On April 1, 2024, Carelon Post Acute Solutions, LLC (formerly known as myNexus) began operating as Carelon Medical Benefits Management, Inc.

Provider materials that formerly included the Carelon Post Acute Solutions name, such as determination letters and provider forms, have adopted the new name. However, there will be no changes in the way you submit a case nor to the contact information you use for checking case status.

Please see below for a list of FAQ. Additional questions can be directed to our Health Care Networks team using the contact information below:

• Home health providers: HHprovider_relations@carelon.com
• Post-acute institutional management (PAC-IM) providers: PACprovider_relations@carelon.com
• Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers: DMEprovider_relations@carelon.com

Thank you for your continued partnership.

Carelon Medical Benefits Management transition FAQ

Q: Will there be any changes to the Carelon Post Acute Solutions provider website?

A: The name of our website has been updated to reflect Carelon Medical Benefits Management branding. Additionally, the web address you use today will automatically redirect to a new Carelon Medical Benefits Management site. There will be no changes to the case submission process.

Q: Are any phone number changes planned as part of this transition?

A: No, our inbound phone numbers will not change. The reference to Carelon Post Acute Solutions in recorded scripting will use the Carelon Medical Benefits Management name.

Q: How will third party websites, such as Availity, be impacted?

A: There will be no change to the way you access these websites. Within the sites, any reference to Carelon Post Acute Solutions will be replaced with the new name. This may take some time to fully complete.

Q: Will references to Carelon Post Acute Solutions on health plan websites and other materials be changed?

A: Yes, while you may continue to see the Carelon Post Acute Solutions company name on health plan websites for some time, these references will be updated over time through scheduled content update cycles. If your office includes the Carelon Post Acute Solutions name in any materials or web properties, we encourage you to update them to Carelon Medical Benefits Management during your next update cycle.

Q: Will information about Carelon Post Acute Solutions continue to be found on the corporate website?

A: Yes, post-acute care will be part of the Carelon Medical Benefits Management portfolio of solutions. You can learn more at careloninsights.com.

Q: Will provider resources, such as key documents and the provider finder, be impacted?

A: Our provider resources will continue to be available through our corporate website and our Provider Resources site.

Q: Does this impact provider agreements with Carelon Post Acute Solutions? Will I need to sign a new agreement?

A: No, there is no impact to provider agreements. You do not need to sign a new agreement regardless of whether your current contract is with MyNexus, Inc. or Carelon Post Acute Solutions.

Q: Do I need to complete credentialing again through Carelon Medical Benefits Management?

A: No, providers will not need to re-credential until their normal credentialing cycle.

Q: Will my claims be impacted?

A: No, claims are not impacted. Payer IDs will remain the same.

Q: Will I need to update my W-9?

A: Providers may need to update their W-9. If you need an updated W-9 from Carelon Medical Benefits Management, please contact the Carelon Provider Relations department at HHprovider_relations@carelon.com.

Maintaining your online provider directory information is essential for member and healthcare partners to connect with you when needed. Access your online provider directory information by visiting anthem.com/provider, then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information we show in our online directory has changed.

Updating your information

Anthem uses the provider data management (PDM) capability available on Availity Essentials to update your provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate provider demographic data set by the Consolidated Appropriations Act (CAA).

PDM features include:

• Updating provider demographic information for all assigned payers in one location.
• Attesting to and managing current provider demographic information.
• Monitoring submitted demographic updates in real-time with a digital dashboard.
• Reviewing the history of previously verified data.

Accessing the PDM application

Log on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

PDM training

PDM training is available:

• Learn about and attend one of our training opportunities by visiting here.
• View the Availity PDM quick start guide here.
• For Roster Automation Standard Template and Roster Automation Rules of Engagement specific training, listen to our recorded webinar here.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account.

If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY.

Providers must code their claims to the highest level of specificity in accordance with industry standard coding guidelines such as ICD-10-CM coding guidelines and reporting. When an ICD-10-CM diagnosis code has a specified laterality within the code description, the modifier that is appended to a CPT^® or HCPCS code must correspond to the laterality within the ICD-10 description.

For CMS 1500 form claims processed on or after May 30, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny claim lines that have a laterality diagnosis submitted with a CPT or HCPCS modifier that does not correspond to the diagnosis.      

Example one:

Example two:

Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT, HCPCS code(s), and/or modifiers billed.

Anthem will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex Code: 00W19

If you have questions about this communication or need assistance, contact your provider relationship management associate.

We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities.

Use the information below to help complete required patient information on donor claims. Correct completion of the form is needed to process the claim.

Donor claims

There are two patients involved in an organ donation — the donor and the recipient. The insurance plan for the recipient is responsible for paying the donor claim. The recipient can be the subscriber or a dependent to the subscriber (Note: Plans are instructed to include living donor charges on the recipient claims).

