 Provider News ColoradoMay 2024 Provider Newsletter Contents
COBCBS-CRCM-056133-24 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Providers must code their claims to the highest level of specificity in accordance with industry standard coding guidelines such as ICD-10-CM coding guidelines and reporting. When an ICD-10-CM diagnosis code has a specified laterality within the code description, the modifier that is appended to a CPT® or HCPCS code must correspond to the laterality within the ICD-10 description. For CMS 1500 form claims processed on or after May 30, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny claim lines that have a laterality diagnosis submitted with a CPT or HCPCS modifier that does not correspond to the diagnosis. Example one:Reported diagnosis: | E11.3593 (Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral) | Billed CPT code: | 67228-RT Treatment of extensive or progressive retinopathy (e.g., diabetic retinopathy), photocoagulation. | Determination: | It is not appropriate to report an RT modifier when the laterality of bilateral is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied. |
Example two:Reported diagnosis | S91.011A (Laceration without foreign body, right ankle, initial encounter) | Billed CPT code: | 27786-LT (Closed treatment of distal fibular fracture: lateral malleolus; without manipulation) | Determination: | It is not appropriate to report an LT modifier when the laterality of right is identified in the ICD-10 diagnosis. Therefore, the claim lime will be denied. |
Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT, HCPCS code(s), and/or modifiers billed. Anthem will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines. Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex Code: 00W19 If you have questions about this communication or need assistance, contact your provider relationship management associate. We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-053055-24 Providers must code their claims to the highest level of specificity in accordance with industry standard coding guidelines such as ICD-10-CM coding guidelines and reporting. When an ICD-10-CM diagnosis code has a specified laterality within the code description, the modifier that is appended to a CPT® or HCPCS code must correspond to the laterality within the ICD-10 description. On a CMS 1500 form, for professional submitted claims processed on or after June 1, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny claim lines that have a laterality diagnosis submitted with a CPT or HCPCS modifier that does not correspond to the diagnosis. See examples belowReported diagnosis: E11.3593 (Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral): - Billed CPT code: 67228-RT Treatment of extensive or progressive retinopathy (for example, diabetic retinopathy), photocoagulation.
- Determination: It is not appropriate to report the RT modifier when the laterality of bilateral is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied.
Reported diagnosis: S91.011A (Laceration without foreign body, right ankle, initial encounter): - Billed CPT code: 27786-LT (Closed treatment of distal fibular fracture: lateral malleolus; without manipulation)
- Determination: It is not appropriate to report a LT modifier when the laterality of right is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied.
Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT, HCPCS code(s), and/or modifiers billed. Anthem will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines. EOB messageDiagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex codes: v19 and 00V19 If you have questions about this communication or need assistance, contact your provider relationship account manager. We are committed to a future of shared success. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-053403-24-CPN52942 Maintaining your online provider directory information is essential for member and healthcare partners to connect with you when needed. Access your online provider directory information by visiting anthem.com/provider, then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information we show in our online directory has changed. Updating your informationAnthem uses the provider data management (PDM) capability available on Availity Essentials to update your provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate provider demographic data set by the Consolidated Appropriations Act (CAA). PDM features include: - Updating provider demographic information for all assigned payers in one location.
- Attesting to and managing current provider demographic information.
- Monitoring submitted demographic updates in real-time with a digital dashboard.
- Reviewing the history of previously verified data.
Accessing the PDM applicationLog on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. PDM trainingPDM training is available: - Learn about and attend one of our training opportunities by visiting here.
- View the Availity PDM quick start guide here.
- For Roster Automation Standard Template and Roster Automation Rules of Engagement specific training, listen to our recorded webinar here.
Not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account. If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-056357-24-CPN55995 On April 1, 2024, Carelon Post Acute Solutions, LLC (formerly known as myNexus) began operating as Carelon Medical Benefits Management, Inc. Provider materials that formerly included the Carelon Post Acute Solutions name, such as determination letters and provider forms, have adopted the new name. However, there will be no changes in the way you submit a case nor to the contact information you use for checking case status.
