As we announced in the October 2021 edition of Provider News, Anthem Blue Cross and Blue Shield (Anthem) is working to comply with the requirements of the Consolidated Appropriations Act, or CAA.

 

Improving the accuracy of provider directory information

 

As part of the CAA, soon providers will be asked to verify their online provider directory information on a regular basis to help ensure Anthem members can locate the most current information for in-network providers and facilities. It is important that you keep your information up to date. Here’s what you can do now:

 

• Review your online provider directory information on a regular basis to ensure it is correct. You can check your directory listing on Anthem’s Find Care Consumers, members, brokers, and providers use the Find Care tool to identify in-network physicians and other healthcare providers supporting member health plans. To ensure we have your most current and accurate information, please take a moment to access Find Care. Go to Anthem.com, select Providers, then under Provider Overview, choose Find Care.

 

• Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:
  • add/change an address location
  • name change
  • tax ID changes
  • provider leaving a group or a single location
  • phone/fax number changes
  • closing a practice location

Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.

 

Consolidated Appropriations Act implementation

 

The Consolidated Appropriations Act does not preempt state law requirements. This means that the CAA applies in addition to any state law requirements of providers to update their provider directory information.

 

On August 20, 2021, the Tri-Agencies (Departments of Labor, Health and Human Services and the Treasury) announced that regulations to implement the provider directory requirements would be issued on or after January 1, 2022. Health plans are expected to implement the provider directory requirements based on a good faith, reasonable interpretation of the requirements by January 1, 2022, with a primary focus on ensuring that members who rely on provider directory information that inaccurately depicts a provider’s network status are only liable for in-network cost sharing amounts. Anthem is moving forward with compliance of this good faith, reasonable interpretation of the requirements while awaiting additional regulatory guidance.

 

Watch for upcoming editions of Provider News in 2022 for updates on our ongoing efforts to comply with the CAA requirements.

 

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As a reminder, we will continue to upgrade our claim editing software for professional services monthly throughout 2022, with most updates occurring quarterly. These upgrades may apply to same provider, provider group (tax identification number). They may also apply across providers and across claim types (professional and facility) and include, but are not limited to:

• Addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits such as:
  • ICD-10 laterality and Excludes1 notes
  • Add-on procedures (indicated by + sign)
  • Code book parenthetical statements and other directives about appropriate code use (e.g. “separate procedure”, “do not report”, “list separately in addition to”, etc.)
• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to incidental, mutually exclusive, and unbundled (rebundle) edits
• Updates to assistant and co-surgeon eligibility in accordance with the policy
• Updates to edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

 

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As a reminder, Anthem Blue Cross and Blue Shield (Anthem) will continue to upgrade our claim editing software for outpatient facility services monthly throughout 2022, with most updates occurring quarterly. These upgrades will include, but are not limited to:

• Addition of new and revised codes (for example CPT, HCPCS, ICD-10, modifiers, and revenue codes) and their associated edits

• Updates related to the appropriate use of various code combinations, which can include, but are not limited to:

• Procedure code to revenue code
• HCPCS to revenue code
• Type of bill to procedure code
• Type of bill to HCPCS code
• Procedure code to modifier
• HCPCS to modifier

• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC)

 

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Talking to a teenager about Chlamydia can be difficult. But, if untreated, the typical teenager could develop Pelvic Inflammatory Disease (PID) or worse, infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. For a free Chlamydia How-To Implementation Guide for Healthcare Providers, visit the National Chlamydia Coalition website at http://chlamydiacoalition.org.

 

One of the largest growing populations for Chlamydia is teens and young adults aged 15 to 24. Through annual screening – a simple urine test in your office or in an off-site lab – teens and young adults can maintain good health.

 

Chlamydia Screening in Women (CHL): HEDIS_® recommends annual screenings for teens starting at age 16 and for women up to age- 24. Sexually active teens and women as well as those who meet any of the following criteria should be tested each calendar year:

• Made comments or talked to you about sexual relations   
• Taken a pregnancy test
• Been prescribed birth control (even if used for acne treatment)   
• Received Gynecological services
• A history of sexually transmitted diseases
• A history of sexual assault or abuse

 

Description	CPT Codes
Chlamydia tests	87110, 87270, 87320, 87490, 87491, 87492, 87810
Pregnancy test exclusion	81025, 84702, 84703

 

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The annual behavioral health access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded during the first through third quarters of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine follow-ups.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Anthem’s demographic database, i.e. incorrect or non-working phone numbers; practitioner moved, retired, or deceased; the practice has resigned their Anthem contract, accepts private pay only, or is no longer in practice; as well as, staff refusing to participate in the survey. We ask that you update office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Anthem’s contract.

