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!

Continuing to build on the initial launch of the new public provider pages, we recently released a brand new, redesigned landing page for Provider Resources. The most recent release also includes a new Communications page with a clear and concise access point for Newsletters and eUpdates, as pictured below. 

This October, we’ll be introducing exciting changes to the anthem.com public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for manuals and an improved, streamlined experience for Reimbursement Policies.

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

We have collaborated with Availity to operate and service the entry point for all EDI submissions to Anthem, otherwise known as the EDI Gateway.

Who is Availity?

Most of you know Availity as web portal or claims clearinghouse, but they are much more.  Availity is also an intelligent EDI Gateway for multiple vendors and will be the EDI connection for all Anthem Inc. and its affiliates.

If you currently use a clearinghouse, billing company or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Anthem.

How are you submitting EDI transactions today?

• If you currently transmit your EDI Submissions using a clearinghouse or billing company, you should contact your clearinghouse to confirm your EDI submission path has not changed. If you are notified of any potential impacts with connectivity, workflow or financial, please know there is no cost alternate submission options available with Availity.

• If you currently submit directly to Anthem and already have an Availity login for the portal, you can use that same login for your EDI services.

• Please visit https://apps.availity.com/web/welcome/#/anthem to learn more.

How can you directly transmit EDI transactions to Availity?

Below are the different ways you can submit direct EDI transactions to Availity:

• Submit transaction files through FTP: If you work with a practice management system, health information system, or other automated system that supports an FTP connection, you can securely upload EDI transactions to the Availity FTP site where they are automatically picked up by Availity and submitted to Anthem

• Submit transaction files through the Availity Portal: If you have batch files of EDI transactions that you need to process and you choose not to use the Availity FTP site, you can manually upload the batch files through the Availity Portal.

• Submit transactions through manual data entry in the Availity Portal: The Availity Portal makes it easy to submit transactions, such as eligibility and benefits inquiries or claims, by entering data into our user-friendly web forms.

What are your next steps?

• It may take time to work with your clearinghouse or billing company, so please take action now to help ensure continuity of your EDI transactions.

• If you choose to submit direct, we recommend that you register with Availity for your EDI transmissions and begin migrating your volume by the end of  2018 by visiting this URL- https://apps.availity.com/web/welcome/#/anthem

• The EDI transactions include the 837, 835 and 27X (eligibility and claim status).

• Availity will be working directly with your clearinghouse, billing company or your organization if you choose to submit directly.

We look forward to delivering a smooth transition to the Availity EDI Gateway. If you have any questions please contact Availity Client Services at 800-Availity (800-282-4548), Monday through Friday, 8:00 a.m. to 7:30 p.m.  

Great news! Anthem, Inc. and our affiliates now use Availity as our designated EDI service. If you currently use a clearinghouse, billing company, or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Anthem.

Check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session. During this fast paced hour, learn how to:

• Understand Availity’s EDI Gateway and Clearinghouse workflow for 837, 270/271, 276/277, and 835 transactions.
• Use the Availity Portal to manage file transfers, set up EDI reporting preferences, manage your FTP account, and more.
• Enroll for and manage 835 ERA delivery with Availity.
• Access and navigate the Availity EDI Guide.
• and more…..

Upcoming Sessions

Currently scheduled upcoming sessions include:

• October 29, 2018, 1:00 p.m. – 2:00 p.m. ET
• November 7, 2018, 11:00 a.m. – 12:00 p.m. ET

Enroll

1. Log in to the Availity Portal.
2. Select Help and Training > Get Trained.
3. In the Availity Learning Center (ALC) Catalog, select Sessions.
4. Scroll Your Calendar to find and enroll for a live session.

Can’t make it?

We’ve got you covered with a recording of a previous live session. In the ALC, search the catalog by keyword (song) and enroll for the on-demand option.

Need Help?

Email training@availity.com if you have issues enrolling for a live webinar.

The Education and Reference Center (ERC) offers the Communication & Education section where you can find training materials, important policy information, commonly used forms and reference guides on Anthem’s proprietary tools. When you visit the ERC, you can efficiently navigate to all available electronic resources using only the Availity Portal.

The Communication & Education section has been updated to include valuable reference material for Anthem proprietary tools.

With an Availity log in you can easily view any new content added to the ERC. There is no additional role assignment needed.  

