Beginning in April 2021, our online directories will identify professional providers who offer telehealth services in their practice.

We encourage providers to utilize the online Provider Maintenance Form to notify us about your telehealth services and we will add a telehealth indicator to your online provider directory profile.

Visit anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.

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Effective July 1, 2021, we will upgrade to the 25th edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC), Recovery Facility Care (RFC), and Behavioral Health Care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

Goal length of stay (GLOS) for inpatient and surgical care (ISC)

New guidelines for behavioral health care (BHC) and recovery facility care (RFC)

Anthem customizations to MCG care guidelines 25th Edition

Effective July 1, 2021, the following MCG care guidelines 25th edition customizations will be implemented.

Transcranial Magnetic Stimulation, W0174 (previously ORG: B-801-T) - Revised Clinical Indications for Procedure and added the following:

• Need for acute TMS treatment, up to 6 weeks
• Acute treatment course needed as indicated by
  • (a) Initial course of treatment for major depressive disorder (severe), or
  • (b) Relapse of symptoms after remission
• Continuation of acute treatment, up to 6 months
• TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
  • Maintenance TMS treatment
  • Continuation of acute TMS treatment for longer than 6 months
  • TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, anxiety disorders, bipolar depression, neurodevelopmental disorders, obsessive-compulsive disorder, peripartum depression, post-traumatic stress disorder, substance use disorders, Tourette's syndrome.

Visit our website for a detailed summary of customizations, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25^th Edition.

For questions, please contact the provider service number on the back of the member's ID card.

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We are pleased to announce that a new Anthem Provider Manual, incorporating information for both professional and hospital/facility providers, will be available on anthem.com July 1, 2021. The provider manual replaces the prior version published in July 2020, and it allows you to link directly to many important forms, policies, and tools on our website. These links to material that is frequently updated on our website will help ensure that you are receiving the most current information available.

The manual can be found on https://www.anthem.com/provider/policies/manuals/. Scroll down to the Manual Library to view and/or download the provider manual as well as BlueCard and Medicare Advantage manuals.

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Did you know your Availity administrator for your organization is the key to opening doors to self-service transaction roles such as EDI. A role is a group of job functions, also known as permissions. Each role consists of one or more permissions. Assigning roles is part of the process when you add a new Availity user with the Add User feature.

What EDI roles do I need?

EDI Management - This role consists of the following permissions available under EDI File Management in the Availity menu:

• EDI Reporting Preferences– Specify the EDI batch report files you want users at your organization to receive, along with file formats and other reporting preferences.
• EDI Send and Receive Files– Review EDI batch report files for batch files submitted using Availity's EDI File Management feature. In addition, review payer responses to Availity Web-based claim forms submitted to payers that process claims in batches.
• File Restore– Restore archived EDI files to your ReceiveFiles

Set up EDI Reporting Preferences

Availity's batch EDI processing generates response files for each batch file that you submit. The administrator for an organization can set reporting preferences that specify which response files are generated. In the Availity Portal menu, click Claims & Payments > EDI Reporting Preferences.

Enroll for the Direct Data Entry Transaction

You must be assigned the Claims role to submit professional claims or encounters. If you cannot access the claim form, contact your administrator to assign the Claims role to you. Submit transactions through manual data entry in Availity Portal. In the Availity Portal menu, click Claims & Payments > Professional Claim/Facility Claim/Dental Claim < Confirm which organization and payer you would like to submit claims for and continue to complete the fields to be directed to the simple and time saving claim form to enter claim information.

Need more help?

The EDI Connection Services Startup Guide is a helpful resource to help you get started, set up your EDI reporting preferences and submit transactions through manual data entry in Availity Portal.

Contact Availity

• Select Help & Training > Get Trained to display the Availity Learning Center (ALC) in a new browser tab. Search the catalog to locate and enroll in courses. Based on your needs.
• 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:
  • Administrator
  • Claim submission
  • Electronic Data Interchange (EDI)
  • Glossary

• Select Help & Training > Availity Support to:
• Open a ticket to request support
• Get support via Chat

Call 1-800-AVAILITY (282-4548) to speak with an Availity Client Service rep for more support.

