As we announced in the October edition of Provider News, Anthem is working to comply with the requirements of the Consolidated Appropriations Act, or CAA.

Improving the accuracy of provider directory information

As part of the CAA, soon providers will be asked to verify their online provider directory information on a regular basis to help ensure Anthem members can locate the most current information for in-network providers and facilities. It is important that you keep your information up to date. Here’s what you can do now:

• Review your online provider directory information on a regular basis to ensure it is correct. You can check your directory listing on Anthem’s Find Care Consumers, members, brokers, and providers use the Find Care tool to identify in-network physicians and other healthcare providers supporting member health plans. To help ensure we have your most current and accurate information, please take a moment to access Find Care. Go to anthem.com, select Providers, then under Provider Overview, choose Find Care.

• Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:
  • add/change an address location
  • name change
  • provider leaving a group or a single location
  • phone/fax number changes
  • closing a practice location

Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.

Consolidated Appropriations Act implementation

The CAA does not preempt state law requirements. This means that the CAA applies in addition to any state l aw requirements of providers to update their provider directory information.

On August 20, 2021, the Tri-Agencies (Departments of Labor, Health and Human Services and the Treasury) announced that regulations to implement the provider directory requirements would be issued on or after January 1, 2022. Health plans are expected to implement the provider directory requirements based on a good faith, reasonable interpretation of the requirements by January 1, 2022, with a primary focus on ensuring that members who rely on provider directory information that inaccurately depicts a provider’s network status are only liable for in-network cost sharing amounts. Anthem is moving forward with compliance of this good faith, reasonable interpretation of the requirements while awaiting additional regulatory guidance.

Watch for upcoming editions of Provider News in 2022 for updates on our ongoing efforts to comply with the CAA requirements.

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Anthem 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 Anthem’s 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 go to anthem.com, and select Providers > Provider Resources > Policies, Guidelines and Manuals > Select your state > View Medical Policies and Clinical 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. to 5 p.m., Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8 a.m. to 7 p.m. ET.
• 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 12 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. 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.

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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/providers > For Providers > under Provider Resources, select Policies, Guidelines & Manuals > scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.

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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.

Anthem is 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 patients and caregivers are better prepared and informed about healthcare decisions and goals.

Contact us

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Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Anthem is taking 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 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 our anthem.com Provider website for behavioral health and other medical practitioners including:

• Coordination of Care Form
• Coordination of Care Letter Template - Behavioral Health
• Coordination of Care Letter Template - Medical

The following behavioral health forms, brochures, and screening tools for substance abuse and attention-deficit/hyperactivity disorder (ADHD) are also available on our anthem.com Provider website:    

• Alcohol Use Assessment Brochure
• Antidepressant Medication Management
• Edinburgh Postnatal Depression Scale
• Opioid Use Assessment Brochure
• Substance Brief Intervention/Referral Tool (SBIRT)
• Vanderbilt ADHD Diagnostic Parent Rating Scale

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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 members’ rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem has adopted a member rights and responsibilities statement.

To read the member rights and responsibilities statement, visit the Policies, Guidelines and Manuals page of our provider website. Scroll down the page and select “Read about member rights.” Under the FAQ question titled “Laws and Rights that Protect You” you can find information about Anthem member rights and responsibilities.

Practitioners may access the FEP member portal at fepblue.org/memberrights to view the FEPDO Member Rights Statement.

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Talking to a teenager about chlamydia can be difficult. But, if untreated, this typical teenager could develop pelvic inflammatory disease (PID) or worse, infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. For a free Chlamydia How-To Implementation Guide for Healthcare Providers, visit the National Chlamydia Coalition website at  http://chlamydiacoalition.org.

The largest growing populations for chlamydia are teens and young adults aged 15 to 24. Through annual screening – a simple urine test in your office or in an off-site lab – you can help teens and young adults maintain good health.

