We are excited to announce the release of Provider Contract and Fee Schedule Notifications! Starting in Mid-July, when Anthem Blue Cross and Blue Shield (Anthem) notifies you of a statewide fee schedule update or provider contract amendment, you can log into Availity.com and download a digital copy of your content.

 

Over the last few months, we have been tirelessly working to improve our service and believe that online Provider Contract and Fee Schedule Notifications will help you appreciate your experience with Anthem even more.

 

In order to be ready for the digital downloads, you should log in to Availity, access the Provider Online Reporting application and register your authorized users. Going forward, you will see newsletter articles notifying you when you can download content, or if your state requires a mail notification, you may receive a letter or postcard notifying you of content ready for download.

 

See details below on how to log in and access your reports:

 

Provider Online Reporting Reference Guide

 

How to get started

 

This document will familiarize you with the Provider Online Reporting application found on the Availity Portal.  Using our web-based reporting application, you will be able to access regularly updated reports.

 

• For Availity Administrators – How to assign access
• For Users – How to navigate to the reports

 

If your organization is not currently registered for the Availity Portal, go to www.availity.com and select Register to complete the online application.

 

Your Administrator will need to take the following steps to assign access to Provider Online Reporting:

1. Assign the user role of Provider Online Reporting to your Availity access.
2. Select Payer Spaces in the navigation bar and then choose the payer tile that corresponds to the market.
3. Accept the User Agreement (once every 365 days).
4. On the Applications tab, select Provider Online Reporting.
5. Choose the organization and select Submit.
6. In the Provider Online Reporting application, register the tax ID by selecting Register/Maintain Organization.
7. Last, register users to the program by selecting Register Users and completing the required fields.

 

Accessing reports:

1. After logging in to Availity, select Payer Spaces in the navigation bar and then choose the payer tile that corresponds to the market.
2. Accept the User Agreement (once every 365 days).
3. On the Applications tab, select Provider Online Reporting.
4. Choose the organization and select Submit.
5. Select Report Search, choose the type of report, and then launch your program’s reporting application.

The Home page in Provider Online Reporting will open. The page lists all programs the organization is eligible for.
Use the navigation options on the left side of the page to easily move around within the tool.

The Report Search page launches the corresponding reporting application for your program. Select the appropriate program from drop-down menu.

 

For further assistance with Availity, please contact Availity Client Services at 1-800-282-4548.

For other questions, contact your local contract advisor, consultant or Provider Relations representative.

 

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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 current health crisis illuminates this quite clearly. It is imperative to offer care that is tailored to the unique needs of patients, and Anthem Blue Cross and Blue Shield is committed to supporting our providers in this effort. 

 

MyDiversePatients.com offers education resources to help you support the needs of your diverse patients and address disparities, including:

• Free Continuing Medical Education (CME) learning experiences about disparities, potential contributing factors and opportunities for providers 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.

 

Stronger Together offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.

 

While there is no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com and Stronger Together is to start reversing these trends…one person at a time.

 

Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted health care partner by visiting these resources today.

 

My Diverse Patients

Stronger Together Health Equity Resources

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Anthem Blue Cross and Blue Shield (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 November 1, 2020, 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’s (AMA’s) CPT^® Manual and the Centers for Medicare and Medicaid Services (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 as compared to their peers with similar risk-adjusted members. 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. This initiative will not impact every level 4 or 5 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 that 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).

 

For questions on this program, please contact your Provider Solutions representative.

 

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There is no doubt the coronavirus (COVID-19) crisis has taken a toll on all of us. The pandemic has led to immeasurable challenges but we are here to help you ease back into business. We want to remind you, as the Availity migration continues full speed ahead, Anthem Blue Cross and Blue Shield (Anthem) will guide you to make it a smooth transition Just as all good things end, such as summer, the Availity EDI migration also has a target closing date of September 15, 2020.

 

Take Action Today: Availity setup is simple and at no cost for you!

 

Use this “Welcome” link to get started today: https://apps.availity.com/web/welcome/#/

 

All EDI transmissions currently sent or received today via the Anthem gateway are now available on the Availity EDI Gateway. 

