 Provider News IndianaJuly 1, 2019 July 2019 Anthem Provider News - IndianaChanges to Prior Authorization Requirements and/or Material Changes to Contract may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements starred (*) below.
Clinical Guidelines
- Updates to AIM Advanced Imaging Clinical Appropriateness Guidelines*
Reimbursement
- Clinical Validation: Professional*
- Update to Provider UM reimbursement penalties and corresponding update to Provider Manual*
Other Important Updates
- Pharmacy: Clinical Criteria updates for specialty pharmacy
- FEP: Anthem Federal Employee Health Benefit Program® (FEP) PPO Members will now require prior approval for specific Specialty Drugs and Site of Care
Medicare and Medicaid News
Fee Schedule information is confidential and proprietary to Anthem Blue Cross and Blue Shield (Anthem) in your Provider Agreement (the “Agreement”). The Agreement has general restrictions regarding disclosure of such confidential information. For example, neither Anthem nor Provider may disclose confidential and proprietary information except: 1) as required by Regulatory Requirements; 2) upon the express written consent of the parties; 3) as required to perform the obligations of the Agreement; or 4) as required to deliver Health Services or administer a Health Benefit Plan.
Please refer to your specific Agreement for a complete list of disclosure restrictions.
Anthem provider agreements restrict the disclosure of confidential information, including Fee Schedule information, to third-parties (e.g., consultants, lenders, legal advisors, and business advisors). Absent Anthem’s written consent, those restrictions surrounding disclosure extends to those third parties that conduct business on behalf of providers.
Upon disclosure, all third parties are subject to the confidentiality requirements as set forth in the Agreement.
Disclosure of confidential and proprietary information, in violation of the terms of the Agreement, could subject Provider to penalties.
Effective for dates of service beginning October 1, 2019, and after, Anthem Blue Cross and Blue Shield (Anthem) will increase the reimbursement penalty for failure to comply with the Utilization Management (UM) program’s prior authorization requirements for services rendered to commercial plan members. Late prior authorizations, and late notices in the case of emergency admissions, are currently subject to a penalty and will be subject to the increase in the penalty. Failure to comply with Anthem’s prior authorization requirements, and late notice requirements in the case of emergency admissions, will result in a 50% reduction in reimbursement to the Provider and Facility.
As a reminder, Anthem requires prior authorization prior to the delivery of certain elective services in both the inpatient and outpatient settings. For an emergency admission, prior authorization is not required; however, you must notify Anthem of the admission within the timeframe specified in the Provider Manual or as otherwise required by law, as failure to give timely notification for emergency admissions will also result in reimbursement penalties of 50% to providers and facilities.
Enforcement of the program requirement will lead to greater consistency in our processes. This notice updates Anthem’s UM program reimbursement penalties and the corresponding sections of the Provider Manual effective October 1, 2019, to reflect this change to the reimbursement penalty for non-compliance. As a reminder, Providers and Facilities may not balance bill the member for any such reduction in payment.
* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.
In our company’s ongoing efforts to streamline and simplify our payment recovery process, we continue to consolidate our internal systems and will begin transitioning our National Accounts membership to a central system in 2019. While this is not a new process, we are transitioning the National Accounts membership to align with the payment recovery process across our other lines of business.
Currently, our recovery process for National Accounts membership is reflected in the EDI PLB segment on the electronic remittance advice (835). This segment will show the negative balance associated with the member account number. Monetary amounts are displayed at the time of the recovery adjustment.
As National Accounts membership transitions to the new system and claims are adjusted for recovery, the negative balances due to recovery are held for 49 days to allow ample time for you to review the requests, dispute the requests and/or send in a check payment. During this time, the negative balances due are reflected on paper remits only within the “Deferred Negative Balance” sections.
After 49 days, the negative balances due are reflected within the 835 as a corrected and reversed claim in PLB segments.
If you have any questions or concerns, please contact the E-Solutions Service Desk toll free at (800) 470-9630. If you currently submit claims directly to the Anthem EDI Gateway, now is the time to make the move.
It is mandatory that, all trading partners must transition to the Availity EDI Gateway to avoid future disablement.
Do you already have an Availity User ID and Login? You can use the same login for your Anthem EDI transactions.
- Log in to the Availity Portal and select Help & Training | Get Trained. In the Availity Learning Center, search the Catalog by key word “SONG” for live and on-demand resources created especially for you.
If you wish to become a direct a trading partner with Availity, the setup is easy.
