For the most up-to-date information from Anthem about COVID-19, please bookmark Provider News Home and check back often.  The most recent articles will be displayed in the Provider Spotlight section.

For a repository of all COVID-19 related articles in one location, please reference COVID-19 Information – Maine under Articles by Publication.

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The Provider Manual will be updated for an effective date of July 1, 2020, and is now available on the provider portal of our website, anthem.com. Select Providers, then under the Provider Resources heading, select Policies, Guidelines and Manuals. Enter Maine as state, scroll to Provider Manuals and select Download the Manual. Archived copies of the 2018 and 2019 provider manual will remain available at the same location for reference to prior information. However, for current reference needs, please ensure that you select the July 2020 manual after July 1, 2020.

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As a reminder, we are continuing to update our claim editing software for outpatient claims on a monthly basis throughout 2020. 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 (NCCI) edits
• 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, medically unlikely edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
• apply to any provider or provider group (tax identification number) and may apply to both institutional and professional claim types including looking across claim types to determine where conflicts may exist between professional (CMS-1500) claims and institutional (CMS-1450) claims.

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Diabetes is a complex chronic illness requiring ongoing patient monitoring. NCQA includes diabetes in its HEDIS® measures on which providers are rated annually. Since diabetes HbA1c testing is a key measure to assess for future medical conditions related to complications of undiagnosed diabetes, the National Committee for Quality Assurance (NCQA) requires health plans to review claims for diabetes in patient health records.  The findings contribute to health plan stars ratings for commercial and Medicare plans and the Quality Rating System (QRS) measurement for Marketplace plans. A systematic sample of patient records is pulled annually as part of the HEDIS® medical record review to assess for documentation.

Which HEDIS measures are diabetes measures?

The diabetes measures focus on members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following assessments:

• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (>9.0%)
• HbA1c control (<8.0%)
• Dilated retinal exam
• Medical attention for nephropathy

The American College of Physicians’ guidelines for people with type 2 diabetes recommend the desired A1c blood sugar control levels remain between 7 to 8 percent.¹

In order to meet the HEDIS measure “HbA1c control <8”, you must document the date the test was performed and the corresponding result. For this reason, report one of the four Category II codes and use the date of service as the date of the test, not the date of the reporting of the Category II code.

NOTE: Multiple dates of service may be associated with a single lab test (e.g., a collection date, a reported date and a claim date). For a laboratory test CPT II code to count toward HEDIS, the Category II date of service and the test result date must be no more than seven days apart.

Continued management and diverse pathways to care are essential in controlling blood glucose and reducing the risk of complications. While it is extremely beneficial for the patient to have continuous management, it also benefits our providers. As HEDIS rates increase, there is potential for the provider to earn maximum or additional revenue through Pay for Quality, Value Based Services, and other pay-for-performance models.³

Sources include:

− Diabetes Prevalence: 2015 state diagnosed diabetes prevalence, cdc.gov/diabetes/data; 2012 state undiagnosed diabetes prevalence, Dall et al., ”The Economic Burden of Elevated Blood Glucose Levels in 2012”, Diabetes Care, December 2014, vol. 37.

− Diabetes Incidence: 2015 state diabetes incidence rates, cdc.gov/diabetes/data

− Cost: American Diabetes Association, “Economic Costs of Diabetes in the U.S. in 2017”, Diabetes Care, May 2018.

− Research expenditures: 2017 NIDDK funding, projectreporter.nih.gov; 2017 CDC diabetes funding, www.cdc.gov/fundingprofiles

1 https://www.medicalnewstoday.com/articles/321123#An-A1C-of-7-to-8-percent-is-recommended

2 https://www.ama-assn.org/system/files/2020-01/cpt-cat2-codes-alpha-listing-clinical-topics.pdf 3 https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.htm

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We understand the increased risk and strain on the health care system during the fight against COVID-19, and we support you in the response and treatment of your patients. Telehealth is now an option to assess your patients with risk adjustable conditions.  Our Prospective Risk Adjustment program works to improve risk adjustment accuracy and focus on performing appropriate interventions for patients with undocumented hierarchical condition categories (HCC), in order to help you close your patients’ gaps in care. This program involves:

• Member outreach encouraging primary care physician (PCP) in-person or telehealth visits
• Refer to our COVID-19 FAQs in Provider News for updates about telehealth reimbursement guidance. 
• Provider outreach sharing previously coded and suspected conditions, and encouraging member visits
• PCP alternatives to complete health assessments

Inovalon Requests

Consistent with 2019, we have again engaged a vendor, Inovalon – an independent company that provides secure, clinical documentation services – to help us comply with the provisions of the Affordable Care Act that require us to assess members’ relative health risk levels.  In the coming weeks and months, Inovalon will begin sending letters to providers as part of a new risk adjustment cycle, asking for your help with completing Health Assessments for some of our members.

