By the end of 2018, Anthem members will begin receiving a new explanation of benefits (EOB) that is designed to help members better understand their health care benefits and out-of-pocket expenses. The new design will look more like a health care summary. EOBs will continue to include important information about services rendered, the amount paid to the provider, and the member out-of-pocket expense.

The new EOB will also include:

• Ways members can save on health care expenses
• A preventive care checklist, sharing important screenings that were missed
• A summary of the member’s most recent claims

Learn more about our newly designed EOB. 

If Anthem is due a refund as a result of an overpayment discovered by a Provider or Facility, refunds can be made in one of the following ways:

• Submit a refund check with supporting documentation outlined below, or
• Submit the Provider Refund Adjustment Request Form with supporting documentation to have claim adjustment/recoupment done off a future remittance advice

When voluntarily refunding Anthem on a Claim overpayment, please include the following information:

• Provider Refund Adjustment Request Form (see directions below for how to access online)
• All documents supporting the overpayment including EOBs from Anthem and other carriers as appropriate
• Covered Individual ID number
• Covered Individual’s name
• Claim number
• Date of service
• Reason for the refund (as indicated on the form of common overpayment reasons)

Please be sure the copy of the provider remittance advice is legible and the Covered Individual information that relates to the refund is circled. By providing this critical information, Anthem will be able to expedite the process, resulting in improved service and timeliness to Providers and Facilities.

Important Note: If a Provider or Facility is refunding Anthem due to coordination of benefits and the Provider or Facility believes Anthem is the secondary payer, please refund the full amount paid. Upon receipt and insurance primacy verification, the Claim will be reprocessed and paid appropriately.

How to access the Provider Refund Adjustment Request Form online:

To download the “Provider Refund Adjustment Request Form” directly from anthem.com.  Select Providers, and Providers Overview.  Select Find Resources in Your State, and pick Colorado.  From the Provider Home page, Under the Self Service and Support heading, choose Download Commonly Requested Forms and select Provider Refund Adjustment Request Form.

Please utilize the proper address noted in the grid below to return payment:

The Interactive Care Reviewer (ICR)* tool offers a streamlined process to request inpatient and outpatient procedures as well as locate information on previously submitted requests for Anthem members via the Availity Portal.

The ICR tool provides many benefits including fax reduction, authorization determination and a comprehensive view of all your authorization requests. In addition to these benefits, the ICR tool has recently completed some enhancements to improve convenience and efficiency.

Enhancements to the ICR tool include:

• Increase in saved Favorites: The number of favorites that can be saved increased to 25 for all provider types including requesting, servicing, facility DME, and refer to providers.

• Changes to ICR Dashboard tabs: The Authorization Referral Inquiry tab at the top of the dashboard changed to Check Case Status tab. The Search Organization Requests changed to Search Submitted Requests.

Check Case Status: The ability to view any cases submitted that are associated with the tax IDs on the request. This includes submission by phone, fax, and etc.

Search Submitted Requests: The ability to search for any ICR case requested by your organization or a request that your organization is associated with. This includes requests with a status of review not required.

• Changes to Check Case Status tab: The Search by Reference Referral Number changed to Search by Reference/Authorization Request Number.

Search by Reference Authorization Request Number: The ability to search by reference request number or authorization request number and a tax ID associated with the case.

To learn more about the ICR tool:

• Attend one of the monthly ICR webinars by registering HERE.

Webinar:  Introduction to Availity EDI Gateway services for Anthem provider organizations

Are you an Anthem provider that needs help transitioning to using Availity’s Gateway solutions? Are you looking for SFTP or other batch upload options? If yes, check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session.

During this webinar, you’ll learn how to:

• Understand Availity’s EDI Gateway and Clearinghouse workflow
• Enroll for and manage 835 ERA delivery with Availity
• Use the Availity Portal to manage file transfers, set up EDI reporting preferences
• Access and navigate the Availity EDI Guide
• and more

Enrollment information

1. Log in to the Availity Portal at Availity.com.
2. Click Help & Training | Get Trained.
3. In the Catalog, click Sessions.
4. Scroll through Your Calendar to view upcoming live events.

