Join us throughout the year in a new Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving STARs ratings.

 

Program objectives:

• Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s quality and STARs ratings.

 

Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.

 

REGISTER HERE for our upcoming clinical quality webinars

 

1275-0821-PN-CNT

3072F: new language about two-year compliance

The Comprehensive Diabetes Care HEDIS_® Measure Retinal Eye Exam (DRE) valuates the percent of adult members ages 18 to 75, with diabetes (type 1 and type 2), who had a retinal eye exam during the measurement year.

 

Changes to 3072F

The definition for the code 3072F (negative for retinopathy) has been redefined to: Low risk for retinopathy (no evidence of retinopathy in the prior year). This can be particularly confusing because it would not be used at the time of the exam. It would be used the following year, along with the exam coding for the current year, to indicate that retinopathy was not present the previous year.

 

A simpler coding solution

Using these three codes count toward the DRE measurement if they are billed in the current measurement year, or the prior year. This means you can submit the appropriate code at the time of the exam, and it covers both years:

 

CPT Code	Description
2023F	Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)
2025F	7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed: without evidence of retinopathy (DM)
2033F	Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed: without evidence of retinopathy (DM)

 

For more about diabetic retinopathy, visit CMS.gov or use this link to read more. 

 

Meeting the measurement for all diabetes care

These exams are also important in evaluating the overall health of diabetic patients, as well as meeting the Comprehensive Diabetes Care HEDIS measure:

• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (>9.0%)
• HbA1c control (<8.0%)
• Retinal Eye exam performed
• Blood Pressure control (<140/90 mm Hg)

 

Record your efforts in the member’s medical records for the HbA1c tests and results, retinal eye exam, blood pressure, urine creatinine test and the estimated glomerular filtration rate test. Meeting the mark and closing gaps in care is key to good health outcomes.

 

HEDIS_® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

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Reductions in missed appointments are significant

Telehealth visits are having a significant impact on missed appointments according to a study published in Counselling Psychology Quarterly. Prior to transitioning to telehealth, clinicians in the study “Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice,”¹ experienced a 14.25% missed appointment rate. After transitioning to telehealth, the missed appointment rate fell to 5.63%.

 

Rate of missed appointments before and after transitioning to telehealth

The graph below illustrates the changes in the average rate of missed appointments (cancellations and no-show) for each of the eight clinicians in the study between the periods before and after the transition to telehealth.

https://www.tandfonline.com/doi/full/10.1080/09515070.2020.1777390
“While there are a number of limitations to consider regarding this data, [which is further discussed in the study], the statistically significant reduction in missed appointments pre-and-post [digital] transition is striking,” cited in the study report.

 

Telehealth and telephone visits with members after a behavioral health (BH) inpatient stay meet HEDIS^® criteria for the measure: Follow-up after Hospitalization for Mental Illness (FUH). With transportation being one of the barriers to after hospitalization follow-up, telehealth visits could be an ideal solution.²

 

The FUH HEDIS measure evaluates:

• Members 6 years and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.

Two areas of importance for this HEDIS measure are:

1. The percentage of behavioral health inpatient discharges for which the member received follow-up within 7 days after discharge.
2. The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.

These two consecutive follow-up appointments are paramount to positive outcomes as well as meeting this HEDIS measure. Telehealth visits can greatly increase the likelihood of keeping follow-up appointments leading to reduced numbers of re-hospitalization and more favorable outcomes for these patients. To learn more about the FUH HEDIS measure, visit the NCQA website.

 

1Counselling Psychology Quarterly. Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice. https://www.tandfonline.com/doi/full/10.1080/09515070.2020.1777390

2Traveling towards disease: transportation barriers to health care access. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/#:~:text=Transportation%20barriers%20are%20often%20cited,and%20thus%20poorer%20health%20outcomes.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

1264-0821-PN-CNT

Providers currently submit prior authorization requests to AIM Specialty Health_® (AIM) for outpatient diagnostic imaging services. These prior authorizations are often reviewed based on provider attestation of certain requirements. As part of our ongoing quality improvement efforts, we want you to know that some review requests may require documentation to substantiate the attestations that supports the clinical appropriateness of the request. This documentation can be uploaded during the intake process.

 

When requested, providers must submit such documentation from the patient’s medical record. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. Such documentation is limited to what has been asserted via the prior authorization review attestations. If the request would be denied as not medically necessary, providers can participate in a prior authorization discussion with an AIM physician reviewer.

 

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Know best: Shingles vaccinations are a Medicare Part D benefit whether administered in your office or in the pharmacy

 

We want you to have the information you need when filing claims for our Medicare Advantage members so your payments are received quickly and effortlessly. The shingles vaccine and the administration of the vaccine is commonly billed in error under the member’s Medicare Part B medical benefit. The shingles vaccination is a Medicare Part D pharmacy benefit, which requires the member to pay in advance of reimbursement. The member then submits the prescription drug claim form to their Medicare Part D plan for reimbursement. 

 

You can also refer the member to the pharmacy for the vaccine. The claim is usually filed for the member by the pharmacy provider using a clearinghouse platform that enables Medicare Part D claims transactions. Or, if you have access to clearinghouse platforms that enable you to file pharmacy transactions, that is another option for administering the vaccination in your office and for further serving the member.

 

The Centers for Medicare & Medicaid Services (CMS) has a helpful resource, MLN Fact Sheet: Medicare Part D Vaccines, that offers an all-inclusive look into patient access, vaccine administration, and reimbursement. Use this link to download a copy.

 

We want you to have all the information you need to know best. For more information about filing claims, visit this link.

 

ABSCARE-0988-21

 

This communication applies to the Medicaid and Medicare Advantage programs in Kentucky.

 

CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7_® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

 

The Clinical Data Acquisition Group for Anthem Blue Cross and Blue Shield (Anthem) integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:

• Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings.

 

Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.

 

Email the Clinical Data and Analytics team at ADT_Intake@anthem.com to get started today.

 

AKY-NU-0302-21

Please continue to read news and updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

 

• Learn more about Infliximab Step Therapy - Effective 7/15/2021.
  
  
• Learn more about the prior authorization requirement changes
  effective October 1, 2021 – UM AROW 1907.

 

ABSCRNU-0241-21

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The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield Medicaid has adopted a Members Rights’ and Responsibilities Statement, which is located within the provider manual.

 

If you need a physical copy of the statement, call Provider Services at 855-661-2028.

 

AKY-NU-0318-21

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization.

 

Our medical policies and UM criteria are online at providers.anthem.com/kentucky-provider/resources, or you can request a free copy of our UM criteria from our Medical Management department. Within seven calendar days of the date of denial, providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at the number listed below.

 

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title and being with Anthem when initiating or returning calls regarding UM issues.

 

You can submit precertification requests by:

• Calling us at 855-661-2028.
• Faxing to 800-964-3637.
• Submitting online at availity.com.*

 

Have questions about utilization decisions or the UM process?

Call our Clinical team at 855-661-2028 Monday through Friday from 7 a.m. to 7 p.m.

 

AKY-NU-0316-21

Anthem Blue Cross and Blue Shield Medicaid is available to offer assistance in these difficult moments with our Complex Case Management program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members, families, PCPs, and caregivers. In addition, the complex case management process uses the experience and expertise of the Case Management team to educate and empower our members by increasing self-management skills. Our complex case managers can help to find services and resources to assist eligible members with chronic conditions that may involve social determinants of health. Our case managers direct members to community resources and make referrals when possible. The complex case management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare.

 

Members can refer themselves or caregivers and family members can refer members by calling the Member Services number located on the back of their ID card. They will be transferred to a team member based on the immediate need. For example, a member newly diagnosed with diabetes will receive assistance from our diabetic complex case manager, who will help them find diabetic resources available in their community. Providers can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

 

You can contact us by email at kentuckycm@anthem.com or by phone at 855-661-2027, ext. 106 103 5259. Case Management business hours are Monday through Friday from 8 a.m. to 5 p.m. Eastern time, except holidays.

 

AKY-NU-0315-21

Mental disorders among children may cause serious changes in the way children typically learn, behave or handle their emotions, which cause distress and problems getting through the day. Healthcare professionals use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5),¹ to help diagnose mental health disorders in children.

 

The most common mental disorders of childhood and adolescence fall into the following categories:

• Anxiety disorders (generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobic disorder)
• Depression
• Posttraumatic stress disorder (PTSD)
• Separation anxiety disorder
• Social anxiety disorder
• Obsessive-compulsive disorder
• Bipolar disorder
• Disruptive behavioral disorders (attention-deficit/hyperactivity disorder ADHD, conduct disorder, and oppositional defiant disorder)
• Eating disorders
• Schizophrenia (less common).

 

Other conditions and concerns that affect children’s learning, behavior and emotions include learning and developmental disabilities, autism, and risk factors like substance use and self-harm.

 

ICD-10-CM coding:

• Chapter 5 of the ICD-10-CM code set categorizes mental disorders.
• Codes from chapter 5 are assigned based on the express documentation of the provider’s clinical judgment regarding the patient’s mental or behavioral disorder(s). The codes are not assigned based on symptoms, signs, or abnormal clinical laboratory findings.

 

Affective disorders

 

Major depressive disorder (MDD) is classified in ICD-10-CM as:

• F32: Major depressive disorder, single episode
• F33: Major depressive disorder, recurrent

 

When documenting major depressive disorder, keep in mind that proper and specific coding requires clear documentation of the:

• Episode: single versus recurrent.
• Severity: mild, moderate, or severe.
• Psychotic features, when present.
• Status of remission as either partial or full.

 

Remember to document any established causality between multiple mental health conditions. For example:

• Suppose the patient has a diagnosis of depression and a diagnosis of anxiety with a causal relationship between the two conditions. In such cases, documentation must establish the relationship by stating depression with, due to, or related to anxiety

 

ICD-10-CM classifies bipolar disorders under the following categories:

• F30: Manic episode (bipolar disorder, single manic episode, and mixed affective episode)
• F31: Bipolar disorder (manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction)
• F34: Persistent mood affective disorders (cyclothymic disorder and dysthymic disorder)
• F39: Unspecified mood affective disorder (affective psychosis not otherwise specified).

 

Nonpsychotic mental disorders

Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders are classified in categories F40 to F48.

 

Anxiety disorders are classified in ICD-10-CM under the following categories:

• F40: Phobic anxiety disorders
• F41: Other anxiety disorders
• F42: Obsessive-compulsive disorder.

 

Reactions to stress

ICD-10-CM provides category F43 for coding reactions to severe stress and adjustment disorders. Code F43.0, Acute stress reaction, classifies acute reaction to stress, including acute crisis reaction, crisis state, and psychic shock.

 

Posttraumatic stress disorder (PTSD) is classified in ICD-10-CM to subcategory F43.1, with fifth-characters for unspecified, acute, or chronic.

 

Adjustment disorders are classified to subcategory F43.2, with the fifth-character axis being the nature of the reaction, such as anxiety, depression, or other symptoms. For example:

• F43.24: Child adopted from a foreign country, suffering from culture shock with conduct disturbance.

 

Behavioral syndromes associated with physiological disturbances and physical factors

Categories F50 to F59 are devoted to behavioral syndromes associated with physiological disturbances and physical factors. These codes are not assigned when the conditions are present due to mental disorders classified elsewhere or organic in origin. This grouping includes, for example:

• F50: Eating disorders (such as anorexia nervosa and bulimia nervosa)
• F51: Sleep disorders, not due to a substance or known physiological condition
• F54*: Psychological and behavioral factors associated with disorders or diseases classified elsewhere
• F59: Unspecified behavioral syndromes associated with physiological disturbances and physical factors

* Code F54 classifies psychological and behavioral factors associated with diseases classified elsewhere. Typical conditions that are often associated with code F54 include asthma and dermatitis.

 

Schizophrenic disorders:

• Those types of disorders are classified in category F20, with a fourth character indicating the type of schizophrenia.
• The codes from category F20 are followed by an excludes one note indicating they should not be reported with codes classifying a brief psychotic disorder (F23) , cyclic schizophrenia (F25.0), schizoaffective disorder (F25-F25.9) and schizophrenic reaction not otherwise specified (NOS) (F23).
• Assign code F20.9, Schizophrenia, unspecified, for chronic schizophrenia with acute exacerbation. The existing ICD-10-CM codes for schizophrenia do not differentiate severity or an acute exacerbation (AHA Coding Clinic, Second Quarter 2019, p.32).

 

Attention deficit hyperactivity disorder (ADHD)

ICD-10-CM codes for ADHD include:

• F90.0: Attention-deficit hyperactivity disorder, predominantly inattentive type.
• F90.1: Attention-deficit hyperactivity disorder, predominantly hyperactive type.
• F90.2: Attention-deficit hyperactivity disorder, combined type.
• F90.8: Attention-deficit hyperactivity disorder, other types.
• F90.9: Attention-deficit hyperactivity disorder, unspecified type.

 

The ADHD diagnosis may not be established at the time of the initial physician office visit. Therefore, it may take two or more visits before the diagnosis is confirmed or ruled out. ICD-10-CM outpatient coding guidelines specify not to assign a diagnosis code when documented as rule out, working diagnosis or other similar terms indicating uncertainty.

 

Instead, the outpatient coding guidelines instruct to code the condition(s) to the highest degree of certainty for that encounter/visit, requiring the use of codes that describe symptoms, signs or another reason for the visit.

 

History codes (categories Z80 to Z87) may be used as secondary codes if the historical condition or family history impacts current care or influences treatment. Personal and family history of ADHD has an impact on the clinical assessment of an individual for this disorder; the ICD-10-CM codes to report the history of ADHD in an individual include:

• Z86.59: Personal history of other mental and behavioral disorders.
• Z81.8: Family history of other mental and behavioral disorders.

 

Psychosocial circumstances

ICD-10-CM provides codes for behaviors that are not classified as behavioral disorders, such as:

• R41.840: Attention and concentration deficit
• R45.83: Excessive crying of child, adolescent, or adult
• R45.87: Impulsiveness
• R46.81: Obsessive-compulsive behavior
  
  

Resources:

¹American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5)

• ICD-10-CM Expert, 2021. Optum
• Coding Clinic. Optum
• Mental illness in children. https://www.webmd.com/anxiety-panic/mental-health-illness-in-children
• Children’s Mental Health https://www.cdc.gov/childrensmentalhealth/symptoms.html

 

AKY-NU-0305-21

As patient panels grow more diverse and needs become more complex, providers and office staff need more support to help address patients’ needs. Anthem Blue Cross and Blue Shield (Anthem) wants to help.

 

Cultural competency resources

Here is an overview of the cultural competency resources available on our provider website.

• Cultural Competency and Patient Engagement includes:
  • The impact of culture and cultural competency on healthcare.
  • A cultural competency continuum, which can help providers assess their level of cultural competency.
  • Disability competency and information on the Americans with Disabilities Act (ADA).
• Caring for Diverse Populations Toolkit includes:
  • Comprehensive information, tools and resources to support enhanced care for diverse patients and mitigate barriers.
  • Materials that can be printed and made available for patients in provider offices.
  • Regulations and standards for cultural and linguistic services.
• My Diverse Patients offers:
  • A comprehensive repository of resources to providers to help support the needs of diverse patients and address disparities.
  • Courses with free continuing education credit through the American Academy of Family Physicians.
  • Free accessibility from any device (for example, desktop computer, laptop, phone or tablet), no account or login required.

 

To access these resources, go to providers.anthem.com/ky > Resources > Provider Training Academy > Cultural Competency Resources.

 

In addition, providers can access Stronger Together, which 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.

 

Prevalent non-English languages (based on population data)

Like you, Anthem wants to effectively serve the needs of diverse patients. It’s important for us all to be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the prevalent

non-English languages spoken by 5% or 1,000 individuals in Kentucky.¹

 

Prevalent non-English languages in Kentucky: Spanish

 

Language support services

As a reminder, Anthem provides language assistance services for our members with limited English proficiency (LEP) or hearing, speech, or visual impairments. Please see the provider manual for details on what is available and how to access resources. In addition, the cultural competency resources shared above provide guidance on communicating and serving diverse populations effectively.

 

¹ Source: American Community Survey, 2019 American Community Survey 1-Year Estimates, Table B16001, generated 10/04/2020.

 

AKY-NU-0314-21

Well-child visits and vaccinations are essential services

In May 2020, the CDC released a report showing a drop in routine childhood vaccinations as a result of COVID-19; a result of stay-at-home orders and concerns about infection during well-child visits. Both the American Academy of Pediatrics and the CDC recommend the continuation of routine childhood vaccinations during the COVID-19 pandemic, noting they are essential services.

To encourage well-visits and vaccinations, here are some extra steps you can take to ensure visits are as safe as possible for both patients and staff. They include:

• Scheduling sick visits and well-child visits during different times of the day.
• Asking patients to remain outside until it’s time for their appointment to reduce the number of people in waiting rooms.
• Offering sick visits and well-child visits in different locations.

 

It is important to identify those children who have missed immunizations and well-child visits to schedule these essential in-person appointments. To help, the CDC has published vaccine catch-up guidance on their website.

 

Help your patients earn rewards

For additional encouragement, Anthem Blue Cross and Blue Shield (Anthem) members can earn $25 or more in gift cards for completing vaccines and/or well visits through our Healthy Rewards program. Please encourage your patients to enroll in the program on the Anthem website so they can earn rewards for these activities. 

Anthem	CIS-3	IMA-2	WCV
Ages	0 to 1 (before 2nd birthday)	11 to 12 (before 13th birthday)	3 to 21
Reward amount	$25	$25	$25

 

Patients can enroll online at https://mss.anthem.com/ky or by calling 888-990-8681 (TTY 711).

 

Helpful information for keeping babies and children healthy:

Childhood Immunization Status (CIS) HEDIS^® measure requires that all children are immunized by their 2nd birthday:

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

 

Billing codes:

• MMR:
  • CPT^®: 90707, 90710
  • ICD-10-CM: B05.0-4, B05,81, B05.89, B05.9
• Mumps:
  • ICD-10-CM:0-3, B26.81-85, B26.89, B26.9
• Rubella:
  • ICD-10-CM:-00-02, B06.09, B06.81-82, B06.89, B06.9
• Rubella antibody:
  • CPT: 86762
• Hepatitis A:
  • CPT: 90633
  • ICD-10-CM:0, B15.9
• Influenza:
  • CPT: 90655, 90657, 90662, 90673, 90685, 90686-90689
  • HCPCS: G0008
• Rotavirus vaccine (RV):
  • CPT: 90681 (two-dose), 90680 (three-dose)

 

Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS measure:

• One meningococcal vaccine (MCV) injection between 11 and 13 years of age
• One tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between 10 and 13 years of age
• Two or three HPV vaccines between 9 and 13 years of age

 

Billing codes:

• Meningococcal:
  • CPT: 90734
• Tdap:
  • CPT: 90715
• HVP:
  • CPT: 90649, 90650, 90651

 

Please refer to the Anthem HEDIS coding booklet for coding guidelines.

 

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

AKY-NU-0309-21

This communication applies to the Medicaid and Medicare Advantage programs in Kentucky.

 

CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7_® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

 

The Clinical Data Acquisition Group for Anthem Blue Cross and Blue Shield (Anthem) integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:

• Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings.

 

Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.

 

Email the Clinical Data and Analytics team at ADT_Intake@anthem.com to get started today.

 

AKY-NU-0302-21

Anthem Blue Cross and Blue Shield Medicaid does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

 

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure code.

 

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at providers.anthem.com/kentucky-provider/claims/reimbursement-policies.

 

AKY-NU-0295-21

On February 21, 2020, May 15, 2020, and June 18, 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. These policies were developed, revised or reviewed to support clinical coding edits.

 

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

 

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

 

AKY-NU-0252-20

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 Medicaid. Please note, this does not affect the prescription drug benefit. 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.

 

AKY-NU-0244-20

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

 

• Learn more about the InterQual April 2021 revisions.
  
  
• Learn more about the prior authorization requirement changes effective October 1, 2021 – UM AROW 1837.

 

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