When billing for services rendered to the transplant donor, the care provider enters the recipient’s name, date of birth, sex, and Anthem ID number.

Completing forms

Review the information outlined below for billing instructions needed to process donor claims.

CMS-1450 (UB-04 Uniform Bill):

• UB box 8b — recipient’s name*
• UB box 10 — recipient’s birthdate
• UB box 11 — recipient’s sex
• UB box 42 — donor ICD-10-CM codes and revenue codes
• UB box 58 — subscriber’s name
• UB box 59 — relationship code of 39 or 40
• UB box 60 — subscriber ID number
• UB box 66 — donor diagnosis codes
• UB box 80 — note this is a donor claim submission with donor’s name

CMS-1500 (Health Insurance Claim Form):

• HCFA box 1a — subscriber’s ID number
• HCFA box 2 — recipient’s name*
• HCFA box 3 — recipient’s date of birth and gender
• HCFA box 4 — subscriber’s name
• HCFA box 6 — relationship to subscriber, other (Complete with 39 or 40.)
• HCFA box 19 — note, this is a donor claim submission with donor’s name
• HCFA box 21 — donor diagnosis code
• HCFA box 53 (electronic claim) — will list the donor’s name:
• Example: Claim note ref code: ADD Claim note Text: 39-Jones, Sally

* The recommendation is that the recipient’s name be billed. However, the care provider can bill with the donor’s name. If the claim is billed with the recipient’s name, it has a better chance at adjudication upon initial submission.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

When determining transportation to an alternative hospital and to help avoid medical necessity denials for rotary wing air ambulance transports to another hospital, please remember the criteria below.

The use of air and water ambulance services is considered medically necessary when all the following criteria are met:

1. The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
2. The individual’s condition must be such that any form of transportation other than by ambulance would be medically contraindicated; and
3. The individual’s condition is such that the time needed to transport by land poses a threat to the individual’s survival or seriously endangers the individual’s health*; or the individual’s location is such that accessibility is only feasible by air or water transportation; and
4. There is a medical condition that is life threatening, or first responders deem to be life threatening, including, but not limited to, the following:

1. Intracranial bleeding; or
2. Cardiogenic shock; or
3. Major burns requiring immediate treatment in a burn center; or
4. Conditions requiring immediate treatment in a hyperbaric oxygen unit; or
5. Multiple severe injuries; or
6. Transplants; or
7. Limb-threatening trauma; or
8. High risk pregnancy; or
9. Acute myocardial infarction; if this would enable the individual to receive a more timely medically necessary intervention (such as percutaneous transluminal coronary angioplasty [PTCA] or fibrinolytic therapy).

* Air transportation may be appropriate if the time between identification of the need for transportation until arrival at the intended destination for ground ambulance would be at least 30 minutes longer than air transport.

For additional details on Clinical UM Guideline CG-ANC-04 Ambulance Services: Air and Ground please visit the Anthem provider site.

Clinical UM guidelines are subject to change. Administrative services only (ASO) accounts may utilize alternate criteria. All terms and conditions of the member’s benefit plan apply.

For more information please contact Provider Services.

It’s time for some of your patients to renew their Medicaid benefits. As states begin to recommence Medicaid renewals, we want to ensure you have the information needed to help your Medicaid patients renew their healthcare coverage. Some patients have never had to renew their coverage at all, while other patients may have forgotten the process entirely.

We’re here to help.

What steps do my patients need to take?

• Ready: Patient gets their documents ready.
• Set: Patient ensures their form is all set
• Renew: Patient sends renewal form via:
  • Web: ky.gov
  • Phone: 855-306-8959
  • Mail: Send to your local Department of Community Based Services office.

What if I need assistance?

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to availity.com, and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact.

Call to action

We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities. We are excited to share a new and improved way to care for people living with sickle cell disease (SCD). Anthem has created a comprehensive SCD care management program. The program partners with members and care providers to remove barriers to care, improve and facilitate treatment adherence, and increase the quality of life for people living with SCD. By focusing on the prevention of SCD complications and building strategies for effective pain management, we aim to reduce preventable emergency department (ED) utilization and hospital admissions.

Our goal is to ensure that members with SCD receive comprehensive whole person care that goes beyond treating disease symptoms. Through this program, we will provide disease education, medication adherence monitoring, care coordination, as well as connections to community resources that support social drivers of health and other critical services. By building trusting relationships between Anthem, our members, care providers, and community resources, we assist our members in achieving the best quality of life possible.

To refer a Medicaid-enrolled member to the SCD Care Coordination program, call Provider Services at 855-661-2028.

