The X12 275 5010 version of electronic attachments transactions for claims will:

• Bring value to you by eliminating the need for mailing paper records.
• Electronic acknowledgment provides a transaction audit trail -- proof of delivery/receipt.
• Reduces administrative cost associated with manual processing
• Save time waiting for paper correspondents

This new functionality includes both solicited and unsolicited attachments.

• Solicited Attachment - Documentation submitted in response to a specific request.
• Unsolicited Attachment - Documentation is known to be needed and submitted at the same time as the claim.

Ability to send a 275 transaction

Your practice management software or billing service/clearinghouse must have the ability to send a 275. We encourage you to have a conversation with them to determine their ability to set up the X12 275 attachment transaction capabilities.

Where to find help

The new EDI batch process, X12 275 5010v Companion Guide, assists with specific attachment requirements and enables providers to electronically submit attachments based on your business needs.

• The companion guide can be downloaded at: (anthem.com/edi)
• Availity documentation can be found at: availity.com

Use the Availity Welcome Application below to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions.

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday - Friday

8 a.m. - 7 p.m. ET.

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A valid CLIA Certificate Identification number is required and must be included on each electronic claim billed for laboratory services, subject to CLIA legislation. You may not receive reimbursement for your electronic claims if the required certification number is missing.

Apply for a CLIA Certificate here.  This CMS mandate went in to effect on May 1, 2020. Please work with your software vendor or clearinghouse to ensure that the required information is included in your electronic files to avoid EDI claim rejections.

For detailed information on the tests subject to CLIA, please refer to the CMS link.                  

Prior Authorization and Referral Request (278)

The EDI 278 transaction supports healthcare providers to submit an authorization and referral requests electronically. A prior authorization issued by Anthem provides you the go-ahead to perform the necessary service and a referral used to refer a member to a specialty provider. Transmit this transaction in real-time or batch mode. You will receive confirmation numbers to validate receipt of request.

Inpatient Admission and Discharge Notification 278N

Use the Hospital Admission Notification (278N) transaction to exchange admission notification data between an inpatient facility and Anthem in a standard format.

Similar to the HIPAA 278 transaction that you may already use to submit authorizations or referrals, the EDI 278N is the simplest, most efficient way to communicate facility admissions. You can also transmit through Availity in either batch or real-time format.

What are the benefits of 278 and 278N transaction?

Both transactions offer:

• Simplify administrative tasks and increase productivity.
• Reduce administrative costs through automation and fewer phone calls, faxes or keying.
• Increase data accuracy by reducing manual errors.

Specifically for 278N, hospitals that have implemented EDI 278N:

• Experience an improvement in notification submissions within 24 hours.
• Can confirm a notification of admission is on file in the form of a service reference number generated upon registration.
• Submit notification of discharge.

How to send a 278 and 278N Transaction

Look for more communications coming soon around how to work with your practice management software vendor or billing/service clearinghouse, or view a companion guide to send a 278 or 278N transaction.

Where to find help

The new Prior Authorization and Inpatient Admission & Discharge Notification via Electronic and Digital Self Service, X12 5010v Companion Guides, assists with specific 278 and 278N requirements.

• The companion guide can be download at: anthem.com/edi
• Availity documentation can be found at: availity.com

Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions. In addition, the Availity Quick Start Guide will assist you with any EDI connection questions.

If you need assistance, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 7:30 p.m. Eastern Time.

Take Action Today: Availity setup is simple and at no cost for you!

Use this “Welcome” link to get started today: https://apps.availity.com/web/welcome/#/

All EDI transmissions currently sent or received today via the Anthem gateway are now available on the Availity EDI Gateway. 

• 837 Institutional and Professional
• 837 Dental
• 835 Electronic Remittance Advice
• 276/277 Claim Status
• 270/271 Eligibility Request
• 275 Medical Attachments
• 278 Prior Authorization/Referrals
• 278N Inpatient Admission and Discharge Notification

Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:

• Migrate your direct connection with Anthem and become a direct submitter with Availity.
• Use your existing Clearinghouse or Billing Company for your EDI transmissions. (Work with them to ensure connectivity to the Availity EDI Gateway).
• Use Direct Single Claim entry through the Availity Portal.

Show your team what you learned this summer!

Enroll in one of Availity’s free courses and training demos at your convenience. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.

Follow these steps to register at www.Availity.com:

1. Log in to the Availity Portal and select Help & Training | Get Trained to access the Availity Learning Center (ALC).
2. Select Sessions from the menu under the search catalog field.
3. Scroll Your Calendar to locate your webinar.
4. Select View Course and then Enroll. The ALC will email you instructions to attend.

