The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement.

 

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

Pateint360 is a Longitudinal Patient Record (LPR) where you can access the complete view of Anthem Blue Cross and Blue Shield (Anthem) information associated with an Anthem member.

 

You may have noticed that the Care Reminders tab on your Anthem patient’s Eligibility and Benefits return on Availity was recently removed. You can still retrieve these important patient gaps in care through Patient360.

 

You are required to have the Patient360 role assigned to you by your Availity administrator to see the Patient360 tab located at the top of the patient’s Eligibility and Benefits return. To access Patient360 select the tab and follow the steps to open the application.

 

If your patient does have a gap in care, you will see the red alert button on the top of Patient360 Member Care Summary. Details of the care gap can be found in the Active Alerts section.

 

Availity Eligibility and Benefits: Patient360 access





Patient360 Active Alerts located on the Member Care Summary

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

 

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website at anthem.com │Providers │Providers Overview │Select Find Resources for Your State, and pick Colorado │ From the Health & Wellness tab, select Practice Guidelines.

 

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits.  In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization.  Anthem’s medical policies are available on Anthem’s website at anthem.com.

 

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 our website at anthem.com.  Select Providers │ under the Provider Resources heading, select Policies and Guidelines │ select your state │ View Medical Policies & UM Guidelines.

 

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.

 

To discuss UM Process and Authorizations	To Discuss Peer-to-Peer UM Denials w/Physicians	To Request UM Criteria	TTY/TDD
Phone 800-832-7850 FAX - 800-763-3142   Transplant 888-574-7215   Autism 844-269-0538   FEP Phone 800-860-2156 FAX 800-732-8318 (UM) FAX 877-606-3807(ABD)	Local:  303-764-7227 Toll-free: 866-287-1654   No fax number to request Peer-to-Peers.   FEP Phone 800-860-2156	800-797-7758   No fax number. Providers leave message with: provider name, provider phone number, member’s name, member ID, and reference number.   FEP Phone 800-860-2156 FAX 800-732-8318 (UM) FAX 877-606-3807(ABD)	711 or  TTY / Voice 800-659-2656(TTY) /  800-659-3656(V)

 

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.

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral.  Anthem Blue Cross and Blue Shield (Anthem) would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

 

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 Form and Coordination of Care Letter Templates for both Behavioral Health and other Medical Practitioners.* Behavioral Health tools are available, which includes forms, brochures, and screening tools for Substance Abuse, ADHD, and Autism. Please refer to the website for a complete list.**

 

*Access to the forms and template letters are available at www.anthem.com/provider/forms/

**Access to the Behavioral Health tools are www.anthem.com/provider/forms/

Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.

 

Anthem is available to offer assistance in these difficult moments with our Case Management (CM) 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?

 

CM Email Address	MC Telephone Number	CM Business Hours
Case.management@anthem.com	1-888-613-1130	Monday-Friday, 8am - 7pm MT
National NationalWest-CM@anthem.com	1-877-783-2756   1-888-574-7215 (Transplant)	Monday-Friday, 8am-9pm PST, Saturday 9am-4:30pm PST Monday-Friday 8:30am-5pm EST (Transplant)
Federal Employee Program (FEP) No email	1-800-711-2225	8am-7pm EST

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.  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:

                                                                         

· Allergy Program · Cancer Testing · Cardiovascular Disease · Companion Diagnostics · Dermatology · Diabetes · DNA Testing · Endocrine Disorders · Esoteric Coagulation · Gastroenterology

· Genetic Testing · Genetic Counseling · Genomics · HLA Lab for National Marrow Donor Program · Hematopathology · Infectious Disease · Immunology · Liver Disease · Kidney Disease

· Medical Drug Monitoring · Molecular Diagnostics · Newborn Screening · Pain Management · Pathology Expertise w/range of Subspecialties ·    Pharmacogenomics · Preimplantation Genetic Diagnosis · Reproductive Health

· Obstetrics / Gynecology · Oncology · Toxicology · Whole Exome Sequencing · Virology · Women’s Health · Urology

 

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

In our company’s ongoing efforts to streamline and simplify our payment recovery process, we will be consolidating our National Accounts membership to a central system. With this change we will be aligning the payment recovery processes to be the same as the majority of our other lines of business.

 

Our recovery process for National Accounts membership is reflected on the Electronic Remittance Advice (835) in the PLB segment. The requested recovered amount on the Electronic Remittance Advice (835) is displayed at the time of the recovery.

 

As National Accounts membership transitions and claims are adjusted for recovery on the central system, the requested recovered amount will be held for 49 days. This will 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” section.

 

After 49 days, the requested recovered amount is reflected on the Electronic Remittance Advice (835) in the PLB segment.

 

If you have any questions or concerns, please contact the E-Solutions Service Desk toll free at 1-800-470-9630.

Maintaining accurate provider information is critically important to ensure our members have timely and accurate access to care.