Tip: You can also search the ALC Catalog by a special keyword set up just for you. The keyword is song.

Webinar Schedule

Enroll for an upcoming webinar (and check back again later for additional dates and times).

• Monday, 8/20/2018, 3:00 p.m. to 4:00 p.m. Eastern time
• Thursday, 8/23/2018, 1:00 p.m. to 2:00 p.m. Eastern time
• Tuesday, 9/25/2018, 12:00 noon to 1:00 p.m. Eastern time
• Thursday, 9/27/2018, 3:00 p.m. to 4:00 p.m. Eastern time

Additional Training

You can search the Catalog by keyword to access live and on-demand training recommendations curated by Availity Learning especially to help you with this transition. The keyword is “song” for Anthem.

Anthem has partnered with Availity to become our designated EDI Gateway.  The effort is currently underway, and both are committed to providing transparency for our customers.

All EDI submissions currently received today via the Anthem EDI Gateway are all now available on the Availity EDI Gateway.  There is no impact to the provider’s participation status with Anthem and no impact on how claims adjudicate.

If you are connected to Availity you can use your same connection for your EDI submissions.

If you are using another clearinghouse, contact your clearinghouse to validate their transition dates. If your clearinghouse notifies you of changes regarding connectivity, workflow, or the financial cost of EDI transactions, there is a no-cost option available to you – You can submit claims directly through Availity.

Your organization can register with Availity to submit the following transactions:

• 837 – Institutional
• 837 – Professional
• 837 – Dental
• 835 – Electronic Remittance Advice
• 276/277 – Claim Status – real-time
• 270/271 – Eligibility – real-time

Next steps:

• Anthem and Availity will continue to communicate and provide assistance with this transition going forward.
• Availity will be working directly with all trading partners.
• We do recommend that you register with Availity for your EDI transmissions for a free fully subsidized option.

How to register with Availity:

• If your organization is not already registered with Availity you can go to www.availity.com, click REGISTER and then follow the steps to register.
• Look for emails, from Availity, containing your log in credentials.
• If your organization is already registered with Availity, you can log in and click My Providers | Enrollments Center if you need to complete new 835 enrollment or make changes.

We look forward to delivering a smooth transition to the Availity EDI Gateway.

This is a reminder to ensure that you are referring Anthem members to participating labs. Not only does your Anthem agreement obligate you to refer to participating labs where available, but members will only receive their full benefits from participating providers.  As a result, referring your patient and our member to a non-participating lab may expose them to a greater financial responsibility. 

Unfortunately, there are certain non-participating labs that are offering to waive or cap co-payments, coinsurance or deductibles to our members in order to increase their overall revenue. These practices undermine member benefits and may encourage over-utilization of services.

These billing practices are also questionable in their legality.  Such a practice may present violations under state or federal anti-kickback laws, and may constitute abuse of health insurance under the Colorado criminal code.

For a listing of Anthem participating laboratories, please check our online directory. Go to anthem.com.  Choose Select Providers, and Providers Overview.  Select Find Resources in Your State, and pick Colorado.   From the Provider Home tab, select the enter button from the blue box on the left side of page titled Find a Doctor. 

Note:  When searching for laboratory, pathology, or radiology services, under the field “I am looking for a:” select Lab/Pathology/Radiology; and then under the field “Who specializes in:”, select Laboratories, Pathology, or Radiology as appropriate for your inquiry.

LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs:

LabCorp is capable of providing services that range from routine testing, such as basic blood counts and cholesterol tests, to highly complex diagnosing of genetic conditions, cancers, and other rare diseases.  LabCorp has specialized laboratories which cover the following areas of testing:

Note:  This relationship with LabCorp does not affect network hospital-based lab service providers, contracted pathologists, or contracted independent laboratories. 

As part of our commitment to provide you with the latest clinical information, we have posted a VBAC shared decision making aid to our provider portal.  

This is a tool for you to discuss with your patients to aid in making a decision regarding their treatment options.  This has been reviewed and certified by the Washington Health Care Authority (HCA) and is available on our website.  To access the aid, go to anthem.com, select Providers from the top menu, and choose Providers Overview.  Select Find Resources in Your State, and pick Colorado. From the Health & Wellness page, choose Practice Guidelines, then Shared Decision-Making Aid.

