New prior authorization requirements for providers may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements starred (*) below.

Changes to Prior Authorization Requirements

• Prior authorization updates for specialty pharmacy are available*
  
  
• Medical Policy update*
  
  
• Updates to AIM Cardiology clinical appropriateness guidelines*
  
  
• Updates to AIM Advanced Imaging clinical appropriateness guidelines*
  
  
• Updates to AIM Radiation Oncology clinical appropriateness guidelines*
  
  
• Reimbursement policy update: Bundled services and supplies (Professional)*
  
  
• Reimbursement policy update: DRG newborn inpatient stays (Facility)*

Through predictive analytics, health care teams can now receive real-time solutions to claim denials

Anthem is committed to providing digital first solutions. Our health care teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem has the answers before you ask the questions. With an initial focus on claim-level insights, Anthem has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to completion. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOB.

Access Claims Status Listing on Payer Space from our secure provider portal through anthem.com using the Log In button or through availity.com. We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.

Anthem has made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online – all in one place.

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem is using digital technology to improve the health care experience.

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We want to make you aware of upcoming changes to the Indiana Anthem Blue Cross and Blue Shield (Anthem) BlueCard^® Program Provider Manual. The manual includes enhanced content and should be helpful in understanding the BlueCard^® Program that enables members of one Blue Plan to obtain health care service benefits while traveling or living in another Blue Plan’s service area.

This updated BlueCard^® Program Provider Manual will replace the current BlueCard^® Program Provider Manual January 15, 2021.

We have posted the updated Provider Manual to the public provider website at anthem.com. To view the new manual, visit anthem.com, select Provider, and select the Policies, Guidelines & Manuals. Select Indiana followed by Provider Manual Download the Manual. On the Provider Manual page, scroll down to the Provider Manual Library and select the BlueCard Provider Manual or click here.

If you have questions, please contact your local Professional Provider Network Contractor at 1-800-455-6805.

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Are you looking for creative ways to talk to your patients about certain preventive care services such as breast cancer screening and adolescent vaccinations including the HPV vaccination?  As flu season approaches, do you want a way to educate your patients about the dangers of antibiotic resistance? Short educational videos, approximately two minutes in length, are available on anthem.com > Providers > Forms and Guides > under the Category heading, select Patient Care.

By providing education and addressing common fears and concerns, these brief videos offer an alternative approach to patient engagement on these important topics. Take a look today!

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The Provider Digital Engagement Supplement is another example of how Anthem Blue Cross and Blue Shield (Anthem) is using digital technology to improve the health care experience. The Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits all in one comprehensive resource. We want 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.

Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:

• File claims
• Check statuses
• Verify eligibility and benefits
• Submit prior authorizations

Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website.

Get payments faster

Eliminate paper remittances

Member IDs go digital

Having a member email their ID card directly to you for file upload eliminates the need for you to scan or print, making it easier for you and the member. Member ID cards can also be accessed from the Availity. Save time by accepting the digital member ID cards when presented by the member via their App or email.

Read more about going digital with Anthem in the Provider Digital Engagement Supplement available online. Go to anthem.com, select Providers, under the Provider Resources heading select Forms and Guides. Pick your state if you haven’t done so already.  From the Category drop down, select Digital Tools, then Provider Digital Engagement Supplement.

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As of December 1, 2020, the providers listed below are participating air ambulance providers with Anthem Blue Cross and Blue Shield (Anthem). That means, for members picked up in Indiana, these participating providers have contractually agreed to accept the Anthem Rate as payment in full for approved and medically necessary transport, and will bill those members for cost-shares only.

Some air ambulance providers choose not to participate with Anthem. 

• These air ambulance providers may, and often do, charge members rates that are significantly higher than the Anthem contracted provider rates.
• These non-contracted air ambulance providers attempt to collect from Anthem members the difference between Anthem’s allowed amount and their billed amount.

