We appreciate the role you play in managing the health of our members. As the physician of a patient who has coverage compliant with the Affordable Care Act (ACA), you play a vital role in accurately documenting the health of the patient to help ensure compliance with ACA program reporting requirements. When patients visit your practice, we encourage you to document ALL of their health conditions, especially chronic diseases. Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.

Please ensure that all codes captured in your electronic medical record (EMR) system are also included on the claim(s), and are not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing four. If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.

 

Reminder about ICD-10 coding

The ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits. Additionally, Anthem uses ICD-10 codes submitted on claims to monitor health care trends, cost, and disease management. Additionally, the Centers for Medicare & Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a patient’s health.

 

Using specific ICD-10 diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.

• Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.
• Include any secondary diagnosis codes that are actively being managed.
• Include all chronic historical codes, as they must be documented each year pursuant to the ACA.  (Such as an amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).

Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions. ICD-10 coding guidelines still apply, so please ensure coding on a telehealth visit claim is to the highest specificity with all diagnosis codes. Previous Anthem Provider News editions provide telehealth reimbursement guidance to follow for claims submission.

 

If you are interested in a coding training session specific to risk adjustable conditions, please email Alicia Estrada, Georgia’s Commercial Risk Adjustment Network Education Representative, at Alicia.Estrada@anthem.com.

 

567-0820-PN-GA

We are excited to announce the release of Provider Contract and Fee Schedule Notifications! Starting in Mid-July, when Anthem notifies you of a statewide fee schedule update or provider contract amendment, you can log into Availity.com and download a digital copy of your content.

Over the last few months, we have been tirelessly working to improve our service and believe that online Provider Contract and Fee Schedule Notifications will help you appreciate your experience with Anthem even more.

In order to be ready for the digital downloads, you should log in to Availity, access the Provider Online Reporting application and register your authorized users. Going forward, you will see newsletter articles notifying you when you can download content, or if your state requires a mail notification, you may receive a letter or postcard notifying you of content ready for download.

See details below on how to log in and access your reports:

 

Provider Online Reporting Reference Guide

How to get started

This document will familiarize you with the Provider Online Reporting application found on the Availity Portal.  Using our web-based reporting application, you will be able to access regularly updated reports.

• For Availity Administrators – How to assign access
• For Users – How to navigate to the reports

 

If your organization is not currently registered for the Availity Portal, go to availity.com and select Register to complete the online application.

 

Your Administrator will need to take the following steps to assign access to Provider Online Reporting:

1. Assign the user role of Provider Online Reporting to your Availity access.
2. Select Payer Spaces in the navigation bar and then choose the payer tile that corresponds to the market.
3. Accept the User Agreement (once every 365 days).
4. On the Applications tab, select Provider Online Reporting.
5. Choose the organization and select Submit.
6. In the Provider Online Reporting application, register the tax ID by selecting Register/Maintain Organization.
7. Last, register users to the program by selecting Register Users and completing the required fields.

 

Accessing reports:

1. After logging in to Availity, select Payer Spaces in the navigation bar and then choose the payer tile that corresponds to the market.
2. Accept the User Agreement (once every 365 days).
3. On the Applications tab, select Provider Online Reporting.
4. Choose the organization and select Submit.
5. Select Report Search, choose the type of report, and then launch your program’s reporting application.

For further assistance with Availity, please contact Availity Client Services at 800-282-4548.

For other questions, contact your local Provider Relations consultant.

579-0820-PN-GA

Quality health care requires standard documentation requirements to ensure consistency for the care of our members. These standards are reviewed annually to ensure they align with our current policies. These standards ensure effective medical record documentation and provide clear and consistent guidelines to ensure that providers maintain records in a current, organized, and effective manner. The medical record criteria that is encouraged for our network of independently contracted providers are outlined below.

