The new professional reimbursement policy for Documentation Standards for Episodes of Care will be effective February 1, 2021.  This policy will replace the current Documentation Guidelines for Adaptive Behavior Assessments and Treatment for Autism Spectrum Disorder and Documentation Guidelines for Central Nervous System Assessments and Tests policies. Those policies will be retired as of February 1, 2021. The Documentation Standards for Episodes of Care policy will be considered an administrative policy and will serve as an overarching documentation standards policy.

 

For more information about this policy, visit the Reimbursement Policies page at anthem.com.  

 

748-1120-PN-NE

Beginning with dates of service on or after February 1, 2021, we will update our Bundled Services and Supplies Section 2 Coding list to indicate that the following codes:

 

• 43281 - laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh,
• 43282 - laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh or other prosthesis,
• 43283 - laparoscopy, surgical, esophageal lengthening procedure,
• 43332 - repair paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis, and
• 43333 - repair paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis, 

 

are not eligible for separate reimbursement when reported with bariatric procedure codes 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887 and 43888. 

 

Additionally, the Bundled Services Section 2 coding list will be updated to include the telehealth originating site facility fee HCPCS code (Q3014) when reported with an E&M code in place of service 11.

 

For more information about this policy, visit the Reimbursement Policies page at anthem.com.  

 

754-1120-PN-NE

Beginning with dates of service on or after February 1, 2021, our policy language has been updated to add Modifier FB to the related coding section and indicate that when used in the adjudication of a claim reimbursement may be affected.

 

Modifier FB is defined as an item provided without cost to provider, supplier or practitioner, or full credit received for replaced device.

 

For more information about this policy, visit the Reimbursement Policies page at anthem.com.  

 

751-1120-PN-NE

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 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.

 

726-1120-PN-CT

In this 60-minute webinar, you will learn how to use Availity's attachment tools to submit and track supporting documentation electronically to Anthem and affiliate payers. We will explore key workflow options to fit your organization’s needs, including how to:

 

• Work a request in the inbox of your Attachments Dashboard
• Enter and submit a web claim including supporting documentation
• Use EDI batch options to trigger a request in your inbox
• Track attachments you submitted using sent and history lists in your Attachments Dashboard
• Get set up to use these tools

 

As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.

 

Register for an upcoming webinar session:

 

1. In the Availity Portal, select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options:
   • In the Catalog, search by webinar title or keyword.
     • To find this specific live session quickly, use keyword medattach.
   • Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you’ll receive emails with instructions to join the session.

 

Webinar Dates:

 

DATE	DAY	TIME
November 4, 2020	Wednesday	Noon to 1:00 p.m.
November 17, 2020	Tuesday	2:00 p.m. to 3:00 p.m.
December 4, 2020	Friday	3:00 p.m. to 4:00 p.m.
December 15, 2020	Tuesday	3:00 p.m. to 4:00 p.m.

 

762-1120-PN-NE

US Antibiotic Awareness Week is November 18-24, 2020. This one-week observance gives organizations and providers an opportunity to raise awareness on the appropriate use of antibiotics and reduce the threat of antibiotic resistance. The Centers for Disease Control and Prevention (CDC) has over 10 hours of free Continuing Education available for providers.

 

The CDC promotes Be Antibiotics Aware, an educational effort to raise awareness encouraging safe antibiotic prescribing practices and use. Be Antibiotics Aware has many resources for health care professionals (in outpatient and inpatient settings) including videos such as The Right Tool and Antibiotics Aren’t Always the Answer that can be utilized in provider’s waiting rooms. 

 

722-1120-PN-NE

Anthem is committed to creating innovative tools that help simplify health care. In pursuit of that commitment, we recently enhanced our digital tool that enables members to share their personal health data with physicians and hospitals. This tool, referred to as My Health Records, merges patient health records from providers who may have cared for an individual member and stores the data in one secure place that is accessible to the member via the Sydney Health mobile app and anthem.com. My Health Records provides a new way for members to access their personal health information from multiple providers’ databases then view, download and share their health data and medical records with doctors via their smartphone or computer.

