An Integrated Care Model affords members with plans purchased on the Health Insurance Marketplace (also called the Exchange) the ability to have continuity of care with each care management case.  A single Primary Care Nurse provides case and disease assessment and management. This continuity provides opportunity for the member to get assistance working through an acute phase of an illness and then work with their nurse on the necessary behavioral changes needed to improve their health and enhance their well-being. The program is based on nationally recognized clinical guidelines and serves as an excellent adjunct to physician care.

The Integrated Care Model helps exchange members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. Our nurse care managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers.

Nurse Care Managers encourage participants to follow their physician’s plan of care; not to offer separate medical advice. In order to help ensure that our service complements the physician’s instructions, we collaborate with the treating physician to understand the member’s plan of care and educate the member on options for their treatment plan.

Members or caregivers can refer themselves or family members using the information below.

To contact Case Management:

Email:                     centregcmref@anthem.com

Phone:                    1-888-662-0939 / 800-944-0339

Business Hours:     Monday - Friday, 8:00 am - 7:00 pm ET

Use Availity and EDI to verify eligibility, members' cost shares and benefits at time of service. Since the cost share information will no longer display on many of our ID cards, we urge providers to access Availity (our secure Web-based provider tool) and the EDI (Electronic Data Interchange) to verify member benefits and eligibility to obtain the most up-to-date cost share information in order to collect the applicable deductibles and coinsurance amounts at the time of service as appropriate. If a member presents an older ID card with outdated benefits at the provider office, it can create confusion about the member's cost share.

As always, please request that a member enrolled in our health benefit plans present their most current ID cards at the time of service. When filing claims to Anthem, enter the member’s ID numbers exactly as the numbers appear on the card, including the alpha-numeric prefix, to help speed claims processing and reimbursement.

As the streamlined ID cards are adopted over time, it will help reduce misunderstandings around cost shares since real-time information is readily available via Availity about members' benefits and cost shares. Additionally, members will be encouraged to learn more about their benefits through Anthem's digital and online tools. Members can retain their cards for as long as they remain in the same product plan, regardless of changes to cost share information.

Electronic ID cards

As a reminder, members can now view, download, email, and fax an electronic version of their member ID cards using the Anthem Anywhere mobile app. And because our electronic ID cards look just like our physical ID cards, members can show either an electronic or physical ID card when obtaining services. Anthem member ID cards are also available through the Availity portal.

For questions, contact the provider service number on the back of members' ID cards.

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway.  Availity is well known as a Web portal and claims clearinghouse.  In addition, Availity functions as an EDI Gateway for multiple payers and is the single EDI connection for our company.

Your organization can submit and receive the following electronic transactions through Availity’s EDI Gateway:

• 837- Institutional Claims
• 837- Professional Claims
• 837- Dental Claims
• 835 - Electronic Remittance Advice
• 276/277- Claim Status
• 270/271- Eligibility Request

If you wish to become a direct a trading partner with Availity, the setup is easy. Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions. 

If you prefer to use your clearinghouse or billing company, please work with them to ensure connectivity.

Need Assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

835 Electronic Remittance Advice (ERA)

Effective June 1, 2018, please use Availity to register and manage account changes for ERA.

If you were previously registered to receive ERA, you must register using Availity to manage account changes.

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

If you were previously registered to receive EFT only, you must register using EnrollHub to manage account changes. No other action is needed.

Contacting Availity

If you have any questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 7:30 p.m. ET.

• Help ensure correct coding and billing practices are being followed
• Help ensure compliance with industry standards such as Centers for Medicare & Medicaid Services (CMS), American Medical Association (AMA), National Uniform Billing Committee (NUBC), and national specialty and academy guidelines
• Reinforce compliance with standard code edits and rules (i.e., CPT, HCPC, ICD-10, NUBC)

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.

Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS^®) commercial data collection project for 2018. You play a central role in promoting the health of our members. By documenting services in a consistent manner, it is easy for you to track care that was provided and identify any additional care that is needed to meet the recommended guidelines. Consistent documentation and responding to our medical record requests in a timely manner eliminates follow up calls to your office and also helps improve HEDIS^® scores, both by improving care itself and by improving our ability to report validated data regarding the care you provided. The records that you provide to us directly affect the HEDIS^® results that are listed below.

