 Provider News ColoradoJanuary 2021 Anthem Provider News and Important Updates -- ColoradoCMS average sales price (ASP) first quarter fee schedule with an effective date of January 1, 2021 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on February 1, 2021. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.
Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a standardized survey conducted between February and May each year to assess consumers’ experience with their provider and health plan. A random sample of your adult and child patients may receive the survey. Over half of the questions used for scoring are directly impacted by providers. The survey questions are:
- When you needed care right way, how often did you get it?
- How often did you get an appointment for a check-up or routine care as soon as you needed?
- How often was it easy to get the care, tests, or treatment you needed?
- How often did you get an appointment to see a specialist as soon as you needed?
- How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
- How would you rate your personal doctor?
- How would you rate the specialist you see most often?
To learn more about how you can improve the patient experience review What Matters Most: Improving the Patient Experience, an online course for providers and office staff. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. The What Matters Most training can be accessed at: www.patientexptraining.com.
Your efforts to create an exceptional care experience for your patients will help to strengthen their healthcare journey.
Anthem recognizes all coding changes from both the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) effective the date provided by the coding source. This includes the Evaluation and Management (E/M) changes effective January 1, 2021.
The following updates pertaining to Evaluation and Management services have been identified:
- CPT code 99201 (new patient E/M) will be a deleted code.
- CPT codes 99202 through 99215 (new/established E/M) definitions have changed. Selection of these E/M codes can now be based on either Medical Decision Making or Time.
- CPT code 99417 (prolonged services) and HCPCS Code G2212 (prolonged services) will be recognized as billable codes. These codes will be payable based on our existing Prolonged Services policy, which will be updated to reflect the new code along with the modifications to existing prolonged service codes CPT codes 99354 and 99355.
- HCPCS Code G2211 (complexity inherent to evaluation and management associated with primary medical care) will not be separately reimbursed for this service. We will be updating our Bundled Services and Supplies policy to reflect this position.
Additionally, we are in the process of updating reimbursement policies impacted by the E/M service changes such as the Documentation and Reporting Guidelines for Evaluation and Management Services.
When you understand your patients’ health coverage and local health plan networks, you can help maximize your patients’ benefits and boost your own success. Here are some details you should know about new Blue HPN products and the high performance network in Colorado: New health plans built around Anthem’s Blue High Performance Network are live, effective January 1, 2021.
Blue HPN® provides value to our Members and clients. Anthem Blue Cross Blue Shield is launching Blue HPN to keep pace with the rapidly evolving nature of healthcare and to answer the call from our national employer groups to improve health outcomes and affordability of care for their organizations and employees.
Blue HPN is a national network designed from our local market expertise, deep data and strong provider relationships, and aligned with local networks across the country. These local networks are then connected to the national chassis to form a national Blue HPN network. In Colorado, the Blue HPN network includes the same set of providers as the Pathway PPO/EPO Network that was already in place.
You may see patients accessing this network through either a small group, large group, or national account plans with an Exclusive Provider Organization (EPO) plan design. Under EPO plans, out of network benefits are limited to emergency or urgent care. Members must select a primary care provider, but PCP referrals are not required for specialty care.
Blue HPN health plans sold in Colorado will have a plan prefix of C5X, H8C, or H6D, but keep in mind that other prefixes may be part of HPN plan member IDs. Below is a sample ID card for a member from Colorado enrolled in the national employer Blue HPN plan. Note the new “HPN” indicator in the suitcase icon.
Please see our Blue High Performance Network Quick Reference Guide for additional details.
Anthem hosted a “Working with Anthem” webinar focused on Blue HPN in November. If you missed the webinar you may access a webinar recording. Select the Registration link below, and the access the “Event Recordings”. The recordings are password protected and case sensitive. The password for this webinar is “WwA112020”. Register for a Working with Anthem Webinar.
Introducing self-service claim denial review on our secure provider portal.
Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:
- File claims
- Check statuses
- Verify eligibility and benefits
- Submit prior authorizations
The Provider Digital Engagement Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits - all in one comprehensive resource. Find it on Anthem.com > Providers > Forms & Guides > Under the Category heading, select Digital Tools > Provider Digital Engagement Supplement.
Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit Anthem.com and use the Log In button for access to our secure provider portal, or via the Availity EDI website.
Accept digital member ID cards
- Save time by accepting the digital member ID card when presented by the member via their App or email.