If you worked with Inovalon in 2019, many thanks for your help. This year will bring a new round of assessments because chronic conditions must be assessed and coded each and every year. As always, if you have questions about the requests you receive, you can reach Inovalon directly at 877-448-8125.

Prospective program ask of providers:

• Anthem network providers – usually PCPs – receive letters from Inovalon, requesting that they:
• Schedule a comprehensive in-person or telehealth visit with patients identified by Inovalon to confirm or deny if previously coded or suspected diagnoses exists, and;
• Submit a health assessment documenting the previously coded or suspected diagnoses (also called SOAP Notes - Subjective, Objective, Assessment and Plan).
• Incentives for properly submitted health assessments (these incentives are in addition to the office visit reimbursement):
  • $100 for each health assessment properly submitted electronically
  • $50 for each health assessment properly submitted via fax

Submit electronically via Inovalon’s ePASS tool:

• Inovalon ePASS^® training webinars
  • Every Wednesday - 3:00 p.m. - 4:00 p.m.
• Join an ePASS webinar:
  • Register by sending an email to ePASSProviderRelations@inovalon.com with your name, organization, contact information and the date of the webinar you wish to attend.

Alternative Engagement

ePASS® is our preferred method for submission. However, to improve engagement and collaborate with our providers who are not submitting via ePASS®, we have identified other tools which may be helpful. If in 2019 your practice utilized some of these alternative options for prospective member outreach, we thank you for continuing on these alternative forms of program participation into 2020. 

For those providers not familiar with our alternative options, they are listed here. Telehealth visits are also an acceptable form of a patient visit for these alternative engagement options. Any questions your office has on these can be directed to either your local Provider Representative, or the Anthem CRA Network Education Representative listed below.

• EPHC providers using PCMS - Providers participating in our Enhanced Personal Health Care (EPHC) program can use member reports from our PCMS tool to schedule members for comprehensive visits. PCMS does have a link to take you directly to the Inovalon ePASS® tool where completed health assessments will result in a $100 incentive payment per submitted health assessment.
• List of members to be scheduled - Anthem CRA provides member/patient reports for providers to schedule members for comprehensive visits. Providers use normal gap closure through claims submission. No health assessment needed. Not eligible for additional incentive.
• EPIC Patient Assessment Form (PAF) - Providers with EPIC as their electronic medical record (EMR) system can fax the EPIC PAF to Inovalon at 866-682-6680 with a coversheet indicating "see attached Anthem Progress Note,” which is eligible for a $50 incentive payment.
• Providers Existing Patient Assessment Form (PAF) - Utilize providers existing EMR system and applicable PAF. Must be submitted to Inovalon at 866-682-6680 with coversheet indicating, "see attached Anthem Progress Note,“ which is eligible for a $50 incentive payment.

If you have any questions please contact our Commercial Risk Adjustment Network Education Representative, Alicia Estrada, at Alicia.Estrada@anthem.com. Thank you for your continued efforts with our CRA Program.

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Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Advanced Imaging of the Chest and AIM Oncologic Imaging Clinical Appropriateness Guidelines.

Advanced Imaging of the Chest:

Tumor or neoplasm

• Allowed follow up of nodules less than 6 mm in size seen on incomplete thoracic CT, in alignment with follow up recommendations for nodules of the same size seen on complete thoracic CT
• Added new criteria for which follow up is indicated for mediastinal and hilar lymphadenopathy
• Separated mediastinal/hilar mass from lymphadenopathy, which now has its own entry

Parenchymal lung disease – not otherwise specified

• Removed as it is covered elsewhere in the document (parenchymal disease in Occupational lung diseases and pleural disease in Other thoracic mass lesions)

Interstitial lung disease (ILD), non occupational including idiopathic pulmonary fibrosis (IPF)

• Defined criteria warranting advanced imaging for both diagnosis and management

Occupational lung disease (adult only)

• Moved parenchymal component of asbestosis into this indication
• Added Berylliosis

Chest wall and diaphragmatic conditions

• Removed screening indication for implant rupture due to lack of evidence indicating that outcomes are improved
• Limited evaluation of clinically suspected rupture to patients with silicone implants

Oncologic Imaging:

MRI breast

• New indication for BIA-ALCL
• New indication for pathologic nipple discharge
• Further define the population of patients most likely to benefit from preoperative MRI

Breast cancer screening

• Added new high risk genetic mutations appropriate for annual breast MRI screening

Lung cancer screening

• Added asbestos-related lung disease as a risk factor

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s 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 Web Portal at availity.com.
• Call the AIM Contact Center toll-free number: 866-714-1107, Monday – Friday, 8:00 a.m. – 5:00 p.m.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

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Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Sleep Disorder Management Clinical Appropriateness Guideline.

Sleep Disorder Management:

Bi-Level Positive Airway Pressure Devices

• Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and aligns with Medicare requirements for use of BPAP.

Multiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing

• Style change for clarity
• Code Changes:  None 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s 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 Web Portal at availity.com.
• Call the AIM Contact Center toll-free number: 866-714-1107, Monday – Friday, 8:00 a.m. – 5:00 p.m.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

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Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM  Musculoskeletal Program: Interventional Pain Management Clinical Appropriateness Guideline.

Musculoskeletal Program: Interventional Pain Management Guideline:

General requirements – conservative management

• Addition of physical therapy or home therapy requirement and one complementary modality based on preponderance of benefit over harm to conservative care
• Align with approach to conservative management defined in spine and joint surgery guidelines

Epidural injection procedures and diagnostic selective nerve root blocks

• Addition of statement about adherence to ESI procedural best practices established by FDA Safe Use Initiative. Recommendations are intended for provider education and will not be used for adjudication.
• Clarification of intent around requirement for advanced imaging for repeat injections

Paravertebral facet injection/nerve block/neurolysis

• Remove indication for 4 unilateral medial branch blocks per session based on panel consensus
• Procedural clarification restricting use of corticosteroids for diagnostic MBB based on panel consensus
• Limit use of intra-articular steroid injection to mechanical disruption of a facet synovial cyst
• Remove indication for intra-articular steroid injections based on new evidence for lack of efficacy
• Increase duration of initial RFN efficacy needed to avoid a MBB to 6 months based on panel consensus
• Clarification that MBB or RFN is not medically necessary after spinal fusion

Spinal cord and nerve root stimulators

• Clarify inclusion of different stimulation methods for spinal cord stimulation
• Add new indication for dorsal root ganglion stimulation
• Clarify exclusions for spinal cord and dorsal root ganglion stimulation

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s 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 Web Portal at availity.com.
• Call the AIM Contact Center toll-free number: 866-714-1107, Monday – Friday, 8:00 a.m. – 5:00 p.m.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

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As we communicated in the February 2020 edition of Provider News, effective for dates of service on and after May 17, 2020, the AIM Musculoskeletal Program: Joint Surgery Clinical Appropriateness Guidelines will be updated. These updates relate to the criteria in the following sections:

• Hip arthroplasty
• Knee arthroscopy and open procedures
• Shoulder arthroplasty including the removal of the  indication for subacromial impingement with rotator cuff tear  

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s 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 Web Portal at availity.com.
• Call the AIM Contact Center toll-free number: 866-714-1107, Monday – Friday, 8:00 a.m. – 5:00 p.m.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

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Effective August 1, 2020, Anthem will continue to allow reimbursement for unlisted, unspecified or miscellaneous codes. Unlisted, unspecified or miscellaneous codes should only be used when an established code does not exist to describe the service, procedure or item rendered. Reimbursement is based on review of the unlisted, unspecified or miscellaneous codes on an individual claim basis. Claims submitted with unlisted, unspecified or miscellaneous codes must contain specific information and/or documentation for consideration during review.

For additional information, please review the Unlisted, Unspecified or Miscellaneous Codes reimbursement policy.

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Anthem and AMH Health, LLC want to make multi-dose packaging available to your patients to help support medication adherence. It’s a simpler, safer way for your patients to manage their medications. Multi-dose packaging is a free service available to members at select network pharmacies.

What is multi-dose packaging?

Multi-dose packaging (MDP) involves organizing prescription and over-the-counter products to provide ease to patients when taking their routine medications. Each MDP dispenser provides patients with a personalized roll of pre-sorted medication packs, labeled with the date and time of the patient's next scheduled dose. MDP helps reduce the stress of determining which medications to take, when to take them and how much of them to take.

Who provides these services?

MDPs can be shipped to the CVS retail pharmacy of choice or directly to a patient’s home at no additional charge. The MDP Care team is available 24/7 to address patient questions and concerns. The team also coordinates mid-month prescription changes with local CVS pharmacies. CVS MDP is licensed in all states and the District of Columbia.

If CVS isn't the right fit based on geography, PillPack can provide MDP services for your patients. Packages can include prescription medication, over-the-counter medication and vitamins, and will include a date and time stamp on each packet to help your patients remember to take their medications. Patient copays should be the same; in some cases, it may be cheaper.

How do I refer my patients to MDP providers?

For CVS: Patients can enroll online at https://www.CVS.com/multidose or call 1-800-753-0596. Patients residing in the District of Columbia, Georgia or South Carolina should call 1-844-650-1637 (due to remote practice restrictions). Members may also enroll at their local CVS pharmacy.

For PillPack: Patients interested in PillPack can enroll online at https://www.pillpack.com/blue or via phone by calling 866-282-9462.

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

• New Prior Authorization requirements for Medicare Advantage
• New behavioral health Medicare Advantage individual and Group Retiree Solutions provider fax
• New behavioral health Medicare Advantage individual and Group Retiree Solutions provider fax for AMH Health, LLC