 Provider News ColoradoDecember 2022 Anthem Provider News - ColoradoMaterial Adverse Change (MAC)
Reimbursement changes to COVID-19 laboratory services codes for Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem) in Colorado.
Beginning with dates of service on or after March 1, 2023, or the end of the public health emergency (PHE), whichever is the latter, reimbursement for COVID-19 laboratory services codes may be reduced for providers contracted as independent laboratory (ancillary) providers and participating in an Anthem independent laboratory provider network.
New COVID-19 laboratory service codes were implemented and reimbursed at rates to meet the needs of providers during the PHE. Reimbursement will be revised to Anthem’s standard reimbursement methodology for independent laboratory providers for the following codes:
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U0001
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86328
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87426
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87811
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0226U
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U0002
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86408
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87428
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0202U
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0240U
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U0003
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86409
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87635
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0223U
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0241U
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U0004
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86413
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87636
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0224U
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|
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U0005
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86769
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87637
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0225U
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The revised standard fee schedule for the COVID-19 laboratory services codes outlined above can be viewed on www.availity.com* beginning January 12, 2023.
If you have any questions regarding this notice, please contact your designated Provider Network manager. Please incorporate this notice into your Anthem’s Provider Agreement folder.
We have provided many articles advising of the compliant messaging when our members call your office during an urgent situation after regular business hours.
The annual after-hours access studies performed by our vendor, North American Testing Organization* based in California, assesses adequate phone messaging for our members with perceived emergency or urgent situations after office hours. Unfortunately, all Anthem Blue Cross and Blue Shield (Anthem) plans assessed still fall short of the expectation of having a live person or a directive in place for after-hours calls.
Well, the members are experiencing this lack of ability to reach instructions and have voiced their opinions in the member experience survey fielded annually for commercial and marketplace exchange via a behavioral health specific survey. An average of 29% of members have a need to contact their behavioral health practitioner after regular hours for urgent care. They are recalling, in the last 12 months, if they were able to reach the office for instructions, get a consultation they needed or get a timely call back?
This chart represents the office level accessibility when contacted by the survey vendor compared to the member satisfaction survey results of the member’s success getting their urgent needs meet after hours. As shown, the office level results are significantly below the expected 90% access to members with urgent symptoms.
Ironically, members express getting advice as soon as needed more often than the office assessment captures. Although a number of members sometimes, or never, reached the practitioner’s office for urgent instructions.
To help both your patients’ and Anthem’s ability to reach your practice, we ask that you verify or update your office information using the online Provider Maintenance Form and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.
- Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
- Be sure to turn on a messaging mechanism when you leave the office.
- Be sure you are using the acceptable messaging for compliance with your contract.
Per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:
Emergency situations
Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to the Emergency Room (ER) or live person connects the caller directly to the practitioner.
Emergent/Urgent situations
Compliant responses for urgent needs after hours:
- Live person or via a service, advises their practitioner or on call practitioner is available and connects.
- Live person or recording directs or directly connects caller/patient to Urgent Care, 24-hour crisis services, 911 or ER.
- May also, but not instead of directing, suggest caller/patient may contact their BH care practitioner (via cell phone, pager, text, email, voicemail, etc.) or request a call back for further urgent instructions.
- Mechanism connects the caller to their practitioner or the practitioner on call. (Must directly connect.)
- A live person or recording must express if there are prior arrangements with patients for after hour needs, to be compliant.
Non-compliant responses for urgent needs after hours:
- No provision for after hour accessibility.
- Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions.
These scenarios are non-compliant because there is no direct connection to their practitioner, thus not ensuring a timely callback. This prompt can be used in addition to, but not in place of instructions.
Is your practice compliant?
Anthem Blue Cross and Blue Shield (Anthem) 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. Our 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 the web. Just go to anthem.com, and select Providers > Provider Resources > Policies, Guidelines and Manuals > Select your state > View Medical Policies and Clinical 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. to 5 p.m., Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8 a.m. to 7 p.m. ET.
- 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.
