationships, and aligned with local networks across the country. These local networks are then connected to the national chassis to form a national Blue HPN network.

You may see patients accessing this network through either a small group, large group, or national account plans with an Exclusive Provider Organization (EPO) plan design. Under EPO plans, out of network benefits are limited to emergency or urgent care. Members must select a primary care provider, but PCP referrals are not required for specialty care.

Members or providers can use our Find a Doctor/Find Care at anthem.com/ca searchable directory to verify Blue HPN participation or find a participating doctor.

Member ID Cards

Blue HPN members will be issued a new ID card to identify and access Blue HPN providers. Virtual ID cards will also be available to members through the Sydney Health and Engage Wellbeing apps.

The new “Blue High Performance Network” logo and “HPN” indicator in the suitcase icon are the most reliable indicators that a member is enrolled in an HPN plan.

All Blue HPN plan ID cards will reflect Blue HPN in a suitcase on the front of the card and a disclaimer on the back of the ID card that reads “Services rendered by a non-Blue HPN provider will be limited to Urgent and Emergent care.”

Additionally:

• Anthem National Account (ANA) Blue HPN ID cards will always reflect the Blue High Performance Network name on the front of the ID card.
• Local LG and SG Blue HPN ID cards will always reflect both the national Blue High Performance Network and the local Blue HPN Anthem state network on the front of the ID card.

Still have questions? Please contact us at CaContractSupport@anthem.com.

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In this 60-minute webinar, you will learn how to use Availity's* Attachment tools to submit and track supporting documentation electronically to Anthem and affiliate payers.

We will explore new key workflow options to fit your organization’s needs, including how to:

• Work a request in the inbox of your Attachments Dashboard.
• Enter and submit a web claim including supporting documentation.
• Use EDI batch options to trigger a request in your inbox.
• Track attachments you submitted using sent and history lists in your Attachments Dashboard.
• Get set up to use these tools.

As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.

Register for an upcoming webinar session:

1. In the Availity Portal, select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options:
   • In the Catalog, search by webinar title or keyword.
     • To find this specific live session quickly, use keyword medattach.
   • Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you’ll receive emails with instructions to join the session.

Webinar Dates and Times (PST):

As a reminder, we will update our claim editing software monthly for professional services throughout 2021 with the most common updates occurring quarterly in February, May, August and November of 2021. These updates will:

• reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
• include updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
• include assistant surgeon eligibility in accordance with the policy
• include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
• apply to any provider, provider group (tax identification number) and/or across providers and claim type (professional/facility) for the same member

Anthem Blue Cross (Anthem) recognizes all coding changes from both the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) effective the date provided by the coding source.  This includes the Evaluation and Management (E/M) changes effective January 1, 2021. 

The following updates pertaining to Evaluation and Management services have been identified:

• CPT code 99201 (new patient E/M) will be a deleted code.
• CPT codes 99202 through 99215 (new/established E/M) definitions have changed.  Selection of these E/M codes can now be based on either Medical Decision Making or Time.
• CPT code 99417 (prolonged services) and HCPCS Code G2212 (prolonged services) will be recognized as billable codes.  These codes will be payable based on our existing Prolonged Services policy, which will be updated to reflect the new code along with the modifications to existing prolonged service codes CPT codes 99354 and 99355.
• HCPCS Code G2211 (complexity inherit to evaluation and management associated with primary medical care) will not be separately reimbursed for this service.  We will be updating our Bundled Services and Supplies policy to reflect this position. 

Additionally, we are in the process of updating reimbursement policies impacted by the E/M service changes such as the Documentation and Reporting Guidelines for Evaluation and Management Services. 

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As a reminder, we will update our claim editing software monthly for outpatient facility services throughout 2021 with the most common updates occurring quarterly in 2021. These updates will:

• reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers, Revenue Codes) and their associated edits
• include appropriate use of various code combinations, which can include, but are not limited to, procedure code to revenue code, HCPCS to revenue code, type of bill to procedure code, type of bill to HCPCS code, procedure code to modifier, and HCPCS to modifier
• include updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• include updates to reflect coding requirements as designated by industry standard sources such as The National Uniform Billing Committee (NUBC)

Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a standardized survey conducted between February to May each year to assess consumers’ experience with their provider and health plan.  A random sample of your adult and child patients may receive the survey.  Over half of the questions used for scoring are directly impacted by providers. The survey questions are:

• When you needed care right way, how often did you get it?
• How often did you get an appointment for a check-up or routine care as soon as you needed?
• How often was it easy to get the care, tests, or treatment you needed?
• How often did you get an appointment to see a specialist as soon as you needed?
• How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
• How would you rate your personal doctor?
• How would you rate the specialist you see most often?

