As providers, you are committed to providing the best care for your patients – our members.  That care may now include telehealth visits.  Recognizing the continuing increased need for telephone and virtual services during the COVID-19 public health emergency, the U.S. Department of Health and Human Services (HHS) has given additional consideration to the treatment of telephone-only services in the HHS-operated Risk Adjustment Program.  HHS has clarified that telephone-only service CPT codes (98966-98968 and 99441-99443) are valid for the Risk Adjustment Program.  Telephone-only visits may benefit your patients who have not participated in, or felt comfortable using, a telehealth video visit.  Thank you for your continued commitment to assessing your patients’ health and closing possible gaps in care.

 

Please contact the Commercial Risk Adjustment Network Education Representative if you have any questions:

Socorro.Carrasco@anthem.com.

 

 

658-1020-PN-CONV

The National Accounts 2021 Pre-certification list has been published. Please note, providers should continue to verify member eligibility and benefits prior to rendering services.

 

 

660-1020-PN-CONV

CMS average sales price (ASP) fourth quarter fee schedule with an effective date of October 1, 2020 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on November 1, 2020. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.

 

 

648-1020-PN-CONV

Anthem Blue Cross and Blue Shield (Anthem) offers you the ability to have a copy of the member’s ID card without having to physically handle the member’s card. This easy, low-touch access to view a member’s ID card is available from the Availity Portal.

 

Accessing via the Availity Portal

 

When conducting an eligibility and benefits (E&B) inquiry for Anthem members via Availity, select Patient Registration | Eligibility and Benefits Inquiry and complete the required eligibility and benefits fields.  From the Eligibility and Benefits results page, simply select View Member ID Card. Note: the Availity Portal requires you to enter the member’s ID number as well as a date of birth, or the member’s first and last name into the search options in order to submit an E&B inquiry.

 

 

Images of both the front and back of the member ID card are available, allowing you to get all of the pertinent information without the need to make a phone call. The images can be saved directly to your practice management system as PDF files.

 

Accessing via the member’s mobile app

 

Another option available is to access the member’s digital version of their ID card as many members have transitioned to using a digital card instead of a paper card. Members are able to email or fax a copy of the electronic ID card from their phone/app.

 

We encourage you to integrate these options into your workflow now.

 

 

677-1020-PN-CONV

An online course for providers and office staff that addresses gaps in care and offers approaches to communication with patients.  This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians.

 

The What Matters Most training can be accessed at: www.patientexptraining.com.

 

 

653-1020-PN-CONV

Anthem Blue Cross and Blue Shield (Anthem) providers may now learn how to use Availity's attachment tools to submit and track supporting documentation electronically by attending one of the upcoming live webinars hosted by Availity. 

 

The attachments application is a multi-payer, multi-workflow feature. It allows inclusion of multiple records across a variety of workflows and request types to support different business processes for payers.

 

By attending one of the upcoming webinars, attendees will learn both the digital and electronic processes that include:

• How your organization gets set up
• Demonstrations of the tools used to submit attachments via Availity Portal
• Navigating the Attachments dashboard
• View electronic records of your submissions

 

As part of the session, we will answer questions and provide handouts and a job aid for you to reference later.

 

Register for an upcoming webinar session

1. In Availity Portal, select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options.
   • In the Catalog, search by webinar title or keyword (medattach).
   • Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you will receive emails with instructions to join the session.

 

October/November Dates

 

Date	Day	Time
10/07/2020	Wednesday	4:00 p.m. – 5:00 p.m. ET
10/20/2020	Tuesday	11:00 a.m. – 12:00 p.m. ET
11/04/2020	Wednesday	4:00 p.m. – 5:00 p.m. ET
11/17/2020	Tuesday	2:00 p.m. – 3:00 noon ET

 

Where can you find more help?

Select Help & Training > Find Help to display Availity Help in a new browser window.

Use Contents to display topics.

 

Depending on your needs, consider exploring these topics:

 

• Claim Submission
• Attachments (new)
• Medical Attachments (legacy)

 

 

702-1020-PN-CONV

As employers across the country host open enrollment periods for their employees, many will offer a new option this fall: plans built around a Blue High Performance Network (HPN).