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To discuss UM Process
and Authorization
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To Discuss Peer-to-Peer
UM Denials w/Physician
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To Request UM Criteria
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TTY/TDD
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Business Hours
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800-832-7850
Fax: 800-763-3142
Transplant
888-574-7215
Fax: 866-255-2471
National Transplant
844-644-8101
Fax: 888-438-7051
Autism
Call customer service number on back of member’s ID card.
FEP
800-860-2156
Fax: 800-732-8318 (UM)
Fax: 877-606-3807 (ABD)
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Local: 303-764-7227
No fax number to request Peer-to-Peers.
Adaptive Behavioral Treatment
Call customer service number on back of member’s ID card.
FEP
800-860-2156
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800-797-7758
No fax number. Providers leave message with: provider name, provider phone number, member’s name, member ID, and reference number.
800-860-2156
Fax: 800-732-8318 (UM)
Fax: 877-606-3807(ABD)
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711; or
TTY/Voice:
800-676-3777
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Monday – Friday (except on holidays)
8:30 a.m. to 5 p.m.
More hours may be available in your area.
FEP
Monday – Friday
8 a.m. to 7 p.m. ET
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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.
We have provided many articles advising providers of the compliant messaging when our members call your office during an urgent situation after regular business hours.
The annual after-hours access studies performed by our vendor, North American Testing Organization* based in California, assesses adequate phone messaging for our members with perceived emergency or urgent situations after office hours. Unfortunately, most of the Anthem Blue Cross and Blue Shield (Anthem) plans assessed still fall short of the expectation of having a live person or a directive in place for after-hours calls.
Members are experiencing this lack of ability to reach instructions and have voiced their opinions in the member experience surveys fielded annually for Commercial and Marketplace Exchange. An average of 16% of members have a need to contact their provider’s office after regular hours for urgent care. They are recalling, in the last 12 months, if they were able to reach the office via an appropriate message, a transfer directly to their doctor or service for instructions, or advice.
This chart represents the office level accessibility when contacted by the survey vendor compared to the CAHPS® (Commercial) and EES© (Marketplace Exchange) member satisfaction survey results of the member’s success getting their urgent needs meet after hours.
As shown, the office level results are barely meeting or are below the expected 90% access to members with urgent symptoms. More telling is members express getting advice as soon as needed less often than the office assessment captures. A sizable number of members sometimes or never reach the doctor’s office for urgent instructions.
  To help both your patients’ and Anthem’s ability to reach your practice, we ask that you verify or update your office information using the online Provider Maintenance Form, and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.
- Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
- Be sure to turn on a messaging mechanism when you leave the office.
- Be sure you are using the acceptable messaging for compliance with your contract.
Per the provider manual, have your messaging or answering service include appropriate instructions, specifically:
- Emergency situations:
- A compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to the emergency room (ER) or live person connects the caller directly to the practitioner.
- Urgent situations:
- Compliant responses for urgent needs after hours:
- Live person, via a service or hospital, advises their practitioner or on-call practitioner is available and connects.
- Live person or recording directs caller/patient to urgent care, ER or call 911:
- May also, but not instead of directing, suggest caller/patient contact their healthcare practitioner (via cell phone, pager, text, email, voicemail, etc.) or request a call back for further urgent instructions.
- Mechanism connects the caller to their practitioner or the practitioner on call. (Must directly connect.)
- Non-compliant responses for urgent needs after hours:
- No provision for after-hours accessibility.
- Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions.
These scenarios are non-compliant because there is no direct connection to their practitioner, thus not ensuring a timely callback. This prompt can be used in addition to, but not in place of instructions.
Is your practice compliant?
The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare 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 under the FAQ question about Laws and Rights that Protect You. To access, go to https://www.anthem.com and select For Providers. From there, select Policies, Guidelines & Manuals under Provider Resources. Select your state, and scroll down to Member Rights and Responsibilities under More Resources. Choose the Read about member rights link. Practitioners may access the FEP member website at www.fepblue.org/memberrights to view the FEPDO Members’ Rights and Responsibilities statement.
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem) in Colorado.