 

The primary appointment type not meeting compliance is consistently obtaining the initial routine appointment. This is the initial conversation with a professional after the intake assessment for a new patient for a non-urgent condition. Please refer to compliant timeframe and explanation below.

 

To be compliant, per the Provider Manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:

• Non-life-threatening emergency – The patient must meet with their BH practitioner, another practitioner in the practice or a covering practitioner within 6 hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate.
  • Explanation - These calls concern members in acute distress whose ability to conduct themselves for their own safety, or the safety of others, may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. The situation has the potential to escalate into an emergency without clinical intervention.
• Urgent – The patient must meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 48 hours.
  
  • Explanation - These calls are non-emergent with significant psychological distress when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
• Initial routine office visit – A new patient must meet with a designated BH practitioner or another equivalent practitioner in the practice within 10 business days. It can be after the intake assessment or a direct referral from a treating practitioner.
  • Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms which presents no immediate distress, and can wait to schedule an appointment without any adverse outcomes.
• Routine office visit – The patient must meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 30 calendar days.
  • Explanation - These calls concern existing members to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
• BH follow-up appointment after discharge – The patient must meet with their practitioner or another practitioner in the practice within 7 calendar days.
  • Explanation – These calls concern members being released from inpatient psychiatric hospital care requesting a follow-up appointment to evaluate what has taken place since release, including med management.

 

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The annual after-hours access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate phone messaging for our members with perceived emergency or urgent situations after regular office hours. Unfortunately, most of the Anthem Blue Cross and Blue Shield (Anthem) Plans assessed fell short of the expectation of having a live person or a directive in place after hours.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to an inability to reach the provider and/or the lack of after-hours messaging altogether. They include:

• inaccurate provider information in Anthem’s demographic database to allow assessment of the after-hours messaging
• no voicemail or messaging at all
• voicemail not reflecting the practitioner’s name, and/or
• calls being auto forwarded with no identification, no voicemail or messaging

 

To help both your patients’ and Anthem’s ability to reach your practice, we ask that you update your office information using the online Provider Maintenance Form and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.

 

What does this mean for our members and your patients? The annual member experience survey of Anthem enrollees indicated of those needing advice, a sizable number sometimes, or never, reached the provider’s office for urgent instructions. To improve upon these instances of failing to meet our member’s needs, implement these three steps:

1. Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
2. Be sure to turn on the messaging mechanism when you leave the office.
3. Be sure you are using the acceptable messaging for compliance with your contract.

 

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:

 

Emergency situations

Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER.  

 

Urgent situations

Compliant responses for urgent needs after hours:

• Live person, via a service or hospital, advises practitioner or on call practitioner is available and connects.
• Live person or recording directs caller/patient to Urgent Care, ER or call 911.

 

Non-compliant responses for urgent needs after hours:

• No provision for after-hours accessibility.
• Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. (Not a direct connection to their practitioner.)

 

Is your practice compliant?

 

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Anthem Blue Cross and Blue Shield (Anthem) 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 under-utilization. Our medical policies are available on Anthem’s website at anthem.com.

 

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 go to anthem.com, and select Providers > Provider Resources > Policies, Guidelines and Manuals > Select Indiana > View Medical Policies and Clinical UM Guidelines.

 

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 a.m. to 5 p.m., Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8 a.m. to 7 p.m. 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 12 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 following phone lines are for physicians and their staffs. Members should call the customer service number on their health plan ID card.

