Anthem Commercial Risk Adjustment (CRA) contracts with Inovalon – an independent company that provides secure, clinical documentation services – to help us comply with provisions of the Affordable Care Act (ACA) that require us to assess members’ relative health risk level and report to CMS on those conditions.  Your offices have been receiving Inovalon SOAP (Subjective; Objective; Assessment; and Plan – these are health assessments) packets all year long as part of our risk adjustment cycle, asking for the physicians’ help with completing health assessments for some of their patients who are our members.

 

Incentives for submitting SOAP’s/Health Assessments

SOAPs submitted as paper are eligible for a $50 incentive; SOAPs submitted electronically through Inovalon’s ePASS system are eligible for a $100 incentive. 

 

Submission deadline and important reminder

While the dates of service for the patient visits must have been by December 31, 2019, the SOAP notes/Health Assessments can be submitted up until February 15, 2020. We will still pay the incentive payments for these submissions through February 15, 2020.

 

Questions or assistance with SOAPs

Need help with ePASS or have questions? Simply email your inquiry to Inovalon at ePASSsupport@inovalon.com with your name, organization, contact information, and any questions that you might have. Trained representatives are available to assist you.  If you prefer to reach Inovalon by phone, please call 877-448-8125, Monday–Friday, 8:00 a.m.–9:00 p.m. ET; Saturday–Sunday, 10:00 a.m.–6:00 p.m. ET.

 

If you have any questions regarding our risk adjustment process, please contact our CRA Network Education Representative, Alicia Estrada, by emailing her at Alicia.estrada@anthem.com.

 

Anthem is collaborating with leading organizations on a new school-based initiative called Shine Light on Depression to help tackle the issue of teen depression and suicide in middle and high school youth nationwide. The Shine Light on Depression e-toolkit (e.g., website) will provide school communities with free, ready-to-use tools designed to raise awareness of depression and suicide prevention in a positive, fact-based, and inclusive manner. This approach will help build a community in which there is open discussion and appropriate vocabulary about the subject of depression and places it in the broader context of good mental health. The e-toolkit features customizable classroom lessons to empower educators to lead effective depression awareness programs, family-community workshop materials to help adults and families talk about how to support teens, and teen club resources that empower students to lead activities and help each other by talking and listening. With 24,053 secondary schools in the U.S., the Shine Light on Depression e-toolkit has the potential to impact large numbers of individuals who are at risk of depression and suicide and support schools in meeting state teaching mandates. Visit Shine Light on Depression to learn more.

 

Shine Light on Depression is a unique collaboration of organizations committed to raising awareness of depression and suicide prevention among young people: American School Health Association, Anthem, Inc., Erika’s Lighthouse, JetBlue Airways Corporation, and the National Parent Teachers Association.

Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments (CLIA) 1988 federal statute and regulations require additional information to be considered for payment.

 

A valid CLIA Certificate Identification number is required for reimbursement of clinical laboratory services reported on a CMS-1500 claim form (or its electronic equivalent) beginning May 1, 2020. The CLIA Certificate Identification number must be submitted in one of the following ways:

Claim Format and Elements	CLIA Number Location Options	Referring Provider Name and National Provider Identifier (NPI) Number Location Options
CMS-1500	Must be represented in field 23	Submit the referring provider name and NPI number in fields 17 and 17b, respectively.
Electronic transaction 837 Professional; Health Insurance Portability and Accountability Act (HIPAA) Version 5010	Must be represented in the 2300 loop, REF02 element, with qualifier of “X4” in REF01	Submit the referring provider name and NPI number in the 2310A loop, NM1 segment.

Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the “QW” modifier when any CLIA Waived laboratory service is reported on a CMS-1500 claim form in order for the procedure to be evaluated to determine eligibility for benefit coverage.

 

Laboratory procedures are only covered and therefore payable if rendered by an appropriately licensed or certified laboratory. Therefore, any claim that does not contain the CLIA ID will be considered incomplete and rejected beginning May 1, 2020.

 

If you have additional questions, please call the telephone number on the back of the member’s identification card.

