As part of our streamlined provider claims payment dispute process, Anthem Blue Cross and Blue Shield (Anthem) providers have the ability to submit claim payment disputes via Availity, for members enrolled in our Anthem Blue Cross and Blue Shield Medicaid and Medicare Advantage benefit plans. Effective November 20, 2021, providers will now also be able to submit claim payment disputes via Availity for Anthem’s Commercial lines of business.

As a reminder, unlike inquiries about claims status, provider disputes, or requests for additional information, provider claim payment disputes occur after a claim is finalized, and a provider disagrees with the claim payments Anthem has issued.  Some examples include claim disputes regarding manual processing errors, contract interpretation, reduced payments, code editing, eligibility, timely filing*, and other health plan denials.

Anthem’s streamlined provider claim dispute process utilizing Availity across all Anthem lines of business, allows a more cohesive and efficient approach for providers when:

• Filing a claim payment dispute.
• Sending supporting documentation to Anthem.
• Checking the status of a claim payment dispute.
• Viewing the history of a claim payment dispute.

 

* Reminder, we will consider reimbursement of a claim that has been denied due to failure to meet timely filing if you can: 1) provide documentation that the claim was submitted within the timely filing requirements or 2) demonstrate good cause exists.

 

Reminder on how the provider claim payment dispute process works

For Anthem, the provider claim payment dispute process consists of the following:

 

Commercial claims payment dispute: A written notice to Anthem challenging, appealing or requesting reconsideration of a claim or clinical determination that has been denied, adjusted, contested, or seeking resolution of a contract dispute; or disputing a request for reimbursement of an overpayment of a claim.

 

Providers may submit the claim payment dispute in writing effective November 20, 2021, via Availity.  Providers are encouraged to submit all commercial disputes via Availity. 

 

When submitting a claim payment dispute for commercial claims, please include as much information as you can including but not limited to the following:

• A clear explanation of the basis for which the provider or facility believes the payment amount should be
• Whether the request for reimbursement is for the overpayment of a claim, contest, denial, adjustment, or other action

 

Please refer to the Provider Manual for additional details.

 

Anthem will issue a written determination stating the pertinent facts and explaining the reasons for its determination within 45 working days after the date of receipt of the dispute.

Submitting commercial claim payment disputes in writing

When submitting a claim payment dispute in writing, providers must include the Claim Information/ Adjustment Request Form and submit to:

Anthem Blue Cross and Blue Shield

700 Broadway

Denver, CO 80273

 

Submitting claim payment disputes via Availity, the preferred method, as of November 20, 2021

For step-by-step instructions to submit a claim payment dispute through Availity:

• Log into Availity at availity.com .
• Select Help & Training | Find Help.
• Under Contents, select Overpayments and Appeals.
• Select Dispute a Claim.

 

Through Availity, you can upload supporting documentation and receive immediate acknowledgement of your submission.

 

Anthem’s review and providers’ other options

Anthem will review the claim payment dispute once received and communicate an outcome in writing or through the Availity portal.  Providers can check the status of a claim payment dispute on the Availity portal at any time.

Once the claim payment dispute is submitted, the decision is final. A claim payment dispute may not be submitted through the provider appeals department (Grievance and Appeals) again. Please refer to the Provider Manual for additional information.

Webinars available

To learn more about the claim dispute tool, register for a live webinar:

• Log in to Availity and select Help & Training | Get Trained.
• Select Sessions and go to Your Calendar to locate a webinar.
• Select View Course and then select Enroll.
• The Availity Learning Center will email you with instructions to attend.

As always, providers can refer to the Provider Manual, as the manual includes additional information about inquiries, the provider claim dispute process.

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Effective January 1, 2022, continuous glucose monitors (CGMs) will no longer be covered under the medical benefit as durable medical equipment for certain Anthem Blue Cross and Blue Shield (Anthem) fully insured groups. For these members, CGMs will only be covered under their pharmacy benefit. This applies for both new prescriptions and refills.

We will notify affected members via mail. Members who need to transfer CGMs from their medical benefit to their pharmacy benefit will need a new prescription from their provider.

Note that some Anthem groups will retain their medical DME coverage for CGMs and these members will have the option of using either the medical or pharmacy benefit. Generally, members receive their CGMs faster when obtained using their pharmacy benefit, so we encourage the use of the pharmacy benefit.