Register for EFT to get funds faster
- Electronic Funds Transfer (EFT) eliminate the need for paper checks. Safe, secure and faster, payments are deposited directly to your bank account. Register here.
Eliminate paper remittances
- Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.
We appreciate your health care team going digital with Anthem as of January 1, 2021, enabling us to realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.
Introducing self-service claim denial review on our secure provider portal.
Anthem Blue Cross and Blue Shield (Anthem) wants to make your job easier -- and that includes real-time feedback to claim denials. Through predictive analytics, we now have insight into the reasons for claim denial. We have taken that information and streamlined the inquiries by reason codes. It is available to you digitally, through our secure provider portal.
Now, within minutes, you will know why a claim denied. We will also provide the steps needed so you can take action faster to correct the claim. There is less wait time and faster payment.
There is no need to call for updates or experience unnecessary delays waiting for the explanation of benefit.
With little more than a click:
- Review a complete list of claims, including claims with proactive insights
- Learn the reasons for claim denial
- Access the information you need to move the claim forward
Predictive analytics and self-service claim denial information is just another way Anthem is using digital technology to improve your healthcare experience.
From Anthem.com, use the Log In button to access our secure provider portal Availity.com. Go to Payer Spaces, to access Claims Status Listing.
You no longer need to pick up the phone or head to the fax machine to check the status of an authorization request or update a case. Anthem Blue Cross and Blue Shield (Anthem) has added new features to Interactive Care Reviewer (ICR), our online medical and behavioral health authorization tool to improve your digital self-service experience.
- Do you need to update a case that was submitted by phone or fax? Now you can add clinical notes and make other updates to these authorization requests through ICR. To make the update you need to have the Authorization & Referral Request role assigned to you by your Availity Administrator.
- To locate the case, log on to the Availity Portal and select Patient Registration | Authorizations & Referrals, then choose Auth/Referral Inquiry.
- Search for the case in ICR by Member, Reference/Authorization Request Number, or by Date Range.
- From the ICR Case Overview screen select Update Case to update service codes, provider information or clinical notes. If you only need to make changes or add to your notes, select Update Clinical. Select Submit Update to complete the request.
- We’ve removed the guesswork from the notes that are recommended for many standard authorization requests. ICR provides a check list of the supporting clinical information that will assist Anthem with completing the review. The list is located on the Clinical Details You can upload notes, images and photos directly through ICR. You can include the documentation immediately or you can submit your request then return to the case in ICR later and select Update Clinical to add the missing information.
- Check the status of a submitted case at a glance. The ICR UM tracker, located on the Case Overview screen provides a quick view of where the case is in the review process. You can view when Anthem received the request, when the clinical review is underway and completed and the final decision.
Additionally, we’ve added a new application to Payer Spaces – Chat with Payer that you can use to check the status of a submitted authorization request. This is a great option if you don’t have the role assignments required to access ICR and research a case.
- To access the Chat with Payer application from Availity’s home page, select Payer Spaces | Chat with Payer. Complete the form with the required information. You need to include the patient name, birth date and health plan member ID number. Choose Authorization Status as your topic for chat to conduct a live chat with a representative.
You’re invited!
In this 60-minute webinar, you will learn how to use Availity's* Attachment tools to submit and track supporting documentation electronically to Anthem and affiliate payers.
We will explore new key workflow options to fit your organization’s needs, including how to:
- Work a request in the inbox of your Attachments Dashboard.
- Enter and submit a web claim including supporting documentation.
- Use EDI batch options to trigger a request in your inbox.
- Track attachments you submitted using sent and history lists in your Attachments Dashboard.
- Get set up to use these tools.
As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.
Register for an upcoming webinar session:
- In the Availity Portal, select Help & Training > Get Trained.
- The Availity Learning Center opens in a new browser tab.
- Search for and enroll in a session using one of these options:
- In the Catalog, search by webinar title or keyword.
- To find this specific live session quickly, use keyword medattach.
- Select the Sessions tab to scroll the live session calendar.
- After you enroll, you’ll receive emails with instructions to join the session.
Webinar Dates and Times (MT):
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DATE
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DAY
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TIME (MT)
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January 8, 2021
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Friday
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11:00 A.M. to 12:00 P.M.
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January 19, 2021
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Tuesday
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1:00 P.M. to 2:00 P.M.
