Join us in a Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving STARs ratings.

 

Program objectives:

• Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s quality and STARs ratings.

 

Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.

 

REGISTER HERE for our upcoming clinical quality webinars!         

 

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The National Accounts 2022 pre-certification list has been published. Please note, providers should continue to verify member eligibility and benefits prior to rendering services.

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Material adverse change (MAC)

 

AIM Specialty Health®

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 prior authorization 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 prior authorization 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 website 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
• Rehabilitative services
• Outpatient sleep testing and therapy services
• Cancer care quality program
• Musculoskeletal (for fully insured)
• Upper gastrointestinal endoscopy in adults, and site of care for certain surgical services

For more details on these programs, please visit the AIM website. 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 on 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.

 

Add to preapproval
CG-MED-59 Upper Gastrointestinal Endoscopy in Adults	0652T, 0653T, 0654T	Added 7/1/2021 (New Codes)
TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection	0055U, 0087U, 0118U	Added 12/01/2021

 

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Adults 40–75 years of age with diabetes, who do or do not have clinical atherosclerotic cardiovascular disease (ASCVD), should be started on a statin for primary and secondary prevention of ASCVD regardless of lipid status.¹

 

Studies show that statin use reduces comorbidities and mortality from heart disease and non-adherence to statins may increase cardiovascular events and even death.²

Clinicians play a powerful role in ensuring their patients are adherent to their statin therapies. In fact, 90% of patients can be successfully adherent to statin therapy with a personalized approach.

We created this video to offer clinicians best practices in helping their patients remain adherent to their statin therapies.

The following 7 strategies can help increase adherence to statin therapy in your patients:

1. Initiate statin therapy for patients with diabetes or clinical ASCVD as appropriate

• For diabetics without ASCVD, use MODERATE INTENSITY statin for primary prevention.²
• For diabetics with ASCVD, use HIGH INTENSITY statin for secondary prevention.¹
• Low Intensity statins are not recommended unless unable to tolerate moderate or high intensity.⁴

 

Medications One of the following medications must have be dispensed to satisfy the SUPD measure.
Drug Category	Medications
Statin medication	·       Lovastatin ·       Fluvastatin ·       Pravastatin ·       Simvastatin ·       Rosuvastatin ·       Atorvastatin ·       Pitavastatin
Statin combination products	·       Atorvastatin / amlodipine ·       Atorvastatin / ezetimibe ·       Lovastatin / niacin ·       Simvastatin / ezetimibe ·       Simvastatin / niacin ·       Simvastatin / sitagliptin
Timeframe	Standard exclusion(s)
Any time during the measurement year	·       End-stage renal disease ·       Hospice ·       Rhabdomyolysis or        myopathy ·       Pregnancy, lactation, or fertility ·       Liver disease ·       Pre-diabetes ·       Polycystic ovary syndrome (PCOS)

 

2. If a statin is not suitable for a patient, document exclusion criteria with the appropriate ICD-10 code
3. Educate patients about the long-term cardiovascular benefits of statin therapy and potential side effects 
4. Try a lower dose, different statin, or consider intermittent statin therapy if there were previous statin-associated side effects

Intensity and Dose of Statin Therapy
High Intensity	Moderate Intensity	Low Intensity
5.       Daily dose lowers LDL-C on average by ≈ ≥50%	6.       Daily dose lowers LDL-C on average by ≈ 30% to <50%	7.       Daily dose lowers LDL-C on average by <30%
8.       Atorvastatin 40-80 mg 9.       Rosuvastatin 20-40 mg	10.   Atorvastatin 10-20 mg 11.   Rosuvastatin 5-10 mg 12.   Simvastatin 20-40 mg 13.   Pravastatin 40-80 mg 14.   Lovastatin 40 mg 15.   Fluvastatin XL 80 mg 16.   Fluvastatin 40 mg bid 17.   Pitavastatin 2-4 mg	18.   Simvastatin 10 mg 19.   Pravastatin 10-20 mg 20.   Lovastatin 20 mg 21.   Fluvastatin 20-40 mg 22.   Pitavastatin 1 mg

 

5. Inform patients that a significant number of generic statin medications are available for $0 for a 90-day supply on most plans
6. Encourage patients to use their plan ID card to fill statin medications
7. Watch this video to learn best practices on helping improve statin therapy adherence and your organization’s overall quality and STARS performance.

