An updated BlueCard® Program Provider Manual will be available on our provider website January 1, 2021. The manual includes enhanced content that should be helpful in understanding the BlueCard® Program that enables members of one Blue Plan to obtain health care service benefits while traveling or living in another Blue Plan’s service area.

 

To locate the manual, go to anthem.com and select Providers. Under Provider Resources, select Policies, Guidelines & Manuals, then select your state. Scroll down to the Provider Manual section and select Download the Manual.  On the Provider Manual page, scroll down to the Provider Manual Library and select the BlueCard Provider Manual.

 

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Our utilization management (UM) decisions are based on 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, select Providers, and under Provider Resources, select Policies and Guidelines. Select state and scroll to View Medical Policies & UM Guidelines.

 

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 our website at anthem.com, select Providers, and under Provider Resources, select Policies and Guidelines. Select state and scroll to View Medical Policies & UM Guidelines.

 

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 through Friday (except on holidays). More hours may be available in your area. Federal Employee Program® (FEP®) 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 numbers are for physicians and their staffs only. Members should call the customer service number on their health plan ID card.

 

To Discuss UM Process and Authorizations	To Discuss Peer-to-Peer UM Denials w/Physicians	To Request UM Criteria	TDD/TTY
800-238-2227    Transplant: 800-255-0881   Behavioral Health: 800-934-0331   Autism: 844-269-0538   FEP Phone: 800-860-2156 Fax: 800-732-8318 (UM) Fax: 877-606-3807 (ABD)	800-437-7162   FEP 800-860-2156   Adaptive Behavioral Treatment 844-269-0538	800-437-7162   FEP Phone: 800-860-2156 Fax: 800-732-8318 (UM) Fax: 877-606-3807 (ABD)	711, or  TTY: 800-842-9710 Voice: 800-833-8134

 

For language assistance, members can simply call the Customer Service phone number on the back of their ID cards 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.

 

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Managing illness can sometimes be a difficult thing to do. Knowing whom to contact, understanding test results 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 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 members and caregivers are better prepared and informed about healthcare decisions and goals.

 

Case management contact information: 

Email Address  (if available)	Telephone	Business Hours
CMReferralSpecialistNE@anthem.com      Federal Employee Program® (FEP®) – no email	800-231-8254     FEP: 800-711-2225	Mon. - Fri., 8:00 a.m. - 7:00 p.m.   FEP: Mon. - Fri., 8:00 a.m. - 7:00 p.m.

 

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The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients 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.

 

To access the statement, go to anthem.com/FAQs, select state, then “Laws and Rights that Protect You”. Practitioners may access the Federal Employee Program® member portal to view the FEPDO Member Rights Statement.

 

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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 of its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other health care practitioners at the time treatment begins.

 

We expect all health care practitioners to:

 

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. 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 anthem.com including a Coordination of Care Form and Coordination of Care letter templates for both behavioral health and other medical practitioners. Behavioral health tools are also available which includes forms, brochures, and screening tools for substance abuse, ADHD, and autism. Visit our provider website to see all provider tools available.

 

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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 > select Providers, then under Provider Resources, choose Policies, Guidelines & Manuals and select your state. Scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.

 

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As of December 1, 2020, the providers listed below are participating air ambulance providers with Anthem in Connecticut. That means, for members picked up in Connecticut, these participating providers have contractually agreed to accept our reimbursement rate as payment in full for approved and medically necessary transport, and will bill those members for cost-shares only.

 

Some air ambulance providers choose not to participate with us.   

• These air ambulance providers may, and often do, charge members rates that are significantly higher than our contracted provider rates.
• These non-contracted air ambulance providers attempt to collect from our members the difference between our allowed amount and their billed amount.

 

To help our members avoid the high costs of air transportation from non-contracted providers, we ask that, whenever possible, you choose a participating air ambulance provider for your patients who are Anthem members. Utilizing participating providers:

• Protects the member from balance billing for what may be excessive amounts,
• Assures the most economical use of the member’s benefits, and
• Is consistent with your contractual obligations to refer to in-network providers where available.

