Have you been using the medical attachment tool on the Availity Portal to submit solicited medical records in support of a claim? You’ll now find these changes that were recently introduced:

 

• Select the “Attachment – New” option to submit medical records when Anthem has requested additional information to process a claim.
• To send a solicited attachment, now find the ‘Send Attachment’ link on the top, right side of the page.
• Expanded file size – each attachment can now be up to 40 MB with a total of 80 MB as the file size limit.

 

If you have not tried the Medical Attachment tool to submit electronic documentation in support of a claim, now is the time to give it a try! This tool makes the process of submitting requested medical records simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Anthem) medical record attachments through the Availity Portal.

 

How to access/setup the solicited medical attachments tool for your office

Availity Administrators must complete these steps:

1. From My Account Dashboard, select Enrollments Center > Medical Attachments Setup, follow the prompts and complete the following sections:
2. Select Application > choose Medical Attachments Registration
3. Provider Management > Select Organization from the drop-down. Add NPIs and/or tax IDs. (Multiples can be added separated by spaces or semi-colons.)
4. Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name.

 

Submitting medical attachments

Once the above setup is completed, Availity Users will complete these steps:

1. Log in to www.availity.com
2. Select Claims and Payments > Attachments-New > Send Attachment Tab
3. Complete all required fields of the form
4. Attach supporting documentation
5. Submit

               

Need training?

To access additional training for this Availity feature:

1. Log in to the Availity Portal at www.availity.com
2. At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
3. In the new window a list of available topics will open. Locate and click Medical Attachments.
4. Under the Recordings section, click View Recording

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

 

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website at anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Health and Wellness > Practice Guidelines.

 

One of the measures we report on is Controlling High Blood Pressure (CBP). This measure focuses on the percentage of members who are 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement year (2018).

 

What’s new for 2019?

• The CBP measure is no longer strictly a hybrid measure, which means that we review both medical records and claims. We can now use claims data to confirm both the diagnosis of hypertension as well as the blood pressure reading (CPT II codes).
• If you submit a claim using CPT II codes to document the blood pressure reading, we can now use that information, eliminating the need to request the medical record from you.
• Compliant BP is defined as <140/90 mm Hg for all members.
• Blood pressure readings taken from remote monitoring devices that are electronically submitted directly to the provider can be utilized for the measure.

 

What do we need from you?

We need the last two (2) office visit notes from 2018 with the blood pressure documented. Also, if the member was diagnosed with end stage renal disease, renal dialysis, renal transplant or pregnancy in 2018, please send that documentation as well.

 

Common chart deficiencies

• Recheck elevated blood pressures readings and document all BP readings in the medical record.

 

For more information on HEDIS visit anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Select Health & Wellness tab from the blue bar at the top of the page > Quality Improvement and Standards > HEDIS Information.

 

Thank you for your continued cooperation and support of HEDIS.

 

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

As a participating provider, please be reminded of your contractual obligation to help ensure our members have prompt access to services. Please visit anthem.com to access our Provider Manual for our guidelines on access to care for primary care practitioners (PCPs), specialty care practitioners (SCPs) and behavioral health practitioners (BHPs). We use several methods to monitor adherence to these standards. Monitoring is accomplished by:

 

1. Assessing the availability of appointments via phone calls by our staff or designated vendor to the provider’s office
2. Analysis of member complaint data
3. Analysis of member satisfaction surveys

 

The following information is excerpted from the Provider Manual for your review:

 

Physician/provider access goals and calendar requirements

One of our goals is to make accessing medical care easy for members by assuring a comprehensive network of physicians and providers close to their homes.  As a result, we have implemented the following plan-wide geographic access goals as guidelines for our network.  It is our goal to provide members with access to the following within our defined service areas:

 

• Two PCPs within five miles of each member
• Two OB/GYNs within eight miles of each member
• Full range of specialists (including non-MD allied providers) within 15 miles of each member

 

Calendar access requirements

• Primary care providers:
  • Preventive care - members scheduling periodic routine exams (well care/preventive visits), appointments should be available within 45 calendar days of a member’s call. Care provided to prevent illness or injury; examples include, but are not limited to, routine physical examinations, immunizations, mammograms and pap smears.
  • Urgent care appointment with acute symptoms - appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to, sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, non-resolving headache.
  • Routine care with symptoms – must have access to care within five (5) days of the member’s call.
  • Routine check-up – must have access to care within 10 business days of the member’s call.  This consists of care provided for non-symptomatic visits or follow-up.

