CommercialSeptember 1, 2021
National Accounts 2022 Pre-certification list
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September 2021 Anthem Provider News - KentuckyContentsCommercialSeptember 1, 2021 National Accounts 2022 Pre-certification listCommercialSeptember 1, 2021 HEDIS® medical record submission made easier with our Remote EMR Access ServiceCommercialSeptember 1, 2021 Cure for the common cold: Rest, fluids and this free prescription padCommercialSeptember 1, 2021 Six SIMPLE strategies to help increase medication adherenceCommercialSeptember 1, 2021 Statin therapy for patients with diabetesCommercialSeptember 1, 2021 Register now for our September CME webinarsCommercialSeptember 1, 2021 Get your payments faster when you sign up for electronic funds transferCommercialSeptember 1, 2021 Updated guidance on prior authorization requirements for admissions to in-network skilled nursing facilitiesCommercialSeptember 1, 2021 Reimbursement policy update: Drug Screen Testing - ProfessionalCommercialSeptember 1, 2021 New reimbursement policy update: Inpatient Facility Transfers - Facility - RETRACTIONCommercialSeptember 1, 2021 Reimbursement policy update: Sexually transmitted infections testing - ProfessionalCommercialSeptember 1, 2021 Updates for specialty pharmacy are available - September 2021Medicare AdvantageSeptember 1, 2021 Prior authorization form notificationMedicare AdvantageSeptember 1, 2021 Utilization management authorization rule operationsMedicare AdvantageSeptember 1, 2021 Reimbursement Policy Update: DRG Inpatient Facility TransfersMedicare AdvantageSeptember 1, 2021 Keep up with Medicare news - September 2021MedicaidSeptember 1, 2021 Keep up with Medicaid news - September 2021To view this publication online:Or scan this QR code with your phone CommercialSeptember 1, 2021 National Accounts 2022 Pre-certification listThe National Accounts 2022 Pre-certification list has been published. Please note, providers should continue to verify member eligibility and benefits prior to rendering services.
To view this article online:Or scan this QR code with your phone CommercialSeptember 1, 2021 HEDIS® medical record submission made easier with our Remote EMR Access ServiceInstead of faxing multiple pages of medical records for HEDIS® studies, use Anthem Blue Cross and Blue Shield (Anthem)’s Remote EMR Access Service we offer to providers that allows us to access your EMR system directly to pull the documentation we need. Our Remote EMR Access Service helps reduce the time and costs associated with medical record retrieval while improving efficiency and lessening the impact on your office staff.
We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS® measure updates. We complete medical record retrieval based on minimum necessary guidelines:
Let us help you! Getting started with Remote EMR Access is just one click away. Download and complete this registration form and email it to us at Centralized_EMR_Team@anthem.com.
To learn more about our Remote EMR Access Service, view the Frequently Asked Questions below. How do you retrieve our medical records? We access your EMR using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally, on our secure network drives. Is printing necessary? Yes. The NCQA audit requires print-to-file access. Is this process secure? Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives. Why does Anthem need full access to the entire medical record? There are several reasons we need to look at the entire medical record of a member:
What information do I need to submit to use your Remote EMR Access Service? Complete the registration form that requests the following information:
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
To view this article online:Or scan this QR code with your phone CommercialSeptember 1, 2021 Cure for the common cold: Rest, fluids and this free prescription padBe Antibiotic Aware campaign offers a prescription solution to antibiotics
A mother has a sick child and like all good mothers, wants comfort and care. And a prescription for antibiotics. BMJ Journals published a study that rated how many patients with upper respiratory infections (URI) prior to consultation with their physician expected a prescription for antibiotics1.
Evidence-based data does not support the use of antibiotics in the treatment of the common cold because they do not improve symptoms or shorten the course of the illness.2
Instead of putting away the prescription pad, use this one.
Offered by the CDC’s Be Antibiotics Aware campaign, the “Relief for common symptoms of colds and cough” prescription pad provides an alternative to unnecessary antibiotics. Get it through the CDC website here.
