You no longer need to pick up the phone or head to the fax machine to check the status of an authorization request or update a case. We have added new features to Interactive Care Reviewer (ICR), our online medical and behavioral health authorization tool to improve your digital self-service experience.

• Do you need to update a case that was submitted by phone or fax? Now you can add clinical notes and make other updates to these authorization requests through ICR. To make the update you need to have the Authorization & Referral Request role assigned to you by your Availity Administrator.
  • To locate the case, log on to the Availity Portal and select Patient Registration, Authorizations & Referrals, then choose Auth/Referral Inquiry.
  • Search for the case in ICR by Member, Reference/Authorization Request Number, or by Date Range.
  • From the ICR Case Overview screen select Update Case to update service codes, provider information or clinical notes. If you only need to make changes or add to your notes, select Update Clinical. Select Submit Update to complete the request.
• We’ve removed the guesswork from the notes that are recommended for many standard authorization requests. ICR provides a checklist of the supporting clinical information that will assist us with completing the review. The list is located on the Clinical Details You can upload notes, images and photos directly through ICR. You can include the documentation immediately or you can submit your request then return to the case in ICR later and select Update Clinical to add the missing information.
• Check the status of a submitted case at a glance. The ICR UM tracker, located on the Case Overview screen provides a quick view of where the case is in the review process. You can view when we received the request, when the clinical review is underway and when we completed the final decision.

Additionally, we’ve added a new application to Payer Spaces – Chat with Payer that you can use to check the status of a submitted authorization request. This is a great option if you don’t have the role assignments required to access ICR and research a case. 

To access the Chat with Payer application from Availity’s home page, select Payer Spaces | Chat with Payer.  Complete the form with the required information. You need to include the patient name, birth date and health plan member ID number. Choose Authorization Status as your topic for chat to conduct a live chat with a representative. 

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Introducing self-service claim denial review on our secure provider portal

Anthem wants to make your job easier — and that includes real-time feedback to claim denials. Through predictive analytics, we now have insight into the reasons for claim denial. We have taken that information and streamlined the inquiries by reason codes, and have made that information available to you digitally, through our secure provider portal.

Within minutes, you will know why a claim denied. We will also provide the steps needed so you can take action faster to correct the claim. There is less wait time and faster payment.

There is no need to call for updates or experience unnecessary delays waiting for the explanation of benefit.

With little more than a click:

• Review a complete list of claims, including claims with proactive insights
• Learn the reasons for claim denial
• Access the information you need to move the claim forward

Predictive analytics and self-service claim denial information is just another way we are using digital technology to improve your health care experience.

From anthem.com, use the Log In button to access our secure provider portal Availity.com. Go to Payer Spaces to access Claims Status Listing.

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Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:

• File claims
• Check statuses
• Verify eligibility and benefits
• Submit prior authorizations

The Provider Digital Engagement Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits - all in one comprehensive resource. Find it on anthem.com > Providers > Forms & Guides > Digital Tools.

Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit anthem.com and use the Log In button for access to our secure provider portal, or via the Availity EDI website.

Accept digital member ID cards

• Save time by accepting the digital member ID card when presented by the member via their App or email.

Register for EFT to get funds faster

• Electronic funds transfer (EFT) eliminate the need for paper checks. Safe, secure and faster, payments are deposited directly to your bank account. Register here.

Eliminate paper remittances

• Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.

We appreciate your health care team going digital with Anthem as of January 1, 2021, enabling us to realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.

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We recognize all coding changes from both the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) effective the date provided by the coding source. This includes the Evaluation and Management (E/M) changes effective January 1, 2021. 

The following updates pertaining to Evaluation and Management services have been identified:

• CPT code 99201 (new patient E/M) will be a deleted code.
• CPT codes 99202 through 99215 (new/established E/M) definitions have changed. Selection of these E/M codes can now be based on either medical decision making or time.
• CPT code 99417 (prolonged services) and HCPCS code G2212 (prolonged services) will be recognized as billable codes. These codes will be payable based on our existing Prolonged Services policy, which will be updated to reflect the new code along with the modifications to existing prolonged service codes CPT codes 99354 and 99355.
• HCPCS code G2211 (complexity inherent to evaluation and management associated with primary medical care) will not be separately reimbursed for this service. We will be updating our Bundled Services and Supplies policy to reflect this position. 