If you have questions, please contact Provider Services.

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More than 42 million Americans reach for cigarettes regularly, but almost 70 percent of them say they want to quit. What gives? Maybe the traditional ways to quit smoking, such as going cold turkey or wearing a nicotine patch haven’t worked for them in the past. Thankfully, there are plenty of new ways to kick the smoking habit. Here are five approaches to share with patients who are trying to quit.

1. Download a Quit Smoking App
   There are plenty of downloadable quit smoking apps ready to coach patients along the way. Many former smokers recommend the LIVESTRONG MyQuit Coach, a free app available on iTunes.
   
   2. Start a Quit Reward Fund
   According to a study from The New England Journal of Medicine, putting money on the line can help smokers quit. Researchers found 15.7% of people successfully quit for at least six months when they were offered an $800 reward. Patients can set aside their own money as a deposit that they get back when they successfully quit.

 

3. Ask Human Resources about Resources
   Many employers offer smoking cessation programs, which offer cash rewards, savings on insurance or other perks for not taking a puff. According to the American Lung Association, up to 57% of their smoking cessation program participants reported quitting smoking by the end of the program. Freedom From Smoking®, offered by American Lung Association is an often recommended program.

 

4. Quit Smoking with Meditation
   For many smokers, the act of lighting up is automatic. But a Yale University study found meditating and practicing mindfulness can cancel that relationship and slash cravings. Recommend a mobile app like Stop Smoking – Mindfulness Meditation App to Cessation Smoking Support.

 

5. Consider Medication
   Over-the-counter nicotine patches are designed to lessen withdrawal symptoms and have been a go-to for decades. But if those haven’t worked prescription medications can reduce cravings or make smoking less enjoyable.

 

Measure Up! Medical Assistance with Smoking and Tobacco Use Cessation (MSC) HEDIS® measure looks at members 18 and older to assess different facets of providing medical assistance with smoking and tobacco use cessation:

• Advising smokers and tobacco users to quit
• Discussing cessation medications
• Discussing cessation strategies

 

Measure adherence is determined by member response through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey.

 

Sources:
https://quitsmokingcommunity.org/the-6-best-quit-smoking-apps/
https://itunes.apple.com/us/app/livestrong-myquit-coach-dare/id383122255?mt=8&ign-mpt=uo%3D4
http://www.nejm.org/doi/full/10.1056/NEJMoa1414293#t=articleDiscussion
http://elischolar.library.yale.edu/cgi/viewcontent.cgi?article=1712&context=ymtdl
https://itunes.apple.com/us/app/stop-smoking-mindfulness-meditation/id621443244?mt=8
http://www.health.harvard.edu/blog/whats-best-way-quit-smoking-201607089935
http://www.lung.org/support-and-community/corporate-wellness/help-employees-stop-smoking.html?referrer=https://www.google.com/

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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

Topic:	New claim dispute tool on Availity for Commercial business
Date/Time:	Tuesday, November 30, 2021, from 12:00-1:00pm MT
Description:	Learn about the new functionality now on Availity allowing providers to submit Claim Disputes online for Commercial line of business.   The Anthem provider claim payment dispute process consists of two steps.   1.       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.   2.       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 tool is already available for Medicare and Medicaid and will be available starting in late November for commercial business as well.
Registration link:	https://anthem.webex.com/anthem/onstage/g.php?PRID=b6a696587e498199466cadc7231c908d

Webinars are offered using Cisco WebEx. There is no cost to attend.  Access to the internet, an email address and telephone is all that's needed.  Attendance is limited, so please register today.

 

Watch for additional topics and dates in future issues of our monthly provider newsletter throughout the year.  We also will continue to offer our Fall Provider Seminars which will continue to cover a variety of topics in face-to-face and webinar options.

 

Recorded sessions: 

Most sessions are recorded, and playback versions are available on our Registration Page.  The top portion of the page will show “Upcoming Events” and the bottom portion will show “Event Recordings”.

 

Note: 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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Each year, the CDC encourages healthcare professionals, patients, and families to learn more about antibiotics by promoting U.S. Antibiotic Awareness Week (USAAW). Highlighting the importance of improving antibiotic prescribing and use, USAAW brings these lifesaving drugs to the forefront.