Measure up: HEDIS® guidelines for URI/Pharyngitis URI measures the percentage of episodes for members 3 months of age and older with a URI diagnosis that did not result in an antibiotic dispensing event.
Appropriate testing for pharyngitis (CWP) evaluates members 3 years of age and older where the member was diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.
Records and billing codes URI: In the patient’s medical records, document results of all strep tests or refusal for testing. If antibiotics are prescribed for another condition, take care to associate the antibiotic with the appropriate diagnosis.
CWP: In the patient’s medical records, document results of all strep tests or refusal for testing. If antibiotics are prescribed for another condition, take care to associate the antibiotic with the appropriate diagnosis.
To view this article online:Or scan this QR code with your phone CommercialSeptember 1, 2021 Six SIMPLE strategies to help increase medication adherenceDid you know the cost Impact of medication non-adherence is $528 billion from non-optimized medication therapy?1 That’s equivalent to 16% of U.S. total health expenditures and contributes to 275,689 deaths per year.2
As a healthcare provider, you can motivate your patients to adhere to their medication regimens, which can contribute to improved outcomes and increased STARS performance. Lack of medication adherence also negatively impacts your STARs performance, which in turn can negatively impact your reimbursement.
We developed this video to offer best practices in boosting medication adherence among your patient population.
Use the six SIMPLE strategies below to help improve medication adherence among your patient population. S – Simplify the regimen
I – Impart knowledge
M – Modify patient beliefs and behavior
P – Provide communication and trust
L – Leave the bias
E – Evaluate adherence
Watch this video to learn more best practices on helping improve medication adherence and your organization’s overall quality and STARS performance.
To view this article online:Or scan this QR code with your phone CommercialSeptember 1, 2021 Statin therapy for patients with diabetesAchieve 90% patient statin therapy adherence with a personalized approach
Adults 40–75 years of age with diabetes, who do or do not have clinical atherosclerotic cardiovascular disease (ASCVD), should be started on a statin for primary and secondary prevention of ASCVD regardless of lipid status.1
Studies show that statin use reduces comorbidities and mortality from heart disease and non-adherence to statins may increase cardiovascular events and even death.2
Clinicians play a powerful role in ensuring their patients are adherent to their statin therapies. In fact, 90% of patients can be successfully adherent to statin therapy with a personalized approach.
We created this video to offer clinicians best practices in helping their patients remain adherent to their statin therapies.
The following seven strategies can help increase adherence to statin therapy in your patients: 1. Initiate statin therapy for patients with diabetes or clinical ASCVD as appropriate
2. If a statin is not suitable for a patient, document exclusion criteria with the appropriate ICD-10 code
potential side effects
previous statin-associated side effects
5. Inform patients that a significant number of generic statin medications are available for $0 for a 90-day supply on most plans
6. Encourage patients to use their plan ID card to fill statin medications
7. Watch this video to learn best practices on helping improve statin therapy adherence and your organization’s overall quality and STARS performance.
To view this article online:Visit https://providernews.anthem.com/kentucky/articles/statin-therapy-for-patients-with-diabetes-5-8572 Or scan this QR code with your phone CommercialSeptember 1, 2021 Register now for our September CME webinars
Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.
REGISTER HERE for our upcoming clinical quality webinars!
To view this article online:Visit https://providernews.anthem.com/kentucky/articles/register-now-for-our-september-cme-webinars-4-8571 Or scan this QR code with your phone CommercialSeptember 1, 2021 Get your payments faster when you sign up for electronic funds transferEffective November 1, 2021, EnrollSafe will replace CAQH Enrollhub as the electronic funds transfer (EFT) enrollment portal for Anthem Blue Cross and Blue Shield (Anthem) providers. As of November 1, 2021, CAQH Enrollhub will no longer offer EFT enrollment to new users.
When you sign up for EFT through EnrollSafe, the new enrollment portal, you’ll receive your payments up to seven days sooner than through the paper check method. Not only is receiving your payment more convenient, so is signing up for EFT. What’s more, it’s easier to reconcile your direct deposits.