Please see below for a list of FAQ. Additional questions can be directed to our Health Care Networks team using the contact information below: - Home health providers: HHprovider_relations@carelon.com
- Post-acute institutional management (PAC-IM) providers: PACprovider_relations@carelon.com
- Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers: DMEprovider_relations@carelon.com
Thank you for your continued partnership. Carelon Medical Benefits Management transition FAQ Q: Will there be any changes to the Carelon Post Acute Solutions provider website?A: The name of our website has been updated to reflect Carelon Medical Benefits Management branding. Additionally, the web address you use today will automatically redirect to a new Carelon Medical Benefits Management site. There will be no changes to the case submission process. Q: Are any phone number changes planned as part of this transition?A: No, our inbound phone numbers will not change. The reference to Carelon Post Acute Solutions in recorded scripting will use the Carelon Medical Benefits Management name. Q: How will third party websites, such as Availity, be impacted?A: There will be no change to the way you access these websites. Within the sites, any reference to Carelon Post Acute Solutions will be replaced with the new name. This may take some time to fully complete. Q: Will references to Carelon Post Acute Solutions on health plan websites and other materials be changed?A: Yes, while you may continue to see the Carelon Post Acute Solutions company name on health plan websites for some time, these references will be updated over time through scheduled content update cycles. If your office includes the Carelon Post Acute Solutions name in any materials or web properties, we encourage you to update them to Carelon Medical Benefits Management during your next update cycle. Q: Will information about Carelon Post Acute Solutions continue to be found on the corporate website?A: Yes, post-acute care will be part of the Carelon Medical Benefits Management portfolio of solutions. You can learn more at careloninsights.com. Q: Will provider resources, such as key documents and the provider finder, be impacted?A: Our provider resources will continue to be available through our corporate website and our Provider Resources site. Q: Does this impact provider agreements with Carelon Post Acute Solutions? Will I need to sign a new agreement?A: No, there is no impact to provider agreements. You do not need to sign a new agreement regardless of whether your current contract is with MyNexus, Inc. or Carelon Post Acute Solutions. Q: Do I need to complete credentialing again through Carelon Medical Benefits Management?A: No, providers will not need to re-credential until their normal credentialing cycle. Q: Will my claims be impacted?A: No, claims are not impacted. Payer IDs will remain the same. Q: Will I need to update my W-9?A: Providers may need to update their W-9. If you need an updated W-9 from Carelon Medical Benefits Management, please contact the Carelon Provider Relations department at HHprovider_relations@carelon.com. Carelon Post Acute Solutions, LLC is an independent company providing services on behalf of the health plan.
Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-054832-24-CPN53974 To remain compliant with Colorado Regulation 4-2-80, we are required to obtain data on providers and front-office staff who have completed cultural sensitivity and antibias training in 2023. We have developed two options to collect the data: (1) your office can fill out an online survey; or (2) you can respond via the enclosed spreadsheet. If you choose to complete the survey, you can access the survey through Check Market® at https://s-us.chkmkt.com/n16vx or via the QR code provided at the end of this article. Please complete the survey by providing answers to the questions listed below. This survey needs to be completed by your providers and/or office staff and returned to us by June 15, 2024. The following questions need to be answered by your providers and/or office staff and returned to us by June 15, 2024: - Practice name as indicated in your Anthem individual or group agreement
- Group or individual NPI
- Practice address
- Type of training: cultural competency; antibias, health equity, etc.
- Training provided by: Anthem, My Diverse Patients, CMS, other health plan, etc.
