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 > Select a state > Find Resources for [state] > Health & Wellness tab > Practice Guidelines.

We recently moved into a strategic collaboration with Availity to serve as our designated EDI Gateway and E-solutions Service Desk. The following are points to be aware of with this change:

• Beginning June 1, 2018, you will be able to manage all changes and new setup requests for the electronic remittance advice (835) through the Availity Portal.
• To register or manage account changes for electronic funds transfers (EFT) only, please continue to use the EnrollHub at https://solutions.caqh.org
• If you submit your electronic transactions directly to us and have your own practice management software, Availity provides trading partner services and access to Portal tools through an easy setup experience.
• If you use a clearinghouse, they will work with Availity on your behalf.
• We are working with Availity to develop new ways to simplify how you manage claims and other administrative tasks online.

Next steps if you are a direct submitter:

Key factors:

• You will be able to manage changes or new registrations for the electronic remittance advice (835) through your Availity Portal account beginning June 1, 2018. We encourage you to register with Availity to initiate the change to the Availity EDI Gateway.
• Together with Availity, we are committed to transparency with this change, and will emphasize the continuity of quality service to our trading partners.

We look forward to delivering a smooth transition to Availity for our EDI services. If you have any questions, please contact the E-Solutions service desk at 800-470-9630 or Availity at 800-AVAILITY (282-4548).

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 or facility is not currently treating. PHI can be misrouted to providers and facilities by mail, fax or e-mail. 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 or 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 Services to report receipt of misrouted PHI.

We’d like to remind you of the criteria for submitting an expedited appeal/grievance as well as the process to begin a standard or expedited appeal/grievance.

Expedited Appeals

As outlined in your Provider Manual, expedited appeals/grievances must meet certain criteria. An expedited appeal is available if services have not been provided and the timeframe of a standard appeal review could:

• seriously jeopardize the covered individual’s life or health;
• jeopardize the covered individual’s ability to regain maximum function; or if
• in the opinion of a health care professional with knowledge of the member’s medical condition, subject the covered individual to severe pain that cannot be adequately managed without the health care service or treatment being requested.

We will respond to qualifying expedited appeals within 72 hours of receiving the request. 

Expedited appeals/grievances should not be mailed. Please fax your request with a letter of intent and supporting documentation to 855-321-3642.

(Please note that the appeals toll-free telephone number, 855-365-0953, should only be used for Connecticut fully-insured members or State of Connecticut members. Please be sure to check the member’s group information before calling this telephone number. Please also be aware that supporting documentation is needed to begin any request.

Please note: For administrative services only (ASO) members, call the service telephone number listed on the member’s identification card to inquire how to begin an expedited appeal/grievance, or see how to request the appeal/grievance via fax below. If you would like to begin an expedited request please be sure the request meets the expedited criteria.

Standard Appeals

If your situation does not meet the expedited process and you would like to begin a standard appeal/grievance, mail the request to:

Anthem Blue Cross and Blue Shield

PO Box 1038

North Haven CT 06473-4201

If you have questions, please refer to your Provider Manual which can be found on anthem.com.

Beginning July 1, 2018, we will introduce a streamlined member identification (ID) card to help reduce confusion about member cost share. The updated member ID card will maintain the current style, but specific cost share information (such as copays or coinsurance) will be removed from the card.

Providers can access Availity and the electronic data interchange (EDI) to verify member benefits and obtain the most up-to-date cost share information for a member’s plan. If a member presents an older ID card with outdated benefits at the provider office, it can create confusion about member cost share.

As the streamlined ID card is adopted, it will help reduce misunderstandings around cost share. Additionally, members will be encouraged to learn more about their benefits through our digital and online tools, and can retain their card for as long as they remain in the same product plan, regardless of changes to cost share information.

As a reminder, members can now view, download, email, and fax an electronic version of their member ID card using the Anthem Anywhere mobile app. Electronic ID cards will also be updated as described above.

Please note, this update does not apply to National Accounts, Federal Employee Program® (FEP®), Medicaid or Medicare plans.

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

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

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

……and much more

Registration is fast and easy. There is no limit to the number of subscribers who can register for Network eUPDATEs, so you can submit as many e-mail addresses as you like.

Beginning July 1, 2018, many Anthem members will be able to make payments to providers for their out-of-pocket expenses with Healthcare Bill Payments, a new feature via the member portal at anthem.com. Now, your patients can quickly and easily pay you online as soon as their claim information is available.

We have engaged InstaMed®, a healthcare payments network, to offer Healthcare Bill Payments. InstaMed is a payment card industry (PCI) level one service provider and certified at the highest levels for both healthcare and payment processing.

Providers registered with InstaMed will conveniently receive patient payments by direct deposit into their bank account without ever mailing a patient bill or making a phone call. Plus, patients enjoy a simple, convenient payment option.