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Anthem and Availity are excited to announce the Prior Authorization/Referrals 278 and Inpatient Admission and Discharge Notification 278N 5010 transactions functionality. 

Authorization and Referral Request (278) 

Use this transaction to electronically submit authorization and referral requests. You have the option to transmit this transaction in real-time or batch mode, and you will receive confirmation numbers to validate receipt of request.

• An authorization is a review and approval of specific services
• A referral is used to refer a patient to a specialty provider

Hospital Admission Notification (278N)

Use this transaction to electronically submit hospital admission notifications between your facility and health plan.  The EDI 278N is the easiest, most efficient way to communicate facility admissions.  Just like the 278, you can also transmit in either batch or real-time format which includes the ability to update a previously submitted date.

What are your benefits for using these transactions?

• Streamline administrative tasks and increase productivity
• Reduce administrative costs through automation
• Increase data accuracy by reducing manual errors
• Confirm a notification of admission is on file in the form of a service reference number that is generated upon registration
• Submit notification of discharge
• Accomplish more with less ‒ fewer phone calls, faxes or keying

Getting Started

• If you use a clearinghouse or vendor work with them to ensure they have the capability to exchange these transactions.
• If you use practice management software have your Availity administrator use the following path to enroll:
  • My Providers > Enrollment Center > Transaction Enrollment

Useful Documents

• Availity EDI Companion Guide communicates Availity-specific requirements and other information that supplements requirements and information already provided in standard EDI and HIPAA communications.
• Anthem specific companion guide communicates requirements for submitting these transactions. These are located on the company website at - anthem.com/edi.
• The Availity Quick Start Guide will assist you with any EDI connection questions you might have.

If you need assistance, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8:00 a.m. to 8:00 p.m.

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The Information Center has replaced the Education and Reference Center application in Payer Spaces on the Availity Portal. There you’ll find important policies, forms and helpful resources.

If you’re looking for specific education materials, we invite you to visit the Custom Learning Center in Availity, which was designed to offer education/training content and to be a learning environment.  Content previously posted in the Communication & Education tab have now migrated there. Find the Custom Learning Center tool in Payer Spaces > Applications > Access the Custom Learning Center.

Locate the Information Center in Payer Spaces. Depending on your market, the Information Center contains a number of sections:

• Administrative Support
• Behavioral Health
• Clinical Resources
• Medicaid                              
• Medicare
• Federal Employee Program® (FEP®)

To view content in both of these valuable tools, visit Payer Spaces today.

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The Centers for Medicare & Medicaid Services (CMS) has issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates, that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS has identified Health Level 7^® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

Anthem’s Clinical Data Acquisition Group has integrated admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange can help Anthem:

• Better support members with care coordination and discharge planning – leading to healthier outcomes for our members – your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings to better manage out-of-pocket expenses.

Anthem would like to digitally exchange HLT ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real time HL7 ADT messaging data, or at least within 24-hours of admission, discharge or transfer, enables Anthem to most effectively manage care transitions.

Contact the Clinical Data and Analytics team to get started today at ADT_Intake@Anthem.com.

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Healthcare and mental healthcare professionals have a vital role in identifying, treating, and addressing racial trauma and injustice, moving our communities towards racial equity, and improving the health and wellbeing of all Americans.

We can impact the injustice of racism together.

Anthem has partnered with Motivo*, the first HIPAA-compliant digital platform that connects mental health therapists and clinical supervisors, to take on the challenge of facilitating conversations on racial injustice, trauma, and inequality among our providers and associates.

We are hosting Racial Equity forums on a quarterly basis to keep the conversation going. Please register for the next forum, Deconstructing Bias, to learn more about the impact of racism on healthcare and the people we serve, and what we can do about it.  

In Pursuit of Racial Equity: Deconstructing Bias

Wednesday, June 9, 2021
4:00 p.m. – 5:30 pm

Register today!

