What’s in it for you

First, monthly you will receive a list of your patients who are Anthem members enrolled in Affordable Care Act (ACA) compliant coverage who may have gaps in care to help you reach out to them, so they can come in for office visits earlier. 

Second, we’ve heard resoundingly from providers that participation in these programs helps them better evaluate their patients and, as a result, perform more strongly in population health management and gain sharing programs. Many cite that they ask different questions today that allow them to better manage their patients end to end.

Finally, when you see Anthem ACA members and submit health assessments, we pay incentives of $50 for a paper submission and $100 for an electronic submission. For additional details on how to earn these incentives and the options available, please contact the CRA Network Education Representative listed below.   

What’s in it for your patients

Anthem is completing monthly postcard campaigns to members with ACA compliant coverage when we suspect a high-risk condition with messaging to encourage the member to call his or her Primary Care Provider (PCP) and schedule an annual checkup. The goal is to get the members to have a visit with their PCPs, so the PCPs have an overall picture of their patients’ health and schedule any screenings that may be needed. Telehealth visits have become very flexible formats for patients and doctors to meet, so we encourage telehealth visits to be scheduled if that is what the patient is most comfortable with at this time.

We will continue these monthly postcard mailings throughout the remainder of 2020 to encourage the members to schedule an annual checkup, which supplements any patient outreach you may be doing.

If you have any questions regarding our reporting processes, please email CRA Network Education Representative, Alicia Estrada at Alicia.Estrada@anthem.com.

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Custom Learning Center in the Availity portal offers an array of learning opportunities where you can access required training, recommended/elective trainings and view additional learning resources. Access to the Custom Learning Center is via Payer Spaces in the Availity Portal. 

Highlights of the Custom Learning Center

• All the learning is in one place
• You can filter topics of interest
• View all your completed training
• Course resources may include links to a job aid

Your required courses are easily accessible and the available content is specific to your region. You may track your accomplishments, and view or download your training history via the Custom Learning Center Dashboard.

Select Access Your Custom Learning Center from the Applications tab in Payer Spaces.

Examples of trainings offered in the Custom Learning Center:

• Authorizations
• Coding and Documentation
• Claims and Payments
• Recommended administrative support courses

In addition, illustrated reference guides are located on Custom Learning Center – Resources. Select Resources from the menu located on the upper left corner of the screen. Usually, you may download or print reference guide materials.

Current Reference Guide topics include:

• Interactive Care Reviewer – Request Appeals Reference Guide
• Interactive Care Reviewer – Inquiries Reference Guide
• Patient 360 Navigation
• Remittance Inquiry Tips

Be sure to visit the Custom Learning Center in the Availity Portal often. New content is regularly added to the site.

For questions regarding the Availity Portal, please contact Availity Client Services at 1-800-282-4548.

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Effective with dates of service on or after October 1, 2020, members with commercial plans covered by Anthem will require a medical necessity review of the hospital outpatient level of care for certain upper endoscopy and colonoscopy procedures. The clinical guideline, Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services, CG-SURG-52, will apply to the review process. The review will be administered by AIM Specialty Health_® (AIM).

AIM will evaluate the clinical information in the request against CG-SURG-52, to determine if the hospital-based outpatient setting is the appropriate level of care for the endoscopy service. Your office may contact AIM to request a peer-to-peer discussion before or after the determination.

The level of care medical necessity review only applies to procedures performed in an outpatient hospital setting. This does not apply to requests for review of endoscopy performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Anthem is the secondary payer.

For a complete list of procedures subject to the medical necessity level of care review, and additional information, such as Frequently Asked Questions, visit aimproviders.com/surgicalprocedures.

Submit a request for review

Starting Sept. 21, 2020, ordering providers may submit prior authorization requests for the hospital outpatient level of care for these procedures for dates of service on or after October 1, 2020 to AIM in one of the following ways:

• Access AIM 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.

AIM will offer webinars, beginning in May, to provide information on navigating the AIM ProviderPortal_SM. To register for a webinar visit aimproviders.com/surgicalprocedures.

Please note, this review does not apply to the following plans: BlueCard_®, Federal Employee Program_® (FEP_®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Anthem members on the Medical Policy & Clinical UM Guidelines page at anthem.com.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.  

