Electronic solutions at your fingertips

We are working robustly to establish Anthem as a digital-first enterprise and to streamline your daily working tasks by using electronic functionalities. In support of the Digital-First Solutions, we are excited to publish two provider bulletins regarding the submission of medical attachments and itemized bills in partnership with Availity.

The objective of the bulletins is to provide a simple guide for you and your staff with step-by-step navigation instructions as well as information on where to find help and training with medical attachments.

The provider bulletins are posted on the Custom Learning Center (CLC) under the Resources tab. Follow these steps to access the documents:

• Availity > Payer Spaces > Select Payer Tile > Applications > Custom Learning Center
• Select Catalog > Resources to locate, view or download the Provider Bulletins

Please encourage your staff who have questions on the process or who are not submitting claim attachments electronically to review these valuable resources for assistance.

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All associates who make utilization management decisions are required to adhere to the following principles:

• Utilization management decision making is based only on appropriateness of care and service and existence of coverage.
• We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support, or tend to support denials of benefits.
• Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization, or create barriers to care and service.

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We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well.  The current health crisis illuminates this quite clearly.  It is imperative to offer care that is tailored to the unique needs of patients, and [Health Plan Name] is committed to supporting our providers in this effort. 

MyDiversePatients.com offers education resources to help you support the needs of your diverse patients and address disparities, including:

• Free Continuing Medical Education (CME) learning experiences about disparities, potential contributing factors and opportunities for providers to enhance care.
• Real life stories about diverse patients and the unique challenges they face.
• Tips and techniques for working with diverse patients to promote improvement in health outcomes.

Stronger Together offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.

While there is no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com and Stronger Together is to start reversing these trends…one person at a time.

Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted health care partner by visiting these resources today.

My Diverse Patients

Stronger Together Health Equity Resources

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We’d like to provide a reminder on how to bill when the member requests a ‘deluxe’ or upgraded version of a hearing aid.

If a member is requesting a deluxe hearing aid that exceeds the cost of the device that is medically necessary, please bill as follows:

• Report the appropriate HCPCS code and standard charge for the least expensive device that meets the member’s medical needs and is considered medically necessary on the first line of the claim.
• Report code S1001 and the balance between the base model considered medically necessary and the deluxe model on the second line of the claim.
• Prior to providing service, have the member sign a waiver indicating the member is aware that the deluxe model is not covered by their insurance and that they will be liable for the difference in cost between the deluxe and standard charges.

Below is an example of a claim for a deluxe hearing aid:

Deluxe item total charge $180

• Line item 1- V code- $100 (charge for the base model that meets member’s needs)
• Reimbursement will be based on the provider’s contract and the member cannot be billed for any amounts not paid unless specifically indicated on the remittance advice as member liability.
• Line item 2- S1001- $80 (amount exceeding the base model charge)
• This code will deny as member liability and can be billed to the member.

If it is felt that the deluxe model is medically necessary, the member can appeal to the appropriate customer services call center noted on the back of the member’s ID card.

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Often, healthcare costs incurred by Anthem members are a result of recommendations made by their physicians. As a participating physician with Anthem, you have the ability to help reduce your patients’ healthcare costs. Choices, such as where to refer a member for negative pressure wound therapy, can have a significant impact on your patients’ ultimate out-of-pocket liability. We are sharing the following information with you for consideration when referring patients for negative pressure wound therapy.

Our members, your patients, often participate in health benefit plans that may have coinsurance or deductibles. Your patients may experience significant differences in cost depending on which negative pressure wound therapy providers the members are referred to. Following is a sample listing of high quality, low cost national negative pressure wound therapy providers that participate with Anthem.  Referring to these providers will likely lower your patients’ out-of-pocket costs. 

You can find all of Anthem’s participating durable medical equipment (DME) orthotics and prosthetics providers, at “Find Care” – Anthem’s doctor finder and transparency tool – at anthem.com.

We are committed to seeking ways to reduce healthcare costs, and your referrals to network- participating providers can help make a difference.  We appreciate your partnership in considering the financial impact to your patients – our members – especially during these challenging economic times.

If you have questions, please contact your local Network Relations Consultant or call Provider Services.

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Digital online scheduling feature now available in the Availity Portal

The Appointment Scheduler application in Availity Payer Spaces is an online appointment-scheduling feature that allows providers to manage appointments with patients that may want to schedule appointments directly. Providers can manage patients’ appointment requests and maintain their appointment availability.

Providers can receive new appointment requests from active members, along with important information like the member’s ID number, contact information and any special health information they want the doctor to know. Providers can modify or deactivate their availability at any time. Availity Users with the role of “Office Staff” can set up physicians in the practice to accept online appointment requests.

Enrollment for Appointment Scheduler is easy. To access Appointment Scheduler in the Availity portal: Availity>Payer Spaces>Select Payer Tile>Applications

Appointment Scheduler features:

• Manage appointment requests and view physician availability
• Configure appointment availability
• Notification of new visit requests on Availity Notification Center and via email
• Members are notified directly via text or email once appointment is confirmed
• Send patient reminders via the Appointment Scheduler application
• Customize office locations and available times, as well as the types of appointments accepted

Visit the Appointment Scheduler application in the Availity portal today.

