We are committed to improving the way we do business with our provider community. Listening to your feedback, we are pleased to announce a new look and feel is coming to Provider News in the first half of 2023 with additional improvements planned throughout the rest of the year.

Stay tuned for more updates.

HEDIS medical record submission made easier with our remote EMR access service

Let us take on the responsibility to retrieve medical records for the annual HEDIS^® hybrid project by signing up for the remote electronic medical record (EMR) access service offered by Anthem.

We offer providers the ability to grant access to their EMR system directly to pull the required documentation to aid your office in reaching compliance while reducing the time and costs associated with medical record retrieval.

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 claims evidence related to the HEDIS measures.
• We access the least amount of information needed for use, disclosure, or for the specific medical records request.
• We only save to file and do not physically print any PHI.

Getting started with remote EMR access

Download and complete the registration form, then email it to us at: Centralized_EMR_Team@anthem.com.

FAQ

How does Anthem retrieve your medical records?

We access your EMRs using a secure website and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.

Is printing access 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 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 nonstandard format, such as an in‑office lab slip scanned into miscellaneous documents.

What information do I need to submit to use the remote EMR access service?

Complete the registration form that requests the following information:

• Practice/facility demographic information (for example, address, NPI, TIN, etc.)
• EMR system information (for example, type of EMR system, required access forms, access type, etc.)
• List of current providers/locations or a website for accessing this list

Remote Access not an option? We are now offering onsite visits for HEDIS hybrid retrieval. Email us at Centralized_EMR_Team@anthem.com for more information.

The best way to send supporting documents when disputing, appealing, or sending us additional information about a claim is to use the digital applications available on Availity.com.* Using Availity.com to send attachments, such as medical records or an itemized bill, is:

• We’ll receive the documents needed faster than through the mail.
• Less expensive. No need to pull records, copy them, and then mail them. Digital submissions can be uploaded directly to the claim.
• Submitting attachments digitally is the easiest way to send them and the best way for us to receive them.
• More accurate. The information needed to identify the claim is automated, so the risk associated with submitting incorrect information on paper is eliminated.

However, if you choose to send documentation through the mail, it is important that you include at least one of the three following elements; otherwise, we will not be able to match the document to the claim and the correspondence will be returned to you, causing further delays:

1. Valid claim number
   or

2. Valid member ID with prefix and correct dates of service
   or

3. Valid member ID with prefix and billed charges

For a clinical appeal, ensure these elements are included:

1. Valid claim number
   or

2. Valid member ID with prefix and correct dates of service
   or

3. Valid member ID with prefix) and billed charges
   or

4. Member name, member date of birth, and correct dates of service
   or

5. Member name, member date of birth, authorization, or reference number

This is important: We cannot match the attachment to the correct claim or member if these elements are not included with your non-digital (fax or mail) submission.

The preferred method for submitting supporting documentation is digitally because the documents are attached directly to the claim. This reduces the possibility that incorrect information is included on the paper submission.

To attach documents to your claim digitally, go to Availity.com and use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim and use the Submit Attachments button to upload your supporting documentation.

For a claim dispute or an appeal, from Availity.com, use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim, use the Dispute button, and upload your supporting documentation. If the Dispute button capability is not available, refer to the provider manual for information about how to file a claim dispute/appeal.

If you do send supporting documentation through the mail or fax, you must include the elements noted above. It is preferrable that you include this information on the first page of the correspondence you send to us. If this information is not included on your paper correspondence, we will return the correspondence to you because we are not able to validate the documentation.

For information about submitting attachments digitally, use this link to access Availity: Learn about the new claim attachments workflow.

*Change to Prior Authorization Requirements

The following Anthem Blue Cross and Blue Shield (Anthem) Medical Polices and Clinical Guidelines were reviewed on November 10, 2022.

To view medical policies and utilization management guidelines, go to anthem.com, select Providers, and then select your state. Under Provider Resources, select Policies, Guidelines & Manuals.

To help determine if prior authorization is needed for Anthem members, go to anthem.com, select Providers, and then select your state. Under Claims, select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card.

To view Medical Policies and Utilization Management Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program^® [FEP^®]), visit www.fepblue.org > Policies & Guidelines.

Below are the current Clinical Guidelines and/or Medical Policies we reviewed, and updates were approved.

* Denotes prior authorization required

*Change to Prior Authorization Requirements

Effective for dates of service on and after April 1, 2023, the following code updates will apply to the AIM Specialty Health_®* Percutaneous Coronary Intervention Clinical Appropriateness Guidelines.