Our racial equity forums focus on:

• Exploring how racism takes shape in healthcare.
• Discussing how to identify racism in your practice and how to be an ally to your patients.
• Understanding the impact of prolonged exposure to racism on people of .
• Providing you with actionable resources to put an end to racism in your practice.

Since October 2020, Anthem has sponsored two virtual forums featuring healthcare professionals from Anthem and Motivo: Racial Trauma in America and The Road to Allyship: Playing Your Part in Racial Equity.

We know we are on the right track because the Racial Equity Forum participants say so.

• 90% received meaningful information about the influence that racism and white privilege may have on their perspectives and gained an understanding on what actions they can take to make a difference and be an ally.
• 86% obtained useful information and resources that will enhance their ability to serve patients.
• 75% agreed that the forum helped them understand a different perspective.
• 76% had some of their perspectives and beliefs challenged.

Systematic racism is a part of today’s healthcare system.

• US physicians underestimate the pain level of Black patients 47% of the time vs. 33.5% of the time for white patients (PNAS).
• Black women die from pregnancy or childbirth 243% more often than white women (CDC).

The first step to addressing racism is to recognize its existence, subtle or otherwise.

These conversations can be uncomfortable, but this is how you can do something about racial injustice now.

At Anthem, we are determined to reduce racism in our communities with your support and participation.

*Motivo is an independent company providing a virtual forum on behalf of Anthem.

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Having the common goal of reaching all Latinos in the US, Anthem, Inc., the Beckman Research Institute of City of Hope, the National Hispanic Medical Association, and Pfizer, Inc., announce the launch of Tomando Acción por Nuestra Salud/Taking Action for Our Health, a free interactive bilingual website aimed at eliminating health disparities in the Latino community. The website encourages preventive health screenings for cancer, emotional health, heart health, and prediabetes. It also provides tools to help people care for the emotional health of their families and themselves in the language of their preference.

The interactive website highlights the importance of health screenings, addresses barriers and provides information on access to low and no cost healthcare services in the community. The easy to use website, guides participants through four programs where they can learn about risk factors, take action to get screened, monitor their progress, and share their results with their doctors, health care teams or family and friends to let them know they are taking steps to protect their health and help encourage others to participate as well.

The website is not exclusive for Anthem members. Health care providers are encouraged to share the website with all of their Latino patients.

The website identifies four major targets of undue poor health outcomes for Latinos. In response, Tomando Acción por Nuestra Salud/Taking Action for Our Health strives to help increase cancer screening, screening for depression/anxiety-risk, heart diseases and prediabetes and provides tools to address emotional health. The website includes a 4-part workshop series “Compartiendo el Café y el Chocolate/Coffee and Chocolate” to help people care for the emotional health of their family and themselves. This is a program, specifically for Hispanics, that uses a holistic approach to emotional stability. It builds on cultural strengths to balance four key items—community, body, mind, and spirit.

To access Tomando Acción por Nuestra Salud/Taking Action for Our Health visit: Taking Action for Our Health.

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The fast, easy way to have your questions answered

If you have questions about prior authorizations (PA), you now have a new option to have them answered quickly and easily. With Anthem Chat, providers can have a real-time, online discussion with a PA specialist.

• Faster access to PA provider services experts
• Real-time answers to your questions about PA and live help for submissions, similar to the call experience
• Access to denial information and clinical team for resolution
• 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 healthcare experience, with a goal to save you valuable time. To start, access the service through Payer Spaces on Availity.

To access chat, log on to www.Availity.com. Select Payer Spaces then select the health plan. Once in Payer Spaces, select the Chat with Payer box from Applications.

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Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Anthem contracted laboratories and identify the proper CPT codes to use.

Contact your Anthem representative for additional information or visit anthem.com/coronavirus/providers.