Our pharmacy benefit management partner, IngenioRx,* will join the Carelon family of companies and change its name to CarelonRx on January 1, 2023.
This change will not affect the ways in which CarelonRx will do business with care providers and there will be no impact or changes to the prior authorization process, how claims are processed, or level of support.
If your patients are having their medications filled through IngenioRx’s home delivery and specialty pharmacies, please take note of the following information:
- IngenioRx Home Delivery Pharmacy will become CarelonRx Mail.
- IngenioRx Specialty Pharmacy will become CarelonRx Specialty Pharmacy.
These are name changes only and will not impact patients’ benefits, coverage, or how their medications are filled. Your patients will not need new prescriptions for medicine they currently take.
When e-prescribing orders to the mail and specialty pharmacies:
- Prescribers will need to choose CarelonRx Mail or CarelonRx Specialty Pharmacy, not IngenioRx, if searching by name.
- If searching by NPI (National Provider Identifier), the NPI will not change.
In addition to the mail and specialty pharmacies, your patients can continue to have their prescriptions filled at any in-network retail pharmacy.
Keeping you well informed is essential and remains our top priority. We will continue to provide updates prior to January and throughout 2023.
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 Blue Cross and Blue Shield 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?
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 healthcare practitioners. This includes PCPs, medical specialists, and 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 healthcare practitioner. Anthem urges all its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other healthcare practitioners at the time treatment begins.
We expect all healthcare practitioners to:
- Discuss with the patient the importance of communicating with other treating practitioners.
- Obtain a signed release from the patient and file a copy in the medical record.
- Document in the medical record if the patient refuses to sign a release.
- Document in the medical record if you request a consultation.
- If you make a referral, transmit necessary information, and if you are furnishing a referral, report appropriate information back to the referring practitioner.
- Document evidence of clinical feedback (for example, 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 our provider website for behavioral health and other medical practitioners including:
- Coordination of Care Form.
- Coordination of Care Letter Template — Behavioral Health.
- Coordination of Care Letter Template — Medical.
The following behavioral health forms, brochures, and screening tools for substance use and attention-deficit/hyperactivity disorder (ADHD) are also available on our provider website:
- Alcohol Use Assessment
- Antidepressant medication management.
- Edinburgh Postnatal Depression Scale.
- Opioid Use Assessment brochure.
- Substance Brief Intervention/Referral Tool (SBIRT).
- Vanderbilt ADHD Diagnostic Parent Rating Scale.
Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Colorado, has updated our Provider and Facility Manual to become effective December 1, 2022.
As of today, the new manual is available online:
- Go to anthem.com and select Providers.
- Under the Provider Resources heading, select Policies, Guidelines, and Manuals.
- Select Colorado if you haven’t done so already.
To access the manual effective December 1, 2022:
- Under the Provider Manual heading, select Download the Manual under the banner.
- This version is effective beginning December 1, 2022, but available for review as of September 1, 2022.
To access the manual still effective until August 31, 2022:
Please note that the manual is available in a PDF version for ease of printing, but we encourage you to view online or only print individual sections to help conserve paper.
Changes were made to the following sections:
- Insurance requirements
- Credentialing
- Claims submission
- Medical records submission (solicited and unsolicited)
- Electronic data interchange (EDI)
- Claim payment disputes
- Clinical appeals
- Reimbursement requirements and policies
- Medical Policies and Clinical Utilization Management (UM) Guidelines
- Utilization management
- AIM Specialty Health®*
- Quality Improvement Program
- Member rights and responsibilities
- Overview of HEDIS®
- Centers of Medical Excellence
- Audit and review
- Fraud, waste, abuse, and detection
Thank you for your continued participation in our network.
Submitting your updates in a timely manner helps ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information we show in our online directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form webpage for complete instructions.
Online update options include:
- Add/change an address location.
- Name change.
- Tax ID changes.
- Provider leaving a group or a single location.
- Phone/fax number changes.
- Closing a practice location.
Note that some updates may require additional documentation.
The Consolidated Appropriations Act (CAA), effective since January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
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 > For Providers > Select Policies, Guidelines & Manuals under Provider Resources > scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.