To help Anthem members avoid the high costs of air transportation from non-contracted providers, we ask that, whenever possible, you choose a participating air ambulance provider for your patients who are Anthem members.

Utilizing participating providers:

• Protects the member from balance billing for what may be excessive amounts,
• Assures the most economical use of the member’s benefits, and
• Is consistent with your contractual obligations to refer to in-network providers where available.

To schedule fixed wing or rotary wing air ambulance services, please:

1. Contact Anthem for precertification for all non-emergent transports, using the number on the back of the member’s ID card, then
2. Call one of the phone numbers listed below.

Please have the following information ready when you call one of the contracted air ambulance providers:

• Basic medical information about the patient, including the patient’s name and date of birth or age.  If the service was not pre-certified with Anthem, the air ambulance provider will also need to receive a full medical report from the attending facility.
• Current location of the patient, the name of the hospital or facility caring for the patient and its address (city and state)
• Location where patient is to be transported, including the name of the destination hospital/facility and address
• Approximate transport date or timeframe
• Special equipment or care needs

Should you have questions regarding the air ambulance network, including providers contracted for air ambulance pickups outside of Indiana, please contact your Provider Network Manager.

Anthem contracted air ambulance providers for Indiana

First, call Anthem for precertification if required by the member’s policy.

Then call one of the following: 

Fixed Wing (Airplane) Providers (HCPCS codes: A0430 & A0435)

Rotary Wing (Helicopter) Providers (HCPCS Codes: A0431 & A0436)

To arrange air transport originating outside the U.S., U.S. Virgin Islands, and Puerto Rico: Call 800-810-BLUE for BCBS Global Core (formerly BlueCard Worldwide)

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Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form, on anthem.com.

The impact of COVID-19 in 2020 prohibited Anthem from conducting the annual after-hours access studies to assess phone messaging for our members for perceived emergency or urgent situations after regular office hours.  We will resume the survey in the second quarter of 2021 and expect when your office is contacted, you will be able to accommodate a member’s urgent concerns after hours.

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, such as:

Emergency situations

The compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects the caller directly to the doctor.

Urgent situations

The compliant response for urgent needs would direct the caller to urgent care or ER, to call 911 or connect the caller to their doctor or the doctor on call.

Messaging that only gives callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions is not complaint, as there is no direct connection to their health care practitioner. This prompt can be used in addition to, but not in place of the emergency and urgent instructions. 

Is your practice compliant?

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Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Anthem Blue Cross and Blue Shield (Anthem) would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. Anthem urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other health care practitioners at the time treatment begins.

We expect all health care practitioners to:

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
   - Diagnosis
   - Treatment plan
   - Referrals
   - Psychopharmacological medication (as applicable)

In an effort to facilitate coordination of care, Anthem has several tools available on the provider website including a coordination of care form and coordination of care letter templates for both behavioral health and other medical practitioners.* Behavioral health tools are available, which includes forms, brochures, and screening tools for substance abuse, ADHD, and autism. Please refer to the website for a complete list.**

*Access to the forms and template letters are available at www.anthem.com/provider/forms/

**Access to the Behavioral Health tools are www.anthem.com/provider/forms/

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The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement. It can be found on our website, under the FAQ question about “Laws and Rights that Protect You.” 

To access, go to anthem.com and select “Provider.” From there, select “Policies, Guidelines & Manuals” under Provider Resources.  Select your state, and scroll down to “Member Rights and Responsibilities” under More Resources. Click the “Read about member rights” link. 

Practitioners may access the FEP member portal at fepblue.org/memberrights to view the FEPDO Member Rights Statement.

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Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. Anthem Blue Cross and Blue Shield (Anthem)’s medical policies are available on Anthem’s website at anthem.com.

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below. 

UM criteria are also available on the web. Just go to anthem.com, then select the Providers tab at the top of the webpage > under Provider Resources select Policies, Guidelines & Manuals > select your state > scroll down and select View Medical Policies and Clinical UM Guidelines.

