If you have questions, you now have a new option to have them answered quickly and easily. With Anthem Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity.

• Faster access to provider services for all questions
• Real-time answers to your questions about PA and appeals status, claims, benefits, eligibility, and more
• A platform that is easy to use making it simpler to receive help
• The same high level of safety and security you have come to expect with Anthem

Chat is one example of how Anthem is using digital technology to improve the health care experience, with a goal to save you valuable time. To get started, please access the service through Payer Services on Availity.

Use Provider Chat: Select Payer Spaces, select Anthem, and from Applications select Chat.

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Using our secure provider portal or EDI submissions (via Availity), administrative tasks can be reduced by more than fifty percent when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, just click here for EDI or here for the secure provider portal (Availity).

Get payments faster

By eliminating paper checks, Electronic Funds Transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and you can receive payments faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance, which meets all HIPAA mandates - eliminating the need for paper remittances.

Member IDs go digital

Anthem members are transitioning to digital member identification cards making it easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member. For more information on accessing this tool, see our October Provider News article:  Electronic member ID cards available on the Availity Portal.

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member identification cards to EDI transactions, application programming interface (API) to Direct Data Entry, we cover it all in our Provider Digital Engagement Supplement to the provider manual available here and on our secure provider portal through Availity. The Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits.

The Provider Digital Engagement Supplement to the provider manual is another example of how Anthem is using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now and go digital with Anthem.

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My Health Records allows members to share important health information with physicians, such as:

• Lab results and historical insights with visualizations
• Medications, Conditions, Immunizations, Vaccinations
• Health records
• Health records of dependents (14 years and under)
• Easy access to provider information
• Personalized health data tracking over time
• Integration for member authorization to more health record data

The enhanced digital tool gives physicians and hospitals a holistic view of a member’s up-to-date health data. This complete health data in one trusted place enables providers and members to feel more confident in making important life decisions easily and quickly.

*This tool is now available to Anthem members in our Medicare, Individual, Small Group and Fully Insured Large Group business segments and will be available to members in our Large Group ASO and Anthem National Account business segments in early 2021.

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We will explore key workflow options to fit your organization’s needs, including how to:

• Work a request in the inbox of your Attachments Dashboard.
• Enter and submit a web claim including supporting documentation.
• Use EDI batch options to trigger a request in your inbox.
• Track attachments you submitted using sent and history lists in your Attachments Dashboard.
• Get set up to use these tools.

As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.

Register for an upcoming webinar session:

1. In the Availity Portal, select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options:
   • In the Catalog, search by webinar title or keyword.
     • To find this specific live session quickly, use keyword medattach.
   • Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you’ll receive emails with instructions to join the session.

Webinar Dates:

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For assistance in determining proper coding guidance, the following site should be helpful: cdc.gov/nchs/icd/icd10cm.htm

One of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 notes. An Excludes 1 note indicates that the excluded code identified in the note should not be billed with the code or code range listed above the Excludes 1 note. These notes appear below the affected codes – if the note appears under the Category (first three characters of a code), it applies to the entire series of codes within that category.  If the Excludes 1 note appears beneath a specific code (3, 4, 5, 6 or 7 characters in length) then it applies only to that specific code 

• Reporting Z01.419 with Z12.4
  • Z01.41X (encounter GYN exam w/out abnormal findings) has an Excludes 1 note below that includes Z12.4.
  • Z12.4 (encounter for screening malignant neoplasm cervix)
• Reporting Z79.891with F11.2X
  • Z79.891 (long-term use of Opiates) has an Excludes 1 note after it for F11.2X. F11.2X (Opioid dependence)
• Reporting M54.2 with M50.XX
  • M54.2 (Cervicalgia) has an Excludes 1 note below it for M50.XX (cervicalgia due to intervertebral disc disorder)
• Reporting M54.5 with S39.012X and/or M54.4x
  • M54.5 (low back pain) has an Excludes 1 note below it which includes; S93.012X (strain of muscle, fascia and tendon of lower back), M54.4X (low back pain) M51.2X (lumbago due to intervertebral disc disorder)
• Reporting J03.XX with J02.XX, J35.1, J36, J02.9
  • J03. - (Acute tonsillitis) has an Excludes 1 note below it which includes; J02. - (acute sore throat),   J35.1 (hypertrophy of tonsils), J36 (Peritonsillar abscess)
• Reporting N89 with R87.62X, D07.2, R87.623, N76.XX, N95.2, 00
  • N89 (Other inflammatory disorders of the vagina) has an Excludes 1 note below the category for
  • R87.62X(abnormal results from vaginal cytological exam), D07.2 (vaginal intraepithelial neoplasia),
  • R87.623(HGSIL of vagina), N76.XX inflammation of the vagina), N95.2 (senile [atrophic] vaginitis),
  • A59.00 (trichomonal leukorrhea)

Finally, if you believe an Excludes1 note denial is incorrect, please consult the ICD-10-CM codebook to verify appropriate use of the billed codes and provide supporting documentation through the normal dispute process as to why the billed diagnoses codes are appropriately used together.

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Both paper and electronic claim formats accommodate the CLIA number. 

• On the CMS-1500 form, Box 23 (Prior Authorization) is reserved for the CLIA number.
• On the 837P, REF segments are available: REF (X4) in loops 2300 and 2400, and REF (F4) in loop 2400. 

Note: The CLIA number for the Referring Clinical Laboratory should be included in REF (F4) 

The following examples illustrate how the CLIA number as well as procedure code modifiers QW and 90 should be filed:

Additional information regarding CLIA is available on the CMS website at cms.gov/Regulations-and-Guidance/Legislation/CLIA/

If you have additional questions, please call the telephone number on the back of the member’s identification card.

The CDC promotes Be Antibiotics Aware, an educational effort to raise awareness encouraging safe antibiotic prescribing practices and use. Be Antibiotics Aware has many resources for health care professionals (in outpatient and inpatient settings) including videos such as The Right Tool and Antibiotics Aren’t Always the Answer that can be utilized in provider’s waiting rooms. 

To help prevent delays in claim processing and post-service reviews, ordering providers submit pre-service request to AIM in one of the following ways:

• Access AIM ProviderPortal directly at providerportal.com available 24/7 to process orders in real-time
• Access AIM via the Availity web portal at availity.com

As a reminder, AIM reviews the following services for clinical appropriateness:

• Advanced diagnostic imaging
• Cardiology tests and procedures (e.g. MPI, echocardiography, PCI, cardiac catheterization)
• Medical oncology treatments through the Cancer Care Quality Program
• Radiation oncology treatments (e.g. IMRT, brachytherapy)
• Sleep testing, treatment and supplies
• Genetic testing
• Musculoskeletal (e.g., spine and joint surgeries, pain management)
• Rehabilitative services (physical, speech and occupational therapy)
• Surgical Site of Care (e.g., gastroenterology, other surgeries will be implemented which will be communicated via Provider News)

Services performed in an emergency or inpatient setting are excluded from AIM programs.

This update applies to local fully-insured Anthem members and members who are covered under a self-insured (ASO) benefit plan, with services medically managed by AIM. It does not apply to BlueCard, Medicare Advantage, Medicaid, Medicare Supplement, and Federal Employee Program (FEP).

For more information please contact the phone number on the back of the member ID card.

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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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• Prior authorization requirements for the below codes
• AIM Musculoskeletal program expansion update
• AIM rehabilitation prior authorizations suspended for Group Retiree Solutions members until December 31, 2020
• Transition to AIM Rehabilitative Service Clinical Appropriateness Guidelines

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Preferred CGM edits do not apply to the following plans/plan types:

• Employer Group Waiver Plans (EGWP) Medicare Advantage Part D (MAPD) through Anthem
• Employer Group Waiver Plans (EGWP) Medicare Advantage (MA only) through Anthem
• Individual Medicare Advantage Plans (MA only) through Anthem

Delivery channels

Only members enrolled in a plan using preferred CGM edits will need to obtain their CGM systems from a retail or mail order pharmacy. Members on a plan without preferred CGM edits will be able to obtain their CGM systems through durable medical equipment (DME) providers in addition to retail and mail order pharmacies. Please check member and plan benefits to confirm the available delivery channels for accessing CGM products.

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Blue Shield (Anthem) and AMH Health, LLC Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity.* Provider Chat offers:

• Faster access to Provider Services for all questions.
• Real-time answers to your questions about prior authorization and appeals status, claims, benefits, eligibility, and more.
• An easy to use platform that makes it simple to receive help.
• The same high level of safety and security you have come to expect with Anthem and AMH Health.

Chat is one example of how Anthem and AMH Health are using digital technology to improve the health care experience, with the goal of saving valuable time. To get started, access the service through Payer Services on Availity.

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

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

If you have questions or would like additional information, use this email.

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The FDA approves new drugs/biologics using various pathways of approval. Recent studies on the effectiveness of drugs/biologics going through these different FDA pathways illustrates the importance of clinicians being aware of the clinical data behind a drug or biologic approval in making informed decisions.

Here is a list of the approval pathways the FDA uses for drugs/biologics:

• Standard Review: The Standard Review process follows well-established paths to make sure drugs/biologics are safe and effective when they reach the public. From concept to approval and beyond, FDA performs these steps: reviews research data and information about drugs and biologics before they become available to the public, watches for problems once drugs and biologics are available to the public, monitors drug/biologic information and advertising, and protects drug/biologic quality. To learn more about the Standard Review process, go here.
• Fast Track: Fast Track is a process designed to facilitate the development and expedite the review of drugs/biologics to treat serious conditions and fill an unmet medical need. To learn more about the Fast Track process, go here.
• Priority Review: A Priority Review designation means FDA’s goal is to take action on an application within six months. To learn more about the Priority Review process, go here.
• Breakthrough Therapy: A process designed to expedite the development and review of drugs/biologics that may demonstrate substantial improvement over available therapy. To learn more about the Breakthrough Therapy process, click here.
• Orphan Review: Orphan Review is the evaluation and development of drugs/biologics that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. To learn more about the Orphan Review process, click here.
• Accelerated Approval: These regulations allowed drugs/biologics for serious conditions that filled an unmet medical need to be approved based on a surrogate endpoint. To learn more about the Accelerated Approval process, click here.

Please open the attached PDF titled “New molecular entities approvals. January to August 2020.pdf” to view new molecular entities approvals from January to August 2020.

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