We would like to educate you on a new network to support new product offerings available starting this year.  Our network called “Pathway”, previously a subset of our standard HMO network only, is now going to be available as a PPO network option for certain PPO/EPO plan offerings effective January 1, 2020. 

 

The Pathway PPO network will be the same as our Pathway HMO network, but will now be available for PPO plan offering options.  Those providers already participating in our Pathway HMO Network, have been invited to participate in our Pathway PPO Network unless they have chosen to opt out.

 

The reimbursement rates for the Pathway PPO network will be the same as your Pathway HMO reimbursement rates. 

 

Please note:  Since the Anthem Rates are the same for both Pathway HMO and Pathway PPO, participation for the Pathway PPO network is required to remain in the Pathway HMO network.  We are not able to accommodate participation in Pathway HMO only.

 

Important distinction for Pathway PPO plan options:

 

• Members will have access to the Pathway network when rendering services inside Colorado.
  • No out-of-network benefits inside Colorado unless Emergency.
    
    
• Members will have access to the PPO network ONLY when rendering services outside of Colorado.

 

Identifying Members accessing the Pathway Network:

 

Network Name (On Member ID cards)	Product Type	Health Benefits Plan Option	Three-Character Prefix
Pathway X	HMO	Individual (Exchange)	VAB
Pathway X	HMO	Small Group (Exchange)	VAC
Pathway	HMO	Individual (Off Exchange)	VAA
Pathway	HMO	Small Group (Off Exchange)	XFX
Pathway	HMO	National Accounts	QWP
Pathway Network	HMO	Large Group	VAE
Pathway PPO	PPO	Small Group	PWL, CQQ
Pathway PPO	PPO	Large Group	WUS

 

Note:  While the “Pathway” network name may be slightly different depending on the Health Benefit Plan option, the network utilized for these on and off Exchange plans is the same.

 

Pathway PPO sample Member ID card

 

Small Group sample

 

 Large Group sample

 

 

Provider Webinar opportunities discussing Pathway PPO Network

 

We will be conducting a “Working with Anthem” webinar regarding a Pathway PPO Overview on January 29, 2020 at 12pm MT.  Please join us to learn about our new Pathway PPO network and the new products available to access this network starting January 1, 2020. Requirements for attending an online webinar include: access to a computer with internet access, phone, and email address.

 

Webinar Registration link:  go to anthem.com, and select Provider.  Under the Communications heading, select Education an Training.  (Select Colorado, if you have not done so already). Under the Seminars and Webinars heading, select the plus sign next to Working with Anthem webinars, then Register for a Working with Anthem Webinar. 

 

Thank you for the care you provide to our members.

CMS average sales price (ASP) first quarter fee schedule with an effective date of January 1, 2020 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on February 1, 2020. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.

Now is the time to ask all of your patients to present their current ID card.  Many members were assigned new identification numbers effective January 1, 2020 and new ID cards were provided digitally or mailed to all affected members in late December 2019. To ensure claims are processed appropriately, here is some helpful information.

 

Tips for Success: When Anthem members arrive at your office or facility, ask to see their current member identification card at each visit. Many of our members no longer receive a paper card so they will present you with their digital card on their mobile device.  Requesting a copy of the most current ID card will help you:

 

• Identify the member’s product
• Obtain health plan contact information
• Speed claims processing

 

Note:  Claims submitted with an incorrect ID number may be unable to be processed and may be returned for correction and resubmission with the correct ID.  

 

Tips for Success: When you contact a member about a claim returned for an invalid ID, and they do not recall receiving a new ID card or they misplaced their ID card, please ask the member to confirm their member ID using one of the following options:

 

• Log in to their member account on anthem.com
• Use Anthem mobile app called Sydney (formerly Anthem Anywhere) to access their electronic ID card
• Members can fax or email their most current card from anthem.com, or the Sydney mobile app, to your office if needed.
• Call their Anthem member services number

 

Following the tips above will result in a successful start to your New Year. 