With a focus on helping to fight antibiotic resistance, USAAW asks you to Be Antibiotic Aware¹ and share this information with your patients:

1. Antibiotics can save lives. When a patient needs antibiotics, the benefits outweigh the risks of side effects or antibiotic resistance.
2. Antibiotics aren’t always the answe Everyone can help improve antibiotic prescribing and use.
3. Antibiotics do not work on viruses, such as those that cause colds, flu, bronchitis, or runny noses.
4. Antibiotics are only needed for treating infections caused by bacteria, but even some bacterial infections get better without antibiotics, including many sinus infections and some ear infections.
5. Antibiotics will not make patient’s feel better if the illness is a virus. Respiratory viruses usually go away in a week or two without treatment.
6. If antibiotics are needed, they should be taken exactly as prescribed. Provide information about potential side effects, including those that could result in treatment.
7. Antibiotics are critical tools for treating life-threatening conditions.

Each year in the United States, more than 2.8 million infections occur from antibiotic-resistant bacteria. More than 35,000 people die as a result.

 

Measure up: Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)

This HEDIS® measure looks at the percentage of members ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event. Visit the NCQA website for exceptions.

Description	CPT®/HCPCS/ICD-10
Acute Bronchitis	ICD-10: J20.3, J20.4, J20.5, J20.6, J20.7, J20.8, J20.9, J121.0, J21.1, J21.8, J21.9
Online assessments	CPT: 98970, 98971, 98972, 99422, 99423, 99457 HCPCS: G0071, G2010, G2012, G2061, G2062, G2063
Telephone visits	CPT: 98966, 98967, 98968, 99441, 99442, 99443

 

To learn more about antibiotic prescribing and use, visit www.cdc.gov/antibioticuse.

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

¹CDC www.cdc.gov/antibiotic-use

1406-1121-PN-CO

The Anthem Blue Cross and Blue Shield (Anthem) VYNE Medical electronic medical attachment program has expired. As a result, many claims with electronic medical attachments submitted through VYNE Medical are not aligning properly to their corresponding claim, causing those claims to be denied.

Effective immediately, you should submit medical attachments through Availity to avoid claims denials. Availity allows your organization or clearinghouse to submit attachments through EDI. 

If you’re using a clearinghouse to submit claims and associated attachments, please advise them immediately to start using Availity to submit claims and attachments.

To submit a medical attachment with your claim submission, log onto availity.com and select the Claims & Payments tab. To submit medical attachments after you have submitted a claim, log onto availity.com, select the Claims & Payment tab and then select Attachments – New.

If you or your clearinghouse is not enrolled in Availity, the process is simple. Assign an Availity administrator for your organization and visit Availity.com/provider-portal-registration to go through the step-by-step process for enrollment. There is no cost to enroll or use Availity for the many digital functions it enables.

For more information about enrolling in Availity, contact their client services department at 1-800-282-4548, Monday through Friday, 8:00 a.m. to 8:00 p.m. Eastern.

1405-1121-PN-CO

Healthcare and mental healthcare professionals have a vital role in improving health and wellbeing in our communities by identifying and treating racial trauma and injustice experienced by the individuals we serve. At Anthem Blue Cross and Blue Shield (Anthem), we are committed to addressing racism in our society through open discussions about trauma, injustice, and inequality. These conversations are critical to improving the wellbeing of all Americans and the communities in which we live and serve.

 

We can impact the injustice of racism together.

Anthem has partnered with Motivo*, the first HIPAA-compliant digital platform that connects mental health therapists and clinical supervisors, to engage providers and associates in conversations on racial injustice, trauma, and inequality. Together, we are continuing to evolve the conversation and digging deeper on a quarterly basis to keep the dialogue going.

 

Our racial equity forums focus on:

• Exploring how racism impacts health outcomes.
• Discussing how to identify racism in your practice and how to be an ally to your patients.
• Recognizing implicit bias (we all have it!) and how it affects the care provided to your patients.
• Understanding the impact of prolonged exposure to racism on people of .
• Providing you with actionable resources to recognize and reduce racism that may exist in your practice.

Since October 2020, Anthem has sponsored four virtual forums: Racial Trauma in America, The Road to Allyship: Playing Your Part in Racial Equity, In Pursuit of Racial Equity: Deconstructing Bias Forum, and Exploring the Impact of Racial Trauma on the Health & Wellbeing of Children.