To learn more about how you can improve the patient experience review What Matters Most: Improving the Patient Experience, an online course for providers and office staff. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. The What Matters Most training can be accessed at: www.patientexptraining.com.

You no longer need to pick up the phone or head to the fax machine to check the status of an authorization request or update a case. Anthem Blue Cross (Anthem) has added new features to Interactive Care Reviewer (ICR), our online medical and behavioral health authorization tool to improve your digital self-service experience.

1. Do you need to update a case that was submitted by phone or fax? Now you can add clinical notes and make other updates to these authorization requests through ICR. To make the update you need to have the Authorization & Referral Request role assigned to you by your Availity Administrator: 
   • To locate the case, log on to the Availity Portal and select Patient Registration | Authorizations & Referrals, then choose Auth/Referral Inquiry.
   • Search for the case in ICR by Member, Reference/Authorization Request Number, or by Date Range.
   • From the ICR Case Overview screen select Update Case to update service codes, provider information or clinical notes. If you only need to make changes or add to your notes, select Update Clinical. Select Submit Update to complete the request.

2. We’ve removed the guesswork from the notes that are recommended for many standard authorization requests. ICR provides a check list of the supporting clinical information that will assist Anthem with completing the review. The list is located on the Clinical Details You can upload notes, images and photos directly through ICR. You can include the documentation immediately or you can submit your request then return to the case in ICR later and select Update Clinical to add the missing information.

3. Check the status of a submitted case at a glance. The ICR UM tracker, located on the Case Overview screen provides a quick view of where the case is in the review process. You can view when Anthem received the request, when the clinical review is underway and completed and the final decision.

Additionally, we’ve added a new application to Payer Spaces – Chat with Payer that you can use to check the status of a submitted authorization request. This is a great option if you don’t have the role assignments required to access ICR and research a case. 

To access the Chat with Payer application from Availity’s home page, select Payer Spaces | Chat with Payer.  Complete the form with the required information. You need to include the patient name, birth date and health plan member ID number. Choose Authorization Status as your topic for chat to conduct a live chat with a representative. 

Anthem Blue Cross (Anthem) wants to make your job easier — and that includes real-time feedback to claim denials. Through predictive analytics, we now have insight into the reasons for claim denial. We have taken that information and streamlined the inquiries by reason codes. It is available to you digitally, through our secure provider portal.

Now, within minutes, you will know why a claim denied. We will also provide the steps  needed so you can take action faster to correct the claim . There is less wait time and faster payment.

There is no need to call for updates or experience unnecessary delays waiting for the explanation of benefit.

With little more than a click:

• Review a complete list of claims, including claims with proactive insights
• Learn the reasons for claim denial
• Access the information you need to move the claim forward

Predictive analytics and self-service claim denial information is just another way Anthem is using digital technology to improve your healthcare experience.

From Anthem.com, use the Log In button to access our secure provider portal Availity.com. Go to Payer Spaces to access Claims Status Listing.

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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.

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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

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. Select Providers, under Communications go to Education and Training. Scroll down to view Training, Educational and Resource offerings.

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Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before with our Provider News publication. 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 email addresses as you like.

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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 are 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.

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The following updates will apply to the AIM Clinical Appropriateness Guidelines for Advanced Imaging for claims with dates of service on and after March 14, 2021.

Chest imaging, and head and neck imaging

Hoarseness, dysphonia and vocal cord weakness/paralysis — primary voice complaint:

• Required laryngoscopy for the initial evaluation of all patients with primary voice complaint

Brain imaging, and head and neck imaging

Hearing loss:

• Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is non-diagnostic or unable to be performed
• Higher allowed threshold for consecutive frequencies to establish sensorineural hearing loss
• Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance

Tinnitus:

• Removed sudden onset symmetric tinnitus as an indication for advanced imaging

Head and neck imaging

Sinusitis/rhinosinusitis:

• Added more flexibility for the method of conservative treatment in chronic sinusitis
• Required conservative management prior to repeat imaging for patients with prior sinus CT

Temporomandibular joint dysfunction:

• Removed requirement for radiographs/ultrasound

Cerebrospinal fluid (CSF) leak of the skull base:

• Added scenario for management of known leak with change in clinical condition

Brain imaging

Ataxia, congenital or hereditary:

• Combined with congenital cerebral anomalies to create one section

Acoustic neuroma:

• More frequent imaging for a watch and wait or incomplete resection
• New indication for neurofibromatosis type 2 (NF 2)Neurofibromatosis type 2
• More frequent imaging when MRI shows findings suspicious for recurrence
• Single post-operative MRI following gross total resection
• Included pediatrics with known acoustics (rare but NF 2)

Tumor — not otherwise specified:

• Repurposed for surveillance imaging of low grade neoplasms

Seizure disorder and epilepsy:

• Limited imaging for the management of established generalized epilepsy
• Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy

Headache:

• Removed response to treatment as a primary headache red flag
• Include pregnancy as a red flag risk factor

Mental status change and encephalopathy:

• Added requirement for initial clinical and lab evaluation to assess for a more specific cause

Oncologic imaging

General enhancements — Updates to Scope/Definitions, general language standardization

General content enhancements — Overall alignment with current National Comprehensive Cancer Network (NCCN) recommendations, resulting in:

• Removal of indications/parameters not addressed by NCCN
• Average risk inclusion criteria for CT colonography
• New allowances for MRI abdomen and/or MRI pelvis by tumor type, liver metastatic disease
• New indications for acute leukemia (CT, PET/CT), multiple myeloma (MRI, PET/CT), ovarian cancer surveillance (CT), bone sarcoma (PET/CT)
• Updated standard imaging prerequisites prior to PET/CT for bladder/renal pelvis/ureter, ectal, esophageal/GE junction, gastric and non-small cell lung cancers
• Additional PET/CT management scenarios for cervical cancer, Hodgkin Lymphoma

Other content enhancements by section:
Cancer screening: New indication for pancreatic cancer screening.

Breast cancer: New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment breast MRI after breast conserving therapy or unilateral mastectomy.

Prostate cancer: MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE.

Axumin PET/CT: Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI).

As a reminder, ordering and servicing providers may submit prior authorization requests to:

• Access the AIM ProviderPortal_SM directly at https://aimspecialtyhealth.com/providerportal.
  • Online access is available 24/7 to process orders and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity* Portal at https://availity.com.
• Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. CT

If you have questions related to guidelines, please contact AIM by email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

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HEDIS overview

The National Committee for Quality Assurance (NCQA) is a non-profit organization that accredits and certifies health care organizations. The NCQA establishes and maintains the Healthcare Effectiveness Data and Information Set (HEDIS^®). HEDIS is a tool comprised of standardized performance measures used to compare managed care plans. The overall goal is to measure the value of health care based on compliance with HEDIS measures. HEDIS also allows stakeholders to evaluate physicians based on health care value rather than cost. This article will outline specific changes to the HEDIS measures as outlined by the NCQA. The changes are effective for the measurement year (MY) 2020 to 2021. It is important to note that the state health agency has the authority to determine which measures and rates managed care organizations should capture.

HEDIS data helps calculate national performance statistics and benchmarks and sets standards for measures in NCQA Accreditation.

Health plans use HEDIS performance results to:

• Evaluate the quality of care and services.
• Evaluate provider performance.
• Develop performance improvement initiatives.
• Perform outreach to providers and members.
• Compare performance with other health plans.

HEDIS MY 2020 new measures:

• Follow-up After High-Intensity Care for Substance Use Disorder (FUI)
• Pharmacotherapy for Opioid Use Disorder (POD)
• Breast Cancer Screening (BCS-E)
• Follow-up Care for Children Prescribed ADHD Medication (ADD-E)
• Prenatal Depression Screening and Follow-up (PND)
• Postpartum Depression Screening and Follow-up (PDS)

HEDIS MY 2020 retired measures:

• Annual Monitoring for Patients on Persistent Medications (MPM)
• Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)
• Standardized Healthcare-Associated Infection Ratio (HAI).

Retired measures are no longer maintained by NCQA or included in the HEDIS measurement set. NCQA has determined that specific measures are clinically inappropriate and are no longer in use. Once retired, the measures are not used in any product, program or service, and all use must stop.

