Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com, then at the top of the webpage, select Find Care.

Submit updates and corrections to your directory information by following the instructions on the Provider Maintenance Form online. Update options include:

• add/change an address location
• name change
• phone/fax number change
• provider leaving a group or a single location
• closing a practice location

The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current.

We share a health vision with our care providers that means real change for consumers.

According to ICD-10-CM guidelines for coding and reporting, it is inappropriate to bill certain diagnosis codes as a primary or first listed diagnosis. Instead, these codes should always be sequenced as a secondary or subsequent diagnosis. Effective for claims processed on or after March 2, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny:

• Professional claims submitted on a CMS-1500 form that report inappropriate primary diagnosis codes as the only diagnosis on the claim or claim line; and facility claims submitted on a CMS‑1450 form that report inappropriate primary diagnosis codes as the principal diagnosis or only code on the claim.

As provided by ICD-10-CM guidelines, inappropriate primary diagnosis codes include but are not limited to:

• External Cause Codes of Morbidity (V, W, X, or Y codes ICD-10-CM): Describes an environmental event causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. These codes are intended to be supplemental to the principal or primary diagnosis code indicating the nature of the condition. In addition, based on this guideline, a diagnosis code of external causes cannot be the only diagnosis on the claim.
• Manifestation Codes: Certain conditions contain both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD Manual coding guidelines have established a coding convention that requires the underlying condition to be sequenced first followed by the manifestation. According to the ICD Manual coding guidelines, the primary, first listed, or principal diagnosis cannot be a manifestation code. In addition, based on this guideline, a manifestation code cannot be the only diagnosis on the claim.
• Sequela Codes: A sequela (7th character S) code cannot be listed as the primary, first listed, or principal diagnosis on a claim. Coding of a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by the sequela (7th character S) code. In addition, based on this guideline, a sequela (7th character S) code cannot be the only diagnosis on a claim.
• Secondary Diagnosis: According to ICD guidelines, a secondary diagnosis code can only be used as a secondary diagnosis. Since these codes are only for use as supplemental codes, any procedure or service received with a secondary diagnosis code as the principal or primary diagnosis will be denied as incorrectly coded.

• EOB Message: We denied this service since it was reported incorrectly. Per CMS (Federal) correct coding guidelines, specific supplementary classification ICD-10 codes cannot be used as the primary diagnosis or as the only diagnosis on the claim.

Ex-Codes: 00V16 and v16

If you have questions about this communication or need assistance, contact Provider Services at:

• Hoosier Healthwise: 806-408-6132
• Healthy Indiana Plan: 844-533-1995
• Hoosier Care Connect: 844-284-1798

Anthem wants to remind you of a training resource that’s available for all providers. It’s called Provider Pathways, an on-demand digital eLearning that’s comprised of a collection of topics called modules. Each module covers a different aspect of doing business with Anthem. Depending on what you need, you can take one or all the modules.

How to find Provider Pathways

Provider Pathways — Doing Business with eLearning for Anthem gives you the flexibility for scheduling training for yourself and your staff. You can find this training on the provider website:

• Go to https://providers.anthem.com/in
• Select Training Academy under Resources in the top navigation.
• Once on the site, select Provider Pathways under Training Resources.

If you have questions about this provider resource, please reach out to your Health Care Networks team.

Effective June 1, 2024, Anthem will transition from CG-BEH-02 (Adaptive Behavioral Treatment) and MCG W0153 (Behavioral Health Care Applied Behavioral Analysis), to MCG B-806-T Behavioral Health Care Applied Behavioral Analysis (Original MCG Guideline), for medical necessity/clinical appropriateness reviews.

If you have questions, please contact the provider service number on the back of the member's ID card.

Summary

On September 21, 2023, and October 4, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

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

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross and Blue Shield patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes. Select here for our conversation guide for tips on how to engage patients who may be from a culture different from your own.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management associate or call Provider Services on the back of your patient’s member ID card.

Through our efforts, we can help deliver high quality, equitable healthcare.

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross and Blue Shield patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes. Select here for our conversation guide for tips on how to engage patients who may be from a culture different from your own.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management associate or call Provider Services on the back of your patient’s member ID card.

Through our efforts, we can help deliver high quality, equitable healthcare.

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross and Blue Shield patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management associate or call Provider Services at:

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

Through our efforts, we can help deliver high quality, equitable healthcare.

The controlling blood pressure (CBP) HEDIS^® measure can be challenging. It not only requires proof of a blood pressure (BP) reading but also that the patient’s BP is adequately controlled. CBP care gaps can open and close throughout the year depending on if the patient’s most recent BP reading is greater than 139/89 mmHG. It is important that we have record of your patients’ BP readings and that you schedule any members who have not had a BP reading or who have had high readings recorded this year.

Tips when scheduling members to close CBP care gaps:

• When scheduling appointments, encourage office staff to ask patients to avoid caffeine and nicotine for at least an hour before their scheduled appointment time.
• If possible, update your scheduling app or your reminder text message campaigns to include a reminder about abstaining from caffeine as well as a reminder to arrive early to avoid a sense of rushing.

Tips for lower BP readings during the appointment:

• Ask the patient if they tend to get nervous at appointments and have higher readings as a result. If they do, take their BP at both the start and end of the appointment. Document the lower reading.
• Readings could vary arm to arm. If slightly elevated in one arm, try the other and document the lower reading.

Getting credit for adequately CBP readings:

• Submit readings via category II CPT^® codes on claims:

• Ensure readings are carefully and appropriately documented within your electronic medical records (EMR) system.
• If you have questions on how to submit readings, speak to your care consultant or program manager.
• Be sure to adequately code patients who meet the exclusion criteria.