Open the attached document titled “GA medical policy and clinical guideline updates 2.1.2020” to view the new and/or revised Medical Policies and Clinical Guidelines adopted by the Medical Policy and Technology Assessment Committee. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be either not medically necessary or investigational/not medically necessary. Clinical Guidelines adopted by Anthem and all the Medical Policies are available at anthem.com/provider under “see policies and guidelines”. Please note that our medical policies now include NOC (Not Otherwise Classified) codes to expedite the process of determining services that may require medical review. If you do not have access to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical UM Guideline by calling Provider Services at (800) 241-7475 Monday through Friday from 8:00 a.m. to 7:00 p.m. or send written requests (specifying the medical policy or guideline of interest, your name and address to where the information should be sent) to:

 

Anthem Blue Cross and Blue Shield

Attention: Prior Approval, Mail Code GAG009-0002

3350 Peachtree Road NE

Atlanta, GA 30326

 

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

 

See attach PDF titled “GA medical policy and clinical guideline updates 2.1.2020”

Open the attached document titled “GA preapproval list change notification 2.1.2020” to view the new and/or revised Medical Policies and Clinical Guidelines adopted by the Medical Policy and Technology Assessment Committee.

 

See attach PDF titled “GA preapproval list change notification 2.1.2020” 

Effective for dates of service on and after May 17, 2020, the following updates will apply to the AIM Musculoskeletal Program: Joint Surgery and Spine Surgery Clinical Appropriateness Guidelines.

 

Joint Surgery Updates by section: 
Shoulder Arthroplasty

• Added steroid injection for all joints exclusion based on panel recommendation
• Added exclusions for use of xenografts or biologic scaffold for augmentation or bridging reconstruction, use of platelet rich plasma or other biologics and concomitant subacromial decompression
• Removed indication for subacromial impingement with rotator cuff tear  

Hip arthroplasty

• Added exclusion for steroid injection for joint being replaced within the past 6 weeks
• Added labral tear indication

Knee Arthroscopy and Open Procedures

• Added chondroplasty indication
• Narrowed use of lateral release to lateral compression as a cause for anterior knee pain or chondromalacia patella
• Added a conservative management and advanced osteoarthritis exclusion to patellar compression syndrome section

Code changes

• Added CPT codes 27425, 27570

 

Spine Surgery Updates by section: 
No criteria changes
Code changes only

• Added CPT codes 0200T, 0201T

As a reminder, ordering and servicing providers may submit prior approval requests to AIM in one of several ways: 

• Access AIM’s ProviderPortal_SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com.
• Call the AIM Contact Center toll-free number: 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

 

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after May 17, 2020, the following updates will apply to the AIM Advanced Imaging:  Vascular Imaging Clinical Appropriateness Guidelines.

 

Updates by section: 
Aneurysm of the abdominal aorta or iliac arteries

• Added new indication for asymptomatic enlargement by imaging
• Clarified surveillance intervals for stable aneurysms as follows:
  • Treated with endografts, annually
  • Treated with open surgical repair, every 5 years

Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified

• Added surveillance indication and interval for surgical bypass grafts

As a reminder, ordering and servicing providers may submit prior approval requests to AIM in one of several ways:

• Access AIM’s ProviderPortal_SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com.
• Call the AIM Contact Center toll-free number: 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

 

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Medicare Advantage

 

CMS requires that all hospitals and critical access hospitals (CAHs) provide written notification and an oral explanation to individuals receiving observation services as outpatients for more than 24 hours.

 

Hospitals should use the OMB-approved standardized Medicare Outpatient Observation Notice (MOON), form CMS-10611. All hospitals and CAHs are still required to provide this statutorily required notification. The notice and accompanying instructions are available online.

 

The MOON was developed to inform all Medicare beneficiaries, including Anthem Blue Cross and Blue Shield members, when they are an outpatient receiving observation services, and are not an inpatient of the hospital or CAH. The notice must include the reasons the individual is an outpatient receiving observation services and the implications of receiving outpatient services, such as required Medicare cost-sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility services.

 

Hospitals and CAHs must deliver the notice no later than 36 hours after observation services are initiated or sooner if the individual is transferred, discharged or admitted.

Medicare Advantage

 

Modifier 62: Co-Surgeons

(Effective 05/01/2020)

 

Effective May 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) has updated the Modifier 62: Co‑Surgeons reimbursement policy to expand the current policy’s language, adding that Anthem does not consider surgeons performing different procedures during the same surgical session as co-surgeons, and Modifier 62 is not required.

 

Assistant surgeon and/or multiple procedures rules and fee reductions apply if a co-surgeon acts as an assistant in performing additional procedure(s) during the same surgical session.

 

Please note that assistant surgeon rules do not apply to procedures appropriately billed with Modifier 62.

 

Please visit anthem.com/medicareprovider to view the Modifier 62: Co-Surgeons reimbursement policy for additional information regarding percentages and reimbursement criteria.

 

Medicare Advantage

 

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

• 2020 Medicare risk adjustment provider trainings
• Reimbursement Policy Update Multiple and Bilateral Surgery: Professional and Facility Reimbursement