COVID-19 testing coding guidelines

• For a new or established patient, CPT code 99211 would be appropriate if patient is being seen for no other services besides a specimen collection.
• For a patient assessment in addition to a specimen collection it is appropriate to bill the applicable E&M service, CPT codes 99202-99215. Specimen collection is a component of the E&M service and is not separately reimbursable.
• Effective April 1, 2021, CPT codes G2023 and G2024 are appropriate when billed by clinical laboratories only and are not appropriate for provider practices.

Refer patients to anthem.com/coronavirus to find convenient testing locations

If an Anthem member requests a COVID-19 test, you may refer them to anthem.com or the Sydney Health mobile app to find testing locations near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:

• Appointments or walk-ins
• Drive-thru service
• Antibody testing
• Testing for children
• Rapid test results

Send swab tests to Anthem-contracted laboratories

When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high value health care.

Consider antigen testing when rapid test results are needed

• Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), e.g. PCR. Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.
• Antigen tests can be used to detect current infection, are relatively easy to use, and most can provide point-of-care testing results. The Centers for Disease Control and Prevention (CDC) notes that proper interpretation of antigen test results (and confirmatory testing with NAAT when indicated) is important for accurate clinical management of patients with suspected COVID-19; more information can be found here.
• The CDC notes that when molecular tests are unavailable or rapid turnaround time is needed, antigen tests can generally be used for diagnosis of COVID-19.
• Antigen tests are typically less sensitive and clinicians should interpret negative results carefully.  When symptoms are present or a high clinical suspicion exists, negative antigen tests should be confirmed with a molecular test.
• When antigen tests are used in symptomatic patients, positive antigen tests can be interpreted as indicative of SARS-CoV-2 infection and do not usually require follow-up testing.

Consider using COVID-19 and flu combination testing when appropriate

• According to the CDC, clinicians should consider testing for other causes of respiratory illness, including infections such as influenza, when clinically appropriate.

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Effective for dates of service on and after July 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will increase the reimbursement penalty for failure to comply with the Utilization Management (UM) program’s prior authorization requirements for services rendered to commercial plan members. Late prior authorizations, and late notices in the case of emergency admissions, are currently subject to a penalty and will be subject to the increase in the penalty. Failure to comply with Anthem’s prior authorization requirements, and late notice requirements in the case of emergency admissions, will result in a 100% reduction in reimbursement to the provider and facility. 

As a reminder, Anthem requires prior authorization prior to the delivery of certain elective services in both the inpatient and outpatient settings. For an emergency admission, prior authorization is not required; however, you must notify Anthem of the admission within the timeframe specified in the Provider Manual or as otherwise required by law. Failure to give timely notification for emergency admissions will also result in reimbursement penalties of 100% to providers and facilities.

Enforcement of the program requirement will lead to greater consistency in our processes. This notice updates Anthem’s UM program reimbursement penalties and the corresponding sections of the Provider Manual to reflect this change to the reimbursement penalty for non-compliance. These updates will be reflected in the next updated version of the Provider Manual. As a reminder, providers and facilities may not balance bill the member for any such reduction in payment.

In May 2020, the Centers for Disease Control (CDC) released a report that showed a drop in routine childhood vaccinations as a result of COVID-19; a result of stay at home orders and concerns about infection during well-child visits. Both the American Academy of Pediatrics and the CDC recommend the continuation of routine childhood vaccinations during the COVID-19 pandemic, noting they are essential services.

To encourage well-visits and vaccinations, here are some extra steps you can take, if you haven’t already, to make visits as safe as possible for both patients and staff. They include:

• Scheduling sick visits and well-child visits during different times of the day
• Asking patients to remain outside until it’s time for their appointment to reduce the number of people in waiting rooms
• Offering sick visits and well-child visits in different locations

It’s important to identify those children who have missed immunizations and well-child visits to schedule these essential in-person appointments. To help, the CDC has published vaccine catch-up guidance on their website.

Important update from The National Committee for Quality Assurance (NCQA)
In a recent webinar, NCQA stressed the importance of getting childhood immunizations as soon as possible citing the impacts from the possible summer COVID-19 vaccine launch for children. Physicians are being advised that children should not receive any other vaccinations two (2) weeks prior to or two (2) weeks after receiving a COVID-19 vaccine. They reemphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactive scheduling and preplanning.