 

To schedule fixed wing or rotary wing air ambulance services, please:

1. Contact Anthem for precertification for all non-emergent transports, using the number on the back of the member’s ID card, then
2. Call one of the phone numbers listed on the back of this page.

 

Please have the following information ready when you call one of the contracted air ambulance providers:

• Basic medical information about the patient, including the patient’s name and date of birth or age.  If the service was not precertified with Anthem, the air ambulance provider will also need to receive a full medical report from the attending facility.
• Current location of the patient, the name of the hospital or facility caring for the patient and its address (city and state)
• Location where patient is to be transported, including the name of the destination hospital/facility and address
• Approximate transport date or timeframe
• Special equipment or care needs

 

Should you have questions regarding the air ambulance network, including providers contracted for air ambulance pickups outside of [Connecticut] [Maine] [New Hampshire], please contact the Provider Call Center.

 

First, call Anthem for precertification if required by the member’s policy. Then call one of the following: 

 

Fixed wing (airplane) providers (HCPCS codes: A0430 & A0435)

Provider Name	Phone	Location Address	Web site
AeroCare Medical Transport Systems	630-466-0800	43W 752 Hwy 30 Sugar Gove, IL 60554	www.aerocare.com
Air Med International	877-288-5340	950 22nd St., Ste. 800 Birmingham, AL 35203	www.airmed.com

 

Rotary wing (helicopter) providers (HCPCS codes: A0431 & A0436)

Provider Name	Phone	Location Address	Web site
Air Evac EMS Inc.	800-247-3822	1001 Boardwalk Springs Place, Ste. 250 O’Fallon, MO  63368	www.lifeteam.net
Med Trans Corp	800-347-0881	220 Westcourt Rd. Denton, TX  76207	www.med-trans.net

 

To arrange air transport originating outside the U.S., U.S. Virgin Islands, and Puerto Rico, call 800-810-BLUE for BCBS global core formerly BlueCard worldwide.

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For participating Anthem commercial ASO plans, we have expanded our hospice benefit to align with our previous expansion for commercial fully-insured members. These expanded hospice benefits allow members with a life expectancy of up to 12 months (increased from 6 months) and allow disease modifying treatments to continue alongside hospice services. If you have a patient with an advanced illness and life expectancy of less than 12 months, now is the time to talk about hospice. Hospice is a powerful support resource for patients that can work in tandem with their treatment.

 

Provider benefits:

• Improved communication: By removing obstacles to hospice care, providers can introduce hospice benefits earlier while empowering patients to express their goals, values and care preferences.
• Centralized care: The treating physician remains at the center of the patient’s overall treatment plan – supported by the entire hospice team. Patients get the benefit of expert medical care, pain management, and emotional and spiritual support all working together.
• Planning resource: Hospice professionals are a useful resource for physicians to help aid in discussions with patients and families related to: caregiver stress, fears of the future, end-of-life discussions and bereavement planning.

 

Patient benefits:

• More patient and caregiver support, earlier: Relaxing the previous benefit life expectancy maximum and treatment limitations will help patients with advanced illnesses access hospice services earlier, ultimately choosing the care that fits their personal needs.
• Coordinated team: Patients will have a dedicated hospice team that coordinates access to medication, medical supplies, and equipment. Patients can depend on hospice services for their care needs rather than emergency room and intensive care professionals who are unfamiliar with their histories, goals, and preferences.
• Improved quality of life: Patients receive help sooner, manage their pain and symptom relief better, and families are able to discuss planning of personal needs more effectively.

 

Note: This update does not apply to Federal Employee Program® (FEP®), Medicare and

Medicaid. Providers should continue to verify eligibility and benefits for all Anthem members prior to rendering services or referring members for hospice care.

