Provider News CaliforniaMay 2022 Anthem Blue Cross Provider News - CaliforniaChange Healthcare will transition out of the post-payment hospital bill audit (HBA) program by the end of 2022. Effective immediately, Anthem Blue Cross’ (Anthem) complex and clinical audit (CCA) team will conduct the HBA program. For a short period of time, Change Healthcare may continue to contact you to finalize any work that is in process, or already scheduled.
Anthem continues to work with Cotiviti as a post-payment DRG validation audit partner. Effective immediately, the Anthem CCA team is assuming a larger role in conducting post-payment DRG validation audits and DRG readmission audits. In addition to receiving requests from Anthem’s CCA team, network-participating providers may continue to receive letters from Cotiviti requesting access to medical records for the purpose of conducting these audits. We will do our best to avoid duplicate medical record requests from Anthem and Cotiviti.
Thank you for your continued efforts to expedite medical record requests.
This notification applies to all lines of business and all markets. If you have questions about this notification, please contact the Provider Services Call Center.
The total economic cost of alcohol use disorder has been estimated to be $249 billion according to the Centers for Disease Control and Prevention (CDC)1, $27 billion of which has been accounted for healthcare costs2. The CDC projects the economic impact to society is about $807 per person, per year.3
Alcohol use disorder also impacts the economy through work force disruptions caused by tardiness, absenteeism, employee turnover and conflict in the workplace. It causes a reduction in potential employees, customer and taxpayer bases.4
According to the CDC, alcohol use was directly tied to 95,000 deaths annually between 2011 and 2015. This was more than all illicit substances combined. The CDC estimates that alcohol-attributed disease resulted in almost 685,000 years of potential life lost for the same period.
This chart shows the years of potential life lost (YPLL) related directly or indirectly to alcohol use disorder:
Cause
|
YPLL
|
Total YPLL
|
>2.7 million
|
100% alcohol attributed disease
|
684,750
|
Suicide
|
334,058
|
Motor vehicle crashes
|
323,610
|
Liver disease
|
202,391
|
Heart disease
|
118,021
|
Cancer
|
88,729
|
If you need assistance connecting your patients to opioid, substance use or alcohol use disorder treatment, contact your Anthem Blue Cross health plan.
Many resources are available for health professionals to support hypertension prevention and management and educate others. To support that effort, the Centers for Disease Control and Prevention (CDC)’s Division for Heart Disease and Stroke Prevention has put together these sets of educational materials for health professionals and patients:
Visit the Million Hearts® website for more resources designed for health professionals. Million Hearts® is a national initiative co-led by CDC and the Centers for Medicare & Medicaid Services (CMS). Million Hearts® aims to prevent 1 million heart attacks and strokes within five years.
Measure Up: Controlling High Blood Pressure (CBP) HEDIS® measure
The HEDIS measure Controlling High Blood Pressure (CBP) assesses adults ages 18–85 with a diagnosis of hypertension and whose blood pressure was properly controlled based on the following criteria:
- Adults 18–59 years of age whose blood pressure was <140/90 mm Hg
- Adults 60–85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg
- Adults 60–85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg
Patient claims should include one systolic reading and one diastolic reading:
CPT II Code
|
Most recent systolic blood pressure
|
3074F
|
<130 mm Hg
|
3075F
|
130-139 mm Hg
|
3077F
|
≥ 140 mm Hg
|
CPT II Code
|
Most recent diastolic blood pressure
|
3078F
|
<80 mm Hg
|
3079F
|
80-89 mm Hg
|
3080F
|
≥ 90 mm Hg
|
When charting your patient’s blood pressure readings, in addition to the systolic and diastolic readings, and dates, if the patient has an elevated blood pressure, but does not have hypertension, note the reason for follow-up.
Additional tips for talking to patients:
- Continue to educate patients about the risks of hypertension
- Encourage weight loss, regular exercise and diet
- Advise patients who are smoking to quit
- Talk about chronic stress and ways to cope with it in a healthy way
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Resource: Centers for Disease Control and Prevention. https://www.cdc.gov/bloodpressure/educational_materials.htm
Anthem Blue Cross (Anthem) and Self-Insured Schools (SISC) welcomes Santa Clara Unified School District (USD) to the High-Performance Network (HPN). Santa Clara USD members enrolled in an EPO plan are utilizing Anthem’s HPN network. Santa Clara USD members can be identified with alpha prefix H5A.