Each year our goal is to improve our process for requesting and obtaining medical records for our HEDIS^® project. In order to demonstrate the exceptional care that you have provided to our members and in an effort to improve our scores, you and your office staff can help facilitate the HEDIS^® process improvement by:

• Responding to our requests for medical records within five days, if possible
• Providing the appropriate care within the designated timeframes
• Accurately coding all claims
• Documenting all care clearly in the patient’s medical record

Further information regarding documentation guidelines and administrative codes can be found on the HEDIS^® page of our Provider Portal. 

In addition, more information on HEDIS^® can be found by visiting the provider portal at: www.anthem.com > Provider > Choose State > Find Resources for your state > Health & Wellness (top menu) > Quality Improvement and Standards > HEDIS Information. You will find reference documents entitled “HEDIS 101 for Providers” and “HEDIS Physician Documentation Guidelines and Administrative Codes”.

To view the HEDIS 2018 COMMERCIAL HMO and PPO Report, click here.

Now is the time to review your patient’s records to ensure that they have received their preventative care and/or immunizations before the end of the year.

Again, we thank you and your staff for demonstrating teamwork as we work together to improve the health of our members and your patients. We look forward to working with you again next HEDIS season.

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

Anthem is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means.  No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

To contact Case Management:

Commercial

Email:                     centregcmref@anthem.com

Phone:                    1-888-662-0939 / 800-944-0339

Business Hours:     Monday - Friday, 8:00 am - 7:00 pm ET

Federal Employee Program (FEP)

Phone:                    1-800-711-2225

Business Hours:     Monday - Friday, 8:00 am - 7:00 pm ET

The ConditionCare program helps members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. A team of registered nurses with added support from other health professionals such as dietitians, pharmacists and health educators work with members to help them understand their condition(s), their doctor’s orders and how to become a better self-manager of their condition. 

Engagement methods vary by the individual’s risk level but can include:

• Education about their condition through mailings, email newsletters, telephonic outreach, and/or online tools and resources.
• Round-the-clock phone access to registered nurses.
• Guidance and support from Nurse Care Managers and other health professionals.

Physician benefits:

• Save time by answering patients’ general health questions and responding to concerns, freeing up valuable time for the physician and their staff.
• Support the doctor-patient relationship by encouraging participants to follow their doctor’s treatment plan and recommendations.
• Inform the physician with updates and reports on the patient’s progress in the program.

Please visit anthem.com/provider > select Kentucky > Find Resources for Kentucky > Health & Wellness, and select Condition Care to find more information about the program such as program guidelines, educational materials and other resources.

Also available is the Care Management Program Referral Form to be used to refer other patients you feel may benefit from our program.

If you have any questions or comments about the program, call 1-877-681-6694. 

Our nurses are available Monday through Friday, 8:00 am to 9:00 pm, and Saturday, 9:00 am to 5:30 pm. ET.

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Anthem would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. Anthem urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between Behavioral Health and other health care practitioners at the time treatment begins.

We expect all health care practitioners to:

In an effort to facilitate coordination of care, Anthem has several tools available on the Provider website including a Coordination of Care template and cover letters for both Behavioral Health and other Healthcare Practitioners.  Access to the forms and cover letters are available at anthem.com/providers > select your state > Find Resources for your state > then select Answers@Anthem.

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below.  UM criteria are also available on the web. Just select “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” from the Provider home page at anthem.com.

We work with providers to answer questions about the utilization management process and the authorization of care.  Here’s how the process works:

• Call us toll free from 8:30 am - 5:00 pm, Monday through Friday (except on holidays). More hours may be available in your area.  Federal Employee Program hours are 8:00 am - 7:00 pm ET.
• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day.  Calls received after midnight will be returned the same business day. 
• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

The phone numbers below are for physicians and their staffs. Members should call the member service number on their health plan ID card.

Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls.  They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.

• Acute Inpatient Medical Hospital
• Acute Inpatient Rehabilitation
• Skilled Nursing
• Long Term Acute Care
• Integrated Health Management (360 Health)

Anthem precertification approvals are valid for admission dates through November 30, 2018.

Anthem Integrated Health Management engagement is valid through DOS November 30, 2018.

To request precertification and engagement in Integrated Health Management (360 Health), facilities are encouraged to utilize the self-service tools available through the Availity portal or by using the available fax forms located on the BCBSM.com website.