 

Blue HPN® provide value to our Members and clients.  Anthem Blue Cross Blue Shield is launching Blue HPN to keep pace with the rapidly evolving nature of healthcare and to answer the call from our national employer groups to improve health outcomes and affordability of care for their organizations and employees.  Blue HPN networks will go live January 1, 2021 in more than 50 cities across the country.

 

Blue HPN 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 then connected to the national chassis to form a national Blue HPN network. In Colorado, the Blue HPN network includes the same set of providers as the Pathway PPO/EPO Network that was already in place.

 

If you are not sure whether your practice is part of the Pathway PPO/EPO network and therefore the Blue HPN, ask your office manager or business office, or contact your Anthem Provider Relations Representative. Blue HPN participation will be displayed in provider profiles in our online provider directory January 1, 2021.

 

Beginning January 1, you may see patients accessing this network through either 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 the national employer Blue HPN plan. Note the new “HPN” indicator in the suitcase icon.

 

Anthem will host a “Working with Anthem” webinar focused on Blue HPN Wednesday, November 18, 2020 at 12 p.m. MT. Please join us to learn about the Blue HPN and the new products built around this network.

 

Register for a Working with Anthem Webinar.  Webinars are recorded. Even if you are not able to attend on the scheduled date, please register to ensure you receive event recording details once available.

 

 

683-1020-PN-CO

We are continuing our series of “Working with Anthem” webinars for 2020.  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).

2020 Subject Specific Webinars -- October schedule

 

Topic:	Pathway Essentials
Date/Time:	Wednesday, October 28, 2020, 12-1pm MT
Description:	Join our webinar to learn more about details such as: ·  what is the Pathway Essentials Network ·  how do I know if I'm participating ·  how to identify members aligned with this network ·  sample member ID cards ·  plus more
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:  Even if you are unavailable to attend, please register to ensure you receive the event recording password once available as it’s distributed to all that register. 

 

 

656-1020-PN-CO

In anticipation of Anthem Blue Cross and Blue Shield and HMO Colorado Inc. (Anthem) open enrollment period this fall, we continue to develop networks to support new product offerings.  We will be offering a new narrow HMO network for the Individual and Small Group market in select counties in the Denver Metro and Boulder market. 

 

The Pathway Essentials network will be an HMO narrow network, available in the following counties: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Clear Creek, Elbert, Gilpin, Jefferson and Park.   Note:  this is a subset of our Pathway HMO network which is still in effect as a statewide network in Colorado.

 

Our Pathway Essentials network is aligned with the following hospital systems:

 

• Boulder Community Hospital
• HCA
• Medical Center of Aurora
• North Suburban Medical Center
• Presbyterian/St. Luke’s Medical Center
• Rose Medical Center
• Sky Ridge Medical Center
• Swedish Medical Center
• Spalding Rehabilitation Hospital
• Rocky Mountain Hospital for Children (HCA)
• Craig Hospital

 

Note: The Pathway Essentials network includes all behavioral health, ABA (autism), and ancillary providers (PT/OT/ST, home infusion, home health, DME, lab) in our standard HMO network, unless affiliated with a non-participating hospital system, as well as American Specialty Health (vendor for Chiropractic, Acupuncture, and Registered Dieticians).

 

Important Distinction:  While “Pathway” is included in the network name, Pathway Essentials is a separate network from our Pathway HMO network.  But, providers participating in the Pathway Essentials network, must also be participating in the Pathway HMO network. 

 

Anthem sent Amendments in July to those providers that will be participating in the Pathway Essentials network in addition to their continued participation in the Pathway HMO network.  The reimbursement rates for the Pathway Essentials HMO network will be the same as the Pathway HMO reimbursement rates. 

 

Identifying Members accessing the Pathway Essentials Network:

 

Three-Character Prefix	Health Benefits Plan Option	Product Type	Network Name (On Member ID cards)
P4E, X4X	Individual	HMO	Pathway Essentials
P3Y	Small Group	HMO	Pathway Essentials
P3S	Anthem Balance Funding (ABF)	HMO	Pathway Essentials

  

Pathway Essentials sample Member ID card

 

 

Provider Webinar opportunities featuring the Pathway Essentials Network

 

We will be conducting a “Working with Anthem” webinar regarding the Pathway Essentials on Wednesday, October 28, 2020 at 12pm MT.  Please join us to learn about our new Pathway Essentials network and the new products available to access this network starting January 1, 2021.

