We are continuing our series of “Working with Anthem” webinars for 2019.  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).

2019 Subject Specific Webinars - March schedule

Topic:	New Claim Payment Dispute option on Availity - coming 3/18/19
Date/Time:	March 26, 12pm MT
Description:	Learn about the new functionality now on Availity allowing providers to submit Claim Payment Disputes online.   The Anthem provider claim payment dispute process consists of two steps.   Claim Payment Reconsideration: This is the first step in the Anthem provider payment dispute process. The reconsideration represents your initial request for an investigation into the outcome of the claim. Most issues are resolved at the claim payment reconsideration step.   Claim Payment Appeal: This is the second step in the Anthem provider payment dispute process. If you disagree with the outcome of the reconsideration, you may request an additional review as a claim payment appeal.   This webinar will walk you through an overview of the tool to allow you to start submitting any applicable Claim Payment Disputes electronically, and start saving you time!
Registration link:	https://antheminc.webex.com/antheminc/onstage/g.php?PRID=9ada1c60117342da8bf0ff05a4f4d9c1

 

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.

We wanted to give you an update to an article previously communicated in our January 2019 Provider Newsletter regarding the launch of the claim payment dispute tool on the Availity Portal.  We had targeted this new tool to be available in early March, and we are now targeting March 18, 2019.  When this tool launches it will be available for Local Plan member claim payement disputes.  We are anticipating the tool will be available for BlueCard member claim payment disputes shortly after this launch.  We will send another announcement when claim payment disputes become available for BlueCard members.  (Please note:  Federal Employee Program (FEP) member claim payment disputes are out of scope for this tool at this time.)

 

At the time of our launch of this new tool, you will have the ability to submit claim payment disputes electronically through the Availity Portal using the new Dispute Claim option accessed from the Claim Status page.

 

This tool makes it easier to:

• Electronically file a claim payment dispute
• Send supporting documentation
• Check the status of your claim payment dispute
• View your claim payment dispute history

 

A Claim Payment Reconsideration will be the first step of a claim payment dispute submitted through Availity.  Anthem will review the request and communicate an outcome through the Availity Portal back to you. If needed, you can then choose to submit a Claim Payment Appeal.

 

Once the claim payment dispute is submitted for a second time (through the Claim Payment Appeal step), the decision is final, and may not be submitted again.

 

All Users with the Role assignment of “Claim Status” will have access to the Dispute Claim option from the Claim Status page.  Contact your Availity Administrator to obtain access, if you do not currently have “Claim Status” functionality.

 

Claim Payment Dispute Tool Training

 

You can get a jump start on your training and be ready to go as soon as the tool is fully launched.  To learn more about the claim payment dispute tool, register for a live webinar or view a previous recording:

1. Log in to Availity at www.availity.com and select Help & Training | Get Trained
2. Type Appeals in the search field
3. Enroll in a course

 

Claim Status and Remittance Inquiry page enhancements

 

When the claim payment dispute tool is launched, you will notice some other changes to the Availity Portal Claim Status and Remittance Inquiry page:

 

• You will see a new option under the Claims & Payments menu for “Claim Status and Remittance Inquiry”. Once this tool is launched this new link will replace the previous “Claim Status Inquiry” link (see screen shot below).  
  • Note: If you previously had “Claim Status Inquiry” saved as a favorite, you will need to save the new “Claims Status and Remittance Inquiry” link as a favoriate as the favorite feature will not transfer over to the new link automatically. 

• You will also see a new Go To menu on the patient Eligibility and Benefit Detail page to navigate seamlessly to the new Claims Status and Remittance Inquiry page.

• The new claim status look also includes color coded patient ID cards and easy to read claim detail.

 

Secure Messaging Changes

 

Once the claim payment dispute tool is launched, you will also see changes to the Secure Messaging tool.  A new Actions menu on the updated Claim Status page will be used to access the Secure Messaging tool. The link Do you have a question about this claim? will no longer be available with the update to this page.  You can also use the Actions menu to edit or print the claim screen.

 

Claim Status Tool Training

 

To learn more about the changes to the claim status tool, view the training demo:

1. Log in to Availity and select Help & Training | Get Trained
2. Type Claims Status – Training Demo in the search field
3. Enroll in the course

 

“Working with Anthem” webinars

 

Don’t foget we are also hosting our “Working with Anthem” webinars this month and the topic will be the new Claim Payment Dispute tool, as well as, the additional changes to Claim Status page and the Secure Messaging tool.  A representative from Availity will be a guest presenter and providing a live demo.  Check our our registration link to register today!