Find the ERC on the Availity Portal under Payer Spaces > Anthem > Applications. If you are having trouble locating the Education and Reference Center, type Education and Reference Center in the Availity Search option located on the top navigation menu. Select the heart next to the application to save it to your Favorites.

Numerous studies have shown that a patient’s primary health care experience and, to some extent their health care outcomes, are largely dependent upon health care provider and patient interactions.  We offer a new online learning course – What Matters Most: Improving the Patient Experience, to address gaps in and offer approaches to communication with patients. This curriculum is available at no cost to providers and their clinical staff nationwide and is acceptable for up to one (1) prescribed credit by the American Academy of Family Physicians.

Through the use of compelling real-life stories that convey practical strategies for implementing patient care, providers learn how to apply best practices.  Did you know?

• Substantial evidence points to a positive association between the patient experience and health outcomes.
• Patients with chronic conditions, such as diabetes, demonstrate greater self-management skills and quality of life when they report positive interactions with their health care providers.
• Patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physician's practice than patients with the highest-quality relationships.

How will this benefit you and your office staff?  You’ll learn tips and techniques to:

• Improve communication skills
• Build patient trust and commitment
• Expand your knowledge of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey

The course can be accessed at www.patientexptraining.com using your smartphone, tablet, or computer.

Like you, we are committed to improving the patient experience in all interactions, and we are proud to work collaboratively with our provider network to provide support and tools to reach our goal.

Take the course today!

The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) which prohibits member cost sharing for defined preventive services for non-grandfathered policies. The appropriate use of modifier 33 will reduce claim adjustments related to preventive services and your corresponding refunds to members.

Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.

Modifier 33 should be appended to codes represented for services described in the US Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.

The CPT® 2018 Professional Edition manual shares the following information regarding the billing of modifier 33, “When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”

The Special Investigations Unit (SIU) is tasked to conduct investigations involving allegations of fraud, waste and abuse, to work with our providers to resolve billing practice issues in order to reduce or eliminate future payment issues, and, where appropriate, to recover overpayments.

As part of our role to help safeguard our members and provide relevant information to providers, we are relaying the following recent Food and Drug Administration (FDA) Warning Letters:  

Estring - On June 19, 2018, the Food and Drug Administration issued a letter of warning to Pfizer for "false or misleading" promotional materials related to ESTRING® (estradiol vaginal ring). According to the FDA the posted “… video is especially concerning from a public health perspective because it fails to include any risk information about Estring, which is a drug that bears a boxed warning due to several serious, life-threatening risks, including endometrial cancer, breast cancer, and cardiovascular disorders, as well as numerous contraindications and warnings. The video thus creates a misleading impression about the safety and efficacy of Estring”.

Xtampza – On February 9, 2018, the Food and Drug Administration issued a letter of warning to Collegium Pharmaceuticals for publicly providing false or misleading representations regarding Xtampza (oxycodone) ER because it “fails to adequately communicate information about the serious risks associated with Xtampza ER use”.

Further details regarding these Warning Letters from the FDA can be obtained at:

Estring:

https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/EnforcementActivitiesbyFDA/WarningLettersandNoticeofViolationLetterstoPharmaceuticalCompanies/UCM612143.pdf

Xtampza:

https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/EnforcementActivitiesbyFDA/WarningLettersandNoticeofViolationLetterstoPharmaceuticalCompanies/UCM597584.pdf

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.

We have completed the HEDIS data collection for 2018 and want to thank all of our provider offices and their staff who assisted us. Your collaboration in this process allows us to strive for the best HEDIS results possible.

This is the 7th year for our incentive program to acknowledge some of our providers who either responded in a timely manner or went “Above & Beyond” to help make our HEDIS data collection successful. Any practices that responded within 5 business days of our initial request or who went out of their way by taking additional steps to help us with data collection were entered in a drawing to receive a gift. We are pleased to announce that our incentive winners are as follows:

HEDIS drawing winners

Sheepscot Eye Associates

Central Maine Clinical Associates

Pines Women and Children

Alfond Center for Health

Roger C Hall, MD

Winners Above and Beyond:

Great Works Family Practice - Kelly Poole  

Martin’s Point Healthcare - Kim Batchelder

Our HEDIS results reflect the care you provide to our members. Now is the time to review your patient’s records to ensure that they have received their preventative care and/or immunizations before the end of the year.