Note: In some plans “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “level of care” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “level of care.”

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According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures,  it is generally appropriate to perform joint codes (CPT codes 27130, 29871, 29892) and 4 spine codes (CPT codes 22633, 22634, 63265 and 63267)  in an hospital outpatient setting. To avoid additional clinical review for these procedures, providers requesting prior authorization, should either choose “hospital observation” admission as the site of service or Hospital Outpatient Department (HOPD). If the provider determines that an inpatient stay is necessary due to post-operative care requirements, they can initiate a concurrent review request for inpatient admission with the health plan by contacting the number on the back of the member ID card.

Total hip arthroplasty (CPT code 27130) is currently reviewed for medical necessity and level of care. Effective October 1, 2020, 4 spine codes (CPT codes 22633, 22634, 63265 and 63267) and 2 joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures.  We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:

• Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
• Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.

Peer to peer conversations are available to a provider at any time to discuss the applicable clinical criteria and to provide information about the circumstances of a specific member.  

Providers should continue to submit pre-service review requests to AIM using one of the following ways:

• Access AIM 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 toll-free number at 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

For questions, please contact the provider number on the back of the member ID card.

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How do we accomplish those activities while minimizing your time involvement?

Initial admission review process

Contact us by phone at 1-800-860-2156 or electronically through Anthem’s online inpatient review system for providers. 

Whether you call us or electronically submit information to Anthem’s FEP Medical Management Department to report an inpatient admission, once we certify the admission, we will provide an initial length of stay determination. At that time, we will also request the discharge planner’s name and phone number to help facilitate discharge planning/case management, 

Next steps after initial admission approval

After you receive initial admission approval, you will need to call:

• With a discharge date if it falls within the initial length of stay period OR
• If the patient stays one or more days longer than the initial length of stay approved, we require updated clinical (information?) for review and for approval of any subsequent length of stay decisions.
• We will also need an update on any discharge plans.

Working together

The Anthem FEP Medical Management Department is committed to working with you and look for opportunities to coordinate the patient’s benefits and discharge plans. Please feel free to contact the Anthem FEP UM team members for assistance at 1-800-860-2156.

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Line of business:  Individual Medicare Advantage, Group Retiree Solutions, and Medicare-Medicaid Plans

AIM will continue to manage the supply codes for automatic positive airway pressure (APAP) and continuous positive airway pressure (CPAP) requests.

Anthem will continue to follow the COVID-19 Public Health Emergency orders from CMS until the waivers no longer apply.  If the Public Health Emergency Orders are no longer in place beginning July 1, 2020, the following codes will require prior authorization with Anthem rather than with AIM when used in combination with the BiPAP codes above.

Precertification requests

Submit precertification requests via:

• Fax: 1-866-959-1537
• Phone: Please dial the customer service number on the back of the member’s card, identify yourself as a provider and follow the prompts to reach the correct precertification team. There are multiple prompts. Select the prompt that fits the description for the authorization you plan to request
• Web: Use the Availity Web Tool by following this link: https://apps.availity.com/availity/web/public.elegant.login

AIM Specialty Health® is an independent company providing utilization management services on behalf of Anthem Blue Cross and Blue Shield.

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

For questions or additional information, please send us an email.

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If you are interested in learning about the electronic modalities available, please contact your Optum representative or the Optum Provider Support Center at 1-877-751-9207 from 8:00 a.m. to 7:00 p.m. Eastern time, Monday through Friday.

The IOA Program is designed to help participating providers ensure chronic conditions are addressed and documented to the highest level of specificity at least once per calendar year for all of our participating Medicare Advantage plan members. The IOA Program is designed to help overall patient quality of care (preventive medicine screening, chronic illness management and trifurcation of prescriptions for monitoring of high-risk medications and medication adherence) and care for older adults when generated for a Special Needs Plan (SNP) member.

Success stories

Below are some achievements Optum has accomplished with provider groups through the IOA Program:

• As a result of incorporating technology and/or different types of resources offered under the IOA Program, numerous provider offices demonstrated an increase in productivity, documentation and coding accuracy.
• Providers have taken advantage of the IOA Program resources to help alleviate some of the burden for their staff and office resources.