 

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The impact of COVID-19 in 2020 prohibited Anthem from conducting the annual appointment access studies to assess how well practices meet appointment access requirements for behavioral healthcare (BH). We will resume the survey in the second quarter of 2021, and expect that when members contact your office, you will be able to accommodate their urgent concerns after hours.

 

To be compliant, per the Provider Manual, providers should meet the following access standards:

• Non life-threatening emergency – The patient must be seen in the office by their BH practitioner, another practitioner in the practice or a covering practitioner within six hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate.
  • Explanation - These calls concern members in acute distress, whose ability to conduct themselves 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. The situation has the potential to escalate into an emergency without clinical intervention.
• Urgent – The patient must be seen in the office by their BH practitioner, another practitioner in the practice or by a covering practitioner within ME 48 hours CT and NH 24 hours.
  • Explanation - These calls are non-emergent with significant psychological distress, when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
• Initial routine office visit – A new patient must be seen in the office by a designated BH practitioner or another equivalent practitioner in the practice within ten business days .
  • Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms, which present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
• Routine office visit – The patient must be seen in the office by their BH outcomes. It can be after the practitioners intake assessment or a direct referral from a treating practitioner, another practitioner in the practice or by a covering practitioner within 30 calendar days.
  • Explanation - These calls concern existing members, to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
• BH follow-up appointment after discharge – The patient must be seen in the office by their practitioner or another practitioner in the practice within seven calendar days.
  • Explanation – These calls concern members being released from inpatient psychiatric hospital care, requesting a follow-up appointment to evaluate what has taken place since release, including med management.

 

Methods used to monitor adherence to these standards consist of assessing the accessibility of appointments via phone calls from North American Testing Organization, a vendor working on Anthem’s behalf, and analysis of member complaint and member experience data.

 

Please note: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form on anthem.com. Select Providers, your state, then under Provider Resources, select Provider Maintenance.

 

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Please note: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form on anthem.com. Select Providers, your state, then under Provider Resources, select Provider Maintenance.

 

The impact of COVID-19 in 2020 prohibited us from conducting the annual after-hours access studies to assess phone messaging for our members for perceived emergency or urgent situations after regular office hours. We will resume the survey in the second quarter of 2021, and expect that when members contact your office, you will be able to accommodate their urgent concerns after hours.

 

To be compliant, per our Provider Manual, your messaging or answering service must include appropriate instructions such as:

 

• Emergency situations

The compliant response for an emergency instructs the caller/member to hang up and call 911 or go to ER, or connects the caller directly to the doctor.  

• Urgent situations

The compliant response for urgent needs would direct the caller to urgent care or ER, to call 911 or connect the caller to their doctor or the doctor on call. 

 

Messaging that only gives callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions is not complaint, as there is no direct connection to their health care practitioner. This prompt can be used in addition to, but not in place of the emergency and urgent instructions. 

 

Is your practice compliant?

 

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We are committed to reducing cost while improving health outcomes. To that end, effective March 1, 2021, we will require prior authorization for our commercial business for the following services:

 

Code	Description
53447	Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session
53445	Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff
36465	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein)
36466	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg
33477	Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed

 

Providers can submit pre-service review requests using one of the following ways:

• Availity portal at www.availity.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.

• Call toll-free number at 800-238-2227, Monday – Friday, 8:30 a.m. to 5:00 p.m.

 

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The quick reference guide for the new Blue Care Prime Network, offering information and contacts for Provider Service, claim submission, correspondence and appeals has been published on https://www.anthem.com/provider/contact-us/. Select Connecticut, then Quick Reference Guide – Blue Care Prime Network. The QRG is attached for your reference.

Our website contains additional information for providers, including directories, formularies, practice guidelines, provider newsletters and more. To access our directories, visit anthem.com, select Providers, under Provider Resources select Find Care, then select state.

 

Note: This reference guide refers to in-network services. It is for illustrative purpose only, and is subject to the provisions of the subscriber agreement, master group policy, or other applicable coverage document.