1. Every page in the medical record contains the patient name or ID number.
2. Allergies/No Known Drug Allergies (NKDA) and adverse reactions are prominently displayed in a consistent location.
3. All presenting symptom entries are legible, signed and dated, including phone entries. Dictated notes should be initialed to signify review.  Signature sheet for initials are noted.
4. The important diagnoses are summarized or highlighted.
5. A problem list is maintained and updated for significant illnesses and medical conditions.
6. A medication list or reasonable substitute is maintained and updated for chronic and ongoing medications.
7. History and physical exam documentation identifies appropriate subjective and objective information pertinent to the patient’s presenting symptoms, and treatment plan documentation is consistent with findings.
8. Laboratory tests and other studies are ordered, as appropriate, with results noted in the medical record. (The clinical reviewer should see evidence of documentation of appropriate follow-up recommendations and/or non-compliance to care plan).
9. Documentation of Advance Directive/Living Will/Power of Attorney discussion (including copies of any executed documents) in a prominent part of the medical record for adult patients is encouraged.
10. Documentation of continuity and coordination of care between the PCP, specialty physician (including BH specialty) and/or facilities if there is reference to referral or care provided elsewhere. The clinical review will look for a summary of findings or discharge summary in the medical record. Examples include progress notes/report from consultants, discharge summary following inpatient care or outpatient surgery, physical therapy reports, and home health nursing/ provider reports.
11. Age appropriate routine preventive services/risk screening is consistently noted, i.e. childhood immunizations, adult immunizations, mammograms, pap tests, etc., or the refusal by the patient, parent or legal guardian, of such screenings/immunizations in the medical record.

582-0820-PN-GA

There is no doubt the coronavirus (COVID-19) crisis has taken a toll on all of us. The pandemic has led to immeasurable challenges but we are here to help you ease back into business. We want to remind you, as the Availity migration continues full speed ahead, Anthem will guide you to make it a smooth transition Just as all good things end, such as summer, the Availity EDI migration also has a target closing date of September 15, 2020.

Take Action Today: Availity setup is simple and at no cost for you!

Use this “Welcome” link to get started today: apps.availity.com/web/welcome/#/

All EDI transmissions currently sent or received today via the Anthem gateway are now available on the Availity EDI Gateway. 

• 837 Institutional and Professional
• 837 Dental
• 835 Electronic Remittance Advice
• 276/277 Claim Status
• 270/271 Eligibility Request
• 275 Medical Attachments
• 278 Prior Authorization/Referrals
• 278N Inpatient Admission and Discharge Notification

Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:

• Migrate your direct connection with Anthem and become a direct submitter with Availity.
• Use your existing Clearinghouse or Billing Company for your EDI transmissions. (Work with them to ensure connectivity to the Availity EDI Gateway).
• Use Direct Single Claim entry through the Availity Portal.

 

Show your team what you learned this summer!

Enroll in one of Availity’s free courses and training demos at your convenience. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.

Follow these steps to register at Availity.com:

1. Log in to the Availity Portal and select Help & Training | Get Trained to access the Availity Learning Center (ALC).
2. Select Sessions from the menu under the search catalog field.
3. Scroll Your Calendar to locate your webinar.
4. Select View Course and then Enroll. The ALC will email you instructions to attend.

If you and your clearinghouse have already migrated over to Availity, thank you and you are a step ahead! If not, start the process now to make the transition before September 15, 2020.

 

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday–Friday 8:00 a.m.–7:00 p.m. ET.

 

585-0820-PN-GA

Anthem and Availity Electronic Data Interchange (EDI) is excited to announce the X12 275 5010 version of electronic attachments transactions for claims functionality is now available for you.

The X12 275 5010 version of electronic attachments transactions for claims will:

• Bring value to you by eliminating the need for mailing paper records.
• Electronic acknowledgment provides a transaction audit trail – proof of delivery/receipt.
• Reduces administrative cost associated with manual processing
• Save time waiting for paper correspondents

 

This new functionality includes both solicited and unsolicited attachments.

• Solicited Attachment: Documentation submitted in response to a specific request.

• Unsolicited Attachment: Documentation is known to be needed and submitted at the same time as the claim.

