Patient360 is a dashboard you can access through the Availity Portal that gives you a full 360° view of your Anthem patient’s 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 available 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 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 the 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 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 Availity’s 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.
   1. (To use the catalog filter to narrow the results select Payer Spaces from the Category )
3. Select Download to view and/or print the reference guide

641-0920-PN-CONV

Anthem Blue Cross and Blue Shield (Anthem) would like to provide health plan information for National Account members living in Colorado utilizing the Pathway network.  These may be both Anthem and non-Anthem National Accounts

 

“CO Pathway” Network

 

National Account members living in Colorado have a health care plan which accesses the Pathway network with an EPO/PPO plan design.  The network name on the card will indicate “CO Pathway” rather than “Pathway”, “Pathway EPO/PPO”, or “Pathway Network” as you’ve seen previously.  While the “Pathway” network name may be slightly different for these members, the network utilized is the same whether the member ID cards reference “CO Pathway”, “Pathway”, “Pathway EPO/PPO”, or “Pathway Network”.

 

When receiving care inside Colorado, National Account members must access the Pathway network for their in-network benefits.  If a National Account member chooses to receive services from an out-of-network provider, his/her out-of-network cost shares (deductible, coinsurance, out-of-pocket maximum) will apply, with the exception of emergency care. 

 

Exceptions: 

• Emergency care services will be covered as in-network benefits regardless of whether services are rendered at an in-network or out-of-network hospital as long as the service is deemed to be an emergency. 
• Preventive care services must be provided by a Pathway provider. There are no out-of-network benefits available for preventive care services. 

 

Note:  Other National Accounts may access the CO Pathway network option in the future.  Some National Accounts may allow preventive care services under out of network benefits.  Please verify eligibility and benefits prior to rendering services.

 

Eligibility and Benefit specifics can be accessed through the Availity portal at availity.com, or by contacting the Customer Service number on the back of the Member ID card.

 

PPO Suitcase logo on Member ID card

Because a National Account with members living in multiple states, these members’ benefits are administered differently than our Local Plan members.  As such, the members living in Colorado will have a PPO in the suitcase logo on their ID card.  The PPO in the suitcase means these members have access to the PPO network when traveling outside of Colorado. 

 

National Accounts utilizing the Pathway Network

• Each National Account will have its own prefix.
• The Network Name will be listed as “CO Pathway” on ID cards.

 

There are different types of National Accounts.  It may be either a Home or Host National Account:

• Home = Anthem Account;
• Host = Partner Plan account (other Blues)

 

Identifying members tied to the Pathway network

 

National Account members living in Colorado and accessing the “CO Pathway” network will have a customized three-character prefix on Member ID cards (the 3 characters at the beginning of their ID number), but the prefixes will vary by group.  The best way to identify a National Account member is by the network name being “CO Pathway”. 

 

Three-Character Prefix	Health Benefits Plan Option	Product Type	Network Name (On Member ID cards)
VAB	Individual (Exchange)	HMO	Pathway
VAC	Small Group (Exchange)	HMO	Pathway
VAA	Individual (OFF Exchange)	HMO	Pathway
QWP, XFX	Small Group (OFF Exchange)	HMO	Pathway
VAE	Large Group	HMO	Pathway Network
QAB	Federal Employee Program	HMO	Pathway Network
Varies*	National Accounts	HMO	CO Pathway
PWL, CQQ	Small Group	EPO/PPO	Pathway EPO/PPO
WUS	Large Group	EPO/PPO	Pathway EPO/PPO

*Each National Account will have its own prefix. 

 

Note:  We’ve updated our Networks at a Glance document to include the National Account information. 

 

Sample Member ID Card for National Account members accessing the “CO Pathway” network

 

(Please note the Member ID card below is just a sample, and does not include actual member information such as copays, but is included when the Member ID cards are generated and sent to members prior to the effective date.)

 

National Account -- Home Account (Anthem account) sample

 

National Account -- Host Account (Partner Plan (other Blues)) sample

 

Anthem is dedicated to providing excellent customer service for our National Account members and their providers.  If you have any additional questions, please contact the number on the back of the member ID card.

 

 

638-0920-PN-CO

Anthem Blue Cross and Blue Shield (Anthem) will begin publishing new indicators in our online provider directories to help members easily identify facilities and physicians designated as medication assisted treatment (MAT) providers for opioid use disorder.

 

These directory indicators fall into four categories related to MAT:

• Facility that provides MAT
• Physician who provides MAT
• Facility with a certified opioid treatment program
• Facility that provides counseling for opioid use disorders

 

We encourage facilities and individual providers who provide these services to update their demographic information so these MAT indicators can be added to our directories.