To discuss UM process and authorization	To discuss peer-to-peer UM denials w/physician	To request UM criteria	TTY/TDD
800-568-0075   KEHP 844-402-5347   Transplant 800-824-0581   National Transplant 844-644-8101 Fax: 888-438-7051   Behavioral Health 866-582-2293   Autism 844-269-0538   FEP 800-860-2156 Fax-UM: 800 732-8318 Fax-ABD: 877 606-3807	888-870-9342   National 800-821-1453 866-776-4793 888-870-9342   Adaptive Behavioral Treatment 844-269-0538   FEP 800-860-2156	877-814-4803   Behavioral Health 866-582-2293   FEP 800-860-2156 Fax-UM: 800 732-8318 Fax-ABD: 877 606-3807	711, or   TTY/ASCII/HCO: 1-800-648-6056   Voice: 1-800-648-6057

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.

 

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.

 

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Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.

 

Anthem Blue Cross and Blue Shield (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.

 

How do you contact us?

CM Email Address	CM Telephone Number	CM Business Hours
centregcmref@anthem.com	888-662-0939 800 944 0339 (KY only)	Monday through Friday 8 a.m. to 7 p.m. ET
centregcmref@anthem.com	877-636-3716 (KEHP)	Monday through Friday 8 a.m. to 8 p.m. ET

 

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The delivery of quality health care requires cooperation between patients, their providers and their health care 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 (Anthem) has adopted a member rights and responsibilities statement.

 

To read the member rights and responsibilities statement, visit the Policies, Guidelines and Manuals page of our provider website. Scroll down the page and select “Read about member rights.” Under the FAQ question titled “Laws and Rights that Protect You” you can find information about Anthem member rights and responsibilities.

 

Practitioners may access the FEP member portal at fepblue.org/memberrights to view the FEPDO Member Rights Statement.

 

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Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral.  Anthem Blue Cross and Blue Shield (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:

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:

• Diagnosis
• Treatment plan
• Referrals
• Psychopharmacological medication (as applicable)

 

In an effort to facilitate coordination of care, Anthem has several tools available on our anthem.com Provider website for behavioral health and other medical practitioners including:

• Coordination of Care Form
• Coordination of Care Letter Template – Behavioral Health
• Coordination of Care Letter Template – Medical

 

The following behavioral health forms, brochures, and screening tools for substance abuse and attention-deficit/hyperactivity disorder (ADHD) are also available on our anthem.com Provider website:

• Alcohol Use Assessment Brochure
• Antidepressant Medication Management
• Edinburgh Postnatal Depression Scale
• Opioid Use Assessment Brochure
• Substance Brief Intervention/Referral Tool (SBIRT)
• Vanderbilt ADHD Diagnostic Parent Rating Scale

 

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As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

 

All guidelines are reviewed annually and updated as needed. The current guidelines are available on our website at anthem.com > Provider > Select Policies, Guidelines & Manuals under Provider Resources> scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.

 

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For more than a decade, Blue Precision – Anthem Blue Cross and Blue Shield (Anthem)’s physician transparency program – has recognized specialists for meeting or exceeding established quality and cost effectiveness measures.  Thank you to all those physicians participating in our networks and for the care you provide to our members. 

 

As we announced in the July 2021 edition of Provider News, Anthem has made the business decision to retire our Blue Precision program effective December 31, 2021.  Blue Precision recognition icons and other program information will be removed from anthem.com and our “Find Care” provider tool by January 1, 2022.

 

Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.  We look forward to working collaboratively with you in other physician programs to provide our members with continued access to affordable and quality healthcare. 

 

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In the August 2021 edition of Provider News, we announced an expansion to the AIM Specialty Health® (AIM) musculoskeletal program for medical necessity review of the requested site of service for certain joint and interventional pain procedures for Anthem fully-insured members. This program has been delayed. AIM will begin accepting prior authorization requests on December 13, 2021 for dates of service on January 1, 2022 and after.

 

Medical necessity for musculoskeletal procedures are still required. All codes and clinical guidelines included in the musculoskeletal program can be found on the AIM MSK website.

 

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

 

• Prior authorization updates for specialty pharmacy effective December 1, 2021
  
  
• Prior authorization updates for specialty pharmacy effective January 1, 2022

Getting vaccinated against COVID-19 is one of the best and safest ways people can protect themselves and their families against the virus. As a participating practice in the COVID-19 Provider Vaccine Incentive program, we recognize your hard work by offering incentives for helping patients make the choice to become vaccinated.