- Course duration (in hours or days)
- Number of providers who attended the training
- Number of providers in the practice
- Number of front office staff attended the training
- Number of front office staff in practice
- Date training completed
- Certificate or continuing medical education (CME) awarded (Y/N)
If you choose to respond via the enclosed spreadsheet, please complete the spreadsheet and return to our mailbox, Coloradocontracting@anthem.com. In the email subject line, add 2023 Cultural Competency. Training opportunitiesFor ongoing training, we offer e-learning experiences at our on-demand provider training hub, ON24®. Visit the Provider Education and Training site and select My Diverse Patients. The current CME course, My Inclusive Practice — Improving Care for LGBTQIA+ Patients (offered by My Diverse Patients), is available any time to network providers and office staff. Optional provider demographic dataAvaility Essentials added the fields below to satisfy Colorado Regulation 4-2-80, adopted by the Division of Insurance of the Colorado Department of Regulatory Agencies. Gender and disability fields added to type 1 provider information in Provider Data ManagementWhen updating the general information about type 1 providers (individual providers/practitioners) in the Provider Data Management (PDM) application, you can now enter information in these fields: - Gender at birth — When you tick the box for this field, you can select the provider's gender at birth.
- Provider gender identity — When you tick the box for this field, you can select the provider's gender identity. You can select multiple values.
- Provider sexual orientation — When you tick the box for this field, you can select the provider's sexual orientation. You can select multiple values.
- Provider disability — When you tick the box for this field, you can select Yes or No for questions that appear.
The demographic data will be used to improve racial health equity, reduce health disparities for covered persons who experience higher rates of health disparities and inequities, and provide aggregate information about the diversity of the providers in our network. This reporting will not include any personally identifiable information because it is reported in the aggregate. To register for Availity EssentialsSigning up is easy and 100% secure. There is no cost for our providers to register or to use any of the digital applications. Visit Availity.com and select the Log in to Essentials button in the upper right to create a free account. We appreciate your continued support and the care you provide to our members, your patients. QR code to complete your survey about 2023 training as required by Colorado: 
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CM-056835-24-SRS56807 Digital Request for Additional Information (RFAI) is the easiest way to submit attachments requested by your payer using Availity Essentials. There is no need to fax or mail paperwork to complete your claim submissions anymore; just use the digital channels provided for your organization. Availity Essentials notification centerThe notification center is located on the top of the Availity Essentials home page. If your payer has requested documentation, there will be a message stating there are requests in your work queue. Simply select the hyperlink to be navigated to the Attachment Dashboard to view the request. Availity Essentials Attachment DashboardThe Attachment Dashboard is where all attachment requests are displayed. You can use the hyperlink in the notification center or navigate to Claims & Payments > Attachments New. To locate a specific RFAI request, the request number will begin with RFAI. If you notice multiple requests in your dashboard, take advantage of the filters. You have the option to search, filter, and sort for multiple values, such as tax ID, NPI, and request type. Select Upload Attachment to view the type of document requested. Your uploaded requests will be visible in the History tab once accepted. Select the Record History icon on the right side of the request to view the Availity Transaction ID for specific Availity Essentials questions or Health Plan Transaction ID if you need to contact your payer for questions. Digital RFAI progress dashboardThis dashboard, located in Payer Spaces, allows your organization to understand how many digital requests have been sent, how many finalized claims there are based on your attachment submissions, and the average turnaround time from the initial payer request to the claim finalization. To view your Digital RFAI Progress Dashboard application, select Payer Spaces from the drop-down menu and choose your payer tile. Get trainedAvaility Essentials has training on-demand. This includes a pre-check for administrators and a Learn How to Submit Digital Requests for Additional Information training. Log in to Availity Essentials > Help & Training > Get Trained > Enter RFAI in the keyword search. Visit the Provider Learning Hub to take Availity on-demand training. If you have questions, call Availity Client Services at 800-Availity (800-282-4548). Availity Client Services is available Monday to Friday, 8 a.m. to 8 p.m. ET. With your help, we can continually build towards a future of shared success. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-052715-24-CPN52154 Roster Automation is our technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel template. On March 29, we introduced a new Roster Automation functionality on the Upload Roster File page of Availity PDM. With this enhancement, you can view: - Date received and status of rosters submitted in the last 12 months.
- Errors in submitted rosters that result in the need of manual intervention to process. The types of issues included in the error report will be incorrectly formatted data and required data elements that are missing from the roster.