 

Please register for the next forum:
 

Equity, COVID, and holidays: Coping with grief

December 8, 2021
4:00-5:30 p.m. EST

Register today!

 

Continuing education credits available for those who sign up and participate!

Registration information will be sent closer to the date of the forum.

 

The first step in doing your part to addressing racism is to recognize that it exists.

These conversations may feel uncomfortable at first, and that’s ok – this is how we will make progress together in creating a more just and equitable society.

  *Motivo is an independent company providing a virtual forum on behalf of Anthem.

1403-1121-PN-CO

We recently offered a series of CME webinars on a variety of topics. If you missed any of them, you can still register for the recorded webinars and earn CME credits. The webinars offer best practices to overcoming barriers in achieving clinical quality goals and attaining better patient outcomes. We also expect to offer more live CME webinars in the coming weeks.

 

• Learn strategies to help you and your care team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.

 

Attendees will receive one CME credit upon answering required questions at the conclusion of each webinar.

 

Register here for our upcoming live and on-demand clinical quality webinars!

1391-1121-PN-CO

The HEDIS® Electronic Clinical Data Systems (ECDS) reporting methodology encourages the exchange of the information needed to provide high-quality health-care services. 

The ECDS Reporting Standard provides a method to collect, and report structured electronic clinical data for HEDIS quality measurement and improvement. 

Benefits to providers:

• Reduced burden of medical record review for quality reporting
• Improved health outcomes and care quality due to greater insights for more specific patient-centered care

ECDS reporting is part of the National Committee for Quality Assurance (NCQA’s) larger strategy to enable a Digital Quality System and is aligned with the industry’s move to digital measures. 

Click here to learn more about NCQA’s digital quality system and what is means to you and your practice.

ECDS Measures

The first publicly reported measure using the HEDIS® Electronic Clinical Data System (ECDS) reporting standard is the Prenatal Immunization Status (PRS) measure.  In 2022, NCQA will include the PRS measure in Health Plan Ratings for Medicaid and Commercial plans for measurement year 2021.

 

For HEDIS Measurement Year 2022, the following measures can be reported using ECDS:
 

Childhood Immunization Status CIS-E*

Immunizations for Adolescents IMA-E*

Breast Cancer Screening BCS-E

Colorectal Cancer Screening COL-E

Follow-Up Care for Children Prescribed ADHD Medication ADD-E

Metabolic Monitoring for Children and Adolescents on Antipsychotics APM-E*

Depression Screening and Follow-Up for Adolescents and Adults DSF-E

Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults DMS-E

Depression Remission or Response for Adolescents and Adults DRR-E

Unhealthy Alcohol Use Screening and Follow-Up ASF-E

Adult Immunization Status AIS-E

Prenatal Immunization Status PRS-E (Accreditation measure for 2021)

Prenatal Depression Screening and Follow-Up PND-E

Postpartum Depression Screening and Follow-Up PDS-E

 

*Indicates that this is the first year that the measure can be reported using ECDS

Of note, NCQA added the ECDS reporting method to three existing HEDIS measures: Breast Cancer Screening, Colorectal Cancer Screening and Follow-up Care for Children Prescribed ADHD Medication. Initially, the ECDS method will be optional which provides health plans an opportunity to report using the ECDS method while transitioning to ECDS only in the future.

Other sources:

HealthITgov: https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/health-information-exchange

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Each year, Anthem Blue Cross and Blue Shield (Anthem) performs a review of a sample of our members’ medical records as part of the HEDIS quality study. HEDIS® is part of a nationally recognized quality improvement initiative and is used by the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA) and several states to monitor the performance of managed care organizations.

For 2021, Anthem will begin requesting medical records in January 2022. No special authorization is needed for you to share member medical record information with us, since quality assessment and improvement activities is a routine part of healthcare operations.

HEDIS review is time sensitive, so please submit the requested medical records within the timeframe indicated in the initial HEDIS request document.

