AIM Specialty Health®

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 prior authorization 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 prior authorization 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 website 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
• Rehabilitative services
• Outpatient sleep testing and therapy services
• Cancer care quality program
• Musculoskeletal (for fully insured)
• Upper gastrointestinal endoscopy in adults, and site of care for certain surgical services

For more details on these programs, please visit the AIM website. Clicking the previous links will direct you 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

Verify eligibility and benefits on 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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• Regular wellness visits ensure children receive scheduled immunizations that prevent illness. It is also a great opportunity to discuss nutrition and safety in the home.
• Growth and development. Evaluating children for growth and development enables parents to see how much their children have grown since the last visit. It is also an opportunity to share the children’s development, to discuss milestones, social behaviors, and learning.
• Raising concerns. Offering parents an opportunity to share concerns at the start of the visit will help in your evaluation of the patient. They may want to talk about development, sleep and eating habits and behaviors.
• Team approach. Regular visits create strong, trustworthy relationships among physician, parent, and child. The American Academy of Pediatrics (AAP) supports well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental, and social health of a child.

Measure up: Well-Child Visits in the first 30 months of life (W30)

This HEDIS® measure is described as the percentage of members who had to the following number of well-child visits with a PCP during the last 15 months. These rates are reported:

• Well-child visits in the first 15 months: Six or more well-child visits with children who turned age 15 months during the measurement year.
• Well-child visits for ages 15 to 30 months: Two or more well-child visits with children who turned age 30 months during the measurement year.

Tips

• Telehealth visits are acceptable in meeting the measurement requirements.
• Consider scheduling well-child visits in advance of the child reaching the age for the visit.

Coding

• ICD-10:110, Z00.111, Z00.121, Z00.129, Z00.2, Z00.3, Z02.5, Z76.1, Z76.2
• HCPCS: G0438-G0439, S0302
• CPT: 99381-99382, 99391-99392, 99461

1Parent Plus: Importance of routine pediatrician visits. American Academy of Pediatrics. https://publications.aap.org/aapnews/news/12481?autologincheck=redirected

2Catch up on well-child visits and recommended vaccinations. Centers for Disease Control and prevention. cdc.gov/vaccines/parents/visit/vaccination-during-COVID-19.html 

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The Anthem Blue Cross and Blue Shield (Anthem) Blue High Performance Network (BlueHPN^®) is part of a national network of high performance networks created in collaboration with the Blue Cross Blue Shield Association.  

Effective January 1, 2022, Georgia’s BlueHPN includes new service areas in Savannah, Columbus, and Augusta, in addition to the already active Atlanta-Sandy Springs-Roswell metropolitan area network.   

Member ID cards and other plan material feature one small change for 2022: BlueHPN is now a single word rather than two.   

 As was true in 2021, you may see patients accessing the BlueHPN through either a national employer plan, Blue Connection plan, or large or small group employer health savings account (HSA) plans with an Exclusive Provider Organization (EPO) network. Under EPO plans, out-of-network benefits are limited to emergency or urgent care. Members may be required to select a primary care provider (PCP), but PCP referrals are not required for specialty care. 

Provider profiles in our “Find Care” provider directory show updated Blue HPN participation for 2022.

You can verify BlueHPN network participation by contacting your local Anthem network consultant.

Below is a sample ID card for a member from Georgia enrolled in the national employer BlueHPN plan. Note the “Blue High Performance Network” logo and “BlueHPN” indicator in the suitcase icon. 

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Submitting prior authorizations is now easier and multi-payer

We know how much easier it is when you have access to digital apps that streamline your work. Thousands of providers already use the Availity* Authorization app to submit prior authorizations for other payers. Now, we want to make it easier to submit prior authorization requests to Anthem by making the app available in 2022 to our providers as well.

ICR is still available

If you need to refer to an authorization that was submitted through the Interactive Care Reviewer (ICR), you still have access to that information. We have developed a pathway for you to access your ICR dashboard — You simply follow the prompts provided through the Availity Authorization app.

Innovation in progress

While we grow the Availity Authorization app to provide even greater functionality and to expand Anthem-specific prior authorizations, we have provided access to ICR for:

• Appeals
• Behavioral health authorizations
• Federal Employee Program authorizations
• Medical specialty pharmacy authorizations

Notices in the Availity Authorization app will guide you through the process for accessing ICR for these Alternate Authorization/Appeal functions.

Begin submitting digital prior authorizations through the Authorization app in 2022

If you aren’t already familiar with the Availity Authorization app, live training and recorded webinars are available.

You can always log onto availity.com to view the webinars at your convenience. From Help & Training, select Get Trained to access the Availity Learning Center. Select the Session tab to see all upcoming live webinars.

Tip: To find the authorization training faster, use keyword AvAuthRef in the search field.

Now, give it a try
Eliminate the time and costs associated with faxing prior authorizations by using the Availity Authorization app. It’s easy, convenient, and available when you are, 24/7.