Numerous studies have shown that a patient’s primary health care experience and, to some extent their health care outcomes, are largely dependent upon health care provider and patient interactions.  Anthem offers a new online learning course – What Matters Most: Improving the Patient Experience, to address gaps in and offer approaches to communication with patients.  This curriculum is available at no cost to providers and their clinical staff nationwide and is acceptable for up to one (1) prescribed credit by the American Academy of Family Physicians.

Through the use of compelling real-life stories that convey practical strategies for implementing patient care, providers learn how to apply best practices.  Did you know?

• Substantial evidence points to a positive association between the patient experience and health outcomes.

• Patients with chronic conditions, such as Diabetes, demonstrate greater self-management skills and quality of life when they report positive interactions with their health care providers.
• Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician's practice than patients with the highest-quality relationships.

How will this benefit you and your office staff?  You’ll learn tips and techniques to:

• Improve communication skills.
• Build patient trust and commitment.
• Expand your knowledge of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

The course can be accessed at www.patientexptraining.com using your smartphone, tablet, or computer.

Like you, Anthem is committed to improving the patient experience in all interactions, and we are proud to work collaboratively with our provider network to provide support and tools to reach our goal.

Take the course today!

A key goal of Anthem’s provider transparency efforts is to improve quality while controlling health care costs. One of the ways this is done is by giving primary care physicians (PCPs) in the Enhanced Personal Health Care (EPHC) Program quality and/or cost information about the health care providers to which the PCPs refer their Attributed Members (the “Referral Providers”). If a Referral Provider is higher quality and/or lower cost, this component of the Program should result in their getting more referrals from PCPs. The converse should be true if Referral Providers are lower quality and/or higher cost. Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost information so that they can better understand how their health care dollars are being spent. This will give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

Cost Opportunity Report

• The Cost Opportunity Report is available for EPHC providers to access via Provider Care Management Solutions (PCMS).
• The report was created to help users quickly identify meaningful and actionable opportunities to optimize costs and help achieve shared savings targets within the EPHC Program.
• By providing a standard set of potential cost opportunity metrics, the Cost Opportunity Report can be used to help evaluate the relative success of providers within the EPHC Program.
• Metrics are selected based on size of financial opportunity, ability of PCPs to affect changes, mix of impacted service types, mix of utilization and unit price impact.
• Metrics are reviewed on a periodic basis and may be added, changed or removed.

Cost Efficient Outpatient Surgery Report

• The Cost Efficient Outpatient Surgery Report is a supplemental report available for EPHC providers in the Colorado market.
• It provides a total cost comparison of providers who perform surgical/common procedures in outpatient or ambulatory surgery center (“ASC”) settings.
• The Cost Efficient Outpatient Surgery Report helps EPHC providers determine who to refer Attributed Members to for more cost-effective care.
• Total cost is case mix adjusted and includes professional, facility, anesthesia, and implants (if applicable).
• Surgeons/providers are compared to their Colorado peers based on cases at outpatient and ASC locations.
• Surgeon complication rates are reviewed as part of report generation

Anthem accepts electronic medication pre-certification requests for commercial health plans. This feature reduces processing time and helps determine coverage quicker. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.

Electronic pre-certification (ePA) offers many benefits:

• More efficient review process
• Ability to identify if a pre-certification is required
• Able to see consolidated view of ePA submissions in real time
• Faster turnaround times
• A renewal program that allows for improved continuity of care for members with maintenance medication
• Pre-certification are preloaded for the provider before the expiration date.

Providers can submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.

While ePA helps streamline the pre-certification process, providers can also initiate a new prior authorization request by fax or phone. Please note, the contact numbers for all Medicare plans will change effective September 1, 2018.

If you have other questions, please contact the provider service number on the member ID card.

The Affordable Care Act (ACA) requires many health plans to cover recommended preventive care services without member cost sharing when the services are rendered by an in-network provider and/or facility. Screening colonoscopies (even when polyps are removed) are included as a covered preventive care service. Since colonoscopies are rendered for both screening and diagnostic purposes, it is very important for providers to use appropriate coding guidelines when reporting colonoscopies. When inappropriate CPT and ICD-10 codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.

