 Provider News MaineJanuary 2020 Anthem Maine Provider NewsTo view the 2020 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), go to www.fepblue.org > select Benefit Plans > Brochure & Forms. You’ll find the Service Benefit Plan Brochure and Benefit Plan Summary information for year 2020. For questions please contact FEP Customer Service at 800-722-0203.
Connecting with Anthem and staying informed is easy, fast and convenient with our provider eUpdates. eUpdates feature short topic summaries on late breaking news that impacts providers such as:
- Website updates
- System changes
- Policy updates
- Claims and billing updates
- And more…..
Registration is fast and easy. There is no limit to the number of subscribers who can register for our eUpdates, so your facility or practice can submit as many email addresses as you like. Sign up today! Now is the time to ask all of your patients to present their current ID card. Many members were assigned new identification numbers effective January 1, 2020, and new ID cards were provided digitally or mailed to all affected members in late December 2019. To help ensure claims are processed appropriately, here is some helpful information.
Tips for success:
- When Anthem members arrive at your office or facility, ask to see their current member identification card at each visit. Many of our members no longer receive a paper card so they will present you with their digital card on their mobile device. Doing so will help you:
- Identify the member’s product
- Obtain health plan contact information
- Speed claims processing
Note: Claims submitted with an incorrect ID number may be unable to be processed and may be returned for correction and resubmission with the correct ID.
- When you contact a member about a claim returned for an invalid ID, and they do not recall receiving a new ID card or they misplaced their ID card, please ask the member to confirm their member ID using one of the following options:
- Log in to their member account on anthem.com
- Use our mobile app called Sydney (formerly Anthem Anywhere) to access their electronic ID card
- Fax or email their most current card from anthem.com or the mobile APP to your office if needed
- Call their member services number
Following the tips above will help to bring a successful start to your New Year.
The New Year always gives us an opportunity to set new goals. Starting in 2020, we want to help you check off a few “to do” items. As the Availity migration continues full speed ahead, let’s get you started on your first goals of the year:
Don’t delay - transition to Availity today!
All EDI transmissions currently sent or received today via the Anthem EDI Gateway are now available on the Availity EDI Gateway.
- 837 - Institutional and Professional
- 837 - Dental
- 835 - Electronic Remittance Advice
- 276/277 - Claim Status
- 270/271 - Eligibility Request
- 275 - Medical Attachments
Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:
- Migrate your direct connection with Anthem and become a direct submitter with Availity.
- Use your existing clearinghouse or billing company for your EDI transmissions. (Work with them to ensure connectivity to the Availity EDI Gateway).
- Use Direct Single Claim entry through the Availity Portal.
Availity setup is simple and at no cost for you!
Use this “Welcome” link to get started today.
Learn something new
Enroll in one of Availity’s free courses and training demos. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.
Follow these steps to register at www.Availity.com:
- Log in to the Availity Portal and select Help & Training | Get Trained to access the Availity Learning Center (ALC).
- Select Sessions from the menu under the search catalog field.
- Scroll Your Calendar to locate your webinar.
- Select View Course and then Enroll. The ALC will email you instructions to attend.
If you and your clearinghouse have already migrated, you are a step ahead! If not, take action today to make the transition.
For questions, contact Availity Client Services at 1-800-Availity (800-282-4548) for assistance Monday – Friday, 8:00 a.m. – 7:00 p.m.
We are launching the use of Availity’s medical attachment functionality to begin requesting medical records and itemized bill information from providers electronically instead of paper requests. This change applies only to the process of requesting and receiving medical records; it is not a change to the audit program. We began transitioning providers to this new process in an active limited launch in October 2019. We will complete the transition by February 10, 2020.
Important facts regarding this change:
- This change only affects providers who use Availity and who have opted into using the medical attachment functionality through the permissions in Availity’s enrollment center.
- The new functionality is for medical record requests for post pay claims for the Payment Integrity Quality Claims Review (provider audit) department only.
