Maintaining accurate provider information is critically important to ensure our members have timely and accurate access to care.

Additionally, Anthem is required by Centers for Medicare & Medicaid Services (CMS) to include accurate information in provider directories for certain key provider data elements.  For Anthem to remain compliant with federal and state requirements, changes must be communicated 30 days in advance of a change or as soon as possible.

Key data elements

The data elements required by CMS and crucial for member access to care are: 

• Physician name
• Location (such as address, suite if appropriate, city/state, zip code)
• Phone number
• Accepting new patient status
• Hospital affiliations
• Medical group affiliations

 

Anthem is also encouraged (and in some cases required by regulatory/accrediting entities) to include accurate information for the following provider data elements:

• Physician gender
• Languages spoken
• Office hours
• Provider specialty/specialties
• Physical disabilities accommodations
• Indian Health Service status
• Licensing information (i.e., medical license number, license state, National Provider Identifier - NPI)
• Email and website address

How to verify and update your information

To verify information, go to anthem.com and select “Providers,” and then under “Provider Resources” select “Find a Doctor” tool.  Use “Search as a Guest” at the bottom.  If your information is not correct, please update the information as soon as possible. 

 

To update information, go to anthem.com and select “Providers,” and then under “Provider Resources” select "Provider Maintenance" and follow the online prompts.

On January 1, 2019, a change to CPT codes for psychological and neuropsychological test administration and evaluation services was released. The new codes did not crosswalk on a one-to-one basis with the deleted codes.

 

The coding changes separated test administration from test evaluation, psychological testing from neuropsychological testing, and defined the testing performed by a professional or technician. The new codes were as follows:

 

Neurobehavioral status exams are clinical interview examinations performed by a psychologist or neuropsychologist to assess thinking, reasoning and judgment. Providers should continue to use CPT code 96116 when billing for the first hour and new code 96121 when billing for each additional hour.

 

Testing evaluation services include the selection of the appropriate tests to be administered; integration of patient data; interpretation of standardized test results and clinical data; clinical decision-making; treatment planning; and reporting and interactive feedback to the patient, family members, or caregivers, when performed. Providers should now use CPT code 96130 to bill for the first hour of psychological testing evaluation services and 96131 for each additional hour. Neuropsychological evaluation services should now be billed using CPT code 96132 for the first hour and 96133 for each additional hour.

 

Test administration and scoring by a psychologist or neuropsychologist (two or more tests using any method) should now be billed using CPT code 96136 for the first 30 minutes and 96137 for each additional 30 minutes.

 

Test administration and scoring by a technician (two or more tests using any method) should now be billed using CPT code 96138 for the first 30 minutes and 96139 for each additional 30 minutes.

 

Single automated test administration should be reported with newly created code 96146 for a single automated psychological or neuropsychological instrument that is administered via electronic platform and formulates an automated result. Psychologists should not use this code if two or more electronic tests are administered and/or if administration is performed by the professional or technician. Instead, the psychologist should use the appropriate codes listed above for test administration and scoring.

 

Screening and risk assessment (repetitive assessment after screening) include brief emotional/behavioral assessment with scoring and documentation, per standardized instrument, should now be billed using CPT code 96127 separately from testing.

Anthem Blue Cross and Blue Shield values the relationship we have with our providers, and we always look for opportunities to help expedite the claim processing. When a Federal Employee visits the provider office, the provider should obtain the most current medical insurance information, which will help to establish the primary carrier and will alleviate claim denials and support accurate billing. For questions please call Federal Employee Customer Service at 800-282-2473.

 

In our company’s ongoing efforts to streamline and simplify our payment recovery process, we will be consolidating our National Accounts membership to a central system. With this change we will be aligning the payment recovery processes to be the same as the majority of our other lines of business.

 

Our recovery process for National Accounts membership is reflected on the Electronic Remittance Advice (835) in the PLB segment. The requested recovered amount on the Electronic Remittance Advice (835) is displayed at the time of the recovery.

 

As National Accounts membership transitions and claims are adjusted for recovery on the central system, the requested recovered amount will be held for 49 days. This will 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” section.

 

After 49 days, the requested recovered amount is reflected on the Electronic Remittance Advice (835) in the PLB segment.

 

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

As a reminder, we will update our claim editing software monthly throughout 2020 with the most common updates occurring in quarterly in February, May, August and November of 2020. 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, medically unlikely edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
• apply to any provider or provider group (tax identification number) and may apply to both institutional and professional claim types

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Anthem Blue Cross and Blue Shield (Anthem) 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:

• Diagnosis
• Treatment plan
• Referrals
• Psychopharmacological medication (as applicable)

 

In an effort to facilitate coordination of care, Anthem has several tools available on the Provider website including a Coordination of Care Form and Coordination of Care Letter Templates for both Behavioral Health and other Medical Practitioners. Behavioral Health tools are available, which includes forms, brochures, and screening tools for Substance Abuse, ADHD, and Autism. Please refer to the website for a complete list.

