 Provider News GeorgiaFebruary 2022 Anthem Provider News - GeorgiaThe Consumer Assessment of Healthcare Providers and Systems (CAHPS) is an annual standardized survey conducted starting February 2022 through May2022 to assess consumers’ experience with their provider and health plan. A random sample of your adult or child patients may get the survey. Over half of the questions used for scoring are directly impacted by providers. These questions are:
- When you needed care right way, how often did you get care as soon as you needed?
- How often did you get an appointment for a check-up or routine care as soon as you needed?
- How often was it easy to get the care, tests, or treatment you needed?
- How often did you get an appointment to see a specialist as soon as you needed?
- How often did your personal doctor seem informed and up-to-date about the care you got from other doctors or other health providers?
- How would you rate your personal doctor?
- How would you rate the specialist you see most often?
- How would you rate all your health care in the last 6 months?
Interested in how you can improve CAHPS performance? Anthem offers an online course for providers and office staff designed to learn how to improve communication skills, build patient trust and commitment, and expand your knowledge of the CAHPS survey. The Improving the Patient Experience course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. It can be accessed at mydiversepatients.com/le-ptexp.html.
  National Wear Red Day is a great way to keep heart aware. It is also a great opportunity to have a conversation with your patients about their heart health. The Centers for Disease Control and Prevention (CDC) has information you can share with your patients, including a helpful Know the Facts about Heart Disease flyer that’s free for health care professionals.
Controlling high blood pressure, diabetes, extra weight, and unhealthy diets are heart disease contributors that you can help your patients recognize. For information about these heart disease risks to share with your patients, use the CDC website for toolkits, flyers, and give-a-ways.
Measure Up: Controlling High Blood Pressure (CBP)
Known as the “silent killer,” high blood pressure or hypertension increases the risk of heart disease.
The HEDIS® measure CBP looks at the percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (140/90) in the measurement year. Record all blood pressure readings and the dates they were taken being sure to record the exact reading. Blood pressure readings captured during telehealth, virtual care, telephone, or e-visit should also be recorded.
Measure Up: Statin Therapy for Patients with Cardiovascular Disease and Diabetes (SPC/SPD)
Statins are effective at lowering cholesterol and protecting against heart attack and stroke. Patients with diabetes also have elevated cardiovascular risk.
- Statin therapy for patients with cardiovascular disease (STC). HEDIS measure assesses males 21-75 years of age and females 40-75 years of age who have clinical atherosclerotic cardiovascular disease and who received and adhered to statin therapy.
- Statin therapy for patients with diabetes (STD) assesses adults 40-75 years of age who have diabetes and who do not have clinical ASCVD, who received and adhered to statin therapy.
Adherence to prescribed medication is key to patient care and SPC/SPD measure success.
ATTACHMENTS (available on web): Image 1535.jpg (jpg - 0.06mb) Filing claim payment disputes for our commercial members is now available on Availity.com. When you have additional information to share about a claim that has been denied, filing the dispute electronically is a cost-effective and time-saving alternative to paper and fax. This application enhancement enables a fast, efficient, and streamlined process for filing claim disputes:
- Supporting documentation can be digitally upload
- Dispute inquiries are digitally available on your dashboard
- Retrieve correspondence related to your dispute digitally through your dashboard
- A digital history for electronically filed disputes is conveniently located in one place on your dashboard
Two-step claim payment dispute process
There are two steps to the claim payment dispute process, and both can be accomplished in one place -through Availity.com:
- Claim payment reconsideration: This is your initial request; asking us to investigate the outcome of a claim. Most issues are resolved during reconsideration, which we try to resolve within 30 days. In those instances when additional documentation is needed, the determination may go beyond 30 days. If this occurs, we will notify you. Access notifications about delays and determinations conveniently from your dashboard.
- Claim payment appeal: If you disagree with the outcome from the reconsideration determination, you may request an additional review. When submitting a claim payment appeal, include the additional information needed to help us understand why the claim requires additional review. If a claim payment appeal requires clinical expertise, it will be reviewed by the appropriate Anthem clinical professionals. We make every effort to resolve the claim payment appeals within 60 days. If additional information is required to make a determination, notification will be available on your dashboard.
Receive determination electronically
Anthem will review the claim payment dispute and communicate an outcome on Availity.com. Check the status of a claim payment dispute at any time from your dashboard.
Attend a Training Webinar
For step-by-step instructions about how to submit a claim payment dispute through Availity, attend one of these convenient live webinars:
- Tuesday, February 1, 2022 at 2:00 p.m.
- Thursday, February 3, 2022 at 1:00 p.m.
- Tuesday, February 15, 2022 at 1:00 p.m.
- Thursday, February 17, 2022 at 2:00 p.m.
Register for training by logging onto Availity.com, select Help & Training, Get Trained and pick the session most convenient for you. Self-guided training is also available through Get Trained.
The Consolidated Appropriations Act (CAA) effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. We are asking you to review your online provider directory information to help ensure Anthem Blue Cross and Blue Shield (Anthem) members can locate the most current information for in-network providers and facilities.