- There will be no duplicate requests (both paper and electronic).
- In Availity, the request will come into the provider’s Medical Attachment “inbox”:
- The original letter historically sent via paper is accessible through a hyperlink in the Availity system as a pdf electronic copy. The letter content is the same as it was in paper format.
- Each electronic request letter will have a timeframe for responding to the request. After the timeframe has passed for that letter, you will not be able to respond to that electronic letter. If you wish to upload medical records after the response time has expired, please refer to the Availity training referenced below.
- Providers can respond to the request by uploading records in Availity. The attachments are received in almost real time and are delivered electronically to the payer’s systems through secure means - - nothing is stored in Availity.
- The following are not included or not impacted:
- Vendor requests for medical records on behalf of the payer.
- Providers that do not use Availity or have not turned on permissions for Medical Attachments within Availity.
- The request timing or verbiage in the request letter.
- At this time, the Program Integrity Special Investigations Unit (SIU) post pay review, but they will be included at a future date.
Resources
Training is available in Availity located here Availity Training on Electronic Medical Records for Program Integrity.
Can I start using the functionality earlier?
Yes. If you chose to opt in earlier, please ensure you are configured within Availity. You may request early access via this email address: dl-Prod-Availity-Provider-Support@anthem.com.
For additional information, see the attached Frequently Asked Questions.
As we have been communicating in Provider News, we are now in the final stages of migration from the legacy medical attachments submission tool to the ‘Attachments-New’ option via Availity.
What is happening to the current attachment tool?
- The legacy medical attachments tool will be retired soon* with access via the Attachments-New option available now.
- The history of the information you have previously submitted is still available on the legacy tool at this time.*
- Read only access to the history is in the final stages.*
*Look for messaging on the legacy attachment tool for specific dates.
How to access/setup the solicited medical attachments tool for your office
Availity Administrators must complete these steps:
- From My Account Dashboard, select Enrollments Center > Medical Attachments Setup and complete the following sections:
- Select Application > choose Medical Attachments Registration
- Provider Management > Select Organization from the drop-down. Add NPIs and/or tax IDs.
- Assign user access by checking the box in front of the user’s name.
Submitting medical attachments
Once the above setup is completed, Availity Users will complete these steps:
- Log in to www.availity.com
- Select Claims and Payments > Attachments-New > Send Attachment Tab
- Complete all required fields of the form
- Attach supporting documentation
- Submit
Training
To access additional training for this Availity feature: Log in and select Help & Training > Get Trained to open the Availity Learning Center (ALC) Catalog in a new browser tab. Search the Catalog by keyword (attachments) to find training demo and on-demand courses. Select Enroll to enroll for a course and then go to your Dashboard to access it any time. Effective for dates of service on and after May 1, 2020, the updated clinical UM guideline, MCG ORG: W0163 Pelvic Organ Prolapse Repair, will now include the medical necessity review for pelvic organ prolapse repair surgery.
Initially, the clinical guideline only applied for pelvic organ prolapse length of stay review. With this update, the guideline will also address the preoperative and post-service medical necessity review of pelvic organ prolapse repair procedures. This change is effective for dates of service on and after May 1, 2020.
This clinical guideline does not apply to the Federal Employee Program® (FEP®), Medicare or Medicaid. Beginning with claims processed on and after April 26, 2020, we will be enhancing our outpatient facility edits for revenue codes, Current Procedural Terminology (CPT®) codes, Healthcare Common Procedure Coding System (HCPCS) and modifiers. Enhanced edits include appropriate use of various code combinations that 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, and HCPCS to modifier. These edits are based on national correct coding guidelines and principles.
The following coding resources are excellent resources to use for guidance: CPT codebook, HCPCS codebook, National Uniform Billing Committee (NUBC) and the Uniform Billing (UB) Editor codebook. Additionally, we will begin adoption of the National Correct Coding Initiatives (NCCI) for outpatient facilities to include industry-standard column one and column two procedure-to-procedure codes.