Ways to submit your records:

• Remote EMR Access Service – New!
  As we published in the September edition of Provider News, we now offer the Remote EMR Access Service to providers to submit member medical record information to Anthem. If you are interested in more information, please contact us at Centralized_EMR_Team@anthem.com.
• Upload to our secure portal
  Medical records can be uploaded to Anthem’s secure portal using the instructions in the request document.
• Fax
  Medical records can be faxed to Anthem using the instructions in the request document.
• Mail
  Medical records can be mailed to Anthem using the instructions in the request document.

 

We appreciate the quality of care you provide to our members. Your assistance is crucial to ensuring our data is statistically valid, auditable, and accurately reflects quality performance.

 

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

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Anthem Blue Cross and Blue Shield (Anthem) covers annual wellness visits and well-woman visits at 100% with no member cost-sharing when provided by in-network providers for members that have ACA-compliant plans. Beginning January 1, 2022, Anthem will encourage some ACA-compliant individual and small group plan members to schedule annual wellness visits or well-woman visits with their physician within the first 90 days of the plan renewal.

Some providers currently require patients to schedule wellness visits or well-woman visits at least one year past their most recent visit. This practice helps ensure a patient does not exceed more than one wellness visit per calendar year. Beginning January 1, 2022, providers can perform the annual wellness visit or well-woman visit for these members, even if it has been less than one year since the last wellness visit. The claim for the wellness visit or well-woman visit will be processed as a preventive care service covered at 100% as long as its billed accordingly.
 

Please note, this benefit may not apply to all health plans. Providers should continue to verify eligibility and benefits for all members prior to providing services or receiving member copayments, deductibles, or coinsurance.

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In an ongoing effort to promote accurate claims processing and payment, Anthem Blue Cross and Blue Shield (Anthem) requires the referring physician name and national provider identifier (NPI)to be included on professional home infusion therapy services claims in field 17 and 17a on CMS1500 claim forms.

Providers should report the referring physician information in accordance with the Anthem guidelines in the EDI Companion Guide for electronically submitted claims.

If you have questions regarding this process, please contact your Provider Experience representative.  

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Blue High-Performance Network plans offer access to providers with a record of delivering high-quality, efficient care. BlueHPN® networks first went live January 1, 2021, in more than 50 cities across the country. Since then, our national customer base has grown, and again this fall, major employers will offer plans with access to our high-performance network for the 2022 benefit year.

Member ID cards and other plan material will feature one small change for 2022: BlueHPN is written as a single word rather than two.

As a reminder, BlueHPN is a national network designed from our local market expertise, deep data, and strong provider relationships, and aligned with local networks across the country. These local networks are connected to the national chassis to form a national BlueHPN network. In Colorado, the BlueHPN network includes the same set of providers as the Pathway PPO/EPO Network.

If you are not sure whether your practice is part of the Pathway PPO/EPO network and therefore BlueHPN, ask your office manager or business office, or contact your Anthem Provider Relations Representative. Updated BlueHPN participation will be displayed in provider profiles in Anthem’s online provider directory January 1, 2022.

Keep in mind that you may see patients accessing this network through a small group, large group, or national account plans with an Exclusive Provider Organization (EPO) plan design. Under EPO plans, out of network benefits are limited to emergency or urgent care. Members must select a primary care provider, but PCP referrals are not required for specialty care.

Below is a sample ID card for a member from Colorado enrolled in a national employer BlueHPN plan for the 2022 benefit year. Note the new “Blue High Performance Network” logo and “BlueHPN” indicator in the suitcase icon.



1414-1121-PN-CO

Please continue to check for important Medicare Advantage updates at https://www.anthem.com/ca/provider/medicare-advantage/ for the latest Medicare Advantage information, including:

 

• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list

Availity* serves as our electronic data interchange (EDI) partner for all electronic data and transactions. The Availity EDI processing generates response files for each submitted electronic file and delivers them to the submitter’s Availity mailbox. It is important to review these responses to understand where your claims are in the process.

 

Electronic file submitter:

• If your organization uses a clearinghouse or vendor, they have an Availity mailbox to submit clients’ files. Availity delivers the responses for claims to the same mailbox, and the clearinghouse or vendor is responsible for returning the results to their clients and resubmitting any files rejected for formatting, interchange, or transaction set errors. The submitter in this scenario is the clearinghouse or vendor.
• If your organization uses a practice management software, an Availity mailbox is set up during initial registration for your electronic file submissions. The submitter is your organization and is responsible for analyzing the responses to verify there are not any file errors or claim rejections that require correction and resubmission within timely filing guidelines.

