In February, we introduced our new Authorization Rules Lookup tool that you can access through Availity Payer Spaces. This new self-service application displays prior authorization rules so you can quickly verify if the outpatient services require prior authorization for members enrolled in Anthem’s commercial plans.

In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:

• Medical Policies and Clinical Guidelines
• Third Party Guidelines, if applicable (such as AIM Specialty Health, IngenioRx)

Access the Authorization Lookup application through Availity Payer Spaces

Access to the tool does not require an Availity role assignment.

1. Select Payer Spaces
2. Select the Anthem Blue Cross Blue Shield tile from the Payer Spaces menu
3. Select the Applications tab
4. Select the Authorization Rules Lookup tile

Once you are in the tool, you will need to provide the following information to display the service’s prior authorization rules:

• Tax ID
• National Provider Identifier (NPI)
• Member ID and birth date
• Member’s group number or contract code

(This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)

• CPT/HCPCS code

Give this new tool a try and discover how much this will improve the efficiency of your authorization process.

Please note: If a prior authorization is required for outpatient services, you may submit the case through Interactive Care Reviewer, Anthem’s online authorization tool that is also accessible through the Availity Portal.

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To help ensure accuracy and eliminate delays in the adjudication of your claims, the itemized bill must be included with qualifying claim submissions. Submitting an itemized bill (unsolicited* medical attachment) for a high dollar claim just got easier!

To submit an itemized bill (unsolicited medical attachment):

1. Log in to Availity Portal
2. Select Claims & Payments | Attachments – New
3. Select Send Attachment
4. Under Request for Information, select No, if you are including the supplemental information/attachment for an 837 claim PWK. (see example below)

1. Include provider, patient and claim information
2. Attach supporting documentation and reason (example shown below)
3. Send attachment(s)

Providers may also submit a claim attachment using the Availity Portal for solicited** medical attachments.

To submit supporting documentation in response to a formal (solicited) request from the payer:

• Log in to Availity Portal
• Select Claims & Payments | Attachments – New
• Select Send Attachment
• Under the Request for Information, select Yes, if you are responding to a request from the health plan or need to submit documentation for a specific claim number (see example below)
• Add supporting documentation and reason
• Submit

Additionally, if you attended a previous webinar, we have updated information on submitting an EDI 837 batch that includes a PWK segment in loops 2300/2400. The update is regarding the linkage between the electronic claim and your supplemental documentation that can be submitted through the Availity portal.

What does this mean for you?

You may now submit attachments electronically (EDI) using the PWK segment to specify that documents are being submitted in support of the claim and no additional face sheet or coversheet is needed.

Here are the steps:

• Log in to Availity Portal
• Select Claims & Payments I Attachments - New
• From the Inbox tab, select the appropriate claim or open the request in your work queue
• Add files with supporting documentation
• Submit

Get trained

• Attend an Availity-hosted webinar to learn more about all capabilities. You can register for an upcoming live webinar hosted by Availity here, or
• Log into Availity.com and select Help & Training | Get Trained to open the Availity Learning Center in a new tab (it is your dedicated ALC account).

• Search by keyword (Medattach) to find on-demand and live training options
• Click Enroll to enroll for a course and then go to your Dashboard to access it any time

Get started today with these wide-ranging capability enhancements to transform your business operations to a quick, secure, paperless and simple process to fulfill medical records requests electronically through Availity.

*Unsolicited attachment: Documentation submitted without a formal request from the payer

**Solicited attachment: Documentation submitted in response to a specific request from payer

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On November 1, 2020, AIM Specialty Health^® (AIM) began administering the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints using AIM clinical guidelines for Anthem fully-insured members and certain ASO groups.   

Effective March 14, 2021, the AIM Small Joint Surgery Guideline will be updated with the following:

• Clarified requirements for imaging reports
• Removed radiographic requirement for confirmation of lesser toe deformities
• Added ankle arthrodesis and total ankle arthroplasty as new indications for revision of failed previous reconstructions
• Removed total ankle arthroplasty requirements for adjacent joint or inflammatory arthritis
• Clarified contraindications only apply to total ankle arthroplasty

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

• Access AIM’s ProviderPortal_SM directly at www.providerportal.com. Real-time, online access is available 24/7 to process orders, 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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We will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.

We encourage providers who offer telehealth services to use the online Provider Maintenance Form to notify us, and we will add a telehealth indicator to your online provider directory profile.

Please contact Provider Services with any questions.

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The medical policies, clinical utilization management (UM) guidelines and third party criteria below were developed and/or revised to support clinical coding edits for Anthem and AMH Health, LLC. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The medical policies and clinical UM guidelines below are followed in the absence of Medicare guidance.

Please share this notice with other members of your practice and office staff.

Visit our website to view our medical policies and clinical UM guidelines.

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• *GENE.00055 – Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
  • Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications
• *LAB.00037 – Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
  • Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered investigational and not medically necessary for screening, diagnosis or management of irritable bowel syndrome, and for all other indications
• *DME.00011 – Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
  • Revised scope to only include non-implantable devices and moved content addressing implantable devices to SURG.00158
  • Added “non-implantable” to bullet point on percutaneous neuromodulation therapy
  • Added percutaneous electrical nerve field stimulation (PENFS) as investigational and not medically necessary for all indications
• *SURG.00062 – Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
  • Expanded scope to include percutaneous testicular vein embolization for varicocele and added embolization of the testicular (spermatic) veins as investigational and not medically necessary as a treatment of testicular varicocele
• *CG-LAB-15 – Red Blood Cell Folic Acid Testing
  • RBC folic acid testing is considered not medically necessary in all cases
• *CG-LAB-16 – Serum Amylase Testing
  • Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions
• *CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules
• Added the Afirma Xpression Atlas as not medically necessary
• 00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
  • A new medical policy was created from content contained in DME.00011.
  • There are no changes to the policy content.
  • Publish date is December 16, 2020.
• CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing
  • A new clinical guideline was created from content contained in GENE.00026.
  • There are no changes to the guideline content.
  • Publish date is December 16, 2020.

Medical policies

On November 5, 2020, the medical policy and technology assessment committee (MPTAC) approved the following medical policies applicable to Anthem and AMH Health, LLC. These guidelines take effect March 8, 2021.

Clinical UM guidelines

On November 5, 2020, the MPTAC approved the following clinical UM guidelines applicable to Anthem and AMH Health, LLC. These guidelines were adopted by the medical operations committee for Anthem and AMH Health members on November 19, 2020. These guidelines take effect March 8, 2021.

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Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.

Anthem and AMH Health, LLC are committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem and AMH Health have the answers before you ask the questions. With an initial focus on claim-level insights, Anthem and AMH Health have streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the Explanation of Payment (EOP).

Access the Claims Status Listing on Payer Spaces from https://www.anthem.com/medicareprovider using the Log In button or through the secure provider portal via Availity*. We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim

status changes, other claims needing resolution are added, and claims are resolved faster.

Anthem and AMH Health made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem and AMH Health are using digital technology to improve the healthcare experience. If you have questions, please reach out to your Provider Relations representative.

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

• MCG Care Guidelines 24th edition customization for Anthem
• MCG Care Guidelines 24th edition customization for AMH Health, LLC
• DME checklist of information needed from providers for AMH Health, LLC members
• DME checklist of information needed from providers for Anthem members