Beginning with claims processing on or after August 1, 2024, Anthem will use coding policies to support the use of anatomical modifiers. These policies were developed to promote national correct coding methods and to control improper coding that leads to incorrect payment. This update is part of continuing efforts to process claims accurately without having to request additional documentation from care providers.

What are the policies for using anatomical modifiers in procedure coding?

CPT^® and HCPCS Level II guidelines supporting the use of anatomic-specific modifiers were used to develop these policies, which validate the area or part of the body on which a procedure is performed. Procedure codes that do not specify right or left require the appropriate anatomical modifier. If an anatomical modifier is necessary to differentiate right or left and is not appended, the claim will be denied. Likewise, if a modifier is appended to a procedure code that does not match the appropriate anatomical site, the claim will be denied.

Action needed

CPT and HCPCS Level II guidelines support the following set of anatomical modifiers to facilitate correct coding for claims processing. Care providers are encouraged to follow these guidelines and append the modifiers relevant to the procedure code on the service line.

The anatomical modifiers, which must be reported, are:

We are committed to a future of shared success. If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.

For all claim dispute requests received, 7% are because we don’t receive the proper documentation with claims involving other carriers.

When working with another carrier, submit documentation from the other carrier when you send the claim to Anthem to help avoid the claim from denying for timely filing. You can submit the documentation and the claim through Availity Essentials using the Claims and Payments application.

If we are the secondary payer, we will need to receive an Explanation of Benefits (EOB) along with the claim submission to determine our payment amount. To avoid a timely filing denial, the documentation must demonstrate that submission to the other insurer was within Anthem’s timely filing limit and must reflect that it was received within the timely filing limit starting from the date of the remittance advice or explanation of payments.

If you submit to the other carrier first and receive a rejection, submit the denial letter from the other insurance carrier along with the claim. To avoid a timely filing denial, the denial letter must be dated and printed on letterhead, and the claim and documentation must be submitted to Anthem within the timely filing limit starting from the date of the denial letter.

When a claim is submitted to us as the primary payer, and we are the secondary payer, our claims system will deny the claim because we don’t have the EOB. This can delay your receiving payment and can also cause you to miss the timely filing guideline.

If you need to dispute a claim due to timely filing, review Timely filing: Acceptable forms of proof.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

Resource

The Skilled Nursing Facility (SNF) Workforce & Quality Incentive Program (WQIP) incentivizes facilities to improve quality of care, advance equity in healthcare outcomes, and invest in workforce. WQIP functions as a directed payment program in Medi-Cal delivery system for eligible network providers. WQIP is authorized by Welfare & Institutions Code Section 14126.024 (added by Assembly Bill (AB)186 (Chapter 46, Statutes of 2022)) for dates of service January 1, 2023, through December 31, 2026. WQIP succeeds the former SNF Quality and Accountability Supplemental Payment (QASP) program.

If you have WQIP program-related questions or concerns, please reach out to WQIP support staff at SNFWQIP@dhcs.ca.gov.

DHCS will issue guidance to Anthem later in 2024 to make final payments for CY 2023 based on SNF WQIP-Eligible Days reported to DHCS's data warehouse by June 30, 2024, and final scores for all SNF WQIP metrics including acuity-adjusted staffing hour metrics, staff turnover metric, MDS clinical metrics, claims based clinical metrics, Medi-Cal disproportionate share metric, and MDS racial and ethnic data completeness metric.

At this link WQIP Qualifying List is a document with NPIs that DHCS has on file for facilities as of May 7, 2024.

If your current or previous NPI is not listed on the WQIP Qualifying List, please email the DHCS SNFWQIP inbox at SNFWQIP@dhcs.ca.gov and complete the form provided in the automatic reply. Note that if an incorrect NPI is listed along with all correct NPIs, there is no reason to reach out to DHCS via email. Please note, only submit one form per facility.