Percutaneous coronary intervention:

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortal_SM directly at providerportal.com
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Essentials at availity.com

If you have questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

*Change to Prior Authorization Requirements

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates by guideline

• Imaging of the Brain:
  • Meningioma — Added more frequent surveillance for WHO grade II/III
  • Bell’s palsy — Limited the use of CT to scenarios where MRI cannot be performed
  • Seizure disorder — Added indication for advanced imaging in pediatric patients with nondiagnostic electroencephalogram (EEG)
• Imaging of the Head and Neck:
  • Perioperative imaging — Added indication for imaging prior to facial feminization surgery
• Imaging of the Chest:
  • Perioperative imaging — Added indication for imaging prior to lung volume reduction procedures
  • Imaging abnormalities — Added indication for evaluation of suspected tracheal or bronchial pathology
• Imaging of the Abdomen/Pelvis:
  • Uterine leiomyomata — Added indication for advanced imaging when ultrasound suggests leiomyosarcoma
  • Pancreatic indications — Added indication for pancreatic duct dilatation
  • Pancreatic mass — Added allowance for more frequent follow up of lesions with suspicious features or in high-risk patients
  • Pancreatitis — Removed allowance for MRI following nondiagnostic CT
  • Pelvic floor disorders — Added indication for MRI pelvis in chronic constipation when preliminary testing is nondiagnostic
  • Abdominal/pelvic pain, undifferentiated — Removed indication for MRI following nondiagnostic CT
• Oncologic Imaging:
  • National Comprehensive Cancer Network annual alignments for breast cancer screening and the following: Cervical, Head and Neck, Histiocytic Neoplasms, Lymphoma (Non-Hodgkin and Leukemia), Multiple Myeloma, Thoracic, and Thyroid cancers
  • Prostate Cancer:
    • Updated respective conventional imaging prerequisites for 18F Fluciclovine/11C PET/CT and 68Ga PSMA/18F-DCFPyL PET/CT, based on utility of conventional imaging at various PSA thresholds (and removal of low-risk disease waiver from conventional imaging footnote).
    • Addition of 68Ga PSMA or 18F-DCFPyL PET/CT indication aligned with FDA-approved use of Pluvicto (radioligand) treatment for metastatic castrate-resistant disease

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of the following ways:

• Access AIM’s ProviderPortal_SM directly at providerportal.com:
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access AIM via Availity* Essentials at availity.com.

For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines at http://www.aimspecialtyhealth.com/ClinicalGuidelines.html.

Note: AIM will join the Carelon* family of companies and change its name to Carelon Medical Benefits Management, Inc. on March 1, 2023.

To view the 2023 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program^® (FEP), go to www.fepblue.org > select Tools & Resources > Brochure & Resources. Here, you will find the Service Benefit plan brochure, benefit plan summaries, and Quick Reference Guides on information for year 2023. If you have questions, please contact FEP Customer Service at:

CO – 800-852-5957

CT – 800-438-5356

GA – 800-282-2473

IN – 800-382-5520

KY – 800-456-3967

ME – 800-722-0203

MO – 800-392-8043

NV – 800-727-4060

NH – 800-852-3316

NY – 800-522-5566

OH – 800-451-7602

VA – 800-552-6989

WI – 800-242-9635

*Change to Prior Authorization Requirements

Prior authorization clinical review for non-oncology use of specialty pharmacy drugs is managed by Anthem Blue Cross and Blue Shield’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health_®* (AIM), a separate company.

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

Including the National Drug Code (NDC) code on your claim may help expedite claim processing for drugs billed with a Not Otherwise Classified (NOC) code.

Reminder: Clinical Criteria name change

In January 2023, we changed the name of Clinical Criteria documents from ING-CC-XXXX to CC‑XXXX; however, the content within the documents remains unchanged.

Prior authorization updates

Effective for dates of service on and after May 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

* Oncology use is managed by AIM.

⁺ The applicable Clinical Criteria is attached to this article in PDF format.

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

Step therapy updates

Effective for dates of service on and after May 1, 2023, 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. 

Access our Clinical Criteria to view the complete information for these step therapy updates.

Clinical Criteria CC-0107 currently has a step therapy preferring Avastin and the biosimilar Mvasi. This update is to notify that the new biosimilar Vegzelma will be added to existing step therapy as a non-preferred agent.

* Oncology use is managed by AIM.

⁺ The applicable Clinical Criteria is attached to this article in PDF format.

Clinical Criteria CC-0072: This is a courtesy notice to notify that there is an expansion in the preferred products in the step therapy for Clinical Criteria CC-0072 Vascular Endothelial Growth Factor inhibitors. Currently, Avastin and Eylea are preferred. Effective April 1, 2023, Byooviz, Cimerli, Lucentis, and Vabysmo will change from non-preferred to preferred product status.

Quantity limit updates

Effective for dates of service on and after May 1, 2023, 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 to view the complete information for these quantity limit updates.

⁺ The applicable Clinical Criteria is attached to this article in PDF format.