For the most up-to-date information from Anthem about COVID-19, please bookmark Provider News Home and check back often.

We are continuing our series of “Working with Anthem” webinars for 2020.  These webinars are focused on one topic each session, and designed to help our 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).

2020 Subject Specific Webinars -- April schedule

 

Topic:	Working with Anthem Webinars:  New Provider Enrollment Application - CO
Date/Time:	Tuesday, April 28, 2020 at 12:00pm MT
Description:	Learn about the functionality on Availity allowing providers to submit a New Provider Enrollment Application online.   Digital provider enrollment offers many benefits: Supports enrollment of professional providers, whose organizations do not have a credentialing delegation agreement with Anthem. New individual providers or groups can request a contract. Existing groups can add providers to their existing contract. Providers can check the status of an application in real-time using the enrollment dashboard.   This webinar will walk you through an overview of the tool to allow you to start submitting Provider Enrollment applications electronically, and start saving you time!
	https://anthem.webex.com/anthem/onstage/g.php?PRID=b6a696587e498199466cadc7231c908d

 

Webinars are offered using Cisco WebEx. 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 register today.

 

Watch for additional topics and dates in future issues of our monthly provider newsletter throughout the year.  We also will continue to offer our Fall Provider Seminars which will continue to cover a variety of topics in face-to-face and webinar options.

 

Recorded sessions: 

Most sessions are recorded and playback versions are available on our Registration Page.  The top portion of the page will show “Upcoming Events” and the bottom portion will show “Event Recordings”.

 

Event Recordings Note:

 

As we have a new registration link effective September 1, 2019, event recordings will be split into two URLs. 

 

• Recordings after September 1, 2019 will be available from the current registration link, under the “Event Recordings” heading.

 

• Archived Event Recordings from January -- August 2019 are available here.

As recently communicated in the February 2020 edition of Anthem’s Provider News, the AIM Rehabilitative program for Anthem’s Commercial Membership will relaunch April 1st.  AIM Specialty Health® (AIM), a separate company, will perform prior authorization review of physical, occupational and speech therapy services.  Requests may be submitted via the AIM ProviderPortal for dates of service April 1, 2020 and after.   

 

The AIM Rehab Program follows the Anthem Clinical Guidelines that state the services must be delivered by a qualified provider of therapy services acting within the scope of their licensure. Qualified providers acting within the scope of their license, including chiropractors, who intend to provide PT, OT or ST services should request prior authorization for those services through AIM. 

 

Please note that if you are providing PT/OT/ST services to an Anthem Commercial member whose state of issuance is part of the AIM Rehab Program, you will be required to obtain an authorization.

 

Anthem is also transitioning vendors for review of Rehabilitative Services for our *Medicare members to include out-patient PT, OT, and SLP, to AIM Specialty Health April 1, 2020 for dates of service April 1, 2020 and after.  *This does not apply to members in the states of FL, NJ and NY for whom prior authorization will still be required. Please review the update in an upcoming notice for more information about the AIM Rehabilitative Program for Medicare members.

 

Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Colorado (Anthem) is the proud payer of Colorado Higher Education Insurance Benefits Alliance (CHEIBA). 

 

CHEIBA offers their employees multiple plan options, but we’d like to clarify some of the specifics around the HMO/POS plan offering.

Here’s how the HMO/POS Plan options works:

HMO Colorado offers employer groups a point-of-service (“POS”) rider designed to complement BlueAdvantage HMO benefits. The POS rider is an “opt-out” product for members who want to receive covered health care services without guidance from a PCP in our HMO network.

 

In-network (HMO benefits): A member must select a PCP. If the member seeks services from a provider participating in our HMO Network, the member receives BlueAdvantage HMO benefits, less any in-network copayments. This is the member’s greatest benefit level. 

 

Important Note regarding HMO benefits:  There is NO DEDUCTIBLE for members utilizing providers in our HMO network.

 

Out-of-network (POS or “Opt Out” benefits): A member can choose to receive health care services from an out-of-network provider. Certain services under the POS provision will be covered at a lower benefit level than services received from an in-network provider. This means members may have to pay an annual deductible, as well as coinsurance, for these services. The out-of-network provider’s reimbursement for POS services is based on HMO Colorado’s maximum benefit allowance, according to the member’s Health Benefit Plan. Certain services require pre-certification.

