Beginning July 1, 2020, most of Anthem’s ACA-compliant, non-grandfathered health plans will cover pre-exposure prophylaxis (PrEP) medication at 100% with no member cost share, when used for prevention of HIV and dispensed at an in-network pharmacy with a prescription. 

Since medications used for PrEP can also be used to treat HIV, we will review medical and pharmacy claims data to determine if a member has been diagnosed and prescribed treatment for HIV or prescribed PrEP for preventive purposes. When prescribed for prevention of HIV, this drug is covered with no member cost share. When prescribed for treatment of HIV, member cost shares apply based on the member’s benefit plan. Coverage includes Truvada (200-300 mg), and its generic components, Emtriva 200 mg and tenofovir 300 mg. When medically necessary, a prior authorization process is available for Descovy to be covered with no member cost share when used for prevention of HIV.

Providers can contact the provider service number on the back of the member ID card to determine if a member’s plan includes this benefit.

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As a provider, we understand you are committed to providing the best care for our members, which now involves telehealth visits. Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions. As we reported in the May and June newsletters, we are completing our prospective and retrospective reviews for 2020 for Anthem’s Commercial Risk Adjustment (CRA) program. The retrospective program focuses on medical chart collection. The prospective program focuses on member health assessments for patients with undocumented hierarchical condition categories (HCCs), in order to help close patients’ gaps in care.

What’s in it for you?

• First, monthly you will receive a list of your patients who are Anthem members enrolled in Affordable Care Act (ACA) compliant coverage who may have gaps in care to help you reach out to them, so they can come in for office visits earlier.

• Second, we’ve heard resoundingly from providers that participation in these programs helps them better evaluate their patients and, as a result, perform more strongly in population health management and gain sharing programs. Many cite that they ask different questions today that allow them to better manage their patients end to end.

• Finally, when you see Anthem ACA members and submit health assessments, we pay incentives of $50 for a paper submission and $100 for an electronic submission. For additional details on how to earn these incentives and the options available, please contact the CRA Network Education Representative listed below.

What’s in it for your patients?

We are completing monthly postcard campaigns to members with ACA-compliant coverage when we suspect a high-risk condition with messaging to encourage the member to call his or her primary care provider (PCP) and schedule an annual checkup. The goal is to get members to have a visit with their PCPs so the PCPs have an overall picture of their patients’ health and schedule any screenings that may be needed. Telehealth visits have become very flexible formats for patients and doctors to meet, so we encourage telehealth visits to be scheduled if that is what the patient is most comfortable with at this time.

We will continue these monthly postcard mailings throughout the remainder of 2020 to encourage the members to schedule an annual checkup, which supplements any patient outreach you may be doing.

If you have any questions regarding our reporting processes, please contact Alicia Estrada, the CRA Network Education Representative at Alicia.Estrada@anthem.com.

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Effective July 1, 2020, we will begin using the new acute viral illness guidelines that have been added to the 24th edition of MCG. Based on the presenting symptoms or required interventions driving the need for treatment or hospitalization, these guidelines are not a substantive or material change to existing MCG guidelines we use now, such as systemic or infectious condition, pulmonary disease, or adult or pediatric pneumonia guidelines.

Inpatient and Surgical Care (ISC)

• Viral Illness, Acute – Inpatient Adult (M-280)
• Viral Illness, Acute – Inpatient Pediatric (P-280)
• Viral Illness, Acute – Observation Care (OC-064)

Recovery Facility Care (RFC)

• Viral Illness, Acute – Recovery Facility Care (M-5280)

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

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The Custom Learning Center in the Availity portal offers an array of learning opportunities where you can access required training, recommended/elective trainings and view additional learning resources. Access to the Custom Learning Center is via ‘Payer Spaces’ in the Availity Portal. 

Highlights of the Custom Learning Center

• All the learning is in one place
• You can filter topics of interest
• View all your completed training
• Course resources may include links to a job aid

Your required courses are easily accessible and the available content is specific to your region. You may track your accomplishments, and view or download your training history via the Custom Learning Center ‘Dashboard’. Select ‘Access Your Custom Learning Center’ from the ‘Applications’ tab in ‘Payer Spaces’.

Examples of trainings offered in the Custom Learning Center:

• Authorizations
• Coding and Documentation
• Claims and Payments
• Recommended administrative support courses

In addition, illustrated reference guides are located on Custom Learning Center – Resources. Select ‘Resources’ from the menu located on the upper left corner of the screen. Usually, you may download or print reference guide materials.

Current Reference Guide topics include:

• Interactive Care Reviewer – Request Appeals Reference Guide
• Interactive Care Reviewer – Inquiries Reference Guide
• Patient 360 Navigation
• Remittance Inquiry Tips

Be sure to visit the Custom Learning Center in the Availity Portal often. New content is regularly added to the site.