For questions regarding the precertification or engagement process call 1-800-676-BLUE (2583).

Claims processing changes

The claims processing system for these members will be changing. As part of this change the benefits for these members will be administered directly by Blue Cross Blue Shield of Michigan, rather than from Anthem. This means that the utilization review program will be administered through Blue Cross Blue Shield of Michigan, who uses the services of AIM Specialty Health. The submission process for utilization review requests will be the same, through the AIM Portal, but will follow the program design for Blue Cross Blue Shield of Michigan. 

Prior authorization changes

Of particular note, Blue Cross Blue Shield of Michigan will require prior authorization for in-lab sleep testing by instate providers. Preapproval must be obtained for the following procedure codes:

• 95805
• 95807
• 95808
• 95810
• 95811

The procedure codes will require preauthorization for both office settings and hospital outpatient locations.

All authorized attended sleep study services should be performed at a laboratory or center accredited by the American Academy of Sleep Medicine or the Joint Commission.

Effective January 1, 2019, Medicare providers will have toll free phone numbers specifically designated for their service inquiries. These new provider numbers will be listed separately on the back of the member ID cards and should be used beginning January 1, 2019. The associates answering your provider service calls are trained to answer your questions and resolve your issues as quickly as possible. To ensure you receive the most efficient service, please refrain from using the member services line and use only 1-844-421-5662 or the provider services phone number listed on the back of the member ID card for individual Medicare Advantage calls beginning January 1, 2019.

• Medicare Advantage Reimbursement Policy October Provider Bulletin  
• Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila  
• July Medicare Advantage reimbursement policy  
• Submit PA medication requests electronically; new phone number for MA prescription PAs 
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019  
• Inpatient Readmissions  
• Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective Sept. 1   

Next steps

Contact your clearinghouse to validate their transition dates to Availity. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you — you can submit claims directly through Availity!

Register with Availity

If you wish to submit directly through Availity for your 837 (claim), 835 (electronic remittance advice) and 27X (claim status and eligibility) transactions, please visit https://www.availity.com to register.

We look forward to delivering a smooth transition to the Availity EDI Gateway.

If you have any questions please contact Availity Client Services at 1-800-282-4548, Monday to Friday, 8 a.m. to 7:30 p.m. Eastern time. 

Need up-to-date pharmacy information?

Log in to our provider website (https://mediproviders.anthem.com/ky) to access our Formulary, Prior Authorization form, Preferred Drug List and process information.

Have questions about the Formulary or need a paper copy? Call Provider Services at 1-855-661-2028.

Our Member Services representatives serve as advocates for our members. To reach Member Services, please call 1-855-690-7784 (TTY 711).

The credentialing process must be completed before a practitioner begins seeing members and enters into a contractual relationship with a health care insurer. As part of our credentialing process, practitioners have certain rights as briefly outlined below.

Practitioners can request to:

• Review information submitted to support their credentialing application.

• Correct erroneous information regarding a credentialing application.

• Be notified of the status of credentialing or recredentialing applications.

The Council for Affordable Quality Healthcare (CAQH®) universal credentialing process is used for all providers who contract with Anthem Blue Cross and Blue Shield (Anthem). To apply for credentialing with Anthem, go to the CAQH website at https://www.caqh.org and select CAQH ProView™. There is no application fee.

We encourage practitioners to begin the credentialing process as soon as possible when new physicians join a practice. Doing so will help minimize any disruptions to the practice and members’ claims.

Summary of change: As of August 1, 2018, Anthem Blue Cross and Blue Shield Medicaid drug screen and benefit details were updated to ensure alignment with state and company requirements. 

What this means to me

As of August 1, 2018, the codes below were configured to ensure benefit guidelines are in place as listed below. Please share this information with office staff and other providers in your practice.

What if I need assistance?

If you have questions about this communication, contact your local Provider Relations representative or call Provider Services at 1-855-661-2028.

Are you looking for innovative ways to improve your patients’ experiences?

Numerous studies have shown that a patient’s primary health care experience and, to some extent their health care outcomes, are largely dependent upon health care provider and patient interactions. Recently, Anthem Blue Cross and Blue Shield (Anthem) announced the launch of a new online learning course — What Matters Most: Improving the Patient Experience — to address gaps in and offer approaches to communication with patients. This curriculum is available at no cost to providers and their clinical staff nationwide.