We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well. The COVID-19 pandemic has reignited public attention about the serious public health risks and consequences of disparities, and the critical need for health equity.
Health equity means everyone has the opportunity to reach their highest level of health, and barriers to doing so must be removed. Health disparities are health differences that are closely linked with social, economic, and/or environmental disadvantage.1 Achieving health equity requires focus on the elimination of barriers and disparities associated with factors such as race, ethnicity, gender, gender identity, religion, socioeconomic status, disability, and even where you live.2 As a result, it is imperative to offer access to care that is tailored to the unique needs of patients, and Anthem Blue Cross is committed to supporting our providers in this effort.
MyDiversePatients.com is where you can find resources, information, and techniques to help provide individualized care every patient deserves, regardless of their diverse backgrounds. There you can also find opportunities for free Continuing Medical Education (CME) credit for learning experiences on topics related to cultural competency and disparities. Mydiversepatients.com is free and accessible from any device (desktop computer, laptop, phone, or tablet) with no account or log in required. Scan the QR code below for direct access to mydiversepatients.com.
Stronger Together is a website where you can find free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created in collaboration with national organizations and are available for you to share with your patients and communities. Scan the QR code below for direct access to Stronger Together.
While there is no single, easy answer to address health care disparities, the vision of MyDiversePatients.com and Stronger Together is a start to reversing health care inequity one person at a time.
Submitting your updates in a timely manner helps to ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information in our online provider directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Online update options include:
- add/change an address location
- name change
- tax ID changes
- provider leaving a group or a single location
- phone/fax number changes
- closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. We appreciate your help in keeping our online provider directories current.
These guidelines are developed to provide helpful information on how to report services to [brand] for the administration and observation of the drug Spravato®.
Eskatamine is sold under the brand name Spravato® and is indicated for adults with treatment-resistant depression. Based on the prescribing information, patients who have the drug administered in the professional provider’s office should be monitored for 2 hours to assess for complications.
A main component in understanding how to report the administration of this drug is to identify whether the professional provider has purchased the drug for administration or whether the drug has been supplied and reported by a pharmacy. There are specific codes to report for each scenario:
Professional provider purchased and administered:
For professional providers that supply, administer, and provide the required observation of Spravato®, one of the following packaged service codes should be billed and should not include separate billing of the drug or the billing of the post-administration observation:
HCPCS Code
|
Description
|
G2082
|
Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
|
G2083
|
Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
|
Note: When Spravato® is being supplied by the outpatient hospital and administered in an outpatient hospital, the facility should bill G2082 and G2083 in conjunction with revenue center code (RCC) 919 and the drug should not be billed separately. In addition, there should not be a separate professional claim submitted as procedure codes G2082 and G2083 describe both the drug and the professional services.
Pharmacy supplied and professional provider administered:
When a pharmacy supplies Spravato® and is reporting this service in a separate claim, the drug should be billed with the HCPCS code, S0013 – Esketamine, nasal spray, 1 mg.
If the provider administering Spravato® did not purchase the drug, then the provider should not report the supply of the drug on their claim, as this will be reported by the pharmacy.
Post-administration observation:
When the provider does not bill a packaged service code (listed above), the professional provider may report an Evaluation and Management (E/M) service including the appropriate prolonged services code.
CPT Codes
|
Description
|
99202 - 99205
|
Office or other outpatient visit for the evaluation and management of a new patient
|
99212 - 99215
|
Office or other outpatient visit for the evaluation and management of an established patient
|
99417
|
Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes
|
In accordance with the American Medical Association’s (AMA’s) CPT® Manual, CPT code 99417 should only be billed when reported with CPT codes 99205 and 99215. Medical records must support coding. Please refer to Anthem’s Prolonged Services – Professional Reimbursement Policy for additional information.
Effective March 1, 2022, the following Part B medications from the current Clinical Utilization Management (UM) Guidelines will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below.
Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.
Clinical UM Guidelines
|
Preferred drug(s)
|
Nonpreferred drug(s)
|
· ING-CC-0062
|
· Inflectra
· Remicade, Infliximab (unbranded)
|
· Avsola
· Renflexis
|
Effective April 1, 2022, the Southern California Drug Benefit Fund will offer an Anthem Blue Cross (Anthem) Medicare Preferred (PPO) plan. Anthem will provide medical benefits for the Southern California Drug Benefit Fund retirees through the Anthem Preferred Provider Organization (PPO) product, which includes the National Access Plus benefit. The PPO plan allows members to receive services from any provider, as long as the provider is eligible to receive payments from Medicare.