• 837 Institutional and Professional
• 837 Dental
• 835 Electronic Remittance Advice
• 276/277 Claim Status
• 270/271 Eligibility Request
• 275 Medical Attachments
• 278 Prior Authorization/Referrals
• 278N Inpatient Admission and Discharge Notification

Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:

• Migrate your direct connection with Anthem and become a direct submitter with Availity.
• Use your existing Clearinghouse or Billing Company for your EDI transmissions. (Work with them to ensure connectivity to the Availity EDI Gateway).
• Use Direct Single Claim entry through the Availity Portal.

 

Show your team what you learned this summer!

 

Enroll in one of Availity’s free courses and training demos at your convenience. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.

 

Follow these steps to register at availity.com :

1. Log in to the Availity Portal and select Help & Training | Get Trained to access the Availity Learning Center (ALC).
2. Select Sessions from the menu under the search catalog field.
3. Scroll Your Calendar to locate your webinar.
4. Select View Course and then Enroll. The ALC will email you instructions to attend.

If you and your clearinghouse have already migrated over to Availity, thank you and you are a step ahead! If not, start the process now to make the transition before September 15, 2020.

 

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday through Friday, 8 a.m. to 7 p.m. Eastern time.

 

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The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory testing in the U.S. through the Clinical Laboratory Improvement Amendments (CLIA). The objective of the CLIA program is to ensure quality laboratory testing.

 

A valid CLIA Certificate Identification number is required and must be included on each electronic claim billed for laboratory services, subject to CLIA legislation. You may not receive reimbursement for your electronic claims if the required certification number is missing.

 

How to apply for a CLIA Certificate

 

This CMS mandate went in to effect on May 1, 2020. Please work with your software vendor or clearinghouse to ensure that the required information is included in your electronic files to avoid EDI claim rejections.

Link: https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/How_to_Apply_for_a_CLIA_Certificate_International_Laboratories

 

For detailed information on the tests subject to CLIA, please refer to the CMS link below:

https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/

 

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Anthem Blue Cross and Blue Shield (Anthem) and Availity Electronic Data Interchange (EDI) is excited to announce the X12 275 5010 version of electronic attachments transactions for claims functionality is now available for you.  

 

The X12 275 5010 version of electronic attachments transactions for claims will:

• Bring value to you by eliminating the need for mailing paper records.
• Electronic acknowledgment provides a transaction audit trail – proof of delivery/receipt.
• Reduces administrative cost associated with manual processing
• Save time waiting for paper correspondents

 

This new functionality includes both solicited and unsolicited attachments.

• Solicited Attachment – Documentation submitted in response to a specific request.
• Unsolicited Attachment – Documentation is known to be needed and submitted at the same time as the claim.

 

How to send a 275 transaction

 

Your practice management software or billing service/clearinghouse must have the ability to send a 275. We encourage you to have a conversation with them to determine their ability to set up the X12 275 attachment transaction capabilities.

 

Where to find help

 

The new EDI batch process, X12 275 5010v Companion Guide, assists with specific attachment requirements and enables providers to electronically submit attachments based on your business needs.

 

The companion guide can be download at: anthem.com/edi

 

Availity documentation can be found at: availity.com

 

Use the “Availity Welcome Application” below to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions.

 

EDI Welcome App: apps.availity.com/web/welcome/#/

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday through Friday, 8 a.m. to 7 p.m. Eastern time.

 

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Anthem Blue Cross and Blue Shield (Anthem) and Availity Electronic Data Interchange (EDI) is excited to announce the Prior Authorization/ Referrals 278 and Inpatient Admission and Discharge Notification 278N 5010 transactions functionality is coming soon.

 

Prior Authorization and Referral Request (278)

 

The EDI 278 transaction supports healthcare providers to submit an authorization and referral requests electronically.

 

A prior authorization issued by Anthem provides you the go-ahead to perform the necessary service and a referral used to refer a member to a specialty provider. Transmit this transaction in real-time or batch mode. You will receive confirmation numbers to validate receipt of request.

Inpatient Admission and Discharge Notification 278N

 

Use the Hospital Admission Notification (278N) transaction to exchange admission notification data between an inpatient facility and Anthem in a standard format.

Similar to the HIPAA 278 transaction that you may already use to submit authorizations or referrals, the EDI 278N is the simplest, most efficient way to communicate facility admissions. You can also transmit through Availity in either batch or real-time format.

What are the benefits of 278 and 278N transaction?