Do you use a clearinghouse today?
- We encourage you to contact your clearinghouse to ensure they have made the move.
Need Assistance?
The Availity Quick Start Guide will assist you with any EDI connection questions you may have.
If you need additional assistance, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 7:30 p.m. Eastern Time. Continuing our 2019 CRA reporting updates, Anthem Blue Cross and Blue Shield (Anthem) requests your assistance with respect to our CRA reporting processes.
As we reported in the May and June newsletters, we are completing our prospective and retrospective reviews for 2019. Prospectively, we intervene to encourage the participation of the members we have identified as appropriate for clinical assessments. Retrospectively, certified coders review medical charts to determine if there are diagnosis codes that have not been reported.
What’s in it for you?
First, monthly you will receive lists of our members who are your patients to help you reach out to those who may have gaps in care, so they can come in for office visits earlier.
Second, we’ve heard resoundingly from providers that participation in these programs helps them better evaluate their patients (who are our members) and, as a result, perform more strongly in population health management and gain sharing programs. Many cite that they ask different questions today that allow them to better manage their patients end to end.
Finally, when you see Anthem members and submit assessments, we pay incentives of $50 for a paper submission and $100 for an electronic submission. For additional details on how to earn these incentives and the options available, please contact our CRA Network Education Representative listed below.
What’s in it for your patients?
Anthem has completed monthly postcard campaigns to members with Affordable Care Act (ACA) compliant coverage when we suspect a high risk condition with messaging to encourage the member to call his or her Primary Care Provider (PCP) and schedule an annual checkup. The goal is to get the members in to see their PCPs, so the PCPs have an overall picture of their patients’ health and schedule any screenings that may be needed.
We will continue these monthly postcard mailings throughout all of 2019 to continue to encourage the members to be seen in your office, which supplements any patient outreach you may be doing as well.
If you have any questions regarding our reporting processes, please contact our CRA Network Education Representative by emailing Natalie.Wilder@anthem.com.
In 2018, the Indiana legislature passed House Bill 1143 which, among other things, requires health care providers to submit, and health plans to accept, requests for most prior authorization requests through a secure electronic transmission beginning for requests sent on and after January 1, 2020.
Anthem has multiple secure electronic transmission portals available for providers to submit prior authorization requests depending on the type of health service being provided.
Are you ready?
If you are not using our electronic portals for your prior authorization requests, now would be good time to register and to begin using them.
- Availity. Prior authorizations for medical and behavioral health services are submitted using the Availity portal. For more information about Availity, please visit our website at https://www.anthem.com/provider/availity/. Here you can learn about all of the services offered through the Availity portal, register to use Availity, and find out how to access training on Availity.
- AIM ProviderPortalSM. For services administered by AIM Specialty Health®, providers may submit electronic prior authorization requests to AIM using AIM’s ProviderPortalSM directly at https://providerportal.com/.
To learn more about this law, please visit the Indiana Legislature website and view the Indiana House Bill 1143 and the final statute Health Care Services Prior Authorization (IC 27-1-37.5-10).
For more information, please view our Frequently Asked Questions (FAQ) on anthem.com. If you have additional questions, please contact Provider Services.
We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well.
The reality is burden of illness, premature death, and disability disproportionately affects certain populations1. MyDiversePatients.com features robust educational resources to help support you in addressing these disparities. You will find:
- CME learning experiences about disparities, potential contributing factors and opportunities for you to enhance care.
- Real life stories about diverse patients and the unique challenges they face.
- Tips and techniques for working with diverse patients to promote improvement in health outcomes.
While there’s no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com is to start reversing these trends…one patient at a time.
Accelerate your journey to becoming your patients’ trusted health care partner by visiting MyDiversePatients.com today.
1Centers for Disease Control and Prevention. (2013, Nov 22). CDC Health Disparities and Inequalities Report — United States, 2013. Morbidity and Mortality Weekly Report. Vol 62(Suppl 3); p3. Effective for dates of service on and after September 28, 2019, the following updates will apply to the AIM Advanced Imaging Clinical Appropriateness Guidelines.
