Beginning June 1, 2020, Anthem is introducing our Anthem Health Access Plans for certain large group employers currently enrolled in our commercial lines of business only.

Anthem Health Access Plans cover the diagnosis and treatment for COVID-19 at 100% in accordance with Anthem guidelines. 

These benefit plans cover preventive care, unlimited telemedicine, office visits, prescriptions, and more.  In addition, members enrolled in these plans have digital ID cards and access to Sydney Health and Sydney Care (Anthem’s mobile app that runs on intelligence – as part of our digital strategy). 

These plans include some coverage exclusions or limitations. For information about eligibility, available benefits, and a list of exclusions, please visit Availity – our web-based provider tool at availity.com. 

We are committed to working with our provider partners to help our members focus on their health and well-being. The new Health Access plans give your patients the needed coverage to manage their everyday health needs.

NOTE:  As with all eligibility and benefits inquiries on Availity, providers must have the member ID number (including the three-character prefix) and one or more search options of date of birth, first name and last name.

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Anthem is now using the Notification Center on the Availity Portal home page to communicate vital, time sensitive information. A Take Action call out and a red flag in front of the message will make it easy to see that there is something new requiring your attention.

The Notification Center is currently being used to notify you if there are payment integrity requests for medical records or recommended training in the Custom Learning Center. Select the Take Action icon to instantly access the custom learning recommended course.

For membership where the disputes tool is available, Availity will also post a message in the notification center when a dispute request you have submitted is finalized. Selecting the Take Action icon will allow easy access to your appeals worklist for details.

Viewing the Notification Center updates should be included as part of your regular workflow so you are always aware of any outstanding action items and can respond timely.

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Below are some commonly used codes for your convenience.

CPT® is a registered trademark of the American Medical Association Copyright 2020 American Medical Association. All rights reserved.

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The Follow-Up after Hospitalization for Mental Illness (FUH) HEDIS measure evaluates members (6 years and older) who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.

Two areas of importance for this HEDIS measure are:

• The percentage of behavioral health inpatient discharges for which the member received follow-up within 7 days after discharge.
• The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.

On a regular basis, we continue to monitor if these two consecutive follow-up appointments are being recommended and scheduled during the inpatient stay as part of discharge planning by the eligible behavioral health facilities (such as psychiatric hospitals, freestanding mental health facilities and acute  care hospitals with psychiatric units), as well as practicing behavioral health providers. 

Please consider the following for improving member outcomes for this measure:

1. Earliest follow up with a BH provider can help with continuing treatment after leaving the hospital.
2. With greater emphasis on care coordination, primary care providers can help facilitate the BH follow up appointments.
3. Weekend member discharges have shown to have very inconsistent follow up after discharge. Start discharge planning as soon as possible while members are inpatient so those who are discharged on weekends have scheduled follow up appointments.
4. In addition, other social determinants of health pertinent to the member such as housing, food, living in a rural area, transportation, job schedule, family and social support, child care, etc., can impact follow-up opportunities. Please address these needs and issues; refer to resources that can help support the member.
5. Social workers at the facilities can contact Anthem member services to learn if additional sources of assistance are available through Anthem such as case management and other referrals.
6. Telehealth services have been identified as part of follow up for this HEDIS measure available in certain parts of the country. Telehealth follow up may not be the best choice for everyone; however, not having a BH follow up for several weeks can be detrimental to the member can be a reason for relapse.

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The ICR tool on the Availity Portal will now utilize sophisticated clinical analytics in order to provide an immediate decision on an authorization for higher levels of care such as inpatient, intensive outpatient (IOP) and partial hospitalization (PHP). Here are a few of the many reasons behavioral health providers will benefit from using ICR with the newly enhanced functionality:

1. Reduction of administrative burden
2. Quicker access to care for some services deemed eligible for our immediate decisions
3. Increased member focus
4. Prioritizes more complex cases
5. Reduced possibility of errors such as illegible faxes
6. Maximize the amount time spent with members

Follow these instructions to access ICR through the Availity Portal

First, ask your Availity administrator to grant you the appropriate role assignment.

Do you create and submit prior authorization requests?

Required role assignment: Authorization and Referral Request

Do you check the status of the case or results of the authorization request?

Required role assignment: Authorization and Referral Inquiry

Once you have the authorization role assignment, log onto Availity with your unique user ID and password follow these steps.

1. Select Patient Registration from Availity’s home page
2. Select Authorizations & Referrals
3. Select Authorizations (for requests) | Select Auth/Referral Inquiry (for inquiries)

Training:

Follow these instructions to access ICR on demand training through the Availity Custom Learning Center:

• From Availity’s home page, select Payer Spaces | Anthem | Applications | Custom Learning Center tile.
• From the Courses screen use the filter catalog, and select Interactive Care Reviewer – Online Authorizations from the menu and click Apply.

You will find two pages of online courses consisting of on demand videos and reference documents illustrating navigation and features of ICR. Enroll for the course(s) you want to take immediately or save for later.

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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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.   

Open the attached document titled “GA medical policy and clinical guideline updates 6.1.2020” to view the new and/or revised Medical Policies and Clinical Guidelines adopted by the Medical Policy and Technology Assessment Committee.