If you and your clearinghouse have already migrated over to Availity, thank you and you are a step ahead! If not, start the process now to make the transition before September 15, 2020.

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday - Friday

8 a.m. - 7 p.m. ET.

MyDiversePatients.com offers education resources to help you support the needs of your diverse patients and address disparities, including:

• Free Continuing Medical Education (CME) learning experiences about disparities, potential contributing factors and opportunities for providers to enhance care.
• Real life stories about diverse patients and the unique challenges they face.
• Tips and techniques for working with diverse patients to promote improvement in health outcomes.

Stronger Together offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.

While there is no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com and Stronger Together is to start reversing these trends…one person at a time.

Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted health care partner by visiting these resources today.

My Diverse Patients

Stronger Together Health Equity Resources

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This is a reminder to ensure that you are referring Anthem members to participating labs. LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs.  The relationship with LabCorp does not affect network hospital-based lab service providers, contracted pathologists, or contracted independent laboratories.  Physicians may continue to refer to all par providers as they have in the past.

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.  As a reminder, Quest Diagnostics is a non-participating laboratory for all lines of business in Colorado. 

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, and select Providers.  Select your state if you haven’t done so already.  Under the Provider Resources heading, select Find a Doctor.  Select your state if you haven’t done so already. 

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.

Please ensure that all codes captured in your electronic medical record (EMR) system are also included on the claim(s), and are not being truncated by your claims software management system.  For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing four.  If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.

Reminder about ICD-10 coding

The ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits.  Additionally, Anthem uses ICD-10 codes submitted on claims to monitor health care trends, cost, and disease management. Additionally, the Centers for Medicare & Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a patient’s health.

Using specific ICD-10 diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.

• Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.
• Include any secondary diagnosis codes that are actively being managed.
• Include all chronic historical codes, as they must be documented each year pursuant to the ACA.  (Such as an amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).

Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions.   ICD-10 coding guidelines still apply, so please ensure coding on a telehealth visit claim is to the highest specificity with all diagnosis codes.  Previous Anthem Provider News editions provide telehealth reimbursement guidance to follow for claims submission.

If you are interested in a coding training session specific to risk adjustable conditions, please contact the Commercial Risk Adjustment Network Education Representative:  Socorro.Carrasco@anthem.com.

Expansion of AIM Musculoskeletal Program Effective November 1, 2020

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Change Notification to Provider and Facility Manual effective November 1, 2020

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• Change of address/location
• Name change
• Tax ID changes
• Provider leaving a group or a single location
• Change in phone/fax numbers
• Closing a practice location
• Change in status for Accepting New Patients
• Plus more

As a reminder, our Find Care online tool is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans.

Action Needed:

To help ensure we have the most current and accurate information, please take a moment to access the Find Care tool and review how you and your practice are being displayed.

• Select Search as a Guest, then Search by All Plans and Networks
• Enter the appropriate search criteria to find your Provider information

Report discrepancies:

Please make any necessary corrections using the Provider Maintenance Form. The Provider Maintenance Form (PMF) is available online at anthem.com. Select Providers │ under Provider Resources heading, select Provider Maintenance Form (Note: select Colorado, if you haven’t done so already).  The PMF can be found on the Availity Portal by selecting your state │ Payer Spaces │ Anthem Blue Cross and Blue Shield │Resources │ Provider Maintenance Form.

Tips for submitting your updates:

• Address changes:

• You must select both of the following option to make a complete address change:
  • Address -- Add Location to add a NEW address, and
  • Address -- Terminate to remove an OLD
• Note: Please ensure you are submitting this for all address types; e.g. physical, billing, correspondence addresses, etc.

• Termination changes:
  
  
  • Provider Leaving a Group:
    • Use this option to select when it is 1 provider leaving a group.
  • Termination of Provider Participation Agreement:

Use this option when the entire Tax ID is terming

• Roster or List updates:
  
  
  • When making changes for organizations, utilize the Roster or List updates when:
    • your organization is delegated credentialing, or
    • Making 5 or more demographic changes to your organization
  • Note: Access this option by selecting Organization, then select Roster of List Updates
    
    

 

“Working with Anthem” webinar -- August

Don’t forget we are also hosting our “Working with Anthem” webinar and this month’s topic will help Quick Tips for adding, changing, terming a provider using the Provider Maintenance Form. Anthem contracted providers are required to update their demographic information when changes occur to their practice / organization using our online Provider Maintenance Form (PMF).

