For more information on the claim dispute process, please see the table in the attached PDF titled Anthem provider claims dispute process.

It’s important to note that providers and facilities will not be penalized for filing a claim payment dispute.

Attend a training webinar

For step-by-step instructions about how to submit a claim payment dispute through Availity, register for training by logging onto Availity.com > Help & Training > Get Trained > Select the session most convenient for you. Self-guided training is also available through Get Trained.

For a more detailed explanation of our claims payment dispute and clinical appeal process, please review the Provider Manual.

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

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Understanding how to use the many time saving applications on Availity Essentials* is important to working together digitally. Anthem Blue Cross and Blue Shield has developed a learning place just for that purpose — the Provider Learning Hub.

Using the Provider Learning Hub available from https://www.anthem.com/provider is the easiest and quickest way to access courses and learning guides about claim submission, attachments and status, eligibility and benefits, and more.

These new and improved learning experiences apply to Availity Essentials and electronic data interchange (EDI) transactions:

• Visit the Provider Learning Hub for short, easy-to-follow training videos with supporting resources — no username and password required.
• Handy filtering options make it easy to find what you are looking for.
• The Favorites folder lets you save courses for easy access later.
• Register once and on future visits your preferences are populated, eliminating the need for any additional logon information.

Get started today!

Access the Provider Learning Hub today using this link or from https://www.anthem.com/provider under Important Announcements on the home page.

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

Submit updates and corrections to your directory information using our online Provider Maintenance Form. Online update options include:

• Add/change an address location.
• Name change.
• Tax ID changes.
• Provider leaving a group or a single location.
• Phone/fax number changes.
• Closing a practice location.

Once you submit the form, we will send you an email acknowledging receipt of your request.

The Consolidated Appropriations Act (CAA) contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. By reviewing your information regularly, you can help us ensure your online provider directory information is current.

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The following services will be added to prior authorization for GA local members for the effective dates listed below.

Eligibility and benefits can be verified by accessing Availity* via the Anthem Blue Cross and Blue Shield (Anthem) provider website or by calling the number on the back of the member’s identification card. Service preapproval is based on the 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 approval prior to rendering the designated services listed below may result in denial of reimbursement.

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

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

Consultation codes will no longer be allowed for Anthem Blue Cross and Blue Shield for Medicare Advantage. This determination aligns with CMS guidance and does not allow reimbursement for inpatient (99251-99255) or outpatient (99241-99245) consultation codes and requires providers to bill the appropriate office visit evaluation and management (E/M) code for consultation services.

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Material adverse change (MAC)

Effective for dates of service on and after December 1, 2022, the specialty Medicare part B drug listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

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(Policy 21-001, effective 01/01/2022)

In the October 2021 edition of the provider newsletter, we announced that a new reimbursement policy titled Sexually Transmitted Infections Testing — Professional would be effective for dates of service on or after January 1, 2022. We have made a decision to retract this reimbursement policy.

If you have any questions, contact your Provider Experience associate or visit the Contact Us page on our provider website (https://www.anthem.com/medicareprovider) for up-to-date contact information.

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Material adverse change (MAC)

Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

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This FAQ is for informational purposes only and is intended to provide guidance regarding the changing landscape of Medicare telehealth. This guidance is not all-inclusive; it is intended to address frequently asked questions and common Medicare telehealth topics. The content included herein is not intended to be a substitute for the provisions of applicable statutes or regulations or other relevant guidance issued by CMS, as those items are subject to change from time-to-time.

General

Q. What virtual services are categorized as telehealth?

According to CMS, there are three main types of virtual services that physicians and other qualified healthcare providers can render to Medicare beneficiaries: (i) Medicare telehealth visit; (ii) virtual check-ins; and (iii) e-visits. Medicare telehealth visits are those facilitated by a telecommunication system between a provider and a patient. Virtual check-ins, which may or may not be face-to-face, are brief (5 to 10 minutes) interactions with an established patient and provider via telephone or other telecommunications platform and are used to determine whether an office visit or other service is needed. E-visits are non-face-to-face, patient-initiated communications between an established patient and their provider through an online patient portal. Please refer to the CMS Telemedicine Fact sheet for additional information.

As a result of the COVID-19 public health emergency (PHE), CMS has expanded the types of services that may be offered via telehealth. A complete list of Medicare telehealth services payable under the Medicare Physician Fee Schedule can be found here: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.

In accordance with the Social Security Act and CMS guidance, healthcare professionals such as physicians, nurse practitioners, physician assistants, certified registered nurse anesthetists, certified nurse-midwives, clinical social workers, clinical psychologists, and registered dietitians may perform and bill for acceptable telehealth services within their scope of practice and consistent with federal and state requirements. For more information, please view the Social Security Act and the CMS List of Telehealth Services.

