CMS average sales price (ASP) third quarter fee schedule with an effective date of July 1, 2021, will go into effect with Anthem Blue Cross and Blue Shield on August 1, 2021. To view the ASP fee schedule, please visit the CMS website at
www.cms.gov/medicare/medicare-fee-for-service-part-b-drugs/mcrpartbdrugavgsalesprice?redirect=/mcrpartbdrugavgsalesprice/.



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Overview:

Join us throughout the year in a new Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving Star ratings.

Program objectives:

• Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas including telehealth, pharmacy measures, chronic disease monitoring, cancer screenings, documentation and more.
• Apply the knowledge you gain from the webinars to improve your organization’s quality.

Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.

REGISTER HERE for our upcoming clinical quality webinars!  
    

It wasn’t too long ago when patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. Thanks to a small, portable device, patients on warfarin can now self-test with a finger prick drop of blood. There is more to self-testing than the ease and convenience, though. Patients are happier! Their quality of life improved because they can keep up with their activities – even travel, without the stress of making and keeping testing appointments.

Self-testing: Measurable difference when correct coding is reflected

This type of quality care and improved outcomes are making a measurable difference in the lives of our members. We want this success accounted for in the INR clinical quality measure and with your help, we can do it.  Use these codes to reflect INR In-home monitoring when noting the INR results for your patients.

The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.

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For more than a decade, Blue Precision – Anthem Blue Cross and Blue Shield’s (Anthem) physician transparency program – has recognized specialists for meeting or exceeding established quality and cost effectiveness measures.  Thank you to all those physicians participating in our networks and for the care you provide to our members.

Anthem is announcing that we have made the decision to retire our Blue Precision program effective December 31, 2021. Blue Precision recognition icons and other program information will be removed from anthem.com and our “Find Care” provider tool by January 1, 2022.

Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.  We look forward to working collaboratively with you in other physician programs to provide our members with continued access to affordable and quality healthcare. 

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Many members have both primary and secondary insurance policies, and it’s important to know which policy is primary. We want to make it as easy as possible for you to find out so you can avoid claim denials for not filing the secondary claim within the timely filing guidelines.

Before the member arrives for their appointment, check the primary insurance carrier using the Eligibility and Benefits app in Availity. Log onto Availity.com, go to payer spaces, select us as the payer and use the Patient Registration tab to run an Eligibility and Benefits Inquiry. If you find that we are the primary payer, confirm that when the member arrives for their appointment. After providing services, submit the member’s claim as usual – you can use Availity for that, too, through the Claims & Payments app.

If we are the secondary payer, we will need the explanation of benefits (EOB) from the primary carrier along with the claim submission to determine our payment amount. You can submit the EOB and the claim through Availity using the Claims & Payments app.

When a claim is submitted to us as the primary payer, and we are the secondary payer, our claim system will deny the claim because we don’t have the EOB. This can cause a delay in receipt of your payment and can even cause you to miss the timely filing guideline.

We want you to have of the information you need to know the very best way to file your claims. For more information about filing claims, visit Anthem.com/provider/claims-submissions. For help using Availity, log onto Availity.com and select the Help & Training tab.

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In a recent study published by Pediatrics¹, economic hardship, school closing and shutdowns led to sedentary lifestyles and increases in childhood obesity. The research analyzed doctor visits pre-pandemic then during the pandemic period and the increases were dramatic. Overall obesity increased from 13.7% to 15.4%. Increases observed ranged from 1% in children aged 13 to 17 years to 2.6% for those aged 5 to 9 years.

The study recommended new approaches to Weight Assessment and Counseling. These include recommending virtual activities that promote increased physical activity. Focusing on ways to remain safe and active with outside activities, such as park visits, walks and bike riding were also suggested.

The Centers for Disease Control and Prevention has a great resource, “Ways to promote health with preschoolers.” This fun flyer shows how we can all work together to support a healthy lifestyle. You can download a copy here.

The HEDIS® measure Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) requires a nutritional evaluation and pro-active guidance as part of a routine health visit.

• When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.
• When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.
• Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.

HEDIS® measure WCC looks at the percentage of members, 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:

• Body mass index (BMI) percentile (percentage, not value)
• Counseling for nutrition
• Counseling for physical activity

Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.

Code services correctly to measure success

These diagnosis and procedure codes are used to document BMI percentile, weight assessment, and counseling for nutrition and physical activity:

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

American Academy of Pediatrics. American Academy of Pediatrics raises concern about children’s nutrition and physical activity during pandemic. Available at: http://services.aap.org/en/news-room/news-releases/aap/2020/american-academy-of-pediatrics-raises-concern-about-childrens-nutrition-and-physical-activity-during-pandemic/. Accessed December 10, 2020

¹ https://pediatrics.aappublications.org/content/147/5/e2021050123?cct=2287#F1

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Our “Working with Anthem” 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

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: 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.

