The Department of Health & Human Services (HHS) requires health plans to report whether or not our in-network providers offer telehealth services.

If you provide telehealth services, please tell us by submitting your information to us through Availity.com. Updating your telehealth status will not affect your participation with us. We will add a telehealth indicator to your online provider directory profile, allowing our members to know you offer telehealth services.

If you have questions about submitting your information, please see the instructions below.

If your organization is not currently registered with Availity, you will need to create an account. The person(s) designated as your administrator(s) should go to Availity.com and select Get Started in the upper right corner of the webpage. You may also navigate directly to Availity’s registration website by selecting here.

Begin your application here. To update your application:

1. Log in to Availity Essentials.
2. Select My Providers.
3. Select Provider Data Management.

Please update your telehealth information at the service location.

Anthem continues to be dedicated to delivering access to quality care for our members, providing higher value to our customers and helping improve the health of our communities. In an ongoing effort to promote accurate claims processing and payment, Anthem is taking additional steps to assess selected claims for evaluation and management (E/M) services submitted by professional providers.

Beginning on February 1, 2025, we will be using an analytic solution to facilitate a review of whether coding on these claims is aligned with national industry coding standards.

Providers should report E/M services in accordance with the American Medical Association (AMA) CPT^® manual and CMS' guidelines for billing E/M service codes, Documentation Guidelines for Evaluation and Management. The appropriate level of service is based primarily on the documented medical history, examination, and medical decision-making.

Counseling, coordination of care, the nature of the presenting problem, and face-to-face time are considered contributing factors. The coded service should reflect and not exceed that needed to manage the member’s condition(s).

Claims will be selected from providers who are identified as coding at a higher E/M level compared to their peers with similar risk-adjusted members.

Prior to payment, Anthem will review the selected E/M claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is higher than the E/M code level supported on the claim.

If the E/M code level submitted is higher than the E/M code level supported on the claim, Anthem reserves the right to:

• Deny the claim and request resubmission of the claim with the appropriate E/M level.
• Pend the claim and request documentation supporting the E/M level billed.
• Adjust reimbursement to reflect the lower E/M level supported by the claim.

The maximum level of service for E/M codes will be based on the complexity of the medical decision-making and reimbursed at the supported E/M code level and fee schedule rate.

What is the impact of this change?

This initiative will not impact every level four or five E/M claim. Providers whose coding patterns improve and are no longer identified as an outlier are eligible to be removed from the program. Providers who believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the dispute resolution process (including submission of such documentation with the dispute).

Beginning with claims processing on or after December 1, 2024, we will update our outpatient facility claims editing process to deny claim lines when an add-on code is reported without a primary procedure code.

An add-on code is a specific type designated by the HCPCS or CPT^®. These codes describe additional procedures or services performed with a primary procedure.

According to CPT guidelines, add-on codes must be reported with a primary procedure code.

If you believe you have received a claim denial in error, please follow our claim dispute process.

With your help, we can continually build towards a future of shared success.

In July, we announced an enhancement to the 277CA to notify you of submission errors discovered during claims processing.  

As of November 1, 2024, the 277CA will include additional corrective action types for your review. As communicated in July, these errors will still be sent through physical mailing.

With these added error types, there is no reduction to the services we already provide.

Through our efforts, we are committed to reducing administrative burden, improving communication, and ensuring timely payments because we value you, our care provider partners.

Find Care, the doctor finder and transparency tool in the Anthem online directory, provides Anthem members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options such as sorting providers based on distance, alphabetical order, and provider name.

In our November 2022 newsletter, we provided an update regarding Personalized Match, an additional Find Care sorting option for Commercial members. We informed you that this provider sorting option was based on provider efficiency and quality outcomes described in a methodology document linked in the newsletter article, in addition to member search radius.

We want to inform you that, beginning in December 2024 or later, we will be enhancing Personalized Match. This will expand upon the existing program. Newer components of the provider personalization metrics will contain up to 10 times as many features as compared to existing metrics such as gaps in care and additional types of service cost and utilization. Personalized Match will continue to display providers with the highest overall ranking within the member’s search radius, first. Members will continue to have the ability to sort based on distance, alphabetical order, and provider name.

Helpful resources on Availity

You may review a copy of the Personalized Match methodology that has been posted on Availity, our secure web-based provider tool, using the following navigation:

• Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.

If you have general questions regarding these upcoming changes, please submit an inquiry via the web at Availity.com. If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.com.

Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.

We are excited to announce the release of an Applied Behavior Analysis (ABA) Provider Resource Guide designed to assist with proper billing and documentation practices. This essential guide simplifies the complexities of ABA coding and requirements, ensuring that you can navigate these processes with ease.

Refer to attached ABA Provider Resource Guide.

Anthem embraces opportunities to foster collaboration efforts with care providers to help ensure proper coding and payment of claims. A recent review showed that drug testing claims are being submitted for members in treatment at residential treatment centers (RTCs) for substance use disorders (SUDs) for American Society of Addiction Medicine (ASAM) levels 3.1 and 3.5.

The Indiana Health Coverage Program (IHCP) Provider Reference Module for Behavioral Health Services states that drug testing is included in the bundle of services covered by the per diem payment for ASAM levels 3.1 and 3.5.

Table 3 ─ low-intensity residential treatment (ASAM level 3.1) billing guidance

Table 4 ─ high-intensity residential treatment (ASAM level 3.5*) billing guidance

Coverage for drug testing with service codes 80305, 80306, 80307, G0480, G0481, and G0482 are included in the per diem payment for RTC 3.5 level of care (procedure code H0010) and RTC 3.1 level of care (procedure code H2034) when the member is in active treatment in that level of care.