 

To submit updated professional demographic information, please visit anthem.com and locate the Provider Maintenance Form to submit changes to your information. For facility updates, please contact your Contract Manger. Please contact Provider Services if you have any questions.

 

 

630-0920-PN-CONV

As a provider, we understand you are committed to providing the best care for our members, which may now include telehealth visits.  Telehealth visits are an acceptable form for seeing your patients, and assessing if they have risk adjustable conditions in support of the Anthem Commercial Risk Adjustment (CRA) prospective program. The prospective program is well under way for 2020, and focuses on member health assessments for patients with undocumented Hierarchical Condition Categories (HCC’s), in order to help close patients’ gaps in care.  We continue to provide updates regarding the prospective program to solicit your help getting patients in for a wellness visit before the calendar year ends, and we offer incentives to recognize your efforts (see details below.)

 

Inovalon Requests

 

Inovalon -- an independent company that provides secure, clinical documentation services -- helps us comply with the provisions of the Affordable Care Act (ACA) that require us to assess members’ relative health risk levels.  Please submit health assessments to Inovalon when completed and if you have questions, you can reach Inovalon directly at 1-877-448-8125.

 

Prospective Program ask of Providers

 

Anthem network providers -- usually PCPs -- receive letters from Inovalon, requesting that they:

1. Schedule a comprehensive in person or telehealth visit  with patients identified by Inovalon to confirm or deny if previously coded or suspected diagnoses exists, and;
2. Submit a Health Assessment documenting the previously coded or suspected diagnoses (also called SOAP Notes - Subjective, Objective, Assessment and Plan).

 

Incentives offered for properly submitted Health Assessments

 

• $100 for each Health Assessment properly submitted electronically via Inovalon’s ePASS® tool
• $50 for each Health Assessment properly submitted via fax

 

ePASS® is Training is available to ensure health assessment completion accuracy

 

• Training Webinars every Wednesday - 3:00 - 4:00 PM EST
• Register by sending an email to ePASSProviderRelations@inovalon.com with your name, organization, contact information and the date of the webinar you wish to attend. Information will be provided on how to join the webinar.

 

Alternative Engagement

 

Inovalon’s ePASS® tool is our preferred method for submission. However, we offer alternate options to be flexible and meet your needs. If in 2019 your practice utilized these alternative options for prospective member outreach, we thank you for continuing to utilize these alternative forms of program participation in 2020.

 

For those providers not familiar with alternative options, they are listed here. Telehealth visits are also an acceptable form of a patient visit for these alternative engagement options.  Any questions can be directed to the Anthem CRA Network Education Representative listed below.

 

• EPHC Providers using PCMS - Providers participating in our Enhanced Personal Health Care (EPHC) program can use member reports from our PCMS tool to schedule members for comprehensive visits. PCMS does have a link to take you directly to the Inovalon ePASS® tool where completed health assessments will result in a $100 incentive payment per submitted health assessment.
• List of Members to be scheduled - Anthem CRA provides member/patient reports for providers to schedule members for comprehensive visits. No health assessment needed. Not eligible for additional incentive because CRA will get the diagnosis for gap closure through claims submission.
• EPIC Patient Assessment Form (PAF) - Providers with EPIC as their electronic medical record (EMR) system can fax the EPIC PAF to Anthem CRA at 1-855-244-0926 with a coversheet indicating "see attached Anthem Progress Note,” which is eligible for a $50 incentive payment.
• Providers Existing Patient Assessment Form (PAF) - Utilizes providers’ existing EMR system and applicable PAF. Must be submitted to Anthem CRA at 1-855-244-0926 with coversheet indicating, "see attached Anthem Progress Note,“ which is eligible for a $50 incentive payment.

 

Please contact the Commercial Risk Adjustment Network Education Representative if you have any questions: Socorro.Carrasco@anthem.com.

 

Thank you for your commitment to assessing your patient’s health and closing possible gaps in care.

 

 

623-0920-PN-CONV

We are offering providers that are using Change Healthcare for revenue cycle management an opportunity to have a streamlined in-workflow solution native to Relay Assurance application.

 

Starting September 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will launch the use of Change Healthcare’s Medical Attachment functionality for electronic communications as an additional digital option. This new functionality allows providers to upload medical records and itemized bill documents electronically instead of through traditional paper communications. This functionality can improve communications and increase transparency for medical record requests and will not otherwise impact the audit program.