HEDIS MY 2020 revised hybrid measures:

• Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
• Childhood Immunization Status (CIS)
• Immunizations for Adolescents (IMA)
• Cervical Cancer Screening (CCS)
• Colorectal Cancer Screening (COL)
• Care for Older Adults (COA)
• Controlling High Blood Pressure (CBP)
• Medication Reconciliation Post-Discharge (MRP)
• Transitions of Care (TRC)
• Prenatal and Postpartum Care (PPC)
• Well-Child Visits in the First 15 Months of Life (W15)
• Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)
• Adolescent Well-Care Visits (AWC)

HEDIS MY 2020 revised administrative measures:

• Appropriate Testing for Children with Pharyngitis (CWP)
• Statin Therapy for Patient’s with Cardiovascular Disease (SPC)
• Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART)
• Osteoporosis Management in Women Who Had a Fracture (OMW)
• Follow-Up After Hospitalization for Mental Illness (FUH)
• Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)
• Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
• Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)
• Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP).

HEDIS and telehealth

HEDIS measures include synchronous telehealth (which requires real-time interactive audio and video telecommunications), telephone visits and online assessments, as appropriate. A measure specification will indicate when telephone visits or online assessments are eligible for use in reporting.

A measure specification that is silent about telehealth is assumed to include telehealth. Correct coding requires billing telehealth services using standard CPT^® and HCPCS codes for professional services in conjunction with a telehealth modifier and a telehealth POS code. Therefore, the CPT or HCPCS code in the value set will meet criteria (regardless of whether a telehealth modifier or POS code is present). A measure specification will indicate when telehealth is not eligible for use and is excluded.

The future of HEDIS

The future of HEDIS focuses on six core ideas:

• Allowable adjustments: New flexibility lets users modify measures without changing their clinical intent.
• Licensing and certification: Updated requirements ensure the accuracy of the results.
• Digital measures: HEDIS specifications that download directly into users’ data systems bring new ease of use.
• Electronic clinical data systems (ECDS): This new reporting method helps clinical data create insight for managing the health of individuals and groups.
• Schedule change: A new schedule gives users more time by providing the complete measure specifications sooner – 11 months earlier than the traditional timeline
• Telehealth: The access to care that telehealth has brought during COVID-19 is vital to quality now after the pandemic.

Resources:

HEDIS^® Measures and Technical Resources. https://www.ncqa.org/HEDIS^®/measures

Disease Management/Population Health is designed to support providers in caring for patients with chronic health care needs. Anthem Blue Cross (Anthem) provides members enrolled in the program with continuous education on self-management, assistance in connecting to community resources, and coordination of care by a team of highly qualified professionals whose goal is to create a system of seamless health care interventions and communications.

Who is eligible?

Disease Management/Population Health case managers provide support to members with:

• Asthma.
• Bipolar disorder.
• COPD.
• Diabetes.
• Congestive heart failure.
• Coronary artery disease.
• HIV/AIDS.
• Hypertension.
• Major depressive disorder — adults.
• Major depressive disorder — children and adolescents.
• Schizophrenia.
• Substance use disorder.

Our case managers use member-centric motivational interviewing to identify and address health risks, such as tobacco use and obesity, to improve condition-specific outcomes. Interventions are rooted in evidence-based clinical practice guidelines from recognized sources. We implement continuous improvement strategies to increase evaluation, management and health outcomes.

For more information on our program and how to refer an Anthem member for this program, please visit our website at https://providers.anthem.com/ca.

Your input and partnership is valued. Once your patient is enrolled in the Disease Management/Population Health program, you will be notified by the case manager assigned.

We look forward to working with you.

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

In the December 2020 edition of Provider News, Anthem  indicated the transition of the clinical criteria for medical necessity review of CG-SURG-74 Total Ankle Replacement services to AIM Specialty Health small joint guidelines would be effective February 4, 2020. The actual effective date is February 4, 2021.

These reviews will continue to be completed by the Anthem Utilization Management team.

You may access and download a copy of the AIM Small Joint Guidelines here.

We apologize for any confusion this error may have caused.

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Click here for more information about the Policy Update — Emergency Department: Leveling of Evaluation and Management Services.