Understanding the errors made when completing a roster allows you to ensure subsequent submissions do not contain those issues. Error-free rosters reduce the need for manual intervention, which improves data accuracy and processing time. As you learn how to use the information available in the new error reports, we will continue to correct issues on your behalf. In the future, you will need to correct any errors submitted in a roster (for example, missing data, incorrectly formatted data). Rows in a roster that contain an error will not be processed and the addition, change, or termination will not be updated in our systems. More information about when you will need to correct errors, and how to do so, will be sent in future communications and covered in future virtual webinars. Utilize the Roster Submission GuideFind it online: On Availity.com > Payer Spaces > Select Payer Tile > Resources > Roster Submission Guide using Provider Data Management. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-057357-24-CPN57211 In our previous communications about the Authorizations and Referrals application on Availity Essentials, we mentioned the Preference Center where you can select your preferred method of communication for authorization cases. Below, find details on how to easily access the Preference Center and set your communication preference. The Preference Center, which can be accessed by your Availity administrator or their assistant, will be available on Availity Essentials within Payer Spaces by the end of April 2024. Access the Preference CenterAfter logging in to Availity Essentials, your Availity administrator, or their assistant, will select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Preference Center application tile. The Preference Center will prompt them to select your organization. Set your preferred communication mode for authorization casesAfter selecting your organization, select the preference option for Authorization and Referrals to see the preferred communication mode for authorization cases and adjust the preference (Digital Access (Default) or Digital + Mail) based on your business needs. Once in the preference setting for Authorizations and Referrals, all tax IDs and NPIs for your organization registered with Availity Essentials will be displayed on the screen. The default communication mode for authorization cases will be set to Digital Access for all organizations, including all combinations of tax IDs and NPIs. You can change the mode of communication to Digital + Mail for any combination of tax ID and NPI. There is no need to manually enter the tax IDs and/or NPIs to set this preference. Instead, use the search bar to focus on the tax IDs and NPIs you want to make changes to. Additionally, you can add more NPIs to your current registration and set the preferred communication mode for the new NPIs under the selected tax IDs. Manage preferences (Availity administrators)Availity administrators can learn more about managing preferences related to Authorization Decision letters in the Custom Learning Center, available in Payer Spaces on Availity Essentials. After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Custom Learning Center application, then select the Resources section to view or download the Reference Guide on managing receipt of Authorization Decision letters. Through our shared health vision, we can affect real change. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-056476-24 Save time and get faster results by using Availity Essentials to submit disputes for atypical care providers. As part of our ongoing efforts to optimize and enhance the Claims Status application in Availity Essentials, we recently launched the ability for non-medical/atypical care providers — such as providers of non-emergency transportation, case management, or environmental modifications — to use the Dispute functionality in the enhanced Claims Status app. This new functionality allows atypical care providers to be more efficient and accurate in their dispute submission process. Below are a few simple and important steps and reminders to follow for the best experience and results. First stepRegister with Availity Essentials Non-medical/atypical care providers can submit a dispute using Availity Essentials. Care providers need to first register an organization with Availity Essentials, ensuring an administrator is chosen and their provider information — including tax ID — is added to Manage My Organization. Once the organization is set up as Non-Medical/Atypical on Availity Essentials, it can use various functions, such as submitting disputes. Atypical care providers do not use an NPI to bill claims; therefore, it's important that the setup is completed. Second stepGo to the Claims Status app: - Navigate from the home page to Claims & Payments > Claim Status > select your organization and payer > Claim Status Inquiry page will open.
- When Manage My Organization has been completed, you can select the care provider from the drop-down menu and the tax ID field will display.
- Complete an inquiry by entering the required fields and selecting Submit for requested claims to display.
Third stepSelect Dispute To complete a dispute: - Locate the claim and, if there is an option to appeal, select Dispute to initiate.
- Select Go to details to be navigated to the Appeals Application.
- Locate your initiated dispute and select the action menu to complete the dispute request.
- Choose the request reason, upload supporting documents, and submit the request.
Once completed, your progress will appear in the Notifications Center on the Availity Essentials home page when Web is selected in the contact field. Explore training and resources We are here to support you along the way through on-demand training and resources. Availity Essentials offers keyword search assistance with the option to attend live or recorded demos: - On the Availity Essentials home page, select Help & Training, then select Get Trained to register for upcoming live and recorded training demos for all Availity Essentials capabilities.
