As a reminder, we will update our claim editing software for professional services throughout 2023, with most updates occurring at a minimum quarterly. These updates apply to any provider, provider group (tax identification number) and/or across providers and claim type (professional/facility) and include, but are not limited to:

• The addition of new, and revised codes (for example, CPT^®, HCPCS, ICD-10, modifiers) and associated edits such as:
  • ICD-10 laterality
  • Add-on procedures (indicated by + sign)
  • Code book parenthetical statements and other directives about appropriate code use (for example, separate procedure, do not report, list separately in addition to, etc.)
• Updates to editing for multiple procedure reduction calculations based on relative value unit (RVU) as designated and updated by the Centers for Medicare & Medicaid (CMS) in the physician fee schedule relative value (PFSRV) files
• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to incidental, mutually exclusive, and unbundled (re-bundle) edits
• Updates to code edits associated with reimbursement policies including, but not limited to, updates to the edits that allow/disallow for assistant surgeon/co-surgeon/team surgeon, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by CMS

As a reminder, we will update our claim editing software for outpatient facility services throughout 2023 with most updates occurring at a minimum quarterly. These updates will include, but are not limited to:

• The addition of new and revised codes (for example, CPT^®, HCPCS, ICD-10, modifiers, revenue codes) and associated edits.
• Updates related to the appropriate use of various code combinations, which can include, but are not limited to, CPT/HCPCS code to revenue code, type of bill to procedure code, type of bill to CPT/HCPCS code, and CPT/HCPCS code to modifier.
• Updates to National Correct Coding Initiative edits (NCCI) and Facility Outpatient Hospital Services Medically Unlikely Edits (MUEs).
• Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC) and the Centers for Medicare & Medicaid Services (CMS).

In November 2022, we shared information about updates to claim status inquiries denial descriptions. You should now see these expanded descriptions on your explanation of payment remittance advice. These simplified descriptions should make it easier to understand why your claim denied and how to update your claim with the information needed for processing.

We’re phasing in clear, concise, and simplified denial descriptions that explain in greater detail why the claim or claim line has denied and what to do next. We’ve even included details about how to provide us with information digitally, to move the claim further along in the claims process.

Continuing to improve

The new denial descriptions will be phased in over the next few months. We’re starting with those claims or claim lines that have caused the most confusion based on your feedback. If new denial reasons are added, those descriptions will be expanded, as well.

Save time. Increase efficiency. Go digital! If you’re not enrolled in Availity* Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity.com.

Why is this important?

Each year, a random sample of enrolled members receive a CAHPS* Survey or a Qualified Health Plan Enrollee Survey asking them to evaluate their experiences with healthcare. The surveys ask members to rate their experiences with:

1. Their health plan.
2. Their personal provider.
3. Their specialist.

Several responses are combined and evaluated for the following:

• Getting needed care
• Receiving care quickly
• Communicating with providers
• Sharing in the decision-making process

The responses give us an idea of how your patients and our members perceive us and provide opportunities for us to improve the way we deliver services. Our engagement and interaction with patients and members are critical. Together, we can provide positive experiences for our shared members and patients.

Members receive the survey either by mail or phone between February and May. Some of the questions they are asked include:

• In the last six¹ months, how often did your personal provider explain things in a way that was easy to understand?
• In the last six¹ months, how often did your personal provider listen carefully to you?
• In the last six¹ months, how often did your personal provider show respect for what you had to say?
• In the last six¹ months, how often did your personal provider spend enough time with you?
• Using any number from zero to 10, where zero is the worst personal provider possible, and 10 is the best personal provider possible, what number would you use to rate your personal doctor?
• We want to know your rating of the specialist you saw most often in the last six¹ months. Using any number from zero to 10, where zero is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate the specialist?

Every interaction with a patient is an opportunity to make their healthcare experience positive.

We thank you for striving to provide quality care for our members and for the continued focus on improving our member experience.

Additional information

Continuing medical education (CME) education opportunities: http://www.mydiversepatients.com.

¹ The commercial survey asks the same questions, but for the last [12 months vs. 6 months and] language on the Medicaid Child Survey is slightly different to reflect asking a parent/guardian about their child’s experience.