The New Year always gives us an opportunity to set new goals. Starting in 2020, we want to help you check off a few “to do” items. As the Availity migration continues full speed ahead, let’s get you started on your first goals of the year:

 

Don’t delay and transition to Availity today!

 

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

 

• 837- Institutional and Professional
• 837- Dental
• 835- Electronic Remittance Advice
• 276/277- Claim Status
• 270/271- Eligibility Request
• 275 – Medical Attachments

 

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

 

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

 

Availity setup is simple and at no cost for you!

 

Use this “Welcome” link below to get started today:

 

Learn Something New!

 

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

 

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

 

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

 

If you and your clearinghouse have already migrated, you are a step ahead! If not, take action today to make the transition.

 

For questions contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday – Friday, 8:00 am – 7:00 pm ET.

The Medical Attachment tool makes the process of submitting electronic documentation in support of a claim, simple and streamlined. We are now in the final stages of migration from the Medical Attachments link to the Attachments-New option.

 

What is happening to the current attachment tool?

 

• The legacy tool will be retired soon* with access via Attachments-New option available now.
• The history of the information you have previously submitted is still available on the legacy tool for now*.
• Read only access to the history is in the final stages*

 

*Look for messaging on the legacy attachment tool for specific dates

 

How to assign access to utilize submitting solicited Medical Attachments for your office

 

Availity Administrator, complete these steps:

 

From My Account Dashboard, select Enrollments Center > Medical Attachments Setup, and complete the following sections:

 

1. Select Application > choose Medical Attachments Registration
2. Provider Management > select Organization from the drop-down.
   • Add NPIs and/or Tax IDs
3. Assign user access by checking the box in front of the user’s name

 

Using the Medical Attachments tool

 

Availity User, complete these steps:

 

1. Log in to availity.com
2. Select Claims and Payments > Attachments-New > Send Attachment Tab
3. Complete all required fields of the form
4. Attach supporting documentation
5. Submit

           

Need Training?

 

To access additional training for this Availity feature: Log into Availity.  Select Help & Training > Get Trained to open the Availity Learning Center (ALC) Catalog in a new browser tab. Search the Catalog by keyword (attachments) to find training demo and on-demand courses. Select Enroll to enroll for a course and then go to your Dashboard to access it any time.

Musculoskeletal care and interventional pain management (MSK) pose substantial challenges for employers as costs rise, the population ages and physician practice patterns vary widely. With disorders affecting one in every two American adults1, the need for evidence-based care and proactive consumer engagement is essential to better managing care and cost.

 

With that in mind, we are pleased to announce that select National Accounts will utilize the comprehensive Musculoskeletal and Pain Management Solution, administered by AIM Specialty Health. The new MSK program reviews certain spine and joint surgeries, and interventional pain services against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine.

 

Transition Period

 

To ensure continuity of care, we will have a 90 day transition of care for members in active treatment for pain management or for members that have received prior approval through the Anthem precertification.  Providers do not need to obtain authorization through AIM portal for services already in progress or where prior authorization has been obtained with Anthem. 

 

Please contact anthem.com or call the number on the back of the member ID card for member eligibility.

 

¹ American Academy of Orthopedic Surgeons

We are launching the use of Availity’s medical attachment functionality to begin requesting medical records and itemized bill information from providers electronically instead of paper requests. This change applies only to the process of requesting and receiving medical records; it is not a change to the audit program. We began transitioning providers to this new process in an active limited launch in October 2019. We will complete the transition by February 10, 2020.

 

Important facts regarding this change:

 

• This change only affects providers who use Availity and who have opted into using the medical attachment functionality through the permissions in Availity’s enrollment center.
  
  
• The new functionality is for medical record requests for post pay claims for the Payment Integrity Quality Claims Review (provider audit) department only.
  
  
• There will be no duplicate requests (both paper and electronic).
  