 

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Are you looking for creative ways to talk to your patients about certain preventive care services such as breast cancer screening and adolescent vaccinations including the HPV vaccination?  As flu season approaches, do you want a way to educate your patients about the dangers of antibiotic resistance?  Short educational videos, approximately two minutes in length, are available on anthem.com > Providers > Forms and Guides > under Category, select Patient Care. 

 

By providing education and addressing common fears and concerns, these brief videos offer an alternative approach to patient engagement on these important topics. Take a look today!

 

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The Provider Digital Engagement Supplement is another example of how Anthem is using digital technology to improve the health care experience. The Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits all in one comprehensive resource. We want providers to go digital with us no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.

 

Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:

• File claims
• Check statuses
• Verify eligibility and benefits
• Submit prior authorizations

 

Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website.

 

Get payments faster

• Electronic funds transfer (EFT) eliminate the need for paper checks. Payments are deposited directly to your bank account. It is safe, secure and you receive payments faster.

 

Eliminate paper remittances

• Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.

 

Member IDs go digital

Having a member email their ID card directly to you from the member for file upload eliminates the need for you to scan or print, making it easier for you and the member. Member ID cards can also be accessed via Availity. Save time by accepting the digital member ID cards when presented by the member via their App or email.

 

Read more about going digital with Anthem in the Provider Digital Engagement Supplement available online. Go to anthem.com, select Providers, under the Provider Resources heading select Forms and Guides. Select your state if you haven’t done so already. From the Category drop down, select Digital Tools, then Provider Digital Engagement Supplement.

 

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Through predictive analytics, health care teams can now receive real-time solutions to claim denials

Anthem is committed to providing digital first solutions. Our health care teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, we have the answers before you ask the questions. With an initial focus on claim-level insights, we have streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to completion. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOB.

Access Claims Status Listing on Payer Space from our secure provider portal through Availity. We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

 

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.

Anthem has made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online – all in one place.

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem is using digital technology to improve the health care experience.

 

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Anthem Inc. and Quest Diagnostics have entered into a strategic relationship by collaborating on a variety of outcomes-based programs designed to create an improved health care experience for consumers and providers beginning August 1, 2020.

 

Anthem and Quest will work together to improve efficiency in care delivery and reduce overall costs by leveraging a broad range of tools and programs to drive operational improvements, create pricing transparency, and enhance health care consumer engagement and outcomes.  The strategic relationship will focus on consumers in California, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, New York, Ohio, Virginia, and Wisconsin.    

 

Read the joint press release. 

 

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In 2019, non-oncology medical specialty drug reviews were transitioned from AIM Specialty Health^® (AIM) to IngenioRx. We are implementing changes to the AIM IVR telephone prompts as they relate to IngenioRx medical specialty drug reviews.

 

Currently, if a provider calls any of the existing AIM toll-free numbers to request a non-oncology medical specialty drug review, IVR telephone prompts are available informing the caller of the IngenioRx toll-free number, 833-293-0659.  Callers are then automatically transferred to the IngenioRx number. 

 

Beginning on January 1, 2021, the AIM toll-free numbers will no longer offer these IVR telephone prompts and transfer callers to IngenioRx for non-oncology medical specialty reviews. Providers must contact the IngenioRx review team directly using one of these options:

 

• Phone: 833-293-0659
• Fax: 888-223-0550
• Online: availity.com available 24/7

 

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As communicated in the June and October 2020 editions of Provider News, effective December 1, 2020, we will transition the clinical criteria for medical necessity review of certain rehabilitative services to AIM Rehabilitative Service Clinical Appropriateness Guidelines as part of the AIM Rehabilitation Program.  Reviewed services will include certain physical therapy, occupational therapy and speech therapy services.  