The health plan cannot impose:

• Any exclusions, limitations, or other restrictions on coverage of fertility medications that are different from the exclusions, limitations, or other restriction imposed on any other prescription medications covered under the health benefit plan.
• Deductibles, copayments, coinsurance, benefit maximums, waiting periods, or other limitations on coverage for the diagnosis of and treatment for infertility and standard fertility preservation services, which are different from deductibles, copayments, coinsurance, benefit maximums, waiting periods, or other limitations imposed on benefits for services covered under the health benefit plan that are not related to infertility.

The bill does allow religious exemptions. A religious employer may request, and a carrier must grant, an exclusion if the required coverage conflicts with the religious organization’s genuine religious beliefs and practices. A religious employer who obtains an exclusion must provide its employees reasonable and timely notice of the exclusion of the coverage.

Note: Balance-funded plans for Anthem Blue Cross and Blue Shield typically follow rules for fully insured plans. Administrative services only (ASO) groups can opt out of this coverage using a rider.

HEDIS^® measurement year 2023 documentation for Childhood Immunization Status (CIS)

Measure description:The percentage of children who turn 2 years of age in the measurement year who had the following vaccines on or before their second birthday:

• Four DTaP (diphtheria, tetanus, and acellular pertussis)
• Three IPV (polio)
• One MMR (measles, mumps, and rubella)
• Three HiB (haemophilus influenza type B)
• Three hep B (hepatitis B)
• One VZV (chicken pox)
• Four PCV (pneumococcal conjugate)
• One hep A (hepatitis A)
• Two or three RV (rotavirus)
• Two flu (influenza)

The measure calculates a rate for each vaccine and three combination rates.

HEDIS measurement year 2023 documentation for Lead Screening in Children (LSC)

Measuredescription: The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday.

In provider medical records, we look for the following:

• Immunization records from birth (Department of Health immunization records are acceptable).
• If available, newborn inpatient records documenting hepatitis B.
• For immunizations not recorded on the immunization record, provide progress notes for:
  • Immunizations administered.
  • Patient’s history of disease (chickenpox, hep A, hep B, measles, mumps, rubella).
• Lead testing results and date (capillary or venous) on or before the second birthday.
• Evidence of hospice services in 2023.
• Evidence patient expired in 2023.

Helpful hints:

• Childhood immunizations and lead blood tests must be completed by child’s second birthday.
• Assess immunization needs at every clinical encounter and, when indicated, immunize.
• Ensure immunization records include all vaccines that were ever given including hospitals, health departments, and all former providers, including refusals and contraindications.
• FluMist (LAIV) vaccination (only approved for ages 2 to 49) may be used for the second vaccination; however, it must be given on the child’s second birthday to be compliant.

New COVID-19 laboratory service codes were implemented and reimbursed at rates to meet the needs of providers during the PHE. Reimbursement will now be revised to Anthem's standard reimbursement methodology for the following codes:

If you have any questions regarding this notice, please contact Provider Services or use Availity* Live Chat, which is available during normal business hours. Go to www.availity.com and select Anthem from the payer spaces drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.
COBCBS-CRCM-013118-22-CPN12449

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_®* Rehabilitative and Habilitative Services 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.

• Clarified language about the background of speech-language professionals
• Clarified language about qualified speech-language pathology providers

Speech therapy alternative treatments:

• Clarified language about qualified speech providers
• Definition of blue dye test clarified
• Parkinson Voice Project definition expanded

Physical therapy and occupational therapy adjunctive treatments:

• Added definition of Lee Silverman Voice Treatment BIG — proprietary program of intensive physical and/or occupational therapy of at least one month duration involving large, full-body exercises to improve functional movement and self-care tasks of people with Parkinson’s disease and other neurological conditions. It requires company-certification of providers.
• Added exclusion for Lee Silverman Voice treatment

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM:

• Access AIM’s ProviderPortal_SM 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.

*AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.

• Prior authorization requirement changes
• New specialty pharmacy medical step therapy requirements
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list
  
• Updates to AIM Specialty Health Radiation Oncology Clinical Appropriateness Guidelines