January 2019 Anthem Provider Newsletter - Georgia

Contents

AdministrativeCommercialJanuary 1, 2019

BCBSGa is now Anthem

AdministrativeCommercialJanuary 1, 2019

HEDIS® 2019 starts early February

AdministrativeCommercialJanuary 1, 2019

Provider itemized bill submission criteria

Policy UpdatesCommercialJanuary 1, 2019

Notification of preapproval list changes (January 2019)

Policy UpdatesCommercialJanuary 1, 2019

New Autism codes effective January 1, 2019

Medical Policy & Clinical GuidelinesCommercialJanuary 1, 2019

Anthem Blue Cross and Blue Shield Georgia Medical Policy and Clinical Guideline Updates 1/1/2019

Medical Policy & Clinical GuidelinesCommercialJanuary 1, 2019

Medical policy and clinical guideline updates

PharmacyCommercialJanuary 1, 2019

Pharmacy information available on the web

PharmacyCommercialJanuary 1, 2019

Update regarding drugs not approved by the FDA

PharmacyCommercialJanuary 1, 2019

Simplifying medication prior authorization processes

State & FederalJanuary 1, 2019

Keep up with Medicare news

State & FederalMedicare AdvantageJanuary 1, 2019

Medicare Advantage member Explanation of Benefits redesigned

State & FederalMedicare AdvantageJanuary 1, 2019

Anthem offers risk adjustment and documentation training

AdministrativeCommercialJanuary 1, 2019

BCBSGa is now Anthem

As previously communicated, effective January 1, 2019, Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. (collectively “BCBSGa”) has changed to Anthem Blue Cross and Blue Shield (Anthem), a trusted name that symbolizes quality for millions of consumers across the country.

 

While our trade name and logo have changed, almost everything else will stay the same. The trade name and logo change will be a seamless transition for our providers and hospitals as there will be no change to benefits or provider networks. You will continue to use the same provider IDs, contacts and claims filing processes you’re familiar with. Our members will continue to use the same doctors and hospitals and have access to the same programs and services.

 

Starting today, you’ll find us on the web at anthem.com. We’ve given more than 80 years of dedicated service to our Georgia members. That’s not going to change. In 2019, we’ll carry on that same proud legacy ─ except we’ll do it as Anthem Blue Cross and Blue Shield.

AdministrativeCommercialJanuary 1, 2019

Clinical Practice and Preventive Health guidelines available on the web

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 Health & Wellness page of our provider website.

AdministrativeCommercialJanuary 1, 2019

Use the Provider Maintenance Form to update your practice information

We continually update our provider directories to help ensure that your current practice information is available to our members. At least 30 days prior to making any changes to your practice – updating address and/or phone number, adding or deleting a physician from your practice, etc. – please notify us by completing the Anthem Provider Maintenance Form located on the Provider Forms page of our provider website, Anthem.com. Thank you for your help and continued efforts to keep our records up to date.

AdministrativeCommercialJanuary 1, 2019

HEDIS® 2019 starts early February

We will begin requesting medical records in February via a phone call to your office followed by a fax.

 

The fax will contain 1) a cover letter with contact information your office can use to contact us if there are any questions; 2) a member list, which includes the member and HEDIS measure(s) the member was selected for; and 3) an instruction sheet listing the details for each HEDIS measure. As a reminder, under HIPAA, releasing PHI for HEDIS data collection is permitted and does not require patient consent or authorization.  HEDIS and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities [45 CFR 164.506(c) (4)]. For more information, visit hhs.gov/ocr/privacy.

 

HEDIS review is time sensitive, so please submit the requested medical records within five business days

 

To return the medical record documentation back to us in the recommended 5-day turnaround time, simply choose one of these options:

 

  1. Upload to our secure portal. This is quick and easy. Logon to submitrecords.com, enter the password included with your HEDIS Member List and select the files to be uploaded. Once uploaded you will receive a confirmation number to retain for your records.


OR

 

  1. Send a secure fax to 888-251-2985


OR

 

  1. Mail to us via the US Postal Service to:

Anthem, Inc.