Southern California Drug Benefit Fund members’ copay or coinsurance percentage will be the same whether their provider is in- or out-of-network. Locally or nationwide, doctors or hospitals, member share-of-cost (SOC) does not change.
Non-contracted providers may continue treating Southern California Drug Benefit Fund members and will be reimbursed 100% of Medicare’s allowed amount for covered services, less any member share of cost (SOC).
The Medicare Advantage plan offers the same medical and hospital benefits that Medicare covers including additional benefits that Medicare does not cover, such as 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 at Availity.com.*
Providers will follow their normal claim filing procedures for Southern California Drug Benefit Fund member claims.
Providers may call Provider Services at 833-848-8730 for eligibility, prior authorization requirements, and any questions about the Southern California Drug Benefit Fund member benefits or coverage.
Effective March 1, 2022, the following Part B medications from the current Clinical Utilization Management (UM) Guidelines will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below.
Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.
Clinical UM Guidelines
|
Preferred drug(s)
|
Nonpreferred drug(s)
|
· ING-CC-0062
|
· Inflectra
· Remicade, Infliximab (unbranded)
|
· Avsola
· Renflexis
|
The National Committee for Quality Assurance (NCQA) has changed, revised, and retired HEDIS® measures for measurement year 2022. Below is a summary of the key changes to be aware of.
Diabetes measures
NCQA has separated the Comprehensive Diabetes indicators into stand-alone measures:
- Hemoglobin A1c Control for Patients with Diabetes (HBD) (HbA1c Control < 8 and Poor Control HbA1c)
- Eye Exam Performed for Patients with Diabetes (EED)
- Blood Pressure for Patients with Diabetes (BPD)
- Kidney Health Evaluation for Patients with Diabetes (KED)
The process measure Comprehensive Diabetes HbA1c testing was retired as the goal is to move towards more outcome measures.
Race/ethnicity stratification
To address healthcare disparities, the first step is reporting and measuring performance. Given this, NCQA has added race and ethnicity stratifications to the following HEDIS measures:
- Colorectal Cancer Screening (COL)
- Controlling High Blood Pressure (CBP)
- Hemoglobin A1c Control for patients with Diabetes (HBD)
- Prenatal and Post-Partum Care (PPC)
- Child and Adolescent Well Care Visits (WCV)
NCQA plans to expand the race and ethnicity stratifications to additional HEDIS measures over several years tohelp reduce disparities in care among patient populations. This effort builds on NCQA’s existing work dedicated to the advancing health equity in data and quality measurement.
New measures
Antibiotic Utilization for Respiratory Conditions (AXR): The percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event
This measure was added given antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse. Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic use. Given this new measure, the Antibiotic Utilization measure has been retired.
Deprescribing of Benzodiazepines in Older Adults (DBO): The percentage of Medicare members 65 years of age and older who were dispensed benzodiazepines and achieved a 20% decrease or greater in benzodiazepine dose during the measurement year
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Guidelines recommend that benzodiazepines be avoided in older adults, and deprescribing benzodiazepines slowly and safely, rather than stopping use immediately. There is an opportunity to promote harm reduction by assessing progress in appropriately reducing benzodiazepine use in the older adult population.
Advanced Care Planning (ACP): The percentage of adults 65 to 80 years of age, with advanced illness, an indication of frailty or who are receiving palliative care, and adults 81 years of age and older, who had advance care planning during the measurement year
Advance care planning is associated with improved quality of life, this measure will allow an understanding if it is provided to those who are most likely to benefit from it. Given this new measure, the Care for Older Adults measure has been retired.
Measure changes
Use of Imaging Studies for Low Back Pain (LBP): This measure was expanded to the Medicare line-of-business and the upper age limit for this measure was expanded to age 75. Additional exclusions to the measure were also added.
A complete summary of 2022 HEDIS changes and more information, can be found online.
Source: NCQA.org
Strategic Provider System to launch in April In May 2022, Anthem Blue Cross (Anthem) will replace the current data management system with the new and significantly improved Strategic Provider System (SPS). The SPS data portal will increase website data accuracy, transparency, and timeliness, creating an enhanced provider experience.
SPS offers robust support features that will improve the ability of Anthem to match submitted claims, resulting in more accurate pricing and processing. The easy-to-use website will allow you to:
- Digitally submit demographic data to one location.