Chlamydia Screening in Women (CHL): HEDIS® recommends annual screenings for teens starting at age 16 and for women up to age 24. Sexually active teens, young adults, and women should be tested each calendar year as well as women who have:

• Made comments or talked to you about sexual relations
• Had a pregnancy test
• Been prescribed birth control (even if used for acne treatment)
• Received gynecological services
• A history of sexually transmitted diseases
• A history of sexual assault or abuse

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The annual after-hours access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate phone messaging for our members with perceived emergency or urgent situations after regular office hours. Unfortunately, most of the Anthem Plans assessed fell short of the expectation of having a live person or a directive in place after hours.

The main challenges the vendor encounters while attempting to collect this required, essential data are related to an inability to reach the provider and/or the lack of after-hours messaging altogether. They include:

• inaccurate provider information in Anthem’s demographic database to allow assessment of the after-hours messaging
• no voicemail or messaging at all
• voicemail not reflecting the practitioner’s name, and/or
• calls being auto forwarded with no identification, no voicemail or messaging

To help both your patients’ and Anthem’s ability to reach your practice, we ask that you update your office information using the online Provider Maintenance Form and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.

What does this mean for our members and your patients? The annual member experience survey of Anthem enrollees indicated of those needing advice, a sizable number sometimes, or never, reached the provider’s office for urgent instructions. To improve upon these instances of failing to meet our member’s needs, implement these three steps:

1. Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
2. Be sure to turn on the messaging mechanism when you leave the office.
3. Be sure you are using the acceptable messaging for compliance with your contract.

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:

Emergency situations

Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER.  

Urgent situations

Compliant responses for urgent needs after hours:

• Live person, via a service or hospital, advises practitioner or on call practitioner is available and connects.
• Live person or recording directs caller/patient to Urgent Care, ER or call 911.

Non-compliant responses for urgent needs after hours:

• No provision for after-hours accessibility.
• Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. (Not a direct connection to their practitioner.)

Is your practice compliant?

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As a reminder, we will continue to upgrade our claim editing software for outpatient facility services monthly throughout 2022, with most updates occurring quarterly. These upgrades will include, but are not limited to:

• Addition of new and revised codes (for example CPT, HCPCS, ICD-10, modifiers, and revenue codes) and their associated edits

• Updates related to the appropriate use of various code combinations, which can include, but are not limited to:

• Procedure code to revenue code
• HCPCS to revenue code
• Type of bill to procedure code
• Type of bill to HCPCS code
• Procedure code to modifier
• HCPCS to modifier

• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC)

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As a reminder, we will upgrade our claim editing software for professional services monthly throughout 2022, with most updates occurring quarterly. These upgrades may apply to same provider, provider group (tax identification number). They may also apply across providers and across claim types (professional/facility) and include, but are not limited to:

• addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits such as:
  • ICD-10 laterality and Excludes1 notes
  • Add-on procedures (indicated by + sign)
  • Code book parenthetical statements and other directives about appropriate code use (e.g. “separate procedure”, “do not report”, “list separately in addition to”, etc...)
• updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• updates to incidental, mutually exclusive, and unbundled (rebundle) edits
• updates to assistant and co-surgeon eligibility in accordance with the policy
• updates to edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

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For more than a decade, Blue Precision – Anthem’s physician transparency program – has recognized specialists for meeting or exceeding established quality and cost effectiveness measures. Thank you to all those physicians participating in our networks and for the care you provide to our members. 

As we announced in the July 2021 edition of Provider News, we have made the business decision to retire our Blue Precision program effective December 31, 2021.  Blue Precision recognition icons and other program information will be removed from anthem.com and our “Find Care” provider tool by January 1, 2022.

Going forward, we will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.  We look forward to working collaboratively with you in other physician programs to provide our members with continued access to affordable and quality healthcare. 

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The annual behavioral health access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded during the first through third quarters of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine follow-ups.

The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Anthem’s demographic database, i.e. incorrect or non-working phone numbers; practitioner moved, retired, or deceased; the practice has resigned their Anthem contract, accepts private pay only, or is no longer in practice; as well as, staff refusing to participate in the survey. We ask that you update office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Anthem’s contract.

The primary appointment type not meeting compliance is consistently obtaining the initial routine appointment. This is the initial conversation with a professional after the intake assessment for a new patient for a non-urgent condition. Please refer to compliant timeframe and explanation below.