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As part of this transition of clinical criteria, the following procedures will be subject to prior authorization as part of the AIM Rehabilitation program: 

The following procedure will be removed from the program:

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• 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 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.

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.

Retrospective Chart Requests

We appreciate that care providers across the country on the front line are committed to providing care during these challenging times, and as such, that care results in a visit where we may need the medical chart.  Medical chart collection must be done to obtain undocumented HCC’s on your patients in order to be compliant with the provisions of the Affordable Care Act, (ACA), that require our company to collect and report diagnosis code data for ACA membership.  This process will begin in June. In order to make these chart requests the most efficient for your office, we have electronic options available:

• EMR Interoperability
• Allscripts (Opt in - signature required)
• NextGen
• Athenahealth
• MEDENT
• Remote/Direct Anthem access
• Vendor virtual or onsite visit (if the offices are opened back up from COVID-19 closures)
• Secure FTP

The goal of these electronic options is to both improve the medical record data extraction and the experience for Anthem’s providers. If you are interested in this type of set up or any other remote access options, please contact the Commercial Risk Adjustment Network Education Representative listed below.

Prospective Patient Outreach (Incentive opportunity for properly completed health assessments:  Physicians are eligible to receive $100 for electronic submissions or $50 for paper in addition to the office visit reimbursement.)

We encourage members to form a relationship with their Primary Care Physician to complete a clinical assessment to ensure you have a clearer picture of your patients’ health. Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions. Previous Anthem news updates have given telehealth reimbursement guidance to follow when submitting the claim.

As a reminder, the May newsletter mentioned incentives for prospective program participation ($100 or $50). We would be happy to meet and review incentive opportunities along with other flexible options for program participation and chart collection. Please contact our Commercial Risk Adjustment Network Education Representative, Alicia Estrada at Alicia.Estrada@anthem.com to set up a meeting.

Thank you for your continued efforts with the CRA Program.

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Things to remember

• Review the CPT^® Surgical Package Definition found in the current year’s CPT Professional Edition. Use modifiers such as 25 and 59 only when the services are not included in the surgical package.
• Review the current CPT Professional Edition Appendix A — Modifiers for the appropriate use of modifiers 25, 57 and 59.
• When an evaluation and management (E&M) code is reported on the same date of service as a procedure, the use of the modifier 25 should be limited to situations where the E&M service is “above and beyond” or “separate and significant” from any procedures performed the same day.
• When appropriate, assign anatomical modifiers (Level II HCPCS modifiers) to identify different areas of the body that were treated. Proper application of the anatomical modifiers helps ensure the highest level of specificity on the claim and show that different anatomic sites received treatment.
• Use modifier 59 to indicate that a procedure or service was distinct or independent of other non-E&M services performed on the same date of service. The modifier 59 represents services not normally performed together, but which may be reported together under the circumstances.

If you feel that you have received a denial after appropriately applying a modifier under correct coding guidelines, please follow the normal claims dispute process and include medical records that support the use of the modifier(s) when submitting claims for consideration.

Anthem will publish additional articles on correct coding in provider communications.

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Diabetes is a complex chronic illness requiring ongoing patient monitoring. The National Committee for Quality Assurance (NCQA) includes diabetes in its HEDIS^® measures on which providers are rating annually.

Since diabetes HbA1c testing is a key measure to assess for future medical conditions related to complications of undiagnosed diabetes, NCQA requires that health plans review claims for diabetes in patient health records. The findings contribute to health plan Star Ratings for commercial and Medicare plans and the Quality Rating System measurement for marketplace plans. A systematic sample of patient records is pulled annually as part of the HEDIS medical record review to assess for documentation.

Which HEDIS measures are diabetes measures?

The diabetes measures focus on members 18 to 75 years of age with diabetes (type 1 and type 2) who had each of the following assessments:

• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (> 9%)
• HbA1c control (< 8%)
• Dilated retinal exam
• Medical attention for nephropathy

The American College of Physicians’ guidelines for people with type 2 diabetes recommend the desired A1c blood sugar control levels remain between 7% to 8%.¹

In order to meet the HEDIS measure HbA1c control < 8, providers must document the date the test was performed and the corresponding result. For this reason, report one of the four Category II codes and use the date of service as the date of the test, not the date of the reporting of the Category II code.

To report most recent hemoglobin A1c level greater than or equal to 8% and less than 9%, use 3052F. To report most recent A1c level less than or equal to 9%, use codes 3044F, 3051F and 3052F:²

1. If the most recent hemoglobin A1c (HbA1c) level is less than 7%, use 3044F.
2. If the most recent hemoglobin A1c (HbA1c) level is greater than or equal to 7% and less than 8%, use 3051F.
3. If the most recent hemoglobin A1c (HbA1c) level is greater than or equal to 8% and less than or equal to 9%, use 3052F.

Continued management and diverse pathways to care are essential in controlling blood glucose and reducing the risk of complications. While it is extremely beneficial for the patient to have continuous management, it also benefits our providers. As HEDIS rates increase, there is potential for the provider to earn maximum or additional revenue through Pay for Quality, Value-Based Services and other pay-for-performance models.³

Racial and ethnic disparities with diabetes

It is also important for providers to be aware of critical diabetes disparities that exist for diverse populations.