  
• In Availity, the request will come into the provider’s Medical Attachment “inbox”
  • The original letter historically sent via paper is accessible through a hyperlink in the Availity system as a pdf electronic copy. The letter content is the same as it was in paper format.
  • Each electronic request letter will have a timeframe for responding to the request. After the timeframe has passed for that letter, you will not be able to respond to that electronic letter. If you wish to upload medical records after the response time has expired, please refer to the Availity training referenced below.
  • Providers can respond to the request by uploading records in Availity. The attachments are received in almost real time and are delivered electronically to the payer’s systems through secure means - - nothing is stored in Availity.
    
    
• The following are not included or not impacted:
  • Vendor requests for medical records on behalf of the payer.
  • Providers that do not use Availity or have not turned on permissions for Medical Attachments within Availity.
  • The request timing or verbiage in the request letter.
  • At this time, the Program Integrity Special Investigations Unit (SIU) post pay review, but they will be included at a future date.

 

Resources

 

Training is available for this Availity tool by selecting this link:  Availity Training on Electronic Medical Records for Program Integrity.

 

Can I start using the functionality earlier?

 

Yes.  If you chose to opt in earlier, please ensure you are configured within Availity.  You may request early access via this email address: dl-Prod-Availity-Provider-Support@anthem.com.

 

For additional information, see our Frequently Asked Questions.

We are continuing our series of “Working with Anthem” webinars for 2020.  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).

2020 Subject Specific Webinars -- January schedule

 

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.

Category: Medicare

 

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

 

• Colorado 2020 Medicare Advantage plan changes
• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ
• City of Marietta Offers Medicare Advantage Option
• Prior authorization requirements for E0784, K0553 and K0554
• Pharmacy benefit manager change to IngenioRx
• Medical Policies and Clinical Utilization Management Guidelines update

Category: Medicare

 

On September 19, 2019, the Pharmacy and Therapeutics (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 is publicly available on the provider website, and the effective dates will be reflected in the Medicare Advantage Clinical Criteria Web Posting September 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

ABSCRNU-0097-19 November 2019          505908MUPENMUB

 

Category: Medicare

 

On August 16, 2019, the Pharmacy and Therapeutics (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 is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

ABSCRNU-0085-19 October 2019          505536MUPENMUB

 

Category: Medicare

 

Anthem Blue Cross and Blue Shield communicated to you on June 1, 2019, that we were initiating post-payment reviews for professional emergency room (ER) claims billed with level 5 ER evaluation and management (E/M) codes 99285 and G0384.

 

The implementation of this policy has been postponed.

 

This update relates only to the policy announced June 1, 2019. All other current policies applicable to you, including but not limited to other audit or reimbursement policies pertaining to ER claims, are unaffected by this update. We will keep you informed about the initiation of the review process; however, we require proper coding and billing to ensure prompt and accurate payment.

 

ABSCARE-0107-19 November 2019      506163MUPENMUB

Category: Medicare

 

Overview

 

Many of our members have reported that they received unsolicited calls (or emails) from an individual or company offering to provide durable equipment devices, such as back or leg braces, or items such as topical creams at little or no cost. While it may be tempting to want to receive something for free, members should know that there is a cost. 

 

Although our members may not receive a bill for these devices or medications, the items are billed to the insurance companies, costing hundreds or even thousands of dollars each.

 

How does this impact members?

 

Members should also know that the cost may be more than monetary. Allergic reactions may occur when using medications that are not properly prescribed. Ill-fitting leg or back braces, or equipment that is not specifically intended for the pain experienced by the member, could do more harm than good.

 

This problem is prevalent throughout the country, so all of our members should be aware. Billions of unsolicited telemarketing calls are made each year, many of which are promoting health care services. Calls often spoof local phone numbers or numbers that appear familiar to trick the recipient into accepting the call. 

 

How can I help protect my patients?

 

While the ultimate purpose of these telemarketing calls is to sell these items, the immediate goal of the person or company placing the call is to obtain valuable personally identifiable information (PII) from the member. Without this personal information, such as a social security number or insurance identification number, selling these devices and medications is much more difficult. Share this information with you patients to help them learn how to protect their PII.