We work with providers to answer questions about the UM process and the authorization of care. Here’s how the process works:

• Call us toll free from 8:30 a.m. to 5:00 p.m. Eastern time, Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program hours are 8:00 a.m. to 7:00 p.m. Eastern time.
• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after 12 midnight will be returned the same business day. 
• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

Our UM associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific UM requirements, operational review procedures, and discuss UM decisions with you.

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.

The following phone lines are for physicians and their staffs. Members should call the customer service number on their health plan ID card.

TTY Information

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Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a health care puzzle that for some, are frightening and complex issues to handle.

Anthem is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

How do you contact us?

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Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form, on anthem.com.

The impact of COVID-19 in 2020 prohibited Anthem Blue Cross and Blue Shield (Anthem) from conducting the annual appointment access studies to assess how well practices meet appointment access requirements for our members for behavioral health care (BH). We will resume the survey in second quarter 2021 and expect when your office is contacted, you will be able to accommodate a member’s needs in a timely manner.

To be compliant, per the Provider Manual, providers should meet the following access standards:

• Non-life-threatening emergency – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or a covering Practitioner within six hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate.
  
  Explanation: These calls concern members in acute distress, whose ability to conduct themselves for their own safety, or the safety of others, may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. The situation has the potential to escalate into an emergency without clinical intervention.
  
  

• Urgent – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or by a covering Practitioner within 48 hours. 
  
  Explanation: These calls are non-emergent with significant psychological distress, when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
  
  

• Initial Routine office visit – A new patient must be seen in the office by a designated BH Practitioner or another equivalent Practitioner in the practice within 10 business days. It can be after the intake assessment or a direct referral from a treating Practitioner.
  
  Explanation: This is a routine call for a new patient defined as a patient with non-urgent symptoms, which present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
  
  

• Routine office visit – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or by a covering Practitioner within 30 calendar days.
  
  Explanation: These calls concern existing members, to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
  
  

• BH follow-up appointment after discharge – The patient must be seen in the office by their Practitioner or another Practitioner in the practice within 7 calendar days.
  
  Explanation: These calls concern members being released from inpatient psychiatric hospital care, requesting a follow-up appointment to evaluate what has taken place since release, including med management.

Methods used to monitor adherence to these standards consist of assessing the accessibility of appointments via phone calls from North American Testing Organization, a vendor working on Anthem’s behalf, and analysis of member complaint and member experience data.

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Please continue to check Provider Communications & Updates on the provider webpage for the latest information, including:

• Avsola Medical Step Therapy Notice.
  
  
• Herceptin Biosimilars Medical Step Therapy Notice.
  
  
• Provider Chat: A fast, easy way to get your questions answered.

Anthem Blue Cross and Blue Shield (Anthem) would like to inform our providers about Project Extension for Community Healthcare Outcomes (ECHO) clinics now available through the Indiana University School of Medicine. Currently, there are several weekly ECHO clinics. The clinics are free of charge to participating Anthem providers.

Project ECHO is a learning and guided-practice model providing medical education to help providers increase workforce capability, enhance best practice specialty care and reduce health disparities. Clinic sessions meet online using no-cost Zoom video conferencing and consist of a brief didactic presentation on related topics, followed by case presentations and discussions by participating providers. The participating group of community providers works through each case in a collaborative fashion with guidance from the expert multidisciplinary Project ECHO facilitators.

A team of experts in these topics, led by the Indiana University Department of Psychiatry, will work with participants who want to learn more about opioid use disorder, pregnancy and OUD, neonatal abstinence syndrome, case management, jail services and first responders. Free continuing medical education credit (CME) will be provided to participants. 

Anthem and the Indiana University School of Medicine’s Division of Continuing Medical Education collaborate to provide lifelong learning opportunities that enable health care professionals to improve performance in practice. CME credit is provided to all participants through the Indiana University School of Medicine’s Division of Continuing Medical Education. For more information or to sign up for Project ECHO, please visit https://echo.iu.edu.

