 Provider News ColoradoFebruary 2023 Anthem Provider News - ColoradoThe Controlling High Blood Pressure (CBP) HEDIS ® measure can be challenging as it not only requires proof of a blood pressure (BP) reading, but also that the patient’s blood pressure is adequately controlled. CBP care gaps can open and close throughout the year depending on if the patient’s most recent BP reading is greater than 140/90 mmHG. As we start a new year, it’s important that we have record of your patients’ blood pressure readings and that you continue to monitor patients with elevated readings.
Tips when scheduling members to close CBP care gaps:
- When scheduling appointments, have staff ask patients to avoid caffeine and nicotine for at least an hour before their scheduled appointment time.
- If possible, update your scheduling app and/or your reminder text message campaigns to include reminders about abstaining from caffeine and nicotine prior to appointment time as well as a reminder to arrive early to avoid a sense of rushing.
Tips for lower BP readings during the appointment:
- Ask the patient if they tend to get nervous at appointments and have higher readings as a result. If they do, take their blood pressure at both the start and end of the appointment and document the lower reading.
- Readings can also vary arm to arm. If slightly elevated in one arm, try the other and document the lower reading.
Getting credit for adequately controlled blood pressure readings:
- Submit readings via Category II CPT® codes on claims.
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Description
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Code
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Diastolic BP
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CAT II: 3078F-3080F
LOINC: 8462-4
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Diastolic 80 to 89
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CAT II: 3079F
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Diastolic greater than/equal to 90
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CAT II: 3080F
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Diastolic less than 80
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CAT II: 3078F
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Systolic BP
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CAT II: 3074F, 3075F, 3077F
LOINC: 8480-6
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Systolic greater than/equal to 140
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CAT II: 3077F
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Systolic less than 140
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CAT II: 3074F, 3075F
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- Ensure readings are carefully and appropriately documented within your electronic medical record system.
- If you have questions on how to submit readings, speak to your care or practice consultant.
- Also, be sure to adequately code patients who meet the exclusion criteria:
- Exclusions:
- Palliative care
- Enrolled in hospice
- Frailty and/or advanced illness
- Living in long-term care
- Optional exclusions:
- Dialysis (ESRD), kidney transplant, nephrectomy
- Female members with a diagnosis of pregnancy
- Non-acute inpatient admissions
Our Working with Anthem webinars is 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).
2023 Subject specific webinars – February schedule
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Topic:
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Provider orientation for physical health and behavioral health providers
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Date/time:
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Tuesday, February 23, 2023, from noon to 1 p.m. MT (2 p.m. ET)
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Description:
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This webinar is designed to introduce a number of self-service tools and valuable information about Anthem to our providers/facilities and their office/billing staff for both physical health and behavioral health provider types.
Our agenda will include:
- Anthem overview, including contact information and resources
- Before rendering service – what to do
- Claims support
- Online tools and resources
Whether you are a new provider, have had a change in staff, or just need a refresher, join us for a general overview and onboarding. You will receive an Anthem 101 course to get you up to speed and up to date.
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Registration link:
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Register here
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Webinars are offered using 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.
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: Event recordings will require a password. Please register for the event, even if you are unable to attend, to ensure you will be notified of the event recording and password once it is available.
Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Colorado (Anthem), has launched Colorado Option Standard Plans and networks to support these new plans effective as of January 1, 2023.
We conducted provider webinar trainings on these new networks in 2022. If you missed one of these sessions, please access a recording via this link:
Anthem networks impacted
To be compliant with the Colorado Option laws, Anthem must offer the Colorado Option Standard plans on a network as broad or broader than used for its non-standard health plans in that area/market. To do so, we have created some new networks to support our Colorado Option Standard plans. As you can see, networks supporting the Colorado Option plans are called standard networks while networks supporting non-Colorado Option plans are called non-standard networks.
