In February, we introduced our new Authorization Rules Lookup tool that you can access through Availity Payer Spaces. This new self-service application displays prior authorization rules so you can quickly verify if the outpatient services require prior authorization for members enrolled in Anthem’s commercial plans.

In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:

• Medical Policies and Clinical Guidelines
• Third Party Guidelines, if applicable (such as AIM Specialty Health, IngenioRx)

Access the Authorization Lookup application through Availity Payer Spaces

Access to the tool does not require an Availity role assignment.

1. Select Payer Spaces
2. Select the Anthem Blue Cross Blue Shield tile from the Payer Spaces menu
3. Select the Applications tab
4. Select the Authorization Rules Lookup tile

Once you are in the tool, you will need to provide the following information to display the service’s prior authorization rules:

• Tax ID
• National Provider Identifier (NPI)
• Member ID and birth date
• Member’s group number or contract code

(This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)

• CPT/HCPCS code

Give this new tool a try and discover how much this will improve the efficiency of your authorization process.

Please note: If a prior authorization is required for outpatient services, you may submit the case through Interactive Care Reviewer, Anthem’s online authorization tool that is also accessible through the Availity Portal.

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To help ensure accuracy and eliminate delays in the adjudication of your claims, the itemized bill must be included with qualifying claim submissions. Submitting an itemized bill (unsolicited* medical attachment) for a high dollar claim just got easier!

To submit an itemized bill (unsolicited medical attachment):

1. Log in to Availity Portal
2. Select Claims & Payments | Attachments – New
3. Select Send Attachment
4. Under Request for Information, select No, if you are including the supplemental information/attachment for an 837 claim PWK. (see example below)

1. Include provider, patient and claim information
2. Attach supporting documentation and reason (example shown below)
3. Send attachment(s)

Providers may also submit a claim attachment using the Availity Portal for solicited** medical attachments.

To submit supporting documentation in response to a formal (solicited) request from the payer:

• Log in to Availity Portal
• Select Claims & Payments | Attachments – New
• Select Send Attachment
• Under the Request for Information, select Yes, if you are responding to a request from the health plan or need to submit documentation for a specific claim number (see example below)
• Add supporting documentation and reason
• Submit

Additionally, if you attended a previous webinar, we have updated information on submitting an EDI 837 batch that includes a PWK segment in loops 2300/2400. The update is regarding the linkage between the electronic claim and your supplemental documentation that can be submitted through the Availity portal.

What does this mean for you?

You may now submit attachments electronically (EDI) using the PWK segment to specify that documents are being submitted in support of the claim and no additional face sheet or coversheet is needed.

Here are the steps:

• Log in to Availity Portal
• Select Claims & Payments I Attachments - New
• From the Inbox tab, select the appropriate claim or open the request in your work queue
• Add files with supporting documentation
• Submit

Get trained

• Attend an Availity-hosted webinar to learn more about all capabilities. You can register for an upcoming live webinar hosted by Availity here, or
• Log into Availity.com and select Help & Training | Get Trained to open the Availity Learning Center in a new tab (it is your dedicated ALC account).

• Search by keyword (Medattach) to find on-demand and live training options
• Click Enroll to enroll for a course and then go to your Dashboard to access it any time

Get started today with these wide-ranging capability enhancements to transform your business operations to a quick, secure, paperless and simple process to fulfill medical records requests electronically through Availity.

*Unsolicited attachment: Documentation submitted without a formal request from the payer

**Solicited attachment: Documentation submitted in response to a specific request from payer

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Effective April 1, 2021, several updates to the Advance Notice Policy will be implemented. If a member is scheduled to receive a service or procedure from a non-participating provider, the referring participating provider must provide advance notification to the member so the member may choose whether to oppose or approve the use of a non-participating provider for the service or procedure. The notice must be provided, completed, and dated by the member, and retained in the member’s medical file a minimum of seven (7) days in advance of the procedure or service. In addition, providers or facilities who are instructed to provide copies of signed advance notice policies as the result of an audit will now be required to respond with the required information within fifteen (15) days.