 

Eligibility

The COVID-19 Vaccine Provider Incentive program is open to you if you are a participating Kentucky primary care provider with an Anthem Blue Cross and Blue Shield Medicaid (Anthem) panel size of 25 or more members. All Anthem members identified as receiving COVID-19 vaccination services are included in the methodology. Vaccine results will be determined by a COVID-19 vaccine claim or by confirmation from the Kentucky Vaccine Registry.

 

The results will be calculated for two time periods:

• September 1, 2021 – Initial incentive payment
• December 31, 2021 – Final incentive payment

 

How you can qualify for a bonus

If your practice meets the below thresholds for vaccination with at least one dose by September 1, 2021, you will receive the initial incentive payment based on the following rates:

• 30% Anthem members vaccinated – $20 bonus per vaccinated member
• 40% Anthem members vaccinated – $45 bonus per vaccinated member
• 50% Anthem members vaccinated – $70 bonus per vaccinated member
• 60% Anthem members vaccinated – $100 bonus per vaccinated member
• 75% Anthem members vaccinated – $125 bonus per vaccinated member

 

The final incentive payment is calculated based on members who are newly vaccinated between September 1, 2021 and December 31, 2021 (click here to view the Appendix for calculation examples). If your practice meets the below thresholds for vaccination with at least one dose by December 1, 2021, you will receive the final incentive payment based on the following rates:

• 30%Anthem members vaccinated – $100 bonus per newly vaccinated member
• 40% Anthem members vaccinated – $150 bonus per newly vaccinated member
• 50% Anthem members vaccinated – $175 bonus per newly vaccinated member
• 60% Anthem members vaccinated – $200 bonus per newly vaccinated member
• 75% Anthem members vaccinated – $250 bonus per newly vaccinated member

 

When you will receive your bonus

The first payment will be sent by electronic funds transfer or check based on the payment method used for claim reimbursement. Please allow 7 to 10 business days to receive payment. If you have not received it within that timeframe, reach out to a Provider Experience Consultant at 800-205-5870, option 3. The second payment will be generated on or before January 31, 2022.

 

Visit https://providers.anthem.com/kentucky-provider/communications/covid-19-updates for more information about the COVID-19 Vaccine Provider Incentive program. We greatly appreciate your partnership and look forward to working with you in the future.

 

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

 

Anthem is transitioning to the Availity Authorization app

You may already be familiar with the Availity multi-payer Authorization app because thousands of providers are already using it for submitting prior authorizations for other payers. Anthem is eager to make it available to our providers, too. On December 13, 2021, you can begin using the same authorization app you use for other payers. We hope to make it easier than ever before to submit prior authorization requests to Anthem.

 

ICR is still available

If you need to refer to an authorization that was submitted through ICR, you will still have access to that information. We’ve developed a pathway to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization app.

 

Innovation in progress

While we grow the Availity Authorization app to provide you with Anthem-specific information, you can still access ICR for:

• Appeals
• Behavioral health authorizations
• FEP authorizations
• Medical specialty Rx

 

Notices in the Availity Authorization App will guide you through the process for accessing ICR for Reserved Auth/Appeals functions.

 

Training is available

If you aren’t already familiar with the Availity Authorization app, training is available.

 

Wednesday, December 1, 2021	11:00 a.m. ET
Wednesday, December 8, 2021	12:00 p.m. ET
Friday, December 17, 2021	2:30 p.m. ET
Wednesday January 5, 2022	11:00 a.m. ET
Tuesday, January 11, 2022	3:00 p.m. ET

 

You can always log onto availity.com and view the webinar at your convenience. From Help & Training select Get Trained to access the Availity Learning Center. You can use “AvAuthRef” for a keyword search or select the Session tab to see all upcoming live webinars.

 

Now, give it a try!

Accessing the Availity Authorization app is easy. Just log onto availity.com and the Authorization icon is on the home screen. You can also access the App through the Patient Registration tab by selecting Authorizations and Referrals.

 

If you have questions, please reach out to Availity at 800-282-4548.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

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

 

We have enhanced your ability to search, review, and download a copy of the remittance advice on Availity* when there is not an associated payment. For remit advice with payment, you can continue to search with the Check/EFT number.

