We'd like to share some recent enhancements to the online site for our monthly provider publication – Provider News.

1. Article categories – such as “Administrative”, "Medicare", “Products and Programs” and so on – are now appearing directly under the article title on the website and in PDFs. (This will help differentiate between commercial and government business content.) Please see the sample illustration below.

2. We’ve also enhanced the look and feel of PDFs for individual articles and publications. Within PDFs for publications, you’ll find: 
   • A table of contents
   • A bold line separating each article
   • The URL for each article is included so users can access online if desired
   • Attachments will show if appropriate

We hope you find these changes helpful, as we continue to work to improve our provider communications vehicle and to make the tool even easier to use. 

As recently reiterated in the December 2019 edition of Provider News, effective November 1, 2019, all qualified providers who perform physical, occupational or speech therapy services for Anthem members are required to request prior authorization review from AIM Specialty Health® (AIM). Prior authorization review requests for PT, OT and ST may be submitted to AIM via the AIM ProviderPortal_SM.  

The AIM Rehab Program follows the Anthem Clinical Guidelines that state the services must be delivered by a qualified provider of therapy services acting within the scope of their licensure. Qualified providers acting within the scope of their license, including chiropractors, who intend to provide PT, OT or ST services must request prior authorization for those services through AIM. All non-physical therapists, non-occupational therapists and non-speech therapists must submit claims that include therapy codes contained in CG-REHAB-04, CG-REHAB-05 or CG-REHAB 06 with the modifiers GP (physical therapy services), GO (occupational therapy services) or GN (speech therapy services). 

We are also transitioning vendors for review of rehabilitative services for our Medicare members to include outpatient PT, OT, and ST to AIM Specialty Health. The AIM Rehab program will begin in April 2020. Modifiers must be appended when submitting claims for services delivered under an outpatient occupational or physical therapy plan of care on a CMS -1500 form. Use modifier GP (physical therapy services), GO (occupational therapy services) or GN (speech therapy services).

Please see the notice in the Medicare section of this March 2020 issue of Provider News for more information about the AIM Rehabilitative Program for Medicare members.   

Patient360 is a real time dashboard you can access through the Availity Portal that gives you a robust picture of your Anthem patient’s health and treatment history and will help you facilitate care coordination.

If an Anthem member has a Care Gap Alert, your medical practice can locate Active Alerts on the Member Summary page of the Patient360 application.

What’s new:  Medical providers now have the option available on Patient360 to include feedback for each gap in care that is listed on the patient’s active alerts. However, to be able to access the Care Gap Alert Feedback you will need to provide an individual NPI. If you select an NPI from Express Entry menu, the feedback options will not be available.



Once you have completed all the required fields you will land on the Member Summary page of the application. To provide feedback, select the Resolution Health Index (RHI) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry screen. You can choose the feedback menu option that applies to your patient’s care gap.

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

First, you need to be assigned to the Patient360 Role that your Availity Administrators can locate within the Clinical Roles options.

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

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 that do not have the ICD-10 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 - PCPs, specialists, facilities, behavioral health, ancillary, etc. - may receive letters from vendors such as Inovalon, Verscend, Ciox, Sharecare, and Episource 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. 

We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2020). 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 to allow for remote review)
• 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 Anthem’s 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 our Commercial Risk Adjustment Network Education Representative, Alicia.Estrada@anthem.com.  

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

Billing of patient treatment can be complex, particularly when determining whether modifiers are required for proper payment. Our reimbursement policy and correct coding guidelines establish the appropriate use of coding modifiers. We would like to highlight the appropriate use of some commonly used modifiers.

Things to remember

• Review the “CPT Surgical Package Definition” found in the current year’s CPT Professional Edition.  Use modifiers such as 25 and 59 only when the services are not included in the surgical package.
• Review the current year’s CPT Professional Edition Appendix A - Modifiers for the appropriate use of modifiers 25, 57 and 59.
• When an evaluation and management (E/M) code is reported on the same date of service as a procedure, the use of the modifier 25 should be limited to situations where the E/M service is “above and beyond” or “separate and significant” from any procedures performed the same day.
• When appropriate, assign anatomical modifiers (Level II HCPCS modifiers) to identify different areas of the body that were treated. Proper application of the anatomical modifiers helps ensure the highest level of specificity on the claim and can help show that different anatomic sites received treatment.
• Use modifier 59 to indicate that a procedure or service was distinct or independent of other “non E/M services” performed on the same date of service. The modifier 59 represents services not normally performed together but which may be reported together under the circumstances.

If you feel that you have received a denial after applying a modifier appropriately under correct coding guidelines, please follow the normal claims dispute process and include medical records that support the usage of the modifiers when submitting claims for consideration.

We will be publishing additional articles on correct coding in upcoming newsletters.

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 - appointments should be available within 45 calendar days of a member’s call for scheduling periodic routine exams (well care/preventive visits). 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 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.

Some professional (837P/CMS-1500) claims for services rendered to non-Anthem/BlueCard Blue Cross and Blue Shield members at retail health locations are being reported with a place of service that does not reflect a retail health clinic location. Retail health clinics are small walk-in medical centers located inside retail outlets (e.g. pharmacies, grocery stores, etc.) where consumers can go to receive convenient and affordable basic primary care services. Specifically, for services rendered at a retail health location, some providers are submitting values for Office (11) or Urgent Care Facility (20) instead of the value of Walk-in Retail Health Clinic (17). Reporting place of service as 11 or 20 can cause claims to process incorrectly, and thus result in the need for claim adjustments and rework for providers.

If your practice is a Walk-in Retail Health Clinic, please remind your coding staff to report the most accurate place of service, Walk-in Retail Health Clinic (17), for professional claims when submitting claims for non-Anthem/BlueCard members.