EnrollSafe is safe, secure and available 24-hours a day. Beginning November 1, 2021, log onto the EnrollSafe enrollment hub at enrollsafe.payeehub.org to enroll in EFT. You’ll be directed through the EnrollSafe secure portal to the enrollment page, where you’ll provide the required information to receive direct payment deposits.
Already enrolled in EFT through CAQH Enrollhub? If you’re already enrolled in EFT through CAQH Enrollhub, no action is needed unless making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, after October 31, 2021, use EnrollSafe to update your account.
Electronic remittance advice (ERA) makes reconciling your EFT payment easy and paper-free. Now that you are enrolled in EFT, using the digital ERA is the very best way to reconcile your deposits – securely and safely. You’ll be issued a trace number with your EFT deposit that matches up with your ERA on Availity.
ERAs can be retrieved directly from Availity. Log onto Availity and select Claims and Payments > Send and Receive EDI Files > Received Files folder. When using a clearinghouse or billing service, they will supply the 835 ERA for you. You also have the option to view or download a copy of the Remittance Advice under Payer Spaces > Remittance Inquiry tool.
To view this article online:Or scan this QR code with your phone CommercialSeptember 1, 2021 Updated guidance on prior authorization requirements for admissions to in-network skilled nursing facilitiesPlease note that the following information applies to Anthem Blue Cross and Blue Shield (Anthem) in Kentucky local Commercial health plans.
Anthem is updating guidance on prior authorization requirements for admissions to in-network skilled nursing facilities (SNFs).
This process applies to hospital inpatient transfers to SNFs only. It does not apply to transfers from Acute inpatient Rehab, LTAC to SNF, or SNF to SNF.
The goal of this updated guidance is to minimize any delays in the transfer of members to an in-network SNF facility.
Effective August 1, 2021, Anthem will allow a 5-day initial length of stay upon notification of an admission to an in-network SNF facility for Kentucky local Commercial members.
We will monitor this process through December 31, 2021 and conduct random audits and monitor trends to evaluate its effectiveness
*Note: This process does not apply to admissions to out-of-network SNF facilities.
Frequently Asked Questions (FAQs)
As a SNF provider, do I need to send information and notification to Anthem as I would normally do for a prior authorization? Yes, notification is still required. However, you can notify Anthem of the admission and move the member without having to send in clinical information or wait for an approval. It will be important to verify member benefits.
When do I need to submit clinical information? For the initial SNF admission, no later than two business days after the admission and for continued stay, prior to the last covered day.
Does this apply to SNF, IP Rehab and LTAC admissions and related transportation (air or ground ambulance)? This process is only applicable to the initial SNF admission. Follow standard prior authorization process for IP Rehab, LTAC and any related transportation.
For the SNF initial authorization of 5 days, will Anthem assign a level of care? Anthem UM will assign Level of care once the clinical information is received from the SNF.
What if a member needs to be admitted for wound care and IV antibiotics? If a SNF has any concerns about the criteria for admission, they may still do the full prior authorization process.
If the physician and/or facility are out-of-network for the member, does this process apply? No, the facility AND physician both need to be in network. All out-of-network facilities and providers must follow the full prior authorization process.
What if I am uncertain if the member is a local commercial member? This process is applicable to local commercial accounts only. It does not apply to FEP, National, Medicaid, Medicare, or IHM. If you are uncertain, reach out to the Anthem dedicated nurse for your facility.
To view this article online:Or scan this QR code with your phone CommercialSeptember 1, 2021 Reimbursement policy update: Drug Screen Testing - ProfessionalBeginning with dates of service on or after December 1, 2021, Anthem Blue Cross and Blue Shield will update the policy to indicate that separate reimbursement is not allowed for specimen validity testing when utilized for drug screening because it is included in the CPT and HCPCS code descriptions for presumptive and definitive drug testing. Modifiers will not override this edit; therefore, we have included this information in our Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) reimbursement policy.
For more information about this policy, visit the Reimbursement Policy page at anthem.com.
