The Prefix Reference List has been updated and is available online. Please go to anthem.com.  Select Providers.  Under the Communications heading, select Contact Us.  Choose Colorado, then select Prefix Reference List.

 

 

544-0720-PN-CO

As a provider, we understand you are committed to providing the best care for our members, which now involves telehealth visits.  Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions. As we reported in the May and June newsletters, we are completing our prospective and retrospective reviews for 2020 for Anthem’s Commercial Risk Adjustment (CRA) program.  The retrospective program focuses on medical chart collection.  The prospective program focuses on member health assessments for patients with undocumented Hierarchical Condition Categories (HCC’s), in order to help close patients’ gaps in care.

 

What’s in it for you?

 

• First, monthly you will receive a list of your patients who are Anthem members enrolled in Affordable Care Act (ACA) compliant coverage who may have gaps in care to help you reach out to them, so they can come in for office visits earlier.

 

• Second, we’ve heard resoundingly from providers that participation in these programs helps them better evaluate their patients and, as a result, perform more strongly in population health management and gain sharing programs. Many cite that they ask different questions today that allow them to better manage their patients end to end.

 

• Finally, when you see Anthem ACA members and submit health assessments, we pay incentives of $50 for a paper submission and $100 for an electronic submission. For additional details on how to earn these incentives and the options available, please contact the CRA Network Education Representative listed below.

 

What’s in it for your patients?

Anthem is completing monthly postcard campaigns to members with ACA compliant coverage when we suspect a high-risk condition with messaging to encourage the member to call his or her Primary Care Provider (PCP) and schedule an annual checkup.  The goal is to get the members to have a visit with their PCPs, so the PCPs have an overall picture of their patients’ health and schedule any screenings that may be needed.  Telehealth visits have become very flexible formats for patients and doctors to meet, so we encourage telehealth visits to be scheduled if that is what the patient is most comfortable with at this time.

 

We will continue these monthly postcard mailings throughout the remainder of 2020 to encourage the members to schedule an annual checkup, which supplements any patient outreach you may be doing.

 

If you have any questions regarding our reporting processes, please contact the CRA Network Education Representative at Socorro.Carrasco@anthem.com.

 

 

527-0720-PN-CONV

The Custom Learning Center in the Availity portal offers an array of learning opportunities where you can access required training, recommended/elective trainings and view additional learning resources. Access to the Custom Learning Center is via Payer Spaces in the Availity Portal. 

 

Highlights of the Custom Learning Center

• All the learning is in one place
• You can filter topics of interest
• View all your completed training
• Course resources may include links to a job aid

 

Your required courses are easily accessible and the available content is specific to your region. You may track your accomplishments, and view or download your training history via the Custom Learning Center Dashboard.

Select Payer Spaces > Applications > Access Your Custom Learning Center.

Examples of trainings offered in the Custom Learning Center:

• Authorizations
• Coding and Documentation
• Claims and Payments
• Recommended administrative support courses

 

In addition, illustrated reference guides are located on Custom Learning Center - Resources. Select Resources from the menu located on the upper left corner of the screen. Usually, you may download or print reference guide materials.

 

Current Reference Guide topics include:

• Interactive Care Reviewer – Request Appeals Reference Guide
• Interactive Care Reviewer – Inquiries Reference Guide
• Patient 360 Navigation
• Remittance Inquiry Tips

 

Be sure to visit the Custom Learning Center in the Availity Portal often. New content is regularly added to the site.

For questions regarding the Availity Portal, please contact Availity Client Services at 1-800-282-4548.

 

 

526-0720-PN-CONV

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

 

 

510-0720-PN-CONV

We’ve created a document to outline the process flow for provider questions related to claims. This document will teach providers about:

 

• Resources available for claims questions/issue resolution.
• The steps to access those resources.
• The best time to contact the different teams and resources.
• Process flow to help better understand when different resources are used to help expedite claims related questions or resolve issues.

 

The provider claim questions/issue resolution process flow can be found online at Anthem.com > Providers > under the Provider Resources heading, select Forms and Guides > under Guides heading, Provider claim questions/issue resolution process flow for Commercial members.