 

Below are images reflecting the scenarios that have been enhanced:

 

Paper remittance

Electronic remittance advice (ERA/835)

What has changed?

1. Non-payment number display in the Check Number and Check/EFT Number fields:
   • Old — There were two sets of numbers for the same remittance advice. The paper remittance displayed 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displayed 27 bytes (9999999999 — [year] #############).
   • Enhancement — The updated numbering sequence for the paper remittance and corresponding 835 (ERA) now contain the same 10-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.

 

2. Searching for non-payment remittance:
   • Old — When using Remit Inquiry to locate paper remittance, the search field required a date range and tax ID to locate a specific remittance due to same number scenario (10 bytes (9999999999) being used for every non-payment remittance.
   • Enhancement — Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers provides a faster and simplified process to find the specific remittance.

 

The way your organization receives remittances and payments has not changed; we have simply enhanced the numbering for the non-pay remittances. These changes do not impact previously issued non-payment remittance advice.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

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The following HEDIS_® measures assess the percentage of emergency department (ED) visits for which the member received a follow-up appointment within seven days and 30 days of being seen in the ED for mental illness or for alcohol and other drug abuse and dependence.

 

Follow-Up After ED Visit for Mental Illness (FUM)

Evaluates the percentage of ED visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit with any practitioner for mental illness. Two rates are reported. The percentage of ED visits for which the member received:

1. Follow-up within seven days of the ED visit (8 total days).
2. Follow-up within 30 days of the ED visit (31 total days).

 

Timely follow-up care for people with mental illness can lead to fewer repeat visits to the ED and improved physical and mental health function.

 

Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence (FUA)

Evaluates the percentage of ED visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow-up visit with any practitioner for AOD. Two rates are reported. The percentage of ED visits for which the member received:

1. Follow-up within seven days of the ED visit (8 total days).
2. Follow-up within 30 days of the ED visit (31 total days).

 

According to studies, follow-up care for individuals with AOD who were seen in the ED is associated with reduced substance use, repeat ED visits, and hospital admissions.

 

Helpful tips:

• Maintain appointment availability for patients with recent ED visits.
• Assist in scheduling in-person or telehealth follow-up appointments as soon as possible after the ED visit.
• Use appropriate documentation and correct coding. Use the same diagnosis for mental illness or substance use for follow-up visits (a non-mental health/non-substance diagnosis code will not fulfill the measure).
• Reference the Plan’s Quality Measures Desktop Reference for Medicaid Providers and the HEDIS Benchmarks and Coding Guidelines for Quality that is provided for coding information.
• Educate patients on the importance of compliance with their discharge plan and their follow-up appointments.
• Reach out to patients who cancel their appointments and assist with rescheduling as soon as possible.
• Facilitate referrals to behavioral healthcare specialists when appropriate.

 

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

 

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The American Cancer Society estimates there will be approximately 1,898,160 cancer cases diagnosed in 2021. That’s the equivalent of 5,200 new cases every day.¹ The good news is, patients say they are more likely to get screened when you recommend it. What else can you do to influence cancer screenings?²

1. Understand the power of the physician recommendation:

• Your recommendation is the most influential factor in whether a person decides to get screened.
• Patients are 90% more likely to get a screening when they reported a physician recommendation.
• “My doctor did not recommend it,” is the primary reason for screening avoidance.

2. Measure the screening rates in your practice; it may not be as high as you think:

• Set goals to get screening rates up.
• Follow the HEDIS^® guidelines included in this article to help accurately track your care gap closures.

3. More screening doesn’t have to mean more work for you:

• Reach out to us about available member data — We may be able to help identify those members who are due for screenings.
• Develop a reminder system, which has been demonstrated to be effective, to remind you and staff that patients have screenings due.

4. Help members access benefit information about screenings to eliminate the cost barrier:

• Log on to Availity.com and use the Patient Registration tab to run an Eligibility and Benefits Inquiry.
• Members can access their benefit information by logging on to anthem.com/ky and selecting the Benefits tab, or by using Anthem Medicaid mobile app.

 

Members earn rewards for screenings through the Healthy Rewards Program

Through Healthy Rewards, members receive incentives for completing certain screenings. They can redeem their reward dollars for retail gift cards — just another way we can work together for better health outcomes.

