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 access the aid, visit anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Health and Wellness > Practice Guidelines > Shared Decision Making Aid.  

We have designated Availity to operate and serve as your electronic data interchange (EDI) entry point or also called the EDI Gateway. The EDI Gateway is a no-cost option to our direct trading partners. With this change, we continue our efforts to ensure consistency between your provider portal and the EDI Gateway.

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway.  Availity is well known as a Web portal and claims clearinghouse.  In addition, Availity functions as an EDI Gateway for multiple payers and is the single EDI connection for our company.

Your organization can submit and receive the following electronic transactions through Availity’s EDI Gateway:

• 837 - Institutional Claims
• 837 - Professional Claims
• 837 - Dental Claims
• 835 - Electronic Remittance Advice
• 276/277 - Claim Status
• 270/271 - Eligibility Request

If you wish to become a direct trading partner with Availity, the setup is easy.  Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions. 

If you prefer to use your clearinghouse or billing company, please work with them to ensure connectivity.

Need Assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

835 Electronic Remittance Advice (ERA)

Effective June 1, 2018, please use Availity to register and manage account changes for ERA.

If you were previously registered to receive ERA, you must register using Availity to manage account changes.

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, if you were previously registered to receive EFT only, you must register using EnrollHub to manage account changes. No other action is needed.

Contacting Availity

If you have any questions, contact Availity Client Services at 1-800-Availity (800-282-4548), Monday through Friday 8 a.m. to 7:30 p.m. Eastern Time.

Connecting with Anthem and staying informed is easy, fast and convenient with our provider eUpdates.  eUpdates feature short topic summaries on late breaking news that impacts providers such as:

• Website updates
• System changes
• Policy updates
• Claims and billing updates
• And more…..

Registration is fast and easy. There is no limit to the number of subscribers who can register for our eUpdates, so your facility or practice can submit as many email addresses as you like.  Sign up today!

Beginning January 1, 2019, our Pathway provider networks will support other products in addition to those sold on Access Health CT (the State of Connecticut’s Health Insurance Exchange.)  As communicated in the June edition of Network Update, members of our off-exchange products will be required to use the Pathway Networks to receive in-network benefits. In addition, please note that the names of the Pathway provider networks will change as of this date as well. 

Specifically:

• Members of our small group off-exchange HMO products must use the Pathway CT HMO Network.
• Members of our individual off-exchange HMO products must use the Pathway Enhanced Network.
• Members of our small group off-exchange PPO products must use the Pathway CT PPO Network.
• Members of our individual off-exchange PPO products must use the Pathway Network.

Please be aware of the following:

• Off-exchange products refer to our products, programs and plans sold directly to customers (i.e. off of Access Health CT) and supported by the Pathway Networks listed above.
• You must participate in the applicable Pathway Network(s) to render health care services on an in-network basis to members of off-exchange products.
• Compensation for covered health care service rendered to these members will be the amount(s) corresponding to the applicable Pathway Network(s).

If you do not currently participate in our Pathway Networks and wish to, please contact your Provider Relations Representative.  

If you have any questions, please call the Provider Call Center at 800-922-3242.  Thank you for your continued service and dedication to all our members. 

In our ongoing efforts to streamline and simplify our payment recovery process, we continue to consolidate our internal systems and will begin transitioning our National Accounts membership to a central system in 2019. While this is not a new process, we are transitioning the National Accounts membership to align with the payment recovery process across our other lines of business.

Currently, our recovery process for National Accounts membership is reflected in the EDI PLB segment on the electronic remittance advice (835).  This segment will show the negative balance associated with the member account number.  Monetary amounts are displayed at the time of the recovery adjustment.

As National Accounts membership transitions to the new system and claims are adjusted for recovery, the negative balances due to recovery are held for 49 days to allow ample time for you to review the requests, dispute the requests and/or send in a check payment. During this time, the negative balances due are reflected on paper remits only within the “Deferred Negative Balance” sections. 

After 49 days, the negative balances due are reflected within the 835 as a corrected and reversed claim in PLB segments. 

If you have any questions or concerns, please contact the E- Solutions Service Desk toll free at 800-470-9630.

As a reminder, providers and facilities are required to review all member information received from Anthem to help ensure no misrouted PHI is included. Misrouted PHI includes information about members that a provider of facility is not currently treating.  PHI can be misrouted to providers and facilities by mail, fax or email. Providers and facilities are required to immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained.  In no event are providers and facilities permitted to misuse or re-disclose misrouted PHI. If providers or facilities cannot destroy or safeguard misrouted PHI, providers and facilities must contact Anthem Provider Service to report receipt of misrouted PHI.

Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) commercial data collection project for 2018. You play a central role in promoting the health of our members. By documenting services in a consistent manner, it is easy for you to track care that was provided and identify any additional care that is needed to meet the recommended guidelines.  Consistent documentation and responding to our medical record requests in a timely manner eliminates follow up calls to your office and also helps improve HEDIS scores, both by improving care itself and by improving our ability to report validated data regarding the care you provided. The records that you provide to us directly affect the HEDIS results that are listed below.

Each year our goal is to improve our process for requesting and obtaining medical records for our HEDIS project. In order to demonstrate the exceptional care that you have provided to our members and in an effort to improve our scores, you and your office staff can help facilitate the HEDIS process improvement by:

• Responding to our requests for medical records within five days, if possible
• Providing the appropriate care within the designated timeframes
• Accurately coding all claims
• Documenting all care clearly in the patient’s medical record

Further information regarding documentation guidelines and administrative codes can be found on the HEDIS page of our Provider Portal.  In addition more information on HEDIS can be found by visiting the provider portal at anthem.com/provider > Find Resources for [state] > Health & Wellness (top blue bar) > Quality Improvement and Standards > HEDIS Information. You will find reference documents entitled “HEDIS 101 for Providers” and “HEDIS Physician Documentation Guidelines and Administrative Codes”.

Please click the attachment link to the right to view the 2018 HEDIS rates. 

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 guidelines are available on our website at anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Health and Wellness > Practice Guidelines.

Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.

We are available to offer assistance in these difficult moments with our Case Management (CM) Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals who are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the number located in the grid below. They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

Our members have resources available to help them better manage chronic conditions. The ConditionCare program helps members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. A team of registered nurses with added support from other health professionals such as dietitians, pharmacists and health educators work with members to help them understand their condition(s), their doctor’s orders and how to become a better self-manager of their condition. 

Engagement methods vary by the individual’s risk level but can include:

• Education about their condition through mailings, email newsletters, telephonic outreach, and/or online tools and resources.
• Round-the-clock phone access to registered nurses.
• Guidance and support from nurse care managers and other health professionals.

Physician benefits:

• Save time by answering members’ general health questions and responding to concerns, freeing up valuable time for the physician and their staff.
• Support the doctor-patient relationship by encouraging participants to follow their doctor’s treatment plan and recommendations.
• Inform the physician with updates and reports on the member’s progress in the program.

Please visit our website to find more information about the program such as program guidelines, educational materials and other resources. Go to anthem.com/provider > scroll down and select ‘Find Resources for [state]’. Also on our website is the Patient Referral Form, which you can use to refer other members you feel may benefit from our program.

If you have any questions or comments about the program, call 877-681-6694. Our nurses are available Monday-Friday, 8:00 a.m. - 9:00 p.m., and Saturday, 9:00 a.m. - 5:30 p.m.

For Federal Employee Program® members, call 844-730-0088. Nurses are available Monday – Friday, 9:00 a.m. - 8:00 p.m.

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. We would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. We urge all practitioners to obtain the appropriate permission from these members to coordinate care between behavioral health and other health care practitioners at the time treatment begins.

We expect all health care practitioners to:

• Discuss with the patient the importance of communicating with other treating practitioners.
• Obtain a signed release from the patient and file a copy in the medical record.
• Document in the medical record if the patient refuses to sign a release.
• Document in the medical record if you request a consultation.
• If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
• Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
  • Diagnosis
  • Treatment plan
  •  Referrals
  • Psychopharmacological medication (as applicable)

In an effort to facilitate coordination of care, we have several tools available on our website including a coordination of care template and cover letters for both behavioral health and other healthcare practitioners.* In addition, there is a provider Toolkit on the website with information about alcohol and other drugs which contains brochures, guidelines and patient information.**

*Access to the forms and cover letters are available at anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Answers@Anthem > Coordination of Care.

**Access to the Toolkit is available at anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Health and Wellness > Provider Toolkits.

An Integrated Care Model affords members with plans purchased on the Health Insurance Marketplace (also called the exchange) the ability to have continuity of care with each care management case. A single primary care nurse provides case and disease assessment and management. This continuity provides an opportunity for the member to get assistance working through an acute phase of an illness and then work with their nurse on the necessary behavioral changes needed to improve their health and enhance their well-being. The program is based on nationally recognized clinical guidelines and serves as an excellent adjunct to physician care.

