To help ensure compliance with the coding and billing of a claim submitted with the diagnosis of sepsis, we review clinical information, including lab results, treatment and medical management, in the medical records submitted.  In order to conduct the review accurately and consistently, our review process for sepsis diagnoses applies coding and documentation guidelines, in addition to the updated and most recent sepsis 3 clinical criteria, published in JAMA February 2016. Clinicians and facilities should apply the sepsis 3 criteria when determining at discharge if their patient’s clinical course supports the coding and billing of a diagnosis of sepsis. The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the sepsis 3 definition and criteria.

The Interactive Care Reviewer (ICR), our online authorization tool offers a real time authorization decision for some inpatient and outpatient authorization requests. Recently we updated the list of services that may result in an immediate authorization decision.

To locate the Immediate Decision list* and review the specific details on those services, go to the Availity Portal and select Payer Spaces then choose the Anthem BCBS logo. Scroll down and select Education and Reference Center | Communication & Education. From the Communication & Education dropdown menu, select Interactive Care Reviewer | ICR Immediate Decision List.

 

Access ICR from the Availity Portal, select Patient Management | Authorizations & Referrals. To request an authorization you will need to have the Authorization Referral Request Role assigned to you by your Availity administrator.

 

Attend one of our upcoming webinars and learn about the features that will help you to optimize your ICR experience! Register here.

 

*Excludes: some Medicare Advantage, some Medicaid, Federal Employee Program® (FEP), BlueCard® and some National Account members

Requests involving transplant services

Services administered by vendors such as AIM Specialty Health

Services administered by OrthoNet LLC(Indiana ,Kentucky ,Missouri, Ohio, Wisconsin, California, Colorado and Nevada)

For the above requests, follow the same precertification process that you use today.

Anthem’s Find A Doctor tool provides Anthem members with the ability to search for in-network providers using the member portal at anthem.com. Find A Doctor currently offers multiple sorting options, such as sorting providers based on distance or name.

 

In May 2019, Anthem added a new sorting option to Find A Doctor. The new sorting option is called “Personalized Match” and is based on algorithms which use a combination of provider location, quality, cost results and member information to intelligently sort and display results for a member’s search. The sorting results take into account member factors such as the member’s medical conditions, and medications as well as provider factors such as areas of specialty, quality and efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures. These member and provider features combine to generate a unique ranking of providers for each member conducting the search. Providers with the highest overall ranking within the search radius are displayed first with other providers displayed in descending order based on overall rank and proximity to the center of the search radius. Members will continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology will have no impact on member benefits.

 

Please note, the sorting option “Personalized Match” has been available on Care and Cost Finder since November 12, 2018.  

 

Additional information about Personalized Match:

• Provider factors will be updated on a quarterly basis.
• Providers may review a copy of the sorting methodology here.
• If you have general questions about this sorting option in Find A Doctor and the Care and Cost Finder tool, please contact Provider Customer Service.
• If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.

 

Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions. 

Providers currently submit prior authorization requests to AIM Specialty Health® (AIM) for outpatient diagnostic imaging services, cardiac procedures and sleep studies. As part of our ongoing quality improvement efforts, we want you to know that certain review requests require documentation that supports the clinical appropriateness of the request to be uploaded during the intake process.

 

When requested, providers must submit documentation from the patient’s medical record and/or participate in a prior authorization consultation with an AIM physician reviewer. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. 

This quarter, anthem.com will release more exciting enhancements to the public provider site. The next wave of changes includes a new Behavioral Health page that will provide easy and clear access to content and resources, including newsletters, collaboration documents, and other relevant information for providers. The image below illustrates the new Behavioral Health page.

We will continue to provide updates as we move forward with migrating content to the new provider pages.

As we prepare for potential regulatory proposed standards for electronic attachments, Anthem will be implementing the X12 275 5010 version electronic attachments transactions for claims.

 

Standard electronic attachments will bring value to you by eliminating the need for mailing paper records and reduced processing time overall. 

 

Anthem and Availity will be piloting EDI batch electronic attachments with previously selected providers.  Both solicited and unsolicited attachments will be included in our pilots.

 

Solicited Attachment: Provider sends a claim and Payer determines there is not enough information to process the claim.  Payer will then send the provider a request for additional information (currently via letter).  Provider can then send the solicited attachment transaction with the documentation requested to process the claim.

 

Unsolicited Attachment: When the provider knows that the payer requires additional information to process the claim, the provider will then send the X12 837 claim with the “Paper Work Included” (PWK) segment tracking number.  Then the provider will send the X12 275 attachment transaction with the additional information and include the tracking number that was sent on the claim for matching.