Brain Imaging Guideline contains updates to the following:
- Infection
- Multiple sclerosis and other white matter diseases
- Movement disorders (Adult only)
- Neurocognitive disorders (Adult only)
- Trauma
- Pituitary adenoma
- Tumor
- Hematoma or hemorrhage – intracranial or extracranial
- Hydrocephalus/ventricular assessment
- Pseudotumor cerebri
- Spontaneous intracranial hypotension
- Abnormality on neurologic exam
- Ataxia
- Dizziness or Vertigo
- Headache
- Hearing loss
- Tinnitus
Extremity Imaging Guideline contains updates to the following:
- Congenital or developmental anomalies of the extremity (Pediatric only)
- Discoid meniscus (Pediatric only)
- Soft tissue infection
- Osteomyelitis
- Septic arthritis
- Bursitis
- Capitellar osteochondritis
- Fracture
- Patellar dislocation
- Patellar sleeve avulsion
- Trauma complications
- Bone lesions
- Soft tissue mass – not otherwise specified
- Lisfranc injury
- Labral tear – hip
- Labral tear – shoulder
- Meniscal tear and ligament tear of the knee
- Rotator cuff tear (Adult only)
- Avascular necrosis
- Lipohemarthrosis (Pediatric only)
- Paget’s disease – new multimodality indication
- General Perioperative Imaging (including delayed hardware failure) not otherwise specified
Spine Imaging Guideline contains updates to the following:
- Multiple sclerosis or other white matter disease
- Spinal infection
- Cervical injury
- Thoracic or lumbar injury
- Paget’s disease
- Spontaneous (idiopathic) intracranial hypotension (SIH)
- Perioperative Imaging, including delayed hardware failure, not otherwise specified
- Neck pain (cervical)
- Mid-back pain (thoracic)
As a reminder, ordering providers may submit genetic testing prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM 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 Web Portal at availity.com.
- Call the AIM Contact Center toll-free number 800-554-0580, 8:30 a.m.–7:00 p.m. ET.
For 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 guidelines on the Availity website.
* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.
Effective with dates of service on or after October 1, 2019, we will update our audit process for claims with modifiers used to bypass claim edits by conducting modifier reviews through a pre-payment clinical validation review process. Claims with modifiers such as -25, -59, -57, LT/RT, and other anatomical modifiers will be part of this review process.
In accordance with published reimbursement policies which document proper usage and submission of modifiers, the clinical validation review process will evaluate the proper use of these modifiers in conjunction with the edits they are bypassing (such as National Correct Coding Initiative). Clinical analysts who are registered nurses and coders will review claims pended for validation, along with any related services, to determine whether it is appropriate for the modifier to bypass the edit.
If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process and include medical records that support the usage of the modifier applied when submitting claims for consideration.
* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements. A recent review of our claim trends has identified that many providers are not billing appropriately for modifier 79. According to Appendix A in the CPT Professional Edition, modifier 79 is used to indicate that a procedure or service is an “… unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period”. If the current procedure or service does not fall within the postoperative period of a previously performed 0, (same day), 10 or 90 day postoperative period, by the same provider or a provider in the same group practice, please carefully consider the definition of modifier 79 when adding the modifier to a procedure or service.
According to Appendix A of the CPT Professional Edition codebook, modifier 63 is only used when an invasive procedure is performed on neonates or infants up to a present body weight of 4 kg to indicate significantly increased complexity and physician or other qualified health care professional work commonly associated with these patients. Unless otherwise designated, this modifier should only be appended to the procedures/services identified in the modifier description. Additionally, based on the modifier description, modifier 63 is not valid for use with evaluation and management, anesthesia, radiology, pathology/laboratory, or medicine codes. Furthermore, many procedures performed on infants for correction of congenital abnormalities include additional difficulty or complexity that are inherent to the procedure and are identified by the code nomenclature and the CPT parenthetical “do not use modifier 63 in conjunction with…” These codes are also identified in Appendix F of the CPT Professional Edition codebook. Please note, incorrect reporting of modifier 63 may result in claim denials.
With the adoption of ICD-10-CM code set, we were introduced to diagnosis codes that now indicate the laterality of a condition. At present, diagnosis code descriptions indicate whether the condition is present on the left, right or exists bilaterally. A recent review of our claim denial trends has identified that many providers are not billing appropriately in regards to laterality. For specific guidance for reporting a diagnosis that designates a condition on the left and right versus a bilateral diagnosis, refer to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2019, specifically, the General Coding Guidelines Section and the Chapter Specific Sections. Please carefully consider the information contained in the ICD-10-CM Coding Guidelines when trying to decide between reporting a condition using left diagnosis and right diagnosis codes versus a bilateral diagnosis code.