Did you know?

• Substantial evidence points to a positive association between the patient experience and health outcomes.

• Patients with chronic conditions, such as Diabetes, demonstrate greater self-management skills and quality of life when they report positive interactions with their health care providers.

• Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician's practice than patients with the highest-quality relationships.

How will this benefit you and your office staff? 

Through the use of compelling real-life stories that convey practical strategies for implementing patient care, providers learn how to apply best practices. 

You’ll learn tips and techniques to:

• Improve communication skills.

• Build patient trust and commitment.

• Expand your knowledge of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey.

Get CME credits!

Providers may apply their completion of the course toward continuing medical education (CME) credit certification. The training has been reviewed and is acceptable for up to one (1) prescribed credit by the American Academy of Family Physicians.*

Like you, Anthem is committed to improving the patient experience in all interactions, and we are proud to work collaboratively with our provider network to provide support and tools to reach our goal.

Take the course today!

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Sources

What Is Patient Experience? Agency for Healthcare Research and Quality, Rockville, MD. (Content last reviewed March 2017.) http://www.ahrq.gov/cahps/about-cahps/patient-experience/index.html

CAHPS®: Assessing Health Care Quality From the Patient's Perspective Agency for Healthcare Research and Quality, Rockville, MD. (Content last reviewed March 2016.)

http://www.ahrq.gov/cahps/about-cahps/cahps-program/cahps_brief.html

Physician Communication and Patient Adherence to Treatment: A Meta-analysis Zolnierek, Kelly B. and DiMatteo, M. Robin (2009.)   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728700/

* This Enduring Material activity, What Matters Most: Improving the Patient Experience, has been reviewed and is acceptable for up to 1.00 Elective credit(s) by the American Academy of Family Physicians. AAFP certification begins April 30, 2018. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Substance use disorders can affect a person’s brain and in turn their behavior. Substance use can start with the experimental use of a drug in a social situation or exposure to prescribed medications. Eventually it can lead to an inability to control the use of the legal or illegal drug or medication. When a patient is diagnosed with an alcohol- or drug- use disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations and comorbidities. This article will provide you with the information you need to provide high-quality care to patients struggling with substance use as well as how to code for the services provided to them.

Drug and substance addiction in the U.S.

The U.S. Department of Health and Human Services declared a public health emergency in 2017 due to an unprecedented opioid epidemic. Drug overdose deaths and opioid-involved deaths continue to increase in the U.S.¹

Smoking is the leading preventable cause of death in the United States. According to the Centers for Disease Control (CDC), 15.5 % of all adults (37.8 million people) were current cigarette smokers in 2016.²

Health risks of drug use and smoking

Drugs can have significant and damaging short-term and long-term effects, including psychotic behavior, seizures or death due to overdose. Dependence on drugs can create a number of dangerous and damaging complications, such as accidents, suicide, family/work/school problems and legal issues.

Smoking diminishes overall health and is a known cause of multiple cancers, heart disease, stroke, complications of pregnancy, chronic obstructive pulmonary disease (COPD) and many other diseases. There are also health dangers of involuntary exposure to (second-hand) tobacco smoke. Smoking increases risks for preterm delivery.³

Diagnosis and treatment

Diagnosing substance use disorders requires a thorough evaluation and includes an assessment by a psychiatrist or a psychologist or an independently licensed behavioral health practitioner that has met the state requirements to render a diagnosis. Blood, urine or other lab tests are used to assess drug use.

People with behavioral disorders are more likely to experience a substance use disorder and people with a substance use disorder are more likely to have behavioral health issues when compared to the general population. According to the National Survey of Substance Abuse Treatment Services, about 45% of Americans seeking treatment of substance use/abuse have also been diagnosed with behavioral health problems.⁴

When diagnosing a substance use disorder, most mental health professionals use criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Treatment depends on the type of substance used and any related medical or behavioral health disorders that the patient may have. Some treatment options include:

• Chemical dependence treatment programs
• Detoxification
• Behavioral therapy
• Self-help groups

There are a lot of treatments to support tobacco cessation, including behavioral therapies and FDA-approved medications. Some treatment options to help ensure tobacco cessation include:

• Nicotine replacement therapy (NRT), as well as bupropion and varenicline
• Combination of behavioral treatment and cessation medications
• Mobile devices and social media help to boost tobacco cessation
• Tobacco cessations are not recommended for adolescents due to lacking high-quality studies
• Behavioral counseling can be provided either in person or by telephone and a variety of approaches are available such as Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), telephone support lines, text messaging, web-based services and social media.⁵

HEDIS® quality measures

Initiation and Engagement of Alcohol and Other Drug Abuse Dependence Treatment (IET) is a measure that assesses the percentage of plan members’ ages 13 years and older with the new episode of alcohol or other drug (AOD) abuse or dependence who received the following: initiation of AOD and engagement of AOD.

Initiation of treatment is the percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.

Engagement of treatment is the percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days after the initiation visit.⁶ This measure now includes medication-assisted treatment (MAT) as an appropriate treatment for people with alcohol and opioid dependence. This measure also adds telehealth to treatment options.

Use of Opioids at High Dosage (UOD) is a first year quality measure that assesses the number of members 18 years and older per 1,000 beneficiaries receiving prescription opioids for ≥ 15 days during the measurement year at a high dosage (average morphine equivalent dose > 120 mg).⁷

Use of Opioids from Multiple Providers (UOP) is a first year quality measure that assesses the number of members 18 years and older per 1,000 receiving a prescription for opioids for ≥ 15 days during the measurement year who received opioids from multiple providers. Three rates are reported:

• Multiple prescribers – the rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers during the measurement year
• Multiple pharmacies – the rate per 1,000 members receiving prescriptions for opioids from four or more different pharmacies during the measurement year
• Multiple prescribers and multiple pharmacies – the rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year.⁷

Unhealthy Alcohol Use Screening and Follow-Up (ASF) is a measure that assess the percentage of health plan members 18 years and older who were screened for unhealthy alcohol use using a standardized tool and, if screened positive, received appropriate follow-up care.

• Unhealthy alcohol use screening – the percentage of members who had a systematic screening for unhealthy alcohol use
• Counseling or other follow-up – the percentage of members who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within 2 months of a positive screening.

The intent of the measure: alcohol misuse is a leading cause of illness, lost productivity and preventable death in the U.S.⁷

Medical Assistance with Smoking and Tobacco Use Cessation (MSC) is a survey measure that assesses different facets of providing medical assistance with smoking and tobacco use cessation. There are three components of the survey:

• Advising Smokers and Tobacco Users to Quit: Adults 18 years of age and older who are current smokers or tobacco users and who received cessation advice during the measurement year
• Discussing Cessation Medications: Adults 18 years of age and older who are current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year
• Discussing Cessation Strategies: Adults 18 years of age and older who are current smokers or tobacco users who discussed or were provided cessation methods or strategies during the measurement year.

ICD-10-CM: general coding information

When a patient is diagnosed with an alcohol- or drug-related disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations, and comorbidities.

Details are required from the documentation to identify use, abuse or dependence of the substance.

Based on ICD-10-CM Coding Guidelines, when use, abuse or dependence of the same substance are documented in the medical record, only one code should be assigned based on the following hierarchy:

• If both use and abuse are documented, the code for abuse should be assigned
• If both abuse and dependence are documented, the code for dependence should be assigned

• If use, abuse and dependence are documented, the code for dependence should be assigned
• If both use and dependence are documented, the code for dependence should be assigned.⁸

Alcohol dependence and abuse

• Alcohol related disorders are classified to category F10-. An additional code for blood alcohol level (Y90.-) may be assigned, if applicable

• Alcohol abuse is classified under subcategory F10.-, Alcohol abuse

• Alcohol dependence is classified under subcategory F10.2-, Alcohol dependence
• Both categories alcohol abuse and alcohol dependence, are further subdivided to specify the presence of intoxication or intoxication delirium. Additional characters are also provided to specify alcohol-induced mood disorder, psychotic disorder, and other alcohol-induced disorders

• Codes in sub classification F10.23-, Alcohol dependence with withdrawal, provide additional detail regarding withdrawal symptoms such as delirium and perceptual disturbance