 

What you can do now

Start having conversations with your Clearinghouse and/or Electronic Healthcare Records (EHR) vendor to determine their ability to set up the X12 275 attachment transaction capabilities. 

 

Look for more information around general availability of this exciting option later this summer with details on how to work with Anthem and Availity to send your attachments via electronic batch.

Continuing our 2019 CRA updates, Anthem requests your assistance with respect to our Commercial Risk Adjustment (CRA) reporting processes.

 

As a reminder, there are two approaches that we take (Retrospective and Prospective) to improve risk adjustment reporting accuracy. We are focusing on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), to close the documentation and coding gaps that we are seeing with our members enrolled in our Affordable Care Act (ACA) compliant plans.

 

This month we’d like to focus on the Retrospective approach, and the request to our Providers:

 As a reminder from our March provider newsletter, the Retrospective Program focuses on medical chart collection.  We continue to request members’ medical records to obtain undocumented HCC’s. This particular effort is part of Anthem’s 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.

 

2019 chart collection is about to begin

Retrospective chart collection begins in June and is known as Round 1. Round 2 follows in November, which is our primary chase and largest volume of requests. Round 3 is our last chart collection period and begins in January, 2020.

 

Electronic options for chart collections

Submitting medical charts to payers is extremely burdensome and time consuming for your staff.  Utilizing an electronic option can alleviate the constraints on both staff resources and time.

 

1. Remote/Direct Anthem Access

The most efficient electronic option is to allow the Anthem medical coder team to have direct connection access to your EMR system, so that we may retrieve the records ourselves.  Our team has collaborated with several Providers and Facilities to have direct access to their EMR system so we collect the charts within our own team.  This allows for no vendor interventions and fewer handoffs of the records.  To address compliance concerns, please note that as a health plan, Anthem is a covered entity under the HIPAA Privacy Rule and is bound to protect PHI. 

 

Benefits of providing EMR direct connection access:

• Your Medical Records staff resources would be minimally contacted for the charts we are requesting
  • o Depending on your EMR system, requests may also be handled electronically through “push” notifications
• Your Medical Records staff will release only those records we request into the EMR queue for which we have access
• Cost savings from less administrative impact on staff, as well as, no paper copying costs incurred
• Better privacy/security measures for not having to save the medical record to a desktop and then copy/save before transmittal

2. EMR Interoperability—we have electronic options already in place for the following EMR systems:

• Allscripts (Opt in—signature required—please work directly with the CRA Representative for your region)
• NextGen (Opt out—auto-enrolled)
• Athenahealth (Opt out—auto-enrolled)
• MEDENT (Opt in—signature required—please work directly with the CRA Representative for your region)

3. Inovalon virtual visit or onsite: Inovalon will work directly with your office to utilize electronic connectivity for a virtual visit, or they will have their staff go into the office for medical record retrieval based on a scheduled time that is convenient.

4. Secure FTP: Set up directly with our vendors as a temporary secure FTP to transfer medical records.

 

If you are interested in any of these electronic options, or would like to grant our Anthem medical coders with direct access to your EMR, please contact our CRA Representative Alicia Estrada at Alicia.Estrada@anthem.com.

 

Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests that will begin soon.

Anthem will implement the following clinical guideline, effective July 1, 2019, to support the review for unnecessary inter-facility transfers. This guideline impacts our commercial PPO and HMO products.

 

The inpatient services addressed in this clinical guideline will require prior authorization prior to the inter-facility transfer.

 

Inpatient inter-facility transfers (CG-ANC-07)

This guideline addresses the clinical features of a hospitalized individual who may require services unavailable at an initial acute care facility (originating facility) necessitating a transfer to a second acute care facility (receiving facility).

 

Inter-facility transfers are considered medically necessary when one or more of the following criteria are met:

• The individual requires a medically necessary diagnostic or therapeutic service (for example, organ transplantation) which is not available at the originating facility; or
• The individual requires a level of care (for example, neonatal care unit or level 1 trauma center) which is not available at the originating facility; or
• The individual requires the services of a specialist to evaluate, diagnose or treat his or her condition when that specialist is not available in a timely manner at the originating facility (Note: Timeliness of care is a case/individual specific attribute. It may be appropriate for a medically stable individual to await availability of a specialist for several days while a medically unstable individual may require care more quickly); or
• The individual has received care at a specific prior institution for a condition not normally managed at the originating facility (for example, organ transplant recipient) and return to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue.

 

Inter-facility maternal transfer to allow birth mother to remain with neonate is considered medically necessary when neonate transfer meets the medically necessary criteria listed above and the birth mother requires continued hospitalization due to birth complications or other medically necessary conditions.