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Please continue to read news and updates at anthem.com/ca/medicareprovider for the latest Medicare Advantage information, including:

Medicare Advantage Group Retiree Quick Reference Guide and FAQ

Medicare Advantage Group Retiree Member Eligibility, Alpha Prefix FAQ

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The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

Medicare risk adjustment and documentation guidance (General):

• Series: Offered the first Wednesday of each month from 1:00 to 2:00 P.M. (ET)*
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity, Medicare risk adjustment and documentation guidance, from
  January 8, 2020 to December 2, 2020, has been reviewed and is acceptable for up to 1.00 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

To learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:

https://bit.ly/2TYMgbn

* Note: Dates may be modified due to holiday scheduling

Medicare risk adjustment, documentation and coding guidance (Condition specific)

• Series: Offered the third Wednesday of each month from 1:00 to 2:00 P.M. (ET)
• Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
• Credits: This live series activity, Medicare risk adjustment documentation and coding guidance, from January 15, 2020 to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

For those interested in the following training topics, please register at the link below.

https://bit.ly/2IgxDO9

* Note: Enter the password provided, and the recording will play upon registration.

• Red flag HCCs
• Neoplasms
• Acute, chronic and status conditions
• Diabetes mellitus and other metabolic disorders
• Coinciding conditions in risk adjustment models

Please note that the original training events have been modified due to a transition within WebEx as of August 1, 2020. The date and time of the events have not changed but the program link and invitation detail have been updated. Previously registered participants will need to re-register for a training event using the updated registration link(s) provided in this announcement.

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Click here for more information about SNF admission reporting requirements for D-SNP plans.

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Learn more information about the Policy Update — Nurse Practitioner and Physician Assistant Services, Professional.

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Click here for more information about the updates to AIM Clinical Appropriateness Guidelines for Radiation
Oncology.

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Click here for more information about August 2020 Medical Policies and Utilization Management Guidelines update.

Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health_®* (AIM) Advanced Imaging of the Heart and Diagnostic Coronary Angiography Clinical Appropriateness Guidelines.

Evaluation of patients with cardiac arrhythmias:

• Updated repeat transthoracic echocardiography (TTE) criteria.
• Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia.

Evaluation of signs, symptoms or abnormal testing:

• Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature.

Diagnostic coronary angiography:

• Updated criteria to evaluate patients with suspected congenital coronary artery anomalies.

• Access AIM’s ProviderPortal_SM directly at https://providerportal.com.
  • Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • Access AIM via the Availity* Portal at https://www.availity.com. Call the AIM Contact Center toll free at 1-800-714-0040 from 7 a.m. to 7 p.m.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

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On August 21, 2020, 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 websites, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

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Effective January 1, 2021, United Food and Commercial Workers Unions (UFCW) will offer a Medicare Preferred (PPO) medical plan from Anthem Blue Cross (Anthem).

Retirees with Medicare Parts A and B are eligible to enroll in the Medicare Preferred (PPO) medical plan from Anthem.

The plan includes the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. In addition, UFCW retirees pay no cost share for both in-network and out-of-network services. The Medicare Advantage 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, LiveHealth Online* and SilverSneakers^®.*

The prefix on UFCW member ID cards will be MBL. The cards will also show the UFCW logo and National Access Plus icon.

Providers may submit claims electronically using the electronic payer ID for the Anthem plan in their state or submit a UB-04 or CMS-1500 form to the Anthem plan in their state. Claims should not be filed with original Medicare. Contracted and non-contracted providers may call the Provider Services number on the back of the member ID card for benefit eligibility, prior authorization requirements, and any questions about UFCW member benefits or coverage.

Detailed prior authorization requirements also are available to contracted providers by accessing the Provider Self-Service Tool on Availity.*

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross. LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Anthem Blue Cross.

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Effective January 1, 2021, The University of the Pacific will offer a Medicare Preferred (PPO) with Senior Rx Plus plan from Anthem Blue Cross (Anthem).

Retirees with Medicare Parts A and B are eligible to enroll in the Medicare Preferred (PPO) with Senior Rx Plus plan from Anthem. The plan includes the National Access Plus benefit, which allows retirees to receive  services from any provider, as long as the provider is eligible to receive payments from Medicare. In addition, The University of the Pacific retirees pay no cost share for both in-network and out-of-network services. The Medicare Advantage 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, LiveHealth Online* and SilverSneakers^®.*

The prefix on The University of the Pacific member ID cards will be MBL. The cards will also show the National Access Plus icon.

Providers may submit claims electronically using the electronic payer ID for the Anthem plan in their state or submit a UB-04 or CMS-1500 form to the Anthem plan in their state. Claims should not be filed with Original Medicare. Contracted and non-contracted providers may call the Provider Services number on the back of the member ID card for benefit eligibility, prior authorization requirements, and any questions about The University of the Pacific member benefits or coverage.

Detailed prior authorization requirements also are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com.*

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross. LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Anthem Blue Cross.