If you have questions about this communication or any other item, please contact Provider Services:

• Hoosier Healthwise: 1-866-408-6132
• Healthy Indiana Plan: 1-844-533-1995
• Hoosier Care Connect: 1-844-284-1798

The Aspire Health* telehealth program provides an additional layer of telephonic support to patients facing a serious illness. The program is focused on helping ensure patients understand their diagnosis, facilitating conversations with patients and their families around the patient's goals of care, and helping ensure patients receive care aligned with their goals and values.

The program begins with an initial 30- to 60-minute telephonic assessment by a specially trained Aspire social worker with the conversation focused on building rapport and completing a comprehensive assessment, including understanding the patient's perception of his or her illness and current treatment plan. Follow-up calls occur every 2 to 4 weeks, typically lasting 15 to 45 minutes, with the exact frequency based on a patient's individual need. Aspire's social worker is supported by Aspire's full interdisciplinary team of board-certified palliative care physicians, nurses and chaplains who provide additional telephonic support to patients and their families as needed. Patients enrolled in the telehealth program have access to Aspire's 24/7 on-call support. The average patient is enrolled in the program 6 to 8 months, with key outcomes being the ability for patients to teach-back their current medical situation, articulate their health and quality-of-life goals, and establish a future care plan through either the completion of advance care planning documents and/or a transition to hospice when appropriate.

More information is available at aspirehealthcare.com or by calling the 24/7 Patient & Referral Hotline at 1-844-232-0500.

* Aspire Health is an independent company providing telephonic palliative care services on behalf of Anthem Blue Cross and Blue Shield.

This communication applies to the Medicaid and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem).

Patient360 is a real-time dashboard you can access through the Availity Portal* that gives you a full 360° view of your Anthem patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.

What’s new: Medical providers now have the option to include feedback for Anthem patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.

Once you have completed all the required fields on the Availity Portal to access Patient360, you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. 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 a 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.

Do you need a job aid to help you get started?

The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center:

1. From the Availity home page, select Payer Spaces > Anthem payer tile > Applications > Custom Learning Center.
2. Select Resources from the menu located on the upper left corner of the page.
   (To use the catalog filter to narrow the results, select Payer Spaces from the Category menu.)

3. Select Download to view and/or print the reference guide.

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

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Behavioral health disorders are classified in Chapter 5 of the ICD-10-CM

Behavioral health disorders are commonly underreported on claims. Many Anthem Blue Cross and Blue Shield members may have behavioral health disorders that are not properly managed. Health care providers can assist by taking detailed histories and coding behavioral health issues properly on claims. Below are the ICD-10-CM coding guidelines for behavioral health conditions.

When documenting behavioral disorders, the following descriptors apply:

• Type: Depressive, manic, or bipolar disorder
• Episode: Single or recurrent
• Status: Partial or full remission; identify most recent episode as manic, depressed, or mixed
• Severity: Mild, moderate, severe, or with psychotic elements.

Schizophrenic related disorders

Schizophrenic related disorders are classified in category F20, with a fourth character indicating the type of schizophrenia as follows:

Major depressive disorder (MDD)

Major depressive disorder (MDD) is classified in ICD-10-CM to categories:

• F32.- Major depressive disorder, single episode
• F33.- Major depressive disorder, recurrent.

Categories F32 (F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.81, F32.89, F32.9) and F33 (F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.8, F33.9) are further subdivided with fourth characters, and sometimes fifth characters, to provide information about the current severity of the disorders, as follows:

• 0 Mild
• 1 Moderate
• 2 Severe, without psychotic features
• 3 Severe with psychotic features
• 4 In remission
• 5 In full remission
• 8 Other
• 9 Unspecified.

Fourth characters 1 through 8 are assigned only when provider documentation of severity is included in the medical record.