- Use the search bar to locate specific appeals training.
- The Availity Learning Center user guide will assist with how to locate training.
For questions, contact Availity Client Service: - Online: Help & Training > Availity Support > Contact Support > Create a case or Chat with Support
- By phone: Call 800-AVAILITY (282-4548) Monday through Friday from 8 a.m. to 8 p.m. Eastern time
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-054937-24-CPN54404 Find Care, the doctor finder and transparency tool in the Anthem online directory, provides Anthem members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetical order, and provider name. We previously introduced you to Personalized Match, an additional Find Care sorting option for Medicare Advantage members, which was based on provider efficiency and quality outcomes, in addition to member search radius. Personalized Match was initially limited to PCP searches and was later expanded to include certain specialists. Beginning in June 2024 or later, we will further enhance Personalized Match. Provider availability and STARS rating scores will now more directly influence provider rankings. Additionally, provider recommendations will be driven in part by knowledge about member history derived from claims and other available clinical data. Personalized Match will continue to display providers with the highest overall ranking within the member’s search radius at the top of search results. Members may continue to sort based on distance, alphabetical order, and provider name: - A copy of the Personalized Match phase two methodology will be posted in Availity in the coming weeks.
- If you have general questions regarding this new sorting option, please submit an inquiry via the web at Availity.
- If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.
Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. We are committed to helping patients more easily access the care they need. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-052330-24-CPN52048 Soon, you will be able to submit all your authorizations in one application on Availity.com. You may already be submitting your physical health authorizations through the Availity Essentials multi-payer Authorization application — taking advantage of the time savings and speed to care through digital authorization submissions. You will soon be able to submit both your physical health and behavioral health authorizations through one Authorization application on Availity.com. Using the Availity Authorization application to submit your behavioral health authorizations will not be much different from the process you follow today. You may enjoy more intuitive screens or learn sooner if an authorization is required, but the digital submission process is still the best way to submit your authorization requests and the fastest way to care for our members. You will continue to use Interactive Care Reviewer (ICR) to submit an appeal or authorization for medical specialty prescriptions. Accessing the Availity Authorization application is easy. Ask your organization’s Availity administrator to ensure you have the Authorization role assignment. Without the role assignment, you will not be able to access the Authorization application. Then, log on to Availity.com to access the app through the Patient Registration tab by selecting Authorizations and Referrals. Training is availableTraining is available for the Availity Authorization application. Once registered with the authorization role assignment, visit the training site to enroll for an upcoming live webcast or to access an on-demand recording at the Availity Authorization Training Site. We are focused on reducing administrative burdens, so you can do what you do best — care for our members. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-049451-23-CPN48753 Use the information below to help complete required patient information on donor claims. Correct completion of the form is needed to process the claim. Donor claimsThere are two patients involved in an organ donation — the donor and the recipient. The insurance plan for the recipient is responsible for paying the donor claim. The recipient can be the subscriber or a dependent to the subscriber (Note: Plans are instructed to include living donor charges on the recipient claims). When billing for services rendered to the transplant donor, the care provider enters the recipient’s name, date of birth, sex, and Anthem ID number. Completing formsReview the information outlined below for billing instructions needed to process donor claims. CMS-1450 (UB-04 Uniform Bill):- UB box 8b — recipient’s name*
- UB box 10 — recipient’s birthdate
- UB box 11 — recipient’s sex
- UB box 42 — donor ICD-10-CM codes and revenue codes
- UB box 58 — subscriber’s name
- UB box 59 — relationship code of 39 or 40
- UB box 60 — subscriber ID number
- UB box 66 — donor diagnosis codes
- UB box 80 — note this is a donor claim submission with donor’s name
CMS-1500 (Health Insurance Claim Form):- HCFA box 1a — subscriber’s ID number
- HCFA box 2 — recipient’s name*
- HCFA box 3 — recipient’s date of birth and gender
- HCFA box 4 — subscriber’s name
- HCFA box 6 — relationship to subscriber, other (Complete with 39 or 40.)