• Selection of codes “in remission” for categories F10-F19 requires the provider’s clinical judgement. The appropriate codes for “in remission” are assigned only on the basis of provider documentation, unless otherwise instructed by the classification
• Toxic effect of alcohol is not classified to category F10 but to subcategory T51.0- instead.9

• In most cases, fourth characters indicate whether the disorder is nondependent abuse (1), dependence (2), or unspecified use (9).
• Additional characters also provided to specify intoxication, intoxication delirium, and intoxication with perceptual disturbance.
• Patients with substance abuse or dependence often have related physical complications or psychotic symptoms. These complications are classified to the specific drug abuse or dependence, with the fifth or sixth characters providing further specificity regarding any associated drug-induced mood disorder, psychotic disorder, withdrawal, and other drug-induced disorders (such as sleep disorder).

ICD-10-CM classifies nicotine dependence by substance:

• F17.20-, nicotine dependence, unspecified
• F17.21-, nicotine dependence, cigarettes
• F17.22-, nicotine dependence, chewing tobacco
• F17.29-, nicotine dependence, other tobacco product.⁹

Each category further breaks down the dependence using a sixth character to denote:

1. Opioid overdose. Overview of an epidemic. https://www.cdc.gov/drugoverdose/data/index.htm
2. Current cigarette smoking among adults – United States, 2016. https://www.cdc.gov/mmwr/volumes/67/wr/mm6702a1.htm?s_cid=mm6702a1_w%20
3. CDC. Health effects of cigarette smoking. Retrieved on 1/18/2018 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
4. Treatment for co-occurring mental and substance use disorders. https://www.samhsa.gov/treatment
5. What are treatments for tobacco dependence? Retrieved on 1/18/2018 from https://www.drugabuse.gov/publications/tobacco-nicotine-e-cigarettes/what-are-treatments-tobacco-dependence
6. HEDIS Benchmarks and Coding Guidelines for Quality Care. Amerigroup RealSolutions in healthcare. Retrieved from https://providers.amerigroup.com
7. NCQA updates quality measures for HEDIS 2018. http://www.ncqa.org/newsroom/details/ncqa-updates-quality-measures-for-hedisreg-2018?ArtMID=11280&ArticleID=85&tabid=2659
8. ICD-10-CM Expert for Physicians. The complete official code set (2017). Optum 360
9. Leon-Chisen N. (2017). ICD-10-CM and ICD-10-PCS Coding Handbook 2018. American Hospital Association, Chicago, IL.

The formulary changes listed in the table below were reviewed and approved at the first quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective August 1, 2018, the following formulary changes applied. This notice applies to Anthem Blue Cross and Blue Shield Medicaid (Anthem) benefits in Kentucky.

What action do I need to take?

Please review these changes and work with your Anthem patients to transition them to formulary alternatives. If you determine preferred formulary alternatives are not clinically appropriate for specific patients, you will need to obtain prior authorization to continue coverage beyond the applicable effective date.

What if I need assistance?

We recognize the unique aspects of patients’ cases. If for medical reasons your Anthem patient cannot be converted to a formulary alternative, call our Pharmacy department at 1‑855‑661‑2028 and follow the voice prompts for pharmacy prior authorization. You can find the Preferred Drug List on our provider website at https://mediproviders.anthem.com/ky/pages/pharmacy.aspx.

If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1‑855‑661‑2028.

PA requirements will be added to the following:

• Somatrem — injection, 1 mg (J2940)

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-855-661-2028

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-855-661-2028 for PA requirements.

Effective February 1, 2019, prior authorization (PA) requirements will change for the infusible/injectable drug Sublocade to be covered by Anthem Blue Cross and Blue Shield Medicaid. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Sublocade (Buprenorphine) — implant (J0570)
• Sublocade — injectable (Q9991, Q9992)

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-855-661-2028

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-855-661-2028 for PA requirements.

Professional providers and facilities are required to submit additional documentation for adjudication of applicable types of claims. If the required documentation is not submitted, the claim may be denied. Anthem Blue Cross and Blue Shield Medicaid may request additional documentation or notify the provider or facility of additional documentation required for claims, subject to contractual obligations.

Effective March 1, 2019, if an itemized bill is requested and/or required, then it must include the appropriate revenue code for each individual charge.

For additional information, please review the Claims Requiring Additional Documentation reimbursement policy at https://mediproviders.anthem.com/ky.