66 E. Wadsworth Park Drive

Suite 110H

Draper, UT  84020

 

Please contact your Provider Network Representative to let them know if you have a specific person in your organization that we should contact for HEDIS medical records.

 

Thank you in advance for your support of HEDIS.



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

AdministrativeCommercialJanuary 1, 2019

Provider itemized bill submission criteria

View the attached PDF titled “Provider itemized bill submission criteria” for detailed directions on how to correctly submit an 837 claim submission.

AdministrativeCommercialJanuary 1, 2019

HCPCS code A0998 Ambulance response and treatment with no transport is active and available for use

In early 2018, Anthem became one of the first major insurers to reimburse EMS providers for appropriate and medically necessary care billed under HCPCS code A0998 (Ambulance response and treatment, no transport). The code, which has been active since January 2018 for most standard Anthem benefit plans, allows EMS providers to receive reimbursement for treatment rendered in response to an emergency call to a member’s home or scene, when transportation to the hospital emergency room (ER) was not provided. Previously, Anthem reimbursed EMS providers for treatment rendered only when a patient was transported to the ER.

 

Important reminders:

  • The code is currently active and available for EMS use.
    • If an EMS provider responds to an emergency call and provides appropriate treatment at-home or on-site without transporting to the ER, code A0998 can be used.
  • The EMS provider must render treatment to the patient per EMS protocols which are approved by the medical director at the local or state level.
    • Billing of A0998 when treatment is not rendered is not appropriate.
  • Anthem will apply medical necessity review to A0998 using coverage guideline CG-ANC-06.
  • HCPCS code A0998 applies to all of Anthem’s commercial health plans, and reimbursement will be made in accordance with the member’s benefits.

 

Questions?
For contract questions, please reach out to your contract representative. For questions about using code A0998, please reach out to Jay Moore, Senior Clinical Director for Anthem, Inc.

Policy UpdatesCommercialJanuary 1, 2019

Notification of preapproval list changes (January 2019)

Preapproval changes are listed in the attached PDF. For additional information, you can access the complete Georgia Standard Preapproval List, Georgia Standard Preapproval CODE List and Georgia Standard Adopted Clinical Guideline List using the following links:

 

See attached PDF titled “GA Preapproval List Change Notification 1.1.2019”.

Policy UpdatesCommercialJanuary 1, 2019

New Autism codes effective January 1, 2019

Effective January 1, 2019, the American Medical Association will be replacing the temporary CPT codes used by ABA (Applied Behavior Analyst) treatment services with new permanent CPT codes.  

 

As with all annual CPT coding changes, Anthem will make the necessary updates to all claims and operational systems by the effective date.

Medical Policy & Clinical GuidelinesCommercialJanuary 1, 2019

Anthem Blue Cross and Blue Shield Georgia Medical Policy and Clinical Guideline Updates 1/1/2019

The Medical Policy and Technology Assessment Committee adopted the attached (see PDF) new and/or revised Medical Policies and Clinical Guidelines. 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 Blue Cross and Blue Shield and all the Medical Policies are available at the Anthem Blue Cross and Blue Shield website (Choose Providers > Medical Policies). Please note our medical policies now include NOC (Not Otherwise Classified) codes to expedite the process of determining services that may require medical review. If you don’t 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–Friday from 8:00 a.m. to 7:00 p.m. or send written requests (specifying medical policy or guideline of interest, your name and address to where 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 attached PDF titled “GA Medical Policy and Clinical Guideline Updates 1/1/2019”.

 

Medical Policy & Clinical GuidelinesCommercialJanuary 1, 2019

Medical policy and clinical guideline updates

The Medical Policy and Technology Assessment Committee adopted the following new and/or revised Medical Policies and Clinical Guidelines. 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.   

Reimbursement PoliciesCommercialJanuary 1, 2019

Benefits to be available for chronic care management and advance care planning services effective February 23, 2019

Anthem is committed to investing in primary care, rewarding coordinated, patient-centered care, and promoting proactive chronic care management. In recognition of the time-intensive nature of this work, Anthem will reimburse chronic care management and advance care planning services for Commercial health plans effective for claims processed on or after February 23, 2019.