- HCFA box 19 — note, this is a donor claim submission with donor’s name
- HCFA box 21 — donor diagnosis code
- HCFA box 53 (electronic claim) — will list the donor’s name:
- Example: Claim note ref code: ADD Claim note Text: 39-Jones, Sally
* The recommendation is that the recipient’s name be billed. However, the care provider can bill with the donor’s name. If the claim is billed with the recipient’s name, it has a better chance at adjudication upon initial submission. We are focused on reducing administrative burdens, so you can do what you do best — care for our members. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-056555-24-CPN54528 When determining transportation to an alternative hospital and to help avoid medical necessity denials for rotary wing air ambulance transports to another hospital, please remember the criteria below. The use of air and water ambulance services is considered medically necessary when all the following criteria are met: - The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
- The individual’s condition must be such that any form of transportation other than by ambulance would be medically contraindicated; and
- The individual’s condition is such that the time needed to transport by land poses a threat to the individual’s survival or seriously endangers the individual’s health*; or the individual’s location is such that accessibility is only feasible by air or water transportation; and
- There is a medical condition that is life threatening, or first responders deem to be life threatening, including, but not limited to, the following:
- Intracranial bleeding; or
- Cardiogenic shock; or
- Major burns requiring immediate treatment in a burn center; or
- Conditions requiring immediate treatment in a hyperbaric oxygen unit; or
- Multiple severe injuries; or
- Transplants; or
- Limb-threatening trauma; or
- High risk pregnancy; or
- Acute myocardial infarction; if this would enable the individual to receive a more timely medically necessary intervention (such as percutaneous transluminal coronary angioplasty [PTCA] or fibrinolytic therapy).
* Air transportation may be appropriate if the time between identification of the need for transportation until arrival at the intended destination for ground ambulance would be at least 30 minutes longer than air transport. For additional details on Clinical UM Guideline CG-ANC-04 Ambulance Services: Air and Ground please visit the Anthem provider site. Clinical UM guidelines are subject to change. Administrative services only (ASO) accounts may utilize alternate criteria. All terms and conditions of the member’s benefit plan apply. For more information please contact Provider Services. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-052117-24-CPN51828 The American Society of Addiction Medicine (ASAM) has issued updated criteria for adults (December 2023). The updated criteria will be effective May 1, 2024. The following sources provide an overview of the changes: Since the revised criteria only apply to adults, adolescent cases will depend on criteria currently in use (The ASAM Criteria Treatment Criteria for Addictive, Substance-Related and Co-Occurring Conditions, Third Edition, 2013). Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CM-054310-24 In the March 2024 edition of Provider News, we announced that language was inadvertently removed from the Modifier 26 comment in Section II. The policy has been updated to include the following statement: - When a professional provider has reported modifier 26 to procedure codes designated with NPFSRVF PC/TC indicators 3 or 9, the procedure will not be eligible for reimbursement.
Upon further review, no claims were impacted by this omission. If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-054401-24 HEDIS® is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices. What vaccines are included in the HEDIS Adult Immunization Status (AIS-E) measure? Influenza: The percentage of members 19 years of age and older who are up to date on recommended routine vaccines for influenza. Td/Tdap: The percentage of members 19 years of age and older who are up to date on recommended routine vaccines for tetanus and diphtheria (Td) or tetanus, diphtheria, and acellular pertussis (Tdap). Zoster: The percentage of members 50 years of age and older who are up to date on recommended routine vaccines for zoster. Pneumococcal: The percentage of members 66 years of age and older who are up to date on recommended routine vaccines for pneumococcal. Using correct codes can help your practice improve HEDIS AIS-E results.Using the correct code to capture the vaccine given, or identifying anaphylaxis code to reflect the contraindications, can help your practice with performance rates. Adult immunizationImmunization description | CPT® codes | HCPCS | CVX | Influenza immunization | 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660*, 90661, 90662, 90672*, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90689, 90694, 90756 | G0008 | 88, 135, 140, 141,144, 150, 150, 153, 155, 158, 166, 168, 168, 171, 185, 186, 197, 205 | Td/Tdap | 90714, 90715 | | 09, 113, 115, 138, 139 | Zoster immunization | 90736, 90750 | | 121, 187 | Pneumococcal immunization | 90670, 90671, 90677, 90732 | G0009 | 33, 109, 133, 152, 215, 216 |
* Influenza live virus Sources: 1. NCQA Health Plan Description AND ECDS: Adult Immunization Status, pages 643 to 650.