 

Both transactions offer:

• Simplify administrative tasks and increase productivity.
• Reduce administrative costs through automation and fewer phone calls, faxes or keying.
• Increase data accuracy by reducing manual errors.

 

Specifically for 278N, hospitals that have implemented EDI 278N:

• Experience an improvement in notification submissions within 24 hours.
• Can confirm a notification of admission is on file in the form of a service reference number generated upon registration.
• Submit notification of discharge.

 

How to send a 278 and 278N Transaction

 

Look for more communications coming soon around how to work with your practice management software vendor or billing/service clearinghouse or view a companion guide to send a 278 or 278N transaction.

 

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Quality health care requires standard documentation requirements to ensure consistency for the care of our members. These standards are reviewed annually to ensure they align with our current policies. These standards ensure effective medical record documentation and provide clear and consistent guidelines to ensure that providers maintain records in a current, organized, and effective manner. The medical record criteria that is encouraged for our network of independently contracted providers are outlined below.

 

1. Every page in the medical record contains the patient name or ID number.
2. Allergies/No Known Drug Allergies (NKDA) and adverse reactions are prominently displayed in a consistent location.
3. All presenting symptom entries are legible, signed and dated, including phone entries. Dictated notes should be initialed to signify review.  Signature sheet for initials are noted.
4. The important diagnoses are summarized or highlighted.
5. A problem list is maintained and updated for significant illnesses and medical conditions.
6. A medication list or reasonable substitute is maintained and updated for chronic and ongoing medications.
7. History and physical exam documentation identifies appropriate subjective and objective information pertinent to the patient’s presenting symptoms, and treatment plan documentation is consistent with findings.
8. Laboratory tests and other studies are ordered, as appropriate, with results noted in the medical record. (The clinical reviewer should see evidence of documentation of appropriate follow-up recommendations and/or non-compliance to care plan).
9. Documentation of Advance Directive/Living Will/Power of Attorney discussion (including copies of any executed documents) in a prominent part of the medical record for adult patients is encouraged.
10. Documentation of continuity and coordination of care between the PCP, specialty physician (including BH specialty) and/or facilities if there is reference to referral or care provided elsewhere. The clinical review will look for a summary of findings or discharge summary in the medical record. Examples include progress notes/report from consultants, discharge summary following inpatient care or outpatient surgery, physical therapy reports, and home health nursing/ provider reports.
11. Age appropriate routine preventive services/risk screening is consistently noted, i.e. childhood immunizations, adult immunizations, mammograms, pap tests, etc., or the refusal by the patient, parent or legal guardian, of such screenings/immunizations in the medical record.

 

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We appreciate the role you play in managing the health of our members. As the physician of a patient who has coverage compliant with the Affordable Care Act (ACA), you play a vital role in accurately documenting the health of the patient to help ensure compliance with ACA program reporting requirements. When patients visit your practice, we encourage you to document ALL of their health conditions, especially chronic diseases. Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.

 

Please ensure that all codes captured in your electronic medical record (EMR) system are also included on the claim(s), and are not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing four.  If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.

 

Reminder about ICD-10 coding

 

The ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits. Additionally, Anthem uses ICD-10 codes submitted on claims to monitor health care trends, cost, and disease management. Additionally, the Centers for Medicare & Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a patient’s health.

 

Using specific ICD-10 diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.

• Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.
• Include any secondary diagnosis codes that are actively being managed.
• Include all chronic historical codes, as they must be documented each year pursuant to the ACA. (Such as an amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).

 

Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions. ICD-10 coding guidelines still apply, so please ensure coding on a telehealth visit claim is to the highest specificity with all diagnosis codes. Previous Anthem Provider News editions provide telehealth reimbursement guidance to follow for claims submission.

 

If you are interested in a coding training session specific to risk adjustable conditions, please contact the Commercial Risk Adjustment Network Education Representative: Mary.Swanson@anthem.com

 

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Please continue to check Medicaid Provider Communications & Updates on the provider website for the latest information, including:

 

• InterQual 2020 update
  
  
• Appointment availability and after-hours access requirements

On November 15, 2019, and February 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield Medicaid (Anthem). These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the Anthem provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting February 2020. Visit Clinical Criteria to search for specific policies.

 

If you have questions or would like additional information, use this email.

This HEDIS^® measure looks at the percentage of members ages 18 to 85 years who have had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (< 140/90 mm Hg).