Registration for Healthcare Bill Payments is simple – you can get started today. Here’s what you’ll need:

• Email address
• Tax ID number for your organization
• Bank account information for direct deposit

If you are not registered, these payments are mailed to you as prepaid Mastercard® payments.

For more information about Healthcare Bill Payments:

• Register to attend InstaMed’s upcoming informational webinar on June 14, 2018 at 1:00 p.m.
• Read more about Healthcare Bill Payments.
• See InstaMed’s Frequently Asked Questions.
• Email questions about Healthcare Bill Payments to connect@instamed.com.

This feature does not apply to our Medicare and Medicaid plans, but may be implemented in the future.

As required by the Patient Protection and Affordable Care Act, we offer the same products, programs and plans (collectively Products) directly to consumers that we offer on Access Health CT (the State of Connecticut’s health care exchange).  Members of these off-exchange Products are currently able to access, on an in-network basis, health care services rendered by providers and facilities participating in our BlueCare (HMO/POS) or Century Preferred (PPO) provider network, as applicable. 

Beginning January 1, 2019, all members of our off-exchange Products will be required to utilize our exchange networks to receive in-network benefits. Specifically:

• Members of our small group off-exchange HMO Products must use the Pathway X HMO Exchange Network.
• Members of our individual off-exchange HMO Products must use the Pathway X Enhanced Exchange Network.
• Members of our small group off-exchange PPO Products must use the Pathway X PPO Exchange Network.
• Members of our individual off-exchange PPO Products must use the Pathway X Exchange Network.

For dates of service on and after January 1, 2019, you must participate in the applicable exchange network(s) listed above to render health care services on an in-network basis to members of off-exchange Products. Compensation for covered health care service rendered to members of off-exchange Products will be the amounts corresponding to the applicable Pathway network(s).

If you do not currently participate in our exchange network(s) and wish to, you may contact your Provider Relations Representative.  

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

We recently discovered that some claims for services under the following programs are processing without the required pre-service clinical review through AIM Specialty Health® (AIM®), a separate company:

• Sleep management
• Radiation oncology
• Radiology benefit management (RBM)
• Cardiology

Effective July 1, 2018, our claims systems will be updated to correct this issue. Claims for sleep management, radiation oncology, RBM, and cardiology services continue to require precertification through AIM. For a list of the codes that require pre-service clinical review visit the AIM ProviderPortal℠.

As a reminder, please submit pre-service clinical review requests to AIM in one of the following ways:

• Access AIM’s ProviderPortalavailable 24/7 to process orders in real-time
• Access AIM’s portal via the Availity Web Portal
• Contact AIM’s call center - 866-714-1107, 8:00 a.m. – 5:00 p.m.

Effective for dates of service on and after September 1, 2018, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our pre-service clinical review process.

Pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health (AIM), a separate company.

The following clinical guidelines or medical policies will be effective September 1, 2018:

Effective for dates of service on and after September 1, 2018, the following specialty pharmacy codes from new or current medical policies or clinical UM guidelines will be included in our existing specialty pharmacy level of care review process.

Level of care pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health (AIM), a separate company.

View the Clinical Site of Care (Level of Care) drug list and Clinical Site of Care (Level of Care) pre-service clinical review FAQs for more information.

In the April 2018 edition of Network Update, we announced an expansion of hospice benefits for local Anthem fully-insured plans to begin on June 1, 2018. The newly expanded benefits allow for disease modifying treatments to continue alongside hospice services, as well as member access to hospice services with prognoses of up to 12 months.

Providers should verify whether members have the expanded hospice benefit under their Anthem policy.

For some health plans, updated benefit information will return via an electronic eligibility and benefit inquiry on the Availity Portal or using your Electronic Data Interchange (EDI) interface as early as June 1, 2018. We anticipate that all impacted plans will return the updated language by August 1, 2018. Once updated, hospice inquiries (Service Type 45) will confirm access to the expanded hospice benefit by returning: “Life expectancy up to 12 months with disease modifying treatment allowed.”

Please note: From June 1, 2018 through August 1, 2018, we’ll be updating our systems to report more detailed benefit language. During that timeframe, it may be necessary to contact the Provider Service number on the back of the member’s ID card to confirm if the member’s plan includes the expanded hospice benefit.  

As a reminder, the following plans include the expanded hospice benefits beginning June 1, 2018: commercial fully-insured group and individual plans. The following plans do not include expanded hospice benefits: self-insured plans, Medicare, Medicaid, and FEP.

We continually evaluate coding and billing patterns, and recently identified trends related to the use of code E1399 — DME, miscellaneous. When an appropriate code exists for DME equipment or supply, the more specific code should be used.

