Starting mid-September, search for patient information in Availity Essentials* Eligibility and Benefits without having a member ID. We’ve updated and streamlined the process to eliminate the need for the member ID while maintaining the highest HIPAA standards. Easily search for patient eligibility and benefits details using the Patient Search option of patient last name, patient first name, date of birth, and patient zip code.

Find Eligibility and Benefits Inquiry on Availity’s top menu bar under Patient Registration. Once it becomes available, make sure to use the new search feature when you need to find member information and do not have access to the member ID.

Need the member ID for another capability in Availity Essentials? When you use the new search option in Eligibility and Benefits Inquiry and see the eligibility and benefits details, the member’s current ID details will be available and allow you to transact within other digital capabilities where the member ID is required. 

Watch for more information on the Availity Essentials home page under News and Announcements to notify you when this feature is available. 

Get access to Availity Essentials now

If you and your organization aren’t currently registered for Availity Essentials, now is the time to make that happen. Availity Essentials offers secure online access for working together and is free to our providers. To register, visit the availity.com Registration Information page.

Digital Request for Additional Information (Digital RFAI) is the fastest and easiest way to get us the documents we need to process your claim. Now, it is even better! We’ve added filter, sort, and search features for greater productivity. 

New filtering functions are ideal for organizations where more than one person is responsible for submitting claim attachments. Another great feature: your filters are saved (locked) – so you can see your desired filter view each time you log on but easily clear them when your search criteria changes. 

We are committed to shared success and reporting is just another way we are giving Digital RFAI users a productivity boost. We’ve added reporting fields that can be used for both History and Inbox reports.

Fields available for History and Inbox reports

Expanded reporting fields are downloadable! Use the download option to meet your specific reporting requirements.

We’re here to help! 

Want to know more about receiving digital notifications for faster claims processing? Visit the Digital RFAI learning microsite or reach out to your Provider Relations Account Manager.

Description/Approach 

Provider performance can vary widely in relation to efficiency and quality. Our goal as your Medicare health plan partner is to ensure our members receive high-quality care that leads to improved member health outcomes across a wide range of variables. 

We will add a new sorting option on the Find Care tool for members to leverage when they are searching for a non-PCP specialist provider. This sorting option, called Personalized Match Phase 1, is based on each provider’s score relative to their peers in the patient’s preferred mileage search radius. Providers will be listed in order of their total score, though no individual scores will appear within the tool or be visible to the covered patients. The Personalized Match Phase 1 algorithm will be based on quality and efficiency criteria to assist members in making more informed choices about their medical care. Other sorting options will still be available on Find Care for our members. Members should consider a variety of factors when making decisions for choosing a specialist provider to manage their care. 

We evaluate provider groups and individual providers annually, using updated quality and efficiency methodologies and data.

Continue reading the rest of this article

We understand that providing the information needed to process a claim can cause payment delays, and the manual methods associated with mailing letters and returning information non-digitally is costly and inefficient.

We’re changing that by implementing a new process: Digital Request for Additional Information (Digital RFAI), and we’re inviting you to participate.

Digital requests for additional information are 50% faster than returning documentation any other way — making it the most efficient way to receive and return information — resulting in faster claim payments. 

Participation in Digital RFAI is easy

1. Registration:
   • Your organization’s Availity* administrator will register for Medical Attachments:
     • This enables you to receive digital notices (instead of paper) and to attach the requested documents directly to your claim.
     • Ensure all of your billing NPIs/TINs are registered.
2. User roles:
   • Your Availity administrator will also update or add new users with these specific role assignments through Availity Essentials:
     • Claims Status
     • Medical Attachments
   • This enables the users to view the Availity Attachment Dashboard.
3. Ready to go:
   • After the registration and user roles are completed on Availity, the Digital RFAI process is ready to go. 
   • Requests will automatically appear on the Attachments Dashboard each morning (when documents are needed).

Additional support

You, your organization’s Availity administrator, or other members of your team may need additional support – and we’re to help:

• For Availity Administrators: Take this training to ensure your NPIs are registered properly. 
• For those sending attachments: Take this user training to learn about accessing notifications, sorting and filtering, and other enhancements that improve your experience. 