COVID-19 update

Anthem knows this is a difficult time for everyone. We will continue to adapt and evolve our practices to fully address the changing dynamics of these unprecedented events. Anthem is following the CDC guidelines on social distancing; thus, all nonessential IOA Program personal are to work telephonically/electronically with the provider groups until further notice.

Dates and tips to remember:

• Anthem strongly encourages participating providers to review their patient population as soon as possible. This will help get patients scheduled for an appointment if they have not already scheduled an in-office visit. This will also help the provider manage chronic conditions, which impact the health status of the patient.
• At the conclusion of each office visit with a patient, providers participating in the IOA Program are asked to complete and return an In-Office Assessment The form should be completed based on information regarding the patient’s health collected during the office visit. Participating providers may continue to use the 2020 version of the In-Office Assessment form for encounters that take place on or before December 31, 2020. Anthem will accept the 2020 version of the form for 2020 encounters until midnight January 31, 2021.
• Participating providers are required to submit an Account Setup Form, W9 and completed direct deposit enrollment by March 31, 2021. Participating providers should call 1-877-751-9207 if they have any questions regarding this requirement. Participating providers who fail to comply with this requirement will result in forfeiture of the provider payment for submitted 2020 In-Office Assessment forms if applicable.

If you have any questions regarding the IOA Program, please call Optum at 1-877-751-9207, Monday through Friday from 9:30 a.m. to 7:30 p.m. Eastern time.

*Optum is an independent company providing medical chart review services on behalf of Anthem Blue Cross and Blue Shield.

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Anthem Blue Cross and Blue Shield (Anthem) is offering Special Needs Plans (SNPs) to people eligible for both Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These include supplemental benefits such as hearing, dental, vision and transportation to medical appointments. Some SNP plans include a card or catalog for purchasing over-the-counter items. SNPs do not charge premiums.

SNP members under Anthem benefit from a model of care that is used to assess needs and coordinate care. Within 90 days of enrollment and annually thereafter, each member receives a comprehensive health risk assessment (HRA) that covers physical, behavioral and functional needs, and a comprehensive medication review. The HRA is used to create a member Care Plan. Members with multiple or complex conditions are assigned a health plan case manager.

SNP HRAs, Care Plans and case managers support members and their providers by helping to identify and escalate potential problems for early intervention, ensuring appropriate and timely follow-up appointments, and providing navigation and coordination of services across Medicare and Medicaid programs.

Provider training required

Providers contracted for SNP plans are required to complete an annual training to stay up-to-date with plan benefits and requirements, including details on coordination of care and model of care elements. Every provider contracted for SNP is required to complete an attestation, which states they have completed their annual training. These attestations are located at the end of the self-paced training document.

To take the self-paced training, go to the Model of Care Provider Training link on the Availity Portal.*

How to access the Custom Learning Center on the Availity Portal

1. Log in to the Availity Portal.
   1. At the top of Availity Portal, select Payer Spaces and select the appropriate payer.
2. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
3. In the Custom Learning Center, select Required Training.
4. Select Special Needs Plan and Model of Care Overview.
5. Select Enroll.
6. Select Start.
7. Once the course is completed, select Attestation and complete.

Not registered for Availity?

Have your organization’s designated administrator register your organization for Availity.

1. Visit availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

Q&A

What does it mean to be dual-eligible? What is a D-SNP?

The term dual eligible refers to people with Medicare coverage who also qualify for some type of state Medicaid
benefit — meaning that these members are eligible for both Medicaid and Medicare. These individuals may have higher incidence of chronic conditions, cognitive impairments and functional limitations. D-SNPs are special Medicare Advantage plans that enroll only dual-eligible people, providing them with more intensive coordination of care and services than those offered by traditional Medicare and Medicare Advantage plans.

What is a SNP model of care?

CMS requires Special needs plans (SNPs) to have a model of care that describes how the SNP will administer key components of care management programs, including assessments and training. The model of care describes the unique needs of the population being served and how Anthem will meet these needs. Each SNP model of care is evaluated and scored by the NCQA and approved by CMS.

How does the model of care help physicians?

The three major components of the model of care, 1) the HRA, 2) Care Plan and 3) case manager, support providers in serving D-SNP members. Each member receives a comprehensive HRA that covers physical, behavioral and functional needs, and a comprehensive medication review. Health plan staff use the HRA information to create a Care Plan. Members with multiple or complex conditions may be assigned to a case manager.