 

Inter-facility transfers between an originating facility and a receiving facility are considered not medically necessary when:

• The criteria above have not been met; or
• The services are primarily for the convenience of the individual, the individual’s family, the physician or the originating facility.

Open the attached document titled “GA medical policy and clinical guideline updates 5.1.2019” to view the new and/or revised Medical Policies and Clinical Guidelines adopted by the Medical Policy and Technology Assessment Committee. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be either not medically necessary or investigational/not medically necessary. Clinical Guidelines adopted by Anthem and all the Medical Policies are available at anthem.com/provider under “see policies and guidelines”. Please note that our medical policies now include NOC (Not Otherwise Classified) codes to expedite the process of determining services that may require medical review. If you do not have access to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical UM Guideline by calling Provider Services at (800) 241-7475 Monday through Friday from 8:00 a.m. to 7:00 p.m. or send written requests (specifying the medical policy or guideline of interest, your name and address to where the information should be sent) to:

 

 

NOTE: Any Clinical Guideline included in this standard MPTAC notification is only effective for GA if included on the GA Standard Adopted Clinical Guideline List unless there is a group-specific review requirement in which case it will be considered ‘Adopted’ for that group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in the GA Standard Adopted Clinical Guideline List may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes.   

Please open the attached document titled “GA preapproval list change notification 5.1.2019” to view preapproval changes. For additional information, you can access the complete Georgia Standard Preapproval List, Georgia Standard Preapproval CODE List and Georgia Standard Adopted Clinical Guideline List using the following links:

• Georgia Standard Preapproval List
• Georgia Standard Preapproval CODE List
• Georgia Standard Adopted Clinical Guideline List

This article has been updated. Please view the most recent article published in the July edtion of Provider News titled "CORRECTION: Reminder and update: new Rehabilitative Program effective July 1, 2019." 

As previously communicated in the April 2019 edition of Anthem’s Provider News, AIM Specialty Health® (AIM), a separate company, will begin to perform prior authorization review of rehabilitative (restoring function) and habilitative (enhancing function) services for Anthem fully insured members beginning September 1, 2019. 

 

AIM will manage Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) medical necessity reviews and will require prior authorization for all outpatient facility and office-based rehabilitative and habilitative services following the initial evaluation. AIM will use the following Anthem Clinical UM Guidelines:

• CG-REHAB-04 Physical Therapy
• CG-REHAB-05 Occupational Therapy
• CG-REHAB-06 Speech-Language Pathology Services

 

The clinical criteria to be used for these reviews can be found on the [brand.com] Clinical UM Guidelines page. A complete list of CPT codes requiring prior authorization for the AIM Rehabilitative Program is available on the AIM Rehabilitation microsite. There you can access additional helpful information such as order entry checklists and FAQs.

 

AIM will now begin accepting prior authorization requests on June 24, 2019 for dates of service on and after July 1, 2019. Ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM 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 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

 

Need training?                                                   

Anthem invites you to take advantage of an informational webinar that will introduce you to the Rehabilitative Program and the robust capabilities of the AIM ProviderPortalSM.  Visit the AIM Rehabilitation microsite to register for an upcoming training session.

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

• Medicare risk adjustment provider training
• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ
• Group Retiree members and National Access Plus
• Prior authorization requirements for DME repair and portable oxygen  
• Submitting corrected claims
• 2019 Utilization Management Affirmative Statement concerning utilization management decisions

You want what’s best for your patients’ health. When a patient doesn't follow your prescribed treatment plan, it can be a challenge. Approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed1. What can be done differently?

 

The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg, that is, the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline — the giant, often invisible, patient self-talk that may not get discussed aloud — can create a misalignment between patient and provider.

 

We’ve created an online learning experience to teach the skills and techniques that can help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence — and you’ll earn continuing medical education credit along the way.

 

Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

 

1. Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm.

Anthem Blue Cross and Blue Shield (Anthem) has identified an increased trend in billing emergency department level 5 evaluation and management (E&M) codes. To ensure documentation meets or exceeds the components necessary to support its billing, beginning September 1, 2019, Anthem will initiate postpay reviews for emergency department professional claims billed with level 5 99285 or G0384. Emergency department professional claims with the highest potential for up-coding will be selected.

 

Anthem will request documentation for identified claims. Professional reviews will evaluate the appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and Anthem guidelines. Reimbursement should be based on the emergency department E&M code the submitted documentation supports.

 

Please note, these coding reviews are not related to any prior notification reviews which examine the appropriate use of emergency departments for nonemergencies, nor do they include the examination of emergent versus nonemergent reasons patients utilize emergency room services.