September 2021 Anthem Provider News and Important Updates - Colorado

Contents

AdministrativeCommercialSeptember 1, 2021

Non-participating lab referrals

AdministrativeCommercialSeptember 1, 2021

National accounts 2022 pre-certification list

AdministrativeCommercialSeptember 1, 2021

Register now for our September CME webinars!

AdministrativeCommercialSeptember 1, 2021

Statin therapy for patients with diabetes

AdministrativeCommercialSeptember 1, 2021

6 simple strategies to help increase medication adherence

AdministrativeCommercialSeptember 1, 2021

Cure for the common cold: rest, fluids and this free prescription pad

Digital SolutionsCommercialSeptember 1, 2021

Get your payments faster when you sign up for electronic funds transfer

Reimbursement PoliciesCommercialSeptember 1, 2021

New reimbursement policy update: Inpatient facility transfers (MAC)

Reimbursement PoliciesCommercialSeptember 1, 2021

Reimbursement policy update: Drug screen testing - professional (MAC)

State & FederalMedicare AdvantageSeptember 1, 2021

Reimbursement policy update: DRG inpatient facility transfers

State & FederalMedicare AdvantageSeptember 1, 2021

Prior authorization/pre-certification form notification

State & FederalMedicare AdvantageSeptember 1, 2021

Keep up with Medicare news – September 2021

AdministrativeCommercialSeptember 1, 2021

Non-participating lab referrals

This is a reminder to ensure that you are referring Anthem Blue Cross and Blue Shield (Anthem) members to participating labs. LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs.  The relationship with LabCorp does not affect network hospital-based lab service providers, contracted pathologists, or contracted independent laboratories.  Physicians may continue to refer to all par providers as they have in the past.

Not only does your Anthem agreement obligate you to refer to participating labs where available, but members will only receive their full benefits from participating providers.  As a result, referring your patient and our member to a non-participating lab may expose them to a greater financial responsibility.  As a reminder, Quest Diagnostics is a non-participating laboratory for all lines of business in Colorado.

Unfortunately, there are certain non-participating labs that are offering to waive or cap co-payments, coinsurance or deductibles to our members in order to increase their overall revenue. These practices undermine member benefits and may encourage over-utilization of services.

These billing practices are also questionable in their legality.  Such a practice may present violations under state or federal anti-kickback laws and may constitute abuse of health insurance under the Colorado criminal code.

For a listing of Anthem participating laboratories, please check our online directory. Go to anthem.com.  Choose Select Providers, and Providers Overview.  Select Find Resources in Your State, and pick Colorado.  From the Provider Home tab, select the enter button from the blue box on the left side of page titled Find a Doctor (CO). 

Note:  When searching for laboratory, pathology, or radiology services, under the field “I am looking for a:” select Lab/Pathology/Radiology; and then under the field “Who specializes in:”, select Laboratories, Pathology, or Radiology as appropriate for your inquiry.

 

LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs:

LabCorp is capable of providing services that range from routine testing, such as basic blood counts and cholesterol tests, to highly complex diagnosing of genetic conditions, cancers, and other rare diseases.  LabCorp has specialized laboratories which cover the following areas of testing:

·Allergy Program

·Cancer Testing

·Cardiovascular    Disease

·Companion Diagnostics

·Dermatology

·Diabetes

·DNA Testing

·Endocrine Disorders

·Esoteric Coagulation

·Gastroenterology

·Genetic Testing

·Genetic Counseling

·Genomics

·HLA Lab for National Marrow Donor Program

·Hematopathology

·Infectious Disease

·Immunology

·Liver Disease

·Kidney Disease

·Medical Drug Monitoring

·Molecular Diagnostics

·Newborn Screening

·Pain Management

·Pathology Expertise w/range of Subspecialties

·Pharmacogenomics

·Preimplantation Genetic Diagnosis

·Reproductive Health

Ostetrics/Gynecology

·Oncology

·Toxicology

· Whole Exome Sequencing

·Virology

·Women’s Health

·Urology

 


Note:  This relationship with LabCorp does not affect network hospital-based lab service providers, contracted pathologists, or contracted independent laboratories.