The Integrated Care Model helps exchange members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease.  Our nurse care managers are part of an interdisciplinary team of clinicians and other resource professionals who are there to support members, families, primary care physicians and caregivers. 

Nurse care managers encourage participants to follow their physician’s plan of care; not to offer separate medical advice. In order to help ensure that our service complements the physician’s instructions, we collaborate with the treating physician to understand the member’s plan of care and educate the member on options for their treatment plan. 

Members or caregivers can refer themselves or family members by calling the number located in the grid below. 

Our utilization management (UM) decisions are based on written criteria, the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. Our medical policies are available on our website at anthem.com.

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below. UM criteria are also available on the web. Just select “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” from the Provider home page at anthem.com/provider.

We work with providers to answer questions about the utilization management process and the authorization of care.  Here’s how the process works:

Call us toll-free from 8:30 a.m. – 5:00 p.m. Monday - Friday (except holidays). More hours may be available in your area. Federal Employee Program hours are 8:00 a.m. – 7:00 p.m. If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after midnight will be returned the same business day. Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

The following phone lines are for physicians and their staff.  Members should call the customer service number on their health plan ID card.

For language assistance, members can simply call the customer service phone number on the back of their ID card and a representative will be able to assist them.

Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.

The delivery of quality health care requires cooperation between members, their providers and their health care benefit plans. One of the first steps is for members and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, we have adopted a Members’ Rights and Responsibilities statement.

It can be found on our website at anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Health & Wellness > Quality > Member Rights & Responsibilities. Practitioners may access the FEP member portal at www.fepblue.org/memberrights to view the FEPDO Member Rights Statement.

As a participating provider please be reminded of your contractual obligation to help ensure our members have prompt access to behavioral health care:

• Non-life threatening emergency needs - must be seen, or have appropriate coverage directing the member, within 6 hours. When the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
• Urgent needs - must be seen, or have appropriate coverage directing the member, within 48 hours. Urgent calls concern members whose ability to contract for their own safety, or the safety of others may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. Urgent needs have the potential to escalate into an emergency without clinical intervention.
• Routine office visit - must be within 10 business days. Routine calls concern members who present no immediate distress and can wait to schedule an appointment without any adverse outcomes.

We use several methods to monitor adherence to these standards. Monitoring is accomplished by:

1. assessing the availability of appointments via phone calls by our staff or designated vendor to the provider’s office;
2. analysis of member complaint data; and
3. analysis of member satisfaction.

Providers are expected to make best efforts to meet these access standards for all members.

As a reminder, ordering and servicing providers may submit prior authorization 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 www.availity.com.
• Call the AIM Contact Center toll-free number at 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 January 1, 2019, the following updates will apply to AIM Musculoskeletal Spine Surgery Clinical Appropriateness Guidelines as indicated by section below: 

• Cervical decompression with or without fusion
  • Added criteria for the appropriate use of laminectomy for cordotomy and biopsy, excision, or evacuation
  • Added indications for non-traumatic atlantoaxial instability
• Lumbar laminectomy
  • Added criteria for the appropriate use of laminectomy for biopsy, excision, or evacuation
  • Added indication of dorsal rhizotomy

Beginning with dates of review on and after January 1, 2019, the following updates will apply to AIM Musculoskeletal Interventional Pain Management Clinical Appropriateness Guidelines as indicated by section below: 

• Paravertebral facet injection/nerve block/neurolysis
  • Exclusions: radiofrequency neurolysis for sacroiliac (SI) joint pain is considered not medically necessary

These services or procedures were previously reviewed by Anthem, but will now be reviewed by AIM as part of the musculoskeletal program beginning January 1, 2019. To view the list of those CPT codes, you may access and download a copy of the current guidelines here.

As a reminder, ordering and servicing providers may submit prior authorization 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 www.availity.com.
• Call the AIM Contact Center toll-free number at 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.

Effective for dates of service on and after March 9, 2019, the following updates will apply to all of AIM’s Clinical Appropriateness Guidelines, including Advanced Imaging, Cardiac, Sleep, Radiation Oncology and Musculoskeletal guidelines. 

Clinical appropriateness framework

Replacing pretest requirements, this section will more accurately describe the guideline’s purpose, which is to provide a summary of the fundamental components of a decision to pursue diagnostic testing.  In order to support the full spectrum of AIM solutions, the terms “imaging request” or “diagnostic imaging” are replaced with “diagnostic or therapeutic intervention”.

