 Provider News GeorgiaMarch 1, 2019 March 2019 Anthem Provider Newsletter - GeorgiaThis March, anthem.com will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms, as seen below.
This first version of the new Provider Forms will keep growing and evolving in the coming months.
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.
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 anthem.com/provider website. Thank you for your help and continued efforts to keep our records up to date. Claim Status changes
You will now see updates to the claim status screens on the Availity Portal.
Use the Go To menu on the patient eligibility and benefit detail page to navigate seamlessly to the new look. The new claim status look includes color coded patient ID cards and easy to read claim detail.
 
Secure Messaging changes
A new Actions menu on the updated Claim Status page will be used to access the Secure Provider Messaging tool. The link “Do you have a question about this claim?” will no longer be available with the new claim screen. You can also use the Actions menu to edit or print the claim screen.
 
More information is now available in the Availity Learning Center. Access the training demo through Help & Training | Get Trained from the Availity Portal. Type Claim Status – Training Demo in the learning center’s search field to locate the course and enroll.
Have you been using the medical attachment tool on the Availity Portal to submit solicited medical records in support of a claim? You will now find these changes that were recently introduced:
- Select the “Attachment – New” option to submit medical records when Anthem has requested additional information to process a claim
- To send a solicited attachment, now find the “Send Attachment” link on the top, right side of the page
- Expanded file size – each attachment can be up to 40 MB with a total of 80 MB as the file size limit
- Ability to submit an itemized bill
If you have not tried the Medical Attachment tool to submit electronic documentation in support of a claim, now is the time to give it a try! This tool makes the process of submitting requested medical records simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Anthem) medical record attachments through the Availity Portal.
The existing Medical Attachment tool will not be removed from the Availity Portal immediately but users are encouraged to connect to the “Attachment – New” option for greater capabilities.
How to access solicited medical attachments for your office
Availity Administrator: From My Account Dashboard, select Enrollments Center>Medical Attachments Setup, follow the prompts and complete the following sections:
- Select Application>choose Medical Attachments Registration
- Provider Management>Select Organization from the drop-down. Add NPIs and/or Tax IDs (Multiples can be added separated by spaces or semi-colons)
- Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name
Using medical attachments
Availity User, complete these steps:
- Log in to availity.com
- Select Claims and Payments > Attachments-New >Send Attachment Tab
- Complete all required fields of the form
- Attach supporting documentation
- Submit
Need training?
To access additional training for this Availity feature:
- Log in to the Availity Portal at availity.com
- At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
- In the new window a list of available topics will open. Locate and click Medical Attachments
- Under the Recordings section, click View Recording
A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways this is done is by giving certain providers (“Payment Innovation Providers”) in Anthem’s various Payment Innovation Programs ( e.g., Enhanced Personal Health Care, Bundled Payments, Medical Home programs, etc.) (the “Programs”) quality, utilization and/or cost information about the health care providers (“Referral Providers”) to whom the Payment Innovation Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in their getting more referrals from Payment Innovation Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.
Providing this type of data, including comparative cost information, to Payment Innovation Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.
Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Payment Innovation Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.
Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant. Anthem has designated Availity to operate and serve as your electronic data interchange (EDI) entry point or also called the EDI Gateway. The EDI Gateway is a no-cost option for our providers that choose to submit their own EDI claims to Anthem. If you prefer to use a clearinghouse or billing company, please work with them to ensure connectivity.
As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway.
Do you already have an Availity User ID and Login?
You can use the same login for your Anthem EDI transactions.
- Log in to the Availity Portal and select Help & Training | Get Trained. In the Availity Learning Center, search the Catalog by key word “SONG” for live and on-demand resources created especially for you.
If you wish to become a direct trading partner with Availity, the setup is easy.
Need Assistance?
The Availity Quick Start Guide will assist you with any EDI connection questions you may have.
835 Electronic Remittance Advice (ERA)
Please use Availity to register and manage account changes for ERA. If you were previously registered to receive ERA, you must register using Availity to manage account changes. Log into the Availity Portal and select My Providers | Enrollments Center | ERA Enrollment to enroll for 835 ERA delivery.
Electronic Funds Transfer (EFT)
To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.
If you have any questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8:00 a.m. to 7:30 p.m. Eastern Time.
As a reminder, physicians are required to refer to in-network laboratories. Laboratory Corporation of America (LabCorp) is one of many labs participating in the PPO network. For a complete list of PPO labs see the “Find a Doctor” tool at anthem.com.
LabCorp is the exclusive national clinical reference laboratory provider for Anthem HMO, Open Access POS and Pathways members. For these members, this means referring to LabCorp. By doing so, members are assured of having the highest benefit level and minimum out-of-pocket expense.
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 over one-hundred LabCorp Patient Service Center locations throughout Georgia. To find out about LabCorp Patient Service Center locations, go to 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 our provider network or coverage for your patients, please contact your Anthem network consultant. Each year, Anthem requests your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), in order to document and close the coding gaps.
The CRA Program is specific to our Affordable Care Act (ACA). Members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).
With our Retrospective Program we focus on medical chart collection. We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS). This particular effort is part of Anthem’s compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership. The members’ medical record documentation helps support this data requirement.
Analytics are performed internally on claims which do not have the ICD10 code for which we suspect a chronic condition. These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.
Anthem network providers – may be PCPs, specialists, facilities, behavioral health, ancillary, etc. – may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review. These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf. The vendors’ Web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management.
We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2019 at the latest). While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.