 

Availity electronic file process:

1. Submit electronic file to Availity — Availity validates for file format and returns file acknowledgments to the submitter’s Availity mailbox. If there are any edits at this point, the entire electronic file will not advance and will require resubmission within timely filing guidelines.
2. HIPAA and payer specific edits — The electronic file moves to the next phase, which is HIPAA and business editing. Examples include:
   • Valid subscriber ID for the date of service
   • Billing and coding validation

If an error occurs at this point, the individual claims with the errors must be corrected, resubmitted as an original claim and do not advance. The claims that do not have an edit will then route to the adjudication systems for second-level edit validation.

3. Anthem Blue Cross and Blue Shield payer receives electronic file from Availity — For the Medicare line of business, there is a second level of editing.

 

Edits for this second level return the Delayed Payer Report (DPR). Only claims that pass will advance for adjudication and will be displayed using Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. If there are edits, the claim requires resubmission within timely filing guidelines.

 

Electronic responses

File acknowledgment — Indicates whether we receive an electronic file in the correct format and acceptance by Availity.

• Action required — If any errors occur at this stage, the submitter will need to correct and resubmit the entire electronic file to Availity.

 

Immediate Batch Response (IBR) — This report acknowledges accepted claims and identifies claim edits due to HIPAA and business edits. The report also includes claim counts and charges for the electronic file. Availity creates this file prior to routing accepted claims to the adjudication systems.

• Action required for claims with edits: Rejected claims require resubmission within timely filing guidelines and will not advance to the adjudication system that would display Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. Not applicable to denied claims.

 

Delayed Payer Report (DPR) — This report is currently only returned for the Medicare line of business and contains second-level editing from the adjudication system after Availity has routed claims that passed on the IBR report.

• Action required for claims with edits: Rejected claims would need to be resubmitted and will not display on Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice and paper Explanation of Payment.

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Experience representative or call the Provider Services on the back of patient’s member ID card, or Availity Client Services with any questions at 800-AVAILITY (282-4548).

 

ABSCRNU-0237-21

519370MUPENMUB

 

In 2022, Anthem Blue Cross and Blue Shield (Anthem) will be providing members with a new tool to develop an advance medical directive for many of its DSNP Medicare Advantage plans. Anthem has partnered with MyDirectives,* a leader in the industry for electronic advance directives. Information on the service will be provided to members via their Annual Notice of Change (ANOC), Evidence of Coverage (EOC), and Benefit Summaries.

 

To get started with the Advance Directives program, members will visit the Anthem member website and under the Benefits tab access a link for the Advance Directives program. Selecting this link will take the member to MyDirectives, where they can create a MyDirectives account or link an account if they already use MyDirectives.

 

MyDirectives has an easy-to-use guide that takes members through a series of questions around their care preferences, establishing of healthcare agents (medical powers of attorney), sharing of information, and more. If they already have a written advance directive, the software allows members to upload copies of their current directive, making it easier to store and share when necessary.

 

Physicians and hospitals can access a member’s advance directive via healthcare exchanges such as eHealth Exchange, Carequality, and CommonWell Health Alliance.

The benefit and associated links will be live as of the new plan year. We encourage you to speak to your members about the value of an establishing an advance directive and support members as they go through the process.

ABSCRNU-0269-21

Summary: On August 21, 2020, November 20, 2020, and June 24, 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 (Anthem). 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 need 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.

 

Please 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.

Effective date	Document number	Clinical Criteria title	New or revised
November 1, 2021	*ING-CC-0201	Rybrevant (amivantamab-vmjm)	New
November 1, 2021	*ING-CC-0042	Monoclonal Antibodies to Interleukin-17	Revised
November 1, 2021	*ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
November 1, 2021	ING-CC-0125	Opdivo (nivolumab)	Revised
November 1, 2021	ING-CC-0124	Keytruda (pembrolizumab)	Revised
November 1, 2021	*ING-CC-0102	GnRH Analogs for Oncologic Indications	Revised
November 1, 2021	ING-CC-0076	Nulojix (belatacept)	Revised
November 1, 2021	*ING-CC-0077	Palynziq (pegvaliase-pqpz)	Revised
November 1, 2021	ING-CC-0067	Prostacyclin Infusion and Inhalation Therapy	Revised
November 1, 2021	ING-CC-0194	Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection	Revised