Why this is important

SCD is a chronic condition and is the most common inherited red blood cell disorder in the United States affecting at least 100,000 Americans.¹ The Center for Disease Control and Prevention (CDC) reports that SCD affects one out of every 365 Black and African American births and one out of every 16,300 Hispanic and Latinx births.¹

Most care providers are familiar with the unpredictable symptoms and long-term morbidities that individuals affected by SCD experience, including pain and vaso-occlusive crises, depression, and fatigue. Repeated vaso-occlusion, infarction, and chronic hemolytic anemia lead to organ dysfunction. More than half of people living with SCD have some organ disease and at least 24% have damage affecting multiple organs². Vaso-occlusive events can have devastating consequences across all age groups. For example, it is estimated that 50% of people with SCD will experience cerebral vasculopathy by age 14, and 25% of adults with SCD will experience a stroke by age 45.²

Care providers might lose sight of the high medical costs (estimated to be over $1 million per individual lifetime)^6,1, barriers to care, and reduced quality of life people with SCD face. Despite medical advances in treatments, such as medications and gene therapy, large discrepancies in both outcomes and mortality rates for people with SCD still remain. One startling national statistic shows that life expectancy for people with SCD is at least 22 years lower than that for people without SCD.⁶ These gaps can be attributed to multiple factors including limited access to comprehensive care.

The effects of SCD on quality of life are often unrecognized. Patients with SCD are more likely than people without SCD to have lost workdays and missed school days because of time spent in the hospital or ED.⁶ The prevalence of depression and anxiety among people with SCD is five times greater than that of the general population.²

Patient experience is linked to their perceptions of quality of care.¹⁰ Many people living with SCD report dissatisfaction with the quality of care they receive. Contributing factors to this dissatisfaction include perceptions of racial discrimination, feelings of being stereotyped as drug seekers who do not have legitimate pain, barriers to accessing specialty care, and lack of clinician comfort with disease management — especially pain.¹⁰

The presence of implicit racial bias in healthcare and perceptions of discrimination are directly linked to negative health experiences.² One example comes from a published study that showed people with sickle cell crisis in the ED waited 50% longer for pain treatment than patients who arrived with long bone fractures.³ In another study of ED wait times, patients with SCD waited an average of two hours longer for initial pain treatment compared to patients without SCD.³

Negative healthcare experiences lead to feelings of mistrust, which result in poor health outcomes. Patients with SCD who report experiences of discrimination are 53% more likely to report nonadherence to physician treatment recommendations.¹⁰ The lack of trusting relationships with healthcare providers correlates to low patient self-efficacy. This is compounded by obstacles related to social drivers of health, which disproportionately affect many individuals living with SCD.

We designed this program in our pursuit to deliver the most comprehensive care, and we believe it can foster close collaboration between Anthem and healthcare providers. This joint effort has the potential to address and eliminate the challenges our members with sickle cell disease currently face.

To support this endeavor, Anthem is ready to provide essential tools and resources needed to make a positive impact. Our shared commitment can help enhance the healthcare journey for our members.

HEDIS^® (Healthcare Effectiveness Data Information Set) is a widely used set of performance measures developed and maintained by NCQA (National Committee for Quality Assurance). These are used to drive improvement efforts surrounding best practices.

HEDIS 2024 Documentation for Cervical Cancer Screening (CCS)

Measure description: The percentage of women 21 to 64 years of age who were screened for cervical cancer using either of the following criteria:

• Women 21 to 64 years of age who had cervical cytology performed within the last 3 years.
• Women 30 to 64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
• Women 30 to 64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) co-testing within the last 5 years.

What we are looking for in provider records:

• Documentation in the medical record indicating the date when the cervical cytology was performed and result or finding (2022 to 2024)
• Documentation in the medical record indicating the date when the hrHPV test was performed and result or finding (2020 to 2024)
  • Documentation of HPV test can be counted as hrHPV testing along with result or finding
• Documentation of complete, total, or radical hysterectomy (abdominal, vaginal, or unspecified anytime in the member’s history through 12/31/2024).
• Documentation of vaginal hysterectomy (anytime in the member’s history through 12/31/2024).
• Evidence of hospice services in 2024
• Evidence patient expired in 2024

Please note: Documentation of hysterectomy alone does not meet the criteria, because it is not sufficient evidence that the cervix was removed.

Helpful Hints:

• Educate patient on importance of regular cervical cancer screening.
• OB/GYN and PCP should share cervical cancer screening results.
• Document date and result of member reported cervical cancer or HPV screenings.

HEDIS 2024 Documentation for Prenatal and Postpartum Care (PPC)

Measure description: The percentage of deliveries of live births on or between October 8 of the year prior to the measurement year (2023) and October 7 of the measurement year (2024). For these women, the measure assesses the following facets of prenatal and postpartum care.

• Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment with the Healthy Blue plan.
• Postpartum Care. A postpartum visit on or between 7 and 84 days after delivery.