Anthem Blue Cross and Blue Shield strives to ensure our providers understand documentation compliance, and we are committed to educating our providers in hopes of eliminating errors in documentation practices. It is a best practice and industry standard that physicians sign and date laboratory orders or requisitions.
Although the provider signature is not required on laboratory requisitions, if signed and dated, the requisition will serve as acceptable documentation of a physician order for the testing and so it is strongly encouraged. In the absence of a signed requisition, documentation of your intent to order each laboratory test must be included in the patient’s medical record and available to Anthem Blue Cross and Blue Shield upon request. Documentation must accurately describe the individual tests ordered; it is not sufficient to state “labs ordered.”
Anthem Blue Cross and Blue Shield will consider laboratory order or requisition requirements met with one of the following:
- A signed order or requisition listing the specific test(s)
- An unsigned order or requisition listing the specific test(s), and an authenticated medical record supporting the physician’s intent to order the test(s)
- An authenticated medical record (for example, office notes or progress notes) supporting the physician’s intent to order the specific test(s)
Attestation statements are not acceptable for unsigned physician order or requisitions. Signature stamps are not acceptable.
References:
In the October 2021, edition of the Provider News, Anthem Blue Cross and Blue Shield (Anthem) announced a new commercial policy titled Multiple Bilateral Surgery Processing – Facility effective for dates of service on or after January 1, 2022 . The policy indicated that Modifier 50 must be appended to facility claims when a bilateral procedure is performed. At this time, we have decided to remove this requirement for dates of service on or after January 1, 2022. Bilateral services should be billed as they were billed prior to January 1, 2022. The policy will be updated to remove the following:
- Modifier 50 must be appended to facility claims when a bilateral procedure is performed.
- When a surgical procedure code description contains the terminology bilateral or unilateral or bilateral or the code is considered inherently bilateral, modifiers LT, RT, or 50 should not be appended.
In addition, the policy title will be renamed to Multiple Surgery - Facility.
For specific policy details, visit the reimbursement policy page at anthem.com provider website.
Effective January 1, 2023, Anthem Blue Cross and Blue Shield’s (Anthem) Acupuncture Billed with Evaluation and Management – Professional policy will be retired. The policy aligns with standard correct coding requirements, as outlined in applicable CPT guidelines, which provide that Evaluation and Management services may be reported separately from acupuncture services by using modifier 25 when appropriate. Since the policy does not deviate from this guidance, the policy will be retired.
Anthem will enforce the requirements set forth in applicable CPT® guidelines. As always, Anthem reserves the right to request medical records when needed to validate appropriate billing.
For specific policy details, visit the reimbursement policy page at anthem.com provider website.
Visit the Drug Lists page on anthem.com for more information on:
- Copayment/coinsurance requirements and their applicable drug classes.
- Drug Lists and changes.
- Prior Authorization Criteria.
- Procedures for generic substitution.
- Therapeutic interchange.
- Step therapy or other management methods subject to prescribing decisions.
- Any other requirements, restrictions, or limitations that apply to using certain drugs.
The Commercial and Exchange Drug Lists are posted to the website quarterly on the first day of the month in January, April, July, and October.
To locate the Exchange Select Formulary and pharmacy information, scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.
Federal Employee Program (FEP) pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
Navigating the complexities and nuances associated with the COVID-19 pandemic requires frequent review of benefits and their impacts to our members’ social drivers of health. In recent evaluations, significant challenges have been identified by many agencies supporting our personal home helper benefit.
These nationwide impacts have led to many members unable to use the benefit to its fullest capacity. Therefore, effective January 1, 2023, the personal home helper benefit will no longer be offered within any of Anthem Blue Cross and Blue Shield’s (Anthem’s) Medicare individual plans. Members have been notified via their Annual Notice of Change. Improving the life of our members is Anthem’s focus and, while this change is difficult, Anthem will make best efforts to identify other resources for members or benefits to enhance their quality of life.
Please direct any member concerns or questions to the member services number on the back of their card.
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