 Provider News ColoradoNovember 2019 Anthem Provider News and Important Updates - ColoradoWe 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 - November schedule
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Topic:
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Provider Maintenance Form
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Date/Time:
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Tuesday, November 19, 2019 from 12-1pm MT
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Description:
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Anthem contracted providers are required to update their demographic information when changes occur to their practice / organization using our online Provider Maintenance Form (PMF).
Learn how to utilize the online PMF to submit changes such as the following:
• Change of address/location
• Name change
• Tax ID changes
• Provider leaving a group or a single location
• Change in phone/fax numbers
• Closing a practice location
• Change in status for Accepting New Patients
• Plus more
This webinar will walk you through an overview of the Provider Maintenance Form, and teach you tips to make submitting your changes even easier!
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Registration link:
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https://anthem.webex.com/anthem/onstage/g.php?PRID=b6a696587e498199466cadc7231c908d
Please note this is a new registration link for all “Working with Anthem Webinars” effective September 1, 2019 going forward.
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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”.
Event Recordings Note:
As we have a new registration link effective September 1, 2019, event recordings will be split into two URLs.
- Recordings after September 1, 2019 will be available from the current registration link, under the “Event Recordings” heading.
- Archived Event Recordings from January – August 2019 are available here.
Anthem contracted providers are required to update their demographic information when changes occur to their practice / organization, including:
- Change of address/location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Change in phone/fax numbers
- Closing a practice location
- Change in status for Accepting New Patients
- Plus more
As a reminder, our Find a Doctor online tool is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans.
Action Needed:
To help ensure we have the most current and accurate information, please take a moment to access the Find a Doctor tool and review how you and your practice are being displayed.
- Select Search as a Guest, then Search by All Plans and Networks
- Enter the appropriate search criteria to find your Provider information
Report discrepancies:
Please make any necessary corrections using the Provider Maintenance Form. The Provider Maintenance Form (PMF) is available online at anthem.com. Select Providers │under Provider Resources heading, select Provider Maintenance Form (Note: select Colorado, if you haven’t done so already). The PMF can also be found on the Availity Portal│ Payer Spaces │ Anthem Blue Cross and Blue Shield icon │Resources │ Provider Maintenance Form.
“Working with Anthem” webinar – November 14, 2019
Don’t forget we are also hosting our “Working with Anthem” webinar and this month’s topic will help Anthem providers submit demographic updates online utilizing the Provider Maintenance Form. Learn more about:
- What is a Provider Maintenance Form (PMF)?
- Helpful Information regarding PMF submissions
- Individual vs. Organization
- When to use Provider Leaving Group vs Termination of Provider Participation Agreement
- Overview of each step of the process
- Adding attachments
- Submission verification
- Notice of completion
- Troubleshooting tips
- Definitions
Check out our registration link to register today!
As the physician of a member who has coverage under Affordable Care Act (ACA) compliant plans, you play a vital role in accurately documenting the health of the member to ensure compliance with ACA program reporting requirements. When members visit your practice, we encourage you to document ALL of the members’ health conditions, especially chronic diseases. Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.
Please ensure that all codes captured in your EMR system are also included on the claim(s), and are not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing 4. If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.
Reminder about ICD-10 coding
As you may be aware, the ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits. Additionally, Anthem uses ICD-10 codes submitted on claims to monitor health care trends and costs, disease management, and clinical effectiveness of management of medical conditions. The Centers for Medicare and Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a member’s health.
Using specific ICD diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.
- Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.
- Include any secondary diagnosis codes that are actively being managed.
- Include all chronic historical codes, as they must be documented each year pursuant to the ACA. (E.g.: An amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).
If you are interested in having a coding training session conducted by an Anthem coding auditor, please contact our Commercial Risk Adjustment Representative who supports your area: Socorro.Carrasco@anthem.com.More exciting new changes are coming to the public provider site at anthem.com. This next wave of updates includes a new, enhanced Medical Policies page. The page will have an improved and straightforward process for viewing policies that allows providers to easily scan, sort and filter. In addition, providers will now be able to access “Search” from the Medical Policies landing page. Below is a preview of the streamlined page:
Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Sleep Disorder Management Clinical Appropriateness Guidelines.
- Polysomnography and Home Sleep Testing: Established sleep disorder (OSA or other) – follow-up laboratory studies
- Expanded contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation.
- Management of OSA using APAP and CPAP Devices
- Expanded treatment of mild OSA with APAP and CPAP to patients with any hypertension based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation
- Expanded contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 877-291-0366, Monday–Friday, 8:00 a.m.–6:00 p.m.MT
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. Anthem’s launch of its new pharmacy benefits manager (PBM) solution, IngenioRx, which will serve members of all Anthem affiliated health plans is nearly complete. We began transitioning members on May 1, 2019, and have continued throughout 2019, with all members completely transitioned to IngenioRx by January 1, 2020.
As a reminder, most day-to-day pharmacy experiences will not be affected:
- Members will continue to use their prescription drug benefits as they always have, getting their medications using a retail pharmacy, home delivery, or specialty pharmacy.
- Current home delivery and specialty pharmacy prescriptions and prior authorizations will transfer automatically to IngenioRx when a member transitions, with the exception of controlled substances and compound drugs (see more below).
- If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx after your patient has transitioned.