 

Though it is important for members to have the continuity of receiving care from their PCPs, there are occasions when you may not be available at a time that meets their scheduling needs.  As a reminder, we now contract with walk-in centers and urgent care facilities which are listed in our directory.

 

• Specialists:
  • Urgent care appointment with acute symptoms - appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to, sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, non-resolving headache.
  • Routine check-up – must have access to care within 15 calendar days of the member’s call.  Care provided for non-symptomatic visits for health check.

 

• Behavioral health providers:
  • Non-life threatening emergency needs - must be seen, or have appropriate coverage directing the member, within six (6) hours. Emergent behavioral health care provided when a member is in crisis, experiencing acute distress and/or other symptoms and needs immediate attention; no risk of loss of life.
  • Urgent needs - must be seen, or have appropriate coverage directing the member, within 48 hours. Non-emergent behavioral health illness that requires immediate care; member is experiencing significant psychological distress with symptoms that impairs daily functioning; no risk of loss of life.
  • Initial routine office visit - must be seen within 10 business days. New patient non-urgent appointment scheduled after intake assessment or a direct referral from a treating practitioner.
  • Follow-up routine visit – must be seen within 30 calendar days.  Non-urgent behavioral health care; member has been scheduled for a non-urgent consultation or requires services including, but not limited to, follow-up and existing medication management.

 

After-hours coverage

After-hours coverage, which is required by the Provider Agreement, consists of an attendant or recording assisting the member in accessing urgent services outside of regular office hours.  Note that telephone answering machines and voice mail are not acceptable means of providing access for members if the answering machine or voice mail message only refers members to the emergency room or to call 911. The recording or live person must refer the patient to urgent care center, 911, or emergency room, and also provide the option to contact a live health care practitioner (via cell, pager, beeper, transfer system) , get a call back for urgent instructions, or be transferred directly to the available practitioner or on-call practitioner.

 

Timely access to physicians is a major priority of our members and employer groups. The requirements adopted reflect not only their expectations, but market norms. We will be assessing physicians against these requirements through our customer satisfaction surveys and provider surveys as well as follow-up on any members’ complaints received. However, we are sensitive to problems related to seasonal services, the varying nature of practice specialties, and the challenges faced by busy practices. If your office routinely fails to meet these access and after-hours standards, it is important that you document and we understand the reasons that the requirements are not met.

It is very important that all provider demographic information is accurate and up to date in our systems. We receive a significant number of claims with a name or address that does not match our provider files, and this can result in a claim payment to an incorrect provider or a claim denial. In addition, our members frequently utilize the online provider directories to obtain information regarding our network of participating providers, and having accurate information is essential. Please be sure to notify us of all changes such as:

 

• Telephone number for members to schedule appointments at your practice location
• Practice location address
• Provider name
• Practice name
• Providers terminating or leaving your practice
• Providers joining your practice
• PCPs changing status to or from accepting new patients or not accepting new patients
• Billing address
• Tax ID number
• Specialty
• Hospital admitting privileges

 

How to access the online Provider Maintenance Form:

Visit anthem.com > select Providers, then from the drop-down menu under Provider Resources, select Provider Maintenance.  Follow the instructions provided to update and submit the new information.

 

If you have not previously accessed anthem.com and established your state as Connecticut, you will first need to select Providers > Provider Overview, then select Connecticut.  The website will subsequently default to Connecticut as your state.

 

Advance notice of provider demographic and/or practice changes is required; retroactive changes are not allowed. Requests must be received 30 days prior to the change/update. Any request received with less than 30 days advance notice may be assigned a future effective date. Please provide 90 days advance notice of termination from our network; however, your specific contract provisions may supersede this. Check your contract for any specified requirements regarding length of notice required in advance of your termination request.