ABSCRNU-0261-21

Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health_®* Diagnostic Coronary Angiography and Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

 

Diagnostic coronary angiography:

• Removed indications for asymptomatic patients (in alignment with the ischemia trial)
• Facilitated coronary angiography with a view to intervention in non-culprit vessels following
  ST-segment elevation myocardial infarction (STEMI), in alignment with the complete trial
• For patients undergoing preoperative evaluation for transcatheter aortic valve replacement (TAVR) or other valve surgery, aligned criteria with the updated American College of Cardiology (ACC)/American Heart Association (AHA) guideline for the management of patients with valvular heart disease

 

Percutaneous coronary intervention:

• Revised criteria such that, for some cohorts, only those patients with persistent unacceptable symptoms and moderate or severe stress test abnormalities can proceed to revascularization (in alignment with the ischemia trial)
• For non-left main percutaneous coronary intervention (PCI), expanded use to non-culprit vessels in patients following STEMI, and restricted use to those with moderate or severe stress test abnormalities who have failed medical therapy
• Left main PCI limited to situations where coronary artery bypass grafting (CABG) is contraindicated or refused (in alignment with noble and excel trials)
• Clarified requirements for patients who have undergone CABG: at least 70% luminal narrowing qualifies as stenosis, symptomatic ventricular tachycardia is considered an ischemic symptom, and instant wave-free ratio fractional flow reserve (iFR) is considered in noninvasive testing
• Removed requirement to calculate syntax score for patients scheduled to undergo renal transplantation
• For patients scheduled for percutaneous valvular procedures (e.g., TAVR/TAVI or mitral valve repair), added clarification that PCI should only be attempted for complex triple vessel disease when CABG is not an option
• AIM ProviderPortal_SM — com:
  • Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Availity Portal* — com
• AIM Contact Center toll-free number — 800-714-0040, Monday through Friday, 7 a.m. to 7 p.m. CT

 

What if I need assistance?

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 online.

ABSCRNU-0272-21

The City of New York has awarded their group retiree business to the Retiree Health Alliance, an alliance between Empire BlueCross BlueShield (Empire) and EmblemHealth. Effective January 1, 2022, approximately 240,000 Medicare-eligible City of New York retirees across the United States will transition to Retiree Health Alliance’s NYC Medicare Advantage Plus plan.

 

The NYC Medicare Advantage Plus plan is a Medicare Advantage PPO plan that allows retirees to receive services from both in-network and out-of-network providers. Out-of-network providers must be eligible to receive Medicare payments to provide care to NYC retirees. Under this new plan, City of New York retirees will have no difference in cost share for both in-network and out-of-network services. NYC Medicare Advantage Plus offers the same hospital and medical benefits covered by original Medicare as well as additional benefits original Medicare does not provide, such as an annual routine physical exam, hearing, health and fitness tracker, LiveHealth Online,* and SilverSneakers.*

 

Retirees enrolled in NYC Medicare Advantage Plus will have access to BlueCross BlueShield Medicare Advantage PPO Network Sharing effective January 1, 2022. Recently, you may have received calls from City of New York retirees inquiring if you are participating or if you accept NYC Medicare Advantage Plus. Retirees may also refer to the new plan as Medicare Advantage Plus or the Alliance.

 

Currently, City of New York retiree claims are processed by Medicare as primary and then by Empire for facility services or EmblemHealth for professional services as supplemental coverage under the General Health Insurance/Empire Senior Care plan.

 

• Providers should submit all claims (facility, professional, and ancillary) to your local Blue plan:
  • For independent clinical laboratories, providers should file to the BCBS Plan where the referring provider is located.
  • For durable/home equipment and supplies (D/HME), providers should file to the BCBS Plan where the equipment was shipped to or purchased from in a retail store.
• Providers should not transmit any claims to original Medicare.
• Claims can be submitted electronically or by paper submission (UB-04or CMS-1500 form) to your local Blue plan.

 

For additional information, review the NYC Medicare Advantage FAQ at https://www.anthem.com/da/inline/pdf/abscare-1134-21.pdf.

ABSCRNU-0278-21