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partner. For additional resources, visit the Digital RFAI webpage or contact your Provider Relations Account Manager. 

As we communicated in July, we will use the Provider Data Management (PDM) application on Availity Essentials* to verify and initiate care provider demographic change requests for all professional and facility care providers.** Going forward, Availity PDM is now the intake application for care providers to submit demographic change requests, including submitting roster uploads. Availity PDM will replace all current intake channels for demographic change requests and roster submissions as of October 1, 2023. If preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups.

Take action now

Don’t wait until October to start using the PDM application. Start using it today to take advantage of the benefits of this application and familiarize yourself with the process before the legacy intake channels retire. 

What features does the Availity PDM application provide?

It allows you to:

• Update provider demographic information for all assigned payers in one location.
• Attest and manage current provider demographic information.
• Review the history of previously verified data.

Benefits to our care providers using Availity PDM

The Availity PDM application will ensure the following:

• Consistently updated data
• Decreased turnaround time for updates 
• Compliance with federal and/or state mandates
• Improved data quality through standardization
• Increased provider directory accuracy
• Choice and flexibility to request data updates via the standard PDM experience or by submitting a spreadsheet via a roster upload

Want to submit a roster using Availity PDM?

Don’t wait — Start submitting today. Roster Automation is our new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation today:***

1. Utilize the Roster Automation Standard Template:
   • For your convenience, there is a standard roster Excel document. Find it online here.
2. Follow the Roster Automation Rules of Engagement:
   • A reference document, Roster Automation Rules of Engagement, is available to ensure error-free submissions, driving accurate and more timely updates through automation. More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide). Find it online here.
3. Upload your completed roster via the Availity PDM application.
4. Join our live webinar:
   • Title of webinar: Roster Automation Template and Rules of Engagement Training
   • Date: Monday, August 21, 2023
   • Time: 4 to 5 p.m. ET
   • Registration link: here

What about the previous methods by which I have been submitting information?

While we are in the process of sunsetting our legacy intake channels, we will continue to process submissions received through current intake channels until September 30, 2023. Effective October 1, 2023, all PDM requests, including rosters, must be submitted via Availity PDM. As of this date, all provider demographic change requests, including rosters, will be rejected if submitted through any format/channel other than Availity PDM. Again, if preferred, providers may continue to utilize the Provider Enrollment application in Availity to submit requests to add new practitioners under existing groups.

How to access the Availity PDM application

Log onto availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts.  

 Availity administrators will automatically be granted access to PDM. Additional staff may be given access to Provider Data Management by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

Training is available:

• Learn about and attend one of our training opportunities by visiting here.
• View the Availity PDM quick start guide 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 the digital applications. Start by logging into availity.com and selecting the Register icon at the top of the home screen, or you can use this link to access the registration page. 

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

Note: For national providers who provide services in multiple markets, California (all lines of business), Colorado (Commercial and Medicare), and Nevada (all lines of business) are not available for Availity PDM until our Strategic Provider System migration.  

** Exclusions:

• Behavioral health providers assigned to Carelon Behavioral Health, Inc.* will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health. 
• Any specific state mandates or requirements for provider demographic updates.

*** If any roster data updates require credentialing, your submission will be routed appropriately for further action.

The following Anthem Blue Cross and Blue Shield (Anthem) medical policies and clinical guidelines were reviewed on November 10, 2022, for Indiana, Kentucky, Missouri, Ohio, and Wisconsin.

To view medical policies and utilization management guidelines, go to anthem.com > Select Providers > Select your state > Under Provider Resources, select Policies, Guidelines & Manuals. 

To help determine if prior authorization is needed for Anthem members, go to anthem.com > Select Providers > Select your state > Under Claims, select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card. 

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program^® [FEP]), please visit fepblue.org > Policies & Guidelines.  

Below are the current clinical guidelines and/or medical policies we reviewed and updates that were approved.

* Denotes prior authorization required

The following Anthem Blue Cross and Blue Shield (Anthem) Medical Polices and Clinical Utilization Management Guidelines were reviewed on July 31, 2023, for Indiana, Kentucky, Missouri, Ohio, and Wisconsin.