To find a LabCorp location near you, go to LabCorp.com or call one of the phone numbers below.

For information about specialized assays or about requirements for special collection kits and specimen handling, call LabCorp at 303-792-2600 or toll free at 888-LABCORP (888-522-2677).

1282-0921-PN-CO

                                                                      

AdministrativeCommercialSeptember 1, 2021

Register now for our September CME webinars!



Overview:

Join us in a Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving STARs ratings.

 

Program objectives:

 

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

 

Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.

 

REGISTER HERE for our upcoming clinical quality webinars!

1301-0921-PN-CO


AdministrativeCommercialSeptember 1, 2021

Working with Anthem webinars – September 2021 schedule: Self-service tools: Quick Reference Guide

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: 

Self-service Tools:  Quick Reference Guide

Date/Time:

September 28, 2021 from 12-1pm MT

Description:

Get an overview of our new Self-Service Tools Quick Reference Guide which includes helpful information for Commercial and Medicare Advantage on the following topics:

 

- Public Website

- Availity portal

- Electronic Funds Transfer (EFT)/Electronic Remittance Advice (ERA)

- New provider joining an existing group

- Provider Enrollment application status inquiry

- Provider demographic changes

- Claim questions: Accept/reject, follow up, issue resolution

- Prior Authorizations

- AIM Specialty Health

- Commercial Risk Adjustment (CRA)

- Provider Education and Training

- Provider Communications registration

- 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: 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.

1316-0921-PN-CO

AdministrativeCommercialSeptember 1, 2021

Statin therapy for patients with diabetes

Adults 40–75 years of age with diabetes, who do or do not have clinical atherosclerotic cardiovascular disease (ASCVD), should be started on a statin for primary and secondary prevention of ASCVD regardless of lipid status.1


Studies show that statin use reduces comorbidities and mortality from heart disease and non-adherence to statins may increase cardiovascular events and even death.2

Clinicians play a powerful role in ensuring their patients are adherent to their statin therapies. In fact, 90% of patients can be successfully adherent to statin therapy with a personalized approach.

CALL TO ACTION: We created this video to offer clinicians best practices in helping their patients remain adherent to their statin therapies.

The following 7 strategies can help increase adherence to statin therapy in your patients:

  1. Initiate statin therapy for patients with diabetes or clinical ASCVD as appropriate
    • For diabetics without ASCVD, use MODERATE INTENSITY statin for primary prevention.2
    • For diabetics with ASCVD, use HIGH INTENSITY statin for secondary prevention.1
    • Low Intensity statins are not recommended unless unable to tolerate moderate or high intensity.4

Medications

One of the following medications must have be dispensed to satisfy the SUPD measure.

Drug Category

Medications

Statin medication

·         Lovastatin

·         Fluvastatin

·         Pravastatin

·         Simvastatin

·         Rosuvastatin

·         Atorvastatin

·         Pitavastatin

Statin combination products

·         Atorvastatin / amlodipine

·         Atorvastatin / ezetimibe

·         Lovastatin / niacin

·         Simvastatin / ezetimibe

·         Simvastatin / niacin

·         Simvastatin / sitagliptin

Timeframe

Standard exclusion(s)

Any time during the measurement year

·         End-stage renal disease

·         Hospice

·         Rhabdomyolysis or myopathy

·         Pregnancy, lactation, or fertility

·         Liver disease

·         Pre-diabetes

·         Polycystic ovary syndrome (PCOS)


  1. If a statin is not suitable for a patient, document exclusion criteria with the appropriate ICD-10 code
  2. Educate patients about the long-term cardiovascular benefits of statin therapy and potential side effects 
  3. Try a lower dose, different statin, or consider intermittent statin therapy if there were previous statin-associated side effects