 

References:

1. 2013 ACC/AHA Prevention Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S1-S45, June 24, 2014. https://www.ahajournals.org/doi/pdf/10.1161/01.cir.0000437738.63853.7a

 

2. American College of Cardiology, The New 2017 American Diabetes Statement on Standards of Medical Care in Diabetes: Reducing Cardiovascular Risk in Patients with Diabetes, May 22, 2017. https://www.acc.org/latest-in-cardiology/articles/2017/05/22/11/00/new-2017-american-diabetes-statement-on-standards-of-medical-care-in-diabetes

 

3. CMS, 2019 Medicare-Medicaid Plan Performance Data Technical Notes. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination Office/FinancialAlignmentInitiative/Downloads/MMPPerformanceDataTechNotes.pdf

4. Cochrane Database Syst Rev. 2013:CD004816

 

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Instead of faxing multiple pages of medical records for HEDIS® studies, use Anthem’s Remote EMR Access Service we offer to providers that allows us to access your EMR system directly to pull the documentation we need. Our Remote EMR Access Service helps reduce the time and costs associated with medical record retrieval while improving efficiency and lessening the impact on your office staff.

 

We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS® measure updates. We complete medical record retrieval based on minimum necessary guidelines:

• We only access medical records of members pulled into the HEDIS® sample using specific demographic data.
• We only retrieve the medical records that have evidence related to the HEDIS® measures.
• We only view face sheets when there are demographic discrepancies.
• We exclude data related to hospice, long-term care, inpatient, and palliative care.

 

Let us help you! Getting started with Remote EMR Access is just one click away.

Download and complete this registration form and email it to us at Centralized_EMR_Team@anthem.com.

 

To learn more about our Remote EMR Access Service, view the Frequently Asked Questions below.

 

How do you retrieve our medical records? 
We access your EMR using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally, on our secure network drives.

 

Is printing necessary?
Yes. The NCQA audit requires print-to-file access.

 

Is this process secure?
Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem’s secure network drives.

 

Why does Anthem need full access to the entire medical record?
There are several reasons we need to look at the entire medical record of a member:

• HEDIS® measures can include up to a 10-year look back at a member’s information.
• Medical record data for HEDIS® compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
• Compliant data may be documented or housed in a non-standard format, such as an in-office lab slip scanned into miscellaneous documents

What information do I need to submit to use your Remote EMR Access Service?

• Complete the registration form that requests the following information:
• Practice/facility demographic information (e.g., address, National Provider ID, taxpayer identification numbers, etc.)
• EMR system information (e.g., type of EMR system, required access forms, access type – web based or VPN-to-VPN connection, special requirements needed for access, etc.)
• List of current providers/locations or a website for accessing this list. Also, if applicable, a list of providers affiliated with the group that are not in the EMR System.

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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Did you know the cost Impact of medication non-adherence is $528 billion from non-optimized medication therapy?¹ That’s equivalent to 16% of U.S. total health expenditures and contributes to 275,689 deaths per year.²

 

As a healthcare provider, you can motivate your patients to adhere to their medication regimens, which can contribute to improved outcomes and increased STARS performance.

We developed this video to offer best practices in boosting medication adherence among your patient population.

Use the 6 SIMPLE strategies below to help improve medication adherence among your patient population.