In an effort to improve the process for submitting a demographic change request for multiple providers such as change of address/termination etc., we have enhanced the PMF to allow for the usage of an excel spreadsheet. Please submit one PMF with an excel spreadsheet indicating all provider names and demographic information including a comments column noting the action(s) needed for each provider along with the appropriate effective date. Reminder, please notify us at least 30 days prior of any provider demographic and/or practice changes. For notices of termination from our network, refer to the termination clause in your Agreement for specific notification requirements.  

We are committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

Effective with dates of service on or after June 1, 2020, a medical necessity review of the hospital outpatient level of care for certain upper endoscopy and colonoscopy procedures will be required for members with commercial plans covered by Anthem.The clinical guideline, Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services, CG-SURG-52, will apply to the review process. The review will be administered by AIM Specialty Health® (AIM).

AIM will evaluate the clinical information in the request against CG-SURG-52, to determine if the hospital-based outpatient setting is the appropriate level of care for the endoscopy service. Your office may contact AIM to request a peer-to-peer discussion before or after the determination.

The level of care medical necessity review only applies to procedures performed in an outpatient hospital setting. This does not apply to requests for review of endoscopy performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Anthem is the secondary payer.

For a complete list of procedures subject to the medical necessity level of care review, and additional information, such as Frequently Asked Questions, visit aimproviders.com/surgicalprocedures.

Submit a request for review

Starting May 18, 2020 ordering providers may submit precertification requests for the hospital outpatient level of care for these procedures for dates of service on or after June 1, 2020 to AIM in one of the following ways:

• Access AIM 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 the AIM Contact Center toll-free number at 866-714-1107, Mon. - Fri., 8:00 a.m. - 5:00 p.m.

Beginning in May, AIM will offer webinars to provide information on navigating the AIM ProviderPortal. To register for a webinar visit aimproviders.com/surgicalprocedures. 

Please note, this review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage and Medicare Supplemental plans. Providers can view prior authorization requirements for Anthem members at Medical Policies & Clinical UM Guidelines and Prior Authorization at anthem.com.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the back of the member’s ID card. 

Note: In some plans “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “level of care” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “level of care.”

Effective April 1, 2020, we will transition the utilization management of our Outpatient Rehabilitation Program to AIM Specialty Health® (AIM). AIM is a specialty health benefits company. The Outpatient Rehabilitation Program includes physical, occupational and speech therapy services. We have an existing relationship with AIM in the administration of other programs.

This relationship with AIM will enable us to expand and optimize this program, further ensuring that care aligns with established evidence-based medicine. AIM will follow the clinical hierarchy established by Anthem for medical necessity determination. We make coverage determinations based on guidance from CMS, including national coverage determinations, local coverage determinations, other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.

AIM will continue to use criteria documented in Anthem clinical guidelines CG.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://medicalpolicies.amerigroup.com/am_search.html.

Detailed prior authorization requirements are available online https://www.availity.com by accessing the Precertification Lookup Tool under Payer Spaces. Contracted and non-contracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.

Prior authorization review requirements

For outpatient rehabilitation services rendered, or to be rendered, for dates of service from October 1, 2019 through March 31, 2020, no prior authorization is required. For these service dates, in addition to all other rights Anthem has under our provider contract and law, Anthem and AIM will continue to monitor claims history and utilization trends and will validate provider and member information.

AIM will facilitate training sessions to provide an overview of the program and demonstrate the AIM ProviderPortalSM. Please access the AIM Rehabilitation Provider Portal to register for an upcoming session.

For services that are scheduled on or after April 1, 2020, providers must contact AIM to obtain prior authorization. Beginning March 19, 2020, providers will be able to contact AIM for prior authorization of services to take place on or after April 1, 2020. Providers are strongly encouraged to verify that they have obtained prior authorization before scheduling and performing services.

How to place a review request

Beginning March 19, 2020, you may place a prior authorization request online via the AIM ProviderPortal. This service is available 24/7 to process requests in real time using clinical criteria. Go to www.providerportal.com to register. You can also call AIM at 800-714-0040, Monday through Friday, 8:00 a.m. to 8:00 p.m.

For more information

For resources to help your practice get started with the Outpatient Rehabilitation Program, go to www.aimproviders.com/rehabilitation. For portal login Issues, call 800-252-2021.

The AIM website provides access to useful information and tools, such as order entry checklists, clinical guidelines and an FAQ.

ABSCARE-0322-19

We provide benefits for covered services rendered by nurse practitioners (NPs) and physician assistants (PAs) when operating within the scope of their license. Our policy states that these mid-level practitioners are required to file claims using their specific NPI number, not that of the medical doctor.

We will continue to monitor this area of concern through medical chart review and data analysis. Billing noncompliance may be considered a contract breach.

We recognize the quality of care delivered to our members can be improved by the proper use of NPs and PAs. This notice is not intended to discourage their proper use, but rather to clearly define how services should be appropriately billed.

Thank you for your continued participation. Should you have any questions, please call the Provider Services number located on the back of the member’s card.

ABSCRNU-0121-20

Beginning January 1, 2020, we will be contacting members using non-preferred products with a high patient cost share about the availability of lower patient cost share preferred alternatives. If the member is interested in switching, we will call or fax their provider who can determine whether the preferred alternative is clinically appropriate. This is strictly informational and not a substitute for physician‑directed medical evaluations or treatments.

A list of the included non-preferred products and corresponding preferred alternatives is provided below. 

ABSCRNU-0123-20

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

• Benefits update for special supplemental benefits for the chronically ill
• Prior authorization requirements for CardioMEMS