Manic episodes and bipolar disorders

The table below outlines the ICD-10-CM classification for bipolar disorders. Manic/mania also falls within this code category. The codes in these categories require fourth and/or fifth digits to identify the severity of the current episode and whether or not psychotic symptoms are involved.

Anxiety disorders

Anxiety disorders are classified in ICD-10-CM under the following categories:

• F40 Phobic anxiety disorders
• F41 Other anxiety disorders
• F42 Obsessive-compulsive disorder.

Dissociative and conversion disorders

ICD-10-CM classifies dissociative and conversion disorders to category F44.

Dissociative disorders

Conversion disorders

Behavioral syndromes associated with physiological disturbances and physical factors

Categories F50 through F59 grouping includes the following conditions:

Disorders of adult personality and behavior

Categories F60 through F69 include disorders of adult personality and behavior:

Psychosocial circumstances and encounters

ICD-10-CM provides codes for behaviors that have not yet been classified to behavioral disorders, but that may contribute to the need for further treatment or study. The table below shows some examples:

For behavioral health disorders that resolve and do not require continued treatment, it is appropriate to report code Z86.59, Personal history of other mental and behavioral disorders.

Resources

1. ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2019.
2. ICD-10-CM/PCS Coding. Theory and practice. 2019/2020 Edition. Elsevier.

Need for coding compliance

Coding compliance refers to the process of ensuring that the coding of diagnosis, procedures and data complies with all coding rules, laws and guidelines.

All provider offices and health care facilities should have a compliance plan. Internal controls in the reimbursement, coding, and payment areas of claims and billing operations are often the source of fraud and abuse, and have been the focus of government regulations.

Compliance plan benefits:

• More accurate payment of claims
• Fewer billing mistakes
• Improved documentation and more accurate coding
• Less chance of violating state and federal requirements including self-referral and anti-kickback statutes.

Compliance programs can show the provider practice is making an effort to submit claims appropriately and send a signal to employees that compliance is a priority.

Medical records documentation

All medical records entries should be complete and legible, and should include the legible identity of the provider and date of service.

Each encounter in the medical record must include the patient’s full name and date of birth. Documentation integrity is at risk when there is wrong information on the wrong patient health record because it can affect clinical decision-making and patient safety.

Providers’ signatures and credentials are of the utmost importance in all documentation efforts. The signature is an attestation from the treating and documenting provider that certifies the written document as reflecting the provider’s intentions regarding the services performed during the encounter, and the reason(s).

Specific information is required to describe the patient encounter each time he or she presents for medical services.

Each encounter generally will need to contain the following:

• The chief complaint
• The history of present illness
• The physical examination
• Assessment and care plan.

Common coding and billing risk areas

The following billing risks are commonly subject to Office of Inspector General (OIG) investigations and audits:

• Billing for items or services not rendered or not provided as claimed
• Double billing, resulting in duplicate payment
• Submitting claims for equipment, medical supplies, and services that are not reasonable and necessary
• Billing for non-covered services
• Knowingly misusing provider identification numbers, which results in improper billing
• Unbundling
• Failure to properly use modifiers
• Upcoding the level of service

Evaluation and Management (E&M) claims are typically denied for two reasons:

• Incorrect coding, such as the code not matching the documentation, and insufficient documentation, which can include a lack of a provider signature or no record of the extent and amount of time spent in counseling.
• Coordination of care when it is used to qualify for a particular level of E&M service.

There are several strategies on how to prevent E&M claims being denied:

• In addition to the individual requirements for billing a selected E&M code, providers should also consider whether the service is reasonable and necessary (for example, a level 5 office visit for a patient with a common cold and no comorbidities will not be reasonable and necessary).
• Remember the following when selecting codes for E&M services:
  • Patient type (new or established)
  • Setting/place of service
  • The level of service provided based on the extent of the history, the extent of the examination, and the complexity of the medical decision making (for example, the number and type of the key components performed).