Ordering of multiple diagnostic or therapeutic interventions

Replacing ordering of multiple studies, this section expands its applicability to AIM solutions outside of diagnostic imaging.  Terminology specific to imaging studies is replaced with the term “diagnostic or therapeutic intervention” to reflect a broader application of the principles included here. 

Repeat diagnostic testing and repeat therapeutic intervention

Replacing repeated imaging, these sections establish conditions in which duplication of the initial test or intervention may be warranted, and where such requests will require peer-to-peer discussion. 

As a reminder, ordering and servicing providers may submit prior authorization 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 www.availity.com.
• Call the AIM Contact Center toll-free number at 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.

Effective January 1, 2019, Medicare providers will have toll free phone numbers specifically designated for their service inquiries. These new provider numbers will be listed separately on the back of the member ID cards and should be used beginning January 1, 2019. The associates answering your provider service calls are trained to answer your questions and resolve your issues as quickly as possible. To help ensure you receive the most efficient service, please refrain from using the member services line and use only 844-421-5662 or the provider services phone number listed on the back of the member ID card for individual Medicare Advantage calls beginning January 1, 2019.

Summary of benefits, evidence of coverage and formularies for 2019 individual Medicare Advantage plans will be available at anthem.com/medicareprovider. An overview of notable 2019 benefit changes also is available at Important Medicare Advantage Updates at anthem.com/medicareprovider.  Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider  for the latest Medicare Advantage information.

The Centers for Medicare and Medicaid Services (CMS) and Medicare Advantage and Part D organizations, including Anthem, will implement a new initiative, the Preclusion List, to protect the integrity of the Medicare Trust Funds. Beginning April 1, 2019, Medicare Advantage and Part D organizations will deny payment for items and services furnished by providers that CMS has placed on the Preclusion List. For more information, visit www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/PreclusionList.html.

When a claim must be corrected beyond the initial claim timely filing limit of one year from the date of service, a normal adjustment bill is not allowed. Providers must use the reopening process to correct the error. To learn when and how to initiate reopenings and adjustments, check Important Medicare Advantage Updates at anthem.com/medicareprovider. 

Beginning January 1, 2019, Individual Medicare Advantage plans will move compounded drugs to non-formulary with the exception of home infusion drugs. Group-sponsored Medicare Advantage members will continue to have compounded drug coverage; these drugs will require prior authorization. Compounded home infusion drugs will continue to be covered for both Individual Medicare and group-sponsored members without prior authorizations. Members and/or providers can request a non-formulary exception for compounded drugs. 

CMS updated its guidance to allow Medicare Advantage plans the option of implementing step therapy for Part B drugs as part of a patient-centered care coordination program beginning January 1, 2019.  The goal is to lower drug prices while maintaining access to covered services and drugs for beneficiaries. We will implement step therapy edits to promote clinically appropriate and cost effective drug options for our members. A patient-centered care coordination program will be created to ensure member access to necessary drugs, provide medication reviews and reconciliations, educate members regarding their medications, encourage medication adherence, and provide incentives to members who complete care coordination programs.

Effective January 1, 2019, the City of New Haven, CT will offer an Anthem Medicare Preferred (PPO) plan.  We will provide medical benefits for the City of New Haven retirees through our Local Preferred Provider Organization (LPPO) product, which includes the National Access Plus benefit. With the National Access Plus benefit, retirees are free to receive services from any in-network provider, as well as any out-of-network provider who  is eligible to receive payments from Medicare. City of New Haven retirees will pay the same cost share for both in-network and out-of-network services. The MA plan offers the same hospital and medical benefits that Medicare covers and also covers additional benefits that Medicare does not, such as hearing, LiveHealth Online and SilverSneakers®.

The prefix on the Medicare Advantage ID cards will be ZDX.

Providers may call the number on the back of the member ID card Provider Services at 833-848-8730 for eligibility, prior authorization requirements and any questions about the City of New Haven member benefits or coverage.

Detailed prior authorization requirements are also available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com.

Providers will follow their normal claim filing procedures for City of New Haven member claims.

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

• 2019 Provider Annual Notice of Change
• Prior authorization requirements for Colonoscopy and Upper Gastrointestinal Endoscopy
• Medicare Advantage Reimbursement Policy October Provider Bulletin
• Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila
• July Medicare Advantage reimbursement policy
• Submit PA medication requests electronically; new phone number for MA prescription PAs
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019 
• Inpatient Readmissions
• Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective September 1

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