Requesting a clinical appeal is easy:

Logon to ICR from the Availity Portal and locate the case using one of the search options, or from your ICR dashboard.

• Select the Request Tracking ID link to open the case. If the case is eligible for an appeal you will see the Request Appeal menu option on the Case Overview screen.
• Select Request Appeal to open the Appeal Details screen and complete the required fields on the appeal template. (You also have the option of uploading attachments and images to support your request.)
• Select Submit

Take the steps below to check the status of a clinical appeal:

Logon to ICR from the Availity Portal

• Select Check Appeal Status from the ICR top menu bar
• Type the Appeal Case ID and Member ID in the allocated fields
• Select Submit

The appeal status and detail of the decision will open on the bottom of the screen.

Need more information on how to navigate the new ICR Appeals feature?

Download the ICR Clinical Appeals Reference Guide located on the Availity Portal. Select: Payer Spaces | Applications | Education and Reference Center | Communication and Education. Find the link to the reference guide below the ICR menu.

Additional Training:

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway.  Availity is well known as a Web portal and claims clearinghouse.  In addition, Availity functions as an EDI Gateway for multiple payers and is the single EDI connection for our company.

Your organization can submit and receive the following electronic transactions through Availity’s EDI Gateway:

• 837- Institutional Claims
• 837- Professional Claims
• 837- Dental Claims
• 835 - Electronic Remittance Advice
• 276/277- Claim Status
• 270/271- Eligibility Request

If you wish to become a direct a trading partner with Availity, the setup is easy.

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

If you prefer to use your clearinghouse or billing company, please work with them to ensure connectivity.

Need Assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

835 Electronic Remittance Advice (ERA)

Effective June 1, 2018, please use Availity to register and manage account changes for ERA.

If you were previously registered to receive ERA, you must register using Availity to manage account changes.

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

If you were previously registered to receive EFT only, you must register using EnrollHub to manage account changes. No other action is needed.

Contacting Availity

If you have any questions, contact Availity Client Services at 1-800-Availity

Currently, our recovery process for National Accounts membership is reflected in the EDI PLB segment on the electronic remittance advice (835).  This segment will show the negative balance associated with the member account number.  Monetary amounts are displayed at the time of the recovery adjustment.

As National Accounts membership transitions to the new system and claims are adjusted for recovery, the negative balances due to recovery are held for 49 days to allow ample time for you to review the requests, dispute the requests and/or send in a check payment. During this time, the negative balances due are reflected on paper remits only within the “Deferred Negative Balance” sections. 

After 49 days, the negative balances due are reflected within the 835 as a corrected and reversed claim in PLB segments. 

If you have any questions or concerns, please contact the E- Solutions Service Desk toll free at (800) 470-9630.

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. 

Each year our goal is to improve our process for requesting and obtaining medical records for our HEDIS project. In order to demonstrate the exceptional care that you have provided to our members and in an effort to improve our scores, you and your office staff can help facilitate the HEDIS process improvement by:

• Responding to our requests for medical records within five days, if possible
• Providing the appropriate care within the designated timeframes
• Accurately coding all claims
• Documenting all care clearly in the patient’s medical record

Further information regarding documentation guidelines and administrative codes can be found on the HEDIS page of our Provider Portal.  In addition more information on HEDIS can be found by visiting the provider portal at: www.anthem.com > Provider > Choose State > Find Resources > Health & Wellness (top blue bar) > Quality Improvement and Standards > HEDIS Information. You will find reference documents entitled “HEDIS 101 for Providers” and “HEDIS Physician Documentation Guidelines and Administrative Codes”.

The following table shows some of our key measure rates across Colorodo.

• Yellow boxes indicate rates that are above the national average.
• Bold indicates improvement in rate over the previous year.
• B/R = Biased Rate
• Comprehensive Diabetes Care - Poor HbA1c Control (>9):  Lower rate is good

Now is the time to review your patient’s records to ensure that they have received their preventative care and/or immunizations before the end of the year.

Again, we thank you and your staff for demonstrating teamwork as we work together to improve the health of our members and your patients.  We look forward to working with you again next HEDIS season.

Engagement methods vary by the individual’s risk level but can include:

• Education about their condition through mailings, email newsletters, telephonic outreach, and/or online tools and resources.
• Round-the-clock phone access to registered nurses.
• Guidance and support from Nurse Care Managers and other health professionals.

Physician benefits:

• Save time by answering patients’ general health questions and responding to concerns, freeing up valuable time for the physician and their staff.
• Support the doctor-patient relationship by encouraging participants to follow their doctor’s treatment plan and recommendations.
• Inform the physician with updates and reports on the patient’s progress in the program.