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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).
2021 Subject Specific Webinars -- January schedule
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Topic:
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What’s new in 2021
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Date/Time:
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Tuesday, January 26, 2021 at 12pm MT
***Correction on Date***
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Description:
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This webinar will focus on new things in 2021:
- Pathway Essentials
- Blue High Performing Network (HPN)
- Products offered in 2021/Accessing Insurance Plans accepted
- Provider Digital Engagement Supplement
- Provider Chat
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Registration link:
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https://anthem.webex.com/anthem/onstage/g.php?PRID=b6a696587e498199466cadc7231c908d
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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”.
Note: Even if you are unavailable to attend, please register to ensure you receive the event recording password once available as it’s distributed to all that register.
As a reminder , we will update our claim editing software monthly for outpatient facility services throughout 2021 with the majority of maintenance updates occurring quarterly in 2021. These updates will:
- reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers, Revenue Codes) and their associated edits
- include appropriate use of various code combinations, which can include, but are not limited to, procedure code to revenue code, HCPCS to revenue code, type of bill to procedure code, type of bill to HCPCS code, procedure code to modifier, and HCPCS to modifier
- include updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
- include updates to reflect coding requirements as designated by industry standard sources such as The National Uniform Billing Committee (NUBC)
As a reminder, we will update our claim editing software monthly for professional services throughout 2021 with the majority of maintenance updates occurring quarterly in February, May, August and November of 2021. These updates will:
- reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
- include updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
- include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
- include assistant surgeon eligibility in accordance with the policy
- include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
- apply to any provider, provider group (tax identification number) and/or across providers and claim type (professional/facility) for the same member.
To view the 2021 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>Plan Brochures. Here you will find the Service Benefit Plan Brochure and Benefit Plan Summary information for year 2021. For questions please contact FEP Customer Service at: 800-852-5957.
Starting January 1, 2021, IngenioRx, the pharmacy benefit manager for our affiliated health plans, will make its new standard pharmacy network available to your patients. The standard network will be made up of about 58,000 pharmacies nationwide, including well-known national chains like Costco, CVS, Kroger, Sam’s Club, Target and Walmart.
With robust access, your patients can use any participating pharmacy across the country in the standard network to fill their prescriptions.
Network Notification Plan
Some of your patients covered by an Anthem health plan may currently use pharmacies that are not in this new network. They’ll need to transfer their active prescription(s) to a network pharmacy to ensure there is no interruption of their coverage.
Prior to the network effective date, we’ll notify your patients by letter outlining the easy steps about transferring their prescriptions to another pharmacy in the network.
In addition, to help you easily send prescriptions to a participating pharmacy, upon the member’s effective date, we’ll include messaging via your patients’ electronic medical record. This message will appear if you attempt to submit a prescription to a pharmacy that’s not included in the standard network. This will ensure your patients’ prescriptions are properly routed to a network pharmacy and will help them continue to receive their medications worry-free.
If your patients would like to search for a network pharmacy prior to the new network effective date, they can log in to anthem.com, where instructions will appear with a helpful link to our online pharmacy search tool. They can enter their address/city/state or their zip code to begin searching.
Questions?
Please refer to our helpful Frequently Asked Questions for more details about the new standard network.
The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.
Medicare risk adjustment and documentation guidance (General):
- Series: Offered the first Wednesday of each month from 1:00 to 2:00 P.M. (ET)*
- Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model, with guidance on medical record documentation and coding.
- Credits: This live activity, Medicare risk adjustment and documentation guidance, from
January 8, 2020 to December 2, 2020, has been reviewed and is acceptable for up to 1.00 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
To learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:
https://bit.ly/2TYMgbn
* Note: Dates may be modified due to holiday scheduling
Medicare risk adjustment, documentation and coding guidance (Condition specific)
- Series: Offered the third Wednesday of each month from 1:00 to 2:00 P.M. (ET)
- Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
- Credits: This live series activity, Medicare risk adjustment documentation and coding guidance, from January 15, 2020 to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity
For those interested in the following training topics, please register at the link below.
https://bit.ly/2IgxDO9
* Note: Enter the password provided, and the recording will play upon registration.