 

Chronic care management (CCM) is care rendered by a physician or non‐physician health care provider and their clinical staff, once per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Only one practitioner can bill a CCM service per service period (month). Three CCM codes are included in this payment policy change:  99490, 99487and 99489.

 

Advance care planning (ACP) is a face-to-face service between a physician or other qualified health care professional and a patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document in which a patient appoints an agent and/or records the wishes of a patient pertaining to their medical treatment at a future time if they cannot decide for themselves at that time.  No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary. Two ACP codes are included in the payment policy change: 99497 and 99498

 

Anthem requires patient consent prior to CCM or ACP service(s) being provided. Please refer to the current Claims Requiring Additional Documentation policy for more information. 

 

For more information, review our Bundled Services and Supplies policy dated February 23, 2019 by visiting the Reimbursement Policies page at anthem.com/provider website. 

 

PharmacyCommercialJanuary 1, 2019

Pharmacy information available on the web

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, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit Anthem.com/provider and select “Pharmacy Information”. The commercial drug list is reviewed and updates are posted to the web site quarterly (the first of the month for January, April, July and October). To locate “Marketplace Select Formulary” and pharmacy information, go to Customer Support, select your state, Download Forms and choose “Select Drug List.”  Click the following links for the Federal Employee Program formulary Basic Option and Standard Options. These drug lists are also reviewed and updated regularly as needed.

PharmacyCommercialJanuary 1, 2019

Update regarding drugs not approved by the FDA

Anthem continually monitors and updates the list of drugs not approved by the Food and Drug Administration (FDA), which are considered non-covered under prescription drug benefits. When drugs are added to this list, Anthem notifies impacted members that the drug is not FDA approved and will no longer be covered.

Effective December 1, 2018, these drugs were added to our list of drugs not approved by the FDA.

For new members just beginning an Anthem plan or not yet having used one of these non-FDA-approved drugs, coverage for these drugs ended December 1, 2018.

Existing members who had been identified as already using at least one of the drugs added to the list received a letter to let them know their drug(s) will no longer be covered after December 31, 2018. However, if the patient had a prior authorization for a drug on this list, coverage for that drug continued until the prior authorization expired on December 31, 2018.

PharmacyCommercialJanuary 1, 2019

Simplifying medication prior authorization processes

Anthem is committed to offering efficient and streamlined solutions for submitting prior authorizations (PAs).  This helps reduce the administrative burden while improving the member experience for their patients.

 

Anthem’s Proactive PA process approves select drugs in real time, using an automated prior authorization (PA) process. Proactive PA uses integrated medical and pharmacy data to seamlessly approve medication prior authorization requests where diagnoses are required. Anthem’s prior authorization process helps to ensure clinically appropriate use of medications.

Providers can take advantage of the electronic prior authorization (ePA) submission process by logging in at covermymeds.com. Creating an account is FREE, and many prior authorizations are approved in real time. Read more about the ePA submission process in the previously published article titled “BCBSGa accepts electronic prior authorization requests for prescription medications online.”

Additionally, providers may be able to access real-time, patient-specific prescription drug benefits information through their electronic medical record (EMR) system. To learn more about this feature, review the article titled “Access patient-specific drug benefit information through EMR” that was published in the October 2018 edition of our provider newsletter.

State & FederalJanuary 1, 2019

Keep up with Medicare news

State & FederalMedicare AdvantageJanuary 1, 2019

Medicare Advantage member Explanation of Benefits redesigned

Anthem recently introduced a redesigned monthly Explanation of Benefits (EOB) to Medicare Advantage members.

The new EOB includes:

  • Personalized tips to help members save on health care expenses.
  • A preventive care checklist — to point out opportunities for screenings or other care.
  • Alerts when a claim needs immediate attention.

 

If you or your members have any questions about how to read the new EOB, please call the number on the back of the member ID card.

State & FederalMedicare AdvantageJanuary 1, 2019

Anthem offers risk adjustment and documentation training

Anthem will offer general and condition-specific Medicare risk adjustment, documentation and coding training in 2019. Additional information will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider.