Beginning March 1, 2021, the personalized match sorting option will be available for searches by procedure type. This sorting option is based on algorithms which will use a combination of member and provider features to intelligently sort and display results for a member’s search. The sorting results will take into account member factors such as the member’s medical conditions and demographics. Provider factors such as surgeon-facility pairing (an individual provider who performs a procedure at a specific facility), cost efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures.

These member and provider features will be combined to generate a unique ranking of surgeon-facility pairings or facility providers for each member conducting the procedure search. Surgeon-facility pairings with the highest overall ranking within the search radius will be displayed first with other pairings displayed in descending order based on overall rank and proximity to the center of the search radius.

The personalized match methodology for specialty-based searches remains unchanged. Members continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology has no impact on member benefits.

• Providers may review a copy of the new sorting methodology which has been posted on Availity, our secure web-based provider tool, using the following navigation:  Go to Availity > Payer Spaces > Anthem > Education & Reference Center > Administrative Support > Personalized Provider Procedure Search Methodology.pdf.
• If you have general questions about the Find Care tool or this new sorting option, please contact Provider Customer Service.
• If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors, you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.

Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions. 

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• Do you need to update a case that was submitted by phone or fax? Now you can add clinical notes and make other updates to these authorization requests through ICR. To make the update you need to have the Authorization & Referral Request role assigned to you by your Availity Administrator.
  • To locate the case, log on to the Availity Portal and select Patient Registration | Authorizations & Referrals, then choose Auth/Referral Inquiry.
  • Search for the case in ICR by Member, Reference/Authorization Request Number, or by Date Range.
  • From the ICR Case Overview screen select Update Case to update service codes, provider information or clinical notes. If you only need to make changes or add to your notes, select Update Clinical. Select Submit Update to complete the request.
• We’ve removed the guesswork from the notes that are recommended for many standard authorization requests. ICR provides a check list of the supporting clinical information that will assist Anthem with completing the review. The list is located on the Clinical Details You can upload notes, images and photos directly through ICR. You can include the documentation immediately or you can submit your request then return to the case in ICR later and select Update Clinical to add the missing information.
• Check the status of a submitted case at a glance. The ICR UM tracker, located on the Case Overview screen provides a quick view of where the case is in the review process. You can view when Anthem received the request, when the clinical review is underway and completed and the final decision.

Additionally, we’ve added a new application to Payer Spaces – Chat with Payer that you can use to check the status of a submitted authorization request. This is a great option if you don’t have the role assignments required to access ICR and research a case. 

To access the Chat with Payer application from Availity’s home page, select Payer Spaces | Chat with Payer.  Complete the form with the required information. You need to include the patient name, birth date and health plan member ID number. Choose Authorization Status as your topic for chat to conduct a live chat with a representative.  

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Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a standardized survey conducted between February and May each year to assess consumers’ experience with their provider and health plan.  A random sample of your adult and child patients may receive the survey.  Over half of the questions used for scoring are directly impacted by providers. The survey questions are:

• When you needed care right way, how often did you get it?
• 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 health providers?
• How would you rate your personal doctor?
• How would you rate the specialist you see most often?

To learn more about how you can improve the patient experience review What Matters Most: Improving the Patient Experience, an online course for providers and office staff. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. The What Matters Most training can be accessed at patientexptraining.com.

Your efforts to create an exceptional care experience for your patients will help to strengthen their healthcare journey.   

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• 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 edits (NCCI) and medically unlikely edits (MUEs)
• 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)
• apply to any provider, provider group (tax identification number) and/or across providers and claim type (professional/facility) for the same member

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In this 60-minute webinar, you will learn how to use Availity's Attachment tools to submit and track supporting documentation electronically to Anthem and affiliate payers.

We will explore new key workflow options to fit your organization’s needs, including how to:

• Work a request in the inbox of your Attachments Dashboard.
• Enter and submit a web claim including supporting documentation.
• Use EDI batch options to trigger a request in your inbox.
• Track attachments you submitted using sent and history lists in your Attachments Dashboard.
• Get set up to use these tools.

As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.

Register for an upcoming webinar session:

 In the Availity Portal, select Help & Training > Get Trained.

1. The Availity Learning Center opens in a new browser tab.
2. Search for and enroll in a session using one of these options:
   • In the Catalog, search by webinar title or keyword.
     • To find this specific live session quickly, use keyword medattach.
   • Select the Sessions tab to scroll the live session calendar.
3. After you enroll, you’ll receive emails with instructions to join the session.

Webinar Dates and Times (PST):

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LabCorp is one of many labs participating in Anthem’s PPO network. For a complete list of PPO labs, see the “Find a Doctor” on-line tool at anthem.com. As a reminder, physicians are required to refer to in-network laboratories.

Laboratory specimens can be collected in the office with LabCorp courier pick-up available throughout Georgia. Members may also bring a LabCorp requisition form (completed by their physician) to any of the 100 LabCorp patient service center locations throughout Georgia. For more on LabCorp’s patient service center locations, visit anthem.com.

If you have questions about LabCorp services, need to set-up a LabCorp account, order supplies, or schedule a pick-up, please call LabCorp at 800-762-0890.

If you have questions about Anthem’s provider network or coverage for your patients, please contact the Provider Customer Care line at 800-241-7475 or contact your local network consultant.

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• File claims
• Check statuses
• Verify eligibility and benefits
• Submit prior authorizations

The Provider Digital Engagement Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits - all in one comprehensive resource. Find it on Anthem.com/provider>Forms & Guides>Category>Digital Tools.

Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit Anthem.com and use the Log In button for access to our secure provider portal, or via the Availity EDI website.

Accept digital member ID cards

• Save time by accepting the digital member ID card when presented by the member via their App or email.

Register for EFT to get funds faster

• Electronic Funds Transfer (EFT) eliminate the need for paper checks. Safe, secure and faster, payments are deposited directly to your bank account. Register here.

Eliminate paper remittances

• Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.

We appreciate your health care team going digital with Anthem as of January 1, 2021, enabling us to realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.

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Anthem Blue Cross and Blue Shield wants to make your job easier — and that includes real-time feedback to claim denials. Through predictive analytics, we now have insight into the reasons for claim denial. We have taken that information and streamlined the inquiries by reason codes. It is available to you digitally, through our secure provider portal.

Now, within minutes, you will know why a claim denied. We will also provide the steps needed so you can take action faster to correct the claim. There is less wait time and faster payment. 

There is no need to call for updates or experience unnecessary delays waiting for the explanation of benefit.

With little more than a click:

• Review a complete list of claims, including claims with proactive insights
• Learn the reasons for claim denial
• Access the information you need to move the claim forward

Predictive analytics and self-service claim denial information is just another way Anthem is using digital technology to improve your healthcare experience.

From Anthem.com, use the log In button to access our secure provider portal on Availity.com. Go to Payer Spaces to access Claims Status Listing.

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AIM Specialty Health, a separate company, is a nationally recognized leader delivering specialty benefits management on behalf of Anthem for certain health plan members. Determine if preapproval is needed for a Georgia Anthem member by visiting the “Medical Policy and Clinical UM Guidelines” page on our provider website or by calling the preapproval phone number printed on the back of the member’s ID card. To submit your request for any of the services below, contact AIM online via AIM’s ProviderPortal at aimspecialtyhealth.com/goweb. From the drop-down menu, select GA. You may also call AIM toll-free at 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET

AIM provides benefits management for the programs listed below:

• Imaging Level of Care
• Genetic Testing
• Diagnostic Imaging Management
• Cardiovascular Services
• Radiation Therapy Services
• Outpatient Sleep Testing and Therapy Services
• Cancer Care Quality Program
• Musculoskeletal (for Fully Insured)
• Upper Gastrointestinal Endoscopy

For more details on these programs, please visit the AIM Specialty Health® site at aimspecialtyhealth.com/marketing/guidelines/185/index.html. By clicking on the previous links, you will be directed to sites created and/or maintained by another, separate entity (“External Site”). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Sites. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Sites. The information contained on the External Sites should not be interpreted as medical advice or treatment provided by us.

Eligibility and benefits

Eligibility and benefits can be verified by through anthem.com/provider or by calling the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits. Except in the case of an emergency, failure to obtain preapproval prior to rendering the designated services listed below will result in denial of reimbursement.

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• Medicare Advantage Group Retiree Quick Reference Guide and FAQ
• SNF admission reporting requirements for D-SNP plans
• Policy Update — Nurse Practitioner and Physician Assistant Services, Professional
• Updates to AIM Clinical Appropriateness Guidelines for Radiation Oncology
• Medicare Advantage Group Retiree Member Eligibility, Alpha Prefix FAQ

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The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

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Evaluation of patients with cardiac arrhythmias:

• Updated repeat transthoracic echocardiography (TTE) criteria.
• Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia.

Evaluation of signs, symptoms or abnormal testing:

• Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature.

Diagnostic coronary angiography:

• Updated criteria to evaluate patients with suspected congenital coronary artery anomalies.