What we are looking for in provider records for a prenatal care visit with a PCP or OB/GYN or other prenatal practitioner:

• Documentation in the medical record for deliveries of live births on or between October 8 of the year prior to the measurement year (2023) and October 7 of the measurement year (2024) must include a note indicating the date when the prenatal care visit occurred and evidence of one of the following:
  • Documentation indicating the woman is pregnant or references to the pregnancy for example:
    • Documentation in a standardized prenatal flow sheet
    • Documentation of LMP, EDD, or gestational age
    • Documentation of a positive pregnancy test result
    • Documentation of gravidity and parity
    • Documentation of complete obstetrical history
    • Documentation of prenatal risk assessment and counseling/education
  • Documentation of a basic physical obstetrical examination that includes auscultation for fetal heart tone, or pelvic exam with obstetric observations, or measurement of fundus height (a standardized prenatal flow sheet may be used).
  • Evidence that a prenatal care procedure was performed such as:
    • Screening test in the form of an obstetrical panel (must include all the following: hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing)
    • Torch antibody panel alone
    • A rubella antibody test/titer with an Rh incompatibility (ABO/blood typing)
  • Ultrasound of a pregnant uterus
  • Evidence of nonlive birth
  • Evidence of hospice services in 2024
  • Evidence patient expired in 2024

What We Are Looking For In Provider Records For A Postpartum Care Visit With A PCP Or OB/GYN or other prenatal practitioner:

• Documentation in the medical record must include a note indicating the date when a postpartum visit occurred and one of the following:
  • Pelvic exam
  • Evaluation of weight, BP, breasts, and abdomen
  • Notation of postpartum care
  • Perineal or cesarean incision/wound check
  • Screening for depression, anxiety, tobacco use, substance use disorder, or preexisting mental health disorders
  • Glucose screening for women with gestational diabetes
  • Documentation of any of the following: Infant care or breastfeeding, resumption of intercourse, birth spacing or family planning, sleep/fatigue, resumption of physical activity, attainment of healthy weight
• Evidence of nonlive birth
• Evidence of hospice services in 2024
• Evidence patient expired in 2024

Helpful Hints:

• Educate members on the importance of timely prenatal care.
• Schedule postpartum visit during final prenatal appointment or prior to discharge from hospital.
• Reach out to members to remind them of scheduled prenatal and postpartum appointments.

HEDIS 2024 documentation for Controlling High Blood Pressure (CBP)

HEDIS^® (Healthcare Effectiveness Data Information Set) is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

Measure description: The percentage of members 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose BP (blood pressure) was adequately controlled (< 140/90 mm Hg) during the measurement year.

What we are looking for in provider records:

• Last BP documented in 2024 regardless of reading

Documentation below could be used to exclude the patient:

• Evidence of hospice or palliative services in 2024
• Evidence patient expired in 2024
• Documentation of pregnancy any time during 2024
• Documentation of end stage renal disease, dialysis, nephrectomy, or kidney transplant any time in the member’s history on or prior to December 31, 2024

Helpful hints:

• Take BP at every visit.
• Take a second BP before the end of the office visit if the BP was ≥ 140/90.
• Counsel on healthy habits for managing high blood pressure.
• BPs cannot be taken:
• On the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests.
• From member-reported BPs if taken with a non-digital device such as with a manual blood pressure cuff and a stethoscope.

HEDIS 2024 documentation for Statin Therapy for Patients with Cardiovascular Disease (SPC)

Measure description: The percentage of males 21 to 75 years of age and females 40 to 75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and received statin therapy and remained on the statin for at least 80% of the treatment period.

What we are looking for in provider records

Documentation in the medical record indicating the date the patient was dispensed at least one high-intensity or moderate-intensity statin medication during the measurement year.

All of the following must be present with a dispensed medication:

• Name of the drug (generic or brand name)
• Strength/dose
• Route
• Date when the medication was dispensed, filled, or shipped to the patient

Documentation below could be used to exclude the patient:

• Evidence of hospice services in 2024
• Evidence patient expired in 2024
• Evidence patient received palliative care in 2024
• Evidence patient was pregnant or underwent IVF treatment in 2023 or 2024
• Evidence of ESRD or dialysis in 2023 or 2024
• Evidence of cirrhosis in 2023 or 2024
• Evidence of a dispensed prescription for Clomiphene in 2023 or 2024
• History of myalgia, myositis, myopathy, muscle pain or rhabdomyolysis documented in 2024

Helpful hints:

• Recommended that if the patient has a reaction to statins, record the specific reaction (myalgia, myositis, myopathy, muscle pain or rhabdomyolysis) in the patient’s chart annually.
• Recommended to also include drug quantity and directions with the dispensed medication so that days’ supply can be calculated for the measure.