Have you been using the medical attachment tool on the Availity Portal to submit solicited medical records in support of a claim? You’ll now find these changes that were recently introduced:

 

• Select the “Attachment – New” option to submit medical records when Anthem has requested additional information to process a claim.
• To send a solicited attachment, now find the ‘Send Attachment’ link on the top, right side of the page.
• Expanded file size – each attachment can now be up to 40 MB with a total of 80 MB as the file size limit.

 

If you have not tried the Medical Attachment tool to submit electronic documentation in support of a claim, now is the time to give it a try! This tool makes the process of submitting requested medical records simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Anthem) medical record attachments through the Availity Portal.

 

How to access/setup the solicited medical attachments tool for your office

Availity Administrators must complete these steps:

1. From My Account Dashboard, select Enrollments Center > Medical Attachments Setup, follow the prompts and complete the following sections:
2. Select Application > choose Medical Attachments Registration
3. Provider Management > Select Organization from the drop-down. Add NPIs and/or tax IDs. (Multiples can be added separated by spaces or semi-colons.)
4. Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name.

 

Submitting medical attachments

Once the above setup is completed, Availity Users will complete these steps:

1. Log in to www.availity.com
2. Select Claims and Payments > Attachments-New > Send Attachment Tab
3. Complete all required fields of the form
4. Attach supporting documentation
5. Submit

               

Need training?

To access additional training for this Availity feature:

1. Log in to the Availity Portal at www.availity.com
2. At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
3. In the new window a list of available topics will open. Locate and click Medical Attachments.
4. Under the Recordings section, click View Recording

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

 

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website at anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Health and Wellness > Practice Guidelines.

 

One of the measures we report on is Controlling High Blood Pressure (CBP). This measure focuses on the percentage of members who are 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement year (2018).

 

What’s new for 2019?

• The CBP measure is no longer strictly a hybrid measure, which means that we review both medical records and claims. We can now use claims data to confirm both the diagnosis of hypertension as well as the blood pressure reading (CPT II codes).
• If you submit a claim using CPT II codes to document the blood pressure reading, we can now use that information, eliminating the need to request the medical record from you.
• Compliant BP is defined as <140/90 mm Hg for all members.
• Blood pressure readings taken from remote monitoring devices that are electronically submitted directly to the provider can be utilized for the measure.

 

What do we need from you?

We need the last two (2) office visit notes from 2018 with the blood pressure documented. Also, if the member was diagnosed with end stage renal disease, renal dialysis, renal transplant or pregnancy in 2018, please send that documentation as well.

 

Common chart deficiencies

• Recheck elevated blood pressures readings and document all BP readings in the medical record.

 

For more information on HEDIS visit anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Select Health & Wellness tab from the blue bar at the top of the page > Quality Improvement and Standards > HEDIS Information.

 

Thank you for your continued cooperation and support of HEDIS.

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

We have designated Availity to operate and serve as your electronic data interchange (EDI) entry point, also called the EDI Gateway. The EDI Gateway is a no-cost option for providers that choose to submit their own EDI claims to us. If you prefer to use a clearinghouse or billing company, please work with them to ensure connectivity.

 

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway. 

 

Do you already have an Availity User ID and Login? You can use the same login for your Anthem EDI transactions.  

 

• Log in to the Availity Portal and select Help & Training | Get Trained. In the Availity Learning Center, search the Catalog by key word “SONG” for live and on-demand resources created especially for you.

 

If you wish to become a direct a trading partner with Availity, the setup is easy.

 

• Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions.

Need assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

 

835 Electronic Remittance Advice (ERA)

Please use Availity to register and manage account changes for ERA. If you were previously registered to receive ERA, you must register using Availity to manage account changes. Log into the Availity Portal and select My Providers | Enrollments Center | ERA Enrollment to enroll for 835 ERA delivery.

 

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

 

If you have any questions, contact Availity Client Services at 1-800-Availity (800-282-4548), Monday – Friday, 8:00 a.m. to 7:30 p.m.

We continue to make it easier and more convenient to become an Anthem participating provider. The Digital Provider Enrollment application has been designed to speed up the enrollment process, allow providers to submit data at one time, and obtain real-time updates on the status of an application.

 

Access to the new application is available through Availity, our secure web-based provider portal.

New and current Availity users should ensure their user ID has the correct access. Please ensure that you have been assigned to Provider Enrollment.

 

Digital provider enrollment offers many benefits:

• Supports enrollment of professional providers, whose organizations do not have a credentialing delegation agreement with us.
• New individual providers or groups can request a contract.
• Existing groups can add providers to their existing contract.
• Providers can check the status of an application in real-time using the enrollment dashboard.