 

 

514-0720-PN-CO

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 -- July schedule

 

Topic:	Anthem Networks Overview
Date/Time:	Wednesday, July 29, 2020 from 12:00-1:30pm MT *This session has been extended to 90 minutes because of the volume of content.
Description:	Learn about ALL networks offered in Colorado, how to identify members accessing these networks, including membership ID card samples. Networks included: • Participating (PAR) • PPO • HMO • Blue Priority HMO • Blue Priority PPO • CU Exclusive • UCHealth Network – New July 1, 2020 • UCHealth High Deductible HSA - New July 1, 2020 • Pathway HMO • Pathway PPO – New January 1, 2020 • Mountain Enhanced • WellChoice • Anthem MediBlue Plus (HMO) • Anthem MediBlue Dual Advantage (HMO SNP) • Anthem Medicare Preferred (PPO)
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”.

 

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. 

 

 

512-0720-PN-CO

Please be aware that the Level of Care Medical Necessity Review of Upper and Lower Endoscopy procedures that was previously announced in the March 2020 of Anthem’s Provider News will be effective August 1.   Starting July 20, 2020, ordering providers may submit to AIM prior authorization requests for the hospital outpatient site of care for these procedures for dates of service on or after August 1, 2020.

 

Anthem invites you to take advantage of an informational webinar that will introduce you to the Level of Care Review of Upper and Lower Endoscopy procedures and the capabilities of the AIM ProviderPortal_SM.  Visit the AIM Surgical Procedures microsite to register for an upcoming training session.

 

 

525-0720-PN-CONV

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

 

• Modifier use reminders
• New behavioral health discharge call-in line
• Medical Policies and Clinical Utilization Management Guidelines update
• Updates to AIM Specialty Health advanced imaging Clinical Appropriateness Guidelines
• 2020 affirmative statement concerning utilization management decisions
• Transition to AIM Rehabilitative Services Clinical Appropriateness Guidelines 

 

 

ABSCRNU-0127-20

ABSCRNU-0142-20

ABSCRNU-0143-20

ABSCRNU-0148-20

ABSCRNU-0138-20

ABSCRNU-0152-20

We’ve created a document to outline the process flow for provider questions related to claims. This document will teach providers about:

• Resources available for claims questions/issue resolution.
• The steps to access those resources.
• The best time to contact the different teams and resources.
• Process flow to help better understand when different resources are used to help expedite claims related questions or resolve issues.

 

The provider claim questions/issue resolution process flow can be found online at Anthem.com > Providers > under the Provider Resources heading, select Forms and Guides > under Guides heading, Provider claim questions/issue resolution process flow for Medicare members.

 

 

ABSCRNU-0147-20 April 2020

On November 15, 2019, and February 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 (Anthem). These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the Anthem provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting February 2020. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

 

ABSCRNU-0144-20 April 2020

AIM Specialty Health_® (AIM) currently performs utilization management review for bilevel positive airway pressure (BiPAP) equipment and all associated supplies. Beginning July 1, 2020, the following codes will require prior authorization with Anthem Blue Cross and Blue Shield (Anthem) rather than with AIM.

 

Line of business:  Individual Medicare Advantage, Group Retiree Solutions, and Medicare-Medicaid Plans

E0470	Respiratory assist device, bilevel pressure capability, without back-up rate feature, used with noninvasive interface, such as a nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0471	Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, such as a nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

 

AIM will continue to manage the supply codes for automatic positive airway pressure (APAP) and continuous positive airway pressure (CPAP) requests.

 

Anthem will continue to follow the COVID-19 Public Health Emergency orders from CMS until the waivers no longer apply.  If the Public Health Emergency Orders are no longer in place beginning July 1, 2020, the following codes will require prior authorization with Anthem rather than with AIM when used in combination with the BiPAP codes above.

