Beginning with claims processing on or after December 1, 2024, we will update our outpatient facility claims editing process to deny claim lines when an add-on code is reported without a primary procedure code.

An add-on code is a specific type designated by the HCPCS or CPT^®. These codes describe additional procedures or services performed with a primary procedure.

According to CPT guidelines, add-on codes must be reported with a primary procedure code.

If you believe you have received a claim denial in error, please follow our claim dispute process.

With your help, we can continually build towards a future of shared success.

The Department of Health & Human Services (HHS) requires health plans to report whether or not our in-network providers offer telehealth services.

If you provide telehealth services, please tell us by submitting your information to us through Availity.com. Updating your telehealth status will not affect your participation with us. We will add a telehealth indicator to your online provider directory profile, allowing our members to know you offer telehealth services.

If you have questions about submitting your information, please see the instructions below.

If your organization is not currently registered with Availity, you will need to create an account. The person(s) designated as your administrator(s) should go to Availity.com and select Get Started in the upper right corner of the webpage. You may also navigate directly to Availity’s registration website by selecting here.

Begin your application here. To update your application:

1. Log in to Availity Essentials.
2. Select My Providers.
3. Select Provider Data Management.

Please update your telehealth information at the service location.

As a contracted provider for a special needs plan (SNP) from Anthem, you are required to participate in an annual Model of Care training for providers, per CMS regulations. This training includes a detailed overview of Anthem special needs plans and program information, highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Please remember this training is specific to our plans and delivery of care for members, ensuring their specific care needs are met. Your participation is critical for improved quality and health outcomes.

Training for the SNP product is self-paced and available at Availity.com. The training must be completed by December 31, 2024.

How to access the Custom Learning Center:

1. Log in to the Availity website at Availity.com.
2. At the top of the Availity website, select Payer Spaces and select the appropriate payer.
3. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
4. In the Custom Learning Center, select Required Training.
5. Select Special Needs Plan and Model of Care Overview.
6. Select Enroll.
7. Select Start.
8. Once the course is completed, select Begin Attestation and complete.

Not registered for Availity Essentials?

Have your organization’s designated administrator register your organization for the Availity website:

1. Visit Availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

Refer to these PDF documents for complete registration instructions.

In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care, effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here.

Site of Care Guidelines:

• Site of Care for Advanced Imaging
• Rehabilitative Site of Care
• Surgical Site of Care

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

Effective on November 17, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.

You may access and download a copy of the current and upcoming guidelines here:

• Musculoskeletal:
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

The above guideline updates have a publish date of November 17, 2024.

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

At a glance:

• High Performing Providers will also be known as Anthem Diamond Providers.
• Providers receiving a designation based on the Blue National Physician Performance Dataset will also be known as Anthem Diamond Providers (National).

High Performing Provider program

Over the last several months, we have communicated with our providers about our High Performing Provider program. PCPs and specialists meeting certain criteria are designated High Performing Providers. High Performing Providers may also be referred to as Anthem Diamond Providers.

As a reminder, the following specialties may be designated High Performing Providers (aka Anthem Diamond Providers) from this program:

• PCP: family practice, general practice, geriatric medicine, internal medicine, pediatric medicine, and nurse practitioners
• Specialists: cardiology, endocrinology, nephrology, neurology, neurosurgery, obstetrics gynecology, orthopedic surgery, psychiatry, pulmonology, and rheumatology

If you have any questions about this program, contact Provider Services or your local provider relationship management representative.

Blue National Physician Performance Dataset

This is an Anthem designation program for providers in networks supporting Anthem national accounts and certain out-of-area providers.

As we previously communicated to you, effective January 1, 2025, Anthem may incorporate insights from the Blue National Physician Performance Dataset (Dataset) in various initiatives. For Anthem national accounts and certain out-of-area providers, Anthem will use data made available in the Dataset to assess individual physician’s performance at the NPI level. The individual physician’s performance is assessed across the three domains — cost of care/efficiency, quality of care, and appropriateness of care — for the following 16 primary care and specialty areas: cardiothoracic surgery, cardiovascular disease, endocrinology, neurology, ob/gyn, ophthalmology, orthopedics, pediatrics, primary care, pulmonology, surgery, urology, gastroenterology, otolaryngology, oncology, and radiation oncology.

The providers who qualify for the designation from this Dataset program will also be referred to as Anthem Diamond Providers (National).

If you have any questions regarding this, contact your local provider relationship management representative.

At a glance:

• Care providers must prepare for HEDIS^® medical record reviews starting January 2025.
• Care providers will submit records through Remote Electronic Medical Record (EMR) Access Service, website upload, fax, secure file transfer protocol (SFTP), mail, or on-site.

Background

Each year, we perform 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.

We will begin requesting medical records in January 2025. No special authorization is needed for you to share member medical record information with us since quality assessment and improvement activities are routine parts of healthcare operations.

Ways to submit your records in our preferred order:

• Remote EMR Access Service: We offer the Remote EMR Access Service to care providers to submit member medical record information to us. If you are interested in more information, contact us at Centralized_EMR_Team@anthem.com.
• Upload: Medical records can be uploaded to our secure website using the instructions in the request document.
• Fax: Medical records can be faxed to us using the instructions in the request document.
• SFTP: Medical records can be uploaded via a secure website.
• U. S. Postal Service: Medical records can be mailed to us using the instructions in the request document.
• On-site: Medical records can be pulled by a representative at your local office where medical records are located.

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

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

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.