To view this article online:Or scan this QR code with your phone CommercialSeptember 1, 2021 New reimbursement policy update: Inpatient Facility Transfers - Facility - RETRACTIONRETRACTION: This policy has been retracted. View the retraction notice published in the December 2021 issue of Provider News: RETRACTION: Inpatient Facility Transfers - facility reimbursement policy
For more information about this policy, visit the Reimbursement Policy page at anthem.com.
To view this article online:Or scan this QR code with your phone CommercialSeptember 1, 2021 Reimbursement policy update: Sexually transmitted infections testing - ProfessionalBeginning with dates of service on or after December 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) will implement a new reimbursement policy titled Sexually Transmitted Infections Testing. Anthem considers Sexually Transmitted Infection (STI) testing CPT® codes 87491, 87591, and 87661 to be part of a laboratory panel grouping. When two or more of single test laboratory procedure codes are reported on a claim by the same provider on the same date of service, the codes will be bundled into the comprehensive laboratory procedure code 87801. Anthem will reimburse the more comprehensive, multiple organism CPT code 87801 when two or more single tests are billed separately by the same provider on the same date of service. Reimbursement will be made based on a single unit of CPT code 87801 regardless of the units billed for a single code. The provider is required to bill for the applicable single STI CPT codes as rendered and the comprehensive CPT code will be reimbursed. Modifiers will not override this edit.
For more information about this policy, visit the Reimbursement Policy page at anthem.com.
To view this article online:Or scan this QR code with your phone CommercialSeptember 1, 2021 Updates for specialty pharmacy are available - September 2021Prior authorization updates
Effective for dates of service on and after December 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Access our Clinical Criteria information here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
* Non-oncology use is managed by the medical specialty drug review team. ** Oncology use is managed by AIM.
Quantity limit updates
Effective for dates of service on and after December 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Access our Clinical Criteria information here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).
* Non-oncology use is managed by the medical specialty drug review team. ** Oncology use is managed by AIM.
To view this article online:Or scan this QR code with your phone Medicare AdvantageSeptember 1, 2021 Prior authorization form notificationThe best way to ensure you're submitting everything needed for a prior authorization is to use the prior authorization/precertification form at anthem.com/medicareprovider > Providers > Provider Resources > Forms and Guides. By filling out the form completely and with as much information as possible, you can be sure we have the information to process your request timely.
To view this article online:Visit https://providernews.anthem.com/kentucky/articles/prior-authorization-form-notification-2-8600 Or scan this QR code with your phone Medicare AdvantageSeptember 1, 2021 Utilization management authorization rule operationsOn November 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) prior authorization (PA) requirements will change for L8702 covered by Anthem. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
PA requirements will be added for the following code:
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at anthem.com > Login or by accessing Availity.* Once logged in to availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Contracted and non-contracted providers who are unable to access Availity may call our Provider Services at the number on the back of your patients’ Anthem ID card for assistance with PA requirements.
* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.
To view this article online:Or scan this QR code with your phone Medicare AdvantageSeptember 1, 2021 Reimbursement Policy Update: DRG Inpatient Facility TransfersEffective November 30, 2021, Anthem Blue Cross and Blue Shield claims for members who leave against medical advice and are admitted to another acute care facility on the same day are considered transfers and will follow the criteria detailed in the policy.
For additional information, please review the DRG Inpatient Facility Transfers reimbursement policy at anthem.com/medicareprovider under the Facilities dropdown.
To view this article online:Or scan this QR code with your phone Medicare AdvantageSeptember 1, 2021 Keep up with Medicare news - September 2021Please continue to read news and updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:
To view this article online:Visit https://providernews.anthem.com/kentucky/articles/keep-up-with-medicare-news-september-2021-1-8597 Or scan this QR code with your phone MedicaidSeptember 1, 2021 Keep up with Medicaid news - September 2021Please continue to check Medicaid Provider Communications & Updates on the provider website for the latest information, including:
To view this article online:Visit https://providernews.anthem.com/kentucky/articles/keep-up-with-medicaid-news-september-2021-2-8595 Or scan this QR code with your phone | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||