For questions regarding the Availity Portal, please contact Availity Client Services at 800-282-4548.

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Exciting news! We are introducing Interactive Care Reviewer (ICR), Anthem’s online authorization tool for members enrolled in Anthem plans during 3^rd quarter 2020. ICR offers a streamlined process to request and check the status of medical and behavioral health inpatient and outpatient procedures.

We’ll provide more information in a future edition of Provider News as well as and Availity News and Announcements regarding the launch of ICR.

What benefits/efficiencies does the ICR provide?

• Receive a comprehensive view of all your prior authorization requests. You have a complete view of all the utilization management requests you submitted online, including the status of your requests and specific views that provide case updates and a copy of associated letters.

• Inquiry capability. Ordering and servicing physicians and facilities can locate information on preauthorization requests for those they are affiliated with, including requests previously submitted via phone, fax and ICR.
• Request and check the status of clinical appeals. You can use ICR to request a clinical appeal for denied authorizations and access letters associated with the appeal. 
• Reduces the need to fax. The ICR allows text detail as well as images to be submitted along with the request.
• No additional cost to you. The ICR is a no-cost solution that’s easy to learn and even easier to use.

How will you gain access to ICR?

Get a head start now and ask your Availity administrator to grant you the required ICR role assignment.

• Do you create and submit prior authorization requests?
  • Authorization and Referral Request role assignment
• Do you check the status of the case or results of the authorization request?
  • Authorization and Referral Inquiry role assignment

Once ICR is available, follow these steps to navigate to ICR through Availity

• Select Patient Registration from Availity’s home page
• Select Authorizations & Referrals
• Select Authorizations (for requests) | Select Auth/Referral Inquiry (for inquiries)

Is there training available?

Yes! You can get a jump-start before the July transition and register for a free webinar. We offer training every month to familiarize new users with ICR features and navigation of the tool. Our next webinar is taking place on July 22, 2020. Register here.

Can’t make it to the webinar?

Follow the steps outlined below to access self-paced videos located on the Custom Learning Center. From Availity’s home page, select Payer Spaces | Anthem tile | Applications | Your Custom Learning Center.

• Select ‘Catalog’ from the menu located on the upper left corner of the Custom Learning Center screen.
• Use the catalog filter and select ‘Interactive Care Reviewer-Online Authorizations’ or ‘Authorizations’ from the Category menu.
• Click Apply then enroll for the courses (videos) you want to view.
• Illustrated reference guides that you can print are located on Custom Learning Center Resources. Select ‘Resources’ from the menu located on the upper left corner of the screen. Use the catalog filter and select ‘Authorizations’ or ‘Interactive Care Reviewer-Online Authorizations’ from the Category menu. Select ‘Download’ to view and/or print the reference guide.

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The October 2017 and December 2017 editions of Network Update shared information about the SmartShopper® program which Anthem, in partnership with Sapphire Digital (formerly Vitals®), began offering to our small group members in Maine effective January 1, 2018. Please be advised effective September 1, 2020, all Anthem small group and large group fully insured members that are eligible for SmartShopper will receive enhanced telephonic concierge support for total knee and hip replacement, spine surgery and bariatric surgery. As part of the concierge model, Sapphire will guide members to facilities that are deemed as high-value based on cost and quality measures in order to qualify for rewards.

As a reminder, the SmartShopper® program does not take the place of any precertification/prior authorization requirements you may have as a participating provider.  All referral and precertification/prior authorization requirements remain in place. 

Sapphire utilizes data from the National Consumer Cost Transparency (NCCT) database, developed by the Blue Cross Blue Shield Association, to determine procedural costs in the SmartShopper® program.  The NCCT data is refreshed bi-annually in May and November. Providers may view their data by accessing the current version of the NCCT data via the Anthem POIT web tool through Availity. Sapphire utilizes the Blue Distinction Center designation developed by the Blue Cross Blue Shield Association to determine facilities that have received Blue Distinction Center designation based on quality.  If you have any questions regarding the NCCT data, please contact David Spencer, Provider Network Manager Senior, at 207-822-8453 or david.spencer@anthem.com. 

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As you know, AIM Specialty Health® (AIM) administers the musculoskeletal program, which includes the medical necessity review of certain surgeries of the spine and joints and interventional pain treatment.  For certain surgeries, the review also includes a consideration of the level of care for commercial fully-insured Anthem members and some ASO groups. 