The following services are covered with no member cost share:

• The colonoscopy screening procedure.
• Anesthesia charges when anesthesia is billed with the appropriate screening CPT code (even when polyps are removed).
• Other associated facility charges when the colonoscopy is billed with an appropriate screening diagnosis code.
• When polyps are removed during a screening colonoscopy - the removal, examination and analysis of the polyps.

In the instance where a screening colonoscopy starts out as screening but turns into a diagnostic procedure due to polyps being removed, Anthem follows CPT guidelines for our Commercial members, not Medicare guidelines. The CPT® 2018 Professional Edition manual shares the following information regarding the billing of anesthesia for any screening colonoscopy, “Report 00812 to describe anesthesia for any screening colonoscopy regardless of ultimate findings.”

Effective for professional claims (CMS-1500) processed on or after November 18, 2018, Anthem Blue Cross and Blue Shield (Anthem) will enhance our editing systems to automate edits supported by correct coding guidelines, as documented in industry sources such as CPT, HCPCS Level II, and International Classification of Diseases 10 (ICD-10).  As a result, there will be greater focus on identifying incorrect or inappropriate billing of services by multiple providers within the same tax identification number for the same patient on the same day. This enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

Below are examples of claim edits that will be automated:

• Accurate reporting of modifiers, including LT, RT, 54, 55, 56, 62,76, 77, 78, 79, 80, 81, 82, and AS, which are often reported for the billing of services rendered by the same provider or multiple providers.
• Ensuring global, professional (modifier 26) and technical components (modifier TC) are billed appropriately by one or more providers in facility and office settings.
• Assessing whether services considered once in a lifetime have been billed more than once.
• Ensuring the reporting of procedures and the associated diagnosis codes are correctly reported together.

We are starting something new in 2018 and offering a “Working with Anthem” series of webinars that are comprised of short provider webinars designed to help Colorado providers and their staff learn how to use the tools currently available to improve operational efficiency when working with Anthem Blue Cross and Blue Shield (Anthem).

2018 Subject Specific Webinars – August schedule

Webinar Details Webinars are offered using Cisco WebEx. For additional details, and helpful hints about WebEx, please view our schedule Working with Anthem – Schedule for 2018.

There is no cost to attend.  Access to the internet, an email address and telephone is all that's needed.  Attendance is limited, so please Registrater Today.

Watch for additional topics and dates in future issues of Network Update throughout the year.  We also will continue to offer our Fall Provider Seminars as well covering a variety of topics in face-to-face and webinar options.

We listened to your feedback and are pleased to announce we now have a new look and feel to Network Update.

• Hospital readmissions
• Frequent ER visits
• No engagement with PCP within three months or more
• Readmission risk score >24
• Multiple diagnoses
• Identified social determinants of health

IHD does not replace Case Management, the care or the care management provided by PCPs and specialists. Instead provides an extra layer of support with Community Health Navigators as an extension of care management to help our members navigate the complex health care system.

Services are meant to compliment members’ efforts to improve health outcomes. IHD will make an initial outreach to identified members to determine the appropriate level of services.  IHD will not provide any clinical services.

An IHD Community Health Navigator may reach out to your practice to introduce themselves and establish a relationship with the physician. They may also discuss developing a mechanism by which to share information regarding patients that have been identified for complex care services.

For questions regarding IHD and complex care services, please contact 303-831-3343.

Anthem Blue Cross and Blue Shield (Anthem) is working with Accordant Health Services to provide targeted disease management services for members with rare medical conditions, including:  

• Epilepsy (Seizures)
• Rheumatoid Arthritis (RA)
• Human Immunodeficiency Virus (HIV)
• Multiple Sclerosis (MS)
• Crohn's Disease (CD)
• Ulcerative Colitis (UC)
• Parkinson's Disease (PD)
• Systemic Lupus Erythematosus (SLE or Lupus)
• Myasthenia Gravis (MG)
• Sickle Cell Disease (SCD)
• Cystic Fibrosis (CF)
• Hemophilia
• Scleroderma
• Polymyositis
• Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
• Amyotrophic Lateral Sclerosis (ALS)
• Dermatomyositis
• Gaucher Disease

Members in your care who may benefit from additional outreach and information may receive letters or phone calls from AccordantCare and Anthem. In the course of performing these activities, a nurse may contact you or your facility to obtain member information and/or AccordantCare may request medical information about Anthem members. AccordantCare and Anthem also will let you know of any health changes that may require your attention.