To be compliant, per the Provider Manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:

• Non-life-threatening emergency – The patient must meet with their BH practitioner, another practitioner in the practice or a covering practitioner within 6 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 meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 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 meet with a designated BH practitioner or another equivalent practitioner in the practice within 10 business days. It can be after the intake assessment or a direct referral from a treating practitioner.
  • Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms which presents no immediate distress, and can wait to schedule an appointment without any adverse outcomes.
• Routine office visit – The patient must meet with their BH 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 meet with their practitioner or another practitioner in the practice within 7 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.

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

• Updates to AIM Specialty Health musculoskeletal interventional pain management
  clinical appropriateness guideline
• Medical drug benefit clinical criteria updates
• Protocol for providers serving members with hearing aid coverage administered by Hearing Care Solutions
• New York City Medicare Advantage announcement
• Medical Policies and Clinical Utilization Management Guidelines update

We have enhanced your ability to search, review, and download a copy of the remittance advice on Availity* when there is not an associated payment. For remit advice with payment, you can continue to search with the Check/EFT number.

Below are images reflecting the scenarios that have been enhanced:

Paper remittance

Electronic remittance advice (ERA/835)

What has changed?

1. Non-payment number display in the Check Number and Check/EFT Number fields:

• Old — There were two sets of numbers for the same remittance advice. The paper remittance displayed 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displayed 27 bytes (9999999999 — [year] #############).
• Enhancement — The updated numbering sequence for the paper remittance and corresponding 835 (ERA) now contain the same 10-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.

2. Searching for non-payment remittance:

• Old — When using Remit Inquiry to locate paper remittance, the search field required a date range and tax ID to locate a specific remittance due to same number scenario (10 bytes (9999999999) being used for every non-payment remittance.
• Enhancement — Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers provides a faster and simplified process to find the specific remittance.

The way your organization receives remittances and payments has not changed; we have simply enhanced the numbering for the non-pay remittances. These changes do not impact previously issued non-payment remittance advice.

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Beginning January 1, 2022, Medicare Advantage Organizations (MAOs) and Medicare-Medicaid Plans (MMPs) are responsible for adjudicating claims for COVID-19 vaccines and their administration and for COVID-19 monoclonal antibodies and their administration.

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An overview of notable 2022 benefit changes and service area updates are now available here. Please continue to check https://www.anthem.com/medicareprovider for the latest Medicare Advantage information.

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Effective for dates of service on and after March 13, 2022, the following updates will apply to the listed AIM Specialty Health® (AIM)* Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates by guideline:

Imaging of the brain:

• Acoustic neuroma — removed indication for CT brain and replaced with CT temporal bone
• Meningioma — new guideline establishing follow-up intervals
• Pituitary adenoma — removed allowance for CT following nondiagnostic MRI in macroadenoma
• Tumor, not otherwise specified — added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

Imaging of the head and neck:

• Parathyroid adenoma — specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
• Temporomandibular joint dysfunction — specified duration of required conservative management

Imaging of the heart:

• Coronary CT angiography — removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk

Imaging of the chest:

• Pneumonia — removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
• Pulmonary nodule — aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT

Imaging of the abdomen and pelvis:

• Uterine leiomyomata — new requirement for ultrasound prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
• Intussusception — removed as a standalone indication
• Jaundice — added requirement for ultrasound prior to advanced imaging in pediatric patients
• Sacroiliitis — defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
• Azotemia — removed as a standalone indication
• Hematuria — modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline

Oncologic imaging:

• National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin and non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers.
• Cancer screening — new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
• Breast cancer — clinical scenario clarifications for diagnostic breast MRI and PET/CT

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM via:

• AIM’s ProviderPortal_SM directly at www.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.
• Availity* Portal at www.availity.com.
• Phone at 800-714-0040, Monday through Friday from 6 a.m. to 6 p.m. 

If you have questions related to guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines online.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT^® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override. 

For additional information, please review the Drug Screen Testing reimbursement policy at https://www.anthem.com/medicareprovider.

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