• 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* Portal at availity.com.
  • Call the AIM Contact Center toll free at 800-714-0040 from 8:00 a.m. to 8:00 p.m. EST

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.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield (Anthem). Availity, LLC is an independent company providing administrative support services on behalf of Anthem.
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Chest imaging, and head and neck imaging

Hoarseness, dysphonia and vocal cord weakness/paralysis — primary voice complaint:

• Required laryngoscopy for the initial evaluation of all patients with primary voice complaint

Brain imaging, and head and neck imaging

Hearing loss:

• Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is non-diagnostic or unable to be performed
• Higher allowed threshold for consecutive frequencies to establish sensorineural hearing loss
• Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance

Tinnitus:

• Removed sudden onset symmetric tinnitus as an indication for advanced imaging

Head and neck imaging

Sinusitis/rhinosinusitis:

• Added more flexibility for the method of conservative treatment in chronic sinusitis
• Required conservative management prior to repeat imaging for patients with prior sinus CT

Temporomandibular joint dysfunction:

• Removed requirement for radiographs/ultrasound

Cerebrospinal fluid (CSF) leak of the skull base:

• Added scenario for management of known leak with change in clinical condition

Brain imaging

Ataxia, congenital or hereditary:

• Combined with congenital cerebral anomalies to create one section

Acoustic neuroma:

• More frequent imaging for a watch and wait or incomplete resection
• New indication for neurofibromatosis type 2 (NF 2)Neurofibromatosis type 2
• More frequent imaging when MRI shows findings suspicious for recurrence
• Single post-operative MRI following gross total resection
• Included pediatrics with known acoustics (rare but NF 2)

Tumor — not otherwise specified:

• Repurposed for surveillance imaging of low grade neoplasms

Seizure disorder and epilepsy:

• Limited imaging for the management of established generalized epilepsy
• Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy

Headache:

• Removed response to treatment as a primary headache red flag
• Include pregnancy as a red flag risk factor

Mental status change and encephalopathy:

• Added requirement for initial clinical and lab evaluation to assess for a more specific cause

Oncologic imaging

General enhancements — Updates to Scope/Definitions, general language standardization

General content enhancements — Overall alignment with current National Comprehensive Cancer Network (NCCN) recommendations, resulting in:

• Removal of indications/parameters not addressed by NCCN
• Average risk inclusion criteria for CT colonography
• New allowances for MRI abdomen and/or MRI pelvis by tumor type, liver metastatic disease
• New indications for acute leukemia (CT, PET/CT), multiple myeloma (MRI, PET/CT), ovarian cancer surveillance (CT), bone sarcoma (PET/CT)
• Updated standard imaging prerequisites prior to PET/CT for bladder/renal pelvis/ureter, ectal, esophageal/GE junction, gastric and non-small cell lung cancers
• Additional PET/CT management scenarios for cervical cancer, Hodgkin Lymphoma

Other content enhancements by section

Cancer screening: New indication for pancreatic cancer screening

Breast cancer: New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment breast MRI after breast conserving therapy or unilateral mastectomy

Prostate cancer: MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE

Axumin PET/CT: Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)

As a reminder, ordering and servicing providers may submit prior authorization requests to

• Access the AIM ProviderPortal_SM directly at aimspecialtyhealth.com/providerportal.
  • Online access is available 24/7 to process orders and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity* Portal at availity.com.
• Call the AIM Contact Center toll-free number at 800-714-0040 from 8:00 a.m. to 8:00 p.m. EST

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

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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Medicare risk adjustment and documentation guidance (General):

• Series: Offered the first Wednesday of each month from 1:00 to 2:00 P.M. (ET)*
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity, Medicare risk adjustment and documentation guidance, from
  January 8, 2020 to December 2, 2020, has been reviewed and is acceptable for up to 1.00 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

To learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the following link: https://bit.ly/2TYMgbn

* Note: Dates may be modified due to holiday scheduling

Medicare risk adjustment, documentation and coding guidance (Condition specific)

• Series: Offered the third Wednesday of each month from 1:00 to 2:00 P.M. (ET)
• Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
• Credits: This live series activity, Medicare risk adjustment documentation and coding guidance, from January 15, 2020 to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

For those interested in the following training topics, please register at the link below.

https://bit.ly/2IgxDO9

* Note: Enter the password provided, and the recording will play upon registration.

• Red flag HCCs
• Neoplasms
• Acute, chronic and status conditions
• Diabetes mellitus and other metabolic disorders
• Coinciding conditions in risk adjustment models

Please note that the original training events have been modified due to a transition within WebEx as of August 1, 2020. The date and time of the events have not changed but the program link and invitation detail have been updated. Previously registered participants will need to re-register for a training event using the updated registration link(s) provided in this announcement.

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