 

Important Note about POS or “Opt Out” benefits:  When a member is utilizing their POS benefits, they “Opt Out” of using the HMO network.  Benefits for Covered Services under this Point-of-Service rider are available only when received from Providers within the State Colorado.  Providers may be:

• Participating within Anthem’s PPO network but, not participating within the HMO network.
• Non-participating Provider and have no agreement with Anthem.
• Participating or Non-Participating can make a difference in the members out of pocket expense.

 Sample Member ID Card for CHEIBA members with the HMO/POS health plan option:

(Please note the Member ID card below is just a sample, and does not include actual member information such as copays, but is included when the Member ID cards are generated and sent to members prior to the effective date.)

Accessing HMO / POS or “Opt Out” benefit information on the Availity portal.

Providers can verify eligibility and benefit information online through the Availity portal. 

• Go to www.availity.com
• Log in with user name and password
• Select Patient Registration
• Select Eligibility and Benefits Inquiry

Important Note regarding Benefit/Service Type options on Availity:  Ensure you are selecting the appropriate benefit type for your inquiry to obtain the appropriate benefits. Availity will default to the Health Benefit Plan Coverage option which is a general setting, and this may display the POS “Opt out” benefits first, you will need to scroll further on the page to see the HMO benefits. 

Or if you are an in-network HMO provider, we suggest that you select a more specific benefit type as appropriate to ensure you are collecting appropriate copays.  See example below for selecting Professional (Physician) Visit – Office as the benefit/service type from the drop down list.  These copays display the same information as on the Sample Member ID card. 

Any additional questions:

Anthem is dedicated to providing excellent customer service for CHEIBA associates and their providers, and we look forward to continuing a successful relationship.  If you have any additional questions about CHEIBA health plan options, please contact the CHEIBA Provider Service number at 1-877-833-5742.

We have two provider education/reference documents to help educate providers about our Networks in Colorado.  Both have been updated and are available online.

 

• Networks at a Glance
  
  Our Networks at a Glance document is designed to give a snap shot view of all the network offerings in Colorado. It includes information such as:
  • Network Name
  • Product Type aligned with that specific network
  • Agreement needed for participation
  • Three-character Prefix to identify members aligned with that specific network
  • Whether or not a PCP is required
  • Whether or not a referral is required

 

Networks at a Glance document has been updated and is available online. Please go to anthem.com.  Select Providers.  Under the Provider Resources heading, select Forms and Guides.  Choose Colorado (if you haven’t selected your state already), then select Networks at a Glance.

 

• Networks Overview
  
  Our Networks Overview document complements our Networks at a Glance Document.  It is designed to give a more in-depth look at each of the network offerings in Colorado.  It includes information such as:
  • Summary of each network
  • How to identify members aligned with that specific network
  • Any network specifics, if applicable
  • Sample Member ID Cards

 

Networks Overview document has been updated and is available online. Please go to anthem.com.  Select Providers.  Under the Provider Resources heading, select Forms and Guides.  Choose Colorado (if you haven’t selected your state already), then select Networks Overview.

CMS average sales price (ASP) second quarter fee schedule with an effective date of April 1, 2020 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on May 1, 2020. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways is through Anthem’s value-based programs such as Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, and so on – called the “Programs.”  Certain providers (“Value-Based Program Providers” also known as “Payment Innovation Providers”) in Anthem’s various value-based programs receive quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value-Based Program Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs may result in the provider getting more referrals from Value-Based Program Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

 
Providing this type of data, including comparative cost information, to Value Based Program Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Value Based Program Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, 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.

 

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant.  

Anthem completed its acquisition of Beacon Health Options, a large behavioral health organization that serves more than 36 million people across the country. The company will operate as a wholly owned subsidiary of Anthem.

 

Bringing together our existing solid behavioral health business with Beacon’s successful model and support services creates one of the most comprehensive behavioral health networks in the country. It’s also an opportunity to offer best-in-class behavioral health capabilities and whole person care solutions in new and meaningful ways to help people live their best lives.