Yes, CMS has eased some Health Insurance Portability and Accountability Act (HIPAA) Privacy rules and currently permits the use of telecommunications systems that have audio and video capabilities that allow for simultaneous real-time, interactive communication between a healthcare provider and a patient. During the COVID-19 PHE, the Department of Health & Human Services (HHS) has waived penalties for HIPAA violations, allowing healthcare providers to serve patients using communications technologies, like FaceTime or Skype, when used in good faith. The Department of Health & Human Services (HHS) addresses telehealth remote communications in the Notification of Enforcement Discretion for Telehealth.

Currently, and throughout the duration of the PHE, eligible providers may furnish certain limited services using  audio-only technology. These services are included on the Medicare telehealth list. Unless this list indicates that a service is acceptable for delivery through audio-only interaction, the Medicare telehealth service must be furnished simultaneously using, at a minimum, an interactive audio and video telecommunications system that permits real-time communication between the provider and patient.

Telephonic-only (in other words, telephone) evaluation and management (E/M) service provided by a physician or other qualified healthcare professional to an established patient, parent, or guardian (not originating from a related E/M services provided within the last seven days nor leading to an E/M service or procedure within the next 24 hours) should be billed with codes 99441-99443.

Historically, therapy services, such as occupational therapy, have not been included on the list of approved Medicare telehealth services. However, in light of the public health emergency (PHE) associated with the COVID-19 pandemic, CMS offered additional clarification in the interim final rule and March 17, 2020 Medicare Provider FAQ. There, CMS acknowledged the need to mitigate exposure risks during the PHE by adding therapy services to the telehealth list as of March 1. Importantly, only eligible healthcare providers may render such services.

While practitioners such as physical therapists, occupational therapists, and speech-language pathologists are not among those identified under section 1842(b)(18)(C) of the Social Security Act as eligible to furnish and bill for Medicare telehealth services, such providers are permitted to offer virtual check-ins (G2010 and G2012) and remote evaluations (in other words, e-visits (G2061-G2063)), and telephone E/M services (98966-98968), where appropriate.

As a result of the COVID-19 PHE, many states have relaxed licensing requirements to support continuity of care and prevent impediments to accessing care during these unprecedented times. Further, on March 13, 2020, pursuant to the 1135-based waivers, CMS temporarily waived requirements that out-of-state healthcare providers must be licensed in the state in which they are providing services as well as the state in which they practice. More specifically, CMS will waive this licensing requirement when the following criteria is met: (i) provider is enrolled in the Medicare program; (ii) provider has a valid license to practice in the state associated with their Medicare enrollment; (iii) state in which provider is practicing – in addition to that associated with their Medicare enrollment – is affected by the COVID-19 PHE; and (iv) provider is not affirmatively barred from practice in the state in which they seek to render services or any other state that is part of the 1135 emergency area. Therefore, if the above criteria are met, providers may practice in states other than that in which they are licensed to practice if the state in which the provider wishes to practice via telehealth has – like CMS – waived its licensure requirements. Because licensure and scope of practice laws vary from state to state, it is important to check the applicable state-specific requirements and a member’s benefit agreement.

For additional information on the 1135 Waiver, please consult the Waiver or Modification of Requirements under Section 1135 of the Social Security Act from the US Department of Health and Human Services.

Billing and documentation guidance:

To report telehealth E/M services to Anthem for a real-time, interactive simultaneous audio and video encounter, the applicable E/M CPT code, CPT Telehealth modifier 95, and either POS 02 or POS 10, depending on the location of the patient at the time of service should be used.

Importantly, CPT Telehealth modifier 95 must be used to indicate the encounter as an audio and video, real-time, interactive interaction between a provider and a patient. CPT Telehealth modifier 93 must be used to indicate the encounter as an audio only interaction between a provider and a patient.

No, under section 1834(m)(4)(C) of the Social Security Act, Medicare telehealth visits must meet strict originating site requirements (both geographic and site of service restrictions). Statutory originating sites include locations such as physician or practitioner office, hospital, skilled nursing facility, among other healthcare facilities. However, in the interim final rule, CMS lifted these restrictions for services beginning March 6, 2020, and for the duration of the COVID-19 PHE. There, CMS authorized qualified healthcare providers to render telehealth services to patients wherever they are located, including the patient’s home.

Healthcare providers should document services furnished via telehealth the same way a face-to-face encounter would be documented, except for the elements that require the presence of the patient, in other words, physical examination. Additionally, providers should document that the service was rendered via telehealth to reflect details of the encounter accurately and completely, specifically indicating whether the telehealth visit was with audio and video or whether it was audio only. See above regarding Q&A as to coding guidance, for example, E/M, POS, and CPT Telehealth modifier.