 

Webinar Registration link:  Register for a Working with Anthem Webinar.  Webinars are recorded. Even if you are not able to attend on the scheduled date, please register to ensure you receive event recording details once available.

 

Thank you for the care you provide to our members.

 

 

678-1020-PN-CO

We are excited to announce some updates to our Network Relations Team contact information that we think will best service your needs including faster turnaround times.  As a reminder our Network Relations Team is here to assist you with the follow types of questions/need:

• demographic updates
• credentialing inquiries
• provider education questions/needs

 

While we will still maintain our shared mailbox of COProviderRelations@anthem.com, this will primarily be used just for triaging emails to your designated representative in case you don’t know your direct contact.  Below is an overview of our Network Relations Team and their territory assignments:

 

Non-Ancillary Network Relations
Network Relations:  contact for demographic updates, credentialing inquiries, or provider education questions/needs
CO Provider Relations Team	Statewide:  All professional & facility providers, including Behavioral Health.	COProviderRelations@anthem.com
Jeremy Sterling	I-70 North and Pueblo	Jeremy.Sterling@anthem.com
Brandi Montoya	I-70 South (excluding Pueblo)	Brandi.Montoya@anthem.com
Lolly Esquibel	Western Slope	Lolly.Esquibel@anthem.com
Jackie Ferguson	Director, Network Relations	Jackie.Ferguson@anthem.com
Ancillary Network Relations
Enterprise Ancillary Team	If you aren’t sure of your direct ancillary contact, please utilize the Enterprise Ancillary Team email address for further assistance.	EnterpriseAncillary@anthem.com

 

Note:  Please do not duplicate sending emails to both the shared mailbox and your designated representative.

 

For claims questions/issues resolution Process:

If you have claims related questions, please ensure you are following the steps outlined below first before outreaching to the Provider Relations Team.  The Provider Claim Questions/Issue Resolution Process Flow documents below outline the information we will need to assist you in escalating an issue on your behalf.

 

• Send a Secure Message through Availity portal
• Provider Chat – via Availity I Payer Spaces I Applications I Chat with Payer
• Provider claim questions/issue resolution process flow for COMMERCIAL members
• Provider claim questions/issue resolution process flow for MEDICARE members

 

Updated Escalation Contact List:

Our new Provider Relations Team contact information has been updated on our Escalation Contact List and is available online. Please go to anthem.com.  Select Providers.  Under the Communications heading, select Contact Us.  Choose Colorado, then select Escalation Contact List.

 

 

664-1020-PN-CO

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

 

• Evaluation and management services correct coding
• May 2020 Medical Policies and Clinical Utilization Management Guidelines Update

 

 

ABSCRNU-0165-20

ABSCRNU-0167-20

 

 

Effective October 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will integrate community health workers (CHWs) used by GroundGame Health (GGH)* into our current care management program. Referrals into the program are completed via provider direct referrals or ad hoc referrals from the Anthem Case Management team. Provider direct referrals will include members with the following situations:

• Identified social determinants of health needs including, but not limited to:
  • Living environment
  • Transportation
  • Food insecurity issues
  • Financial issues
  • Social isolation, etc.
• Hospital readmissions
• A readmission risk score of more than 24

 

GGH provides an extra layer of support by using CHWs as an extension of care management to help members navigate the complex health care system. PCHP makes an initial outreach to identified members to determine the appropriate level of services a member may need, but they do not provide any clinical services, replace case management from Anthem, or replace the care and care management provided by PCPs and specialists. Note: There is no requirement that members participate in this program, and members have the opportunity to opt out of the program as they choose.

 

A GGH CHW may reach out to your practice to introduce themselves and establish a relationship with the physician(s) at your practice based on referrals received. CHWs may also discuss developing a mechanism by which to share information regarding patients who have been identified for complex care services.

 

The CHW may also broaden the impact of case management by focusing on action plan developments in various ways, such as helping members fill prescriptions, scheduling appointments and arranging rides to the doctor. CHWs can even accompany members to appointments when appropriate and provide connections to meal delivery services that may be available to them.

