You can now request your Professional Provider Fee Schedule via the Provider Enrollment application through the Availity Essentials website:

• All professional providers can download the complete fee schedule within minutes.
• Providers will be able to pull historic fee schedules (up to three years), and current and future rate(s).
• This is one centralized location to access your commercial network fee schedules.

See details below on how to log in and access your fee schedule application. If your organization is not currently registered for Availity Essentials, go to Availity.com and select Get Started to complete the online application.

How to get started

This document will familiarize you with the fee schedule application found on the Availity Essentials website.

Your administrator will need to assign the user role of Provider Enrollment and Fee schedule, from Manage My Team(s) on Availity.com, to access the application.

Accessing your fee schedule:

1. Log in to Availity.com.
2. Select Payer Spaces in the top menu bar.
3. Select the payer title that corresponds to your market.
4. Accept the User Agreement (once every 365 days).
5. On the Applications tab, select Provider Enrollment.
6. Select Request Fee Schedule link under the My Fee Schedule option on the side menu.
7. Enter the information in the form and select the commercial network, for which you want to get the fee schedule, and choose Submit.
8. On successful submission, select the Fee Schedule Result link to view the result file.

Important notes:

• It might take up to 15 minutes for your rates file to be ready to download. Refresh the results page, and the download icon will display.
• The downloaded file is in Excel format. Please read through the disclaimer before using the rates.
• Review the Reference Guide for the fee schedule from our learning center by navigating to Payer Spaces > Custom Learning Center application > Courses section.

If you have questions regarding the Availity Essentials platform, contact Availity Customer Support.

If you have other questions, contact your local provider relationship account manager.

We are committed to a future of shared success.

Celebrating extraordinary impacts on health:

• The new Care Provider Recognition Program honors excellence in Medicare patient care.
• The annual program launching in the fall of 2024 will award top healthcare providers.
• Winners will be chosen based on quality measures and good standing with health plans.
  

We’re committed to going beyond the contract to make a real impact on health together with our care providers. To celebrate and appreciate our care provider partners for outstanding performance in patient care, we’re excited to announce our new Care Provider Recognition Program.

This program honors successes and highlights those who are driving toward better outcomes. It provides care providers with an opportunity to thank and celebrate teams for going above and beyond to deliver high-quality, cost-efficient care, while driving health equity and exceptional patient experiences, and outcomes.

Launching in the fall of 2024, this annual program will recognize care providers who deliver excellence in care to their Medicare patients, our members — which makes it different from other distinctions in the industry. Winners of the 2024 Care Provider Recognition Award will be announced in mid-‑December. 

Winners will be selected based on the following criteria:

• Top 5% of care providers based on quality measured through our internal Medicare data based on current performance and three-year average, including medical best practices such as preventive care screenings, immunizations, chronic disease management, and medication adherence
• In-network and contract in good standing with an affiliated health plan

Driving toward better health outcomes is a critical shared goal with our care provider partners, and results like these are worthy of the spotlight.

We are committed to finding solutions that help our care provider partners offer quality services to our members.

At a glance:

• Care providers will use the Error Report function in Availity Essentials to identify, rectify, and resubmit errors in rosters.
• The new Results Report is available to view.
• Both the Error and Results Reports can be found on the Upload Roster File page of Availity, with additional guidance available in the Roster Submission Guide.

Error Report an essential tool to identify and correct mistakes

As previously communicated, we introduced an Error Report to the Upload Roster File screen in Availity Essentials Provider Data Management (PDM). Care providers can use this Error Report to understand where errors occurred (specifically which sheet, tab, and row), the cause of the issue, and how to fix it.

As a reminder, you will need to correct any errors submitted in a roster (for example, missing data or incorrectly formatted data) in the future. Rows in a roster that contain an error will not be processed and the addition, change, or termination will not be updated in our systems.

Effective November 15, 2024, care providers are responsible for using the Error Report to identify errors in a roster, correct them, and resubmit the roster rows that contain errors. Rows in a roster that contain an error will not be processed and the addition, change, or termination will not be updated in our systems.

New Results Report identifies added and updated records

For better transparency for our care providers, we’ve now introduced a new Results Report that allows care providers to see the number of unique records that were added or updated based on a specific roster. The Results Report also contains data elements associated with the records, including NPI, TIN, name, address, and effective date. Think of it as a receipt of the actions taken to keep your demographic information accurate. A Results Report has been created for rosters received on and after June 15, 2024.

Both reports are on the Upload Roster File page of Availity

You can find the Results Report, as well as the Error Report, on the Upload Roster File page of Availity PDM. Future informational webinars are coming soon — Watch for updates in the Provider Newsletter.

Use the Roster Submission Guide

Additional information about the Results Report and Error Report can be found in our Roster Submission Guide. Find it online at Availity.com > Payer Spaces > Select Payer Tile > Resources > Roster Submission Guide using Provider Data Management.

Access our previous communications below

Colorado
Connecticut
Georgia
Missouri
New Hampshire
Ohio
Virginia

We look forward to working together to achieve improved outcomes.

On September 23, 2024, Anthem will add new specialties to the Provider Enrollment tool hosted on Availity Essentials to further automate and improve your online enrollment experience.  

Who can use this new tool?

• Therapy providers (physical therapist, occupational therapist, and speech therapist)
• Audiologists and hearing aid fitters
• Registered dieticians (Independent providers should enroll through American Specialty Health (ASH) at ashcompanies.com/Contact or 800-972-4226)
• Acupuncturists

What does the tool provide?

• Enroll as an individual provider.
• Enroll a new group of providers.
• Apply and request a contract. After review, a contract can be sent back to you digitally for an electronic signature. This eliminates the need for paper applications or paper contracts.
• Use a dashboard for real time status on the submitted applications.
• Experience streamlined complete data submission.

Reviewing how the online enrollment application works

Availity’s online application will guide you throughout the enrollment process and provide status updates using a dashboard. As a result, you will know where each provider is in the application process without having to call or email for a status update.

Please note: For any changes to your practice profile, adding or deleting practitioners, and updating demographics, use the Provider Data Management (PDM) application on Availity Essentials that allows you to electronically submit any changes to your practice profile and demographics. Availity administrators and assistant administrators can access PDM by going to Availity > My Providers > Provider Data Management.

Accessing the Provider Enrollment application

Log on to Availity Essentials and select Payer Spaces > Anthem > Applications > Provider Enrollment to begin the enrollment process.

If your organization is not currently registered for Availity Essentials, the person in your organization designated as the Availity administrator should go to Availity.com and select Register.

For organizations already using Availity Essentials, your organization's Availity administrator should go to My Account Dashboard from the Availity home page to register new users and update or unlock accounts for existing users. Staff who need access to the Provider Enrollment tool need to be granted the role of Provider Enrollment. Availity administrators and user administrators will automatically be granted access to Provider Enrollment.

If you are using Availity Essentials today and need access to Provider Enrollment, please work with your organization’s administrator to update your Availity Essentials role. To determine who your administrator is, you can go to My Account Dashboard > My Administrators.

Need assistance with registering for Availity Essentials?

Contact Availity Client Services at 800-282-4548.

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised during Quarter Two, 2024. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications, or criteria, and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit https://anthem.com/provider/policies/clinical-guidelines.

Notes/updates

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• MED.00055 - Wearable Cardioverter Defibrillators:
  • Reformatted language from the to a wearable cardioverter defibrillator and moved punctuation
  • Added Not Medically Necessary statement when individual has an automated external defibrillator
• RAD.00069 - Absolute Quantitation of Myocardial Blood Flow Measurement:
  • The use of absolute quantitation of myocardial blood flow testing is considered Investigational & Not Medically Necessary for all indications
• SURG.00011 – Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting:
  • Revised ocular indications, including the addition of SurSight to Medically Necessary and Not Medically Necessary section and added new Medically Necessary criterion addressing non-healing or persistent corneal epithelial defects
  • Removed VersaWrap from Investigational & Not Medically Necessary statement
  • Removed Phasix Mesh from Investigational & Not Medically Necessary statement
  • Added Phasix Mesh and Phasix ST Mesh to Medically Necessary and Not Medically Necessary statements
• CG-DME-54 - Mechanical Insufflation-Exsufflation Devices:
  • Outlines the Medically Necessary and Not Medically Necessary criteria for use of mechanical insufflation-exsufflation devices

Medical Policies

On May 9, 2024, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These Medical Policies take effect October 10, 2024.

Clinical UM Guidelines

On May 9, 2024, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members on June 27, 2024. These guidelines take effect October 10, 2024.

Effective January 1, 2025, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://anthem.com/provider/medicare-advantage on the Resources tab or for contracted providers by accessing Availity.com.

Effective January 1, 2025, Anthem will change its process for approving members for special supplemental benefits for the chronically ill (SSBCI), such as groceries, utilities, chronic meals (for more than 90 days), and nonemergency transportation to non-health-related destinations.

Per CMS guidelines, to be eligible for SSBCI benefits, a member must have a qualifying chronic condition and meet all the criteria below:

1. Has one or more comorbid and medically complex chronic conditions that are life threatening or significantly limit the overall health or function of the enrollee
2. Has a high risk of hospitalization or other adverse health outcomes
3. Requires intensive care coordination

To ensure that members, care providers, and other clinical teams have a clear understanding of eligibility requirements, Anthem has established a set of Clinical Guidelines that we believe equate to the above criteria. In short, a member would be deemed eligible for an SSBCI benefit if they:

• Have a valid chronic condition as listed in their Evidence of Coverage (EOC)
• And any of the following are true:
  • Had one or more inpatient admissions (inclusive of behavioral health) related to the chronic condition in the last 12 months
  • Had one or more urgent care or emergency room visits related to the chronic condition in the last 12 months
  • Had two or more outpatient visits related to the chronic condition (including primary care or specialty care visits) in the last 12 months
  • Are a patient who requires home health visits related to the chronic condition
  • Are a patient who has an impairment in daily living activities related to the chronic condition (bathing, dressing, toileting, transferring, and eating) or cognitive impairments
  • Are a patient with one or more chronic conditions and a need for one or more pieces of durable medical equipment (DME) in the outpatient setting, including but not limited to: group 3 power/manual wheelchair, noninvasive ventilation (NIV), wound vacuums, bipap machines, mechanical in-exsufflation devices, or group 2 or group 3 mattresses
  • Are successfully enrolled in a chronic special needs plan (CSNP)

In the past, Anthem and many other plans used a member’s chronic condition as the principal cause for eligibility. As a result of the revised guidance, Anthem will need to ensure that all new members as well as those previously approved meet the criteria above.

Use of care provider confirmations to support eligibility

When insufficient evidence is available for Anthem to render an organizational determination on a member’s eligibility, Anthem will request a medical review by its participating care providers that a member meets the clinical guidelines listed above.

The request will generally be faxed to care providers as an SSBCI Provider Confirmation Form, preprinted with member information and including instructions and reference materials such as a summary of eligible conditions and applicable Clinical Guidelines. Since these requests impact a member’s access to benefits, we are requesting that they be treated like any other organizational determination request, preferably returned within three to five days of receipt.

The process for both new and existing members will begin in October 2024 and will impact members’ benefits for the 2025 plan year.

Additional notes for care providers delegated for utilization management by Anthem

For care providers delegated by Anthem for utilization management, this process is being retained by Anthem as it applies to supplemental benefits, which generally are not included in such delegation. Consequently, we ask that these care providers please follow the guidance provided above and work directly with Anthem to establish member eligibility for SSBCI benefits.

For answers to other questions, contact your Provider Services representative.

Beginning with dates of service on or after January 1, 2025, Anthem will update the Modifiers 59 and XE, XP, XS, and XU: Distinct Procedural Service — Professional reimbursement policy Related Coding section to add the following:

• J1202 will deny when reported with G0138

In addition, the policy title was renamed from Distinct Procedural Service: Modifiers 59 and XE, XP, XS, and XU.

For specific policy details, visit reimbursement policy.

Through our efforts, we can help our care provider partners deliver high-quality, equitable healthcare.

In the August 2024 edition of the Provider News, we announced an update to the Nurse Practitioner and Physician Assistant Services policy. To clarify, we are aligning the reimbursement policy with Centers for Medicare & Medicaid Services (CMS) guidelines to indicate which services will be eligible for a payment reduction according to the Nurse Practitioner and Physician Assistant Services reimbursement structure.

The following services were removed from the policy and are eligible for a payment reduction when billed by NP/PA provider.

• Preventive Services
• Radiology Services

The following physician’s services are not subject to the NP/PA reimbursement payment reduction and the services are included in the not considered for payment reduction section.

• Drugs
• Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)
• Laboratory Services and Laboratory Screening Services

For specific policy details visit the reimbursement policy page

The specialty pharmacy updates for Anthem are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.

Note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request a prior authorization review for your patients’ continued use of these medications.

The inclusion of a National Drug Code (NDC) code on your claim will help expedite the claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Effective for dates of service on or after January 1, 2025, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria at https://tinyurl.com/4dv6rxe4 to view the complete information for these prior authorization updates.

Step therapy updates

Effective for dates of service on or after January 1, 2025, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process.

The current Orencia step therapy preferred product list under the medical benefit is being modified to include only those that are considered medical benefit drugs.

Access our Clinical Criteria at https://tinyurl.com/4dv6rxe4 to view the complete information for these step therapy updates.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Quantity limit updates

Effective for dates of service on or after January 1, 2025, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria at https://tinyurl.com/4dv6rxe4 to view the complete information for these quantity limit updates.

At a glance:

• Significant Medicare Part D updates in 2025 include a $2,000 out-of-pocket cap and elimination of the coverage gap.
• Enhanced benefits will remove cost-sharing in catastrophic coverage and expand low-income subsidies to 150% of the federal poverty level (FPL).
• The Medicare Prescription Payment Plan (M3P) will allow members to spread out prescription costs over the year for added financial flexibility.

What's changing in 2025?

Changes in deductible and out-of-pocket thresholds

In 2024, the standard deductible was $545 with the initial coverage limit at $5,030, and the catastrophic coverage threshold was $8,000. By 2025, the deductible will increase to $590, and members will enter the catastrophic phase when their out-of-pocket expenditure reaches $2,000. Members might see higher upfront costs due to the increased deductible, but reaching catastrophic coverage will be significantly easier, offering greater financial protections much sooner.

Elimination of the coverage gap (donut hole)

The elimination of the coverage gap will simplify the benefit structure. Previously, beneficiaries paid 25% of the cost of both brand-name and generic drugs in the coverage gap. The full elimination of this gap will remove the phase where members faced higher out-of-pocket costs, reducing financial uncertainty and streamlining the benefits process.

Introduction of a $2,000 out-of-pocket cap

In 2025, after reaching the $2,000 out-of-pocket cap, members will no longer have to pay added costs for their medications for the remainder of the year. This offers financial protection and predictability in managing healthcare expenses, helping those with high prescription drug costs.

Elimination of cost-sharing in catastrophic coverage

While in 2024, members had to pay 5% of drug costs after reaching the out-of-pocket threshold; this requirement will lift entirely in the next year. This ensures complete coverage once members reach the catastrophic phase, removing the financial burden for members with extremely high drug costs.

Enhanced low-income subsidy (LIS) benefits

We are also introducing enhanced LIS benefits, extending full benefits to individuals with incomes up to 150% of the FPL from the previous 135% FPL threshold. This change means more members will qualify for full LIS benefits, reducing their premiums, deductibles, and copayments, which improves access to necessary medications for low-income beneficiaries.

Introduction of the Medicare Prescription Payment Plan (M3P)

M3P allows members to manage their out-of-pocket Medicare Part D drug costs by spreading the total sum of their filled prescription costs across the calendar year. This option is voluntary, free to enroll, and members can choose to participate at any point during the year. Instead of paying at the pharmacy, members will receive a bill from their health or drug plan to pay for their prescription drugs each month, offering greater financial flexibility and predictability.

Action plan and resources

To ensure a smooth transition, we’ve laid out a comprehensive educational and communication strategy:

• Information campaign: As of July 2024, we began an extensive marketing and educational campaign, including public relations efforts, direct member communications, and care provider briefings.
• Training and support: We are providing training materials, talking points, and FAQs to our support teams, ensuring they are well-prepared to assist you.

Key dates:

• October 15, 2024: Enrollment in M3P begins
• January 1, 2025: All other M3P requirements become effective

Next steps:

• Care providers should stay up to date and make use of the resources we provide to better assist patients. Staying updated on any changes in the formulary and benefit structures will ensure that you can provide the highest quality care possible.
• Members should keep an eye out for detailed communications about their enhanced Medicare Part D coverage. Members can contact our support team for personalized assistance.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

As we move into 2025, our goal is to provide you with the knowledge and resources needed to maximize the new Medicare Part D benefits. Thank you for trusting us to help manage your healthcare needs.

Visit the Drug Lists page on our website at anthem.com/ms/pharmacyinformation/home.html for more information about:

• 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.
• Any other requirements, restrictions, or limitations that apply to using certain drugs.

The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.

To locate the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.

Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.

Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access.

Through our efforts, we are committed to reducing administrative burden because we value you, our care provider partner.