The performance period ranges covered in the Quarterly Performance Report #1 below:

• Acuity Adjusted Staffing Metrics: April 2023-June 2023
• Staffing Turnover: October 2023 refresh rates:
  • With lookback and look-forward quarters: January 2022 to June 2023
  • Without lookback and look-forward quarters: April 2022 to March 2023
• MDS Metrics: July 2022 to June 2023
• Medi-Cal Disproportionate Share: January 2023 to June 2023
• Race/Ethnicity Data Completeness: January 2023 to September 2023

If you have any questions, please reach out to AnthemLiaison@anthem.com.

To ensure compliance with the coding and billing of a claim submitted with the diagnosis of sepsis for our pediatric members, we review clinical information (including treatment and medical management) and laboratory and diagnostic procedure findings in the medical records submitted for review. To conduct the review accurately and consistently, our review process for pediatric sepsis applies coding and documentation guidelines.

Beginning with admission dates of July 1, 2024, and later for members aged 29 days through 17 years of age, we will also apply the updated and most recent publication of the Society of Critical Care Medicine Pediatric Sepsis Definition Task Force criteria known as the Phoenix Sepsis Criteria, published in the Journal of the American Medical Association (JAMA) in January 2024.

Clinicians and facilities should apply the Phoenix Sepsis Criteria when determining at discharge if the pediatric patient’s clinical course supports the coding and billing of a diagnosis of sepsis. The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the Phoenix Sepsis Criteria.

Together, we can work towards improved outcomes.

jamanetwork.com/journals/jama/article-abstract/2814297

Maintaining your online provider directory information is essential for member and healthcare partners to connect with you when needed. Access your online provider directory information by visiting anthem.com/ca/provider. Then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information has changed.

Updating your information

Anthem uses the provider data management (PDM) capability available on Availity Essentials to update your care provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate care provider demographic data set by the Consolidated Appropriations Act (CAA).

PDM features include:

• Updating care provider demographic information for all assigned payers in one location.
• Attesting to and managing current care provider demographic information.
• Monitoring submitted demographic updates in real-time with a digital dashboard.
• Reviewing the history of previously verified data.

Accessing the PDM application

Log on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

PDM training

PDM training is available:

• Log on to Availity.com to learn about and attend one of our training opportunities.
• On Availity.com, you can view the Availity PDM quick start guide.
• Roster Automation Standard Template and Roster Automation Rules of Engagement training:
  • Listen to our recorded webinar on Availity.com.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your care providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account. If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

For those providers and their corresponding vendors (either billing services or clearinghouses) who submit corrected claims through EDI, we’re enhancing the 277CA to notify you of submission errors discovered during our claims processing. Although you’ll continue to receive physical mail notifications related to claims processing issues, the 277CA notifications can expedite the turnaround time by highlighting submission issues upfront.

Now, the 277CA will also communicate the following messages:

• Tax ID and NPI are not registered.
• Billed place of treatment doesn’t correspond with the place of service.
• Rendering provider isn’t valid for the service date.
• Billing NPI doesn’t align with the claim’s tax ID.

Despite the addition of this new feature, there will be no reductions in the services we already provide. Our hope is that this change will augment the speed and communication of our service.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

We hope you are finding our monthly observance articles helpful and informative. We will continue to feature these monthly articles to keep you informed about our resources that are here to support you in caring for all of our members.

We strive to advance health equity so everyone has a fair opportunity to be at their healthiest. As we reduce barriers to whole health — physical, behavioral, and social — and personalize the healthcare journey, we can more effectively advance health equity. While focusing on understanding member needs, we actively develop educational tools for providers.

In recognition of July as Disability Awareness Month, and to commemorate the signing of the Americans with Disabilities Act (ADA) in 1990 that promotes equal rights and accessibility for people with disabilities, we are introducing three eLearning resources and tools on My Diverse Patients. This site offers a comprehensive repository of resources for providers to help support the needs of diverse patients and address disparities. Availability of multiple free continuing medical education (CME) courses with CMEs are offered through the American Academy of Family Physicians (AAFP).