2. HEDIS MY 2024 Volume 2 Value Set Directory 2023-08-01: tabs Measures to Value Sets and Value Sets to Codes. Exclusions:- Members who use hospice services; or
- Members who elect to use a hospice benefit any time during the measurement period; or
- Members who die any time during the measurement period.
- Members with a history of at least one of the following contraindications any time during the measurement period.
Exclusions codes for anaphylaxisImmunization description | SNOMED CT edition USA codes | Description | Influenza immunization | | - Anaphylaxis due to the influenza vaccine any time before or during the measurement period
| Td/Tdap | | Members with a history of at least one of the following contraindications any time before or during the measurement period: - Anaphylaxis due to diphtheria, tetanus, or pertussis vaccine (caused by diphtheria and tetanus)
- Anaphylaxis due to diphtheria, tetanus, or pertussis vaccine (caused by tetanus, diphtheria and acellular pertussis)
- Encephalitis due to diphtheria, tetanus, or pertussis vaccine (post tetanus vaccination)
- Encephalitis due to diphtheria, tetanus, or pertussis vaccine (post diphtheria vaccination)
- Encephalitis due to diphtheria, tetanus, or pertussis vaccine (post pertussis vaccination)
| Zoster immunization | | Members with anaphylaxis due to the herpes zoster vaccine any time before or during the measurement period | Pneumococcal immunization | | Members with anaphylaxis due to the pneumococcal vaccine any time before or during the measurement period |
Helpful tipsImmunization information obtained from the medical record: - A note indicating the name of the specific antigen and the date of the immunization.
- A certificate of immunization prepared by an authorized healthcare provider or agency, including the specific dates and types of immunization administered.
- Document in the medical record of refusal or anaphylaxis reaction to the serum/vaccination.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-054689-24-CPN54510 Visit the Drug Lists page on our website at anthem.com/ms/pharmacyinformation/home.html for more information about: - Copayment/coinsurance requirements and their applicable drug classes.
- Drug lists and changes.
- Prior authorization criteria.
- Procedures for generic substitution.
- Therapeutic interchange.
- Step therapy or other management methods subject to prescribing decisions.
- Any other requirements, restrictions, or limitations that apply to using certain drugs.
The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October. To locate the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed. Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits. Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access. Through our efforts, we are committed to reducing administrative burden because we value you, our care provider partner. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-050732-24-CPN50598, MULTI-BCBS-CM-053029-24-CPN53029 Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CM-056414-24-CPN55907 ATTACHMENTS (available on web): Prior authorization updates for specialty pharmacy (pdf - 0.4mb) Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. COBCBS-CM-055425-24-CPN54800 ATTACHMENTS (available on web): Prior authorization updates for specialty pharmacy (pdf - 0.57mb) Elevance Health, the parent company of our pharmacy benefit management partner, CarelonRx, Inc., has completed its acquisition of Paragon Healthcare, Inc., a company specializing in life-saving and life-giving infusible and injectable therapies. Paragon Healthcare provides infusion services to members through its omnichannel model of ambulatory infusion centers, home infusion pharmacies, and other specialty pharmacy services. The company, headquartered in Plano, Texas, currently serves more than 35,000 members at over 40 ambulatory infusion centers across eight states, as well as in members’ homes. The acquisition of Paragon Healthcare will deepen our capabilities around providing affordable, convenient access to specialty medications for those living with chronic and complex illnesses. Paragon Healthcare will operate as part of CarelonRx. CarelonRx plans to expand Paragon Healthcare’s geographical footprint and operations while bolstering its therapeutic coverage to ensure members receive convenient, timely access to medications. We share a health vision with our care providers that means real change for consumers. CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-054706-24-CPN53991 Effective for dates of service on and after August 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process. 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. HCPCS or CPT® codes | Medicare Part B drugs | J9286 | Columvi (glofitamab-gxbm) | C9162, J3490, J3590, J9999 | Izervay (avacincaptad pegol) | J9333 | Rystiggo (rozanolixizumab-noli) | J9334 | Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-gvfc) |
We look forward to working together to achieve improved outcomes. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-053057-24-CPN52693 CarelonRx mail service pharmacy changed to CarelonRx Pharmacy on January 1, 2024. This pharmacy change does not affect the way CarelonRx works with care providers. There are no changes to the prior authorization process, how claims are processed, or level of support. This change does not impact your patients’ benefits, coverage, or how their medications are filled. When e-prescribing orders to the mail service pharmacy:Prescribers will need to choose CarelonRx Pharmacy, not CarelonRx Mail, if searching by name. If searching by NPI (National Provider Identifier), the NPI is changing to 1568179489. We are taking steps to ensure a smooth transition to our new home delivery pharmacy for your patients: - Patients will receive a letter to alert them of their new pharmacy.