 

As part of this transition of clinical criteria, the following procedures will now be subject to prior authorization as part of the AIM Rehabilitation program: 

 

CPT code	Description
90912	Biofeedback training for bowel or bladder control, initial 15 minutes
90913	Biofeedback training for bowel or bladder control, additional 15 minutes
96001	Three-dimensional, video-taped, computer-based gait analysis during walking
0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional
S8940	Therapeutic horseback riding, per session
S8948	Treatment with low level laser (phototherapy) each 15 minutes
S9090	Vertebral axial decompression (lumbar traction), per session
20560	Needle insertion(s) without injection(s), 1 or 2 muscle(s)
20561	Needle insertion(s) without injection(s), 3 or more muscle(s)
90901	Biofeedback training by any modality (when done for medically necessary indications)
97129	One-on-one therapeutic interventions focused on thought processing and strategies to manage activities
97130	each additional 15 minutes (list separately in addition to code for primary procedure)
92630	Hearing training and therapy for hearing loss prior to learning to speak
92633	Hearing training and therapy for hearing loss after speech

 

The following procedure will be removed from the program:

S9117

back school, per visit

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 availity.com.
• Call AIM’s Contact Center toll-free number at 866-714-1107, Mon. - Fri., 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 and upcoming guidelines here.

 

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Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Radiation Oncology Clinical Appropriateness Guidelines.   

 

Radiation oncology

• Special treatment procedure
  • Removed IV requirement for chemotherapy

CNS cancer 

• IMRT for glioblastomas, other gliomas and metastases: Eliminated the 3D plan comparison requirement. Same change for high-grade and low-grade gliomas.
• IMRT for metastatic brain lesions: Added hippocampal sparing whole brain radiotherapy indication

Lung cancer 

• Eliminated the plan comparison requirement for IMRT to treat stage III non-small cell lung cancer.
• SBRT: Removed “due to a medical contraindication” language
• SBRT: Added “as an alternative to surgical resection” to stereotactic body radiation therapy
• Adjusted fractionation maximum for curative treatment of non-small cell lung cancer up to 35 treatments of thoracic radiotherapy.

 

Proton beam therapy

• Added new indication for hepatocellular carcinoma and intrahepatic cholangiocarcinoma

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 availity.com.
• Call AIM’s Contact Center toll-free number at 866-714-1107, Mon. - Fri., 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 and upcoming guidelines here.

 

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Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Advanced Imaging Clinical Appropriateness Guidelines.

 

Chest imaging and head and neck imaging

• Hoarseness, dysphonia, and vocal cord weakness/paralysis – primary voice complaint
  • Require laryngoscopy for the initial evaluation of all patients with primary voice complaint

 

Brain imaging and head and neck imaging

• Hearing loss
  • Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is non-diagnostic or unable to be performed
  • Higher allowed threshold for consecutive frequencies to establish SNHL
  • Remove CT brain as an alternative to evaluating hearing loss based on ACR guidance
• Tinnitus
  • Remove sudden onset symmetric tinnitus as an indication for advanced imaging

 

Head and neck imaging

• Sinusitis/rhinosinusitis
  • Add more flexibility for the method of conservative treatment in chronic sinusitis
  • Require conservative management prior to repeat imaging for patients with prior sinus CT
• Temporomandibular joint dysfunction
  • Removed requirement for radiographs/ultrasound
• Cerebrospinal fluid (CSF) leak of the skull base
  • Added scenario for management of known leak with change in clinical condition

 

Brain imaging

• Ataxia, congenital or hereditary
  • Combine with congenital cerebral anomalies to create one section
• Acoustic neuroma
  • More frequent imaging for a watch and wait or incomplete resection
  • New indication for neurofibromatosis type 2 (NF 2)
  • More frequent imaging when MRI shows findings suspicious for recurrence
  • Single post-operative MRI following gross total resection
  • Include pediatrics with known acoustics (rare but NF 2)
• Tumor – not otherwise specified
  • Repurpose for surveillance imaging of low grade neoplasms
• Seizure disorder and epilepsy
  • Limit imaging for the management of established generalized epilepsy
  • Require optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy
• Headache
  • Remove response to treatment as a primary headache red flag
• Mental status change and encephalopathy
  • Added requirement for initial clinical and lab evaluation to assess for a more specific cause