Electronic options that may make medical chart collection easier for providers:
- EMR Interoperability
- Allscripts (Opt in – signature required)
- NextGen (Opt out – auto-enrolled)
- Athenahealth (Opt out – auto-enrolled)
- MEDENT
- Remote/Direct Anthem access
- Vendor virtual or onsite visit
- Secure FTP
The goal of these electronic options is to both improve the medical record data extraction and the experience for Anthem’s network-participating hospitals, clinics and physician offices. If you are interested in this type of set up or any other remote access options, please contact our Commercial Risk Adjustment Network Education Representative Alicia Estrada at Alicia.estrada@anthem.com.
Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests. Anthem recently discovered that some specialty pharmacy claims requiring clinical site of care prior authorization through AIM Specialty Health®, a separate company, are processing despite the outcome of the prior authorization review for site of care or absent a prior authorization review for site of care. Effective June 1, 2019 our claim systems will be updated to correct this issue. It is important that coverage is provided for services in the approved site of care. If you need to request a change to the site of care previously approved please contact AIM at 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET. 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, scroll down to “Select Drug Lists.” 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. You want what’s best for your patients’ health. So, it's challenging when a patient doesn't follow your prescribed treatment plan. Why do approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed 1? What can be done differently? The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg—the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline – the Titanic-sized, often invisible, patient self-talk that may not get discussed – can create a misalignment between patient and provider.
So we’ve created an online learning experience for the skills and techniques that may help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust, and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence—and you’ll earn CME credit along the way.
Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.
1 Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm In January, Anthem, Inc. announced that it’s accelerating the launch of IngenioRx, its new pharmacy benefits manager (PBM), which will serve members of all Anthem’s affiliated health plans. We will begin moving some members to IngenioRx in Q2, and we will continue the transition, in waves, with the majority of members moving in the latter part of 2019 and Q1 2020. Medicare Part D business will not be transitioned until January 1, 2020.
As one of our contracted providers, we wanted to share a few details about what this means for you.
- If your patient has an active prior authorization, that will transfer to IngenioRx.
- If your patient currently fills home delivery or specialty prescriptions through Express Scripts, prescriptions with at least one refill will be transferred, with the exception of controlled substances and compound drugs, to IngenioRx Home Delivery Pharmacy and IngenioRx Specialty Pharmacy.
- As your patients transition, new home delivery and specialty prescriptions will need to be sent to IngenioRx.
- For providers using ePrescribing there are no changes, simply select IngenioRx.
- For providers who do not use ePrescribing, you should send your home delivery and specialty prescriptions to IngenioRx.
IngenioRx Home Delivery Pharmacy new prescriptions:
Phone Number: 833-203-1742
Fax number: 800-378-0323
IngenioRx Specialty Pharmacy:
Prescriber phone: 833-262-1726
Prescriber fax: 833-263-2871
- If you want to check whether or not a specific patient has moved to IngenioRx, Availity will display the member’s PBM information under the patient information section as part of the eligibility and benefits inquiry.
- If you have immediate questions, you can contact the Provider Service phone number on the back of your patient’s ID card or call the number you normally use for questions.
Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.
This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.
Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.
If you have questions or feedback, please use this email link. Effective with dates of service on and after April 1, 2019, and in accordance with Anthem’s Pharmacy and Therapeutic (P&T) process, Anthem will update its commercial drug lists. Updates may include changes to drug tiers or the removal of a drug.
To help ensure a smooth transition and minimize member costs, providers should review these changes and consider prescribing a preferred drug to patients currently using a non-preferred drug, if appropriate.
Please note, this update does not apply to the Select Drug List or drugs lists utilized by the Federal Employee Program (FEP).
To view a summary of changes, click here. On December 1, 2018, Anthem introduced the new clinical criteria page for injectable, infused or implanted drugs.
Effective for dates of service on and after March 1, 2019, the following new clinical criteria will be included in our clinical criteria review process. The drugs that require prior authorization will continue to require prior authorization notification with AIM.
Existing prior authorization requirements have not changed for the specific Clinical Criteria below. 9*-+While there are no material changes, the document number and online location has changed. To access the clinical criteria information please click here. The attached PDF includes a table that will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical Guideline/Medical Policy.
Anthem’s pre-service clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
See attached PDF titled “Clinical criteria updates for specialty pharmacy clinical criteria and Clinical Guideline/Medical Policy table”. The following revised clinical criteria will be effective May 1, 2019. Visit anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.
|
Clinical criteria effective date
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Clinical criteria number
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Clinical criteria
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Clinical criteria (new/revised)
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|
May 1, 2019
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ING-CC-0001
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Erythropoiesis Stimulating Agents
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Revised
|
|
May 1, 2019
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ING-CC-0004
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H.P. Acthar Gel®
(repository corticotropin injection)
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Revised
|
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May 1, 2019
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ING-CC-0072
|
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
|
Revised
|
75743MUPENMUB 01/24/2019 Anthem updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433. The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:
- Group code patient responsibility (PR) will be assigned.
- Claim adjustment reason codes (CARCs) will include the following:
- 1 — deductible amount (professional claim)
- 2 — coinsurance amount (professional claim)
- 3 — copay amount (professional and facility claim)
- 247 — deductible for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
- 248 — coinsurance for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
- Remittance advice remark codes (RARCs) will include the following:
- N781 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
- N782 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
- N783 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected copay. This amount may be billed to a subsequent payer.
Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.
75743MUPENMUB 01/24/2019 In 2019, Anthem is offering Dual Eligible Special Needs Plans (D-SNPs) to people who are eligible for both Medicare and Medicaid benefits or who are qualified Medicare beneficiaries (QMBs). D-SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These plans are $0 premium plans. Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments. Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.
Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in Q1 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.
Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.
For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.
75743MUPENMUB 01/24/2019 |