We communicated to you on May 1, 2019, that we were initiating post-payment reviews for professional ER claims billed with level 5 ER E/M codes 99285 and G0384. Our implementation of this policy has been postponed.
Note that this update relates only to the policy announced May 1, 2019. All other current policies applicable to you, including, but not limited to, other audit or reimbursement policies pertaining to ER claims are unaffected by this update. We will keep you informed about the initiation of the review process; however, as always, we require proper coding and billing to ensure prompt and accurate payment. Musculoskeletal care and interventional pain management (MSK) pose substantial challenges for employers as costs rise, the population ages and physician practice patterns vary widely. With disorders affecting one in every two American adults1, the need for evidence-based care and proactive consumer engagement is essential to better managing care and cost.
With that in mind, we are pleased to announce that select National Accounts will utilize the comprehensive Musculoskeletal and Pain Management Solution, administered by AIM Specialty Health. The new MSK program reviews certain spine and joint surgeries/procedures, and interventional pain services against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine.
Transition Period
To help ensure continuity of care, we will have a 90 day transition of care for members in active treatment for pain management or for members who have received prior approval through the Anthem precertification. Providers do not need to obtain authorization through AIM portal for services already in progress or where prior authorization has been obtained with Anthem.
Please contact anthem.com or call the number on the back of the member ID card for member eligibility.
Category: Medicare
The Group Retiree Medicare Advantage PPO plans for Anthem Blue Cross and Blue Shield (Anthem) members may include the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare and accepts the member’s PPO plan. These PPO plans also offer benefits that original Medicare doesn’t cover, including an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online and SilverSneakers.®
If you are already part of our Medicare Advantage PPO network, thank you. The attached FAQ will be helpful as you grow your practice and serve members who may be new to our Group Retiree PPO plans.
Out-of-network providers are paid Medicare allowable rates for covered services, less the members’ copayment, coinsurance and/or deductible. No contract is required.
With the National Access Plus benefit, the member’s cost share doesn’t change — whether local or nationwide; doctor or hospital; in- or out-of-network.
ATTACHMENTS (available on web): MA PPO FAQ.pdf (pdf - 0.4mb) Category: Medicare
In a communication dated June 1, 2019, we advised you that we were initiating post-payment reviews for professional emergency room (ER) claims billed with level 5 ER evaluation and management (E/M) codes 99285 and G0384. The implementation of this policy has been postponed.
Note that this update relates only to the policy announced on June 1, 2019. All other current policies applicable to you, including but not limited to other audit or reimbursement policies pertaining to ER claims, are unaffected by this update. We will keep you informed about the initiation of the review process; however, we require proper coding and billing to help ensure prompt and accurate payment.
Category: Medicare
Anthem offers the Healthcare Quality Patient Assessment Form (HQPAF)/Patient Assessment Form (PAF). This newsletter article focuses on key tips that may help participating providers successfully close out their 2019 HQPAF/PAF.
Dates and tips to remember:
We encourage you to review your patient population as soon as possible. You can help patients schedule an in-office visit. These appointments help the patient manage chronic conditions, which impact the health status of the patient.
At the conclusion of each office visit with the patient, providers who are participating in the HQPAF/PAF program are asked to complete and return a HQPAF/PAF. The form should be completed based on information collected during the visit. Participating providers may continue to use the 2019 version of the HQPAF/PAF for encounters taking place on or before December 31, 2019. We will accept the 2019 version of the HQPAF/PAF for 2019 encounters until midnight on January 31, 2020. Important note: HQPAF/PAF for 2019 dates of service that are rejected due to provider error and corrected by the provider may be submitted through March 31, 2020.
If not already submitted, participating providers are required to submit an Account Setup Form (ASF), W9 and a completed direct deposit enrollment by March 31, 2020. Participating providers should call 877-751-9207 for questions regarding this requirement. Failure by a participating provider to comply with this requirement will result in forfeiture of the provider payment for submitted 2019 HQPAF/PAF program, if applicable.