Five networks: Standard networks are used for the Colorado Option:
- Pathway Standard (New)
- Pathway PPO Standard (New)
- Pathway Essentials Standard (New)
- Pathway Essentials PPO Standard (New)
- Mountain Enhanced Standard (New)
Five networks: Non-standard networks are referred to as our original networks:
- Pathway
- Pathway PPO
- Pathway Essentials
- Pathway Essentials PPO (New (non-standard))
- Mountain Enhanced
Guidelines for participation:
- Providers participating in our Non-Standard (original) networks were invited to participate in our Standard (Colorado Option) networks.
- Per the law, Standard (Colorado Option) networks cannot be narrower than Non-Standard (original) networks. Therefore;
- Participation is required in both Non-Standard (original) and Standard (Colorado Option) networks.
- If a provider chooses not to participate in the New Standard (Colorado Option) networks, they may be removed from the Non-Standard (original) networks as well.
Identifying members tied to Standard Networks in a Colorado Option Plan:
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Approved network name
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Prefix
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Network type
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Medical product type
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LOB
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Product portfolio
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Pathway Standard
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P7F, P7G
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HMO
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HMO
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IND
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Standard
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Pathway PPO Standard
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F6W
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PPO
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EPO
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SG
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Standard
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Pathway Essentials Standard
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R8D, R8E
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HMO
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HMO
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IND
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Standard
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Pathway Essentials PPO Standard
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F6P
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PPO
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EPO
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SG
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Standard
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Mountain Enhanced Standard
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C8P, C9S, R8P
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HMO
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HMO
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IND/SG
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Standard
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As a couple of reminders about these new networks:
- Options for Enrollment for Affordable Care Act (ACA) plans:
- Colorado Connect is a wholly-owned subsidiary of C4HCO which offers Colorado Option plans through a program called OmniSalud.
- OmniSalud is a New program that provides undocumented Coloradans with a safe way to compare affordable health insurance plans and enroll on a secure online platform. For more information on OmniSalud visit: https://connectforhealthco.com/get-started/omnisalud/
- Individual members can enroll on exchange through Connect for Health Colorado (C4HCO) or off exchange:
- Small Group members (off exchange only) enroll through brokers or Anthem directly.
- For any plans utilizing the HMO Colorado Option Standard network, a member must select a primary care provider (PCP). That said, these HMO networks are open access, which means members do not need a referral from their PCP to see any of the providers within their specific Standard network:
- For example:
- A member in a plan utilizing the Pathway Essentials Standard network will select a PCP. The member can see any other provider within the Pathway Essentials Standard network (even another PCP) without a referral.
- The member must stay within their designated network and does not have out of network benefits.
- PCP selection:
- Since the Colorado Connect members come to us through the exchange, they don’t have the option to select a PCP at enrollment.
- Anthem auto-picks a PCP for the member based on geography, and the member can change at any time on the member’s anthem.com website.
The Consolidated Appropriations Act, implemented in 2021, contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current. We ask that you to review your online provider directory information on a regular basis to ensure it is correct. To access your information, go here. Then, under Provider Overview, select Find Care. Submit updates and corrections to your directory information by using our online Provider Maintenance Form. 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.
Once you submit the form, we will send you an email acknowledging receipt of your request. MULTI-BCBS-CM-016525-22-CPN16491 In March 2023, AIM Specialty Health ®* will transition to Carelon Medical Benefits Management Inc. This transition is a name change only, and there will be no process changes. The new name will not impact the way AIM works with health plans and providers. In March, any operational assets that mention AIM Specialty Health (such as determination letters) will adopt the new Carelon Medical Benefits Management Inc. name.
Provider brand transition FAQ
| Provider experience focus area |
| 1. Will the AIM ProviderPortalSM URL or platform name be changed? |
1. No, the website address will not be impacted; all providers will continue to have access to www.providerportal.com. The AIM logo will be replaced with a Carelon logo. No changes are being made to the case submission process.
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2. Will there be any changes to the AIM Clinical Guidelines URL or content?