 

Oncologic imaging

• General enhancements: Updates to Scope/Definitions, general language standardization
• General content enhancements: Overall alignment with current national oncology guideline recommendations, resulting in:
• Removal of indications/parameters not addressed by NCCN
• Average risk inclusion criteria for CT colonography
• New allowances for MRI abdomen and/or MRI pelvis by tumor type, liver metastatic disease
• New indications for acute leukemia (CT, PET/CT), multiple myeloma (MRI, PET/CT), Ovarian cancer surveillance (CT), bone sarcoma (PET/CT)
• Updated standard imaging pre-requisites prior to PET/CT for bladder/renal pelvis/ureter, ectal, esophageal/GE junction, gastric and non-small cell lung cancers
• Additional PET/CT management scenarios for cervical cancer, Hodgkin’s lymphoma

 

Other content enhancements by section:

• Cancer screening: New indication for pancreatic cancer screening
• Breast cancer: New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment breast MRI after breast conserving therapy or unilateral mastectomy
• Prostate cancer: MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE
• Axumin PET/CT: Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic multiparametric MRI)

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 availity.com.
• Call AIM’s Contact Center toll-free number at 866-714-1107, Mon. - Fri., 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 and upcoming guidelines here.

 

801-1220-PN-NE

 

Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Advanced Imaging of the Heart and Diagnostic Coronary Angiography Clinical Appropriateness Guidelines.

 

Evaluation of patients with cardiac arrhythmias

• Updated repeat TTE criteria
• Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia.

 

Evaluation of signs, symptoms, or abnormal testing

• Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature.

 

Diagnostic coronary angiography

• Updated criteria to evaluate patients with suspected congenital coronary artery anomalies

 

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 availity.com.
• Call AIM’s Contact Center toll-free number at 866-714-1107, Mon. - Fri., 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 and upcoming guidelines here.

 

800-1220-PN-NE

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

• Policy Update — Emergency Department: Leveling of Evaluation and Management Services

 

Introducing the Anthem Provider Digital Engagement Supplement to the Provider Manual

Using our secure provider portal or EDI submissions (via Availity), administrative tasks can be reduced by more than fifty percent when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website or the secure provider portal via Availity.

 

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and you can receive payments faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance, which meets all HIPAA mandates - eliminating the need for paper remittances.

 

Member ID cards go digital

Anthem members are transitioning to digital member identification cards making it easier for them and you. The ID card can be easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

 

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available at https://www.anthem.com/medicareprovider > select your state > Providers > Policies, Guidelines & Manuals, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid and Medicare, including medical, dental and vision benefits.

 

The Provider Digital Engagement Supplement to the provider manual is another example of how we are using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Provider Digital Engagement Supplement now by going to https://www.anthem.com/medicareprovider > select your state > Providers > Policies, Guidelines & Manuals. Go digital with Anthem.

 

ABSCRNU-0179-20

The medical policies, clinical utilization management (UM) guidelines and third-party criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

 

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

 

To view a guideline, visit our website. 

Updates:

Updates marked with an asterisk (*) indicate that the criteria may be perceived as more restrictive.