Intensity and Dose of Statin Therapy

High Intensity

Moderate Intensity

Low Intensity

1. Daily dose lowers LDL-C on average by ≈ ≥50%

2. Daily dose lowers LDL-C on average by ≈ 30% to <50%

3.  Daily dose lowers LDL-C on average by <30%

4. Atorvastatin 40-80 mg

5. Rosuvastatin 20-40 mg

6. Atorvastatin 10-20 mg

7. Rosuvastatin 5-10 mg

8. Simvastatin 20-40 mg

9. Pravastatin 40-80 mg

10. Lovastatin 40 mg

11. Fluvastatin XL 80 mg

12. Fluvastatin 40 mg bid

13. Pitavastatin 2-4 mg

14. Simvastatin 10 mg

15. Pravastatin 10-20 mg

16. Lovastatin 20 mg

17. Fluvastatin 20-40 mg

18. Pitavastatin 1 mg


  1. Inform patients that a significant number of generic statin medications are available for $0 for a 90-day supply on most plans
  2. Encourage patients to use their plan ID card to fill statin medications
  3. Watch this video to learn best practices on helping improve statin therapy adherence and your organization’s overall quality and STARS performance.


References:

 

1 2013 ACC/AHA Prevention Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S1-S45, June 24, 2014. https://www.ahajournals.org/doi/pdf/10.1161/01.cir.0000437738.63853.7a

 

2 American College of Cardiology, The New 2017 American Diabetes Statement on Standards of Medical Care in Diabetes: Reducing Cardiovascular Risk in Patients with Diabetes, May 22, 2017. https://www.acc.org/latest-in-cardiology/articles/2017/05/22/11/00/new-2017-american-diabetes-statement-on-standards-of-medical-care-in-diabetes

 

3 CMS, 2019 Medicare-Medicaid Plan Performance Data Technical Notes. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination Office/FinancialAlignmentInitiative/Downloads/MMPPerformanceDataTechNotes.pdf


4 Cochrane Database Syst Rev. 2013:CD004816

1304-0921-PN-CO

AdministrativeCommercialSeptember 1, 2021

6 simple strategies to help increase medication adherence

Did you know the cost Impact of medication non-adherence is $528 billion from non-optimized medication therapy?1 That’s equivalent to 16% of U.S. total health expenditures and contributes to 275,689 deaths per year.2

As a healthcare provider, you can motivate your patients to adhere to their medication regimens, which can contribute to improved outcomes and increased STARS performance.

We developed this video to offer best practices in boosting medication adherence among your patient population.

Use the 6 SIMPLE strategies below to help improve medication adherence among your patient population.

S - Simplify the regimen

  • Limit the # of doses and frequency
  • Encourage adherence aids such as a pill box
  • Utilize generic prescriptions if clinically appropriate
  • Implement real-time pharmacy benefit to understand patient cost-share at the point of care

I - Impart knowledge

  • Assess patient’s knowledge of medication regimen
  • Provide clear medication instructions (written and verbal)
  • Patient-provider shared decision-making

M - Modify patient beliefs and behavior

  • Ask open ended questions about impact of not taking medications
  • Empower patients to self-manage their condition

P - Provide communication and trust

  • Provide emotional support
  • Allow adequate time for the patient to ask question

L - Leave the bias

  • Understand patient’s health literacy and how it affects outcomes
  • Develop a patient-centered communication style

E - Evaluate Adherence

  • Utilize motivational interviewing to confirm adherence
  • Review pharmacy refill records, Rx bottles, lab testing
  • Identify barriers to adherence
  • Determine interventions and follow-up
  • When appropriate, prescribe 90 day fills for chronic conditions  

 

Watch this video to learn more best practices on helping improve medication adherence and your organization’s overall quality and STARS performance.