Inappropriate use of code E1399 often includes, but is not limited to the following:

• Gait trainers (E8001/E8002)
• Shower chairs (E0240)
• Standing frames (E0641)
• Hospital beds (E0250-E0373)
• Stand assist lifts (E0635)

To help ensure proper use of E1399, we conduct post-payment reviews of code E1399.  If a more appropriate code should have been used, we may recoup overpayments accordingly.

We continue to require prior authorization for the use of miscellaneous code E1399. If a prior authorization is approved but the claim is submitted with the incorrect code E1399, the claim may be denied and a corrected claim will need to be resubmitted with the appropriate HCPCS code.

Effective with dates of service on and after October 31, 2018, we will begin using MCG Care Guidelines 22nd edition behavioral health guidelines for the review of behavioral health services. This represents a change from the behavioral health medical policies and clinical guidelines currently used. 

Please note that the following behavioral health medical policies and clinical guidelines (BEH) will be retained at this time:

• 00002 - Transcranial Magnetic Stimulation
• 00004 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
• CG-BEH-01 - Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome
• CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
• CG-BEH-14 - Intensive In-Home Behavioral Health Services

We may continue to use additional medical policies and clinical guidelines to supplement MCG Care Guidelines.

View our medical policies and clinical guidelines and view Customizations to MCG Care Guidelines 22nd edition.

This change impacts our Commercial health plans.

Providers should continue to call the phone number indicated on the back of the member’s ID card to request prior authorization review or for additional questions regarding behavioral health benefits.

Please note that we no longer manage traditional behavioral health outpatient therapy for all fully-insured products, including our health insurance exchange products. Many of our self-funded groups have also removed review of the traditional outpatient therapy visits; however, some groups continue to require a review after a certain number of pass-through visits.

Please be certain to verify benefits for new patients to help ensure you are aware of any requirements. Partial hospitalization, intensive outpatient, applied behavior analysis, trans-cranial magnetic stimulation (TMS) services continue to require prior authorization from the first visit.

We are now providing benefits for crisis stabilization services for commercially-insured members in Connecticut. The Children’s Center of Hamden is providing these services.

Crisis stabilization services are direct mental health care services to non-hospitalized individuals experiencing an acute crisis of a psychiatric nature that may jeopardize their current community living situation. The goals are to avert hospitalization or re-hospitalization; stabilize individuals in psychiatric crisis; and mobilize the resources of the community support system, family members, and others for ongoing maintenance, rehabilitation, and recovery. 

If you are treating an Anthem member who may be appropriate for this service or if you have any questions, please call 800-934-0331.

Beginning with dates of service on and after July 1, 2018, the following updates will apply to AIM Musculoskeletal Program Clinical Appropriateness Guidelines.

Spine surgery guideline: 

• Cervical decompression with or without fusion:
  • Added osteotomy and corpectomy definitions
  • Clarified implant/instrumentation failure
• Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis):
  • Added osteotomy and corpectomy definitions
• Spinal stenosis:
  • Removed bilateral or wide decompression

Interventional pain management guideline: 

• Epidural injection procedures and diagnostic selective nerve root blocks:
  • Added pre-service clinical review exemption for CPT codes 62320 and 62322 when used for post-procedural pain with certain ICD-10-CM diagnoses
• Repeat therapeutic epidural steroid injections, clarified initial injection as therapeutic:
  • Clarified injection sessions for procedural requirements
• Paravertebral facet injection/nerve block/neurolysis:
  • Increased procedural limitation for diagnostic medial branch blocks
  • Increased procedural limitation for therapeutic intra-articular facet joint injections and clarified requirement for conservative treatment between injections
• Sacroiliac joint injections:
  • Added HCPCS code G0260

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

• Access AIM’s ProviderPortal available 24/7 to process orders in real-time
• Access AIM’s portal via the Availity Web Portal
• Contact AIM’s call center - 866-714-1107, 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 June 1, 2018, we will offer an Individualized Care Program to our fully-insured commercial members to provide palliative care support for members with advanced illness in the last 12 months of life.  

This program does not replace the care of PCPs and specialists, but provides an extra layer of support with an interdisciplinary team that includes palliative care physicians, palliative care nurse practitioners, registered nurses, social workers, chaplains and patient care coordinators.

Specific palliative care services include:

• Comprehensive assessments including symptoms, spiritual and psychosocial needs
• Expert symptom management
• Supporting patients in defining their goals, values and preferences and in advance care planning
• Encouraging patients to execute advance directives
• 24/7 access to urgent clinical support from a palliative care team member
• Securing needed resources
• Education on palliative services and hospice care services

An initial telephonic outreach to identified members will be made by a palliative care professional to introduce our Individualized Care Program and to determine the appropriate level of palliative services in one of the following three models:

1. Telehealth services and support at routine intervals to members by palliative trained providers
2. Home based visits by a palliative care nurse practitioner, supported by an interdisciplinary team of palliative providers for members with a high symptom burden, increased risk of hospitalization, or other complex issues. The home based visits will be offered through a collaboration with Aspire Health (available in certain geographic areas).
3. Clinic based services offered through a collaboration with Aspire Health. Aspire’s palliative care team will be embedded within the outpatient clinic/practice of the member’s medical oncologist to provide services to targeted patients (available in certain geographic areas).