We have designated Availity to operate and serve as your electronic data interchange (EDI) entry point, also called the EDI Gateway. The EDI Gateway is a no-cost option for providers that choose to submit their own EDI claims to us. If you prefer to use a clearinghouse or billing company, please work with them to ensure connectivity.

 

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway. 

 

Do you already have an Availity User ID and Login? You can use the same login for your Anthem EDI transactions.  

 

• Log in to the Availity Portal and select Help & Training | Get Trained. In the Availity Learning Center, search the Catalog by key word “SONG” for live and on-demand resources created especially for you.

 

If you wish to become a direct a trading partner with Availity, the setup is easy.

 

• Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions.

Need assistance?

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

 

835 Electronic Remittance Advice (ERA)

Please use Availity to register and manage account changes for ERA. If you were previously registered to receive ERA, you must register using Availity to manage account changes. Log into the Availity Portal and select My Providers | Enrollments Center | ERA Enrollment to enroll for 835 ERA delivery.

 

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

 

If you have any questions, contact Availity Client Services at 1-800-Availity (800-282-4548), Monday – Friday, 8:00 a.m. to 7:30 p.m.

We continue to make it easier and more convenient to become an Anthem participating provider. The Digital Provider Enrollment application has been designed to speed up the enrollment process, allow providers to submit data at one time, and obtain real-time updates on the status of an application.

 

Access to the new application is available through Availity, our secure web-based provider portal.

New and current Availity users should ensure their user ID has the correct access. Please ensure that you have been assigned to Provider Enrollment.

 

Digital provider enrollment offers many benefits:

• Supports enrollment of professional providers, whose organizations do not have a credentialing delegation agreement with us.
• New individual providers or groups can request a contract.
• Existing groups can add providers to their existing contract.
• Providers can check the status of an application in real-time using the enrollment dashboard.

 

To use the new Digital Enrollment application, please ensure your provider data on CAQH is current and in a complete or re-attested status, then log into Availity and use the following navigation: Choose your state > Payer Spaces > Provider Enrollment.

Each year, we request your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented hierarchical condition categories (HCC), in order to document and close the coding gaps. 

 

The CRA Program is specific to our Affordable Care Act (ACA) members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).

 

With our Retrospective Program we focus on medical chart collection. We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS). This particular effort is part of our compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership. The members’ medical record documentation helps support this data requirement.

 

Analytics are performed internally on claims which do not have the ICD10 code for which we suspect a chronic condition. These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.

 

Anthem network providers, including PCPs, specialists, facilities, behavioral health, ancillary, etc., may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review. These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf. The vendors’ web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management. 

 

We ask that our network providers submit the medical record information to the designated vendor within 30 days of the request (no later than March 31, 2019).  While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.

 

Electronic options that may make medical chart collection easier for providers:

 

• EMR Interoperability
  • Allscripts (Opt in -- signature required)
  • NextGen (Opt out -- auto-enrolled)
  • Athenahealth (Opt out -- auto-enrolled)
  • MEDENT

• Remote/direct Anthem access
• Vendor virtual or onsite visit
• Secure FTP

 

The goal of these electronic options is to both improve the medical record data extraction and the experience for our network-participating hospitals, clinics and physician offices.  If you are interested in this type of set up or any other remote access options, please contact Alicia Estrada, our Commercial Risk Adjustment Network Education Representative, at Alicia.Estrada@anthem.com.

 

Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests.  

 

This March, anthem.com will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms. A sample screen image of the upcoming changes is attached to this article. 

This first version of the new Provider Forms will keep growing and evolving in the coming months.

 

We will continue to keep you informed of upcoming changes to the public provider site as we progress toward streamlining our Web platform and other business processes.

Prior to January 1, 2019, Anthem had provider networks unique to our HMO and PPO small group and individual plan products sold on the State of Connecticut’s Health Insurance Exchange, Access Health CT (the “Exchange”).These networks were called the Pathway Networks, and were also sometimes referred to as our “Exchange Networks” or “On-Exchange Networks.”  