An overview of our HEDIS rates will be published in the 4th quarter provider newsletter. In addition, more information on HEDIS can be found by visiting the provider portal at anthem.com/provider > scroll down and select ‘Find Resources for [state]’ > Health & Wellness > Quality Improvement and Standards > HEDIS Information.

Thanks again to all of our provider offices and their staff for assisting us in collecting HEDIS data. We look forward to working with you next HEDIS season!

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

Effective October 14, 2018, we will enforce the requirement to bill the correct modifier and HCPCS for services utilized. Incorrect billing will be rejected and claims will be returned to the provider for correction and resubmittal.

Durable medical equipment (DME) may be purchased, rented or rented until the purchase price has been paid. 

Correct billing will allow member benefits to be applied correctly to include benefit accumulations for a member’s DME benefits.

In our ongoing efforts to encourage medical and behavioral health integration, we continue to promote early identification and intervention of behavioral health issues through primary care. We currently reimburse for screening and assessment for behavioral health and substance use through billing the following codes:

• G0396 /99408 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes
• G0397 / 99409 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention, greater than 30 minutes
• G0442 - Annual alcohol misuse screening, 15 minutes £ G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
• G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
• G0444 - Annual depression screening, 15 minutes

We also support behavioral counseling for specific chronic conditions while in the primary care office.  These services include:

• G0446 - Annual, face-to-face intensive behavioral therapy for cardiovascular disease, 15 minutes
• G0447 - Face-to-face behavioral counseling for obesity, 15 minutes
• G0473 - Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

In addition, we reimburse for the psychiatric collaborative care codes; procedure codes 99492, 99493, 99494 are used to report these services. These codes are reportable by primary care for their collaboration with a qualified behavioral health provider, such as a psychiatrist, licensed clinical social worker, etc. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. These codes are intended to represent the care and management for patients with behavioral health conditions that often require extensive discussion, information-sharing, and planning between a primary care physician and a BH specialist.

The American Psychiatric Association (APA) has created a training program for primary care on the collaborative care model and the use of these codes.  It can be found at APA Training Module. 

Launched in January 2016, LiveHealth Online Psychology is a convenient and easy way for members to connect one on one with a behavioral health provider using their smartphone, tablet or computer.

Through two-way video chat, members can interact with a therapist or psychologist, day or night, by appointment. Appointments are available within 4 days or less and the cost is the same as a regular in-person therapy office visit. The therapists available on LiveHealth Online Psychology can treat issues such as anxiety, depression, stress, grief and relationship issues. For new users, it’s as simple as signing up with a name and email address.

Originally available to adults, LiveHealth Online Psychology also launched its Teen edition in July 2016, accessible by 10 to 17 year olds. To learn more, visit livehealthonline.com/psychology or call 844-784-8409.

Effective for dates of service on and after January 28, 2019, the following updates will apply to the AIM Specialty Health© (AIM) radiation oncology clinical appropriateness guidelines. AIM is a separate company.

Breast cancer

• Removed age and tumor size criteria for accelerated whole breast irradiation (AWBI)

Rectal cancer

• Modified criteria no longer limits treatment with intensity modulated radiation therapy (IMRT) for rectal adenocarcinoma

Pancreatic cancer

• Added criteria for stereotactic body radiation therapy (SBRT) in treating locally advanced or recurrent disease without evidence of distant metastasis

Head and neck cancer

• Added criteria to allow IMRT for head and neck lymphomas
• Clarified no IMRT for stage I/II glottic cancer

Lung cancer

• Added dose volume histogram (DVH) parameter for cardiac V50

Sarcoma

• Removed preoperative and joint sparing requirements for IMRT

Prostate cancer

• Added discussion on hypofractionation
• Added discussion on brachytherapy

As a reminder, ordering and servicing providers may submit pre-service clinical review requests to AIM in one of several ways:

• Access AIM’s ProviderPortalSM 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, 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 guidelines on AIM’s website.

Please note, this program does not apply to the Federal Employee Program® (FEP®) or National Accounts.

Effective for dates of service on and after January 28, 2019, the following updates will apply to the AIM Specialty Health© (AIM), clinical appropriateness guidelines: advanced imaging appropriate use criteria: imaging of the heart. AIM is a separate company.