Helpful information for keeping babies and children healthy

Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:

• Four (4) DTaP (diphtheria, tetanus and acellular pertussis)
• Three (3) IPV (polio)
• One (1) MMR (measles, mumps, rubella)
• Three (3) HiB (H influenza type B)
• Three (3) HepB (hepatitis B)
• One (1) VZV (chicken pox)
• Four (4) PCV (pneumococcal conjugate)
• One (1) HepA (hepatitis A)
• Two (2) or three (3) RV (rotavirus)
• Two (2) Influenza (flu)

Billing codes:

• MMR:
  • CPT: 90707, 90710
  • ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
• Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
• Rubella:
  • ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
  • CPT: 90706
• Rubella antibody CPT: 86762
• Hepatitis A (HepA):
  • CPT: 90633
  • ICD-10-CM: B15.0, B15.9
• Influenza:
  • CPT: 90655, 90657, 90661-90662, 90673, 90685-90689
  • HCPCS: G0008
• Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)

Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:

• One (1) meningococcal vaccine (MCV) injection between 11 to 13 years of age
• One (1) tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
  10 to 13 years of age
• Two (2) or three (3) HPV vaccines between 9 to 13 years of age

Billing codes:

• Meningococcal CPT: 90734
• Tdap CPT: 90715
• HPV CPT: 90649-90651

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

For a complete list of HEDIS® measures, descriptions and coding tips, visit anthem.com.

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The Blue Cross Blue Shield Association recently published an updated study that showed a downward trend in the physical health of millennials (those born between 1981 and 1996) driven largely by behavioral health conditions. There were notable increases in major depression (12%), alcohol use disorder (7%) and tobacco and substance use disorders (5%). 

Millennials with behavioral health conditions were at twice the risk of having a chronic physical condition.

The study included the analysis of millennials’ medical claims over a five year period. Those with ongoing behavioral health conditions were twice as likely to have a chronic physical condition as their peers without a behavioral health diagnosis.

Behavioral health conditions driving adverse health for millennials

Reprinted from the Blue Cross and Blue Shield Association’s 2019 report on the Health of Millennials.

It’s important to follow-up with your patients - millennial, Gen X, Gen Z or baby boomer, who are prescribed antidepressant medications or who have been hospitalized for mental illness or substance use disorders. Not only will members have better behavioral health outcomes, their physical health could be significantly impacted as well. Follow these HEDIS® measures for additional guidance in closing the gaps in behavioral health conditions for all ages.

A note about telehealth

NCQA now accepts telehealth codes for behavioral health and some physical health measures. The modifiers 95 and GT are defined as telehealth services rendered via interactive audio and video telecommunications system. CPT codes 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 98960-98962, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99406-99409 and 99495-99496 may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95.

Antidepressant medication management (AMM): The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported:

• Effective Acute Phase Treatment - The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
• Effective Continuation Phase Treatment - The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).

AMM billing codes:

• BH outpatient:
  • CPT: 99078, 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99510
  • HCPCS: G0155, G0176-G0177, G0409, G0463, H0002, H0004, H0031, H0034-H0037, H0039-H0040, H2000, H2001, H2010-H2011, M0064, T1015
• Emergency department:
  • CPT: 99281-99285
  • UB Rev: 0450-0452, 0456, 0459, 0981
• Major depression ICD-10 CM: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9
• Telephone visit CPT: 98966-98968, 99441-99443
• Telephone modifier value set: 95, GT POS: 02
• Telehealth: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
• Telehealth modifier: 95 or GT
• Telehealth POS: 02

Follow-up after hospitalization for mental illness (FUH) - The percentage of discharges for members six (6) years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are reported:

• The percentage of discharges for which the member received follow-up within 30 days after discharge.
• The percentage of discharges for which the member received follow-up within 7 days after discharge.