• 00052 — Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
• Revised medically necessary indications
• 00134 — Noninvasive Heart Failure and Arrhythmia Management and Monitoring System:
• Revised investigational and not medically necessary indications
• 00077 — Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques:
• Expanded scope and revised investigational and not medically necessary indications
• 00156 — Implanted Artificial Iris Devices
• Revised investigational and not medically necessary indications
• 00157 — Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
• Revised investigational and not medically necessary indications
• 00112 — Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures):
• Revised scope, and investigational and not medically necessary indications
• CG-DME-07 — Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output
• Revised medically necessary and not medically necessary indications
• CG-REHAB-12 — Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology
• A new clinical UM guideline was created from content contained in CG-REHAB-04,
  CG-REHAB-05, CG-REHAB-06.
• There are no changes to the guideline content.
• Publish date is scheduled for December 8, 2020.
• The following AIM Specialty Health® Clinical Appropriateness Guidelines have been revised and will be effective on December 6, 2020. To view AIM guidelines, visit the AIM Specialty Health page:
  • Interventional Pain Management (See August 16, 2020, version.)*
  • Chest Imaging (See August 16, 2020, version.)*
  • Oncologic Imaging (See August 16, 2020, version.)*
  • Sleep Clinical Guidelines (See August 16, 2020, version.)*

 

Medical policies

On August 13, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following medical policies applicable to Anthem. These guidelines take effect December 6, 2020.

 

Publish date	Medical Policy	Medical Policy title	New or revised
10/7/2020	*MED.00134	Non-invasive Heart Failure and Arrhythmia Management and Monitoring System	New
10/7/2020	*SURG.00156	Implanted Artificial Iris Devices	New
10/7/2020	*SURG.00157	Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis	New
9/1/2020	*GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	Revised
10/7/2020	*SURG.00077	Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques	Revised
10/1/2020	*SURG.00112	Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)	Revised

 

Clinical UM guidelines

On August 13, 2020, the MPTAC approved the following clinical UM guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for Medicare Advantage members on September 24, 2020. These guidelines take effect December 6, 2020.

 

Publish date	Clinical UM Guideline	Clinical UM Guideline title	New or revised
10/7/2020	*CG-DME-07	Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output	Revised
10/7/2020	CG-DME-25	Seat Lift Mechanisms	Revised
8/20/2020	CG-GENE-03	BRAF Mutation Analysis	Revised
8/20/2020	CG-SURG-83	Bariatric Surgery and Other Treatments for Clinically Severe Obesity	Revised

 

ABSCRNU-0190-20

 

How do I check eligibility and benefits for these members?

• Online: Eligibility, benefits, claims, links to secure messaging, commonly used forms and remit information are all available through the Availity* Portal at https://www.availity.com. For questions on access and registration, call Availity Client Services at 1-800-AVAILITY (800-282-4548). Availity Client Services is available Monday through Friday, 8:00 a.m. to 7:00 p.m. ET (excluding holidays) to answer your registration questions.
• Phone: Call the Provider Service number on the back of the member’s ID card. You may also verify a member’s eligibility by calling the BlueCard Eligibility Line at 1‑800‑676‑BLUE (2583) and providing the member’s three-digit alpha prefix located on the ID card.

 

As new members enroll in Anthem’s Group Retiree Medicare Advantage plans, they will receive new ID cards. Additionally, existing members may receive new ID cards as a result of benefit changes. Please continue to check member ID cards to ensure you have the most up-to-date eligibility and benefit information.

 

Please note that we are experiencing a high volume of changes for an effective date of January 1, 2021, and some of the changes will affect member prefix, member ID or benefits. Because of this, we encourage providers to request a copy of the member’s ID card, particularly at the beginning of the year when members may have new ID cards.

 

What are the alpha prefixes for Group Retiree Medicare Advantage PPO members?

• AFJ
• CBH
• MEW, MBL
• VAY, VGD
• WSP, WZV              
• XLU, XNS
• YVK, YGZ
• ZDX, ZMX, ZVR, ZVZ

 

ABSCRNU-0183-20

Summary of benefits, evidence of coverage and formularies for 2021 individual Medicare Advantage plans will be available at anthem.com/medicareprovider. An overview of notable 2021 benefit changes will be available at anthem.com/medicareprovider> Read News and Updates. Please continue to check anthem.com/medicareprovider for the latest Medicare Advantage information.

 

ABSCRNU-0182-20