To view Medical Policies and Clinical Utilization Management Guidelines, go to anthem.com > select Providers > select your state > under Provider Resources > select Policies, Guidelines & Manuals.

To help determine if prior authorization is needed for Anthem members, go to anthem.com > select Providers > select your state > under Claims > select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card. 

To view Medical Polices and Clinical Utilization Management Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program^® FEP^®), please visit fepblue.org > Policies & Guidelines.

Below are the new Medical Policies and/or Clinical Utilization Management Guidelines that have been approved.

* Denotes prior authorization required.

The following Anthem Blue Cross and Blue Shield (Anthem) Medical Polices and Clinical Utilization Management Guidelines were reviewed on May 11, 2023, for Indiana, Kentucky, Missouri, Ohio, and Wisconsin.

To view Medical Policies and Clinical Utilization Management Guidelines, go to anthem.com > select Providers > select your state > under Provider Resources > select Policies, Guidelines & Manuals. 

To help determine if prior authorization is needed for Anthem members, go to anthem.com > select Providers > select your state > under Claims > select Prior Authorization. You can also call the prior authorization phone number on the back of the member’s ID card. 

To view Medical Polices and Clinical Utilization Management Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program^® FEP^®), please visit fepblue.org > Policies & Guidelines. 

Below are the new Medical Policies and/or Clinical Utilization Management Guidelines that have been approved.

* Denotes prior authorization required.

Below are the current Medical Policies and/or Clinical Utilization Management Guidelines we reviewed and updates that were approved.

* Denotes prior authorization required.

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization.

Our Medical Policies and UM criteria are online at https://tinyurl.com/2h2r6esf, or you can request a free copy of our UM criteria from our Medical Management department by calling 855-661-2027. Within seven calendar days of the date of denial, providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at 855-661-2027.

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

You can submit precertification requests by:

• Calling us at 855-661-2028.
• Faxing to 800-964-3627.
• Submitting online via Availity Essentials* at Availity.com.

Have questions about utilization decisions or the UM process?

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

Effective October 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield Medicaid for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions), take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims. 

Prior authorization requirements will be added for the following code(s):

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

• Web: Once logged in to Availity Essentials* at Availity.com 
• Fax: 800-964-3627
• Phone: 855-661-2028

Not all PA requirements are listed here. Detailed PA requirements are available to providers at providers.anthem.com/kentucky-provider/communications/news-and-announcements on the Resources tab or, for contracted providers, by accessing Availity.com. Providers may also call Provider Services at 855-661-2028 for assistance with PA requirements.

Effective for dates of service on and after December 1, 2023, the following code will require prior authorization through Carelon Medical Benefits Management, Inc.* (formerly AIM Specialty Health_®).

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon in one of the following ways:

• Access Carelon’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.
• Access Carelon via the Availity Essentials* website at availity.com.

Note: This update does not apply to the Federal Employee Program^®.

If you have any questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective December 1, 2023, prior authorization (PA) requirements will change for the following code(s).  The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield for Medicare members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com.* Providers may also call the number on the back of the member’s ID card for assistance with PA requirements.

Beginning with dates of service on or after December 1, 2023, Anthem Blue Cross and Blue Shield will expand the current Documentation Standards for Episodes of Care — Professional reimbursement policy to apply to facility providers. This policy outlines how and what elements must be documented for an episode of care.

The policy will be retitled Documentation Standards for Episodes of Care — Professional and Facility.  

Effective as of June 14, 2023, Anthem Blue Cross and Blue Shield updated the Documentation and Reporting Guidelines for Evaluation and Management (E/M) Services reimbursement policy to include the 2021 American Medical Association (AMA) CPT^® Level of Medical Decision Making (MDM) table to align with the 2021-2023 Centers for Medicare & Medicaid Services (CMS) and AMA-CPT code changes. This table will be listed under the policy section titled Selecting a Level of Medical Decision Making for Coding an E/M Service. When determining the level of E/M service using MDM, this table will be used instead of the 1995/1997 CMS risk tables and the Marshfield Clinic tables.

