For the most up-to-date information from Anthem about COVID-19, please bookmark Provider News Home and check back often.

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways is through Anthem’s value-based programs such as Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, and so on – called the “Programs.”  Certain providers (“Value-Based Program Providers” also known as “Payment Innovation Providers”) in Anthem’s various value-based programs receive quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value-Based Program Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in the provider getting more referrals from Value-Based Program Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

Providing this type of data, including comparative cost information, to Value Based Program Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Value Based Program Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant.

Anthem completed its acquisition of Beacon Health Options, a large behavioral health organization that serves more than 36 million people across the country. The company will operate as a wholly owned subsidiary of Anthem.

Bringing together our existing solid behavioral health business with Beacon’s successful model and support services creates one of the most comprehensive behavioral health networks in the country. It’s also an opportunity to offer best-in-class behavioral health capabilities and whole person care solutions in new and meaningful ways to help people live their best lives.

From the standpoint of our customers and providers at this time, it’s business as usual:

• Members should continue to call the customer service number on the back of their membership card or access their health plan’s website for online self-service.
• Providers should continue to use the provider service contact information, websites and online self-service portals as part of their agreement with either Anthem or Beacon.
• There will be no immediate changes to the way Anthem or Beacon manage their respective provider networks, contracts and fee arrangements. Anthem and Beacon provider networks, contracts and fee arrangements will remain separate at this time.

We know our providers continue to expect more of their healthcare partner, and at Anthem, we aim to deliver more in return.

For more details, please see the press release.

At Anthem, we continue to make changes to our public provider website to make it easier for you to find the information you need. The end of Q1 brings a few updates for the site at anthem.com:

• Information has been added to our website regarding Patient-Centered Specialty Care (PCSC) – Anthem’s value-based payment program for cardiology, endocrinology and obstetrics/gynecology providers. You can find this information online as an extension of our broader patient-centered, value-based care program – Enhanced Personal Health Care (EPHC).
• Documents listed on the Prior Authorization page can be conveniently accessed via online links.
• Medicare Advantage will be live in the coming days. You will be able to view updated Medicare Advantage pages on the commercial public sites.
• Medical Policies (MP) and Clinical Utilization Management Guidelines (CUMG) now display on our newly designed Web pages.

If you have any questions, please contact Michelle Fraser at michelle.fraser@anthem.com or Nick Kizirnis at nick.kirzinis@anthem.com. 

Effective July 1, 2020, we will upgrade to the 24th edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC), Recovery Facility Care (RFC), and Behavioral Health Care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

 

Goal Length of Stay (GLOS) Changes for Inpatient & Surgical Care (ISC) and Behavioral Health Care (BHC)

Guideline	MCG Code	24th Edition GLOS	23rd Edition GLOS
Aortic Valve Replacement, Transcatheter	S-1320	2 days postoperative	3 days postoperative
Appendectomy, with Abscess or Peritonitis, by Laparoscopy	S-185	Ambulatory or 2 days postoperative	2 days postoperative
Appendectomy, without Abscess or Peritonitis, by Laparoscopy	S-175	Ambulatory postoperative	Ambulatory or 1 day postoperative
Repair of Pelvic Organ Prolapse	S-1020	Ambulatory postoperative	Ambulatory or 1 day postoperative
Urethral Suspension Procedures	S-850	Ambulatory postoperative	Ambulatory or 1 day postoperative
Appendectomy, with Abscess or Peritonitis, by Laparoscopy, Pediatric	P-30	Ambulatory or 2 days postoperative	2 or 3 days postoperative
Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric	P-20	Ambulatory postoperative	Ambulatory or 1 day postoperative
Tibial Osteotomy, Child or Adolescent	S-1131	Ambulatory or 1 day postoperative	1 day postoperative
Schizophrenia Spectrum Disorders, Adult: Inpatient Care	B-014-IP	5 days	6 days
Schizophrenia Spectrum Disorders, Child or Adolescent: Inpatient Care	B-027-IP	5 days	6 days
Transcranial Magnetic Stimulation	B-801-T	Utilize B-801-T for Clinical Indications for procedure	Refer to BEH.00002 for Clinical Indications for procedure

 

New Optimal Recovery Guidelines (ORGs) for Inpatient & Surgical Care (ISC) and New Behavioral Health Care (BHC) New Guidelines

Body System	Guideline Title	MCG - Code
Pediatrics	Appendectomy, with Abscess or Peritonitis, Pediatric	P-35
Pediatrics	Appendectomy, without Abscess or Peritonitis, Pediatric	P-25
Home Care Behavioral Health	Attention-Deficit and Disruptive Behavior Disorders	B-003-HC
Home Care Behavioral Health	Autism Spectrum Disorders	B-012-HC

Anthem Customizations to MCG care guideline 24th Edition

Effective July 1, 2020, the following MCG care guideline 24th edition customizations will be implemented.

• Carotid Artery Stenting (W0165) – Clinical Indications were customized to reference CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
• Deep Brain Stimulation (W0164) – Clinical Indications were customized to refer to SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation.
• Vagus Nerve Stimulation, Implantable (W0166) – Clinical Indications were customized to refer to SURG.00007 Vagus Nerve Stimulation.

 

View a detailed summary of customizations here. Scroll down to other criteria section and select Customizations to MCG Care Guidelines 24th Edition.

 

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

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 November 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

ABSCRNU-0124-20

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

 

Medicare Risk Adjustment and Documentation Guidance (General)

• When: The trainings will be offered the first Wednesday of each month from 1:00 p.m. to 2:00 p.m. ET (from January 8, 2020, to December 2, 2020).
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity has been reviewed and is acceptable for up to 1 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions using the following link: Medicare Risk Adjustment and Documentation Guidance (General)

 

Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (Condition Specific)

• When: The trainings will be offered on the third Wednesday of every other month from noon to 1:00 p.m. ET (from January 15, 2020, to November 18, 2020).
• Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
• Credits: This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

 

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

1. Red Flag Hierarchical Condition Categories (HCCs), part one (January 15, 2020): register for a recording of the session: Training will cover HCCs most commonly reported in error as identified by CMS (Chronic Kidney Disease Stage 5, Ischemic or Unspecified Stroke, Cerebral Hemorrhage, Aspiration and Specified Bacterial Pneumonias, Unstable Angina and Other Acute Ischemic Heart Disease, End-Stage Liver Disease).
2. Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 2 (March 18, 2020): Training will cover HCCs most commonly reported in error as identified by CMS (Atherosclerosis of the Extremities with Ulceration or Gangrene, Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome, Drug/Alcohol Psychosis, Lung and Other Severe Cancers, Diabetes with Ophthalmologic or Unspecified Manifestation)
3. Neoplasms (May 20, 2020)
4. Acute, Chronic and Status Conditions (July 15, 2020)
5. Diabetes Mellitus and Other Metabolic Disorders (September 16, 2020)
6. Topic TBD (November 18, 2020): This Medicare risk adjustment webinar will cover the critical topics and updates that surface during the year

 

ABSCRNU-0125-20

On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 December 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.*

 

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0130-20

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

• EXPRESS: Talking Points for COVID-19 Virus-ABS
• Coding tip for psychological and neuropsychological testing
• Medical Policies and Clinical Utilization Management Guidelines update
• New MA Opioid Treatment Program benefit
• Prior authorization requirements: new 2020 codes for coverage and precertification

ABSCRNU-0106-19, ABSCRNU-0122-20, ABSCRNU-0126-20, ABSCRNU-0120-20