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As previously communicated in the June 2021 edition of Anthem Blue Cross and Blue Shield’s (Anthem) Provider News, Anthem, and AIM Specialty Health_® (AIM), a separate specialty benefits management company expand their relationship to include additional services. Effective July 19, 2021, Anthem and AIM, will launch a new Back Pain Guide Program for Anthem fully insured members.  The new Back Pain Guide program will identify members that are experiencing back pain or are at risk for complications related to back pain conditions and help educate and support members navigate through their back pain journey to reduce risk of chronicity, minimize recurrences, and minimize complications.

Our targeting management process includes:

• Predictive models for members likely to be referred for back surgery based on several risk factors
• Risk stratification to ensure the appropriate level of support is provided
• Targeted outreach to members through our digital engagement platform, email and calls
• Customized education and support of provider treatments based on member’s specific needs
• Education about the availability of supportive services such as behavioral health as appropriate

AIM Back Pain Program Educational Information                                                                                          

The AIM Back Pain Guide Program microsite helps you learn more and access helpful information and tools such as program information and FAQs. Anthem also invites you to take advantage of a free informational webinar that will introduce you to the program_.  Go to the AIM Back Pain Guide Program microsite to access helpful information and register for an upcoming webinar.

We value your participation in our network and look forward to working with you to help improve the health of our members.

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As previously communicated in the May 2021 edition of Anthem Blue Cross and Blue Shield’s (Anthem) Provider News, the AIM Rehabilitative program will be enhanced.  Effective August 1, 2021, AIM Specialty Health_® (AIM), a separate company, will expand the AIM Rehabilitative program to perform medical necessity review of the requested site of service for physical, occupational and speech therapy procedures for Anthem fully insured members.

AIM will require pre-certification for all outpatient facility and office-based rehabilitative and habiliative services.  Prior authorization is recommended for the initial evaluation service codes, unless otherwise prohibited, to alert the provider of the site of care program and ensure the member is receiving care at the appropriate site of service early in the process.  After the evaluation, ongoing services will be subject to site of care review and require prior authorization, including post service review which may result in a denial of coverage for not medically necessary for the site of care. Requests that are not medically necessary at a hospital site may be approved for coverage at a free standing or office-based setting.  AIM will use the following Anthem Clinical UM Guidelines: CG-REHAB-10 Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services. The clinical criteria to be used for these reviews can be found on the Anthem Provider portal Clinical UM Guidelines page. 

Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis, members currently in an episode of care at the start of the program, services with diagnosis of autism, and members ages birth to 6th birthday.

AIM will begin accepting prior authorization requests on July 19, 2021 for services provided on or after August 1, 2021.  Prior authorization requests may be submitted via the AIM ProviderPortal or by calling AIM at 1-877-291-0366, Monday – Friday, 8:00 a.m. – 6:00 p.m. MT.

AIM Rehabilitation Educational Information                                                                                   

The AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists and CPT code lists.  Anthem also invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortal_SM.  Go to the AIM Rehabilitation microsite to access helpful information and register for an upcoming webinar on July 8^th or 27^th at 3:00 p.m. ET. If you have previously registered for other services managed by AIM, there is no need to register again.

We value your participation in our network and look forward to working with you to help improve the health of our members.

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As a reminder, Anthem Blue Cross and Blue Shield (Anthem) Medicare Advantage does not allow separate reimbursement for claims that have been identified as a readmission to the same hospital for the same, similar or related condition unless provider, federal or CMS contracts and/or requirements indicate otherwise, as further described in the existing reimbursement policy located at: https://www.anthem.com/medicareprovider.

If Anthem Medicare Advantage determines that this reimbursement policy has not been followed, Anthem Medicare Advantage may deny the claim prior to payment or recover any paid claim. Providers may dispute any claim denied under this policy consistent with applicable law, your agreement with Anthem Medicare Advantage and Anthem Medicare Advantage policies.

For more detailed information on the Inpatient Readmissions reimbursement policy, please visit https://www.anthem.com/provider/policies/reimbursement.

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Learn more about the updates to the AIM Advanced Imaging Clinical Appropriateness Guidelines.

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Anthem Blue Cross and Blue Shield does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at www.anthem.com/medicareprovider.

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Learn more information about the Prior Authorization Requirement Changes Effective September 1, 2021 – UM AROW 1845.

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Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

• Address disparities for vaccine-preventable diseases.
• Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
• Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.
• Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.

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On October 1, 2021, prior authorization (PA) requirements will change for A0426 and A0428 covered by Anthem Blue Cross and Blue Shield. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added for the following codes:

• A0426 — ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)
• A0428 — ambulance service, basic life support, nonemergency transport (BLS)

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at https://www.availity.com or on the provider website at https://www.anthem.com/medicareprovider > Login. Contracted and noncontracted providers unable to access Availity can call the Provider Services located on the back of their patient’s member ID card for PA requirements.

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On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield and AMH Health, LLC. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other members of your practice and office staff.

Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

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CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7^® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

The Clinical Data Acquisition Group for Anthem Blue Cross and Blue Shield (Anthem) integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:

• Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings.

Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.

Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started today.

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