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We’ve expanded our file size to 100 megabytes

After receiving your feedback, we expanded our server to meet your need to upload larger files to our digital attachment tool, through Availity. You can now upload files up to 100 megabytes, eliminating the need to mail or fax.

Use the attachment tool to upload:

• Medical records
• Itemized bills
• Payment dispute
• EOB
• General correspondence
• Consent forms

The digital attachment tool file size expansion is just one example of how Anthem is using digital technology to improve the healthcare experience, with a goal to save you valuable time.

Access the attachment tool through www.Availity.com. From the Claims & Payments header, select Attachments – New. For more information about how to setup electronic attachments, use the Getting Started Guide: Select Help & Training>Find Help and then the Attachments topic in Contents. Once logged on you can also access the Getting Started Guide using this link.

For information about setting up for Program Integrity attachments, once logged on to Availity, use this link. You can also access Program Integrity attachment information from the Custom Learning Center: Payer Spaces>Custom Learning Center>Electronic Medical Records.

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A WISEWOMAN^TM knows that improving blood pressure is good for the heart

In honor of National High Blood Pressure Education Month, learn more about the CDC’s WISEWOMAN program: Well-Integrated Screening and Evaluation for WOMen Across the Nation. The aim of this program is to improve the delivery of heart disease and stroke prevention services for underserved women, aged 40-64 years. The program focuses on cardiovascular disease risk factors, specifically improving high blood pressure.¹ To learn even more about WISEWOMAN, visit the CDC website.

Resources for your patients
If your patient is one of the tens of millions of American adults who have hypertension, you know encouraging a healthier lifestyle and prescribing the right medications is important to managing the condition. But, if you would like to provide additional information about high blood pressure to your patients, take advantage of the helpful resources available to healthcare professionals through the CDC. The Hypertension Communications Kit provides blood pressure logs, tip sheets, and more. Hypertension Patient Education Handouts include fact sheets, medication information and dozens of useful tools.

Meeting the HEDIS® measure?

Controlling high blood pressure (CBP) assesses adults ages 18-85 with a diagnosis of hypertension and whose blood pressure was properly controlled base on the following criteria

• Adults 18-59 years of age whose blood pressure was <140/90 mm Hg
• Adults 60-85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg
• Adults 60-85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg

Patient claims should include one systolic reading and one diastolic reading²:

When charting your patient’s blood pressure readings, in addition to the systolic and diastolic readings, and dates, if the patient has an elevated blood pressure, but does not have hypertension, note the reason for follow-up.

Additional tips for talking to patients

• Continue to educate patients about the risks of hypertension
• Encourage weight loss, regular exercise, and diet
• Advise patients who are smoking to quit
• Talk about chronic stress and ways to cope with it in a healthy way

1https://www.cdc.gov/wisewoman/about.htm

2https://www.cdc.gov/bloodpressure/index.htm

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The American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care. Known as the “periodicity schedule,” this screenings and assessments guideline provides a comprehensive schedule for each well-child visit, from infancy.

Schedule for well-child visits

The AAP recommends that children should have a total of eight visits before their 30-month birthday (six visits before they are 15 months) with annual visits thereafter. The AAP periodicity schedule aligns with the well-child visits in the first 30 months of life (W30) HEDIS® measure.  Ensuring all visits are completed before the child’s 30-month birthday is critical to assuring compliance with these measures. 

Complete coverage for well-child visits regardless of when visit is received

Well-child visits (WCV) are covered 100% regardless of when the visit is received. Payment is not dependent on a set schedule, so there is no requirement to wait for a milestone birth month to schedule the well-child visit.

HEDIS® measures W30 and WCV

• Well-child visits in the first 30 months of life (W30)
  Description: The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:
  • Well-child visits in the first 15 months. Children who turned 15 months old during the measurement year: six or more well-child visits.
  • Well-child visits for age 15 month to 30 months. Children who turned 30 months old during the measurement year: two or more well-child visits.
• Child and adolescent well-care visits (WCV)
  Description: The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

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

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To more appropriately align program intention to support member care coordination and to help ensure compliance with regulatory requirements surrounding the program, we are amending the approach for enhanced reimbursement that accompanies selection of ‘on-pathway’ chemotherapy drug regimens as part of the AIM Oncology/Cancer Care Quality Program. 

Effective July 1, 2021, enhanced reimbursements for medical oncologists selecting on-pathway drug regimens as part of the AIM Oncology/Cancer Care Quality Program chemotherapy authorization process will be adjusted for specific regimens.  

Impacted regimens include only select oral and hormonal agents for which a monthly in-office visit may not be required. For these impacted regimens, the optional enhanced reimbursement award, billable using S-codes for treatment planning and care coordination management for cancer, will be reduced from a monthly award during each month of treatment to a single award to accompany treatment initiation (S0353).  