 

Record your efforts

Document blood pressure and diagnosis of hypertension. Members whose BP is adequately controlled include:

• Members 18 to 85 years of age who had a diagnosis of HTN and whose BP was adequately controlled (< 140/90 mm Hg) during the measurement year.
• The most recent BP reading during the measurement year on or after the second diagnosis of HTN.
• If no BP is recorded during the measurement year, assume that the member is not controlled.

 

What does not count for this HEDIS measure?

• If blood pressure is taken on the same day as a diagnostic test or procedure or for a change in diet or medication regimen
• If blood pressure is taken on or one day before the day of any test or procedure
• Blood pressure taken during an acute inpatient stay or an emergency department visit

 

Exclusions

• End stage renal disease
• Nephrectomy or Kidney transplant
• Pregnancy
• Non-acute inpatient stay
• Members aged 66 to 80 with frailty and advanced illness
• Members 81 years old and above with frailty

 

Helpful tips

• Have your office staff recheck blood pressure for members with initial diagnosis of hypertension and record readings greater than 140 mm Hg systolic and 90 mm Hg diastolic during outpatient office visits. Educate your staff to record the recheck in member’s medical records.
• Refer high-risk members to our hypertension programs and other programs for additional education and support.
• Educate members and their spouses, caregivers or guardians about the elements of a healthy lifestyle such as:
• Heart-healthy eating and a low-salt diet.
• Smoking cessation and avoiding secondhand smoke.
• Adding regular exercise to daily activities.
• Home BP monitoring.
• Ideal BMI.
• The importance of taking all prescribed medications as directed.
• Remember to include the applicable Category II reporting code on the claim form to help reduce the burden of HEDIS medical record review

 

How can we help?

We support you in helping members control high blood pressure by:

• Providing online Clinical Practice Guidelines on our provider website.
• Reaching out to our hypertensive members through our education and support programs.

 

Other available resources:

• National Heart, Lung, and Blood Institute
• CDC Blood Pressure educational materials

Please continue to check Important Medicare Advantage Updates for the latest Medicare Advantage information, including:

 

• Submit behavioral health authorizations via our online Interactive Care Reviewer (ICR) tool
  
  
• Updates to AIM musculoskeletal program clinical appropriateness guidelines
  
  
• Provider data update
  
  
• Waived copays, deductibles and coinsurance for CCM, complex CCM and TCM
  
  
• AIM Musculoskeletal program expansion
  
  
• New MCG Care Guidelines 24th edition

On November 15, 2019, February 21, 2020, and March 26, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting March 2020. Visit Clinical Criteria to search for specific policies.

 

If you have questions or would like additional information, use this email.

 

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The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

 

Medicare Risk Adjustment and Documentation Guidance (general)

 

When: This training is offered the first Wednesday of each month from 1 p.m. to 2 p.m. Eastern time.

 

Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model with guidance on medical record documentation and coding.

 

Credits: This live activity, Medicare Risk Adjustment and Documentation Guidance, from January 8, 2020, to December 2, 2020, has been reviewed and is acceptable for up to one prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at: Training Registration.

*Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (condition specific)

 

When: This training is offered on the third Wednesday of every other month from 12 noon to 1 p.m. Eastern time.

 

Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.

 

Credits: This live series activity, Medicare Risk Adjustment Documentation and Coding Guidance, from January 15, 2020, to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

 

Session 1: Red Flag HCCs, part one: Training will cover HCCs most commonly reported in error as identified by CMS, including chronic kidney disease (stage five), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease.

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCCs-Part 1

Password: sDBNERC3

 

Session 2: Red Flag HCCs, part two: Training will cover HCCs most commonly reported in error as identified by CMS, including atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, diabetes with ophthalmologic or unspecified manifestation.

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCCs-Part 2

Password: PnPAF4py

 

Session 3: Neoplasms

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Neoplasms

Password: PfUWPcs6

 

Session 4: Acute, Chronic and Status Conditions

Recording link will be provided after October 1, 2020.

 

Session 5: Diabetes Mellitus and Other Metabolic Disorders - September 16, 2020

DM and other Endocrine, Nutritional and Metabolic Disorders

 

Session 6: Coinciding Conditions in Risk Adjustment Models - November 18, 2020

Medicare Risk Adjustment Documentation and Coding Guidance: Coinciding Conditions in Risk Adjustment Models

 

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