 

My Health Records allows members to share important health information with physicians, such as:

• Lab results and historical insights with visualizations
• Medications, conditions, immunizations, vaccinations
• Health records
• Health records of dependents (14 years and under)
• Easy access to provider information
• Personalized health data tracking over time
• Integration for member authorization to more health record data

 

The enhanced digital tool gives physicians and hospitals a holistic view of a member’s up-to-date health data. This complete health data in one trusted place enables providers and members to feel more confident in making important life decisions easily and quickly.

 

This tool is now available to Anthem members in our Medicare, Individual, Small Group and Fully Insured Large Group business segments and will be available to members in our Large Group ASO and Anthem National Account business segments in early 2021.

 

763-1120-PN-NE

 

Introducing the Anthem Provider Digital Engagement Supplement to the Provider Manual

Using our secure provider portal or EDI submissions (via Availity), administrative tasks can be reduced by more than fifty percent when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website or the secure provider portal via Availity.

 

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and you can receive payments faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance, which meets all HIPAA mandates - eliminating the need for paper remittances.

 

Member ID cards go digital

Anthem members are transitioning to digital member identification cards making it easier for them and you. The ID card can be easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

 

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member identification cards to EDI transactions, application programming interfaces and direct data entry, we cover it all in our Provider Digital Engagement Supplement to the provider manual, and on our secure provider portal through Availity. The Supplement outlines our provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits.

 

The Provider Digital Engagement Supplement to the provider manual is another example of how we are using digital technology to improve the health care experience. We are asking providers to go digital with us no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now and go digital with Anthem.

 

774-1120-PN-NE

As we communicated in the October 2017 Network Update, AIM administers pre-service clinical reviews on behalf of Anthem for the services noted below. AIM reviews requests in real time against evidence-based clinical guidelines and Anthem medical policies. Providers are notified via letter or remit message when claims are submitted without the appropriate pre-service review by AIM. If such a letter or message is received, providers will need to obtain a post-service clinical review for the service via the AIM ProviderPortal_SM.  If the documentation/post-service review request is submitted to Anthem, we notify the provider via another letter or remit message to submit to AIM.

 

AIM reviews the following services for clinical appropriateness:

• Advanced diagnostic imaging
• Cardiology tests and procedures (e.g. MPI, echocardiography, PCI, cardiac catheterization)
• Medical oncology treatments through the Cancer Care Quality Program
• Radiation oncology treatments (e.g. IMRT, brachytherapy)
• Sleep testing, treatment and supplies
• Genetic testing
• Musculoskeletal (e.g., spine and joint surgeries, pain management)
• Rehabilitative services (physical, speech and occupational therapy)
• Surgical site of care (e.g., gastroenterology, other surgeries will be implemented which will be communicated via Provider News)

 

Services performed in an emergency or inpatient setting are excluded from AIM programs.

 

This update applies to local fully-insured Anthem members and members who are covered under a self-insured (ASO) benefit plan, with services medically managed by AIM. It does not apply to BlueCard, Medicare Advantage, Medicaid, Medicare Supplement or Federal Employee Program (FEP) members.

 

To help prevent delays in claim processing and post-service reviews, ordering providers should submit pre-service requests to AIM in one of the following ways:

 

• Access AIM ProviderPortal directly at providerportal.com available 24/7 to process orders in real-time
• Access AIM via the Availity web portal at availity.com

 

For more information, please contact the phone number on the back of the member’s ID card.

 

711-1120-PN-NE

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

 

• AIM Musculoskeletal program expansion update
• AIM rehabilitation prior authorizations suspended for Group Retiree Solutions members until December 31, 2020
• Transition to AIM Rehabilitative Service Clinical Appropriateness Guidelines delayed for Anthem members

Introducing the Anthem Provider Digital Engagement Supplement to the Provider Manual

Using our secure provider portal or EDI submissions (via Availity), administrative tasks can be reduced by more than fifty percent when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website or the secure provider portal via Availity.

 

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and you can receive payments faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance, which meets all HIPAA mandates - eliminating the need for paper remittances.

 

Member ID cards go digital

Anthem members are transitioning to digital member identification cards making it easier for them and you. The ID card can be easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

 

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available at https://www.anthem.com/medicareprovider > select your state > Providers > Policies, Guidelines & Manuals, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid and Medicare, including medical, dental and vision benefits.