- Maintain, update, and verify demographic data using a single website.
- Receive clear on-screen alerts and guidance as you maintain your data.
- Obtain access to a simplified quick verification process that will allow you to complete required verifications online, eliminating the need to fax, email, or use separate online forms.
- Receive periodic reminders to help you keep your information current.
What you need to do to get ready for the change
If already enrolled in Availity,* no further action is needed. If you are not enrolled, go to availity.com and select the orange Register button. Availity is a secure provider website where you can enjoy the convenience of digital transactions, including prior authorization and claims submission, as well as benefit and eligibility look-up.
Anthem Blue Cross has partnered with Everlywell* to provide at-home lab tests for a subset of our eligible patients. We mail at-home test kits directly to patients’ homes with instructions on how to complete and return the kits. Clinical Laboratory Improvement Amendments-certified labs process the tests, and an independent physician reviews the results.
We provide PCPs a list of their patients who receive test kit(s) and send individual results to the patient and their doctor. You can help your patients navigate needed testing by encouraging them to complete kits mailed to them. A physician’s recommendation is a significant factor in patient screenings.
A patient may receive up to two at-home test kits:
- Fecal immunochemical test for colorectal cancer screening
- Hemoglobin A1c test to measure average glucose levels over the past two to three months for those with diabetes
How the program works:
- Test kit(s) are automatically mailed to eligible patients, and patient lists are sent to physicians.
- Patients collect samples at home, using instructions provided.
- Patients mail samples to Everlywell in the provided, postage-paid envelope.
- Individual test results are sent to patients and their primary care physician, providing evidence of preventive screening completion.
If you have questions about the at-home testing program, contact your local representative. For additional information about Everlywell, visit everlywell.com.
High-prevalence demographics
The lifetime prevalence of AUD in the U.S. population is approximately 29.1%. However, only 19.8% of people with AUD receive treatment. Prevalence of AUD is high in white and Indigenous people, younger men (age < 65), unmarried people, and those with low incomes.1
22.8 million people over the age of 12 reported having a substance use disorder (SUD) in 2019; AUD accounted for 63% of this population. An additional 12% presented with AUD and another SUD (excluding nicotine) according to the National Survey on Drug Use and Health (NSDUH).2
AUD and COVID-19
Evidence suggests that alcohol consumption increased during the COVID-19 pandemic. One study found that 60% of respondents reported increased alcohol-intake.3 In 2020, alcohol sales increased by 262% online and 21% in stores, which participants reported was due to increased stress, alcohol availability, and lockdown boredom.4 This increase was most substantial between March to April 2020. The study suggests those most affected by COVID-19 (job loss, friend loss, family loss, and isolation) may be more at risk of AUD.3
AUD co-occurring with mental health conditions
People with a variety of mental health conditions are at increased risk of developing an AUD or have an existing co-occurring AUD.5 While the rates are higher for co-occurring disorders with mental health conditions, there is also a higher risk of greater severity and a worse prognosis for both the mental condition and AUD.
Trauma, including adverse childhood events (ACEs) and post-traumatic stress disorder (PTSD), are often precursors for AUD.6 Traumatic brain injuries (TBI) are also associated with AUD. Alcohol intoxication is one of the strongest predictors of a TBI. In addition, people with a TBI are more likely to abuse alcohol.7
In most co-occurring disorders, the mental health condition preceded the AUD. This indicates that people diagnosed with a mental health condition should be screened for AUD. Preventive work should begin at the onset of symptoms of a mental health condition.5
What if I need assistance?
If you have difficulty connecting patients with AUD to treatment, please contact Anthem Blue Cross. If you have questions about this communication or need assistance with any other item, call Provider Services at 800-407-4627.
Email is the quickest and most direct way to receive important information from Anthem Blue Cross. To start receiving email from us (including some sent in lieu of fax or mail), submit your information using our online form (https://bit.ly/3lLgko8).
This communication applies to the Commercial and Medicaid programs for Anthem Blue Cross (Anthem) in California.
Anthem knows that requests for expedited grievances can’t wait. To ensure we process your expedited grievance as quickly as possible, please fax to:
- For Medi-Cal Managed Care members — 866-387-2968
- For members of our Commercial plans — 855-211-3699
As a reminder, expedited grievances are pre-service or concurrent requests for which a delay may cause an imminent and serious threat to the health of the member; severe pain; potential loss of life, limb, or major bodily function; or delay of end-of-life care and treatment.
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