We are updating the maternity notification process at https://Availity.com to make it more user‑friendly.

When specific conditions are met regarding maternity, a screen will appear after the Eligibility & Benefits (E&B) request and prior to the E&B response screen.

On this screen, users will be prompted to answer a few simple questions:

• Is the patient currently pregnant? Yes or no.

If the answer is yes, users will also be asked:

• What is the estimated delivery date?
• What is or was the first prenatal visit date?

After answering these questions, select Submit to proceed to the E&B response screen.

Answering these questions is optional. However, providing this information assists us with gathering relevant maternity information promptly and efficiently. Please note that this process does not replace the Notification of Pregnancy (NOP) process.

TMV is a dashboard you can access through Payer Spaces in the Availity Essentials platform that gives you a full 360‑degree view of your patient’s health and treatment history to 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.

TMV is replacing the previous Patient 360 (P360) dashboard that you may have used to access your patient’s medical records. The TMV user interface is purple and says Total Member View in the upper right corner. TMV highlights include viewing your patients who have a care gap and providing feedback on care gaps. If you were a user of the P360 dashboard, moving to Total Member View will be a simple transition.

Viewing your patients who have a care gap:

• After selecting the Total Member View application tile in Payer Spaces, you will be taken to the Summary tab.
• Within the Summary tab, locate and select the care gap alert name on the Active Alerts card.

Providing feedback on care gaps:

• Select the line item of the care gap on the Active Alerts card you would like to provide feedback on. A Care Gap Alert Feedback Entry dialog box will display.
• From the Latest Feedback field, select the drop‑down arrow, then select the type of feedback you would like to provide (for example, My Patient is compliant with message suggestion, My Patient will not likely comply with this suggestion).
• Once selected, choose Save.

User guide

The Total Member View Availity User Guide illustrates step‑by-step instructions on accessing and navigating through the Availity Essentials platform and how to use the system. This guide is available through the Digital Solutions Learning Hub.

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

Beginning with dates of service on or after May 1, 2025, Anthem will update the Diagnostic Radiopharmaceuticals and Contrast Materials — Professional and Facility reimbursement policy to remove the code list located in the Related Coding section. Providers should continue to follow the policy guidelines that identify the services eligible for reimbursement. Providers can refer to the AMA CPT Manual or HCPCS Level II Manual for correct coding. 

For specific policy details, visit the reimbursement policy page.

As of December 10, 2024, we retired the reimbursement policies titled Office Place of Service — Professional C‑13004 and Place of Service — Professional C‑09001. These policies have been combined to create a new reimbursement policy titled Place of Service — Professional C‑24004.

Under this policy, we require the appropriate place of service code to be billed on a CMS‑1500 claim form to be eligible for reimbursement. The place of service is determined by the following:

• CPT^® or HCPCS Level II code description
• CPT coding guidelines

For specific policy details, visit the reimbursement policies page at https://tinyurl.com/4k4y7e8p.

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

The following services are subject to the Nurse Practitioner and Physician Assistant Services reimbursement payment reduction and will be removed from the physicians’ services exclusion section:

• Preventive Services
• Radiology Services

The following services are not subject to the NP PA reimbursement payment reduction and will be included in the physicians’ services exclusion section:

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

For specific policy details visit the reimbursement policy page.

Our digital first approach enables providers to submit EDI corrected claims through Availity Essentials or the electronic data interchange (EDI).

Corrected claim guidance

When submitting a corrected claim, include all previous information along with any corrections or additions.

To correct a claim billed to us in error, submit the entire claim as a void/cancel. A new claim may be required if we identify missing or incorrect information based on the guidelines in the Claims Submission section. Providers will receive written or electronic notification indicating the missing data.

The provider manual at https://tinyurl.com/cwwxx3mv offers guidance on submitting corrected claims, helping to prevent issues with reimbursement.

For services beginning on January 1, 2025, prior authorization requests for admission to or concurrent stay requests in an inpatient acute rehab facility (ARF) or long‑term acute care hospital (LTACH) will be handled by the FEP Case Management team to review for medical necessity and care coordination. This change impacts members of the Anthem Blue Cross and Blue Shield Federal Employee Program^® (FEP^®), including Federal Employee Health Benefit (FEHB) and Postal Service Health Benefit (PSHB), The FEP Case Management team may be contacted by phone at 800‑711-2225 for FEHB members or 833‑277-5220 for PSHB members. Clinical information should be faxed to 866‑862-4288.

Visit the Drug List page on our website for more information about:

• Copayment/coinsurance requirements and their applicable drug classes.
• Drug lists and changes.
• Prior authorization criteria.
• Procedures for generic substitution.
• Therapeutic interchange.
• Step therapy or other management methods subject to prescribing decisions.
• Any other requirements, restrictions, or limitations that apply to using certain drugs.

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

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

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

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

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

Effective with dates of service on and after January 1, 2025, and in accordance with the CarelonRx, Inc. pharmacy and therapeutics (P&T) process, we updated our drug lists that support commercial health plans. Updates include changes to drug tiers and the removal of medications from the formulary.

Please see the attachment here for more information.

As we previously communicated, Anthem requires providers who are not part of our designated specialty pharmacy network to acquire certain select specialty pharmacy medications administered in the hospital outpatient setting through our contracted medical specialty pharmacy.

Updates

Effective for dates of service on and after April 1, 2025, the HCPCS code J2796 for Nplate (romiplostim), which is presently on the Designated Medical Specialty Pharmacy Drug List, will be replaced with J2802.

Additionally, effective for dates of service on and after April 1, 2025, the following specialty pharmacy medications will be removed from the Designated Medical Specialty Pharmacy Drug List and will no longer need to be obtained from our contracted medical specialty pharmacy:

To access the current Designated Medical Specialty Pharmacy Drug List, please visit anthem.com/provider, select Providers, select Forms and Guides (under the Provider Resources column), select your state, scroll down, and select Pharmacy in the Category dropdown. The Designated Medical Specialty Pharmacy Drug List may be updated periodically by Anthem.

If you have questions or would like to discuss the terms and conditions to be included as a designated specialty pharmacy network provider, please contact your contract manager with Anthem. Thank you for your continued participation in the Anthem networks and the services you provide to our members.