BCBSGa is pleased to announce that we will continue hosting in person Town Hall style provider meeting throughout 2019. 

Topics will include:

• Commercial Risk Adjustment
• Network updates
• Availity
• State Health Benefit Plan (SHBP)
• AIM Specialty Health® (AIM) programs
• Exchanges
• Medicare
• Provider Experience
• Provider Services contacts, general information and updates

February 12, 2019 – Gainesville

The Northeast Georgia History Center

322 Academy Street NE

Gainesville, GA. 30501.

11:30 a.m.–1:00 p.m., lunch will be provided.

Please R.S.V.P by Wednesday, February 6th to RSVPBlue@bcbsga.com

April 9, 2019 – Atlanta

Emory North Decatur

2701 North Decatur Road

Decatur, GA. 30030

9:30 a.m.–11:00 a.m., breakfast will be provided

Please R.S.V.P by Wednesday, April 3rd to RSVPBlue@bcbsga.com.

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway.  Availity is well known as a Web portal and claims clearinghouse. In addition, Availity functions as an EDI Gateway for multiple payers and is the single EDI connection for our company.

Your organization can submit and receive the following electronic transactions through Availity’s EDI Gateway:

• 837- Institutional Claims
• 837- Professional Claims
• 837- Dental Claims
• 835 - Electronic Remittance Advice
• 276/277- Claim Status
• 270/271- Eligibility Request

If you wish to become a direct a trading partner with Availity, the setup is easy.

Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your BCBSGa EDI transmissions. 

If you prefer to use your clearinghouse or billing company, please work with them to ensure connectivity.

Need Assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

835 Electronic Remittance Advice (ERA)

Effective June 1, 2018, please use Availity to register and manage account changes for ERA. If you were previously registered to receive ERA, you must register using Availity to manage account changes.

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time. If you were previously registered to receive EFT only, you must register using EnrollHub to manage account changes. No other action is needed.

Contacting Availity

If you have any questions, contact Availity Client Services at 1-800-Availity

(1-800-282-4548), Monday through Friday 8 a.m. to 7:30 p.m. Eastern Time.

In our company’s ongoing efforts to streamline and simplify our payment recovery process, we continue to consolidate our internal systems and will begin transitioning our National Accounts membership to a central system in 2019. While this is not a new process, we are transitioning the National Accounts membership to align with the payment recovery process across our other lines of business.

Currently, our recovery process for National Accounts membership is reflected in the EDI PLB segment on the electronic remittance advice (835). This segment will show the negative balance associated with the member account number. Monetary amounts are displayed at the time of the recovery adjustment.

As National Accounts membership transitions to the new system and claims are adjusted for recovery, the negative balances due to recovery are held for 49 days to allow ample time for you to review the requests, dispute the requests and/or send in a check payment. During this time, the negative balances due are reflected on paper remits only within the “Deferred Negative Balance” sections. 

After 49 days, the negative balances due are reflected within the 835 as a corrected and reversed claim in PLB segments. 

If you have any questions or concerns, please contact the E- Solutions Service Desk toll free at (800) 470-9630.

Requesting a clinical appeal is easy:

Logon to ICR from the Availity Portal and locate the case using one of the search options, or from your ICR dashboard.

• Select the Request Tracking ID link to open the case. If the case is eligible for an appeal you will see the Request Appeal menu option on the Case Overview screen.
• Select Request Appeal to open the Appeal Details screen and complete the required fields on the appeal template. (You also have the option of uploading attachments and images to support your request.)
• Select Submit

Take the steps below to check the status of a clinical appeal:

Logon to ICR from the Availity Portal

• Select Check Appeal Status from the ICR top menu bar
• Type the Appeal Case ID and Member ID in the allocated fields
• Select Submit

The appeal status and detail of the decision will open on the bottom of the screen.

Need more information on how to navigate the new ICR Appeals feature?

Download the ICR Clinical Appeals Reference Guide located on the Availity Portal. Select: Payer Spaces | Applications | Education and Reference Center | Communication and Education. Find the link to the reference guide below the ICR menu.

Additional Training

If you are new to ICR or want to get a refresher please attend our monthly ICR webinar. The next event is taking place on December 6 at 1:00 p.m. Register Here

An Integrated Care Model affords members with plans purchased on the Health Insurance Marketplace (also called the exchange) the ability to have continuity of care with each care management case. A single Primary Care Nurse provides case and disease assessment and management. This continuity provides opportunity for the member to get assistance working through an acute phase of an illness and then work with their nurse on the necessary behavioral changes needed to improve their health   and enhance their well-being. The program is based on nationally recognized clinical guidelines and serves as an excellent adjunct to physician care.

The Integrated Care Model helps exchange members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease.  Our nurse care managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. 

Nurse Care Managers encourage participants to follow their physician’s plan of care; not to offer separate medical advice. In order to help ensure that our service complements the physician’s instructions, we collaborate with the treating physician to understand the member’s plan of care and educate the member on options for their treatment plan. 