This will impact all authorizations submitted through the AIM authorization process on or after July 1, 2021, regardless of planned treatment dates. 

AIM and Anthem will continuously review the regimen library to ensure S-code award levels remain consistent with program goals regarding care coordination support. 

For a list of the specific regimens that will be impacted by these changes, please see the PDF attachment to this article.

Contact your Anthem network representative or your oncology provider engagement liaison for more information. 

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Effective for dates of service on and after May 1, 2021, the following update will apply to the AIM Oncologic Imaging Clinical Appropriateness Guideline as recommended by the United States Preventive Service Taskforce Lung Cancer: Screening statement.

Expanded low-dose CT screening for ages equal to or greater than 50 and less than or equal to 80 AND 20 or greater pack-year history of cigarette smoking.

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s 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: 866-714-1107, Monday – Friday, 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 and upcoming guidelines here.

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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 August 1, 2021, AIM Specialty Health_® (AIM), a separate company, will expand the AIM Rehabilitative program to perform medical necessity review of the initial evaluation service codes and requested site of service for physical, occupational and speech therapy procedures for Anthem Blue Cross fully insured members, as further outlined below. 

AIM will continue to manage physical therapy (PT), occupational therapy (OT) and speech therapy (ST) medical necessity reviews and will require pre-certification for all outpatient facility and office-based rehabilitative and habilitative services.  Prior authorization will now also be required for the initial evaluation service codes, unless otherwise prohibited, to alert the provider of the site of care program and ensure the member is receiving care at the appropriate site of service early in the process.  After the evaluation, ongoing services will be subject to site of care review and require prior authorization.

AIM will use the following Anthem Clinical UM Guidelines: CG-REHAB-10 Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services. The clinical criteria to be used for these reviews can be found on Anthem’s Clinical Guidelines webpage. Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis, members currently in an episode of care at the start of the program, services with diagnosis of autism, and members ages birth to 3^rd birthday.

A complete list of CPT codes requiring prior authorization for the AIM Rehabilitation program is available on the AIM Rehabilitation microsite. To determine if the AIM Rehabilitation program applies to an Anthem member on or after August 1, 2021, contact the Anthem Provider Services phone number on the back of the member’s ID card for benefit information.  They will be informed whether the AIM Rehabilitation program applies.  AIM will also have a file upload from the health plan of the in-scope membership and will not provide pre-certification for members who are out of scope.  If providers use the Interactive Care Reviewer (ICR) tool on the Availity Portal to pre-certify an outpatient rehabilitative or habilitative service, ICR will produce a message referring the provider to AIM. (Note: ICR cannot accept prior authorization requests for services administered by AIM.)

Members included in the new program

All fully insured members currently participating in the AIM Rehabilitative program are included. Medicaid members will be included in a separate communication. The following groups are excluded:  Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA EGR and Federal Employee Program® (FEP®). 

For self-funded (ASO) groups that currently participate in the AIM Rehabilitative program, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package.

For services provided on or after August 1, 2021, ordering and servicing providers may begin contacting AIM beginning July 19, 2021, for review.  Providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s 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: 866-714-1107, Monday – Friday, 8:00 a.m. – 5:00 p.m.

Initiating a request on AIM’s ProviderPortal_SM for PT/OT/ST and entering all the requested clinical questions will allow you to receive an immediate determination.  If the request is approved, you will receive the Order ID, the number of visits and valid time frame.  The AIM Rehabilitation Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.

AIM Rehabilitation training webinars                                                                         

We invite you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortal_SM.  Go to the AIM Rehabilitation microsite to register for an upcoming webinar on June 22, July 8, or July 27 at 3:00 p.m. If you have previously registered for other services managed by AIM, there is no need to register again.

We value your participation in our network and look forward to working with you to help improve the health of our members.

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

• Anthem Blue Cross and Blue Shield Working with Optum to Collect Medical Records for Medicare Risk Adjustment
• Learn how we are helping our senior members
• Updates to the AIM Specialty Health Musculoskeletal Program Clinical Appropriateness Guidelines

Identifying the most appropriate COVID-19 testing codes, testing sites and type of test to use can be confusing. The guidance below can make it easier for you to refer your patients to high-quality, lower-cost COVID-19 testing sites, find Anthem Blue Cross and Blue Shield (Anthem)-contracted laboratories and identify the proper CPT® codes to use. Contact your Anthem representative for additional information or visit https://www.anthem.com/medicareprovider.

Refer patients to https://www.anthem.com/coronavirus to find convenient testing locations

If an Anthem member requests a COVID-19 test, you may refer them to Anthem to find a testing location near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:

• Appointment or walk-in
• Drive thru service
• Rapid test results
• Antibody testing
• Testing for children

Consider antigen testing as an option when rapid results are needed

Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), (for example, PCR). Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.

Send swab tests to AMH Health-contracted laboratories

When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high-value healthcare.

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