Aspire Health already provides services for members with advanced illness enrolled in our Medicare and Medicaid health plans and has demonstrated improvement in quality and cost of care savings.

If you are an Anthem contracted network provider, an Aspire Health palliative physician may reach out to your practice to introduce themselves in order to establish a physician to physician relationship. They may also discuss developing an individualized mechanism by which to share information regarding patients that have been identified for palliative care services. Aspire will provide clinical updates to your practice on a regular basis to facilitate the best possible co-management of your patient.

If you have questions about our Individualized Care Program, please email IndividualizedCareProgram-PalliativeCare@anthem.com.

For primary care physicians participating in the 2017 Anthem Quality-in-Sights (AQI) Primary Care Quality Incentive Program, please be advised that the results from the 2017 measurement period will be available on our Provider Online Interactive Tool (POIT) portal at the end of July 2018. 

The POIT portal is accessible through Availity. Log onto Availity.com > My Payer Portal > Anthem Provider Portal > Answers@Anthem > Provider Online Interactive Tool (POIT) > Rewards & Recognition at the end of July 2018 to access your scorecard.

Please note, this notice is only applicable to Medicare Advantage members: Cologuard, the at-home colorectal cancer screening, is covered at 100 percent for Anthem Medicare Advantage individual and group-sponsored members. Members will not incur an out-of-pocket cost for the screening and no prior authorization is required.

71411MUPENMUB 03/27/2018

he Medicare peer-to-peer process facilitates a conversation between a provider and an Anthem medical director. The peer-to-process should be used to explain or clarify something that a clinical record cannot convey. To learn how to initiate a peer-to-peer conversation, please see Important Medicare Advantage Updates at anthem.com/medicareprovider

We want to thank our PCPs and hospitals for their coordination of home health care for our members. We want to alert you to important changes to our home health provider network for most of our Medicare Advantage members. We will delegate our provider network for home health care services for most of our Medicare Advantage members to myNEXUS August 1, 2018. 

Additional information will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider.

Medication non-adherence increases mortality and costs the healthcare system billions of dollars per year. We are collaborating with physicians engaged in our Enhanced Personal Health Care (EPHC) programs to promote adherence by increasing 90-day supply prescriptions. Patients who receive 90-day supplies are more likely to be adherent, and our Medicare Advantage plans allow 90-day supplies to be filled for chronic medications at any retail pharmacy. Beginning in July, EPHC providers will receive a monthly report that identifies Medicare members eligible for a 90-day supply.  Please evaluate that member list and discuss the benefits of a 90-day supply with your patients.

Effective July 1, 2018, Anthem will be a Medicare Advantage (MA) plan option for Motion Picture Industry Health and Pension Plans (MPI).  We will provide medical benefits for MPI retirees through a Local Preferred Provider Organization (LPPO) product.  The MA plan offers the same hospital and medical benefits that Medicare covers. In addition, MPI retirees will pay the same cost share for both in-network and out-of-network services. The MA plan also covers additional benefits that Medicare does not such as hearing, acupuncture, LiveHealth Online and SilverSneakers.

MPI retirees will have a customized identification card that includes the MPI logo. The prefix on their cards will be MBL.

Providers will follow their normal claim filing procedures for MPI member claims.   

Effective July 1, 2018, Anthem will be a Medicare Advantage (MA) plan option for Connecticut Teachers’ Retirement Board (TRB).  We will provide medical benefits for TRB retirees through our Local Preferred Provider Organization (LPPO) product.  The MA plan offers the same hospital and medical benefits that Medicare covers. The MA plan also covers additional benefits that Medicare does not such as LiveHealth Online and SilverSneakers. 

TRB retirees will have a customized identification card that includes TRB’s logo.  The prefix on their cards will be ZDX. Providers will follow their normal claim filing procedures for MPI member claims.

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

• Updated: Prior authorizations required for new group-sponsored MA membership 
• Anthem adopts MCG care guidelines 22nd Edition
• Improve Medicare Advantage members’ medication adherence with 90-day prescriptions
• Prior authorization requirements for cardiovascular services  
• Medicare Advantage reimbursement policy provider bulletin
• Medicare risk adjustment and documentation training
• Dual Eligible Special Needs Plans – provider training required
• Prior authorization requirement for Electrical Stimulation Device
• Prior authorization requirements for part B drugs: Zevalin and Eptacog 
• Prior authorization requirements for Part B Drug: Trelstar 

71763MUPENMUB 04/18/2018