If you would like to refer a member to this program, please contact AccordantCare at:

• Phone or Fax: 1-866-247-1150
• Web: https://referral.accordant.com
• Plan name: AnthemReferrals
• Password: ref1088Anthem

Anthem’s Individualized Care Program is available to our fully insured commercial members to provide palliative care support for members with advanced illness in the last 12 months of life.  

This program does not replace the care of PCPs and specialists, but provides an extra layer of support with an interdisciplinary team that includes palliative care physicians, palliative care nurse practitioners, registered nurses, social workers, chaplains and patient care coordinators.

Specific palliative care services include:

• Comprehensive assessments including symptoms, spiritual and psychosocial needs
• Expert symptom management
• Supporting patients in defining their goals, values and preferences and in advance care planning
• Encouraging patients to execute advance directives
• 24/7 access to urgent clinical support from an palliative care team member
• Securing needed resources
• Education on palliative services and hospice care services

1. Telehealth services and support at routine intervals to patients by palliative trained providers
2. Home based visits by a palliative care nurse practitioner, supported by an interdisciplinary team of palliative providers for patients with a high symptom burden, increased risk of hospitalization or other complex issues. The home based visits will be offered through Anthem’s partnership with our subsidiary Aspire Health (available in certain geographic areas)
3. Clinic based services offered through an Anthem partnership with our subsidiary Aspire Health. Aspire’s palliative care team will be embedded within the outpatient clinic/practice of the member’s medical oncologist to provide services to targeted patients (available in certain geographic areas)

Aspire Health already provides services for members with advanced illness enrolled in our Medicare and Medicaid health plans and has demonstrated improvement in quality and cost of care savings.

If you are an Anthem contracted network provider, an Aspire Health palliative physician may reach out to your practice to introduce themselves in order to establish a physician to physician relationship. They may also discuss developing an individualized mechanism by which to share information regarding patients that have been identified for palliative care services. Aspire will provide clinical updates to your practice on a regular basis to facilitate the best possible co-management of your patient.

If you have questions regarding the Individualized Care Program, please email IndividualizedCareProgram-palliativecare@anthem.com.

Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

• Medical Policy Update
• Prior authorization requirements for Part B drugs: Azedra and Poteligeo  
• Prior authorizations required for new group-sponsored MA membership 
• Contracted provider responsibility and liability for Issuance of Notice of Medicare Non Coverage to a Skilled Nursing Facility
• Improve Medicare Advantage members’ medication adherence with 90-day prescriptions
• Prior authorization requirements for cardiovascular services  
• Medicare Advantage reimbursement policy provider bulletin  

72598MUPENMUB 06/18/2018

Anthem accepts electronic medication prior authorization requests for Medicare plans. This feature reduces processing time and helps determine coverage more quickly. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.

Electronic prior authorization (ePA) offers many benefits:

• More efficient review process 
• Ability to identify if a prior authorization is required 
• Able to see consolidated view of ePA submissions in real time
• Faster turnaround times
• A renewal program that allows for improved continuity of care for members with maintenance medication
• Prior authorizations are preloaded for the provider before the expiration date.

Submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.

While ePA helps streamline the prior authorization process, if you must initiate a new PA request by fax or phone, please note that the contact numbers for Medicare Prior Authorization will change September 1, 2018.

If you have other questions, please contact the provider service number on the back of the member ID card.

We have several incentive programs this year to encourage Medicare Advantage members to obtain preventive screenings.  Members may be rewarded when they complete their annual routine physical with their PCP.  Eligible members will receive a gift card for competing their screening mammogram, a colorectal cancer screening or their diabetes retinal exam.  Your member may ask that you confirm these screenings.