 

You can help protect your patients and their personally identifiable information from scams by reminding them of the following:

 

• Don’t fall prey to scams!
• Take a few moments to review your Explanation of Benefits (EOB) and the services listed.
• When receiving robotic (robo) or telemarketing calls:
  • Simply hang up the phone.
  • Beware of threatening or urgent language used by the caller.
  • Do not provide any personally identifiable information such as your social security number or insurance identification number. The caller may imply that they have your information and ask you to provide it to confirm that they have the correct information. Do not provide the information or confirm it if they do happen to have any identification information.
• When receiving emails:
  • Do not open email attachments you weren’t expecting.
  • Check for spelling mistakes and poor grammar.
  • Do not click on the links you are sent. You can type the link into a new browser.
  • Online scams can come from anywhere. Take a few moments to review your EOB and confirm that you received the services listed on the EOB.
• Additional ways to protect yourself:
  • Shred or destroy obsolete documents that contain medical claims information or EOBs.
  • Do not use social media to share medical treatment information.

 

How to report when you receive what you suspect is a scam call or email:

 

1. To file a complaint with the Federal Trade Commission, you can go to: https://ftc.gov/complaint or call 1-877-FTC-HELP.

2. Members may contact their plan’s Member Services department.

 

 

ABSCRNU-0086-19 November 2019          505755MUPENMUB

Category: Medicare

 

Claims will deny when a provider submits a Medicare claim to Anthem Blue Cross and Blue Shield (Anthem) as a secondary payer if the claim has been received prior to the 30-day Medicare remittance period. Providers submitting a paper claim for Medicare claims that are filed with Medicare as the first payer must not file with Anthem as the secondary payer until the 30-day remittance period has expired.

 

These claims rejections are a result of improper timely filing by providers. To eliminate claims rejections when Anthem is the secondary payer, submit the claim 30 days after the Medicare Remittance period.

 

For additional information, call the number on the back of the member’s ID card.

 

ABSCRNU-0094-19 November 2019          505847MUPENMUB

Category: Medicare

 

Anthem Blue Cross and Blue Shield (Anthem) will offer an Institutional Special Needs Plan (I‑SNP), Anthem MediBlue Care On Site (HMO I-SNP), focused on beneficiaries who are living in skilled nursing facilities or qualified beneficiaries living in assisted living centers. Anthem will collaborate with CareMore Health mobile clinicians in the community to deliver a high‑touch, well-coordinated, holistic model of care to institutionalized patients at the member’s bedside. Working alongside primary care physicians to ensure the best possible outcomes for the member, the goal is to improve access to care and better communication with the patient, family, staff and providers. In addition to our contracted mobile providers, the plan includes our Anthem contracted Medicare Advantage HMO fee-for-service providers.

 

In addition to our I-SNP plan, Anthem and CareMore will partner with our Anthem providers to offer a Chronic Special Needs Plan (C-SNP), Anthem MediBlue Diabetes (HMO C-SNP). This plan will focus on providing the best in care to Medicare Advantage beneficiaries with diabetes. Our C-SNP plan is designed to address the greater incidence of chronic disease and disability in the Medicare and Medicaid dual-eligible and Medicare-only populations and enhance the coordination of a member’s primary and acute care, long-term care, and prescription drug benefits through a unified case management program. Members will be eligible for a Healthy Start appointment where a health risk assessment (HRA) will be completed. After the HRA, CareMore clinicians will collaborate with the Anthem member’s PCP to design an individualized care plan.

 

With these new products, the prior authorization requirements will be different from our other Medicare Advantage products. Please ensure when reviewing prior authorization requirements to select Medicare I-SNP C-SNP from the drop-down box on the provider website. Anthem is excited to introduce these products to our Medicare Advantage portfolio. To learn more about our Anthem plans and how we are helping our members receive quality health care, visit https://www.anthem.com or call the number on the back of the member’s ID card. If you wish to become a participating Medicare Advantage HMO provider for these plans, please contact your Provider Contracting representative.

 

ABSCRNU-0101-19          506285MUPENMUB