- If you do not use ePrescribing, send home delivery and specialty pharmacy prescriptions to IngenioRx after your patient has transitioned (see contact information below).
- Members will continue to use the same drug list.
Frequently Asked Questions
Q. When can I expect my patients to transition to IngenioRx?
A. Most Anthem members have already transitioned to IngenioRx. The remaining members will be transitioned on January 1, 2020.
Q. Do providers need to take any action?
A. Federal law does not allow prescriptions for controlled substances or compound drugs to be automatically transferred to another pharmacy, so providers with patients using these medications will need to send a new prescription to IngenioRx after they’ve transitioned.
Q. Will my patients be notified of this change?
A. Anthem will notify members before they transition to IngenioRx. Members currently filling home delivery and specialty pharmacy medications will be notified by mail.
Q. How will a provider know if an Anthem member has moved to IngenioRx?
A. Availity displays member PBM information under the patient information section as part of the eligibility and benefits inquiry. We have enhanced this section of Availity to indicate when a member has moved to IngenioRx. Availity includes the name of the PBM and date the member moved to IngenioRx, or the date the member is scheduled to move to IngenioRx.
Q. How will specialty drugs be transitioned?
A. Specialty pharmacy prescriptions and prior authorizations will automatically transfer to IngenioRx. In addition, the IngenioRx Care Team will call members to introduce them to IngenioRx and discuss the medications they take.
Q. How do I submit prescriptions to IngenioRx?
A. If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx in your ePrescribing system.
If you do not use ePrescribing, you can submit prescriptions using the following information:
IngenioRx Home Delivery Pharmacy new prescriptions:
Phone Number: 1-833-203-1742
Fax number: 1-800-378-0323
IngenioRx Specialty Pharmacy:
Prescriber phone: 1-833-262-1726
Prescriber fax: 1-833-263-2871
Q. What phone number should I call with questions?A. For questions, contact the Provider Service phone number on the back of your patient’s ID card.Category: Medicare
The Blue Cross and Blue Shield Association issued a mandate requiring a change in the way we process Host and Home plan HEDIS® STARS Care Gaps, risk adjustment (RADV) and medical records requests. The goal of this mandate is to improve health outcomes and care management for Medicare Advantage out-of-area members.
More information about this mandate will be published in the December 2019 newsletter.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Category: Medicare
CMS defines an expedited/urgent request as ‘an expedited/urgent request for a determination is a request in which waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in seriously jeopardy.’ Contracted providers should submit requests in accordance with CMS guidelines to allow for organization determinations within the standard turnaround time, unless the member urgently needs care based on the CMS definition of an expedited/urgent request.
Category: Medicare
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. The online process is faster and easier to complete, and the response is automatic, which helps patients get their medications sooner. You can complete this process through your current electronic health record/electronic medical record (EHR/EMR) system or via the following ePA sites:
Creating an account is free and takes just a few minutes. If you are experiencing any issues or have a question about how the systems operate:
- For questions or issues with accessing the Surescripts portal, call 1-866-797-3239.
- For questions or issues with accessing the CoverMyMeds portal, call 1-866-452-5017.
For questions regarding pharmacy benefits, please contact Provider Services at 1-844-396-2330.
Category: Medicare
This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).
Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem for Medicaid and Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions) take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
PA requirements will be added to the following codes:
- 0026U -- Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
- 0533T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
- 0534T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
- 0535T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
- 0536T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
- 0546T -- Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
- 33270 -- Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
- 33271 -- Insertion of subcutaneous implantable defibrillator electrode
- 77299 -- Unlisted procedure, therapeutic radiology clinical treatment planning
- 81205 -- BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (for example, Maple syrup urine disease) gene analysis, common variants (for example, R183P, G278S, E422X)
- 81219 -- CALR (calreticulin) (for example, myeloproliferative disorders), gene analysis, common variants in exon 9
- 81250 -- G6PC (glucose-6-phosphatase, catalytic subunit) (for example, Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (for example, R83C, Q347X)
- 81302 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; full sequence analysis
- 81303 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; known familial variant
- 81304 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; duplication/deletion variants
- 81331 -- SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
- 81332 -- SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
- 81400 -- Molecular pathology procedure, Level 1 (for example, identification of single germline variant for example, SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (for example, medium chain acyl dehydrogenase deficiency)
- 81401 -- Molecular pathology procedure, Level 2 (for example, 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (for example, acquired imatinib resistance)
- 81402 -- Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
- 81402 -- Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
- 81407 -- Molecular pathology procedure, Level 8 (for example, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (for example, generalized epilepsy with febrile seizures), full gene sequence
- 81408 -- Molecular pathology procedure, Level 9 (for example, analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (for example, Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (for example, neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (for example, malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (for example, von Willebrand disease types 1 and 3), full gene sequence
- 97033 -- Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
- C9042 -- Injection, bendamustine hcl (belrapzo), 1 mg
- C9043 -- Injection, levoleucovorin, 1 mg
- C9141 -- Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
- D9130 -- Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
- D9920 -- or management, by report
- J9999 -- Not otherwise classified, antineoplastic drugs
- S3850 -- Genetic testing for sickle cell anemia
To request PA, you may use one of the following methods:
Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.Availity.com. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 1-844-396-2330 for assistance with PA requirements. To reach Medicare Advantage Provider Services, call the number on the back of members’ ID cards.
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