This policy will continue to apply to both facilities and professional providers. The updated policy in its entirety may be viewed on anthem.com/provider > Connecticut > Scroll down and select Find Forms >  Use of a Non-Participating Provider Advance Patient Notice Policy.

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As a participating provider, please remember 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 the following methods to monitor adherence to these access standards:

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 (2) PCPs within five (5) miles of each member
• Two (2) OB/GYNs within eight (8) 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 that 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.

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On November 1, 2020, AIM Specialty Health^® (AIM) began administering the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints using AIM clinical guidelines for Anthem fully-insured members and certain ASO groups.   

Effective March 14, 2021, the AIM Small Joint Surgery Guideline will be updated with the following:

• Clarified requirements for imaging reports
• Removed radiographic requirement for confirmation of lesser toe deformities
• Added ankle arthrodesis and total ankle arthroplasty as new indications for revision of failed previous reconstructions
• Removed total ankle arthroplasty requirements for adjacent joint or inflammatory arthritis
• Clarified contraindications only apply to total ankle arthroplasty

Providers should continue to submit pre-service review requests to AIM using one of the following options:

• Access AIM’s ProviderPortal_SM directly at www.providerportal.com. Real-time, online access is available 24/7 to process orders, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Portal at www.availity.com.
• Call the AIM toll-free number at 866-714-1107, Monday through Friday 8:30 a.m. – 7:00 p.m.

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

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We will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.

We encourage providers who offer telehealth services to use the online Provider Maintenance Form to notify us, and we will add a telehealth indicator to your online provider directory profile.

Please contact Provider Services with any questions.

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The medical policies, clinical utilization management (UM) guidelines and third party criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The medical policies and clinical UM guidelines below are followed in the absence of Medicare guidance.

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

Visit our website to view our medical policies and clinical UM guidelines.

Notes/updates:

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

• *GENE.00055 – Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
  • Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications
• *LAB.00037 – Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
  • Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered investigational and not medically necessary for screening, diagnosis or management of irritable bowel syndrome, and for all other indications
• *DME.00011 – Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
  • Revised scope to only include non-implantable devices and moved content addressing implantable devices to SURG.00158
  • Added “non-implantable” to bullet point on percutaneous neuromodulation therapy
  • Added percutaneous electrical nerve field stimulation (PENFS) as investigational and not medically necessary for all indications
• *SURG.00062 – Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
  • Expanded scope to include percutaneous testicular vein embolization for varicocele and added embolization of the testicular (spermatic) veins as investigational and not medically necessary as a treatment of testicular varicocele
• *CG-LAB-15 – Red Blood Cell Folic Acid Testing
  • RBC folic acid testing is considered not medically necessary in all cases
• *CG-LAB-16 – Serum Amylase Testing
  • Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions
• *CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules
• Added the Afirma Xpression Atlas as not medically necessary
• 00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
  • A new medical policy was created from content contained in DME.00011.
  • There are no changes to the policy content.
  • Publish date is December 16, 2020.
• CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing
  • A new clinical guideline was created from content contained in GENE.00026.
  • There are no changes to the guideline content.
  • Publish date is December 16, 2020.

Medical policies

On November 5, 2020, the medical policy and technology assessment committee (MPTAC) approved the following medical policies applicable to Anthem. These guidelines take effect March 8, 2021.

Clinical UM guidelines

On November 5, 2020, the MPTAC approved the following clinical UM guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on November 19, 2020. These guidelines take effect March 8, 2021.

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Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.

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

Access the Claims Status Listing on Payer Spaces from https://www.anthem.com/medicareprovider using the Log In button or through the secure provider portal via Availity*. We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim

status changes, other claims needing resolution are added, and claims are resolved faster.

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

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem is using digital technology to improve the healthcare experience. If you have questions, please reach out to your Provider Relations representative.

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

• MCG Care Guidelines 24th edition customization for Anthem
• DME checklist of information needed from providers for Anthem members