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits.  In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. Anthem’s medical policies are available on Anthem’s website at anthem.com.

 

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 online at anthem.com/provider. Visit anthem.com/provider, then scroll down and select Find Resources for Georgia (or select Georgia if it’s not already selected). Then click on Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements.

 

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. Eastern.
• 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.

To discuss UM Process & Authorizations	To Discuss Peer-to-Peer UM Denials w/Physicians	To Request UM Criteria	TTY/TDD
800 662-9023, 800 722-6614, 855-343-4851 or 855-343-4852   Transplant 800-824-0581   Behavioral Health: 800-292-2879   Autism: 844 269 0538   University System of Georgia (USG): 800-233-5765 Behavioral Health 844 269-0535   State Health Benefit (SHBP):  Behavioral Health: 855 679-5725           FEP Phone 800-860-2156 FAX 800 732-8318 (UM) FAX 877 606-3807 (ABD)	877-771-9165               Behavioral Health: 800-292-2879       University System of Georgia (USG): 877-771-9165 Behavioral Health:  844 269-0535   State Health Benefit (SHBP): Behavioral Health: 855 679-5725   State Health Benefit (SHBP):  Medical: 855 668 6442   FEP Phone 800-860-2156	800 662-9023, 800 722-6614, 855-343-4851 or 855-343-4852         Behavioral Health: 800-292-2879       University System of Georgia (USG): 800-233-5765 Behavioral Health 844 269-0535   State Health Benefit (SHBP):  Behavioral Health: 855 679-5725     State Health Benefit (SHBP):  Medical: 855 668 6442     FEP Phone 800-860-2156 FAX 800 732-8318 (UM) FAX 877 606-3807 (ABD)	711 Or TTY Voice 800-255-0056(T) 800-255-0135(V)

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.

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement.

 

This information can be found on the Quality Improvement Standards page of our anthem.com/provider website. Practitioners may access the FEP member portal at fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

 

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on the Practice Guidelines page of our anthem.com/provider website.

In November, Anthem Blue Cross and Blue Shield (Anthem) added new functionality to Georgia’s provider enrollment tool hosted on the Availity Portal to further automate and improve your online enrollment experience. 

Who can use this new tool?

• Professional providers, whose organizations do not have a credentialing delegation agreement with Anthem.

Note: Providers who submit via roster or have delegated agreements will continue to use the process in place.

What does the tool provide?

• Add new providers to an already existing group
• Apply and request a contract. After review, a contract can be sent back to you digitally for an electronic signature. This eliminates the need for paper applications or paper contracts. 
  • Enroll a new group of providers.
• A dashboard for real time status on the submitted applications.
• Streamlined complete data submission.

Here’s a review of how the online enrollment application works:

The system automatically accesses CAQH to pull in all updated information you’ve already included in your CAQH application. The CAQH information automatically populates the information Anthem needs to complete the enrollment process – including credentialing and loading your new provider to our database. Please ensure that your provider information on CAQH is updated and is in a complete or re-attested status.

Availity’s online application will guide you throughout the enrollment process, providing status updates using a dashboard. As a result, you know where each provider is in the process without having to call or email for a status. 

Note: For any changes to your practice profile and demographics, continue to use the new online provider maintenance form that allows you to electronically submit to Anthem any changes to your practice profile and demographics. Availity administrators and assistant administrators can access the form on Availity>Payer Spaces>Resources.

Accessing the provider enrollment application

Log on to the Availity Portal and select Payer Spaces >Anthem>Applications>Provider Enrollment to begin the enrollment process.

If your organization is not currently registered for the Availity Portal, the person in your organization designated as the Availity administrator should go to availity.com and select Register. 

For organizations already using the Availity Portal, your organization's Availity administrator should go to My Account Dashboard from the Availity home page to register new users and update or unlock accounts for existing users. Staff who need access to the provider enrollment tool need to be granted the role of “Provider Enrollment.”

(Availity administrators and User Administrators will automatically be granted access to provider enrollment.)

If you are using Availity today and need access to provider enrollment, please work with your organization’s administrator to update your Availity role. To determine who your administrator is, you can go to My Account Dashboard > My Administrators.

Need assistance with registering for the Availity Portal?

Contact Availity Client Services at 1-800-availity (1-800-282-4548).

Pateint360 is a Longitudinal Patient Record (LPR) where you can access the complete view of Anthem information associated with an Anthem member.