Learn how to utilize the online PMF to submit changes such as the following:

• Change of address/location
• Name change
• Tax ID changes
• Provider leaving a group or a single location
• Change in phone/fax numbers
• Closing a practice location
• Change in status for Accepting New Patients
• Plus more!

Check out our registration link to register today!

2020 Subject Specific Webinars -- August schedule

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”.

Note:  Even if you are unavailable to attend, please register to ensure you receive the event recording password once available as it’s distributed to all that register. 

• Submit behavioral health authorizations via our online Interactive Care Reviewer tool
• Waived copays, deductibles and coinsurance for CCM, complex CCM and TCM
• Updates to AIM musculoskeletal program clinical appropriateness guidelines
• Provider data update

ABSCARE-0488-20

ABSCRNU-0155-20

ABSCRNU-0149-20

ABSCRNU-0151-20

AIM will follow the Anthem Blue Cross and Blue Shield (Anthem) clinical hierarchy for medical necessity determination. For Medicare Advantage (MA) products AIM makes clinical appropriateness based on CMS National Coverage Determinations, Local Coverage Determinations, other coverage guidelines, and instructions issued by CMS and legislative benefit changes. Where the existing CMS guidance provides insufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.

Prior authorization requirements

For services scheduled on or after November 1, 2020, providers must contact AIM to obtain prior authorization for the services detailed below. Providers are strongly encouraged to verify they have received a prior authorization before scheduling and performing services.

Detailed prior authorization requirements are available to contracted providers by accessing the Availity Portal* at www.availity.com. Contracted and non-contracted providers may call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements or additional questions as needed.

Small joint replacement (including all associated revision surgeries)

• Total joint replacement of the ankle
• Correction of hallux valgus
• Hammertoe repair

The expanded musculoskeletal program will review certain lower extremity small joint surgeries for clinical appropriateness of the procedure and the setting in which the procedure is performed (Level of Care review). Procedures performed as part of an inpatient admission are included. The clinical guidelines that have been adopted by Anthem to review for medical necessity and level of care are located at:

• AIM Small Joint Surgery Guideline
• AIM Level of Care Guidelines for Musculoskeletal Surgery and Procedures

How to place a review request

You may place a prior authorization request online via the AIM ProviderPortal_SM. This service is available 24/7 to process requests using Clinical Criteria. Go to www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday to Friday 7 a.m. to 7 p.m. Central time.

For more information

For resources to help your practice get started with the musculoskeletal program, go to www.aimprovider.com/msk.

This provider website will help you learn more and provide useful information and tools such as order entry checklists, clinical guidelines, and FAQs.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com.

Inpatient Surgical Care (ISC):

• Viral Illness, Acute — Inpatient Adult (M-280)
• Viral Illness, Acute — Inpatient Pediatric (P-280)
• Viral Illness, Acute — Observation Care (OC-064)

Recovery Facility Care (RFC):

• Viral Illness, Acute — Recovery Facility Care (M-5280)

ABSCRNU-0157-20

Medicare Risk Adjustment and Documentation Guidance (general)

When: This training is offered the first Wednesday of each month from 1 p.m. to 2 p.m. ET.

Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model with guidance on medical record documentation and coding.

Credits: This live activity, Medicare Risk Adjustment and Documentation Guidance, from January 8, 2020, to December 2, 2020, has been reviewed and is acceptable for up to one 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: Training Registration.

* Note: Dates may be modified due to holiday scheduling.

Medicare Risk Adjustment, Documentation and Coding Guidance (condition specific)

When: This training is offered on the third Wednesday of every other month from noon to 1 p.m. ET.

Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.

Credits: This live series activity, Medicare Risk Adjustment Documentation and Coding Guidance, from
January 15, 2020, to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

Session 1: Red Flag HCCs, part one: Training will cover HCCs most commonly reported in error as identified by CMS, including chronic kidney disease (stage five), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease.

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 1

Password: sDBNERC3

Session 2: Red Flag HCCs, part two: Training will cover HCCs most commonly reported in error as identified by CMS, including 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.

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC’s Part 2

Password: PnPAF4py

Session 3: Neoplasms

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Neoplasms

Password: PfUWPcs6

Session 4: Acute, Chronic and Status Conditions

Recording link will be provided after October 1, 2020.

Session 5: Diabetes Mellitus and Other Metabolic Disorders - September 16, 2020

DM and other Endocrine, Nutritional and Metabolic Disorders

Session 6: Coinciding Conditions in Risk Adjustment Models - November 18, 2020

Medicare Risk Adjustment Documentation and Coding Guidance: Coinciding Conditions in Risk Adjustment Models

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 March 2020. Visit Clinical Criteria to search for specific policies.

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