The follow-up visits within seven (7) days and 30 days after hospitalization can both be telehealth visits. Telephone visits alone do not meet this criterion.

FUH billing codes:

• Follow-up visit:
  • CPT: 90791-90792, 90832-90840, 90845, 90847, 90849, 90853, 90875-90876, 98960-98962, 98966-98968, 99078, 99201-99205, 99211-99215, 99217-99223, 99231-99233, 99238-99239, 99241-99245, 99251-99255, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99441-99443, 99483, 99495-99496, 99510 HCPCS: G0155, G0176-G0177, G0409, G0463, H0002, H0004, H0031, H0034, H0036-H0037, H0039-H0040, H2000, H2010-H2011, H2013-H2020, M0064, T1015
• Mental illness ICD-10 diagnosis codes: F03.9x, F20-F25.xx, F28-F34.xx, F39-F45.xx, F48.xx, F50-F53.xx, F59-F60.xx, F63-F66.xx, F68-F69.xx, F80-F82.xx, F84.xx, F88-F93.xx, F95.xx, F98-F99.xx
• Telehealth visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
  Telehealth modifier: 95 or GT
  Telehealth POS: 02

Follow-up after emergency department visit for mental illness (FUM) - The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness. Two rates are reported:

• The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
• The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.

FUM billing codes:

• Outpatient follow-up visit:
  • CPT: 90791-90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90875-90876, 98960-98962, 98966-98968, 99078, 99201-99205, 99211-99215, 99217-99223, 99231-99233, 99238-99239, 99241-99245, 99251-99255, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99441-99443, 99483, 99495-99496, 99510
  • HCPCS: G0155, G0176-G0177, G0409, G0463, H0002, H0004, H0031, H0034, H0036-H0037, H0039-H0040, H2000, H2010-H2011, H2013-H2020, M0064, T1015
• Mental illness ICD-10 diagnosis codes:9x, F20-25.xx, F28-34. xx, F39-45.xx, F48.xx, F50-53.xx, F59-60.xx, F63-66.xx, F68-69.xx, F80-82.xx, F84.xx, F88-93.xx, F95.xx, F98-99.xx
• Intentional self-harm ICD-10 diagnosis code example:92XA
• Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
• Telehealth modifier: 95 or GT
• Telehealth modifier place of service (POS): 02

Follow-up after emergency department visit for alcohol and other drug abuse or dependence (FUA) - The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up visit for AOD. Two rates are reported:

• The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
• The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.

FUA billing codes:

• Initiation, engagement and treatment follow-up visit CPT: 98960-98962, 99078, 99201-99205, 99211-99215, 99241-99245, 99341-99350, 99384-99387, 99394-99397, 99401-99404, 99408-99409, 99411-99412, 99483, 99510
• Alcohol counseling or other follow-up visit:
  • CPT: 99408-99409
  • HCPCS: G0396-G0397, G0443, H0005, H0007, H0016, H0022, H0050, H2035-H2036, T1006, T1012 AOD
• Medication treatment HCPCS: G2067-G2077, G2080, G2086-G2087, H0020, H0033, J0570, J0571-J0575, J2315, Q9991-Q9992, S0109
• Substance use disorder ICD-10: F10-16.xx, F18-19.xx
• Telehealth modifier: 95 or GT
• Telephone visits: 98966-98968, 99441-99443
• Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99408-99409, 98960-98962
• Telehealth modifier place of service (POS): 02

Follow-up after high-intensity care for substance use disorder (FUI) - The percentage of acute inpatient hospitalizations, residential treatment or detoxification visits for a diagnosis of substance use disorder among members 13 years of age and older that result in a follow-up visit or service for substance use disorder. Two rates are reported:

• The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 30 days after the visit or discharge.
• The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 7 days after the visit or discharge.