How to send a 275 transaction

Your practice management software or billing service/clearinghouse must have the ability to send a 275. We encourage you to have a conversation with them to determine their ability to set up the X12 275 attachment transaction capabilities.

Where to find help

The new EDI batch process, X12 275 5010v Companion Guide, assists with specific attachment requirements and enables providers to electronically submit attachments based on your business needs.

• The companion guide can be download at anthem.com/edi.
• Availity documentation can be found at availity.com.
• Use the “Availity Welcome Application” below to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions.
• EDI Welcome App:  apps.availity.com/web/welcome/#/  

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday–Friday 8:00 a.m.–7:00 p.m. ET

 

587-0820-PN-GA

 

Anthem and Availity Electronic Data Interchange (EDI) is excited to announce the Prior Authorization/Referrals 278 and Inpatient Admission and Discharge Notification 278N 5010 transactions functionality is coming soon.

Prior Authorization and Referral Request (278)

The EDI 278 transaction supports healthcare providers to submit an authorization and referral requests electronically. A prior authorization issued by Anthem provides you the go-ahead to perform the necessary service and a referral used to refer a member to a specialty provider. Transmit this transaction in real-time or batch mode. You will receive confirmation numbers to validate receipt of request.

Inpatient Admission and Discharge Notification 278N

Use the Hospital Admission Notification (278N) transaction to exchange admission notification data between an inpatient facility and Anthem in a standard format.

Similar to the HIPAA 278 transaction that you may already use to submit authorizations or referrals, the EDI 278N is the simplest, most efficient way to communicate facility admissions. You can also transmit through Availity in either batch or real-time format.

What are the benefits of 278 and 278N transaction?

Both transactions offer:

• Simplify administrative tasks and increase productivity.
• Reduce administrative costs through automation and fewer phone calls, faxes or keying.
• Increase data accuracy by reducing manual errors.

 

Specifically for 278N, hospitals that have implemented EDI 278N:

• Experience an improvement in notification submissions within 24 hours.
• Can confirm a notification of admission is on file in the form of a service reference number generated upon registration.
• Submit notification of discharge.

How to send a 278 and 278N Transaction

Look for more communications coming soon around how to work with your practice management software vendor or billing/service clearinghouse or view a companion guide to send a 278 or 278N transaction.

 

 

588-0820-PN-GA

In the May 2020 edition of the Provider News, we announced an upcoming change to our Claims Requiring Additional Documentation policy (Facility) effective August 1, 2020.  Please be advised we are delaying the implementation date to October 1, 2020.

 

Effective for dates of service on or after October 1, 2020:

• Outpatient facility claims reimbursed at a percent of charge with billed charges above $20,000 will require an itemized bill to be submitted with the claim.

 

For more information about this policy, visit our Reimbursement Policy page at anthem.com/provider.

 

570-0820-PN-GA

Anthem will apply multiple imaging reimbursement rules to the technical component of diagnostic imaging procedures for dates of service on and after November 1, 2020. These rules apply across diagnostic imaging families, and modalities of radiology procedures and are not limited to contiguous body areas. Multiple imaging reimbursement rules are applied to the maximum allowance for the Technical Component (TC) of the following diagnostic imaging procedures rendered on the same date of service and eligible for reimbursement: Ultrasound, Computed Tomography (CT), Computed Tomographic Angiography (CTA), Magnetic Resonance Imaging (MRI), and Magnetic Resonance Angiography (MRA).

 

When two or more imaging procedures are performed in the same facility on the same patient on the same date of service, reimbursement is:

• 100% of the highest facility allowance for the first imaging procedure for the date of service.
• 50% of the facility allowance for each subsequent imaging procedure for that date of service.

For more information about this policy, visit our Reimbursement Policy page at anthem.com/provider.

 

583-0820-PN-GA

Effective November 1, 2020, AIM Specialty Health_® (AIM), a specialty health benefits company, will expand the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints for Anthem Blue Cross members, as further outlined below.  AIM works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe and affordable. 