- Red flag HCCs
- Neoplasms
- Acute, chronic and status conditions
- Diabetes mellitus and other metabolic disorders
- Coinciding conditions in risk adjustment models
Please note that the original training events have been modified due to a transition within WebEx as of
August 1, 2020. The date and time of the events have not changed but the program link and invitation detail have been updated. Previously registered participants will need to re-register for a training event using the updated registration link(s) provided in this announcement.
On August 21, 2020, 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 websites, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health ®* (AIM) Advanced Imaging of the Heart and Diagnostic Coronary Angiography Clinical Appropriateness Guidelines.
Evaluation of patients with cardiac arrhythmias:
- Updated repeat transthoracic echocardiography (TTE) criteria.
- Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia.
Evaluation of signs, symptoms or abnormal testing:
- Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature.
Diagnostic coronary angiography:
- Updated criteria to evaluate patients with suspected congenital coronary artery anomalies.
- Access AIM’s ProviderPortalSM directly at https://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* Portal at https://www.availity.com. Call the AIM Contact Center toll free at 1-800-714-0040 from 7 a.m. to 7 p.m.
For 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 (Anthem). Availity, LLC is an independent company providing administrative support services on behalf of Anthem.
The following updates will apply to the AIM Clinical Appropriateness Guidelines for Advanced Imaging for claims with dates of service on and after March 14, 2021.
Chest imaging, and head and neck imaging
Hoarseness, dysphonia and vocal cord weakness/paralysis — primary voice complaint:
- Required laryngoscopy for the initial evaluation of all patients with primary voice complaint
Brain imaging, and head and neck imaging
Hearing loss:
- Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is non-diagnostic or unable to be performed
- Higher allowed threshold for consecutive frequencies to establish sensorineural hearing loss
- Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance
Tinnitus:
- Removed sudden onset symmetric tinnitus as an indication for advanced imaging
Head and neck imaging
Sinusitis/rhinosinusitis:
- Added more flexibility for the method of conservative treatment in chronic sinusitis
- Required conservative management prior to repeat imaging for patients with prior sinus CT
Temporomandibular joint dysfunction:
- Removed requirement for radiographs/ultrasound
Cerebrospinal fluid (CSF) leak of the skull base:
- Added scenario for management of known leak with change in clinical condition
Brain imaging
Ataxia, congenital or hereditary:
- Combined with congenital cerebral anomalies to create one section
Acoustic neuroma:
- More frequent imaging for a watch and wait or incomplete resection
- New indication for neurofibromatosis type 2 (NF 2)Neurofibromatosis type 2
- More frequent imaging when MRI shows findings suspicious for recurrence
- Single post-operative MRI following gross total resection
- Included pediatrics with known acoustics (rare but NF 2)
Tumor — not otherwise specified:
- Repurposed for surveillance imaging of low grade neoplasms
Seizure disorder and epilepsy:
- Limited imaging for the management of established generalized epilepsy
- Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy
Headache:
- Removed response to treatment as a primary headache red flag
- Include pregnancy as a red flag risk factor
Mental status change and encephalopathy:
- Added requirement for initial clinical and lab evaluation to assess for a more specific cause
Oncologic imaging
General enhancements — Updates to Scope/Definitions, general language standardization
General content enhancements — Overall alignment with current National Comprehensive Cancer Network (NCCN) recommendations, resulting in:
- Removal of indications/parameters not addressed by NCCN
- Average risk inclusion criteria for CT colonography
- New allowances for MRI abdomen and/or MRI pelvis by tumor type, liver metastatic disease
- New indications for acute leukemia (CT, PET/CT), multiple myeloma (MRI, PET/CT), ovarian cancer surveillance (CT), bone sarcoma (PET/CT)
- Updated standard imaging prerequisites prior to PET/CT for bladder/renal pelvis/ureter, ectal, esophageal/GE junction, gastric and non-small cell lung cancers
- Additional PET/CT management scenarios for cervical cancer, Hodgkin Lymphoma
Other content enhancements by section
Cancer screening: New indication for pancreatic cancer screening
Breast cancer: New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment breast MRI after breast conserving therapy or unilateral mastectomy
Prostate cancer: MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE
Axumin PET/CT: Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)
As a reminder, ordering and servicing providers may submit prior authorization requests to
- Access the AIM ProviderPortalSM directly at https://aimspecialtyhealth.com/providerportal.
- Online access is available 24/7 to process orders and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity* Portal at https://availity.com.
- Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. CT
If you have questions related to guidelines, please contact AIM by 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.
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