 

From the standpoint of our customers and providers at this time, it’s business as usual:

 

• Members should continue to call the customer service number on the back of their membership card or access their health plan’s website for online self-service.
• Providers should continue to use the provider service contact information, websites and online self-service portals as part of their agreement with either Anthem or Beacon.
• There will be no immediate changes to the way Anthem or Beacon manage their respective provider networks, contracts and fee arrangements. Anthem and Beacon provider networks, contracts and fee arrangements will remain separate at this time.

 

We know our providers continue to expect more of their healthcare partner, and at Anthem, we aim to deliver more in return.

 

For more details, please see the press release.

 

At Anthem, we continue to make changes to our public provider website to make it easier for you to find the information you need. The end of first quarter brings a few updates for the site at anthem.com:

 

• Information has been added to our website regarding Patient-Centered Specialty Care (PCSC) – Anthem’s value-based payment program for cardiology, endocrinology and obstetrics/gynecology providers. You can find this information online as an extension of our broader patient-centered, value-based care program – Enhanced Personal Health Care (EPHC).
• Documents listed on the Prior Authorization page can be conveniently accessed via online links.
• Medicare Advantage will be live in the coming days. You will be able to view updated Medicare Advantage pages on the commercial public sites.
• Medical Policies (MP) and Clinical Utilization Management Guidelines (CUMG) now display on our newly designed Web pages.

 

If you have any questions, please contact Michelle Fraser at michelle.fraser@anthem.com or Nick Kizirnis at nick.kirzinis@anthem.com.

Click here for more information about the COVID-19 Virus Talking Points

 

 

ABSCARE-0434-20 March 2020          508967MUPENMUB

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 November 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

ABSCRNU-0124-20 February 2020          507833MUPENMUB

 

On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 December 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.*

 

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0130-20          508037MUPENMUB

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield 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)

 

• When: The trainings will be offered the first Wednesday of each month from 1 p.m. to 2 p.m. ET (from January 8, 2020, to December 2, 2020).
• 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 has been reviewed and is acceptable for up to 1 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.

 

For those interested in joining us 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:

 

Medicare Risk Adjustment and Documentation Guidance (General)

 

Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (Condition Specific)

 

• When: The trainings will be offered on the third Wednesday of every other month from noon to 1 p.m. ET (from January 15, 2020, to November 18, 2020).
• 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 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 joining us for this six-part training series, please see the list of topics and scheduled training dates below:

 

1. Red Flag HCCs Part 1 (January 15, 2020) — register for a recording of the session: Training will cover HCCs most commonly reported in error as identified by CMS (Chronic Kidney Disease Stage 5, Ischemic or Unspecified Stroke, Cerebral Hemorrhage, Aspiration and Specified Bacterial Pneumonias, Unstable Angina and Other Acute Ischemic Heart Disease, End-Stage Liver Disease).
   • Link: Red Flag Hierarchical Condition Categories (HCCs), part one
     
     
2. Red Flag HCCs Part 2 (March 18, 2020): Training will cover HCCs most commonly reported in error as identified by CMS (Atherosclerosis of the Extremities with Ulceration or Gangrene, Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome, Drug/Alcohol Psychosis, Lung and Other Severe Cancers, Diabetes with Ophthalmologic or Unspecified Manifestation)
   • Link: Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 2
     
     
3. Neoplasms (May 20, 2020)
   • Link: Neoplasms
     
     
4. Acute, Chronic and Status Conditions (July 15, 2020)
   • Link: Acute, Chronic and Status Conditions
     
     
5. Diabetes Mellitus and Other Metabolic Disorders (September 16, 2020)
   
   • Link: Diabetes Mellitus and Other Metabolic Disorders
     
     
6. TBD — This Medicare risk adjustment webinar will cover the critical topics and updates that surface during the year (November 18, 2020):
   • Link: Topic TBD

 

ABSCRNU-0125-20 February 2020          507941MUPENMUB

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

 

• Coding tip for psychological and neuropsychological testing
• New MA Opioid Treatment Program benefit
• Medical Policies and Clinical Utilization Management Guidelines update
• Prior authorization requirements: new 2020 codes for coverage and precertification