Anthem will soon ensure that the billing guidance related to drug testing during residential treatment set forth in the IHCP Provider Reference Module is being followed. Claims submitted that do not adhere to this guidance will be denied.

We are grateful for your care of our members and look forward to continued collaboration.

Anthem embraces opportunities to foster collaboration efforts with providers to help ensure proper coding and payment of claims. To this end, we regularly review the Indiana Health Coverage Programs Provider Reference Modules to ensure we are processing claims in a way that is consistent with state guidance.

This letter is sent as a reminder that, per the Indiana Health Coverage Programs (IHCP) Provider References Module for Behavioral Health Services (p. 6) and in accordance with BT201859:

• The IHCP allows reimbursement for services provided by interns in the community mental health center (CMHC) setting. The provider billing for these services must be enrolled with the IHCP as a CMHC (provider type 11, specialty 111). CMHCs owned by or affiliated with a hospital, however, are an exception to this allowance. CMHCs associated with hospitals may not bill separately for intern services because reimbursement for intern services is included in the hospital’s medical education add-on to inpatient claims.
• To qualify for reimbursement, the intern must be a graduate or postgraduate student currently enrolled in an accredited college or university program in one of the following fields of study:
• Medical (including physician assistant)
• Nursing
• Behavioral health (including mental health and addiction treatment)

Further, the student must be approved by the college or university to work as an intern or practicum student at a CMHC.

For reimbursement, the intern must be supervised by an IHCP-enrolled practitioner who is employed by or under contract with the billing CMHC. The services rendered by the intern must be within the supervising practitioner's scope of practice. The following billing guidance applies to services rendered by interns:

• Services must be billed on a professional claim (CMS-1500 claim form or electronic equivalent).
• The supervising practitioner should be listed as the rendering provider on the claim.
• The modifier HL (intern) should be used to indicate that the service was performed by an intern.
• Reimbursement for intern services is at 50 percent of the professional fee schedule amount published on the Professional Fee Schedule, accessible from the fee schedules page at in.gov/medicaid/providers.

We are grateful for your care of our members and look forward to continued collaboration.

As a contracted provider for a special needs plan (SNP) from Anthem, you are required to participate in an annual Model of Care training for providers, per CMS regulations. This training includes a detailed overview of Anthem special needs plans and program information, highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Please remember this training is specific to our plans and delivery of care for members, ensuring their specific care needs are met. Your participation is critical for improved quality and health outcomes.

Training for the SNP product is self-paced and available at Availity.com. The training must be completed by December 31, 2024.

How to access the Custom Learning Center:

1. Log in to the Availity website at Availity.com.
2. At the top of the Availity website, select Payer Spaces and select the appropriate payer.
3. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
4. In the Custom Learning Center, select Required Training.
5. Select Special Needs Plan and Model of Care Overview.
6. Select Enroll.
7. Select Start.
8. Once the course is completed, select Begin Attestation and complete.

Not registered for Availity Essentials?

Have your organization’s designated administrator register your organization for the Availity website:

1. Visit Availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

Refer to these PDF documents for complete registration instructions.

In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care, effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here.

Site of Care Guidelines:

• Site of Care for Advanced Imaging
• Rehabilitative Site of Care
• Surgical Site of Care

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

Effective on November 17, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.

You may access and download a copy of the current and upcoming guidelines here:

• Musculoskeletal:
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

The above guideline updates have a publish date of November 17, 2024.

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

At a glance:

• High Performing Providers will also be known as Anthem Diamond Providers.
• Providers receiving a designation based on the Blue National Physician Performance Dataset will also be known as Anthem Diamond Providers (National).

High Performing Provider program

Over the last several months, we have communicated with our providers about our High Performing Provider program. PCPs and specialists meeting certain criteria are designated High Performing Providers. High Performing Providers may also be referred to as Anthem Diamond Providers.

As a reminder, the following specialties may be designated High Performing Providers (aka Anthem Diamond Providers) from this program:

• PCP: family practice, general practice, geriatric medicine, internal medicine, pediatric medicine, and nurse practitioners
• Specialists: cardiology, endocrinology, nephrology, neurology, neurosurgery, obstetrics gynecology, orthopedic surgery, psychiatry, pulmonology, and rheumatology

If you have any questions about this program, contact Provider Services or your local provider relationship management representative.

Blue National Physician Performance Dataset

This is an Anthem designation program for providers in networks supporting Anthem national accounts and certain out-of-area providers.

As we previously communicated to you, effective January 1, 2025, Anthem may incorporate insights from the Blue National Physician Performance Dataset (Dataset) in various initiatives. For Anthem national accounts and certain out-of-area providers, Anthem will use data made available in the Dataset to assess individual physician’s performance at the NPI level. The individual physician’s performance is assessed across the three domains — cost of care/efficiency, quality of care, and appropriateness of care — for the following 16 primary care and specialty areas: cardiothoracic surgery, cardiovascular disease, endocrinology, neurology, ob/gyn, ophthalmology, orthopedics, pediatrics, primary care, pulmonology, surgery, urology, gastroenterology, otolaryngology, oncology, and radiation oncology.

The providers who qualify for the designation from this Dataset program will also be referred to as Anthem Diamond Providers (National).

If you have any questions regarding this, contact your local provider relationship management representative.