 

Important facts regarding this change:

• This change only affects providers who use Assurance Reimbursement Management™ from Change Healthcare and have opted in to using the Attach Assist
• The new functionality is only for medical record requests for postpay claims for the Payment Integrity Quality Claims Review (Provider Audit) department only.
• There will be no duplicate requests (either paper or electronic). If you opt to use this method, paper requests for medical records will not be sent.
• In Assurance Reimbursement Management™, requests for additional documentation will be displayed to the user on the History tab of the claim. Assurance will be configured such that these requests drive workflow to ensure they are brought to the user’s attention.
  • The original letter, historically sent via paper, is accessible as a PDF electronic copy in the provider’s downloads folder in Assurance for review. The letter content is exactly the same as it was in paper format.
  • Each request letter (first, second and final attempt) will have a timeframe for responding to the request. After the timeframe has passed for that letter, you will not be able to respond to that letter. If you wish to upload medical records after the response time has expired, please refer to the Change Healthcare training referenced below.
  • Providers can respond to the request by uploading records in Assurance Attach Assist. The attachments are received in almost real time and are delivered electronically to the payer’s systems through secure means. Records can be accessed through a hyperlink in Assurance Attach Assist for the particular claim the record is associated.
• The following is out of scope or not impacted:
  • Vendor requests for medical records on behalf of the payer
  • Providers who do not use Assurance Reimbursement Management™ Attach Assist from Change Healthcare or have not configured Attach Assist within Assurance Reimbursement Management™
  • The request timing of request letter and the verbiage in the request letter
  • The Program Integrity Special Investigations Unit postpay review is not included at this time.

 

Resources

Training is available on the Change Healthcare Connect Center at https://rcmknowledgecenter.changehealthcare.com/learn.

 

Can I start using the functionality earlier?

Yes, you can. If you chose to opt in earlier, please ensure you are configured within Assurance Reimbursement Management™. Request early access via email at dl-Prod-ChangeHealthcare-Provider-Support@anthem.com.

For additional information, see our Change Healthcare Medical Attachment functionality via Attach Assist FAQ.


617-0920-PN-CONV

Anthem now offers a full suite of options to assist with medical record submissions.  To ease your administrative burden and recognizing your staff may be working remotely, we have increased the intake channels for required medical records supporting claim submissions.

 

Here are the options available to you:

 

Leverage any of the following Availity-hosted channels for electronic claim attachment transmission:

• EDI Transaction: X12 275 Patient Information (version 5010)
  • Anthem supports the industry standard X12 275 transaction for electronic transmission of supporting claims documentation including medical records (pdf, jpeg, tif file types).
    • Access your X12 275 companion guide for more details.
  • Electronic Integrated Submission -- Submit the claim via EDI 837 batch file and supporting documentation via x12 275.
    
    
• Availity Secure Provider Portal Options
  • Direct Data Entry (DDE) -- The direct data entry claim application allows you to upload supporting documentation for a defined claim (unsolicited process).
  • Attachments-New tool -- Submit solicited or unsolicited supporting documentation for your claims
  • Attend an Availity hosted webinar to learn more about all capabilities

Start your transition today!

 

Start now to adopt these new processes and experience the many advantages to using an electronic option for claim attachment submission. You may find you are able to use these new processes to replace your more manual processes of submitting supporting documentation via fax or US Mail.

 

Advantages:

• Easy Submission  -- medical documentation may include but not limited to:
  • itemized bills
  • medical records
  • discharge summaries
• Less administrative burden -- medical records submitted electronically save an average of 4 minutes per record for staff vs. faxing or mailing your records in
• Electronic acknowledgment with a transaction audit trail -- confirm delivery/receipt
• Comprehensive history -- view past medical record submissions by your organization
• Administrative Savings -- reduce your mailing expense and/or fax related expenses

Want to learn more?

 

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’ll receive emails with instructions to join the session.

 

 

September/ October Dates

Date	Day	Time
09/10/2020	Thursday	11:00 a.m. -- 12:00 p.m. ET
9/21/2020	Monday	12:00 p.m. -- 1:00 p.m. ET
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

For assistance with set-up or submission contact Availity Client Services at 1-800-AVAILITY.

 

 

636-0920-PN-CONV

Migrate Your EDI Transactions to Availity Today! We want to remind you, as the Availity migration continues full speed ahead, Anthem will guide you to make it an effortless transition without having to rush.

 

If you, your clearinghouse or vendor have already migrated over to Availity, thank you and you are a step ahead! If not, start the process today to make the transition before September 15, 2020.

 

Take Action Now! Availity setup is simple and at no cost for you!

Use this link to learn about Availity to get started today: 

All EDI transmissions currently sent or received today via the Anthem gateway are now available on the Availity EDI Gateway. 