 

Beginning January 1, 2019, the Pathway Networks will also support small group and individual products sold by us outside of the Exchange direct to customers. 

 

What this means for you:

As of January 1, 2019, all of our individual and small group products whether sold on the Exchange or by us outside of the Exchange will be supported by the Pathway networks. For individual members, this change is effective as of January 1, 2019. For small group members, this change is effective upon the date of their 2019 renewal (e.g., for small groups that renew February 1, this change will be effective February 1, for small groups renewing March 1, this change will be effective March 1, etc.). Once effective, individual and small group customers must obtain services from providers participating in the Pathway networks in order to receive in-network benefits. 

 

Specifically, as of the applicable dates indicated above, all individual and small group members must use the following networks to receive the in-network level of benefits:

 

• Members of all Anthem small group HMO Plan products must use the Pathway CT HMO Network.
• Members of all Anthem individual HMO Plan products must use the Pathway Enhanced Network.
• Members of all Anthem small group PPO Plan products must use the Pathway CT PPO Network.
• Members of all Anthem individual PPO Plan products must use the Pathway Network.

 

Providers who participate in Anthem networks need to be aware of the following:

 

• Compensation applicable to all Anthem small group products, whether on or off exchange, has always been the same. This did not change as of January 1, 2019. 

 

• As of the dates indicated above, providers participating in Anthem networks must participate in the applicable Pathway Network(s) to render health care services on an in-network basis to members of Off-Exchange Plan products. In-network compensation for covered health care services rendered to these members will be the amount(s) corresponding to the applicable Pathway Network(s).

 

• All Anthem individual members have been advised in their renewal packet of the changes and the need to check our provider directory to confirm participation of their health care providers in the network supporting the plan products they enroll in. All Anthem small group employers have been (or will be) advised of the changes and the need for their employees to confirm participation of their health care providers in the network supporting their plan.

 

More detail on these changes, including product names and prefixes, can be found on our 2019 Individual & Small Employer Group Health Plans Quick Reference Guide.  If you have any questions, please contact your Provider Relations Representative or e-mail our Provider Relations Department at: CTNetworkManagement-SM@anthem.com.

 

Thank you for your continued service and dedication to all our members.

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

 

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

 

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

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

 

• Special Need Plans training required
• 2019 risk adjustment provider training
• New provider learning opportunity: Put the AIM ProviderPortal to work for you
• New provider service phone number beginning January 1, 2019

 

75743MUPENMUB 01/24/2019

                 

The following revised clinical criteria will be effective May 1, 2019. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.

 

Clinical criteria effective date	Clinical criteria number	Clinical criteria	Clinical criteria (new/revised)
May 1, 2019	ING-CC-0001	Erythropoiesis Stimulating Agents	Revised
May 1, 2019	ING-CC-0004	H.P. Acthar Gel® (repository corticotropin injection)	Revised
May 1, 2019	ING-CC-0072	Selective Vascular Endothelial Growth Factor (VEGF) Antagonists	Revised

 

75743MUPENMUB 01/24/2019

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

 

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

 

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

 

If you have questions or feedback, please contact us.

We updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433. The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:

 

• Group code patient responsibility (PR) will be assigned.
• Claim adjustment reason codes (CARCs) will include the following:
  • 1 — deductible amount (professional claim)
  • 2 — coinsurance amount (professional claim)
  • 3 — copay amount (professional and facility claim)
  • 247 — deductible for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
  • 248 — coinsurance for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
• Remittance advice remark codes (RARCs) will include the following:
  • N781 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
  • N782 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
  • N783 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected copay. This amount may be billed to a subsequent payer.

 

Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.

75743MUPENMUB 01/24/2019

In 2019, we are offering dual eligible special needs plans (D-SNPs) to individuals who are eligible for both Medicare and Medicaid benefits or who are qualified Medicare beneficiaries (QMBs). D-SNPs provide enhanced benefits to individuals eligible for both Medicare and Medicaid. These plans are $0 premium plans. Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments. Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.  

 

Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in Q1 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.

 

Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.

For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.

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