Additional updates to this reimbursement policy are as follows:

• Documentation submitted in accordance with this reimbursement policy will remain subject to signature and other requirements as stated in the related Documentation for Episodes of Care reimbursement policy. Therefore, the policy was updated to include the following note: All documents are subject to the Documentation Requirements for Episodes of Care policy.
• The Related Coding section was expanded to include “other” E/M services, as defined in the policy.

For specific policy details, visit the corresponding reimbursement policy page from the list below:

• Colorado
• Connecticut
• Georgia
• Indiana
• Kentucky
• Maine
• Missouri
• Nevada
• New Hampshire
• Ohio
• Wisconsin

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

Beginning with dates of service on or after December 1, 2023, Anthem Blue Cross and Blue Shield (Anthem) will update the Place of Service – Facility reimbursement policy to include professional services billed under revenue codes 960-983 expanded to 960-989. According to the policy, Evaluation & Management (E/M) services and other professional services:

• Must be billed on a CMS-1500 claim form; and
• Are not reimbursable if billed on a UB-04 claim form (excluding E/M services rendered in an emergency room and billed with emergency room revenue codes).

The policy will be retitled Facility Guidelines for Claims related to Professional Services – Facility.

In the July 2023 edition of Provider News, reimbursement policy page we announced multiple updates to the Prolonged Services – Professional reimbursement policy Kentucky effective October 1, 2023.  To clarify, the update to “remove language requiring providers to report start and stop times for reimbursement eligibility” was effective as of May 19, 2023.

Effective June 14, 2023, Anthem Blue Cross and Blue Shield’s split care surgical modifier language was removed from the Global Surgical Package — Professional reimbursement policy and added to a new standalone reimbursement policy titled Split Care Surgical Modifiers — Professional. This policy allows reimbursement based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure. The percentage is determined by the modifier that is appended to the procedure code. The Related Coding section of the policy identifies the applicable modifiers and standard reimbursement percentages.

For specific policy details, visit the reimbursement policy page at anthem.com.

Policy Update

Robotic Assisted Surgery

(Policy G-10004, effective 01/01/2024)

Beginning with dates of service on or after December 1, 2023, Robotic Assisted Surgery reimbursement policy for Anthem Blue Cross and Blue Shield Medicaid will expand to include CPT^® codes for computer-assisted surgical systems.

This policy does not allow separate reimbursement for technology assisted services detailed in the Related Coding section. These services are considered integral to the primary surgical procedure, are included in the primary surgical procedure, and are not separately reimbursed.

The Related Coding section of the policy has been updated to include the following computer assisted surgical musculoskeletal navigation procedures:

• 0054T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (list separately in addition to code for primary procedure)
• 0055T: Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (list separately in addition to code for primary procedure)

The policy has been renamed to Technology Assisted Surgical Procedures which defines both robotic assisted and computer assisted techniques.

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Anthem's Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.^*, a separate company.  

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a not otherwise classified (NOC) code. 

Prior authorization updates

Effective for dates of service on and after December 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process. 

Access our Clinical Criteria to view the complete information for these site of prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Quantity limit updates

Effective for dates of service on and after December 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

Effective April 5, 2023, Sublocade^® can no longer be filled at Accredo Specialty Pharmacy.* Members currently filling through Accredo Specialty Pharmacy will need to switch to CVS Specialty Pharmacy.*   A member of the CVS Specialty Pharmacy Care team will be contacting prescribers to obtain a new prescription. Prescribers can contact CVS Specialty Pharmacy at 877-254-0015.

The following Part B medications from the current Clinical Criteria Guidelines are included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below. 

There are no clinical changes to Clinical Criteria CC-005, Hyaluronan Injections. Based on feedback, the table listing the preferred and non-preferred products has been updated to present the information in a more useful manner. The updated table identifies preferred alternatives based on injection series. 

Clinical Criteria Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

**This collateral ran originally in the July 1, 2023, newsletter and was also posted on the provider portal with an October 1, 2023, effective date. The new date of service will begin on November 1, 2023.** 

Effective for dates of service on and after November 1, 2023, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.  

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.