- If a patient has refills left, we will move them to CarelonRx Pharmacy, and we’ll also transfer auto refills.
- If a patient does not have any refills left of their medication(s), CarelonRx Pharmacy will contact you to obtain a new prescription.
- If a patient is taking a controlled substance, CarelonRx Pharmacy will contact you to obtain a new prescription.
- All prior authorizations will be transitioned to CarelonRx Pharmacy.
CarelonRx Pharmacy delivers an enhanced, digital-first solution to your patients to improve adherence and lower costs, while removing barriers associated with traditional retail and mail order pharmacy models. Some highlights include: - 24/7 text or chat (digitally) directly with our pharmacists at any time.
- Enhanced end-to-end order status tracking from prescription order to delivery.
- Free delivery of their 90-day supply, directly to a patient’s door.
CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CR-045499-23-CPN45113 Estimates suggest that around 35 million American adolescents fail to receive at least one recommended vaccine.* The CDC and the American Academy of Pediatrics advise pre-teens between 10 and 12 years old receive three vaccines: (1) one dose for meningococcal; (2) one dose for tetanus, diphtheria, and pertussis (Tdap); and (3) two doses of human papillomavirus (HPV) given five months apart. Encourage pre-teen immunizationsTake action to provide clear and specific guidance to your patients’ parents to get the recommended vaccines on time. Convey the importance by administering vaccines as part of routine visits and by offering vaccine clinics during non-traditional times when your patients and their parents might be more available. It is helpful to remind patients of their upcoming appointments, follow up to reschedule any missed appointments, and address any concerns or barriers. Although you should check your patients’ benefits, immunizations are generally a covered benefit. Reporting and documenting for HEDISTake action to make sure that all vaccine doses given, including those administered in a pharmacy and an urgent care, are clearly documented in your electronic medical system, your patient’s medical record, and state Immunization Registry. Doses should be clearly reported on claim forms with the assistance of CPT® codes to maximize data collection and to reduce the burden of HEDIS® medical record review, especially since NCQA strongly encourages the electronic collection of Immunizations for Adolescents (IMA) HEDIS data. Contact your provider relationship management representative for additional information and assistance with establishing electronic data exchange. Opportunities to learn more:- An on-demand webinar about the importance of the HPV vaccine and starting the conversation early with parents of 9-year-olds can be found on the Clinical Quality Webinars Hub. One continuing education unit is provided upon completion.
- Mydiversepatients.com includes free resources and courses that might help you with your diverse patient population.
- Letsvaccinate.org provides ready-to-use resources and strategies to help your care team increase vaccination rates.
Through our shared health vision, we can affect real change. * Das, Jai K., et al. Systematic Review and Meta-Analysis of Interventions to Improve Access and Coverage of Adolescent Immunizations. Journal of Adolescent Health. 2016 Oct; 59 (4 Suppl): S40-S48. ncbi.nlm.nih.gov/pmc/articles/PMC5026683.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-057410-24-CPN50907 |