Effective July 1, 2019, Anthem Federal Employee PPO members, (ID numbers beginning with an, ‘R’), aged 18 and older, and not Medicare Primary, will now need to have Prior Approval for the following medications:
List of medications by code
|
Code
|
Procedure Description
|
|
J0129
|
Abatacept injection (Orencia)
|
|
J0490
|
Belimumab injection (Benlysta)
|
|
J1459
|
Injection, immune globulin (Privigen)
|
|
J1555
|
Injection, immune globulin (Cuvitru)
|
|
J1556
|
Injection, immune globulin (Bivigam)
|
|
J1557
|
Injection, immune globulin (Gammaplex)
|
|
J1559
|
Injection, immune globulin (Hizentra)
|
|
J1561
|
Injection, immune globulin (Gamunex-c/Gammaked)
|
|
J1566
|
Injection, immune globulin (Carimune)
|
|
J1568
|
Injection, immune globulin (Octagam)
|
|
J1569
|
Injection, immune globulin (Gammagard liquid)
|
|
J1572
|
Injection, immune globulin (Flebogamma)
|
|
J1575
|
Injection, immune globulin/hyaluronidase (HyQvia)
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|
J1599
|
Injection, immune globulin (Panzyga)
|
|
J1602
|
Golimumab IV (Simponi Aria)
|
|
J1745
|
Infliximab not biosimilar (Remicade)
|
|
J2323
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Natalizumab injection (Tysabri)
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|
J3380
|
Vedolizumab Injection (Entyvio)
|
|
Q5103
|
Infliximab dyyb biosimilar (Inflectra)
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|
Q5104
|
Infliximab abda biosimilar (Renflexis)
|
|
Q5109
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infliximab-qbtx, biosimilar (Ixifi)
|
In addition to acquiring Prior Approval for the medication, the Outpatient Hospital Site of Care must also be approved. The Prior Approval process will identify members who meet the appropriate Anthem site of care criteria and who can safely receive their medication in a location other than an outpatient hospital, including the home.
Effective January 1, 2020 failure to receive Prior Approval for these medications may result in non-coverage of the medication and facility services.
To acquire Prior Approval please contact the Anthem Federal Employee Program Utilization Management Department at (800-860-2156).
In the December 2018 newsletter, Anthem Blue Cross and Blue Shield (Anthem) introduced the new clinical criteria page for injectable, infused or implanted drugs.
Effective for dates of service on and after August 1, 2019, the following new oncology clinical criteria will be included in our clinical criteria review process. The oncology drugs that require prior authorization will continue to require prior authorization notification with AIM.
Existing precertification requirements have not changed for the specific Clinical Criteria below. While there are no material changes, the document number and online location has changed. You can go online to access the Clinical Criteria information.
The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical Guideline/Medical Policy.
Anthem’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
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Clinical Guideline
|
Clinical Criteria Document Number
|
Clinical Criteria Name
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Drug
|
HCPCS Code
|
|
CG-DRUG-76
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ING-CC-0089
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Mozobil (plerixafor)
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Mozobil
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J2562
|
Due to coding updates in the claims system, the claim system edits for the clinical criteria listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. These coding updates may result in a “not medically necessary” determination.
Effective May 1, 2019, we implemented coding updates in the claims system for the following clinical criteria listed below which may result in not medically necessary determinations for certain services.
|
Clinical Criteria Document Number
|
Clinical Criteria Name
|
|
ING-CC-0073
|
Alpha-1 Proteinase Inhibitor Therapy
|
You can go online to access the Clinical Criteria information.
Effective October 1, 2019, Anthem Blue Cross and Blue Shield (Anthem) will transition utilization management of our Outpatient Rehabilitation Program for Medicare Advantage from OrthoNet LLC to AIM Specialty Health® (AIM). AIM is a specialty health benefits company. The Outpatient Rehabilitation Program includes physical, occupational and speech therapy services. Anthem has an existing relationship with AIM in the administration of other programs.
This transition enables Anthem to expand and optimize this program, further ensuring that care aligns with established evidence-based medicine. AIM will follow the clinical hierarchy established by Anthem for medical necessity determination. For Medicare Advantage, Anthem makes coverage determinations based on guidance from CMS including national coverage determinations (NCDs), local coverage determinations (LCDs), other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.
AIM will continue to use criteria documented in Anthem clinical guidelines GC.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://www.availity.com by selecting Clinical Resources in the Education and Reference Center under Payer Spaces.