 

To learn more about GGH, please visit https://groundgamehealth.org. If you have questions regarding GGH, CHWs and complex care services, please call 1-866-739-6323 or email physicianreferral@preferredchp.com.

 

 

ABSCARE-0564-20

As you know, AIM Specialty Health_® (AIM)* administers the musculoskeletal program for Medicare Advantage members, which includes the medical necessity review of certain surgeries of the spine, joints and interventional pain treatment. For certain surgeries, the review also includes a consideration of the level of care.

                                                                                                                           

Effective December 1, 2020, two joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM guideline, it is generally appropriate to perform these two procedures in a hospital outpatient setting. To avoid additional clinical review for these surgeries, providers requesting prior authorization should either choose hospital observation admission as the site of service or

Hospital Outpatient Department (HOPD).

 

We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:

• Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
• Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.

 

On January 1, 2020, CMS removed total hip arthroplasty as well as six spine codes from the inpatient only (IPO) list making these procedures eligible for payment by Medicare in the hospital outpatient setting in addition to the hospital inpatient setting. The two-midnight rule should guide providers on the expected reimbursement. The codes that were removed from the inpatient only list and are also in the AIM Musculoskeletal program are 27130, 22633, 22634, 63265 and 63267. CMS has established a two year grace period (ending December 31, 2021) for site of service reviews of these codes in order to facilitate provider transition to compliance with the two-midnight rule. To this end, it is recommended that providers choose hospital observation or Hospital Outpatient Department (HOPD) during the prior authorization process when clinically appropriate to the respective patient. Choosing hospital observation still allows for the surgery to be performed and recovered in the main hospital, so long as discharge is planned for less than two midnights. Alternatively, the provider may choose to perform the procedure in the Hospital Outpatient Department (HOPD). However, the inpatient setting will still be approved should the provider decide it is the optimal setting for the member.

 

Providers should continue to submit prior authorization requests to AIM using one of the following ways:

• Access AIM ProviderPortal_SM directly at http://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 Portal* at http://www.availity.com.
• Call the AIM toll-free number at 1-800-714-0400, Monday through Friday 8 a.m. to 8 p.m. ET.

 

If you have questions, please contact the provider number on the back of the member’s ID card.

 

 

ABSCRNU-0163-20

On January 1, 2021, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements will change for codes below. 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.

 

Prior authorization requirements will be added for the following codes:

• C1764 Event recorder, cardiac (implantable)
• E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED
• E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS,
• E0731 Conductive Garment For Tens
• G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment
• L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each
• L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength
• L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each
• L3224 Woman's Shoe Oxford Brace
• L3225 Man's Shoe Oxford Brace
• L3300 Shoe Lift Taper To Metatarsal
• L3310 Lift, elevation, heel and sole, neoprene, per in
• L3332 Lift, elevation, inside shoe, tapered, up to one-half in
• L3334 Lift, elevation, heel, per in
• L3340 Heel wedge, SACH
• L3350 Shoe Heel Wedge
• L3370 Shoe Sole Wedge Between Sole
• L3390 Shoe Outflare Wedge
• L3400 Shoe Metatarsal Bar Wedge Ro
• L3450 Shoe Heel Sach Cushion Type
• L3485 Shoe Heel Pad Removable For
• L3540 Ortho Shoe Add Full Sole
• L3580 O Shoe Add Instep Velcro Clo
• L3610 Transfer of an orthosis from one shoe to another, caliper plate, new
• L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing
• L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new
• L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified
• L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
• L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf
• L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf
• L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf
• L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
• L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type
• L3912 Hand-finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the-shelf
• L3913 HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
• L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
• L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated,

off-the-shelf

• L3925 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf
• L3927 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/spring, extension/flexion (for example, static or ring type), may include soft interface material, prefabricated,