Additionally, we are in the process of updating reimbursement policies impacted by the E/M service changes such as the Documentation and Reporting Guidelines for Evaluation and Management Services. 

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As a reminder, we will update our claim editing software monthly for professional services throughout 2021 with the majority of maintenance updates occurring quarterly in February, May, August and November. These updates will:

• reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
• include updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
• include assistant surgeon eligibility in accordance with the policy
• include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
• apply to any provider, provider group (tax identification number) and/or across providers and claim type (professional/facility) for the same member

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As a reminder, we will update our claim editing software monthly for outpatient facility services throughout 2021 with the majority of maintenance updates occurring quarterly. These updates will:

• reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers, revenue codes) and their associated edits
• include appropriate use of various code combinations, which can include, but are not limited to, procedure code to revenue code, HCPCS to revenue code, type of bill to procedure code, type of bill to HCPCS code, procedure code to modifier, and HCPCS to modifier
• include updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• include updates to reflect coding requirements as designated by industry standard sources such as The National Uniform Billing Committee (NUBC)

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Beginning with dates of service on or after January 1, 2021, we will be implementing revised claims editing logic tied to Excludes1 notes from ICD-10-CM 2020 coding guidelines. To help ensure the accurate processing of claims, use ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for member encounters. Please remember to code to the highest level of specificity. For example, if there is an indication at the Category level that a code can be billed with another range of codes, it is imperative to look for Excludes1 notes that may prohibit billing a specific code combination. w q

Visit this site for assistance in determining proper coding guidance.

One of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes1 notes. An Excludes1 note indicates that the excluded code identified in the note should not be billed with the code or code range listed above the Excludes1 note. These notes appear below the affected codes – if the note appears under the category (first three characters of a code), it applies to the entire series of codes within that category.  If the Excludes1 note appears beneath a specific code (3, 4, 5, 6 or 7 characters in length) then it applies only to that specific code. 

In ICD-10-CM, when a category includes an Excludes1 note, it outlines what codes should NOT be billed together.  Examples of this code scenario would include but are not limited to the following:

• Reporting Z01.419 with Z12.4
  • Z01.41X (encounter GYN exam w/out abnormal findings) has an Excludes1 note below it that includes Z12.4 (encounter for screening malignant neoplasm cervix)
• Reporting Z79.891 with F11.2X
  • Z79.891 (long-term use of opiates) has an Excludes1 note below it for F11.2X (opioid dependence)
• Reporting M54.2 with M50.XX
  • M54.2 (cervicalgia) has an Excludes1 note below it for M50.XX (cervicalgia due to intervertebral disc disorder)
• Reporting M54.5 with S39.012X and/or M54.4X
  • M54.5 (low back pain) has an Excludes1 note below it which includes: S93.012X (strain of muscle, fascia and tendon of lower back), M54.4X (low back pain) M51.2X (lumbago due to intervertebral disc disorder)
• Reporting J03.XX with J02.XX, J35.1, J36, J02.9
  • J03.- (acute tonsillitis) has an Excludes1 note below it which includes: J02.- (acute sore throat), J35.1 (hypertrophy of tonsils), J36 (peritonsillar abscess)
• Reporting N89 with R87.62X, D07.2, R87.623, N76.XX, N95.2, A59.00
  • N89 (other inflammatory disorders of the vagina) has an Excludes1 note below the category for: R87.62X (abnormal results from vaginal cytological exam), D07.2 (vaginal intraepithelial neoplasia), R87.623 (HGSIL of vagina), N76.XX inflammation of the vagina), N95.2 (senile [atrophic] vaginitis), A59.00 (trichomonal leukorrhea)

Finally, if you believe an Excludes1 note denial is incorrect, please consult the ICD-10-CM codebook to verify appropriate use of the billed codes and provide supporting documentation through the normal dispute process as to why the billed diagnoses codes are appropriately used together.