Detailed prior authorization requirements are available online by accessing the Precertification Lookup Tool under Payer Spaces at https://www.availity.com. Contracted and non-contracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.
Prior authorization review requirements
For services scheduled to be rendered through September 30, 2019, providers must contact OrthoNet LLC to obtain prior authorizations for outpatient rehabilitation services. Any authorizations OrthoNet LLC makes prior to the transition date of October 1, 2019, will be honored and claims will process accordingly.
For services that are scheduled on or after October 1, 2019, providers must contact AIM to obtain prior authorization. Beginning September 15, 2019, providers will be able to contact AIM for prior authorization on services to take place on or after October 1, 2019. Providers are strongly encouraged to verify that they have obtained prior authorization before scheduling and performing services.
How to place a review request
You may place a request online via the AIM ProviderPortalSM. This service is available 24/7 to process requests in real time using clinical criteria. Go to www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday to Friday 7 a.m. to 7 p.m. Central time.
For more information
For resources to help your practice get started with the Outpatient Rehabilitation Program, go to www.aimproviders.com/rehabilitation. Our provider website helps you learn more and provides access to useful information and tools such as order entry checklists, clinical guidelines and FAQ.
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This information is intended for home health agencies that do not submit their claims to MyNexus and are contracted with Anthem Blue Cross and Blue Shield (Anthem) to be compensated based on the original Medicare Home Health Prospective Payment System. This information is not intended for home health agencies that are contracted to be compensated based on per visit rates.
Below are some billing guidelines we recommend home health providers use when billing a Request for Anticipated Payment (RAP) and final claim to Anthem. This information will assist home health providers in receiving the correct and timely payment according to Medicare guidelines and their contract.
- Anthem should receive the final bill within 120 days after the start date of the episode or 60 days after the paid date of the RAP claim — whichever is greater. If the final bill is not received within this time frame, the RAP payment will be canceled/recouped — This is a Medicare billing requirement.
- Bill the full Medicare allowed amount for the episode as the billed charges. Do not bill only the expected additional payment on the final claim as the billed charges. When this happens, the Lesser of Logic term in your contract affects the final payment made for the services. If the billed charges are less than the final allowed, the payment will be reduced to only pay up to the billed charges. The billed charges on the final claim should be for at least the full Medicare allowed amount for the services rendered. This will allow the claim to process correctly according to Medicare guidelines.
- Example: RAP claim paid $500. The final claim is submitted with billed charges in the amount of $1,000. The Medicare allowed amount is $1,500. Since the billed charges on the final claim are only $1,000, Anthem would only pay an additional $500 for the final allowed according to the Lesser of Logic term in the contract. If the provider would have billed charges in the amount of at least $1,500, then an additional payment of $1,000 would have been paid.
500843MUPENMUB As currently outlined in your provider manual, providers can submit claim payment reconsiderations verbally, in writing or electronically. We are reaching out to notify you about some exciting new tools for electronic submission that will become available through the Availity Portal. In addition, the Medicare Advantage provider manual has been updated with new information regarding claim remediation tools through the Availity Portal.
Beginning June 17, 2019, providers will have the ability to submit claim reconsideration requests through the Availity Portal with more robust functionality. For you, this means an enhanced experience when:
- Filing a claim payment reconsideration.
- Sending supporting documentation.
- Checking the status of your claim payment reconsideration.
- Viewing your claim payment reconsideration history.
New Availity Portal functionality will include:
- Acknowledgement of submission at the time of submission.
- Notification when a reconsideration has been finalized by Anthem Blue and Blue Shield.
- A worklist of open submissions to check a reconsideration status.
With the new electronic functionality, when a claim payment reconsideration is submitted through the Availity Portal, we will investigate the request and communicate an outcome through the Availity Portal. Once an outcome has been determined, the Availity Portal user who submitted the claim payment reconsideration will receive notification through Availity informing the user the reconsideration review has been completed. If you are not satisfied with the reconsideration outcome, continue to follow the process to file a claim payment appeal, as outlined in your provider manual.
You can get a jump start on your training and be ready to go as soon as the tool is fully launched. To learn more about the claim payment dispute tool, register for a live webinar or view a previous recording:
- Log in to Availity at http://www.availity.com.
- Select Help & Training | Get Trained.
- Enter Appeals in the search field.
- Enroll in a course.
Providers who have questions as they begin to use the new functionality should contact Availity at 1-800-282-4548.
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