Best practices to avoid common documentation mistakes

Providers need to formulate a complete and accurate description of the patient’s condition with a detailed plan of care for each encounter. Listing problems without a corresponding plan of care does not confirm physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (for example, diabetes management (DM), chronic kidney disease (CKD), congestive heart failure (CHF): Continue current treatment plan) equally diminishes the complexity and effort put forth by the physician.

The care plan needs to be documented clearly. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another provider is primarily managing the problem. For example, one provider can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD).

Pathology service, laboratory testing, radiology and medicine-based diagnostic testing contributes to diagnosing or managing patient problems.

Documentation tips

• Specify tests ordered and document rationale in the medical record
• Document test review by including a description in the note (for example, elevated glucose levels)
• Indicate when images, tracings, or specimens are personally reviewed; be sure to include a comment on the findings
• Summarize any discussions of unexpected or contradictory test results with the provider performing the procedure or diagnostic study.

Patient risk in E&M is categorized as minimal, low, moderate or high based on the presenting problem, diagnostic procedures ordered and management options selected. Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered less risky than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis. 

To determine the right complexity of the patient’s problems, providers should:

• Document the status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; do not assume that the auditor or coder can infer this from the documentation details.
• Document all diagnostic or therapeutic procedures considered.
• Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.

Frequent auditing is key to medical coding compliance

To ensure your organization’s E&M services are coded appropriately, it is important to periodically review your charts to check for insufficient documentation, miscoding, upcoding and downcoding. Conducting audits of your medical coding process and procedures can help give you an understanding of recurring risk areas and key improvement opportunities. Using these insights, you can then incorporate best practices and address any bad habits, lessening the chances of negative consequences.

Resources

1. CPT^® Professional Edition, 2020. AMA
2. Compliance Guidance. Office of Inspector General. https://oig.hhs.gov/compliance/compliance-guidance/index.asp
3. Risk Adjustment Documentation & Coding, 2^nd edition. American Medical Association

A key goal of the provider transparency initiatives of Anthem Blue Cross and Blue Shield (Anthem) is to improve quality while managing health care costs. One of the ways this is accomplished is through our value-based programs (for example, the Provider Quality Incentive Program, the Provider Quality Incentive Program Essentials, Risk and Shared Savings, etc.), known as the Programs. 

Value-Based Program Providers (also known as Payment Innovation Providers) in our various value-based programs receive quality, utilization and/or cost data, reports and information about other health care providers (Referral Providers). The Value-Based Program Providers can use that information in selecting Referral Providers for their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in the provider getting more referrals from Value-Based Program Providers. If Referral Providers are lower quality and/or higher cost, the converse should be true.

Providing this type of data, including comparative cost information, to Value-Based Program Providers helps them make more informed decisions about managing health care costs, and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

Anthem will share data on which we relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers, including any opportunities for improvement. If you have questions or need support, please refer to your local market representative or care consultant.

Summary of benefits, evidence of coverage and formularies for 2021 individual Medicare Advantage plans will be available at anthem.com/medicareprovider. An overview of notable 2021 benefit changes will be available at anthem.com/medicareprovider> Read News and Updates. Please continue to check anthem.com/medicareprovider for the latest Medicare Advantage information.

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How do I check eligibility and benefits for these members?

Online — Eligibility, benefits, claims, links to secure messaging, commonly used forms and remit information are all available through the Availity* Portal at availity.com. For questions on access and registration, call Availity Client Services at 1-800-AVAILITY (1-800-282-4548). Availity Client Services is available Monday through Friday, 8 a.m. to 7 p.m. ET (excluding holidays) to answer your registration questions.

Phone — Call the Provider Service number on the back of the member’s ID card. You may also verify a member’s eligibility by calling the BlueCard Eligibility Line at 1‑800‑676‑BLUE (2583) and providing the member’s three-digit alpha prefix located on the ID card.