Members or caregivers can refer themselves or family members by calling the number located in the grid below. How do you contact Case Management?

Georgia

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral.  Anthem Blue Cross would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner.  Anthem Blue Cross urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between Behavioral Health and other health care practitioners at the time treatment begins.

We expect all health care practitioners to:

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:

In an effort to facilitate coordination of care, Blue Cross Blue Shield of Georgia has several tools available on the Provider website including a Coordination of Care template and cover letters for both Behavioral Health and other Healthcare Practitioners.* In addition, there is a Provider Toolkit on the website with information about Alcohol and Other Drugs which contains brochures, guidelines and patient information.**

*Access to the forms and cover letters are available at anthem.com>Providers> Provider Home>Answers@Anthem

**Access to the Toolkit is available at anthem.com>Providers>Provider Home> Health and Wellness

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below. UM criteria are also available on the web. Just select “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” from the bcbsga.com/provider website.

We work with providers to answer questions about the utilization management process and the authorization of care.  Here’s how the process works:

• Call us toll free from 8:30 a.m.–5:00 p.m. Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program hours are 8:00 a.m.–7:00 p.m.
• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after midnight will be returned the same business day. 
• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

The following phone lines are for physicians and their staffs. Members should call the customer service number on their health plan ID card.

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.

Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.

Our member rights and responsibilities statement can be found through the Quality Improvement Standards page of our bcbsga.com/provider website. Practitioners may access the FEP member portal at fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on the Practice Guidelines page at bcbsga.com/provider.

We encourage you to continue subscribing to our Network eUPDATE tool. We also ask that you urge your staff and co-workers to register to receive our Network eUPDATE if they have not already done so. This way, you and your staff continue to receive important information and other late breaking or time-sensitive news that you'll need when providing services and filing claims for Anthem members.

It's easy to register for the Network eUPDATE; just a few clicks, and the registration process is complete.

Click Network eUPDATE to register.

Please forward this information to those in your practice or facility who may need this information.

Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) commercial data collection project for 2018. You play a central role in promoting the health of our members. By documenting services in a consistent manner, it is easy for you to track care that was provided and identify any additional care that is needed to meet the recommended guidelines.  Consistent documentation and responding to our medical record requests in a timely manner eliminates follow up calls to your office and also helps improve HEDIS scores, both by improving care itself and by improving our ability to report validated data regarding the care you provided. The records that you provide to us directly affect the HEDIS results that are listed below.

Each year our goal is to improve our process for requesting and obtaining medical records for our HEDIS project. In order to demonstrate the exceptional care that you have provided to our members and in an effort to improve our scores, you and your office staff can help facilitate the HEDIS process improvement by:

• Responding to our requests for medical records within five days, if possible
• Providing the appropriate care within the designated timeframes
• Accurately coding all claims
• Documenting all care clearly in the patient’s medical record

Further information regarding documentation guidelines and administrative codes can be found on the HEDIS page of our Provider Portal. In addition more information on HEDIS can be found on the Quality Improvements and Standards page of our bcbsga.com/provider website. You will find reference documents entitled “HEDIS 101 for Providers” and “HEDIS Physician Documentation Guidelines and Administrative Codes”.

The attached PDF includes a table that shows some of our key measure rates across Georgia.

• Yellow boxes indicate rates that are above the national average.
• Bold indicates improvement in rate over the previous year.
• Comprehensive Diabetes Care - Poor HbA1c Control (>9): Lower rate is good

In Georgia, Commercial HMO rates improved and/or exceeded the national average. 

• Measures with rate increases include:
  Adult BMI Assessment
• Weight Assess/Counseling – BMI Total
• Weight Assess/Counseling – Physical Activity Total
• Chlamydia Screening in Women – Total
• Appropriate Testing Children w/ Pharyngitis
• Appropriate Treatment for Children With Upper Respiratory Infection
• Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
• Spirometry Testing for COPD
  Pharmacotherapy Mgmt COPD – Bronchodilator
• Persistence of Beta-Blocker Treatment after AMI
• Comprehensive Diabetes Care – HbA1c Testing
• Comprehensive Diabetes Care – HbA1c <8
• Comprehensive Diabetes Care – Blood Pressure <140/90
• Use of Imaging Studies for Low Back Pain
• Well-Child Visits in the first 15 Months of Life (6+ visits)
• Well-Child Visits 3 to 6 Years of Life
•  Adolescent Well-Care Visits

Measures where there are opportunities for improvement include:

• Weight Assess/Counseling – Nutrition Counseling Total
• Childhood Immunization Status – Combo 10
• Immunizations for Adolescents – TDAP
• Immunizations for Adolescents – Combo 1
• Cervical Cancer Screening
• Colorectal Cancer Screening
• Controlling High Blood Pressure
• Comprehensive Diabetes Care – Eye Exams
• Comprehensive Diabetes Care – Nephropathy
• Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
• Prenatal/Postpartum Care – Timeliness of Prenatal Care
• Prenatal/Postpartum Care – Postpartum Care