Get access by logging onto availity.com. Under the Patient Registration tab, select Authorizations & Referrals. The app is easy to navigate with intuitive functions that walk you through the submission.

Tips: You will need to have the Authorization Role assignment in order to access the app and to submit prior authorizations. Your organization’s Availity administrator can assign the role to you.

If you have any questions, reach out to Availity at 800-282-4548.

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Effective January 1, 2022, IngenioRx/CVS Specialty Pharmacy* will no longer distribute the brand name drug Botox^®. However, Botox will still be available to Anthem Blue Cross and Blue Shield members through other vendors.

Please note:

• This is not a change in member benefits. This is a change in the Botox vendor only.
• If the member is not using IngenioRx/CVS Specialty Pharmacy to obtain Botox, no action is needed.

For Botox managed under a Medicare member’s part B (medical) benefit

Providers should be using buy and bill for any Medicare member who currently receive Botox through their part B (medical) benefit.  If your patient is receiving, Botox using their part B benefit and is receiving their prescription from IngenioRx/CVS Specialty pharmacy, effective January 1, 2022, IngenioRx/CVS Specialty will no longer filled the prescription. As of January 1, 2022, you will need to buy this drug and bill your patient’s health plan.

If you have questions regarding a Medicare member’s part B benefits, call Provider Services using the information on the back of the member’s ID card.

For Botox managed under a Medicare member’s part D (pharmacy) benefit

Effective January 1, 2022, Medicare members who currently receive Botox through IngenioRx/CVS Specialty Pharmacy using their part D (pharmacy) benefit must change to another in-network specialty or retail pharmacy that can obtain and dispense Botox.

If you have questions regarding a Medicare member’s part D benefit, call Pharmacy Member Services using the information on the back of the member’s ID card.

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield. CVS is an independent company providing pharmacy services on behalf of Anthem Blue Cross and Blue Shield.

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Medicare Advantage

The HEDIS^® Electronic Clinical Data Systems (ECDS) reporting methodology encourages the exchange of the information needed to provide high-quality health-care services. 

The ECDS Reporting Standard provides a method to collect, and report structured electronic clinical data for HEDIS quality measurement and improvement. 

Benefits to providers:

• Reduced burden of medical record review for quality reporting
• Improved health outcomes and care quality due to greater insights for more specific patient-centered care

ECDS reporting is part of the National Committee for Quality Assurance’s (NCQA) larger strategy to enable a Digital Quality System and is aligned with the industry’s move to digital measures. 

Learn more about NCQA’s digital quality system and what it means to you and your practice, at the following link: https://www.ncqa.org/hedis/the-future-of-hedis/hedis-electronic-clinical-data-system-ecds-reporting/.

ECDS measures

The first publicly reported measure using the HEDIS ECDS Reporting Standard is the Prenatal Immunization Status (PRS) measure.  In 2022, NCQA will include the PRS measure in Health Plan Ratings for Medicaid and Commercial plans for measurement year 2021.

For HEDIS measurement year 2022, the following measures can be reported using ECDS: 

• Childhood Immunization Status (CIS-E)*
• Immunizations for Adolescents (IMA-E)*
• Breast Cancer Screening (BCS-E)
• Colorectal Cancer Screening (COL-E)
• Follow-Up Care for Children Prescribed ADHD Medication (ADD-E)
• Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)*
• Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)
• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E)
• Depression Remission or Response for Adolescents and Adults (DRR-E)
• Unhealthy Alcohol Use Screening and Follow-Up (ASF-E)
• Adult Immunization Status (AIS-E)
• Prenatal Immunization Status (PRS-E) (Accreditation measure for 2021)
• Prenatal Depression Screening and Follow-Up (PND-E)
• Postpartum Depression Screening and Follow-Up (PDS-E)

* Indicates that this is the first year that the measure can be reported using ECDS

Of note, NCQA added the ECDS reporting method to three existing HEDIS measures: Breast Cancer Screening, Colorectal Cancer Screening and Follow-up Care for Children Prescribed ADHD Medication. Initially, the ECDS method will be optional, which provides health plans an opportunity to try out reporting using the ECDS method before it is required to transition to ECDS only in the future.

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

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Effective December 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will prefer the referring physician name and NPI to be included on professional claims for home infusion therapy (HIT) services in fields 17 and 17a on the CMS-1500 Claim Form.

Providers should report the referring physician information in accordance with the Anthem guidelines in the Electronic Data Interchange (EDI) Companion Guide for claims submitted electronically.

Thank you for your assistance in our ongoing efforts to promote accurate claims processing and payment. We continue to be dedicated to delivering access to quality care for our members, providing higher value to our customers, and helping improve the health of our communities.

If you have questions regarding this process, contact your Network Manager.

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

• Medical step therapy updates
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list
• AIM Specialty Health Radiation Oncology Clinical Appropriateness Guidelines update