Connecting with Anthem and staying informed is easy, faster and convenient with our Network eUPDATEs. Network eUPDATE is our web tool for sharing vital information with you. It features short topic summaries on late breaking news that impacts providers: 

• Important website updates
• System changes
• Medical policy updates
• Claims and billing updates

……and much more

Registration is fast and easy. There is no limit to the number of subscribers who can register for Network eUPDATEs, so you can submit as many e-mail addresses as you like. Please note: we recently updated our website and the link to register for eUPDATEs is now accessible at the top of the new ‘Newsletters and eUPDATEs’ webpage, which is located on the Publications webpage under the Communications tab.

Effective for professional claims (CMS-1500) processed on or after November 18, 2018, we will enhance our editing systems to automate edits supported by correct coding guidelines, as documented in industry sources such as CPT, HCPCS Level II, and International Classification of Diseases 10 (ICD-10). As a result, there will be greater focus on identifying incorrect or inappropriate billing of services by multiple providers within the same tax identification number for the same patient on the same day. This enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

Below are examples of claim edits that will be automated:

• Accurate reporting of modifiers, including LT, RT, 54-56, 62, 76-82, and AS, which are often reported for the billing of services rendered by the same provider or multiple providers.
• Ensuring global, professional (modifier 26) and technical components (modifier TC) are billed appropriately by one or more providers in facility and office settings.
• Assessing whether services considered once in a lifetime have been billed more than once.
• Ensuring the reporting of procedures and the associated diagnosis codes are correctly reported together. 

The Affordable Care Act (ACA) requires many health plans to cover recommended preventive care services without member cost sharing when the services are rendered by an in-network provider and/or facility. Screening colonoscopies (even when polyps are removed) are included as a covered preventive care service. Since colonoscopies are rendered for both screening and diagnostic purposes, it is very important for providers to use appropriate coding guidelines when reporting colonoscopies. When inappropriate CPT and ICD-10 codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.

The following services are covered with no member cost share:

• Colonoscopy screening procedure
• Anesthesia charges when anesthesia is billed with the appropriate screening CPT code (even when polyps are removed)
• Other associated facility charges when the colonoscopy is billed with an appropriate screening diagnosis code
• Removal, examination and analysis of polyps when the polyps are removed during a screening colonoscopy

In the instance where a screening colonoscopy starts out as screening but turns into a diagnostic procedure due to polyps being removed, we follow CPT guidelines for our Commercial members, not Medicare guidelines. The CPT® 2018 Professional Edition manual shares the following information regarding the billing of anesthesia for any screening colonoscopy, “Report 00812 to describe anesthesia for any screening colonoscopy regardless of ultimate findings.”

As part of our commitment to provide you with the latest clinical information, we have posted a VBAC Shared Decision Making Aid to our provider portal. When discussing treatment options with your patients, you may wish to use this tool as an aid in helping them make treatment decisions. This tool has been reviewed and certified by the Washington Health Care Authority (HCA) and is available on our website. 

To better assess measures of quality for our members, we will begin requiring documentation of a newborn’s gestational age at the time of delivery for all physician delivery claims.

Beginning with dates of service on and after November 1, 2018, all professional delivery claims (59400, 59409, 59410, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620 and 59622) will require an ICD-10 Z3A code indicating the newborn’s gestational age at the time of delivery. If the code is not found on the claim, the claim will be denied with the following reason: “Delivery diagnoses incomplete without report of pregnancy weeks of gestation. You may resubmit the corrected claim with the appropriate ICD-10 code for payment.”

In the October 2017 edition of Network Update, we shared information regarding the application of monetary penalties, such as a reduction in payment, for failure to comply with the pre-certification requirements of the Utilization Management Program. The notice indicated that we require pre-certification prior to certain elective services in both the inpatient and outpatient settings. For an emergency admission, pre-certification is not required; however, you must notify us of the admission within the timeframe specified in the Provider Manual or as otherwise required by law. Failure to comply with these requirements can result in reimbursement penalties for commercial claims. For clarification, the reimbursement penalties may be 30% or 100%, which means the claim may be denied in full. Providers and facilities may not balance bill the member for any such reduction in payment.

For more information about the Utilization Management Program, please see the Provider Manual located on our provider website.