According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures, it is generally appropriate to perform joint codes (CPT codes 27130, 29871, 29892) and four (4) spine codes (CPT codes 22633, 22634, 63265 and 63267) in a hospital outpatient setting. To avoid additional clinical review for these procedures, providers requesting prior authorization should either choose “hospital observation” admission as the site of service or hospital outpatient department (HOPD). If the provider determines that an inpatient stay is necessary due to post-operative care requirements, they can initiate a concurrent review request for inpatient admission with the health plan by contacting the number on the back of the member ID card.

Total hip arthroplasty (CPT code 27130) is currently reviewed for medical necessity and level of care. Effective October 1, 2020, four (4) spine codes (CPT codes 22633, 22634, 63265 and 63267) and two (2) joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:

• Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
• Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.

Peer-to-peer conversations are available to a provider at any time to discuss the applicable clinical criteria and to provide information about the circumstances of a specific member.  

Providers should continue to submit pre-service review requests to AIM using one of the following ways:

• Access AIM 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 AIM via the Availity Portal at www.availity.com.
• Call the AIM toll-free number at 866-714-1107, Monday through Friday, 8:30 a.m. – 7:00 p.m.

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

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

• Modifier use reminders
• 2020 affirmative statement concerning utilization management decisions
• New behavioral health discharge call-in line
• Medical Policies and Clinical Utilization Management Guidelines update
• Updates to AIM Specialty Health advanced imaging Clinical Appropriateness Guidelines
• Transition to AIM Rehabilitative Services Clinical Appropriateness Guidelines
• AMH Health, LLC - Modifier use reminders
• AMH Health, LLC - New behavioral health discharge call-in line
• AMH Health, LLC - Updates to AIM Specialty Health advanced imaging Clinical Appropriateness Guidelines
• AMH Health, LLC - Transition to AIM Rehabilitative Services Clinical Appropriateness Guidelines

Effective July 1, 2020, Maine Education Association Benefits Trust (MEABT) retirees who are eligible for Medicare Parts A and B will be enrolled in a Medicare Advantage Preferred Provider Organization (PPO) plan with Anthem. The Anthem Medicare Preferred (PPO) plan will replace the current MEA Group Companion plan for retirees who are eligible for Medicare Parts A and B. The plan includes 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. In addition, MEABT retirees pay no cost share for both in-network and out-of-network services. The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers, and also covers additional benefits that Original Medicare does not, such as an annual routine physical exam, hearing, vision, acupuncture, LiveHealth Online and SilverSneakers®.

The prefix on MEABT member ID cards will be MEW. The cards will also show the MEABT logo and National Access Plus icon.

Providers may submit claims electronically using the electronic payer ID for Anthem or submit a UB-04 or CMS-1500 form to Anthem. Claims should not be filed with Original Medicare. Contracted and non-contracted providers may call the provider services number on the back of the member ID card for benefit eligibility, prior authorization requirements, and any questions about MEABT member benefits or coverage.

Detailed prior authorization requirements also are available to contracted providers by accessing the Provider Self-Service Tool at https://www.Availity.com.

SilverSneakers is an independent organization providing health and fitness services on behalf of Anthem Blue Cross and Blue Shield.

LiveHealth Online is an independent company providing telehealth services on behalf of Anthem Blue Cross and Blue Shield.

Availity is an independent organization providing a secure provider portal on behalf of Anthem Blue Cross and Blue Shield.

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Anthem and AMH Health, LLC are offering Special Needs Plans (SNPs) to people eligible for both Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These include supplemental benefits such as hearing, dental, vision and transportation to medical appointments. Some SNP plans include a card or catalog for purchasing over-the-counter items. SNPs do not charge premiums.

SNP members under Anthem and AMH Health benefit from a model of care that is used to assess needs and coordinate care. Within 90 days of enrollment and annually thereafter, each member receives a comprehensive health risk assessment (HRA) that covers physical, behavioral and functional needs, and a comprehensive medication review. The HRA is used to create a member Care Plan. Members with multiple or complex conditions are assigned a health plan case manager.

SNP HRAs, Care Plans and case managers support members and their providers by helping to identify and escalate potential problems for early intervention, ensuring appropriate and timely follow-up appointments, and providing navigation and coordination of services across Medicare and Medicaid programs.

Provider training required

Providers contracted for SNP plans are required to complete an annual training to stay up-to-date with plan benefits and requirements, including details on coordination of care and model of care elements. Every provider contracted for SNP is required to complete an attestation, which states they have completed their annual training. These attestations are located at the end of the self-paced training document.

To take the self-paced training, go to the Model of Care Provider Training link on the Availity Portal.

How to access the Custom Learning Center on the Availity Portal

1. Log in to the Availity Portal.
• At the top of Availity Portal, select ‘Payer Spaces’ and select the appropriate payer.
2. On the Payer Spaces landing page, select ‘Access Your Custom Learning Center’ from Applications.
3. In the Custom Learning Center, select ‘Required Training’.
4. Select ‘Special Needs Plan’ and ‘Model of Care Overview’.
5. Select ‘Enroll’.
6. Select ‘Start’.
7. Once the course is completed, select ‘Attestation’ and complete.