You can help us ensure your online provider directory information is current by:
- Reviewing your online provider directory information on a regular basis to ensure it is correct. You can check your directory listing on Anthem’s Find Care Consumers, members, brokers, and providers use the Find Care tool to identify in-network physicians and other healthcare providers supporting member health plans. To ensure we have your most current and accurate information, please take a moment to access Find Care. Go to anthem.com/provider, then under Provider Overview, choose Find Care.
- Submitting updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:
- add/change an address location
- name change
- tax ID changes
- provider leaving a group or a single location
- phone/fax number changes
- closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
1538-0222-PN-GA In the December 2021 edition of Provider News, we announced an update to the Virtual Visits (professional and facility) reimbursement policy to add the following:
- Place of service 10 (telehealth provided in patient’s home)
- Place of service 02 (telehealth provided other than in patient’s home)
To clarify, services reported by a professional provider with a place of service 02 or 10 will be eligible for office place of service reimbursement.
For more information about these policies, visit the Reimbursement Policy page on our anthem.com/provider website.
The Cancer Care Navigator (CCN) program is a comprehensive cancer support solution for oncologists and Anthem Blue Cross and Blue Shield (Anthem) members who are at high risk for complications during treatment. This program is aimed at helping to simplify the complexities of cancer care for members.
Providers are given a single point of contact to connect the practice to the right people at Anthem to help lessen administrative burdens. CCN also gives the practice access to Anthem’s advanced predictive analytics to help identify patients at high risk for complications, in turn allowing providers the opportunity to take preventive action and guide targeted interventions.
Patients are provided with a wealth of support through supplemental services (dietitians, pharmacists, etc.), medication adherence assistance, individualized care plans, and goal setting, as well as after-hours telephonic and digital support.
CCN is the ultimate support service to improve the care experience and quality of life to allow patients time to focus on overall health and well-being. Please feel free to reach out to the CCN team at 1-833-649-0669.
Visit the Drug Lists page on anthem.com for more information on:
- Copayment/coinsurance requirements and their applicable drug classes
- Drug lists and changes
- Prior authorization criteria
- Procedures for generic substitution
- Therapeutic interchange
- Step therapy or other management methods subject to prescribing decisions
- Any other requirements, restrictions, or limitations that apply to using certain drugs
The commercial drug list is posted to the website quarterly on the first day of the month in January, April, July, and October.
FEP Pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.
Effective for dates of service on and after May 1, 2022, the following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
Access the clinical criteria document information.
Anthem’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Anthem’s medical specialty drug review team. Drugs used for the treatment of Oncology will be managed by AIM Specialty Health® (AIM), a separate company
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ING-CC-0001
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Erythropoiesis Stimulating Agents
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ING-CC-0042
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Monoclonal Antibodies to Interleukin-17
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ING-CC-0043
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Monoclonal Antibodies to Interleukin-5
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ING-CC-0049
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Radicava (edaravone)
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ING-CC-0050
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Monoclonal Antibodies to Interleukin-23
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ING-CC-0063
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Stelara (ustekinumab)
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ING-CC-0064
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Interleukin-1 Inhibitors
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ING-CC-0065
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Agents for Hemophilia A and von Willebrand Disease
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ING-CC-0066
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Monoclonal Antibodies to Interleukin-6
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ING-CC-0068
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Growth Hormone
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ING-CC-0071
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Entyvio (vedolizumab)
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ING-CC-0148
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Agents for Hemophilia B
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ING-CC-0149
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Select Clotting Agents for Bleeding Disorders
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ING-CC-0168
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Tecartus (brexucabtagene autoleucel)
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ING-CC-0195
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Abecma (idecabtagene vicleucel)
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Material adverse change (MAC)
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after May 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
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Clinical Criteria
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Drug
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HCPCS or CPT Code(s)
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*ING-CC-0204
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Tivdak
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J3490, J3590, J9999
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ING-CC-0072
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Byooviz
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J3590
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ING-CC-0068
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Skytrofa
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J3490
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* Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after May 1, 2022, the following specialty pharmacy codes from current clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Access our Clinical Criteria to view the complete information for these step therapy updates.
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Clinical Criteria
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Status
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Drug
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HCPCS or CPT Code(s)
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ING-CC-0072
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Non-Preferred
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Byooviz
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J3590
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Quantity limit updates
Effective for dates of service on and after May 1, 2022, the following specialty pharmacy codes from current clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
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Clinical Criteria
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Drug
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HCPCS or CPT Code(s)
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ING-CC-0072
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Byooviz
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J3590
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Medicare Advantage
Effective November 1, 2021, EnrollSafe* at enrollsafe.payeehub.org replaced
Enrollhub® from the Council for Affordable Quality Healthcare, Inc. (CAQH) as the electronic funds transfer (EFT) enrollment website at no cost to Anthem Blue Cross and Blue Shield providers.
EnrollSafe is safe, secure, and available 24-hours a day
Log onto the EnrollSafe enrollment hub at enrollsafe.payeehub.org to enroll in EFT. You will be directed through the EnrollSafe secure website to the Registration page, where you will provide the required information to create an account and then Enroll to supply your banking information.
Already enrolled in EFT through CAQH Enrollhub?
If you were previously enrolled in EFT through CAQH Enrollhub, no action is needed unless you are making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, use enrollsafe.payeehub.org to update your account.
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