If you have any questions about the PAF or HQPAF programs, please call 877‑751‑9207 from 9:30 a.m. to 7:30 p.m., Monday - Friday.
Category: Medicare
Claims will deny when a provider submits a Medicare claim to Anthem as a secondary payer if the claim has been received prior to the 30-day Medicare remittance period. Providers submitting a paper claim for Medicare claims that are filed with Medicare as the first payer must not file with Anthem as the secondary payer until the 30-day remittance period has expired.
These claims rejections are a result of improper timely filing by providers. To eliminate claims rejections when Anthem is the secondary payer, submit the claim 30 days after the Medicare Remittance period.
For additional information, call the number on the back of the member’s ID card.
Category; Medicare
Many of our members have reported that they received unsolicited calls (or emails) from an individual or company offering to provide durable equipment devices, such as back or leg braces, or items such as topical creams at little or no cost. While it may be tempting to want to receive something for free, members should know that there is a cost.
Although our members may not receive a bill for these devices or medications, the items are billed to the insurance companies, costing hundreds or even thousands of dollars each.
How does this impact members?
Members should also know that the cost may be more than monetary. Allergic reactions may occur when using medications that are not properly prescribed. Ill-fitting leg or back braces, or equipment that is not specifically intended for the pain experienced by the member, could do more harm than good.
This problem is prevalent throughout the country, so all of our members should be aware. Billions of unsolicited telemarketing calls are made each year, many of which are promoting health care services. Calls often spoof local phone numbers or numbers that appear familiar to trick the recipient into accepting the call.
How can you help protect your patients?
While the ultimate purpose of these telemarketing calls is to sell these items, the immediate goal of the person or company placing the call is to obtain valuable personally identifiable information (PII) from the member. Without this personal information, such as a social security number or insurance identification number, selling these devices and medications is much more difficult. Share this information with you patients to help them learn how to protect their PII.
You can help protect your patients and their personally identifiable information from scams by reminding them of the following:
- Don’t fall prey to scams!
- Take a few moments to review your Explanation of Benefits (EOB) and the services listed.
When receiving robotic (robo) or telemarketing calls:
- Simply hang up the phone.
- Beware of threatening or urgent language used by the caller.
- Do not provide any personally identifiable information such as your social security number or insurance identification number. The caller may imply that they have your information and ask you to provide it to confirm that they have the correct information. Do not provide the information or confirm it if they do happen to have any identification information.
When receiving emails:
- Do not open email attachments you weren’t expecting.
- Check for spelling mistakes and poor grammar.
- Do not click on the links you are sent. You can type the link into a new browser.
- Online scams can come from anywhere. Take a few moments to review your EOB and confirm that you received the services listed on the EOB.
Additional ways to protect yourself:
- Shred or destroy obsolete documents that contain medical claims information or EOBs.
- Do not use social media to share medical treatment information.
How to report when you receive what you suspect is a scam call or email:
Members may contact their plan’s Member Services department.
Category: Medicare
On September 19, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Medicare Advantage Clinical Criteria Web Posting September 2019. Visit Clinical Criteria to search for specific policies.
For questions or additional information, use this email.
Category: Medicare
On August 16, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2019. Visit Clinical Criteria to search for specific policies.
For questions or additional information, use this email.
Category: Medicare
On January 1, 2020, we will implement a preferred edit on Medicare-eligible continuous glucose monitors (CGMs). Currently, there are two CGM systems covered by CMS under the Medicare Advantage Part D (MAPD) benefit; these are Dexcom and Freestyle Libre. The preferred CGM for Medicare Advantage Part D individual members covered by Anthem will be Freestyle Libre. This edit will only affect members who are newly receiving a CGM system. Members will need to obtain their CGM system from a retail or mail order pharmacy – not a durable medical equipment (DME) facility. For Dexcom coverage requests, call 833-293-0661.
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