 

Precertification requests

Submit precertification requests via:

• Fax – 1-866-959-1537
• Phone – Please dial the customer service number on the back of the member’s card, identify yourself as a provider and follow the prompts to reach the correct precertification team. There are multiple prompts. Select the prompt that fits the description for the authorization you plan to request
• Web – Use the Availity Web Tool by following this link: https://apps.availity.com/availity/web/public.elegant.login

 

A4604	Tubing with heating element
A7046	Water chamber for humidifier, replacement, each
A7027	Combination Oral/Nasal Mask used with positive airway pressure device, each
A7030	Full Face Mask used with positive airway pressure device, each
A7031	Face Mask Cushion, Replacement for Full Face Mask
A7034	Nasal Interface (mask or cannula type), used with positive airway pressure device, with/without head strap
A7035	Headgear
A7036	Chinstrap
A7037	Tubing
A7039	Filter, non-disposable
A7044	Oral Interface for Positive Airway Pressure Therapy
A7045	Replacement Exhalation Port for PAP Therapy
A7028	Oral Cushion, Replacement for Combination Oral/Nasal Mask, each
A7029	Nasal Pillows, Replacement for Combination Oral/Nasal Mask, pair
A7032	Replacement Cushion for Nasal Application Device
A7033	Replacement Pillows for Nasal Application Device, pair
A7038	Filter, disposable

 

 

ABSCARE-0535-20 May 2020 

Introduction

Anthem Blue Cross and Blue Shield (Anthem) is offering Special Needs Plans (SNPs) to people eligible for both Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These include supplemental benefits such as hearing, dental, vision and transportation to medical appointments. Some SNP plans include a card or catalog for purchasing over-the-counter items. SNPs do not charge premiums.

 

SNP members under Anthem benefit from a model of care that is used to assess needs and coordinate care. Within 90 days of enrollment and annually thereafter, each member receives a comprehensive health risk assessment (HRA) that covers physical, behavioral and functional needs, and a comprehensive medication review. The HRA is used to create a member Care Plan. Members with multiple or complex conditions are assigned a health plan case manager.

 

SNP HRAs, Care Plans and case managers support members and their providers by helping to identify and escalate potential problems for early intervention, ensuring appropriate and timely follow-up appointments, and providing navigation and coordination of services across Medicare and Medicaid programs.

 

Provider training required

Providers contracted for SNP plans are required to complete an annual training to stay up-to-date with plan benefits and requirements, including details on coordination of care and model of care elements. Every provider contracted for SNP is required to complete an attestation, which states they have completed their annual training. These attestations are located at the end of the self-paced training document.

 

To take the self-paced training, go to the Model of Care Provider Training link on the Availity Portal.*

 

How to access the Custom Learning Center on the Availity Portal

1. Log in to the Availity Portal.
1. At the top of Availity Portal, select Payer Spaces and select the appropriate payer.
2. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
3. In the Custom Learning Center, select Required Training.
4. Select Special Needs Plan and Model of Care Overview.
5. Select Enroll.
6. Select Start.
7. Once the course is completed, select Attestation and complete.

 

Not registered for Availity?

Have your organization’s designated administrator register your organization for Availity.

1. Visit https://www.availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

 

Q&A

 

What does it mean to be dual-eligible? What is a D-SNP?

The term dual eligible refers to people with Medicare coverage who also qualify for some type of state Medicaid benefit — meaning that these members are eligible for both Medicaid and Medicare. These individuals may have higher incidence of chronic conditions, cognitive impairments and functional limitations. D-SNPs are special Medicare Advantage plans that enroll only dual-eligible people, providing them with more intensive coordination of care and services than those offered by traditional Medicare and Medicare Advantage plans.

 

What is a SNP model of care?

CMS requires Special needs plans (SNPs) to have a model of care that describes how the SNP will administer key components of care management programs, including assessments and training. The model of care describes the unique needs of the population being served and how Anthem will meet these needs. Each SNP model of care is evaluated and scored by the NCQA and approved by CMS.

 

How does the model of care help physicians?

The three major components of the model of care, 1) the HRA, 2) Care Plan and 3) case manager, support providers in serving D-SNP members. Each member receives a comprehensive HRA that covers physical, behavioral and functional needs, and a comprehensive medication review. Health plan staff use the HRA information to create a Care Plan. Members with multiple or complex conditions may be assigned to a case manager.