Reference:

1 Lloyd J et al. How much does medication nonadherence cost Medicare fee-for-service program? Med Care. 2019; 00:1-7.

2 Watannabe JE et al. Cost of prescription drug-related morbidity and mortality. Ann Pharmacother. 2018;52(9):829-837.DOI: 10.1177/060028018765159

1305-0921-PN-CO

AdministrativeCommercialSeptember 1, 2021

Cure for the common cold: rest, fluids and this free prescription pad

A mother has a sick child and like all good mothers, wants comfort and care. And a prescription for antibiotics. BMJ Journals published a study that rated how many patients with upper respiratory infections (URI) prior to consultation with their physician expected a prescription for antibiotics[i]:

Evidence-based data does not support the use of antibiotics in the treatment of the common cold because they do not improve symptoms or shorten the course of the illness.[ii] Instead of putting away the prescription pad, use this one.

Offered by the CDC’s Be Antibiotics Aware campaign, the “Relief for common symptoms of colds and cough” prescription pad provides an alternative to unnecessary antibiotics. Get it through the CDC website here.



Measure up: HEDIS® guidelines for URI/Pharyngitis

URI measures the percentage of episodes for members 3 months of age and older with a URI diagnosis that did not result in an antibiotic dispensing event.

Appropriate Testing for Pharyngitis (CWP) evaluates members 3 years of age and older where the member was diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.

Records and Billing Codes

URI: In the patient’s medical records, document results of all strep tests or refusal for testing. If antibiotics are prescribed for another condition, take care to associate the antibiotic with the appropriate diagnosis.

Description

CPT/HCPCS/ICD-10

Pharyngitis

ICD10CM: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91

URI

ICD10CM: J00, J06.0, J06.9

Online assessments

CPT: 98970, 98971, 98972, 99421, 99422, 99423, 99457                                       HCPCS: G0071, G2010, G2012, G2061, G2062, G2063

Telephone visits

CPT: 98966, 98967, 98968, 99441, 99422, 99423

 

CWI: In the patient’s medical records, document results of all strep tests or refusal for testing. If antibiotics are prescribed for another condition, take care to associate the antibiotic with the appropriate diagnosis.

 

Description

CPT/HCPCS/ICD-10

Pharyngitis

ICD10CM: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91

Group A streptococcal tests

CPT: 87070, 87071, 87081, 87430, 87650-87652, 87880                                           LOINC: 11268-0, 17656-0, 17898-8, 18481-2, 31971-5, 49610-9, 5036-9, 60489-2, 626-2, 6557-3, 6558-1, 6559-9, 68954-7, 78012-2

Online assessments

CPT: 98970, 98971, 98972, 99421, 99422, 99423, 99457                                       HCPCS: G0071, G2010, G2012, G2061, G2062, G2063

Telephone visits

CPT: 98966, 98967, 98968, 99441, 99422, 99423

 

iBMJ Journals. Medical management of acute upper respiratory infections in an urban primary care out of hours facility: cross-sectional study of patient presentation and expectations. https:/bmjopen.bmj.com/content/9/2/e025396

iiNCBI. Upper Respiratory Tract Infection. https//www.ncbi.nlm.nih.gov/books/NBK532961/

1306-0921-PN-CO

 

 

 

AdministrativeCommercialSeptember 1, 2021

HEDIS® medical record submission made easier with our remote EMR access service

Instead of faxing multiple pages of medical records for HEDIS® studies, use Anthem Blue Cross and Blue Shield’s (Anthem) remote EMR access service we offer to providers that allows us to access your EMR system directly to pull the documentation we need. Our remote EMR access service helps reduce the time and costs associated with medical record retrieval while improving efficiency and lessening the impact on your office staff.

We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS® measure updates. We complete medical record retrieval based on minimum necessary guidelines:

  • We only access medical records of members pulled into the HEDIS® sample using specific demographic data.
  • We only retrieve the medical records that have evidence related to the HEDIS® measures.
  • We only view face sheets when there are demographic discrepancies.
  • We exclude data related to hospice, long-term care, inpatient, and palliative care.

 

Let us help you! Getting started with remote EMR access is just one click away.

Download and complete this registration form and email it to us at Centralized_EMR_Team@anthem.com.

To learn more about our remote EMR access service, view the frequently asked questions (FAQ) below.

Q. How do you retrieve our medical records?
A. We access your EMR using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally, on our secure network drives.