You may have noticed that the Care Reminders tab on your Anthem patient’s Eligibility and Benefits return on Availity was recently removed. You can still retrieve these important patient gaps in care through Patient360.

 

You are required to have the Patient360 role assigned to you by your Availity administrator to see the Patient360 tab located at the top of the patient’s Eligibility and Benefits return. To access Patient360 select the tab and follow the steps to open the application.

 

If your patient does have a gap in care, you will see the red alert button on the top of Patient360 Member Care Summary. Details of the care gap can be found in the Active Alerts section.

 

Availity Eligibility and Benefits: Patient360 access

Patient360 Active Alerts located on the Member Care Summary

Beginning with dates of service on or after March 1, 2020, Anthem’s current Durable Medical Equipment policy will be retired and will be replaced by the new Durable Medical Equipment Rent to Purchase policy and the new Durable Medical Equipment Modifiers policy. The new Durable Medical Equipment Rent to Purchase policy has the same reimbursement guidelines and requirements as the current Durable Medical Equipment policy. The new Durable Medical Equipment Modifiers policy has the same reimbursement guidelines for DME Modifiers as the current Durable Medical Equipment policy.

 

For more information about these new policies, visit the Reimbursement Policy page at anthem.com/provider.

As previously communicated in the October 2019 edition of Anthem Blue Cross and Blue Shield’s ("Anthem") Provider News, the AIM Rehabilitative program for commercial membership relaunched November 1st. AIM Specialty Health® (AIM), a separate company, will perform prior authorization review of physical, occupational and speech therapy services. Requests may be submitted via the AIM ProviderPortal for dates of service 11/1 and after. The OrthoNet program is no longer active in applicable markets.

 

Due to the current American Specialty Health (ASH) chiropractor utilization management program in Georgia, chiropractors will continue to be managed by ASH including requests for review of certain codes that may also be part of the AIM Rehab program. Chiropractors in Georgia will not be required to obtain an authorization from AIM.

 

New changes to AIM’s Rehab Program

Anthem and AIM Specialty Health are working together to make improvements to the clinical review of PT/OT/ST Services when used to treat Autism Spectrum Disorder or Pervasive Developmental Delays as defined by the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. 

 

Effective 11/1/2019 in the state of Georgia, preauthorization is not required for PT, OT, or ST out-patient therapy services when receiving skilled treatment for Autism Spectrum Disorder or Pervasive Developmental Delays for members with Anthem commercial plans. You may file your claims without a preauthorization number if you are billing with one of the following ICD-10 codes: F84.0, F84.2, F84.3, F84.5, F84.8, or F84.9. Please note that benefit limits, if applicable, will still be applied.

 

Anthem is also transitioning vendors for review of Rehabilitative Services for our Medicare members to include out-patient PT, OT, and SLP, to AIM Specialty Health. Anthem has decided to delay the implementation of this transition. The AIM Rehab program will now begin in April 2020. Prior authorization will not be required for the above mentioned services through March 2020.  

 

Please be sure to check upcoming editions of Provider News for more information about the AIM Rehabilitative Program for Medicare members.

This article was originally printed on November 1, 2019 with the incorrect effective date and corrected on November 6, 2019. The original article incorrectly stated that the AIM Musculoskeletal Program would begin on November 1, 2019. The correct date that the AIM Musculoskeletal Program will begin is December 2, 2019.

Anthem Blue Cross and Blue Shield (“Anthem”) announced in March 2018 that the AIM Musculoskeletal Program was delayed. AIM Specialty Health® (AIM), a separate company, will perform prior authorization reviews of certain surgeries of the spine and joints, as well as interventional pain treatment to determine medical necessity for Commercial fully insured Anthem members beginning December 2, 2019 for dates of service on and after December 2, 2019.

The new musculoskeletal program includes review of the level of care/setting, and expected length of stay for medical necessity using AIM clinical guidelines which have been adopted by Anthem. All codes and clinical guidelines included in the musculoskeletal program can be found on the AIM MSK website.

The AIM ProviderPortalSM will be available for prior authorization order request submissions twenty-four hours a day, seven days a week, processing requests in real-time using clinical criteria. Providers may also submit request via the AIM Call Center by calling 866-714-1103 Monday through Friday 8:30 a.m.–8:00 p.m.

 

 

Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.

 

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?