off-the-shelf

• L3999 Upper Limb Orthosis Nos
• L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system
• L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee
• L5620 Test Socket Below Knee
• L5645 Addition to lower extremity, below knee (BK), flexible inner socket, external frame
• L5649 Addition to lower extremity, ischial containment/narrow M-L socket
• L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
• 0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
• 0397T Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure.)
• 0421T Transurethral waterjet ablation of prostate, including control of post-operative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)
• 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure.)
• 0480T Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure.)
• 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation
• 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach
• 33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach
• 33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach
• 33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy)
• 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis
• 33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure)
• 33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed
• 33979 Insertion, Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle
• 33990 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only
• 36514 Therapeutic Apheresis; Plasma Pheresis
• 36522 Photopheresis, Extracorporeal
• 37215 Transcatheter Placement Of Intravascular Stent(S), Cervical Carotid Artery, Percutaneous; With Distal Embolic Protection
• 55874 Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed
• A4224 Supplies for maintenance of insulin infusion catheter, per week
• A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
• A5500 Diabetic Shoe For Density Insert
• A5501 Diabetic Custom Molded Shoe
• A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe
• A5504 Diabetic Shoe With Wedge
• A5505 Diabetic Shoe W/Metatarsal Bar
• A5507 Modification Diabetic Shoe
• A5512 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fah
• A5513 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each
• A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries
• C1722 Cardioverter-defibrillator, single chamber (implantable)
• L5671 Addition to lower extremity, below knee (BK)/above knee (AK) suspension locking mechanism (shuttle, lanyard, or equal), excludes socket insert
• L5673 Addition to lower extremity, below knee/above knee, custom fabricated
• L5679 Addition to lower extremity, below knee/above knee, custom fabricated
• L5700 Replace Socket Below Knee
• L5701 Replace Socket Above Knee
• L5940 Endo Bk Ultra-Light Material
• L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature
• L5981 All lower extremity prostheses, flex-walk system or equal
• L5987 All lower extremity prostheses, shank foot system with vertical loading pylon
• L8699 Prosthetic implant, not otherwise specified
• L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code

 

Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.anthem.com/medicareprovider > Login. Contracted and noncontracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.

 

 

ABSCRNU-0172-20

A key goal in our provider transparency initiative is to improve quality while managing health care costs. One of the ways we do that is by offering value-based programs including Freestanding Patient Centered Care (FPCC), Medicare Advantage Enhanced Personal Health Care Essentials and so on (known as the Programs).

 

Value-based program providers (also known as payment innovation providers) in our programs receive quality, utilization and/or cost data, reports, and information about the health care providers (referral providers) to whom the providers may refer their Anthem Blue Cross and Blue Shield (Anthem) patients. If a referral provider is higher quality and/or lower cost, this component of the Programs should result in the provider receiving more referrals from value-based program providers. The converse should be true if referral providers are lower quality and/or higher cost.

 

Providing this type of data to value-based program providers (including comparative cost information) helps them make more informed decisions about managing health care costs, maintain/improve quality of care and succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representative/vendors) may also be given data about value-based program providers or referral providers to better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Upon request, Anthem will share the data used to make these quality/cost/utilization evaluations and will discuss it with referral providers, including any opportunities for improvement.

 

If you have questions or need support, contact your local Market Representative or Care Consultant.

 

 

ABSCRNU-0171-20

Patient360 is a real-time dashboard you can access through the Availity Portal* that gives you a full 360° view  of your Anthem Blue Cross and Blue Shield (Anthem) patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.

 

What’s new: Medical providers now have the option to include feedback for Anthem patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application..

 

Once you have completed all the required fields on the Availity Portal to access Patient360 you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.

 

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

 

First, you need to be assigned to a Patient360 role, which your Availity administrators can locate within the Clinical Roles options.

 

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

                                                                                                                

Do you need a job aid to help you get started?

The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center.

1. From the Availity home page, select Payer Spaces > Anthem payer tile > Applications > Custom Learning Center
2. Select Resources from the menu located on the upper left corner of the page
   (To use the catalog filter to narrow the results, select Payer Spaces from the Category menu.)

3. Select Download to view and/or print the reference guide

 

 

ABSCRNU-0164-20

On February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the [Clinical Criteria Web Posting June 2020]. Visit Clinical Criteria to search for specific policies.

           

If you have questions or would like additional information, use this email.

 

 

ABSCRNU-0173-20