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Effective January 1, 2021, Intel Corporation in California will offer a Medicare Preferred (PPO) from Anthem Blue Cross (Anthem). Anthem will provide medical benefits for the Intel retirees through their Local Preferred Provider Organization (LPPO) product, which includes the National Access Plus benefit. This plan allows members to receive services from any provider, as long as the provider is eligible to receive payments from Medicare.

The Intel Corporation member copayment or coinsurance percentage will be the same whether their provider is in- or out-of-network. Locally or nationwide, doctors or hospitals — the member’s cost share doesn’t change.

Noncontracted providers may continue treating Intel Corporation members and will be reimbursed 100% of Medicare’s allowed amount for covered services, less any member cost share.

The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers and also covers additional benefits that Medicare does not, such as hearing, LiveHealth Online* and SilverSneakers.*

The prefix on the Medicare Advantage ID cards is MBL.

Detailed prior authorization requirements are also available to contracted providers by accessing the Provider Self-Service Tool through the Availity* Portal at https://www.availity.com.

Providers will follow their normal claim filing procedures for Intel Corporation member claims.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross. LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Anthem Blue Cross.

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Effective January 1, 2021, Inland Empire International Brotherhood of Electrical Workers (IBEW) in California will offer a Senior Secure (HMO) Medicare Advantage plan from Anthem Blue Cross. 

Retirees with Medicare Parts A and B who reside in select California counties are eligible to enroll in the Senior Secure (HMO) plan. The Medicare Advantage Prescription Drug 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 the Medicare Advantage HMO ID cards is MHG.

Detailed prior authorization requirements are also available to contracted providers by accessing the Provider Self-Service Tool on the Availity* Portal at https://www.availity.com.

Providers will follow their normal claim filing procedures for Inland Empire IBEW member claims.

Providers may call Provider Services at 1-833-848-8730 for eligibility, prior authorization requirements and any questions about the Inland Empire IBEW member benefits or coverage.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross. LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Anthem Blue Cross

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Effective January 1, 2021, the Los Angeles County Office of Education (LACOE) will offer a Medicare Preferred (PPO) plan from Anthem Blue Cross (Anthem). Anthem will provide medical benefits for LACOE retirees through Anthem’s Local Preferred Provider Organization (LPPO) product, which includes the National Access Plus benefit. This plan allows members to receive services from any provider, as long as the provider is eligible to receive payments from Medicare.

LACOE member copayments or coinsurance percentages will be the same whether his/her provider is in- or out-of-network. Locally or nationwide, doctors or hospitals — the member’s cost share doesn’t change.

Noncontracted providers may continue treating LACOE members and will be reimbursed 100% of Medicare’s allowed amount for covered services, less any member cost share.

The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers and also covers additional benefits that Medicare does not, such as hearing, LiveHealth Online* and SilverSneakers.*

The prefix on the Medicare Advantage ID cards is MBL.

Detailed prior authorization requirements are also available to contracted providers by accessing the Provider Self-Service Tool on the Availity* Portal at https://www.availity.com.

Providers will follow their normal claim filing procedures for LACOE member claims.

Providers may call Provider Services at 1-833-848-8730 for eligibility, prior authorization requirements and any questions about the LACOE member benefits or coverage.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross. LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Anthem Blue Cross.

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

In the December 2020 edition of Provider News, Anthem  indicated the transition of the clinical criteria for medical necessity review of CG-SURG-74 Total Ankle Replacement services to AIM Specialty Health small joint guidelines would be effective February 4, 2020. The actual effective date is February 4, 2021.

These reviews will continue to be completed by the Anthem Utilization Management team.

You may access and download a copy of the AIM Small Joint Guidelines here.

We apologize for any confusion this error may have caused.

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Click here for more information about August 2020 MMP Medical Policies and Utilization Management Guidelines update.

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

In the December 2020 edition of Provider News, Anthem  indicated the transition of the clinical criteria for medical necessity review of CG-SURG-74 Total Ankle Replacement services to AIM Specialty Health small joint guidelines would be effective February 4, 2020. The actual effective date is February 4, 2021.

These reviews will continue to be completed by the Anthem Utilization Management team.

You may access and download a copy of the AIM Small Joint Guidelines here.

We apologize for any confusion this error may have caused.

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Learn more information about the new specialty pharmacy medical step therapy requirements.

On August 21, 2020, 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 websites, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.