This March, anthem.com will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms, as seen below.

 

This first version of the new Provider Forms will keep growing and evolving in the coming months.

 

 

We will continue to keep you informed of upcoming changes to the public provider site as we progress toward streamlining our Web platform and other business processes.

Each year, Anthem requests your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), in order to document and close the coding gaps. 

 

The CRA Program is specific to our Affordable Care Act (ACA) Members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).

 

With our Retrospective Program we focus on medical chart collection.  We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS).  This particular effort is part of Anthem’s compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership.  The members’ medical record documentation helps support this data requirement.

 

Analytics are performed internally on claims which do not have the ICD10 code for which we suspect a chronic condition.  These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.

 

Anthem network providers -- may be PCPs, specialists, facilities, behavioral health, ancillary, etc. -- may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review.  These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf.  The vendors’ Web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management. 

 

We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2019 at the latest).  While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.

 

Electronic options that may make medical chart collection easier for providers:

 

• EMR Interoperability
  • Allscripts (Opt in -- signature required)
  • NextGen (Opt out -- auto-enrolled)
  • Athenahealth (Opt out -- auto-enrolled)
  • MEDENT

• Remote/Direct Anthem access
• Vendor virtual or onsite visit
• Secure FTP

 

The goal of these electronic options is to both improve the medical record data extraction and the experience for Anthem’s network-participating hospitals, clinics and physician offices.  If you are interested in this type of set up or any other remote access options, please contact our Commercial Risk Adjustment Network Education Representative: Socorro.Carrasco@anthem.com

Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests.

The Escalation Contact List  has been updated. Access the updated list online. Please go to anthem.com.  Select Providers.  Under the Communications heading, select Contact Us.  Choose Colorado, then select Escalation Contact List.

A key goal of Anthem Blue Cross and Blue Shield (Anthem)’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways this is done is by giving certain providers (“Payment Innovation Providers”) in Anthem’s various Payment Innovation Programs (e.g., Enhanced Personal Health Care (EPHC), Bundled Payments, Medical Home programs, etc.) (the “Programs”) quality, utilization and/or cost information about the health care providers (“Referral Providers”) to whom the Payment Innovation Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in their getting more referrals from Payment Innovation Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

 

Providing this type of data, including comparative cost information, to Payment Innovation Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Payment Innovation Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local EPHC Market Representative or Care Consultant.

In 2019, Anthem is offering Dual Eligible Special Needs Plans (D-SNPs) to people who are eligible for both Medicare and Medicaid benefits or who are qualified Medicare beneficiaries (QMBs).  D-SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These plans are $0 premium plans.  Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments.  Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.  

 

Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in Q1 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.

 

Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.

For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.

75743MUPENMUB 01/24/2019

Anthem updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433.

 

The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:

• Group code patient responsibility (PR) will be assigned.

 

• Claim adjustment reason codes (CARCs) will include the following:
  • 1 -- deductible amount (professional claim)
  • 2 -- coinsurance amount (professional claim)
  • 3 -- copay amount (professional and facility claim)
  • 247 -- deductible for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
  • 248 -- coinsurance for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)

 

• Remittance advice remark codes (RARCs) will include the following:
  • N781 -- Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
  • N782 -- Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
  • N783 -- Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected copay. This amount may be billed to a subsequent payer.

 

Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.

75743MUPENMUB 01/24/2019

The following revised clinical criteria will be effective May 1, 2019. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.

 

Clinical criteria effective date	Clinical criteria number	Clinical criteria	Clinical criteria (new/revised)
May 1, 2019	ING-CC-0001	Erythropoiesis Stimulating Agents	Revised
May 1, 2019	ING-CC-0004	H.P. Acthar Gel® (repository corticotropin injection)	Revised
May 1, 2019	ING-CC-0072	Selective Vascular Endothelial Growth Factor (VEGF) Antagonists	Revised

 

75743MUPENMUB 01/24/2019

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

 

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

 

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

 

If you have questions or feedback, please use this email link.

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

• Group Retiree members and National Access Plus
• 2019 risk adjustment provider training
• New provider learning opportunity: Put the AIM ProviderPortal to work for you
• New provider service phone number beginning January 1, 2019

75743MUPENMUB 01/24/2019