Healthcare Effectiveness Data Information Set (HEDIS^®) is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

HEDIS 2023 documentation for Childhood Immunization Status (CIS).

Measure description:

The percentage of children 2 years of age in the measurement year who had the following on or before their second birthday:

• Four DTaP (diphtheria, tetanus, and acellular pertussis)
• Three IPV (polio)
• One MMR (measles, mumps, and rubella)
• Three HiB (haemophilus influenza type B)
• Three Hep B (hepatitis B)
• One VZV (chickenpox)
• Four PCV (pneumococcal conjugate)
• One Hep A (hepatitis A)
• Two or three RV (rotavirus)
• Two flu (influenza)

The measure calculates a rate for each vaccine and three combination rates.

HEDIS 2023 documentation for Immunizations for Adolescents (IMA) Measure description: The percentage of adolescents 13 years of age in the measurement year who had the following:

• One MenACWY (meningococcal)
• One Tdap (tetanus, diphtheria toxoids, and acellular pertussis)
• Two or three HPV (human papillomavirus)

The measure calculates a rate for each vaccine and two combination rates.

HEDIS measurement year 2023 documentation for Lead Screening in Children (LSC) Measure description: The percentage of children 2 years of age who had one or more capillary or venous lead blood tests for lead poisoning by their second birthday.

What we are looking for in provider medical records:

• Immunization records from birth (Department of Health immunization records are acceptable).
• If available, newborn inpatient records documenting Hep B.
• For those immunizations not recorded on the immunization record, provide progress notes for the immunizations administered and the patient’s history of disease (chickenpox, Hep A, Hep B, measles, mumps, rubella).
• Anaphylaxis due to the DTaP, IPV, MMR, HIB, Hep B, VZV, PCV, Hep A, RV, or Influenza vaccines.
• Encephalitis due to the DTaP vaccine.
• Diagnosis of severe combined immunodeficiency, immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, leukemia, or intussusception.
• Meningococcal vaccine with a date of service on or between the member’s 11th and 13th birthdays.
• Tdap vaccine with a date of service on or between the member’s 10th and 13^th birthdays.
• At least two HPV vaccines on or between the member’s ninth and 13th birthdays and with dates of service at least 146 days apart, or at least three HPV vaccines with different dates of service on or between the member’s ninth and 13^th birthdays.
• Lead testing results and date (capillary or venous) on or before the child’s second birthday.
• Evidence of hospice services in 2023.
• Evidence patient expired in 2023.

Helpful hints:

• Childhood immunizations and lead blood tests must be completed by the child’s second birthday.
• Assess immunization needs at every clinical encounter, including sick visits and when indicated, immunize.
• Ensure immunization records include all vaccines that were ever given, including hospitals, health departments, and all former providers, including refusals and contraindications.
• FluMist (LAIV) vaccination (only approved for ages 2 to 49) may be used for the second vaccination; however, it must be given on the child’s second birthday to be compliant.

We look forward to working together to achieve improved outcomes.

HEDIS^® measure data is collected by one or more methods:

• Administrative method — claims and supplemental data
• Hybrid method — administrative and medical record data
• Survey method — Health Outcomes Survey (HOS) & Consumer Assessment of Healthcare Providers & Systems (CAHPS^®)
• Electronic Clinical Data Systems (ECDS) — HEDIS reporting standard that leverages electronic data from multiple sources. See below.

The HEDIS ECDS Reporting Standard was introduced in HEDIS 2016 (measurement year 2015) by the National Committee of Quality Assurance (NCQA) and encourages health information exchange, which is the secure sharing of patient medical information electronically. ECDS data collection is part of NCQA’s nationwide plan to capture information regarding aspects of care quality with less reliance on clinical medical record review.

There are four types of ECDS:

1. Electronic Health Record (EHR)/Personal Health Record (PHR): Real-time, patient-centered records that make information available instantly and securely to authorized users. EHRs eligible for this category of ECDS reporting include the NCQA eMeasure certification program or any system that meets the 2015 Edition Base Electronic Health Record (EHR) definition.
2. Health Information Exchange (HIE)/Clinical Registry: HIEs and clinical registries eligible for this reporting category include state HIEs, immunization information systems (IIS), public health agency systems, regional HIEs (RHIO), Patient-Centered Data Homes™ or other registries developed for research or to support quality improvement and patient safety initiatives. Doctors, nurses, pharmacists, other healthcare providers and patients can use HIEs to access and share vital medical information, with the goal of creating a complete patient record. Clinical registries can be sponsored by a government agency, nonprofit organization, healthcare facility or private company, and decisions regarding use of the data in the registry are the responsibility of the registry’s governing committee.
3. Case Management System: A shared database of member information collected through a collaborative process of member assessment, care planning, care coordination or monitoring of a member’s functional status and care experience. Case management systems eligible for this category of ECDS reporting include any system developed to support the organization’s case/disease management activities, including activities performed by delegates.
4. Administrative: Includes data from administrative claim processing systems for all services incurred (in other words, paid, suspended, pending, and denied) during the period defined by each measure’s participation as well as member management files, member eligibility and enrollment files, electronic member rosters, internal audit files, and member call service databases.

Having more time to focus on patient care rather than responding to medical record requests is possible by participating in ECDS. We are focused on reducing administrative burdens, so you can do what you do best – care for our members. Let us help by granting EMR Direct Remote access to our EMR team.

Need more information or ready to sign up?

Please email us today at: Centralized_EMR_Team@anthem.com.