 

The Provider Digital Engagement Supplement to the provider manual is another example of how we are using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Provider Digital Engagement Supplement now by going to https://www.anthem.com/medicareprovider > select your state > Providers > Policies, Guidelines & Manuals. Go digital with Anthem.

 

ABSCRNU-0179-20

Anthem and AMH Health, LLC review the activities of the FDA’s approval of drugs and biologics on a regular basis to understand the potential effects for both our providers and members.

 

The FDA approves new drugs/biologics using various pathways of approval. Recent studies on the effectiveness of drugs/biologics going through these different FDA pathways illustrates the importance of clinicians being aware of the clinical data behind a drug or biologic approval in making informed decisions.

 

Here is a list of the approval pathways the FDA uses for drugs/biologics:

 

• Standard review – The standard review process follows well-established paths to help ensure drugs/biologics are safe and effective when they reach the public. From concept to approval and beyond, FDA performs these steps: reviews research data and information about drugs and biologics before they become available to the public; watches for problems once drugs and biologics are available to the public; monitors drug/biologic information and advertising; and protects drug/biologic quality. Learn more about the standard review process.

• Fast track – Fast track is a process designed to facilitate the development, and expedite the review of drugs/biologics to treat serious conditions and fill an unmet medical need. Learn more about the fast track process.
• Priority review – A priority review designation means FDA’s goal is to take action on an application within 6 months. Learn more about the priority review process.
• Breakthrough therapy – A process designed to expedite the development and review of drugs/biologics which may demonstrate substantial improvement over available therapy. Learn more about the breakthrough therapy process.
• Orphan review – Orphan review is the evaluation and development of drugs/biologics that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. Learn more about the orphan review process.
• Accelerated approval – These regulations allowed drugs/biologics for serious conditions that filled an unmet medical need to be approved based on a surrogate endpoint. Learn more about the accelerated approval process.

 

New molecular entities approvals: January - August 2020

Certain drugs/biologics are classified as new molecular entities (NMEs) for purposes of FDA review. Many of these products contain active ingredients that have not been approved by FDA previously, either as a single ingredient drug or as part of a combination product; these products frequently provide important new therapies for patients.

 

Anthem and AMH Health review the FDA-approved NMEs on a regular basis. To help facilitate the decision-making process, please see the attached PDF list of NMEs approved from January to August 2020 along with the FDA approval pathway utilized.

Source: www.fda.gov

 

ABSCRNU-0178-20

AMHCRNU-0039-20

 

On February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem and AMH Health, LLC (AMH Health). These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting June 2020 (Anthem) and the Clinical Criteria Web Posting June 2020 (AMH Health). Visit Clinical Criteria to search for specific policies.

             

If you have questions or would like additional information, use this email.

 

ABSCRNU-0173-20

AMHCRNU-0036-20

You now have a new option to have questions answered quickly and easily. With Anthem and AMH Health, LLC Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity. Provider Chat offers:

 

• Faster access to Provider Services for all questions.
• Real-time answers to your questions about prior authorization and appeals status, claims, benefits, eligibility, and more.
• An easy to use platform that makes it simple to receive help.
• The same high level of safety and security you have come to expect with Anthem and AMH Health.

 

Chat is one example of how Anthem and AMH Health are using digital technology to improve the health care experience, with the goal of saving valuable time. To get started, access the service through Payer Services on Availity.

Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield and AMH Health, LLC.

 

ABSCARE-0683-20

On January 1, 2020, Anthem implemented a preferred edit on Medicare Part B eligible continuous glucose monitors (CGMs). The preferred CGM is Freestyle Libre.

 

Preferred CGM edits do not apply to the following plans/plan types:

 

• Employer Group Waiver Plans (EGWP) Medicare Advantage Part D (MAPD) through Anthem
• Employer Group Waiver Plans (EGWP) Medicare Advantage (MA only) through Anthem
• Individual Medicare Advantage Plans (MA only) through Anthem

 

Delivery channels

Only members enrolled in a plan using preferred CGM edits will need to obtain their CGM systems from a retail or mail order pharmacy. Members on a plan without preferred CGM edits will be able to obtain their CGM systems through durable medical equipment providers in addition to retail and mail order pharmacies. Please check member and plan benefits to confirm the available delivery channels for accessing CGM products.

 

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