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2. Yes, the clinical guidelines site will be automatically redirected to a new Carelon URL, and the branding will be updated to reflect Carelon.
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3. Are any phone number changes planned as part of this transition?
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3. No, inbound phone numbers are not being changed. References to AIM within recorded scripting will be replaced with Carelon Medical Benefits Management Inc.
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4. Will there be any changes for providers who connect with AIM via other means such as Availity Essentials*?
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4. No, access changes are not needed or planned; however, all references to the AIM company name will eventually be updated to Carelon Medical Benefits Management Inc.
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5. Will AIM references on health plan websites and member materials such as ID cards be changed?
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5. Not right away. Providers may continue to see the AIM company name on health plan websites and member ID cards for some time, but it’s expected that these will be changed through scheduled content update cycles.
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| Corporate website |
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1. Will the AIM corporate website URL be changed?
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1. The corporate website will be moved to www.carelon.com. All links to the ProviderPortal and clinical guideline pages will remain active and will be redirected.
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| Provider microsites |
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1. Will the AIM provider microsite URLs change?
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1. The provider microsite URLs you use today to access information from AIM will be automatically redirected to new Carelon URLs, and the branding will be updated to reflect Carelon branding.
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The best way to send supporting documents when disputing, appealing, or sending us additional information about a claim is to use the digital applications available on Availity.com.* Using Availity.com to send attachments, such as medical records or an itemized bill, is: - We’ll receive the documents needed faster than through the mail.
- Less expensive. No need to pull records, copy them, and then mail them. Digital submissions can be uploaded directly to the claim.
- Submitting attachments digitally is the easiest way to send them and the best way for us to receive them.
- More accurate. The information needed to identify the claim is automated, so the risk associated with submitting incorrect information on paper is eliminated.
However, if you choose to send documentation through the mail, it is important that you include at least one of the three following elements; otherwise, we will not be able to match the document to the claim and the correspondence will be returned to you, causing further delays: - Valid claim number
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- Valid member ID with prefix and correct dates of service
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- Valid member ID with prefix and billed charges
For a clinical appeal, ensure these elements are included: - Valid claim number
or
- Valid member ID with prefix and correct dates of service
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- Valid member ID with prefix) and billed charges
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- Member name, member date of birth, and correct dates of service
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- Member name, member date of birth, authorization, or reference number
This is important: We cannot match the attachment to the correct claim or member if these elements are not included with your non-digital (fax or mail) submission. The preferred method for submitting supporting documentation is digitally because the documents are attached directly to the claim. This reduces the possibility that incorrect information is included on the paper submission. To attach documents to your claim digitally, go to Availity.com and use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim and use the Submit Attachments button to upload your supporting documentation. For a claim dispute or an appeal, from Availity.com, use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim, use the Dispute button, and upload your supporting documentation. If the Dispute button capability is not available, refer to the provider manual for information about how to file a claim dispute/appeal. If you do send supporting documentation through the mail or fax, you must include the elements noted above. It is preferrable that you include this information on the first page of the correspondence you send to us. If this information is not included on your paper correspondence, we will return the correspondence to you because we are not able to validate the documentation. For information about submitting attachments digitally, use this link to access Availity: Learn about the new claim attachments workflow. * Availity, LLC is an independent company providing administrative support services on behalf of health plan. MULTI-BCBS-CM-016609-22-CPN16477 This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem) in Colorado.
We are committed to improving the way we do business with our provider community. Listening to your feedback, we are pleased to announce a new look and feel is coming to Provider News in the first half of 2023, with additional improvements planned throughout the rest of the year.
Stay tuned for more updates.