Q. Is printing necessary?

A. Yes. The NCQA audit requires print-to-file access.

Q. Is this process secure
A. Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives.

Q. Why does Anthem need full access to the entire medical record?
A.There are several reasons we need to look at the entire medical record of a member:
  • HEDIS® measures can include up to a 10-year look back at a member’s information.
  • Medical record data for HEDIS® compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
  • Compliant data may be documented or housed in a non-standard format, such as an in-office lab slip scanned into miscellaneous documents 

 

Q. What information do I need to submit to use your remote EMR access service?
A. Complete the registration form that requests the following information:

  • Practice/facility demographic information (e.g., address, National Provider ID, taxpayer identification numbers, etc.)
  • EMR system information (e.g., type of EMR system, required access forms, access type – web based or VPN-to-VPN connection, special requirements needed for access, etc.)
  • List of current providers/locations or a website for accessing this list. Also, if applicable, a list of providers affiliated with the group that are not in the EMR System.


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

1313-0921-PN-CO

Digital SolutionsCommercialSeptember 1, 2021

Get your payments faster when you sign up for electronic funds transfer

Effective November 1, 2021, EnrollSafe will replace CAQH Enrollhub as the electronic funds transfer (EFT) enrollment portal for Anthem Blue Cross and Blue Shield (Anthem) providers. As of November 1, 2021, CAQH Enrollhub will no longer offer EFT enrollment to new users.

 

When you sign up for EFT through EnrollSafe, the new enrollment portal, you’ll receive your payments up to seven days sooner than through the paper check method. Not only is receiving your payment more convenient, so is signing up for EFT. What’s more, it’s easier to reconcile your direct deposits.

 

EnrollSafe is safe, secure and available 24-hours a day.

 

Beginning November 1, 2021, log onto the EnrollSafe enrollment hub at enrollsafe.payeehub.org to enroll in EFT. You’ll be directed through the EnrollSafe secure portal to the enrollment page, where you’ll provide the required information to receive direct payment deposits.

 

Already enrolled in EFT through CAQH Enrollhub?

 

If you’re already enrolled in EFT through CAQH Enrollhub, no action is needed unless making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.

 

If you have changes to make, after October 31, 2021, use EnrollSafe to update your account.

 

Electronic remittance advice (ERA) makes reconciling your EFT payment easy and paper-free.

 

Now that you are enrolled in EFT, using the digital ERA is the very best way to reconcile your deposits – securely and safely. You’ll be issued a trace number with your EFT deposit that matches up with your ERA on Availity.

 

ERAs can be retrieved directly from Availity.  Log onto Availity and select Claims and Payments > Send and Receive EDI Files > Received Files folder.  When using a clearinghouse or billing service, they will supply the 835 ERA for you.  You also have the option to view or download a copy of the Remittance Advice under Payer Spaces > Remittance Inquiry tool.

 

1294-0921-PN-CO

State & FederalMedicare AdvantageSeptember 1, 2021

Reimbursement policy update: DRG inpatient facility transfers

Effective November 30, 2021, Anthem Blue Cross and Blue Shield claims for members who leave against medical advice and are admitted to another acute care facility on the same day are considered transfers and will follow the criteria detailed in the policy.

For additional information, please review the DRG Inpatient Facility Transfers reimbursement policy at www.anthem.com/medicareprovider under the Facilities dropdown.

 

ABSCRNU-0240-21

519179MUPENMUB

State & FederalMedicare AdvantageSeptember 1, 2021

Prior authorization/pre-certification form notification

The best way to ensure you're submitting everything needed for a prior authorization is to use the prior authorization/precertification form at https://www.anthem.com/medicareprovider > Providers > Provider Resources > Forms and Guides. By filling out the form completely and with as much information as possible, you can be sure we have the information to process your request timely.

 

ABSCRNU-0248-21

519257MUPENMUB

State & FederalMedicare AdvantageSeptember 1, 2021

Keep up with Medicare news – September 2021