FUI billing codes:

• Opioid abuse and dependence ICD-10:10, F11.120, F11.121, F11.122, F11.129
• Other drug abuse and dependence ICD-10:10, F12.120, F12.121, F12.122, F12.129
• Alcohol abuse and dependence ICD-10:10, F10.120, F10.121, F10.14, F10.150
• Telephone visit CPT: 98966-98968, 99411-99443
• Online assessment CPT: 98969-98972, 99421-99423, 99444, 99458
• IET stand alone visit CPT: 98960-98962, 99201-99205, 99211-99215

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

1Millennial Health: Trends in Behavioral Health Conditions. https://www.bcbs.com/the-health-of-america/reports/millennial-health-trends-behavioral-health-conditions

1079-0421-PN-NE

This is an update to the article published in the March 2021 edition of Provider News regarding Site of Care medical necessity reviews for long-acting colony-stimulating factors. The effective date has been moved from June 1, 2021 to August 1, 2021.

Please see below for the complete updated notice.

Effective with dates of service on or after August 1, 2021, medical necessity review of the site of care is required for the following long-acting colony-stimulating factors for oncology indications for Anthem Commercial plan members.

• Neulasta^® & Neulasta Onpro® (pegfilgrastim)
• Fulphila^® (pegfilgrastim-jmdb)
• Udenyca^® (pegfilgrastim-cbqv)
• Ziextenzo^® (pegfilgrastim-bmez)
• Nyvepria™ (pegfilgrastim-apgf)

The review will be administered by AIM Specialty Health_® (AIM).

AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit our Medical Policies and Clinical Guidelines webpage. You may contact AIM to request a peer-to-peer discussion before or after the determination.

The site of care medical necessity review only applies to administration performed in an outpatient hospital setting. This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Anthem is the secondary payer.

Submit a request for review

Starting July 19, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after August 1, 2021 to AIM in one of the following ways:

• Access AIM 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 through 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 prior authorization requirements for Anthem members on the Clinical Criteria webpage.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the member’s ID card.  

Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “site of care.”

1100-0421-PN-NE

Please be advised of the following update regarding the AIM Sleep Program CPT code E1399, NOC: Durable medical equipment, miscellaneous applicable to Anthem Commercial members.  
 

CPT code E1399 is not an appropriate billable code for continuous positive airway pressure (CPAP), automatic positive airway pressure (APAP) or bilevel positive airway pressure (BiPAP) equipment. When requesting authorization for CPAP, APAP, or BIPAP, please do NOT use a not otherwise classified (NOC) code. Instead, use the specific, appropriate code for each of these devices.

Effective April 1, 2021, code E1399 will no longer be part of AIM’s Sleep Therapy program and should not be submitted to AIM for review for CPAP, APAP, or BiPAP equipment.

1051-0421-PN-NE

Beginning in April 2021, our online directories will identify professional providers who offer telehealth services in their practice.

We encourage providers to utilize the online Provider Maintenance Form to notify us about your telehealth services and we will add a telehealth indicator to your online provider directory profile.

Visit anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.

ABSCRNU-0208-21

Anthem Blue Cross and Blue Shield (Anthem) is committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to better healthcare experiences for consumers.

Effective for dates of service on or after July 1, 2021, providers for our Medicare Advantage plan members covered by Anthem will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications, listed below. Reviews for these oncology drugs will continue to be administered by the reviewing company, either AIM Specialty Health_®* or IngenioRx.* 

Providers will be asked whether or not they will accept the dose reduction at the initial review point in the prior authorization process. Within the provider portal, a pop-up question will appear related to dose reduction. If the patient is considered unable to have his or her dose reduced, then a second question will appear asking for the provider’s clinical reasoning. For requests made outside of the provider portal (for example, called-in or faxed-in prior authorization requests), the same questions will be asked by the registered nurse or medical director who is reviewing the request. Since this program is voluntary, the decision made regarding dose reduction will not affect the final decision on the prior authorization.

The dose reduction questions will appear only if the originally requested dose is within 10% of the nearest whole vial. This threshold is based on current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) that it is appropriate to consider dose rounding within 10%. HOPA recommendations can be found here.