Our Care and Cost Finder tool provides many Anthem members with the ability to search and compare cost and quality measures for in-network providers using the secure member portal at anthem.com. The Care and Cost Finder tool currently offers multiple sorting options, such as sorting providers based on distance or name.

Beginning October 14, 2018, Care and Cost Finder will have a new sorting option called “Personalized Match”. The sorting option is based on algorithms which will use a combination of provider location, quality, cost results and member information to intelligently sort and display results for a member’s search. The sorting results will take into account member factors such as the member’s medical conditions, and medications as well as provider factors such as areas of specialty, quality and efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures. These member and provider features will be combined to generate a unique ranking of providers for each member conducting the search. Providers with the highest overall ranking within the search radius will be displayed first with other providers displayed in descending order based on overall rank and proximity to the center of the search radius.

Members will continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology will have no impact on member benefits.

Providers may review a copy of the new sorting methodology here.

If you have general questions about the Care and Cost Finder tool or this new sorting option, please contact Provider Customer Service. If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-5250.

We will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions. 

We accept electronic medication prior authorization requests for commercial health plans. This feature reduces processing time and helps determine coverage quicker. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.

Electronic prior authorization (ePA) offers many benefits:

• More efficient review process
• Ability to identify if a prior authorization is required
• Able to see consolidated view of ePA submissions in real time
• Faster turnaround times
• A renewal program that allows for improved continuity of care for members with maintenance medication
• Prior authorizations are preloaded for the provider before the expiration date

Providers can submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.

While ePA helps streamline the prior authorization process, providers can also initiate a new prior authorization request by fax or phone. Please note, the contact numbers for all Medicare plans will change effective September 1, 2018.

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

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research.

All guidelines are reviewed annually, and updated as needed. The current Practice Guidelines are available on our website.

We have partnered with Availity to become our designated EDI Gateway. The effort is currently underway, and we are committed to providing transparency for our customers.

All EDI submissions currently received today via the Anthem EDI Gateway are all now available on the Availity EDI Gateway. There is no impact to the provider’s participation status with us and no impact on how claims adjudicate.

If you are connected to Availity you can use your same connection for your EDI submissions.

If you are using another clearinghouse, contact your clearinghouse to validate their transition dates. If your clearinghouse notifies you of changes regarding connectivity, workflow, or the financial cost of EDI transactions, there is a no-cost option available to you. You can submit claims directly through Availity.

Your organization can register with Availity to submit the following transactions:

• 837 - Institutional
• 837 - Professional
• 837 - Dental
• 835 - Electronic Remittance Advice
• 276/277 - Claim Status – real-time
• 270/271 - Eligibility – real-time

Next steps:

• Anthem and Availity will continue to communicate and provide assistance with this transition going forward.
• Availity will be working directly with all trading partners.
• We do recommend that you register with Availity for your EDI transmissions for a free fully subsidized option.

How to register with Availity:

• If your organization is not already registered with Availity you can go to www.availity.com, click REGISTER and then follow the steps to register.
• Look for emails, from Availity, containing your log in credentials.
• If your organization is already registered with Availity, you can log in and click My Providers | Enrollments Center if you need to complete new 835 enrollment or make changes.

We look forward to delivering a smooth transition to the Availity EDI Gateway. If you have any questions please contact Availity Client Services at 800-282-4548 Monday through Friday 8:00 a.m. to 7:30 p.m. 

Are you an Anthem provider and need help transitioning to using Availity’s Gateway solutions? Are you looking for standard file transfer protocol (SFTP) or other batch upload options? If yes, check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session.

During this fast-paced hour, you’ll learn how to:

• Understand Availity’s EDI Gateway and Clearinghouse workflow
• Enroll for and manage 835 ERA delivery with Availity
• Use the Availity Portal to manage file transfers, set up EDI reporting preferences
• Access and navigate the Availity EDI Guide…and more

To enroll

• Log in to the Availity Portal.
• Click Help & Training | Get Trained.
• In the Catalog, click Sessions.
• Scroll through Your Calendar to view upcoming live events.

Webinar schedule

• Monday, August 20, 3:00 p.m. to 4:00 p.m.
• Thursday, August 23, 1:00 p.m. to 2:00 p.m.
• Tuesday, August 25, 12:00 noon to 1:00 p.m.
• Thursday, August 27, 3:00 p.m. to 4:00 p.m.