Compared to non-Hispanic whites:⁴

• African Americans, Hispanics, and American Indian/Alaska Natives have higher mortality rates from diabetes.
• African Americans and Hispanics have higher rates of complications from uncontrolled diabetes, including lower limb amputation and end-stage renal disease.
• More than half of Asian Americans and nearly half of Hispanic Americans with diabetes are undiagnosed.⁵
• Asian Americans are at risk for type 2 diabetes at a lower body mass index (BMI); therefore, diabetes screening at a BMI of 23 is recommended.⁶

Sources include:

• Diabetes prevalence:
  • 2015 State Diagnosed Diabetes Prevalence, cdc.gov/diabetes/data.
  • 2012 State Undiagnosed Diabetes Prevalence, Dall et al., “The Economic Burden of Elevated Blood Glucose Levels in 2012”, Diabetes Care, December 2014, vol. 37.
• Diabetes incidence:
  • 2015 State Diabetes Incidence Rates, cdc.gov/diabetes/data.
• Cost:
  • American Diabetes Association, “Economic Costs of Diabetes in the U.S. in 2017”, Diabetes Care, May 2018.
• Research expenditures:
  • 2017 National Institute of Diabetes and Digestive and Kidney Diseases funding, projectreporter.nih.gov.
  • 2017 CDC diabetes funding,cdc.gov/fundingprofiles.

1 https://www.medicalnewstoday.com/articles/321123#An-A1C-of-7-to-8-percent-is-recommended

2 https://www.ama-assn.org/system/files/2020-01/cpt-cat2-codes-alpha-listing-clinical-topics.pdf

3 https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.html

4 Office of Minority Health. Minority Population Profiles:  https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlID=26

5 U.S. Department of Health and Human Services, National Institutes of Health. (2015, September 8), More than half of Asian Americans with diabetes are undiagnosed. Retrieved from https://www.nih.gov/news-events/news-releases/more-half-asian-americans-diabetes-are-undiagnosed.

6 ADA; NCAPIP; AANHPI DC; Joslin Diabetes Center Asian American Diabetes Initiative. (2015, September). Screen at 23. Retrieved from http://screenat23.org/wp-content/uploads/2015/10/Screenat23package-1.pdf.

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

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Medicare Risk Adjustment and Documentation Guidance (General)

When: Offered the first Wednesday of each month from 1 to 2 pm 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 one 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.

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at https://bit.ly/2z4A81e.

*Note: Dates may be modified due to holiday scheduling.

Medicare Risk Adjustment, Documentation and Coding Guidance (Condition specific)

Series: Offered on the third Wednesday of every other month at 12 to 1 pm ET

Learning objective: This is a collaborative learning event with Enhanced Personal Health Care (EPHC) to 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 joining us for this six-part training series, please see the list of topics and scheduled training dates below:

• Red Flag HCCs, part one: Training will cover HCCs most commonly reported in error as identified by CMS (chronic kidney disease stage 5, ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, end-stage liver disease) {Recording will play upon registration.}
• Red Flag HCCs, part two: Training will cover HCCs most commonly reported in error as identified by CMS (atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, diabetes with ophthalmologic or unspecified manifestation) {Recording will play upon registration.}
• Neoplasms (recording link will be available later 2020.)
• Acute, Chronic and Status Conditions (July 15, 2020)

• Diabetes Mellitus and Other Metabolic Disorders (September 16, 2020)
• TBD - This Medicare Risk Adjustment webinar will cover the critical topics and updates that surface during the year (November 18, 2020)

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Risk adjustment is the process by which the Centers for Medicare & Medicaid Services (CMS) reimburses Medicare Advantage plans, based on the health status of their members. Risk adjustment was implemented to pay Medicare Advantage plans more accurately for the predicted health cost expenditures of members by adjusting payments based on demographics (age and gender) as well as health status.

In 2020, Anthem will work with Optum,* who is working with Ciox Health,* to request medical records with dates of service for the target year 2019 through present day.

Jaime Marcotte, Medicare Retrospective Risk Program Lead, is managing this project. If you have any questions regarding this program, please contact Jaime at jaime.marcotte@anthem.com or 1-843-666-1970.

Additional information, including an FAQ, will be available on the provider website at Important Medicare Advantage Updates

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Sleep Disorder Management Clinical Appropriateness Guideline updates by section:

• Bi-Level Positive Airway Pressure (BPAP) Devices:
  • Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and alignment with Medicare requirements for use of BPAP
• Multiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing:
  • Style change for clarity
  • Code changes: none 

As a reminder, ordering and servicing providers may submit prior authorization (PA) requests to AIM by:

• Accessing 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 PA.
• Accessing AIM via the Availity Portal.*
• Calling the AIM Contact Center at 800-714-0040 from 7:00 a.m. to 7:00 p.m. ET.

What if I need assistance?

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

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

• Acquisition of Beacon Health Options
• MCG care guidelines — 24th edition

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