 

The expanded musculoskeletal program will review certain lower extremity small joint surgeries for clinical appropriateness of the procedure and the setting in which the procedure is performed (Level of Care review). The clinical guidelines that have been adopted by Anthem to review for medical necessity and level of care are located here: AIM Small Joint Surgery Guideline and AIM Level of Care Guidelines for Musculoskeletal Surgery and Procedures. AIM will begin accepting prior authorization requests on October 26, 2020 for dates of service on and after November 1, 2020. To determine if prior authorization is needed for an Anthem member, please call the number located on the back of the member’s ID card. 

 

Members included in the new program

All FI and ASO members currently participating in the AIM Musculoskeletal program are included. For self-funded (ASO) groups that currently do not participate in the AIM Musculoskeletal program, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of November 1, 2020.

 

Pre-service review requirements

For surgeries that are scheduled to begin on or after November 1, 2020, all providers must contact AIM to obtain prior authorization review for the following non-emergency modalities:

 

Small Joint replacement (including all associated revision surgeries)

• Total joint replacement of ankle
• Correction of Hallux Valgus
• Hammertoe repair

 

Surgeries performed as part of an inpatient admission are included. 

 

How to place a review request:
Online: Get fast, convenient online service via the AIM ProviderPortal_SM. ProviderPortal is available twenty-four hours a day, seven days a week, and process requests in real-time using clinical criteria. Go to aimspecialtyhealth.com/goweb to register. Registration opens February 19, 2018. 

By phone: Call AIM Specialty Health toll-free at (866) 714-1103, Monday through Friday 8:30 a.m.–7:00 p.m. (ET). Registration opens February 19, 2018.

 

For more information:

Go to aimprovider.com/msk for resources to help your practice get started with the musculoskeletal and pain management program.  Our special website helps you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, FAQs.

 

You can also contact your local Network Relations Representative.

 

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

 

571-0820-PN-GA

 

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 Anthem 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

 

584-0820-PN-GA

The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory testing in the U.S. through the Clinical Laboratory Improvement Amendments (CLIA). The objective of the CLIA program is to ensure quality laboratory testing.

A valid CLIA Certificate Identification number is required and must be included on each electronic claim billed for laboratory services, subject to CLIA legislation. You may not receive reimbursement for your electronic claims if the required certification number is missing.

How to apply for a CLIA Certificate

cms.gov/Regulations-and-Guidance/Legislation/CLIA/How_to_Apply_for_a_CLIA_Certificate_International_Laboratories

This CMS mandate went in to effect on May 1, 2020. Please work with your software vendor or clearinghouse to ensure that the required information is included in your electronic files to avoid EDI claim rejections.

For detailed information on the tests subject to CLIA, please refer to the CMS link below:

cms.gov/Regulations-and-Guidance/Legislation/CLIA/                       

 

586-0820-PN-GA

Effective November 1, 2020, the AIM Musculoskeletal Program will be expanded to include medical necessity reviews for certain elective surgeries of the small joints for Anthem members. AIM Specialty Health_® (AIM) will perform the expanded musculoskeletal program and will review certain lower extremity small joint surgeries for clinical appropriateness of the procedure and the setting in which the procedure is performed (level of care review). The clinical guidelines adopted by Anthem and used by AIM to review for medical necessity and level of care are located here: AIM Small Joint Surgery Guideline and AIM Level of Care Guidelines for Musculoskeletal Surgery and Procedures.

 

AIM will begin accepting prior authorization requests on October 26, 2020, for dates of service on and after November 1, 2020. To determine if prior authorization is required, please call the prior authorization number located on the back of the member’s ID card. 

 

Members included in the new program

All fully insured and administrative services only (ASO) members currently participating in the AIM Musculoskeletal Program are included. For ASO groups that currently do not participate in the AIM Musculoskeletal Program, the program will be offered to ASOs to add to their members’ benefit package as of November 1, 2020.