For the month of July, our featured eLearning Resources & Tools are:

• Health Equity Framework for People with Disabilities:
  • This policy brief provides the rationale for the need for an all-of-government approach to achieve health equity in the United States and its territories for the largest unrecognized minority group in this country — the over 61 million people with disabilities — and sets forth a framework to achieve health equity for all people with disabilities. Disability is a natural part of the human condition, which occurs across all ages, genders, races, ethnicities, languages, and social groups.
• Health Equity for People with Disabilities:
  • The CDC’s Division of Human Development and Disability (DHDD) works to promote health and reduce health inequities for people with disabilities of all ages so they can participate fully in all aspects of their communities throughout their lives and have the opportunity to achieve all they set out to do.
• Connections Between Health Equity and Disability:
  • When it comes to healthcare, significant disparities abound between people with disabilities and able-bodied people. From physical barriers and discrimination to financial hurdles and a lack of available resources, access to healthcare is alarmingly inequitable for people with disabilities around the world.

We're pleased to offer these resources as we work together to deliver high-quality, equitable healthcare.

When we receive a corrected claim and it doesn’t have the original claim number, or the original claim number is not correctly entered, we are not able to process it because we’re not able to connect it to the original claim.

1. For providers and their vendors (clearinghouses or billing services) submitting a corrected claim through EDI, we will send you a 277CA EDI Response Report acknowledging that we’ve received the submission, but are not able to process it:

1. In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
2. It is important that you submit proof of timely filing of the original claim when submitting a corrected claim so we can ensure the claim is processed according to the timely filing guidelines.
   

2. For providers using Claims Status application on Availity.com, you will not be able to access the corrected claim if it was rejected on the 277CA EDI Response Report:

1. In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
2. It is important that you submit proof of timely filing of the original claim when submitting a corrected claim so we can ensure the claim is processed according to the timely filing guidelines.
   

We’ve also developed a training video that can help further in reducing duplicate claims along with a training guide called Making the Claims Process Work for You that can help you in properly submitting a corrected claim. Access the video and download the guide here. Provider information is required to view, but it will only occur the first time viewing this training.

If you have questions about submitting a corrected claim, reach out to your provider representative or work with your EDI vendor to ensure you are receiving the 277CA Response Report.

Effective September 1, 2024, Anthem will implement facility emergency department leveling.

Facilities must use appropriate codes and leveling for all services furnished during the emergency department (ED) encounter. The highest intervention/resource used determines the final facility ED level, which the Special Investigations (SIU) Prepayment Review team assesses for care providers under investigation who are also participating in the prepayment review program.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to Availity.com, select state and the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section on our care provider website for the appropriate contact.

Please note: This policy does not apply for providers using the enhanced ambulatory patient grouping (EAPG) pricing methodology.

With your help, we can continually build towards a future of shared success.

Summary

On November 17, 2023, and March 21, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Summary: On May 19, 2023, August 18, 2023, November 17, 2023, December 11, 2023, and February 23, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Summary: On February 24, 2023, September 11, 2023, and November 17, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective September 1, 2024, Anthem will transition to the following Carelon Medical Benefits Management Clinical Appropriateness Guidelines for medical necessity/clinical appropriateness reviews for requested interventions. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. This does not equate to the presence of a prior authorization requirement. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

• Site of Care Guidelines:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

Please share this notice with other members of your practice and office staff.

The Centers for Medicare & Medicaid Services (CMS) Health Outcomes Survey (HOS) gathers patient-reported health outcomes from members enrolled in Medicare Advantage plans to support quality improvement activities and improve the overall health of members.

Increased awareness of all HOS measures can help guide your provider interactions with your patients and positively impact HOS results and can help impact your Star rating.

Refer to attachment to view full details