In Georgia, Commercial PPO rates improved and/or exceeded the national average.  Measures with rate increases include:

• Adult BMI Assessment
• Weight Assess/Counseling – BMI Total
• Weight Assess/Counseling – Nutrition Counseling Total
• Weight Assess/Counseling – Physical Activity Total
• Cervical Cancer Screening
• Chlamydia Screening in Women – Total
• Appropriate Testing Children w/ Pharyngitis
• Spirometry Testing for COPD
• Pharmacotherapy Mgmt COPD – Bronchodilator
• Comprehensive Diabetes Care – HbA1c Testing
• Comprehensive Diabetes Care – HbA1c <8
• Comprehensive Diabetes Care – Eye Exams
• Comprehensive Diabetes Care – Blood Pressure <140/90
• Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
• Appropriate Treatment Children w/ URI
• Antibiotic Treatment Adults w/ Acute Bronchitis
• Use of Imaging Studies for Low Back Pain
• Prenatal/Postpartum Care – Timeliness of Prenatal Care
• Prenatal/Postpartum Care – Postpartum Care
• Well-Child Visits in the first 15 Months of Life (6+ visits)
• Well-Child Visits 3 to 6 Years of Life
• Adolescent Well-Care Visits

Measures where there are opportunities for improvement include:

• Childhood Immunization Status – Combo 10
• Immunizations for Adolescents – MENIN
• Immunizations for Adolescents – TDAP
• Immunizations for Adolescents – Combo 1
• Colorectal Cancer Screening
• Persistence of Beta-Blocker Treatment after AMI
• Comprehensive Diabetes Care – Nephropathy

Now is the time to review your patient’s records to ensure that they have received their preventative care and/or immunizations before the end of the year.

Again, we thank you and your staff for demonstrating teamwork as we work together to improve the health of our members and your patients. We look forward to working with you again next HEDIS season.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

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

See attached PDF titled GA Standard Preapproval Provider CHANGE Notification 12.1.2018.

As a reminder, our claim editing software will be updated monthly throughout 2019 with the most common updates occurring in quarterly in February, May, August and November of 2019. These updates will:

• reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
• include updates to National Correct Coding Initiative (NCCI) edits
• include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
• include assistant surgeon eligibility in accordance with the policy
• include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

In addition to modifier 79, modifiers 58 and 78 are also based on Same Physician or Other Qualified Health Care Professional as documented below:

• 58 – Staged/Related Procedure/Service by the Same Physician/Other Qualified Health Care Professional during the Postoperative Period.
• 78 – Unplanned Procedure/Service by Same Physician/Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure during the Postoperative Period.

SmartShopper is a full-service incentive and engagement program that encourages members to shop for health care like an expert. Our members can earn a cash reward* when they shop online or by phone for better-value medical services.

How SmartShopper works:

1. A member’s doctor recommends a medical service.
2. The member logs on to SmartShopper, or calls us, to find lower-cost, high-quality options in their area.
3. They have the procedure at the preferred location.
4. Once the procedure is complete and the claim is paid, a reward check is mailed to the member.

SmartShopper makes it easier than ever for Anthem members to find cost-effective care with its high-tech digital platform and high-touch member services. For more information visit VitalsSmartShopper.com.

*Reward payments may be taxable.

Anthem is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the number located in the grid below. They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small.  We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

How do you contact us?

The ConditionCare program helps members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. A team of registered nurses with added support from other health professionals such as dietitians, pharmacists and health educators work with members to help them understand their condition(s), their doctor’s orders and how to become a better self-manager of their condition. 

Engagement methods vary by the individual’s risk level but can include:

• Education about their condition through mailings, email newsletters, telephonic outreach, and/or online tools and resources.
• Round-the-clock phone access to registered nurses.
• Guidance and support from Nurse Care Managers and other health professionals.

Physician benefits:

• Save time by answering patients’ general health questions and responding to concerns, freeing up valuable time for the physician and their staff.
• Support the doctor-patient relationship by encouraging participants to follow their doctor’s treatment plan and recommendations.
• Inform the physician with updates and reports on the patient’s progress in the program.

Please visit the bcbsga.com/provider website to find more information about the program such as program guidelines, educational materials and other resources. Go to bcbsga.com/provider.  Also on our website is the Patient Referral Form, which you can use to refer other patients you feel may benefit from our program.

If you have any questions or comments about the program, call 877-681-6694.  Our nurses are available Monday–Friday, 8:00 a.m.–9:00 p.m., and Saturday, 9:00 a.m.–5:30 p.m.

• 2019 Provider Annual Notice of Change  
• Medicare Advantage Reimbursement Policy October Provider Bulletin  
• July Medicare Advantage reimbursement policy  
• Submit PA medication requests electronically; new phone number for MA prescription PAs 
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019  
• Inpatient Readmissions   
• Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective Sept. 1