To view the 2023 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), go to www.fepblue.org > select Tools & Resources > Brochure & Resources. Here, you will find the Service Benefit plan brochure, benefit plan summaries, and Quick Reference Guides on information for year 2023. If you have questions, please contact FEP Customer Service at: CO – 800-852-5957 CT – 800-438-5356 GA – 800-282-2473 IN – 800-382-5520 KY – 800-456-3967 ME – 800-722-0203 MO – 800-392-8043 NV – 800-727-4060 NH – 800-852-3316 NY – 800-522-5566 OH – 800-451-7602 VA – 800-552-6989 WI – 800-242-9635
Material adverse change
Effective for dates of service on and after April 1, 2023, the following code updates will apply to the AIM Specialty Health®* Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. Percutaneous coronary intervention: CPT® code | Description | C9600 | Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch | C9601 | Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) | C9602 | Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch | C9603 | Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure) | C9604 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel | C9605 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) | C9607 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel | C9608 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure) |
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways: - Access AIM’s ProviderPortalSM directly at providerportal.com
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Essentials at availity.com
If you have questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. * AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. MULTI-BCBS-CR-013612-22-CPN12754 Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.
Updates by guideline
- Imaging of the Brain:
- Meningioma — Added more frequent surveillance for WHO grade II/III
- Bell’s palsy — Limited the use of CT to scenarios where MRI cannot be performed
- Seizure disorder — Added indication for advanced imaging in pediatric patients with nondiagnostic electroencephalogram (EEG)
- Imaging of the Head and Neck:
- Perioperative imaging — Added indication for imaging prior to facial feminization surgery
- Imaging of the Chest:
- Perioperative imaging — Added indication for imaging prior to lung volume reduction procedures
- Imaging abnormalities — Added indication for evaluation of suspected tracheal or bronchial pathology
- Imaging of the Abdomen/Pelvis:
- Uterine leiomyomata — Added indication for advanced imaging when ultrasound suggests leiomyosarcoma
- Pancreatic indications — Added indication for pancreatic duct dilatation
- Pancreatic mass — Added allowance for more frequent follow up of lesions with suspicious features or in high-risk patients
- Pancreatitis — Removed allowance for MRI following nondiagnostic CT
- Pelvic floor disorders — Added indication for MRI pelvis in chronic constipation when preliminary testing is nondiagnostic
- Abdominal/pelvic pain, undifferentiated — Removed indication for MRI following nondiagnostic CT
- Oncologic Imaging:
- National Comprehensive Cancer Network annual alignments for breast cancer screening and the following: Cervical, Head and Neck, Histiocytic Neoplasms, Lymphoma (Non-Hodgkin and Leukemia), Multiple Myeloma, Thoracic, and Thyroid cancers
- Prostate Cancer:
- Updated respective conventional imaging prerequisites for 18F Fluciclovine/11C PET/CT and 68Ga PSMA/18F-DCFPyL PET/CT, based on utility of conventional imaging at various PSA thresholds (and removal of low-risk disease waiver from conventional imaging footnote).
- Addition of 68Ga PSMA or 18F-DCFPyL PET/CT indication aligned with FDA-approved use of Pluvicto (radioligand) treatment for metastatic castrate-resistant disease
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of the following ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com:
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access AIM via Availity* Essentials at availity.com.
For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines at http://www.aimspecialtyhealth.com/ClinicalGuidelines.html.
Note: AIM will join the Carelon* family of companies and change its name to Carelon Medical Benefits Management, Inc. on March 1, 2023.
In June 2022, myNEXUS* announced that it joined the Carelon family of companies. Carelon* is a new healthcare services brand dedicated to solving the industry's most complex challenges. As part of this shift, myNEXUS will begin operating under a new name, Carelon Post Acute Solutions, on March 1, 2023. In March, any documents that mention myNEXUS, such as provider forms or the myNEXUSwebsite (https://www.mynexuscare.com), will begin adopting the new Carelon Post Acute Solutions name. This is a name change only and does not impact the services myNEXUS offers or the way myNEXUS works with providers. Learn more about Carelon and myNEXUS by visiting:
https://www.carelon.com/about-us/businesses/mynexus * myNEXUS/Carelon is an independent company providing post acute care services on behalf of the health plan. MULTI-BCBS-CR-016950-22-CPN16447 |