 

Screening	Reward	Timing
Breast Cancer Screening (BCS)	$25	Every two years
Cervical Cancer Screening (CCS)	$40	Every three years
Chlamydia Screening in Women (CHL)	$25	Annually

 

Measure up: Cancer screening for women HEDIS measure specifications

Organized and continuous screenings along with removal of precancerous lesions can lead to a 60% decrease in cervical cancer.³

 

Cervical Cancer Screening (CCS) is measured by the percentage of women 21 to 64 years of age who were screened for cervical cancer using one of the following criteria:

• Women 21 to 64 years of age who had cervical cytology performed within the last three years
• Women 30 to 64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last five years
• Women 30 to 64 years of age who had cervical cytology/hrHPV co-testing within the last five years

 

Description	Codes
Cervical cytology lab test	CPT: 88141–88143, 88147, 88148, 88150, 88152–88153, 88164–88167, 88174, 88175 HCPCS: G0123, G0124, G0141, G0143, G0145, G0147, G0148, P3000, P3001, Q0091 LOINC: 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5
hrHPV lab test	CPT: 87620–87622, 87624, 87625 HCPCS: G0476 LOINC: 21440-3, 30167-1, 38372-9, 59263-4, 59264-2, 59420-0, 69002-4, 71431-1, 75694-0, 77379-6, 77399-4, 77400-0, 82354-2, 82456-5, 82675-0
Absence of cervix diagnosis	ICD-10-CM: Q51.5, Z90.710, Z90.712
Hysterectomy with no residual cervix	CPT: 51925, 56308, 57530, 57531, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290–58294, 58548, 58550, 58552, 58553, 58554, 58570–58573, 58575, 58951, 58953, 58954, 58956, 59135 ICD-10-PCS: 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ

 

More women in the United States are surviving and thriving after breast cancer than ever before. In fact, in the last 30 years, the breast cancer death rate has dropped an astounding 40%. The decreases are believed to be the result of finding breast cancer earlier through screening, increased awareness, and better treatments.⁴

 

Breast Cancer Screening (BCS): The percentage of women 50 to 74 years of age who had a mammogram to screen for breast cancer. Compliant members have one or more mammograms any time on or between October 1^st, two years prior to the measurement year and December 31^st  of the measurement year.

 

Description

Codes

Mammography

CPT: 77061-77063, 77065-77067 LOINC: 24604-1, 24605-8, 24606-6, 24610-8, 26175-0, 26176-8, 26177-6, 26287-3, 26289-9, 26291-5, 26346-7, 26347-5, 26348-3, 26349-1, 26350-9, 26351-7, 36319-2, 36625-2, 36626-0, 36627-8, 36642-7, 36962-9, 37005-6, 37006-4, 37016-3, 37017-1, 37028-8, 37029-6, 37030-4, 37037-9, 37038-7, 37052-8, 37053-6, 37539-4, 37542-8, 37543-6, 37551-9, 37552-7, 37553-5, 37554-3, 37768-9, 37769-7, 37770-5, 37771-3, 37772-1, 37773-9, 37774-7, 37775-4, 38070-9, 38071-7, 38072-5, 38090-7, 38091-5, 38807-4, 38820-7, 38854-6, 38855-3, 42415-0, 42416-8, 46335-6, 46336-4, 46337-2, 46338-0, 46339-8, 46350-5, 46351-3, 46356-2, 46380-2, 48475-8, 48492-3, 69150-1, 69251-7, 69259-0

 

Sexual health is an essential element of overall health and well-being. Many patients want to discuss their sexual health with you, but most of them want you to bring it up. The National Coalition for Sexual Health has published a guide to help physicians feel comfortable about the conversation. Get a copy of the Sexual Health and Your Patients: A Provider’s Guide by clicking on the title or through this website: http://www.ctcfp.org.

 

Chlamydia Screening in Women (CHL) is measured by the percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.