These key model of care components identify and escalate potential problems for early intervention, ensure appropriate and timely follow-up, and help coordinate services across Medicare and Medicaid programs. Through the provider website, providers have access to review the Care Plan, the results of the HRA and other information to help manage care.

How are transitions of care managed?

Anthem case managers are involved in transitions of care (for example, discharge from hospital to home for those at high risk of readmission). Such transitions may trigger a reassessment and updates to the member’s Care Plan as needed. Following a discharge, case managers help ensure that D-SNP members see their PCP within a week and work through barriers that members experience in adhering to post-discharge medication regimens.

Who makes up the Interdisciplinary Care Team (ICT)?

Members of the ICT include any of the following: nurses, physicians, social workers, pharmacists, the member and/or the member’s caregiver, behavioral health specialists, or other participants as determined by the member, the member’s caregiver, or a relative of the member.

Providers who care for Anthem members are considered participants in the ICT and may be contacted by a case manager to discuss the member’s needs. The case manager may present recommendations concerning care coordination or other needs. The goal of the ICT is to assist providers in managing and coordinating patient care.

Do I have to become a Medicaid provider?

You are not required to become a Medicaid provider, but we recommend that you do. Even if you are only providing services covered by Medicare Part A or Part B to SNP members, we recommend that you attain a Medicaid ID because the state Medicaid agency may require this for the Medicare cost share.

Do I need a separate agreement or contract to see SNP members under Anthem?

No, if you see Medicare Advantage HMO members under Anthem, you are considered contractually eligible to see SNP members under Anthem.

How do I file claims for SNP members?

Claims for services to SNP members are filed the same way claims are filed for Medicare Advantage members under Anthem who are not part of SNP. Providers should ensure that the claim has the correct member ID (including the prefix).

How is the SNP member’s cost sharing handled?

SNP benefits are administered similarly to Medicare fee-for-service benefits. Upon receiving an EOP from Anthem, you should bill the state Medicaid agency or the applicable Medicaid MCO contracted with the state for processing of any Medicare cost sharing applied.

Medicare cost sharing is paid according to each state’s Medicaid reimbursement logic. Some states do not reimburse for Medicare cost sharing if the payment has already met or exceeded Medicaid reimbursement methodology.

Do I have to file claims twice for SNP members?

Yes, when you treat SNP members under Anthem, you will file the initial claim with Anthem and then bill the state Medicaid agency or the applicable Medicaid MCO contracted with the state for Medicare cost sharing processing. Please use the same electronic claim submission or address you currently use for Anthem claims filing.

Do SNP members have access to the same prescription drug formulary as other Medicare Advantage members under Anthem?

Yes, SNP members have coverage for the same prescription drugs listed on the Medicare Advantage prescription drug formulary for Anthem.

Please note that in California the tier placement may vary. Be sure to review the plan’s specific formulary for details on California SNPs as the formulary depends on the market.

What are SNP benefits for Anthem?

The SNP for Anthem members covers all Medicare Part A and Part B services and includes full Part D prescription coverage. Anthem also covers a range of preventive services with no cost sharing for the member. In addition, the SNP includes coverage for supplemental benefits that may include routine dental, vision and nonemergency medical transportation. A summary of the SNP benefits is posted on the provider website for Anthem members.

Any Medicaid benefits available to the member will be processed under their Medicaid coverage directly with the state or the Medicaid organization in which the member is enrolled.

Does the SNP use the same procedure codes and EDI payer codes?

Yes, the SNP uses the same procedure and payer codes and electronic filing procedures as other Medicare Advantage plans under Anthem.

Is the electronic data interchange (EDI) payer ID for this product the same as others?

Yes, all the claim submission information will be the same (this applies to EDI and paper). Providers must submit this information with the correct ID. Please check the EDI section of the provider website for the correct payer codes to use for your market.

*Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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• Modifier use reminders
• 2020 affirmative statement concerning utilization management decisions
• New behavioral health discharge call-in line
• Medical Policies and Clinical Utilization Management Guidelines update
• Updates to AIM Specialty Health advanced imaging Clinical Appropriateness Guidelines
• Transition to AIM Rehabilitative Services Clinical Appropriateness Guidelines

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