S - Simplify the regimen

• Limit the # of doses and frequency
• Encourage adherence aids such as a pill box
• Utilize generic prescriptions if clinically appropriate
• Implement real-time pharmacy benefit to understand patient cost-share at the point of care

I - Impart knowledge

• Assess patient’s knowledge of medication regimen
• Provide clear medication instructions (written and verbal)
• Patient-provider shared decision-making

M - Modify patient beliefs and behavior

• Ask open ended questions about impact of not taking medications
• Empower patients to self-manage their condition

P - Provide communication and trust

• Provide emotional support
• Allow adequate time for the patient to ask question

L - Leave the bias

• Understand patient’s health literacy and how it affects outcomes
• Develop a patient-centered communication styles

E - Evaluate Adherence

• Utilize motivational interviewing to confirm adherence
• Review pharmacy refill records, Rx bottles, lab testing
• Identify barriers to adherence
• Determine interventions and follow-up
• When appropriate, prescribe 90 day fills for chronic conditions  

 

Watch this video to learn more best practices on helping improve medication adherence and your organization’s overall quality and STARS performance.

References:

1 Lloyd J et al. How much does medication nonadherence cost the Medicare fee-for-service program? Med Care. 2019;00:1-7.

2 Watannabe JE et al. Cost of prescription drug-related morbidity and mortality. Ann Pharmacother. 2018;52(9):829-837. DOI: 10.1177/1060028018765159

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A mother has a sick child and like all good mothers, wants comfort and care. And a prescription for antibiotics. BMJ Journals published a study that rated how many patients with upper respiratory infections (URI) prior to consultation with their physician expected a prescription for antibiotics.

Evidence-based data does not support the use of antibiotics in the treatment of the common cold because they do not improve symptoms or shorten the course of the illness. Instead of putting away the prescription pad, use this one.

Offered by the CDC’s Be Antibiotics Aware campaign, the “Relief for common symptoms of colds and cough” prescription pad provides an alternative to unnecessary antibiotics. Get it through the CDC website here.

Measure up: HEDIS® guidelines for URI/Pharyngitis

URI measures the percentage of episodes for members 3 months of age and older with a URI diagnosis that did not result in an antibiotic dispensing event.

 

Appropriate Testing for Pharyngitis (CWP) evaluates members 3 years of age and older where the member was diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.

 

Records and billing codes

URI: In the patient’s medical records, document results of all strep tests or refusal for testing. If antibiotics are prescribed for another condition, take care to associate the antibiotic with the appropriate diagnosis.



CWI: In the patient’s medical records, document results of all strep tests or refusal for testing. If antibiotics are prescribed for another condition, take care to associate the antibiotic with the appropriate diagnosis.

1 BMJ Journals. Medical management of acute upper respiratory infections in an urban primary care out of hours facility: cross-sectional study of patient presentation and expectations. https://bmjopen.bmj.com/content/9/2/e025396

2 NCBI. Upper Respiratory Tract Infection. https://www.ncbi.nlm.nih.gov/books/NBK532961/  

 

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Medicare Advantage

 

Policy Update

DRG Inpatient Facility Transfers

Effective 11/30/21

 

Effective 11/30/21, Anthem Blue Cross and Blue Shield claims for members who leave against medical advice and are admitted to another acute care facility on the same day are considered transfers and will follow the criteria detailed in the policy.

 

For additional information, please review the DRG Inpatient Facility Transfers reimbursement policy at anthem.com/medicareprovider under the Facilities dropdown.

 

 

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Medicare Advantage

 

The best way to ensure you're submitting everything needed for a prior authorization is to use the prior authorization/precertification form at anthem.com/medicareprovider > Providers > Provider Resources > Forms and Guides. By filling out the form completely and with as much information as possible, you can be sure we have the information to process your request timely.

 

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Medicare Advantage

 

On November 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) prior authorization (PA) requirements will change for L8702 covered by Anthem. 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.

 

PA requirements will be added for the following code:

• L8702 — Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at anthem.com/provider/news/archives/?cnslocale=en_US_co&category=medicareadvantage > Login or by accessing Availity.* Once logged in to Availity, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at the number on the back of your patients’ Anthem ID card for assistance with PA requirements.

 

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Medicare Advantage

 

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

• Clinical criteria updates notification May 2021