You can search the Availity Learning Catalog by keyword to access live and on-demand training recommendations curated by Availity Learning especially to help you with this transition. The keyword is “song” for Anthem.

We’ve heard it all our lives:  To be fair, you should treat everybody the same.  But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well.

The reality is burden of illness, premature death, and disability disproportionately affects certain populations.1  MyDiversePatients.com features robust educational resources to help support you in addressing these disparities. 

You’ll find:

• CME learning experiences about disparities, potential contributing factors and opportunities for you to enhance care.
• Real life stories about diverse patients and the unique challenges they face.
• Tips and techniques for working with diverse patients to promote improvement in health outcomes.

While there’s no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com is to start reversing these trends…one patient at a time.

Accelerate your journey to becoming your patients’ trusted health care partner by visiting MyDiversePatients.com today.

1. Centers for Disease Control and Prevention. (2013, Nov 22). CDC Health Disparities and Inequalities Report — United States, 2013. Morbidity and Mortality Weekly Report. Vol 62(Suppl 3); p3.

By the end of 2018, Anthem members will begin receiving a new explanation of benefits (EOB) that is designed to help members better understand their health care benefits and out-of-pocket expenses. The new design will look more like a health care summary. EOBs will continue to include important information about services rendered, the amount paid to the provider, and the member out-of-pocket expense.

The new EOB will also include:

• Ways members can save on health care expenses
• A preventive care checklist, sharing important screenings that were missed
• A summary of the member’s most recent claims

Learn more about our newly designed EOB.

A key goal of our provider transparency efforts is to improve quality while controlling health care costs. One of the ways this is done is by giving primary care physicians (PCPs) in the Enhanced Personal Health Care (EPHC) Program quality and/or cost information about the health care providers to which the PCPs refer their attributed members (the referral providers). If a referral provider is higher quality and/or lower cost, this component of the program should result in their getting more referrals from PCPs. The converse should be true if referral providers are lower quality and/or higher cost. Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost information so that they can better understand how their health care dollars are being spent. 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.

Cost Opportunity Report

• The Cost Opportunity Report is available for EPHC providers to access via Provider Care Management Solutions (PCMS).
• The report was created to help users quickly identify meaningful and actionable opportunities to optimize costs and help achieve shared savings targets within the EPHC Program.
• By providing a standard set of potential cost opportunity metrics, the Cost Opportunity Report can be used to help evaluate the relative success of providers within the EPHC Program.
• Metrics are selected based on size of financial opportunity, ability of PCPs to affect changes, mix of impacted service types, mix of utilization and unit price impact.
• Metrics are reviewed on a periodic basis and may be added, changed or removed.

We will share data on which it relied in making these quality/cost evaluations upon request, and will discuss it with referral providers including any opportunities for improvement. For questions or support, please refer to your Care Consultant.

As we communicated in the December 2017 provider newsletter, we have established a contractual relationship with Alliant Health Solutions to assist us in validating provider compliance with applicable reimbursement policies and identify instances of incorrect billing for behavioral health services. Alliant has initiated the work on our behalf and your compliance is required should you receive a request for information.

Alliant is a behavioral health audit and review company and will examine Anthem outpatient behavioral health claims data. Utilizing systematic sampling methodology and a broad range of algorithms, the audits and findings will be customized to support our expectations as outlined in our Provider Manuals and related policies and procedures. Alliant findings may result in provider audits and record reviews, education and other direct outreach. 

Effective for dates of service on and after November 1, 2018, AIM Specialty Health® (AIM), a separate company, will apply AIM’s Radiation Oncology Clinical Appropriateness Guidelines to pre-service clinical review requests for the services noted below. These guidelines will replace certain Anthem radiation oncology medical policies and clinical guidelines, which are being archived. This update applies to Anthem plans with radiation oncology services medically managed by AIM.

• Proton beam radiation therapy

Ordering and servicing providers may submit pre-service clinical review requests to AIM in one of several ways:

• Access AIM’s ProviderPortal^SM directly at 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 Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 866-714-1107, Monday – Friday, 8:00 a.m. – 5:00 p.m.