Description

Codes

Chlamydia tests

CPT: 87110, 87270, 87320, 87490, 87491, 87492, 87810 LOINC: 14463-4, 14464-2, 14467-5, 14474-1, 14513-6, 16600-9, 21190-4, 21191-2, 21613-5, 23838-6, 31775-0, 31777-6, 36902-5, 36903-3, 42931-6, 43304-5, 43404-3, 43405-0, 43406-8, 44806-8, 44807-6, 45068-4, 45069-2, 45075-9, 45076-7, 45084-1, 45091-6, 45095-7, 45098-1, 45100-5, 47211-8, 47212-6, 49096-1, 4993-2, 50387-0, 53925-4, 53926-2, 557-9, 560-3, 6349-5, 6354-5, 6355-2, 6356-0, 6357-8, 80360-1, 80361-9, 80362-7, 91860-7

 

1 CA: A Cancer Journal for Clinicians. Cancer Statistics, 2021

2 http://thecanceryoucanprevent.org/wp-content/uploads/14893-80_2018-PROVIDER-PHYS-4-PAGER-11-10.pdf

3 National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/9253676/

4 Research to Help Women Prevent Breast Cancer or Live their best life with it. American Cancer Society. https://www.cancer.org/latest-news/research-to-help-women-prevent-breast-cancer-or-live-their-best-life-with-it.html

 

AKYPEC-2940-21

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

 

• Updates to AIM Specialty Health musculoskeletal interventional pain management clinical appropriateness guideline
  
  
• Medical drug benefit clinical criteria updates
  
  
• Protocol for providers serving members with hearing aid coverage administered by Hearing Care Solutions
  
  
• New York City Medicare Advantage announcement
  
  
• Medical policies and clinical utilization management guidelines update
  
  
• Updates to AIM Specialty Health Cardiology Clinical Appropriateness Guidelines 
  (WI only)

An overview of notable 2022 benefit changes and service area updates are now available at this link.

 

Please continue to check https://www.anthem.com/medicareprovider for the latest Medicare Advantage information.

 

ABSCRNU-0283-21

We have enhanced your ability to search, review, and download a copy of the remittance advice on Availity* when there is not an associated payment. For remit advice with payment, you can continue to search with the Check/EFT number.

 

Below are images reflecting the scenarios that have been enhanced:

 

Paper remittance

Electronic remittance advice (ERA/835)

What has changed?

1. Non-payment number display in the Check Number and Check/EFT Number fields:
   • Old — There were two sets of numbers for the same remittance advice. The paper remittance displayed 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displayed 27 bytes (9999999999 — [year] #############).
   • Enhancement — The updated numbering sequence for the paper remittance and corresponding 835 (ERA) now contain the same 10-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.

 

2. Searching for non-payment remittance:
   • Old — When using Remit Inquiry to locate paper remittance, the search field required a date range and tax ID to locate a specific remittance due to same number scenario (10 bytes (9999999999) being used for every non-payment remittance.
   • Enhancement — Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers provides a faster and simplified process to find the specific remittance.

 

The way your organization receives remittances and payments has not changed; we have simply enhanced the numbering for the non-pay remittances. These changes do not impact previously issued non-payment remittance advice.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0260-21

 

Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override.

 

For additional information, please review the Drug Screen Testing reimbursement policy at https://www.anthem.com/medicareprovider.

 

ABSCRNU-0270-21

Effective for dates of service on and after March 13, 2022, the following updates will apply to the listed AIM Specialty Health_® (AIM)* Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

 

Updates by guideline:

• Imaging of the Brain:

• Acoustic neuroma — removed indication for CT brain and replaced with CT temporal bone
• Meningioma — new guideline establishing follow-up intervals
• Pituitary adenoma — removed allowance for CT following nondiagnostic MRI in macroadenoma
• Tumor, not otherwise specified — added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

• Imaging of the Head and Neck:
• Parathyroid adenoma — specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
• Temporomandibular joint dysfunction — specified duration of required conservative management
• Imaging of the Heart:
  • Coronary CT angiography — removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
• Imaging of the Chest:
• Pneumonia — removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
• Pulmonary nodule — aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT
• Imaging of the Abdomen and Pelvis:
• Uterine leiomyomata — new requirement for ultrasound prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
• Intussusception — removed as a standalone indication
• Jaundice — added requirement for ultrasound prior to advanced imaging in pediatric patients
• Sacroiliitis — defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
• Azotemia — removed as a standalone indication
• Hematuria — modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline
• Oncologic Imaging:
• National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin and Non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers.
• Cancer screening — new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
• Breast cancer — clinical scenario clarifications for diagnostic breast MRI and PET/CT

 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM via:

• AIM’s ProviderPortal_SM directly at providerportal.com.
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• The Availity* Portal at availity.com.
• Phone at 800-714-0040, Monday through Friday from 7 a.m. to 7 p.m. CT.

