Anthem Commercial Risk Adjustment (CRA) prospective program update: Assessing your patients for risk adjustable conditions

We understand the increased risk and strain on the health care system during the fight against COVID-19, and we support you in the response and treatment of your patients. Telehealth is now an option to assess your patients with risk adjustable conditions.  Anthem’s Prospective Risk Adjustment program works to improve risk adjustment accuracy and focus on performing appropriate interventions for patients with undocumented Hierarchical Condition Categories (HCC), in order to help you close your patients’ gaps in care.  This program involves:

• Member outreach encouraging primary care physicians (PCP) in-person or telehealth visits.
• Refer to Anthem’s COVID-19 FAQ in Provider News for updates about telehealth reimbursement guidance.
• Provider outreach sharing previously coded and suspected conditions, and encouraging member visits.
• PCP alternatives to complete Health Assessments.

 

Inovalon Requests

Consistent with 2019, we have again engaged a vendor, Inovalon – an independent company that provides secure, clinical documentation services – to help us comply with the provisions of the Affordable Care Act that require us to assess members’ relative health risk levels.  In the coming weeks and months, Inovalon will begin sending letters to providers as part of a new risk adjustment cycle, asking for your help with completing Health Assessments for some of our members.

 

If you worked with Inovalon in 2019, many thanks for your help. This year will bring a new round of assessments because chronic conditions must be assessed and coded each and every year. As always, if you have questions about the requests you receive, you can reach Inovalon directly at 1-877-448-8125.

 

Prospective Program ask of Providers:

• Anthem network providers – usually PCPs – receive letters from Inovalon, requesting that they:
  1. Schedule a comprehensive in-person or telehealth visit with patients identified by Inovalon to confirm or deny if previously coded or suspected diagnoses exists, and;
  2. Submit a Health Assessment documenting the previously coded or suspected diagnoses (also called SOAP Notes - Subjective, Objective, Assessment and Plan).

Incentives for properly submitted Health Assessments (these incentives are in addition to the office visit reimbursement):

• $100 for each Health Assessment properly submitted electronically
• $50 for each Health Assessment properly submitted via fax

 

Submit electronically via Inovalon’s ePASS tool:

• Inovalon ePASS^® Training Webinars
  • Every Wednesday - 3:00 - 4:00 PM EST
• Join an ePASS webinar:
  • Register by sending an email to ePASSProviderRelations@inovalon.com with your name, organization, contact information and the date of the webinar you wish to attend.

 

Alternative Engagement

ePASS® is our preferred method for submission. However to improve engagement and collaborate with our providers who are not submitting via ePASS®, we have identified other tools which may be helpful. If in 2019 your practice utilized some of these alternative options for prospective member outreach, we thank you for continuing on these alternative forms of program participation into 2020. 

 

For those providers not familiar with our alternative options, they are listed here. Telehealth visits are also an acceptable form of a patient visit for these alternative engagement options. Any questions your office has on these can be directed to either your local Provider Representative, or the Anthem CRA Network Education Representative listed below.

• EPHC Providers using PCMS - Providers participating in our Enhanced Personal Health Care (EPHC) program can use member reports from our PCMS tool to schedule members for comprehensive visits. PCMS does have a link to take you directly to the Inovalon ePASS® tool where completed Health Assessments will result in a $100 incentive payment per submitted Health Assessment.
• List of Members to be scheduled - Anthem CRA provides member/patient reports for providers to schedule members for comprehensive visits. Providers use normal gap closure through claims submission.  No Health Assessment needed. Not eligible for additional incentive.
• EPIC Patient Assessment Form (PAF) - Providers with EPIC as their electronic medical record (EMR) system can fax the EPIC PAF to Inovalon at 1-866-682-6680 with a coversheet indicating "see attached Anthem Progress Note,” which is eligible for a $50 incentive payment.
• Providers Existing Patient Assessment Form (PAF) - Utilize providers existing EMR system and applicable PAF. Must be submitted to Inovalon at 1-866-682-6680 with coversheet indicating, "see attached Anthem Progress Note“ which is eligible for a $50 incentive payment.

 

Please contact Alicia Estrada, our Commercial Risk Adjustment Network Education Representative, via email at Alicia.Estrada@anthem.com if you have any questions. 

 

Thank you for your continued efforts with our CRA Program.

 

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