 

These key model of care components identify and escalate potential problems for early intervention, ensure appropriate and timely follow-up, and help coordinate services across Medicare and Medicaid programs. Through the provider website, providers have access to review the Care Plan, the results of the HRA and other information to help manage care.

 

How are transitions of care managed?

Anthem case managers are involved in transitions of care (for example, discharge from hospital to home for those at high risk of readmission). Such transitions may trigger a reassessment and updates to the member’s Care Plan as needed. Following a discharge, case managers help ensure that D-SNP members see their PCP within a week and work through barriers that members experience in adhering to post-discharge medication regimens.

 

Who makes up the Interdisciplinary Care Team (ICT)?

Members of the ICT include any of the following: nurses, physicians, social workers, pharmacists, the member and/or the member’s caregiver, behavioral health specialists, or other participants as determined by the member, the member’s caregiver, or a relative of the member.

 

Providers who care for Anthem members are considered participants in the ICT and may be contacted by a case manager to discuss the member’s needs. The case manager may present recommendations concerning care coordination or other needs. The goal of the ICT is to assist providers in managing and coordinating patient care.

 

Do I have to become a Medicaid provider?

You are not required to become a Medicaid provider, but we recommend that you do. Even if you are only providing services covered by Medicare Part A or Part B to SNP members, we recommend that you attain a Medicaid ID because the state Medicaid agency may require this for the Medicare cost share.

 

Do I need a separate agreement or contract to see SNP members under Anthem?

No, if you see Medicare Advantage HMO members under Anthem, you are considered contractually eligible to see SNP members under Anthem.

 

How do I file claims for SNP members?

Claims for services to SNP members are filed the same way claims are filed for Medicare Advantage members under Anthem who are not part of SNP. Providers should ensure that the claim has the correct member ID (including the prefix).

 

How is the SNP member’s cost sharing handled?

SNP benefits are administered similarly to Medicare fee-for-service benefits. Upon receiving an EOP from Anthem, you should bill the state Medicaid agency or the applicable Medicaid MCO contracted with the state for processing of any Medicare cost sharing applied.

 

Medicare cost sharing is paid according to each state’s Medicaid reimbursement logic. Some states do not reimburse for Medicare cost sharing if the payment has already met or exceeded Medicaid reimbursement methodology.

 

Do I have to file claims twice for SNP members?

Yes, when you treat SNP members under Anthem, you will file the initial claim with Anthem and then bill the state Medicaid agency or the applicable Medicaid MCO contracted with the state for Medicare cost sharing processing. Please use the same electronic claim submission or address you currently use for Anthem claims filing.

 

Do SNP members have access to the same prescription drug formulary as other Medicare Advantage members under Anthem?

Yes, SNP members have coverage for the same prescription drugs listed on the Medicare Advantage prescription drug formulary for Anthem.

 

Please note that in California the tier placement may vary. Be sure to review the plan’s specific formulary for details on California SNPs as the formulary depends on the market.

 

What are SNP benefits for Anthem?

The SNP for Anthem members covers all Medicare Part A and Part B services and includes full Part D prescription coverage. Anthem also covers a range of preventive services with no cost sharing for the member. In addition, the SNP includes coverage for supplemental benefits that may include routine dental, vision and nonemergency medical transportation. A summary of the SNP benefits is posted on the provider website for Anthem members.

 

Any Medicaid benefits available to the member will be processed under their Medicaid coverage directly with the state or the Medicaid organization in which the member is enrolled.

 

Does the SNP use the same procedure codes and EDI payer codes?

Yes, the SNP uses the same procedure and payer codes and electronic filing procedures as other Medicare Advantage plans under Anthem.

 

Is the electronic data interchange (EDI) payer ID for this product the same as others?

Yes, all the claim submission information will be the same (this applies to EDI and paper). Providers must submit this information with the correct ID. Please check the EDI section of the provider website for the correct payer codes to use for your market.

 

 

ABSCRNU-0154-20 May 2020