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, Verscend, Ciox, Sharecare, and Episource 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. 

 

We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request, by March 31, 2020. 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 to allow for remote review)
  • 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 Alicia Estrada, our Commercial Risk Adjustment Network Education Representative, at Alicia.Estrada@anthem.com.

 

Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests.  

Billing of patient treatment can be complex, particularly when determining whether modifiers are required for proper payment. Anthem reimbursement policy and correct coding guidelines establish the appropriate use of coding modifiers. We would like to highlight the following appropriate use of some commonly used modifiers.

• 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 year’s 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 can help 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 applying a modifier appropriately under correct coding guidelines, please follow the normal claims dispute process and include medical records that support the usage of the modifiers when submitting claims for consideration.

 

We will be publishing additional articles on correct coding in upcoming editions of Provider News.

Great news! Commercial Provider Communications would like to share some recent enhancements to the Commercial Provider News site:

1. Article categories are now appearing directly under the article title in both the website and PDFs. Example below:

Patient360 is a real time dashboard you can access through the Availity Portal that gives you a robust picture of your Anthem patient’s health and treatment history and will help you facilitate care coordination.

 

If an Anthem patient has a Care Gap Alert, your medical practice can locate Active Alerts on the Member Summary page of the Patient360 application.

 

What’s new? 

Medical providers now have the option available on Patient360 to include feedback for each gap in care that is listed on the patient’s active alerts.

 

However, to be able to access the Care Gap Alert Feedback you will need to provide an individual NPI. If you select an NPI from Express Entry menu, the feedback options will not be available.

Once you have completed all the required fields you will land on the Member Summary page of the application. To provide feedback, select the Resolution Health Index (RHI) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry screen. You can choose the feedback menu option that applies to your patient’s care gap.

 

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

First, you need to be assigned to the Patient360 Role which your Availity Administrators can locate within the Clinical Roles options.

 

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

Some professional (837P/HCFA-1500) claims for services rendered to non-Anthem Blue plan members at retail health locations are being reported with a Place of Service that does not reflect a retail health clinic location. Specifically, for services rendered at a retail health location, some providers are submitting values for Office (11) or Urgent Care Facility (20) instead of the value of Walk-in Retail Health Clinic (17). Reporting Place of Service as 11 or 20 can cause claims to process incorrectly, and thus result in the need for claim adjustments and rework for providers.

 

If your practice is a Walk-in Retail Health Clinic, please remind your coding staff to report the most accurate Place of Service, Walk-in Retail Health Clinic (17), for professional claims when submitting claims for non-Anthem members.

Effective April 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will transition the utilization management of our Outpatient Rehabilitation Program to AIM Specialty Health® (AIM). AIM is a specialty health benefits company. The Outpatient Rehabilitation Program includes physical, occupational and speech therapy services. Anthem has an existing relationship with AIM in the administration of other programs.

 

This relationship with AIM will enable Anthem to expand and optimize this program, further ensuring that care aligns with established evidence-based medicine. AIM will follow the clinical hierarchy established by Anthem for medical necessity determination. Anthem makes coverage determinations based on guidance from CMS, including national coverage determinations, local coverage determinations, other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.

 

AIM will continue to use criteria documented in Anthem clinical guidelines CG.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online.

 

Detailed prior authorization requirements are available online availity.com by accessing the Precertification Lookup Tool under Payer Spaces. Contracted and noncontracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.

 

Prior authorization review requirements

For services to be rendered for dates of service from October 1, 2019, through March 31, 2020, no prior authorization is required for outpatient rehabilitation services. For these service dates, in addition to all other rights Anthem has under our provider contract and law, Anthem and AIM will continue to monitor claims history and utilization trends and will validate provider and member information.

 

AIM will facilitate training sessions to provide an overview of the program and demonstrate the AIM ProviderPortal_SM. Please access the AIM Rehabilitation Provider Portal to register for an upcoming session.

 

For services that are scheduled on or after April 1, 2020, providers must contact AIM to obtain prior authorization. Beginning March 19, 2020, providers will be able to contact AIM for prior authorization of services to take place on or after April 1, 2020. Providers are strongly encouraged to verify that they have obtained prior authorization before scheduling and performing services.

 

How to place a review request

You may place a prior authorization request online via the AIM ProviderPortal. This service is available 24/7 to process requests in real time using clinical criteria. Go to providerportal.com to register. You can also call AIM at 800-714-0040, Monday through Friday 8:00 a.m. to 8:00 p.m.

 

For more information

For resources to help your practice get started with the Outpatient Rehabilitation Program, go to aimproviders.com/rehabilitation. For portal login Issues, call 800-252-2021.