 

To use the new Digital Enrollment application, please ensure your provider data on CAQH is current and in a complete or re-attested status, then log into Availity and use the following navigation: Choose your state > Payer Spaces > Provider Enrollment.

 

As a reminder, beginning with dates of service April 1, 2019, we will implement various hospital edits in support of the Place of Service and Evaluation and Management reimbursement policy and the Maine Statute MRSA 24-A, Chapter 18, §1912, Standardized Claim Forms, which addresses the claim form billing requirements for professional services.

 

Professional services affiliated with a hospital that are rendered on or off the hospital campus, including those rendered in the outpatient hospital setting, must be billed on the CMS 1500 claim form.  Effective April 1, 2019, additional edits will be applied to the physical, occupational, and speech therapy (PT, OT, and ST) revenue codes (420 – 449).  These services will no longer be allowed on the UB-04 claim form.

 

Medicare Advantage and Medicare Supplemental plans are excluded.

 

What do I need to do to be ready?

In preparation, hospitals whose professional PT, OT, ST providers are not already Anthem approved and credentialed should follow one of the steps below to begin the process of enrolling your professional providers:

1. For enrollment of < 25 providers, complete the online New Provider Application for each individual provider; or
2. For enrollment of > 25 providers, complete the Professional Roster Template.

 

Any questions regarding the enrollment process should be referred to Provider Service at 800-832-6011.

Each year, we request your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented hierarchical condition categories (HCC), in order to document and close the coding gaps. 

 

The CRA Program is specific to our Affordable Care Act (ACA) members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).

 

With our Retrospective Program we focus on medical chart collection. We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS). This particular effort is part of our compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership. The members’ medical record documentation helps support this data requirement.

 

Analytics are performed internally on claims which do not have the ICD10 code for which we suspect a chronic condition. These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.

 

Anthem network providers, including PCPs, specialists, facilities, behavioral health, ancillary, etc., may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review. These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf. The vendors’ web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management. 

 

We ask that our network providers submit the medical record information to the designated vendor within 30 days of the request (no later than March 31, 2019).  While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.

 

Electronic options that may make medical chart collection easier for providers:

 

• EMR Interoperability
  • Allscripts (Opt in -- signature required)
  • NextGen (Opt out -- auto-enrolled)
  • Athenahealth (Opt out -- auto-enrolled)
  • MEDENT

• Remote/direct Anthem access
• Vendor virtual or onsite visit
• Secure FTP

 

The goal of these electronic options is to both improve the medical record data extraction and the experience for our network-participating hospitals, clinics and physician offices.  If you are interested in this type of set up or any other remote access options, please contact Alicia Estrada, our Commercial Risk Adjustment Network Education Representative, at Alicia.Estrada@anthem.com.

 

Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests.  

 

This March, anthem.com will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms. A sample screen image of the upcoming changes is attached to this article. 

This first version of the new Provider Forms will keep growing and evolving in the coming months.

 

We will continue to keep you informed of upcoming changes to the public provider site as we progress toward streamlining our Web platform and other business processes.

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!

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

 

• Special Need Plans training required
• 2019 risk adjustment provider training
• New provider learning opportunity: Put the AIM ProviderPortal to work for you
• New provider service phone number beginning January 1, 2019

 

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The following revised clinical criteria will be effective May 1, 2019. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.

 

Clinical criteria effective date	Clinical criteria number	Clinical criteria	Clinical criteria (new/revised)
May 1, 2019	ING-CC-0001	Erythropoiesis Stimulating Agents	Revised
May 1, 2019	ING-CC-0004	H.P. Acthar Gel® (repository corticotropin injection)	Revised
May 1, 2019	ING-CC-0072	Selective Vascular Endothelial Growth Factor (VEGF) Antagonists	Revised

 

75743MUPENMUB 01/24/2019

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

 

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

 

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

 

If you have questions or feedback, please contact us.

We updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433. The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:

 

• Group code patient responsibility (PR) will be assigned.
• Claim adjustment reason codes (CARCs) will include the following:
  • 1 — deductible amount (professional claim)
  • 2 — coinsurance amount (professional claim)
  • 3 — copay amount (professional and facility claim)
  • 247 — deductible for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
  • 248 — coinsurance for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
• Remittance advice remark codes (RARCs) will include the following:
  • N781 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
  • N782 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
  • N783 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected copay. This amount may be billed to a subsequent payer.

 

Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.

75743MUPENMUB 01/24/2019

In 2019, we are offering dual eligible special needs plans (D-SNPs) to individuals who are eligible for both Medicare and Medicaid benefits or who are qualified Medicare beneficiaries (QMBs). D-SNPs provide enhanced benefits to individuals eligible for both Medicare and Medicaid. These plans are $0 premium plans. Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments. Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.  

 

Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in Q1 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.

 

Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.

For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.

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