As new members enroll in Group Retiree Medicare Advantage plans under Anthem Blue Cross and Blue Shield, they will receive new ID cards. Additionally, existing members may receive new ID cards as a result of benefit changes. Please continue to check member ID cards to ensure you have the most up-to-date eligibility and benefit information.

Please note that we are experiencing an unusually high volume of changes for an effective date of January 1, 2021. Many of the changes do not affect member prefix, member ID or benefits, but some changes will. Because of this, we encourage providers to request a copy of the member’s ID card, particularly at the beginning of the year when members may have new ID cards.

What are the alpha prefixes for Group Retiree Medicare Advantage PPO members?

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

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The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

Please share this notice with other members of your practice and office staff.

To view a guideline, visit https://www11.anthem.com/search.html.

Updates:

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

• 00134 – Noninvasive Heart Failure and Arrhythmia Management and Monitoring System:
  • Revised Investigational and Not Medically Necessary indications
• 00156 – Implanted Artificial Iris Devices:
  • Revised Investigational and Not Medically Necessary indications
• 00157 – Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis:
  • Revised Investigational and Not Medically Necessary indications
• CG-DME-07 – Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output:
  • Revised Medically Necessary and Not Medically Necessary indications
• 00052 – Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling:
  • Revised Medically Necessary indications
• 00077 – Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques:
  • Expanded scope and revised Investigational and Not Medically Necessary indications
• 00112 – Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures):
  • Revised scope, and Investigational and Not Medically Necessary indications
• CG-REHAB-12 – Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology:
  • A new clinical UM Guideline was created from content contained in CG-REHAB-04, CG-REHAB-05, CG-REHAB-06.
  • There are no changes to the guideline content.
  • Publish date is scheduled for December 8, 2020.
• The following AIM Specialty Health_®* Clinical Appropriateness Guidelines have been revised and will be effective on December 6, 2020. To view AIM guidelines, visit the AIM Specialty Health page:
  • Interventional Pain Management (See August 16, 2020, version.)*
  • Chest Imaging (See August 16, 2020, version.)*
  • Oncologic Imaging (See August 16, 2020, version.)*
  • Sleep Clinical Guidelines (See August 16, 2020, version.)*

Medical Policies

On August 13, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect December 6, 2020.

Clinical UM Guidelines

On August 13, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for Medicare Advantage members on
September 24, 2020. These guidelines take effect December 6, 2020.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.

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Click here for more information about the Policy Update — Emergency Department: Leveling of Evaluation and Management Services.

Introducing the Anthem Blue Cross and Blue Shield (Anthem) Provider Digital Engagement Supplement to the provider manual

Using our secure provider portal or EDI submissions (via Availity*), administrative tasks can be reduced by more than 50% 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, please visit the Availity EDI website or the secure provider portal via 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 will deliver payments to you faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the Availity Provider Portal or the EDI 835 remittance, which meets all HIPAA mandates — eliminating the need for paper remittances.

Member ID cards go digital

Members who are transitioning to digital member ID cards, will find it is 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.

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available at https://www.anthem.com/medicareprovider > select your state > Providers > Policies, Guidelines & Manuals, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid and Medicare, 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 Provider Digital Engagement Supplement now by going to https://www.anthem.com/medicareprovider > select your state > Providers > Policies, Guidelines & Manuals. Go digital with Anthem.

Go digital with Anthem.

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

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This communication applies to the Medicaid and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem).

Patient360 is a real-time dashboard you can access through the Availity Portal* that gives you a full 360° view  of your Anthem patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.

What’s new: Medical providers now have the option to include feedback for Anthem patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.

Once you have completed all the required fields on the Availity Portal to access Patient360, you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. 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 a 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.

Do you need a job aid to help you get started?

The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center.:

1. From the Availity home page, select Payer Spaces > Anthem payer tile > Applications > Custom Learning Center.
2. Select Resources from the menu located on the upper left corner of the page.
   (To use the catalog filter to narrow the results, select Payer Spaces from the Category menu.)

3. Select Download to view and/or print the reference guide.

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

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