The Voluntary Dose Reduction Program only applies to specific oncology drugs, listed below. Providers can view prior authorization requirements for Anthem members on the Medical Policy and Clinical Utilization Management Guidelines page at https://www.anthem.com/medicareprovider.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

Note: In some plans, dose reduction to nearest whole vial or waste reduction may be the term used in benefit plans, provider contracts or other materials instead of or in addition to dose reduction to nearest whole vial. In some plans, these terms may be used interchangeably. For simplicity, we have used dose reduction (to nearest whole vial).

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. IngenioRx, Inc. is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. 

ABSCRNU-0211-21

Welcome to the 2021 In-Office Assessment (IOA) program. The IOA program is designed to help providers ensure that all active conditions are continuously being addressed and documented to the highest level of specificity for all Medicare Advantage plan patients of providers participating in the program. This program is designed to help improve all patient quality of care (preventive medicine screening, managing chronic illness and prescription management), as well as care for older adults when generated for a Special Needs Plan member.

If you are interested in learning about the electronic modalities available, please contact your representative or the Optum* Provider Support Center at 877-751-9207, Monday through Friday, from 8:00 a.m. to 7:00 p.m. Eastern time.

Success stories

Below are some achievements that Anthem Blue Cross and Blue Shield (Anthem) was able to accomplish with provider groups through the IOA program:

• As a result of leveraging different types of resources offered by the IOA program (for example, technology), providers’ offices were able to see an increase in staff productivity.
• Providers who have taken advantage of the IOA program resources have seen an increase in their documentation and coding accuracy.

COVID-19 update

Anthem knows this is a difficult time for everyone, as the situation continues to evolve each day. We have considered the severity of the situation and are following CDC guidelines. For the IOA program, all nonessential personal are required to work with provider groups telephonically/electronically until further notice.

Anthem continues to evaluate the situation and guidelines and will keep you notified of any changes. If you have any questions or concerns about the IOA program and COVID-19 updates, please call the Optum Provider Support Center at 877-751-9207, Monday through Friday, from 8:00 a.m. to 7:00 p.m.

Dates and tips to remember:

• To review their population as soon as possible, Anthem strongly encourages participating providers to deliver and continually maintain proper care management, as well as care coordination of their patient population. This will further ensure the current and active conditions that impact patient care, treatment and/or management are continually addressed.
• At the conclusion of each office visit with the patient, providers participating in the IOA program are asked to complete and return a patient assessment. The assessment should be completed based on information regarding the patient’s health collected during the office visit. Participating providers may continue to use the 2021 version of the assessment for encounters that take place on or before December 31, 2021; Anthem will accept the 2021 version of the assessment for 2021 encounters until midnight January 31, 2022.
• If not already submitted, participating providers are required to submit an Account Setup Form, W-9 and completed direct deposit enrollment by March 31, 2022. Participating providers should call the Optum Provider Support Center at 877-751-9207, Monday through Friday, from 8:00 a.m. to 7:00 p.m. with any questions regarding this requirement. Failure to comply with this requirement will result in forfeiture of the provider payment for submitted 2021 assessments, if applicable.

Questions

If you have questions about this communication or the IOA program, please contact your representative or the Optum Provider Support Center at 877-751-9207, Monday through Friday, from 8:00 a.m. to 7:00 p.m.

* Optum is an independent company providing care services on behalf of Anthem Blue Cross and Blue Shield.   

ABSCRNU-0210-21

On December 18, 2020, and December 22, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following clinical criteria applicable to the medical drug benefit for AMH Health, LLC. These policies were developed, revised or reviewed to support clinical coding edits.

Visit clinical criteria to search for specific policies. If you have questions or would like additional information, use this email.

Please see the explanation/definition for each category of clinical criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

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

Note: The clinical criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

ABSCRNU-0213-21

On June 18, 2020, August 21, 2020, and November 20, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following 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.

Visit clinical criteria to search for specific policies. If you have questions or would like additional information, use this email.

Please see the explanation/definition for each category of clinical criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

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

Please note: The clinical criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

ABSCRNU-0207-21