Please note, this program does not apply to FEP or National Accounts.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

Beginning with dates of service on and after October 29, 2018, the following updates will apply to AIM Advanced Imaging Clinical Appropriateness Guidelines.                                                                                                                           

CT chest guideline 

• Expanded list of diagnostic testing abnormalities that may be followed up with CT to include endoscopy, fluoroscopy, and ultrasound in addition to specific chest radiography findings
• Lengthening of timeframe required prior to imaging for chronic cough from 3 to 8 weeks, and more specifics of preliminary workup required prior to imaging
• Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging
• Allowance for use of imaging in the staging of malignancy prior to biopsy confirmation
• Allowance for imaging of suspected pulmonary embolism in pregnancy
• New criteria for appropriate imaging of chest wall mass

CT angiography (CTA) chest guideline 

• Allowance for imaging of suspected pulmonary embolism in pregnancy

CT abdomen/CT pelvis/CT abdomen & pelvis guideline 

• Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging

MRI chest guideline 

• Inclusion of imaging of suspected pectoralis muscle tear
• New criteria for appropriate imaging of chest wall mass

MRI abdomen guideline 

• Addition of hemochromatosis as an indication for imaging in pediatric patients

Ordering and servicing providers may submit pre-service clinical review requests to AIM in one of the following ways:

• Access AIM’s ProviderPortal^SM directly at 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 Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 866-714-1107, Monday – Friday, 8:00 a.m. – 5:00 p.m.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

Beginning with dates of review on and after November 1, 2018, the following updates will apply to AIM level of care Musculoskeletal Surgery Clinical Appropriateness Guidelines:                                                                                                                        

• Addition of criteria for observation in surgical settings, ambulatory surgical centers, and hospital outpatient departments
• Addition of staff, equipment, and resource capabilities in outpatient surgery
• Modifications to the inpatient admission criteria

Ordering and servicing providers may submit pre-service clinical review requests to AIM in one of the following ways:

• Access AIM’s ProviderPortal^SM directly at 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 Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 866-714-1107, Monday – Friday, 8:00 a.m. – 5:00 p.m.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

Beginning with dates of service on and after November 1, 2018, we will expand pre-service clinical review requirements to include upper gastrointestinal (GI) endoscopy, also referred to as esophagogastroduodenoscopy (EGD). AIM Specialty Health® (AIM), a separate company, will administer this EGD review on our behalf.

EGD procedures will be reviewed against clinical guideline CG-MED-59 Upper Gastrointestinal Endoscopy, for clinical appropriateness and to help ensure care aligns with established evidence-based medicine. Please note, procedures performed in an inpatient or observation setting, or on an emergent basis will not be reviewed under CG-MED-59. Note that CG-MED-59 will be available on our anthem.com website prior to its November 1, 2018 adoption.  

A complete list of EGD CPT codes requiring precertification is available on the AIM Surgical Procedures website.

Submit a request for review

Starting October 17, 2018, ordering providers may submit precertification requests for dates of service November 1, 2018 and after to AIM in one of the following ways:

• Access AIM’s ProviderPortal^SM directly at 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 Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m.

Please note, this review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view pre-certification requirements for local Anthem members at Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements at anthem.com. Providers should continue to verify eligibility and benefits for all members prior to rendering services.

For questions, please contact the Provider Service number on the back of the member’s ID card.

We are working with Accordant Health Services to provide targeted disease management services for members with rare medical conditions, including: 

• Epilepsy (seizures)
• Rheumatoid arthritis (RA)
• Human Immunodeficiency virus (HIV)
• Multiple sclerosis (MS)
• Crohn's disease (CD)
• Ulcerative colitis (UC)
• Parkinson's disease (PD)
• Systemic lupus erythematosus (SLE or lupus)
• Myasthenia gravis (MG)
• Sickle cell disease (SCD)
• Cystic fibrosis (CF)
• Hemophilia
• Scleroderma
• Polymyositis
• Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)
• Amyotrophic lateral sclerosis (ALS)
• Dermatomyositis
• Gaucher disease

Members in your care who may benefit from additional outreach and information may receive letters or phone calls from us and/or AccordantCare. In the course of performing these activities, a nurse may contact you or your facility to obtain member information and/or AccordantCare may request medical information about our members.

AccordantCare and Anthem will also let you know of any health changes that may require your attention.

If you would like to refer a member to this program, please contact AccordantCare at:

Phone or Fax: 866-247-1150

Web: https://referral.accordant.com

Plan name: AnthemReferrals Password: ref1088Anthem

We have several incentive programs this year to encourage Medicare Advantage members to obtain preventive screenings. Members may be rewarded when they complete their annual routine physical with their PCP. Eligible members will receive a gift card for completing their screening mammogram, a colorectal cancer screening or their diabetes retinal exam. Our members may ask that you confirm these screenings.