Please visit our website to find more information about the program such as program guidelines, educational materials and other resources. Go to anthem.com.  Select Providers, and Providers Overview.  Select Find Resources for Your State and pick Colorado.  From the Health & Wellness tab, select the Condition Care link. Also on our website find the Referral Form, which you can use to refer other members you feel may benefit from our program.

The Integrated Care Model helps exchange members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease.  Our nurse care managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. 

Nurse Care Managers encourage participants to follow their physician’s plan of care; not to offer separate medical advice. In order to help ensure that our service complements the physician’s instructions, we collaborate with the treating physician to understand the member’s plan of care and educate the member on options for their treatment plan. 

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  How do you contact Case Management?

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner.  Anthem urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between Behavioral Health and other health care practitioners at the time treatment begins.

We expect all health care practitioners to:

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:

• Diagnosis
• Treatment plan
• Referrals
• Psychopharmacological medication (as applicable)

In an effort to facilitate coordination of care, Anthem has several tools available on the Provider website including a Coordination of Care template and cover letters for both Behavioral Health and other Healthcare Practitioners.* In addition, there is a Provider Toolkit on the website with information about Alcohol and Other Drugs which contains brochures, guidelines and patient information.**

*Access to the forms and cover letters are available at anthem.com > Providers > Providers Overview > Find Resources for Your State > Colorado > Provider Home > Answers@Anthem

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below.  UM criteria are also available on the web. Just select “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” from the Provider home page at anthem.com.

We work with providers to answer questions about the utilization management process and the authorization of care.  Here’s how the process works:

• Call us toll free from 8:30 a.m. - 5 p.m. Monday through Friday (except on holidays). More hours may be available in your area.  Federal Employee Program hours are 8:00 a.m. - 7 p.m. Eastern.
• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day.  Calls received after midnight will be returned the same business day. 
• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

The following phone lines are for physicians and their staffs.  Members should call the customer service number on their health plan ID card.

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.

Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls.  They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.

FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. 

AllianceRX Walgreens Prime is the specialty pharmacy program for the Federal Employee Program.  You can view the Specialty Drug List or call us at 1-888-346-3731 for more information.

It can be found on our website.   Go to anthem.com, and select the Providers, and Providers Overview.   Select Find Resources for Your State, and pick Your State.  From the Health & Wellness tab, select the link titled Quality Improvement and Standards, and then the link titled “Member Rights & Responsibilities”.  Practitioners may access the FEP member portal at www.fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website. To access the guidelines, go to anthem.com, and select the Providers, and Providers Overview.   Select Find Resources for Your State, and pick Your State.  From the Health & Wellness tab, select the link title “Practice Guidelines”. You can then choose from Clinical Practice Guidelines, Preventive Health Guidelines, or Behavioral Health Clinical Practice Guidelines.

Anthem is available to offer assistance in these difficult moments with our Case Management Program.  Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers.  The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  They will be transferred to a team member based on the immediate need.  Physicians can also refer by contacting us telephonically or through electronic means.  No issue is too big or too small.  We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

How do you contact us?

The prefix on Colorado PERA cards will be CBH. The cards will also show the Colorado PERA logo and National Access Plus icon.

Providers can submit claims electronically using the electronic payer ID for the Blue Cross Blue Shield plan in their state or submit a UB-04 or CMS-1500 form to the Blue Cross Blue Shield plan in their state. Claims should not be filed with Original Medicare. Contracted and non-contracted providers may call Provider Services at 1-833-244-3888 for benefit eligibility, prior authorization requirements and any questions about Colorado PERA member benefits or coverage.

Detailed prior authorization requirements also are available to contracted providers by accessing the Provider Self-Service Tool at Availity.com.

PROVIDERS: If you have an approved prior authorization with a date of service that is October 1, 2018 or later, please fax the approval to Anthem at 866-959-1537. We will enter the approval in our system and no other action is needed on your part.

For additional information, also reference previous publication New 2019 Health Care Plan information for all Colorado PERA Retirees - CO

74703COPENABS

Effective January 1, 2019, Medicare providers will have toll free phone numbers specifically designated for their service inquiries. These new provider numbers will be listed separately on the back of the member ID cards and should be used beginning January 1, 2019. The associates answering your provider service calls are trained to answer your questions and resolve your issues as quickly as possible. To ensure you receive the most efficient service, please refrain from using the member services line and use only 844-421-5662 or the provider services phone number listed on the back of the member ID card for individual Medicare Advantage calls beginning January 1, 2019.

• CO 2019 Annual Notice of Change
• NV 2019 Annual Notice of Change
• Prior authorization requirements for Colonoscopy and Upper Gastrointestinal Endoscopy
• Medicare Advantage Reimbursement Policy October Provider Bulletin
• Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila
• July Medicare Advantage reimbursement policy
• Submit PA medication requests electronically; new phone number for MA prescription PAs
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective January 1, 2019
• Inpatient Readmissions
• Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective September 1