Not registered for Availity?

Have your organization’s designated administrator register your organization for Availity.

1. Visit https://www.availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

See article attachment for Q and A's. 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield and AMH Health, LLC.

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AIM Specialty Health® (AIM) currently performs utilization management review for bi-level positive airway pressure (BiPAP) equipment and all associated supplies. Beginning July 1, 2020, the following codes will require prior authorization with Anthem and AMH Health, LLC rather than with AIM.

Lines of business:  Individual Medicare Advantage, Group Retiree Solutions, and Medicare-Medicaid Plans

AIM will continue to manage the supply codes for automatic positive airway pressure (APAP) and continuous positive airway pressure (CPAP) requests.

Anthem and AMH Health will continue to follow the COVID-19 Public Health Emergency orders from CMS until the waivers no longer apply. If the Public Health Emergency Orders are no longer in place beginning July 1, 2020, the following codes will require prior authorization with Anthem and AMH Health rather than with AIM when used in combination with the BiPAP codes above.

Precertification requests

Submit precertification requests via:

• Fax: 866-959-1537
• Phone: Please dial the customer service number on the back of the member’s card, identify yourself as a provider and follow the prompts to reach the correct precertification team. There are multiple prompts; select the prompt that fits the description for the authorization you plan to request.
• Web: Use the Availity Web Tool by following this link: https://apps.availity.com/availity/web/public.elegant.login

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Anthem and AMH Health, LLC are proud to offer the 2020 Optum* In-Office Assessment (IOA) Program, formerly known as the Healthcare Quality Patient Assessment Form/Patient Assessment Form (HQPAF/PAF) program. The name change reflects significant advancements in technology over the past few years, evolving from a paper form-based program to a program that securely exchanges clinical information digitally through multiple digital modalities.

If you are interested in learning about the electronic modalities available, please contact your Optum representative or the Optum Provider Support Center at 877-751-9207 from 8:00 a.m. to 7:00 p.m., Monday through Friday.

The IOA Program is designed to help participating providers ensure chronic conditions are addressed and documented to the highest level of specificity at least once per calendar year for all of our participating Medicare Advantage plan members. The IOA Program is designed to help overall patient quality of care (preventive medicine screening, chronic illness management and trifurcation of prescriptions for monitoring of high-risk medications and medication adherence) and care for older adults when generated for a Special Needs Plan (SNP) member.

Success stories

Below are some achievements Optum has accomplished with provider groups through the IOA Program:

• As a result of incorporating technology and/or different types of resources offered under the IOA Program, numerous provider offices demonstrated an increase in productivity, documentation and coding accuracy.

• Providers have taken advantage of the IOA Program resources to help alleviate some of the burden for their staff and office resources.

COVID-19 update

Anthem and AMH Health know this is a difficult time for everyone. We will continue to adapt and evolve our practices to fully address the changing dynamics of these unprecedented events. Anthem and AMH Health are following the CDC guidelines on social distancing; thus, all nonessential IOA Program personal are to work telephonically/electronically with the provider groups until further notice.

Dates and tips to remember:

Anthem and AMH Health strongly encourage participating providers to review their patient population as soon as possible. This will help get patients scheduled for an appointment if they have not already scheduled an in-office visit. This will also help the provider manage chronic conditions, which impact the health status of the patient.

At the conclusion of each office visit with a patient, providers participating in the IOA Program are asked to complete and return an In-Office Assessment form. The form should be completed based on information regarding the patient’s health collected during the office visit. Participating providers may continue to use the 2020 version of the In-Office Assessment form for encounters that take place on or before December 31, 2020. Anthem and AMH Health will accept the 2020 version of the form for 2020 encounters until midnight January 31, 2021.

Participating providers are required to submit an Account Setup Form, W9 and completed direct deposit enrollment by March 31, 2021. Participating providers should call 877-751-9207 if they have any questions regarding this requirement. Participating providers who fail to comply with this requirement will result in forfeiture of the provider payment for submitted 2020 In-Office Assessment forms if applicable.

If you have any questions regarding the IOA Program, please call Optum at 877-751-9207, Monday through Friday from 9:30 a.m. to 7:30 p.m.

* Optum is an independent company providing medical chart review services on behalf of Anthem Blue Cross and Blue Shield and AMH Health, LLC.

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On November 15, 2019, and February 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved clinical criteria applicable to the medical drug benefit medical drug benefit for Anthem and AMH Health, LLC. These policies were developed, revised or reviewed to support clinical coding edits.

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

For questions or additional information, use this email.

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