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Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a standardized survey conducted between February and May each year to assess consumers’ experience with their provider and health plan. A random sample of your adult and child patients may receive the survey. Over half of the questions used for scoring are directly impacted by providers. The survey questions are:

• When you needed care right way, how often did you get it?
• How often did you get an appointment for a check-up or routine care as soon as you needed?
• How often was it easy to get the care, tests, or treatment you needed?
• How often did you get an appointment to see a specialist as soon as you needed?
• How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
• How would you rate your personal doctor?
• How would you rate the specialist you see most often?

To learn more about how you can improve the patient experience review What Matters Most: Improving the Patient Experience, an online course for providers and office staff. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. The What Matters Most training can be accessed at www.patientexptraining.com.

Your efforts to create an exceptional care experience for your patients will help to strengthen their healthcare journey.   

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You’re invited!

In this 60-minute webinar, you will learn how to use Availity's Attachment tools to submit and track supporting documentation electronically to Anthem and affiliate payers.

We will explore new key workflow options to fit your organization’s needs, including how to:

• Work a request in the inbox of your Attachments Dashboard
• Enter and submit a web claim including supporting documentation
• Use EDI batch options to trigger a request in your inbox
• Track attachments you submitted using sent and history lists in your Attachments Dashboard
• Get set up to use these tools

As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.

Register for an upcoming webinar session:

1. In the Availity Portal, select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options:
   • In the Catalog, search by webinar title or keyword.
     • To find this specific live session quickly, use keyword
   • Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you’ll receive emails with instructions to join the session.

Webinar Dates and Times:

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Effective April 1, 2021, the following new customizations will be implemented:

• Gastrointestinal bleeding, upper (W0170, previously ORG M-180) – Customized the clinical indications for admission to inpatient care by revising the hemoglobin; systolic blood pressure; pulse; melena; orthostatic hypotension; and BUN criteria.
• Gastrointestinal bleeding, upper observation care (W0171, previously OCG OC-021) – Customized the clinical indications for observation care by revising the systolic blood pressure and hemoglobin criteria and adding melena or hematochezia and suspected history of bleeding.

To view a detailed summary of customizations, visit our website, scroll down to other criteria section and select Customizations to MCG Care Guidelines 24^th Edition.

For questions, please contact the provider service number on the back of the member's ID card.

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On August 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved clinical criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield and AMH Health, LLC (AMH Health). These policies were developed, revised or reviewed to support clinical coding edits.

The clinical criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2020 (Anthem) and the Clinical Criteria Web Posting August 2020 (AMH Health).Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

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The Medicare Risk Adjustment Regulatory Compliance team at Anthem offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

Medicare risk adjustment and documentation guidance (general):

• Series: Offered the first Wednesday of each month from 1:00 to 2:00 P.M.*
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity, Medicare risk adjustment and documentation guidance, from
  January 8, 2020 to December 2, 2020, has been reviewed and is acceptable for up to 1.00 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

To learn how providers play a critical role in facilitating the risk adjustment process, register here for one of the monthly training sessions.

* Note: Dates may be modified due to holiday scheduling.

Medicare risk adjustment, documentation and coding guidance (condition specific)

• Series: Offered the third Wednesday of each month from 1:00 to 2:00 P.M.
• Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
• Credits: This live series activity, Medicare risk adjustment documentation and coding guidance, from January 15, 2020 to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

For those interested in the following training topics, please register here.  

* Note: Enter the password provided, and the recording will play upon registration.

• Red flag HCCs
• Neoplasms
• Acute, chronic and status conditions
• Diabetes mellitus and other metabolic disorders
• Coinciding conditions in risk adjustment models

Please note that the original training events have been modified due to a transition within WebEx as of
August 1, 2020. The date and time of the events have not changed but the program link and invitation detail have been updated. Previously registered participants will need to re-register for a training event using the updated registration link(s) provided in this announcement.

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Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

• Medicare Advantage Group Retiree Quick Reference Guide and FAQ
• Policy Update — Emergency Department: Leveling of Evaluation and Management Services
• SNF admission reporting requirements for Anthem D-SNP plans
• SNF admission reporting requirements for AMH Health, LLC. D-SNP plans
• Anthem Policy Update — Nurse Practitioner and Physician Assistant Services, Professional
• AMH Health, LLC. Policy Update — Nurse Practitioner and Physician Assistant Services, Professional