 

Pre-service review requirements

For surgeries scheduled to begin on or after November 1, 2020, all providers must contact AIM to obtain prior authorization for the following non-emergency modalities:

 

Small joint replacement (including all associated revision surgeries)

• Total joint replacement of ankle
• Correction of Hallux Valgus
• Hammertoe repair

 

Surgeries performed as part of an inpatient admission are included. 

To place a review request:

• Online: Get fast, convenient, online service via the AIM ProviderPortal_SM , available twenty-four hours a day, seven days a week, processing requests in real-time using clinical criteria.  Go to aimspecialtyhealth.com/goweb to register. 
• Phone: Call AIM Specialty Health toll-free at 866-714-1103, Monday through Friday 8:30 a.m.–7:00 p.m. 

 

For more information:

Go to aimprovider.com/msk for resources to help your practice get started with the musculoskeletal and pain management program. Our website provides access to helpful information and tools such as order entry checklists, clinical guidelines and FAQs.

 

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

 

ABSCRNU-0159-20

On November 15, 2019, February 21, 2020, and March 26, 2020, 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 March 2020. Visit Clinical Criteria to search for specific policies.

 

If you have questions or would like additional information, please send an email to druglist@ingenio-rx.com.

 

ABSCRNU-0156-20

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: This training is offered the first Wednesday of each month from 1:00 p.m. to 2:00 p.m. ET.

 

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, Medicare Risk Adjustment and Documentation Guidance, from January 8, 2020, to December 2, 2020, has been reviewed and is acceptable for up to one 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 at: Training Registration.

*Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (condition specific)

When: This training is offered on the third Wednesday of every other month from noon to 1:00 p.m. ET.

 

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, Medicare Risk Adjustment Documentation and Coding Guidance, from
January 15, 2020, to November 18, 2020, 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:

 

Session 1: Red Flag HCCs, part one: Training will cover HCCs most commonly reported in error as identified by CMS, including chronic kidney disease (stage five), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease.

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 1

Password: sDBNERC3

 

Session 2: Red Flag HCCs, part two: Training will cover HCCs most commonly reported in error as identified by CMS, including 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.

 

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC’s Part 2

Password: PnPAF4py

 

Session 3: Neoplasms

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Neoplasms

Password: PfUWPcs6

 

Session 4: Acute, Chronic and Status Conditions

Recording link will be provided after October 1, 2020.

 

Session 5: Diabetes Mellitus and Other Metabolic Disorders - September 16, 2020

DM and other Endocrine, Nutritional and Metabolic Disorders

 

Session 6: Coinciding Conditions in Risk Adjustment Models - November 18, 2020

Medicare Risk Adjustment Documentation and Coding Guidance: Coinciding Conditions in Risk Adjustment Models

  

 ABSCRNU-0158-20

Effective August 1, 2020, Anthem Blue Cross and Blue Shield will use the new acute viral illness guidelines that have been added to the 24th edition of the MCG Care Guidelines. Based on the presenting symptoms or required interventions driving the need for treatment or hospitalization, these guidelines are not a substantive or material change to the existing MCG Care Guidelines we use now, such as systemic or infectious condition, pulmonary disease, or adult or pediatric pneumonia guidelines.

 

Inpatient Surgical Care (ISC):

• Viral Illness, Acute — Inpatient Adult (M-280)
• Viral Illness, Acute — Inpatient Pediatric (P-280)
• Viral Illness, Acute — Observation Care (OC-064)

 

Recovery Facility Care (RFC):

• Viral Illness, Acute — Recovery Facility Care (M-5280)

 

 

ABSCRNU-0157-20

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

• Medicare Advantage Submit behavioral health authorizations via our online Interactive Care Reviewer tool
• Updates to AIM musculoskeletal program clinical appropriateness guidelines
• Medicare Advantage Provider data update
• Medicare Advantage Waived copays, deductibles and coinsurance for CCM, complex CCM and TCM

 

ABSCARE-0488-20

ABSCRNU-0149-20

ABSCRNU-0151-20

ABSCRNU-0155-20