 

• 837 Institutional and Professional
• 837 Dental
• 835 Electronic Remittance Advice
• 276/277 Claim Status
• 270/271 Eligibility Request
• 275 Medical Attachments
• 278 Prior Authorization/Referrals
• 278N Inpatient Admission and Discharge Notification

 

Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:

 

• Transition your existing connection with Anthem and become a direct submitter with Availity.
• Use your existing Clearinghouse or Billing Company for your EDI transmissions. (Work with them to ensure connectivity to the Availity EDI Gateway).
• Use Direct Single Claim entry through the Availity Portal with the new attachment function

 

Share with your team what you learn

 

Enroll in one of Availity’s free courses and training demos at your convenience. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.

 

Follow these steps to register with Availity:

1. Log in and select Help & Training | Get Trained to open the Availity Learning Center in a new tab Search Catalog field and choose. It is your dedicated ALC account.
2. Search by keyword (Medical Attachments/Attachments) to find on-demand and live training options.
3. Click Enroll to enroll for a course and then go to your Dashboard to access it any time.

 

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday - Friday 8 a.m. - 7 p.m. ET.

 

 

635-0920-PN-CONV

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 -- September schedule

 

Topic:	Provider Claim Questions/Issue Resolution Process Flow
Date/Time:	Tuesday, September 29, 2020, 12-1pm MT
Description:	Learn the best way to get answers to your claim questions/issues for both Commercial and Medicare Advantage members: Resources available for claims questions/issue resolution. The steps to access those resources. The best time to contact the different teams and resources. Process flow to help better understand when different resources are used to help expedite claims related questions or resolve issues.
Registration link:	https://anthem.webex.com/anthem/onstage/g.php?PRID=b6a696587e498199466cadc7231c908d

 

Webinars are offered using Cisco WebEx. There is no cost to attend.  Attendance is limited, so please register today.

 

Watch for additional topics and dates in future issues of our monthly provider newsletter throughout the year.  

 

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. 

 

 

627-0920-PN-CO

If you have questions, you now have a new option to have them answered quickly and easily. With Anthem Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity.

 

• Faster access to provider services for all questions
• Real-time answers to your questions about prior authorization, appeals status, claims, benefits, eligibility, and more
• A platform that is easy to use making it simpler to receive help
• The same high level of safety and security you have come to expect with Anthem

 

Chat is one example of how Anthem is using digital technology to improve the health care experience, with a goal to save you valuable time. To start, access the service through Payer Spaces on Availity.

 

Use Provider Chat: Select Payer Spaces, select Anthem, and from Applications select Chat.

 

 

620-0920-PN-CONV

Material Adverse Change (MAC)

Site of Care* medical necessity reviews expand to numerous surgical procedures begin December 1, 2020

 

 

622-0920-PN-CONV

Anthem’s collaborative partnerships with oncology practices, which include sharing of relevant data, have helped drive improved outcomes. Our ‘Potentially Avoidable Admissions During Chemo’ model uses predictive analytics to equip oncologists with actionable, patient-level data to highlight those at greatest risk for complications during chemotherapy.

 

Since the launch of this model, early results indicate success, as observed by a 13% reduction in avoidable inpatient admissions.¹

 

Our oncology partners have recognized the value of this predictive modeling capability and routinely supplement their own information to proactively outreach to patients who may benefit from additional support during treatment.

 

Mary Scott, RN, from City of Hope says this data enables them make better decisions about patient care, “…best part [of this model] is having some data and some information and some specifics about patients that are deemed to be at risk and keeping them out of the hospital, which is a pretty critical part of our work. I think with the Anthem information we've been able to tackle that in a much better and more organized fashion because they provide us with a list of patients that are high risk, medium risk, and low risk for admission, people who are on chemotherapy, and these regimens can be pretty complicated, pretty toxic, and it helps us to make those better decisions for their care.”

 

Watch this video to hear more about how our collaborative partnerships with oncology practices is leading to improved outcomes.

 

For more information on Anthem’s Cancer Care Solutions, email cancer.quality@anthem.com or contact your Anthem Oncology Provider Clinical Liaison.

 

1 Anthem internal data. Among providers who participate in Anthem’s Cancer Care Solutions programs we observed 12.8% fewer avoidable inpatient days per 1,000 over baseline. Based on Anthem commercial business, January through December 2019.

 

 

626-0920-PN-CONV

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

 

• AIM Musculoskeletal program expansion

 

 

ABSCRNU-0159-20 

On May 15, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC (AMH Health). 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 May 2020 (Anthem) Clinical Criteria Web Posting May 2020 (AMH Health). Visit Clinical Criteria to search for specific policies.

           

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

 

 

ABSCRNU-0162-20