CM Email Address (if available)	CM Telephone #	CM Business Hours
GaLocalCaseManagement@choosehmc.com   National: CMNATIONALACT-ATL@anthem.com	800-353-0923     National: 1-866-202-8727 800-824-0581 (Transplant)         FEP: 1-800-711-2225	Monday–Friday: 8:00 a.m.–7:00 p.m. EST   National: Monday–Friday: 8:00 a.m.–9:00 p.m. EST, Saturday: 9:00 a.m.–5:30 p.m. EST           Monday–Friday: 8:30 a.m.–5:00 p.m. EST (Transplant)   FEP: 8:00 a.m–7:00 p.m. EST

Medicare Advantage

 

On June 20, 2019, the Pharmacy and Therapeutic (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 are publicly available on our provider website, and the effective dates will be reflected online. Visit the Clinical Criteria page to search for specific policies.

 

For questions or additional information, send us an email at druglist@anthem.com.

 

Medicare Advantage

 

(APM ID 0037943)

 

The Blue Cross and Blue Shield Association (BCBSA) has issued a mandate with the goal of improving health outcomes and care management for Medicare Advantage members living outside of a control/home plan service area. This mandate will require a change in the way we process the following requests for Medicare Advantage out-of-area (OOA) membership:

• Stars care gap requests
• HEDIS® requests
• Risk adjustment requests
• Medical record requests

 

This change in process applies to all Blue plans and will go into effect on January 1, 2020.

 

The current process

The current process for the above-mentioned requests involves the control/home plan sending requests to providers via Inovalon/vendor for medical records and supplemental data to address and/or close an identified or suspected HEDIS measure, care gap or risk adjustment. Providers receive requests and submit the requested information to the home plan. The home plan receives the information and uses this information, medical records and supplemental data to complete and/or close the request.

 

The new process

The new process is specific for Medicare Advantage OOA (PPO) members only. These members will be split out from all other members.

 

For Medicare Advantage OOA members whose home plan is Anthem Blue Cross and Blue Shield (Anthem), the Stars care gap, risk adjustment, HEDIS and medical record requests will be processed via the new BCBSA Provider Engagement Data Exchange (PEX) platform. Anthem as control/home plan will submit these requests to BCBSA via the PEX system. BCBSA will then route the request to the health plan with which the provider is contracted (host plan). The host plan will initiate the provider engagement and gather the requested information (for example, medical records). Providers contracted by the host plan will submit the requested documentation to the plan. The host plan will then submit the documentation via the PEX system to BCBSA. BCBSA will sort the responses and documentation and send to the requesting home plan (member’s home plan).

 

When Anthem is the host plan, Anthem will receive requests for Stars care gap, risk adjustment, HEDIS and medical record requests from the member’s home plan via the PEX system. Anthem will process the requests, engage providers, and submit requests for medical records and/or supplemental data to the provider. When the provider supplies a response (medical records, supplemental data or additional requests for information), Anthem will send the responses/documentation to the control/home plan via the PEX system. BCBSA will route the responses/documentation to the requesting home plan.

 

Provider role in new process

Each provider has a key role in the new process. In order to improve the overall care and health outcomes for members, the provider must:

1. Respond to requests for medical records and/or supplemental data in a timely manner.
2. Request additional information from the provider’s contracted plan, if needed, to complete requests.
3. Follow the standard HEDIS, Stars care gap, risk adjustment and medical records requests processes as outlined in the current process.

 

As a control/home plan, Anthem is taking steps to ensure that providers have the resources needed to complete this new process with little or no impact to the provider’s current operations. Additional provider education resources will be communicated as they become available.

 

For additional information, please refer to the service numbers on the back of the Member ID Card.

Medicare Advantage

 

As a reminder, PCPs may only refer Anthem Blue Cross and Blue Shield (Anthem) members to in-network Medicare Advantage providers.

 

Anthem has contracted with specialists to ensure adequate care of our members. The use of contracted network specialists will ensure continuity of appropriate clinical background data and coordination of care with the PCP.

 

Should there be a need to refer the member outside the contracted network, contact Anthem directly for prior authorization (PA). Referring a Medicare Advantage member out-of-network, who does not have out-of-network benefits, could result in claim denials with member liability unless the service is urgent, emergent, out-of-area dialysis or if PA was approved by the plan.

 

Although not required, PA is encouraged for preferred provider organization (PPO) members who want to receive notification of advanced coverage when utilizing an out-of-network provider for services.

 

As a reminder to all providers, the referring physician name and NPI must be reported on the claim when the PCP does not provide the service rendered. This will reduce the number of rejections issued during initial claim processing.

 

Medicare Advantage

 

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

• Learn more about the Group Retiree PPO plans
• CMS reminder: expedited/urgent requests
• Prior authorization requirements for E0784, K0553 and K0554
• Network Update Article: Global 3M19 Medical Policy and Technology Assessment Committee prior authorization requirement updates
• 2020 Medicare Advantage individual benefits and formularies