To help our members receive the DME equipment they need and help ensure no disruption in care, it is important to document that the physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the member. Additional details on this requirement and other information that will help ensure that your prior authorization request for a wheelchair is processed efficiently will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider.

We accept electronic medication prior authorization requests for Medicare plans. This feature reduces processing time and helps determine coverage more quickly. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.

Electronic prior authorization (ePA) offers many benefits:

• More efficient review process 
• Ability to identify if a prior authorization is required 
• Able to see consolidated view of ePA submissions in real time
• Faster turnaround times
• A renewal program that allows for improved continuity of care for members with maintenance medication
• Prior authorizations are preloaded for the provider before the expiration date.

Submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.

While ePA helps streamline the prior authorization process, if you must initiate a new PA request by fax or phone, please note that the contact numbers for Medicare Prior Authorization will change September 1, 2018.

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

The Centers for Medicare & Medicaid Services recently issued regulations related to opioid analgesics to help improve patient safety and reduce the misuse of opioid analgesics.

Beginning January 1, 2019, all short- and long-acting opioids will reject at the point of sale if prescribed for more than seven days. This edit applies to members who do not have an opioid prescription in the previous 60 days.  The edit excludes members with cancer or members in hospice. 

These edits are intended to allow those with intractable pain an opportunity to maintain their pain control while helping reduce the potential for misuse or addiction among those who are experiencing acute pain.   

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

• Inpatient Readmissions Medicare Advantage Update  
• Prior authorization requirements for Part B drugs Retacrit, Damoctocog and Ilumya 
• Medical Policy Update
• Prior authorization requirements for Part B drugs: Azedra and Poteligeo
• Prior authorizations required for new group-sponsored MA membership
• Contracted provider responsibility and liability for Issuance of Notice of Medicare Non Coverage to a Skilled Nursing Facility
• Improve Medicare Advantage members’ medication adherence with 90-day prescriptions
• Prior authorization requirements for cardiovascular services  
• Medicare Advantage reimbursement policy provider bulletin

72598MUPENMUB 06/18/2018

We have entered in to a collaborative partnership for certain Anthem Medicare Advantage plans with OptumCare® Network of Connecticut (OptumCare IPA). This partnership includes our CareMore at-home program and our delegation of certain administrative functions for members who select or are assigned an OptumCare IPA primary care provider (PCP). 

Our delegation of administrative services shall apply to the following Anthem MediBlueSM plans:

• Anthem MediBlue Plus HMO
• Anthem MediBlue Dual Advantage (SNP)
• MediBlue Select (HMO)

Members who have selected a PCP who is part of the OptumCare IPA will be issued new identification cards to reflect the updated information outlined below.

Please note this delegation does not apply to members who select/are assigned PCPs outside of the OptumCare IPA.

Providers who have questions about participation in the OptumCare IPA should call the OptumCare Network Development Department at 860-284-5326.

Effective July 1, 2018, the OptumCare IPA will assume the following administrative functions for Anthem MediBlue Plus HMO, Anthem MediBlue Dual Advantage (SNP), and MediBlue Select (HMO) members who have selected an OptumCare IPA PCP. All other services, including claims processing will be retained by Anthem.

Pre-certification Requests

• Providers should contact OptumCare for pre-certifications. Requests can be submitted to OptumCare electronically through their online portal at https://provider.optumcare.com. (If you do not yet have access, please call OptumCare Network Development at 860-284-5326 to receive log-in information.)
• Pre-certification requests may also be submitted by calling 888-556-7048 or by faxing requests to 855- 268-2904.
• For your convenience, the Anthem Medicare Advantage Precertification Requirements can be accessed here.

Medical Management

• To obtain prior authorization, please call the provider number listed on the back of the member’s identification card 888-556-7048.

Credentialing Process

• Non-OptumCare IPA providers: Providers who are not contracted with the OptumCare IPA must continue to follow the Anthem credentialing process.
• OptumCare IPA providers: OptumCare will handle all credentialing for its participating providers, including submission of any demographic changes or terminations.

If you have any questions, please contact our Medicare Provider Services Unit at 866-673-4157.

72748CTSENABS 06/15/18