 

If you have questions related to guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines online.

 

ABSCRNU-0281-21

 

Beginning January 1, 2022, Medicare Advantage Organizations (MAOs) and Medicare-Medicaid Plans (MMPs) are responsible for adjudicating claims for COVID-19 vaccines and their administration and for COVID-19 monoclonal antibodies and their administration.

 

ABSCRNU-0286-21

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

 

Anthem is transitioning to the Availity Authorization app

You may already be familiar with the Availity multi-payer Authorization app because thousands of providers are already using it for submitting prior authorizations for other payers. Anthem is eager to make it available to our providers, too. On December 13, 2021, you can begin using the same authorization app you use for other payers. We hope to make it easier than ever before to submit prior authorization requests to Anthem.

 

ICR is still available

If you need to refer to an authorization that was submitted through ICR, you will still have access to that information. We’ve developed a pathway to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization app.

 

Innovation in progress

While we grow the Availity Authorization app to provide you with Anthem-specific information, you can still access ICR for:

• Appeals
• Behavioral health authorizations
• FEP authorizations
• Medical specialty Rx

 

Notices in the Availity Authorization App will guide you through the process for accessing ICR for Reserved Auth/Appeals functions.

 

Training is available

If you aren’t already familiar with the Availity Authorization app, training is available.

 

Wednesday, December 1, 2021	11:00 a.m. ET
Wednesday, December 8, 2021	12:00 p.m. ET
Friday, December 17, 2021	2:30 p.m. ET
Wednesday January 5, 2022	11:00 a.m. ET
Tuesday, January 11, 2022	3:00 p.m. ET

 

You can always log onto availity.com and view the webinar at your convenience. From Help & Training select Get Trained to access the Availity Learning Center. You can use “AvAuthRef” for a keyword search or select the Session tab to see all upcoming live webinars.

 

Now, give it a try!

Accessing the Availity Authorization app is easy. Just log onto availity.com and the Authorization icon is on the home screen. You can also access the App through the Patient Registration tab by selecting Authorizations and Referrals.

 

If you have questions, please reach out to Availity at 800-282-4548.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

AKY-NU-0351-21

We are pleased to announce a new no-cost care management program available for your Medicare Advantage covered patients with chronic kidney disease (CKD) or end-stage kidney disease (ESKD). This high-touch program, delivered by Somatus*, is designed to support and enhance your existing patient care by providing hands-on, one-on-one care management to eligible patients with kidney disease.

 

Somatus is the leading and largest provider of kidney care management services in the country. Through an innovative care-delivery model, Somatus surrounds patients with access to the full suite of support services and education needed to delay kidney disease progression and retain quality of life.

 

Somatus’ care management services are personalized to each participating member and may include:

• A full care team comprised of a nurse, community health worker, pharmacist, dietitian, and social worker.
• Ongoing in-home physical assessments, environmental assessments, face-to-face education, and health coaching to identify problems early and avoid potential hospitalizations and complications.
• Comprehensive 1:1 care management of the patient’s kidney disease and co-morbidities, delivered in person (at home, clinic, or hospital) or via telephone.
• Clinical and logistical assistance to help patients transfer safely from hospital to home, if needed.
• Meal planning, appointment scheduling, transportation coordination, connection to local resources and community-based organizations, and more.

 

Anthem Blue Cross and Blue Shield will identify Medicare Advantage patients in your practice that qualify for and would benefit from Somatus’ kidney-care services, and we look forward to working with you to ensure these patients enroll and take part in this no-cost opportunity. A member of the Somatus team will be in touch to discuss your eligible patients and how you can help encourage their participation.

 

For more information about Somatus, visit www.somatus.com or, contact the Somatus Care Team at:

• Phone: 855-851-8354, Monday through Friday, 9 a.m. to 9 p.m. ET
• Email: care@somatus.com

 

* Somatus is an independent company providing care management services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0285-21