 

The AIM website provides access to useful information and tools, such as order entry checklists, clinical guidelines and an FAQ.

ABSCARE-0322-19

Your patient’s current supplemental benefit for Personal Home Helper has been reauthorized for 2020. For billing in 2020, use the new authorization number. For more information or to view the new authorization number, sign into the Availity Portal or call Provider Services at 800-499-9554.

 

Submit claims electronically through Availity

Availity is well known as a web portal and claims clearinghouse, but they are much more. Availity also functions as an electronic data interchange (EDI) gateway for multiple payers and is the single EDI connection for all of Anthem, Inc. It will allow you to submit claims electronically, verify pre-authorization and member information, check claims status, and much more. 

 

To get started, go to anthem.com/edi and select your state.

ABSCRNU-0118-19

Anthem Blue Cross and Blue Shield (Anthem) provides benefits for covered services rendered by nurse practitioners (NPs) and physician assistants (PAs) when operating within the scope of their license. Our policy states that these mid-level practitioners are required to file claims using their specific NPI number — not that of the medical doctor.

 

We will continue to monitor this area of concern through medical chart review and data analysis. Billing noncompliance can be considered a contract breach.

 

Anthem recognizes the quality of care delivered to our members can be improved by the proper use of NPs and PAs. This notice is in no way intended to discourage their proper use, but rather to clearly define how services should be appropriately billed.

 

Thank you for your continued participation. Should you have any questions, please call the Provider Services number located on the back of the member’s card.

ABSCRNU-0121-20

 

Beginning January 1, 2020, patients using nonpreferred products with a high patient cost share are now contacted about the availability of lower patient cost share preferred alternatives. If the patient is interested in switching, we will call or fax their provider who can determine whether the preferred alternative is clinically appropriate. This is strictly informational and not a substitute for physician‑directed medical evaluations or treatments.

 

A list of the included nonpreferred products and corresponding preferred alternatives are listed below. 

Nonpreferred products	Preferred alternative(s)
Aciphex DR	omeprazole pantoprazole
Actos	pioglitazone HCL
Advair Diskus	fluticasone-salmeterol Wixela Inhub
Aggrenox	aspirin-dipyridamole ER
Ampyra ER	dalfampridine ER
Breo Ellipta	fluticasone-salmeterol Wixela Inhub
Cambia	diclofenac sumatriptan
chlorzoxazone	cyclobenzaprine
Coumadin	warfarin
Crestor	rosuvastatin
Dexilant	omeprazole pantoprazole
Dilantin	phenytoin
Diovan HCT	valsartan/hydrochlorothiazide
Duexis	ibuprofen & famotidine
Dymista	fluticasone & azelastine
Epzicom	abacavir-lamivudine
Evzio	naloxone HCL
Farxiga	Jardiance
Gleevec	imatinib
Glumetza	metformin ER (generic Glucophage XR)
Incruse Ellipta	Spiriva
Invega	paliperidone ER
Invokana	Jardiance
Jublia	ciclopirox
Kerydin	ciclopirox
Kombiglyze	Janumet XR
Lamictal	lamotrigine
Lanoxin	digoxin
Lipitor	atorvastatin
Livalo	atorvastatin lovastatin pravastatin simvastatin
Lovaza	omega-3 acid ethyl esters
Mestinon	pyridostigmine
metformin ER (generic Glumetza)	metformin ER (generic Glucophage XR)
metformin ER OSM (generic Fortamet)	metformin ER (generic Glucophage XR)
Mirapex	pramipexole
Myrbetriq ER	oxybutynin
Nexium	omeprazole pantoprazole
Nilandron	nilutamide
Novolin N	Humulin N
Novolog	Humalog
omeprazole-bicarbonate	omeprazole pantoprazole
Onfi	clobazam
Onglyza	Januvia
Pennsaid	meloxicam
Protonix	omeprazole pantoprazole
Renvela	sevelamer
Requip	ropinirole
Restasis	Xiidra
Soolantra	metronidazole azelaic acid
Symbicort	fluticasone-salmeterol Wixela Inhub
Synthroid	levothyroxine
Tresiba	Basaglar Lantus Toujeo
Trokendi XR	topiramate
Tudorza Pressair	Spiriva
Vasotec	enalapril
Vimovo	naproxen & omeprazole
Wellbutrin XL	bupropion XL
Xalatan	latanoprost
Xenazine	tetrabenazine
Zestoretic	lisinopril/hydrochlorothiazide
Zestril	lisinopril
Zileuton ER	montelukast

ABSCRNU-0123-20

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

• Prior authorization requirements for CardioMEMS
• Benefits update for Special Supplemental Benefits for the Chronically Ill