Yes, as of April 30, 2020, CMS expanded the list of acceptable Medicare telehealth services to include the AWV (G0438, Initial AWV and G0439, Subsequent AWV). Though several of the required elements of an AWV look and feel the same when completed via telehealth, some, like recording a patient’s vitals, necessitate adaptation. Healthcare providers should continue to document all information accurately and completely what they are able to collect during a telehealth encounter. Therefore, the provider can ask the patient if they have the ability to measure their height, weight, temperature, blood pressure, and/or heart rate. If so, the patient may be able to do so during the telehealth encounter. Alternatively, the patient may be able to self-report such information; self-reported information should be documented as such.

However, if vitals cannot be captured during a telehealth AWV, an AWV may still be conducted and billed when rendered in accordance with state and federal guidelines. In the interim final rule, CMS provided additional flexibility to providers during the COVID-19 PHE: on an interim basis, CMS removed requirements regarding documentation of history and/or physical exam in the medical record for office/outpatient evaluation and management (E/M) encounters provided via telehealth.

Medicare Risk Adjustment (MRA or risk adjustment)

As of the April 10, 2020, Memo, and as confirmed in the updated January 15, 2021, Memo, CMS authorizes Medicare Advantage organizations (MAOs) to submit diagnoses for risk adjustment from telehealth encounters, only when those encounters meet all criteria for risk adjustment data submission. More specifically, diagnoses submitted for risk adjustment purposes from a telehealth encounter must meet the following requirements:

• Encounter must be face-to-face, using interactive audio telecommunication simultaneously with video telecommunication to permit real-time communication between the provider and the member;
• Provider must use CPT Telehealth modifier 95;
• Provider must use POS 02 for telehealth provided at a location other than the patient’s home or POS 10 for telehealth provided in the patient’s home;
• Services rendered must be those which are allowable by CMS, included within the Anthem benefit package, and clinically appropriate to furnish via a face-to-face telehealth encounter;
• Provider must be an acceptable physician specialty/provider type, for example, physician (MD or DO), physician assistant (PA), or nurse practitioner (NP); and
• Encounter must meet all other criteria for risk adjustment eligibility, which include, but are not limited to, being from an allowable inpatient, outpatient, or professional service.

As a result of the COVID-19 PHE, CMS expanded the definition of face-to-face with regard to risk adjustment data submission criteria. Formerly, this requirement was met only when an in-person encounter between a patient and an acceptable provider type/physician specialty occurred. Under its April 10, 2020, guidance, CMS authorized satisfaction of this required element in a virtual setting via telehealth. To meet the risk adjustment face-to-face requirement for telehealth encounters, CMS requires the provider to simultaneously use an interactive audio and video telecommunications system that permits real-time communication between the provider and patient.

No, an audio-only encounter, such as that facilitated using telephone audio-only, does not satisfy the criteria for risk adjustment data eligibility. To satisfy the criteria for risk adjustment data submission, diagnoses submitted based on a telehealth encounter must be derived from an eligible face-to-face interaction between a provider and patient. More specifically, the interaction must be conducted in real-time with simultaneous use of an interactive audio and video telecommunication system.

To report telehealth Evaluation and Management (E/M) services to Anthem for an audio and video encounter, please use applicable E/M CPT code, CPT Telehealth modifier 95, and either POS 02 or POS 10 depending on the location of the patient at the time of service. CPT Telehealth modifier 95 in addition to the applicable POS must be used so Anthem can identify the encounter as an eligible face-to-face telehealth encounter, in other words, one that took place via real-time, simultaneous interactive audio and video telecommunications system. Providers should also document that the service was rendered via telehealth to reflect details of the encounter accurately and completely, specifically indicating that the telehealth visit was performed with audio and video.

Yes, CMS currently permits the use of telecommunications systems with audio and video capabilities that allow for simultaneous, real-time, interactive communication between a healthcare provider and a patient. During the COVID-19 PHE, penalties for HIPAA violations have been waived. This waiver allows providers to serve patients using communications technologies like Skype or FaceTime when used in good faith. The department of Health and Human Services (HHS) addresses telehealth remote communications in the Notification of Enforcement Discretion for Telehealth.

During an April 29, 2020, stakeholder call, CMS clarified to what DOS its April 10, 2020, guidance regarding the applicability of diagnoses from telehealth services for risk adjustment data submission and payment applied. There, CMS stated that such guidance is applicable to eligible face-to-face telehealth encounters (in other words, those using real-time, interactive audio simultaneously with video) within open data submission periods, which as of the date of publication of this document include 2019 DOS, 2020 DOS, 2021 DOS, and 2022 DOS.

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