 

Additionally, Anthem Blue Cross and Blue Shield (Anthem) is required by Centers for Medicare & Medicaid Services (CMS) to include accurate information in provider directories for certain key provider data elements.  For Anthem to remain compliant with federal and state requirements, changes must be communicated 30 days in advance of a change or as soon as possible.

 

Key data elements

 

The data elements required by CMS and crucial for member access to care are: 

• Physician name
• Location (such as address, suite if appropriate, city/state, zip code)
• Phone number
• Accepting new patient status
• Hospital affiliations
• Medical group affiliations

 

Anthem is also encouraged (and in some cases required by regulatory/accrediting entities) to include accurate information for the following provider data elements:

• Physician gender
• Languages spoken
• Office hours
• Provider specialty/specialties
• Physical disabilities accommodations
• Indian Health Service status
• Licensing information (i.e., medical license number, license state, National Provider Identifier - NPI)
• Email and website address

How to verify and update your information

To verify information, go to anthem.com and select “Providers,” and then under “Provider Resources” select Find a Doctor tool.  Use “Search as a Guest” at the bottom.  If your information is not correct, please update the information as soon as possible. 

 

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 also be found on the Availity Portal │ Payer Spaces │ Anthem Blue Cross and Blue Shield icon │Resources │ Provider Maintenance Form.

 

Access a recorded webinar regarding the Provider Maintenance Form:

 

Note:  If you need assistance with submitting a Provider Maintenance Form, please access our recorded webinar regarding this topic.  Go to anthem.com │ Select Providers │ under Communications heading, select Education and Training │ under Seminars and Webinars heading, select Working with Anthem Webinars │ Register for a Working with Anthem Webinar. 

 

The top portion of the page will show “Upcoming Events” and the bottom portion will show “Event Recordings”.  Use the following access code to view this webinar WwA112019.  (Access code is case sensitive).

We are continuing our series of “Working with Anthem” webinars for 2019.  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).

2019 Subject Specific Webinars -- January schedule

 

Note:  We will not be hosting a training session in December, as attendance is usually difficult because of year end schedules. 

We will resume in January and registration information is included below. 

Topic:	Pathway PPO Overview
Date/Time:	Wednesday, January 29, 2020
Description:	Please join us to learn about our new Pathway PPO network and the new products available to access this network starting January 1, 2020.
Registration link:	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.

On January 1, 2019, a change to CPT codes for Psychological and Neuropsychological test administration and evaluation services was released. The new codes did not crosswalk on a one-to-one basis with the deleted codes.

 

The coding changes separated test administration from test evaluation, psychological testing from neuropsychological testing, and defined the testing performed by a professional or technician. The new codes were as follows:

 

Neurobehavioral status exams are clinical interview examinations performed by a psychologist or neuropsychologist to assess thinking, reasoning and judgment. Providers should continue to use CPT code 96116 when billing for the first hour and new code 96121 when billing for each additional hour.

 

Testing evaluation services include the selection of the appropriate tests to be administered; integration of patient data; interpretation of standardized test results and clinical data; clinical decision-making; treatment planning; and reporting and interactive feedback to the patient, family members, or caregivers, when performed. Providers should now use CPT code 96130 to bill for the first hour of psychological testing evaluation services and 96131 for each additional hour. Neuropsychological evaluation services should now be billed using CPT code 96132 for the first hour and 96133 for each additional hour.

 

Test administration and scoring by a psychologist or neuropsychologist (two or more tests using any method) should now be billed using CPT code 96136 for the first 30 minutes and 96137 for each additional 30 minutes.

 

Test administration and scoring by a technician (two or more tests using any method) should now be billed using CPT code 96138 for the first 30 minutes and 96139 for each additional 30 minutes. 

 

Single automated test administration should be reported with newly created code 96146 for a single automated psychological or neuropsychological instrument that is administered via electronic platform and formulates an automated result. Psychologists should not use this code if two or more electronic tests are administered and/or if administration is performed by the professional or technician. Instead, the psychologist should use the appropriate codes listed above for test administration and scoring.

 

Screening and risk assessment (repetitive assessment after screening) include brief emotional/behavioral assessment with scoring and documentation, per standardized instrument, should now be billed using CPT code 96127 separately from testing.

 

 

References: www.apa.org

Category: Medicare

 

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

 

• Service area benefit changes
• Introducing ConcertoHealth
• CMS reminder: expedited/urgent requests
• Group Retiree PPO program announcement
• Aspire Health for Medicare members in need of palliative care
• Global 3M19 Medical Policy and Technology Assessment Committee prior authorization requirement updates
• Prior authorization requirements for E0784, K0553 and K0554

Category: Medicare

 

On June 20, 2019, the Pharmacy and Therapeutic (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 are publicly available on the provider website, and the effective dates will be reflected in the link to web posting. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

ABSCRNU-0067-19 October 2019          504073MUPENMUB