Carotid duplex ultrasound

• Criteria removed for evaluation of syncope in patients with suspected extracranial arterial disease
• New criteria address evaluation of TAVR (TAVI) in patients with suspected or established extracranial arterial disease

Myocardial perfusion imaging (MPI), stress echocardiography, cardiac PET, and coronary CT angiography (CCTA)

• Clarifications address exercise-induced syncope and exercise-induced dizziness, lightheadedness or near syncope in symptomatic patients with suspected coronary artery disease

MPI, stress echocardiography, cardiac PET

• Criteria added to allow annual surveillance of coronary artery disease in patients with established CAD post-cardiac transplant
• Clarified definition of established coronary artery disease when diagnosed by CCTA
  • more restrictive for patients diagnosed with coronary artery disease by prior coronary angiography, as FFR must be ≤0.8
  • more permissive for patients diagnosed with coronary artery disease by CCTA with FFR ≤0.8 (patients previously excluded)

Resting transthoracic echocardiography (TTE)

• New criteria for evaluation of ventricular function in patients who have undergone cardiac transplantation

Cardiac MRI

• New criteria allows for annual study to quantify cardiac iron load in chronically ill patients with cardiomyopathy who require frequent blood transfusions (e.g., thalassemia)
• Removed allowance for annual LV function evaluation when echocardiography is suboptimal

As a reminder, ordering and servicing providers may submit pre-service clinical review requests to AIM in one of several ways:

• Access AIM’s ProviderPortalSM 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, 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 guidelines on AIM’s website.

Please note, this program does not apply to the Federal Employee Program® (FEP®).

Effective for dates of service on and after January 28, 2019, CPT code A7047 (oral interface used with respiratory suction pump) will be removed from the AIM Specialty Health© (AIM) sleep disorder management clinical appropriateness guidelines and will no longer apply. AIM is a separate company.

As a reminder, ordering and servicing providers may submit pre-service clinical review requests to AIM in one of several ways:

• Access AIM’s ProviderPortalSM 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, 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 guidelines on AIM’s website

Please note, this program does not apply to the Federal Employee Program® (FEP®).  

Extension for Community Healthcare Outcomes (ECHO)

Opioid overdose rates continue to rise. With the support of medication–assisted therapy (MAT) ECHO, you can help save lives. Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website.

Benefits of participating include:

• Addiction treatment training
• Free continuing education credits
• Opportunity to receive expert input on your (de-identified) patient cases
• Access to a virtual learning community for treatment guidelines, tools and patient resources
• Opportunity to ask questions and get a variety of support from specialists

Medication-Assisted Therapy (MAT)

To help ensure members have access to comprehensive evidence-based care, we are committed to helping providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.

When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with buprenorphine or, in some plans, methadone maintenance treatment in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.

For more information

For more information about best practices for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use.

You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for more information about the ECHO and MAT programs.

The AIM Genetic Testing program requires ordering providers to request medical necessity review of all genetic testing services for individual Medicare Advantage members.  Requesting this prior authorization will help ensure that the lab receives timely and accurate payment for these services.

Please submit genetic testing prior authorization requests to AIM through 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 Web Portal at availity.com.
• Call the AIM Contact Center toll-free number at 800-714-0040, Monday - Friday, 6:00 a.m. – 7:00 p.m.

For further questions regarding prior authorization requirements, please contact the Provider Services number on the back of the member’s ID card.

Effective January 1, 2019, we will transition our Medicare back pain management and cardiology programs from OrthoNet LLC to AIM Specialty Health® (AIM), a specialty health benefits company. We have an existing relationship with AIM in the administration of other medical management programs. 

Additional information will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider.

The Centers for Medicare & Medicaid Services has increased its emphasis on the appropriate use of statins among Medicare Advantage beneficiaries diagnosed with diabetes and cardiovascular disease. Please evaluate whether your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

The 2013 American College of Cardiology and the American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults supports the use of moderate-intensity statin therapy in persons with diabetes 40 to 75 years of age to reduce the risks of atherosclerotic cardiovascular disease (ASCVD) events. High-intensity statin therapy is recommended if the patient has an estimated 10-year ASCVD risk ≥7.5 percent. For males 21-75 and females 40-75 years of age with clinical ASCVD, high-intensity statin therapy is recommended unless contraindicated. These guidelines recommend statin therapy in these scenarios regardless of what patient LDL values are.  Please evaluate if your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

Formulary agents are listed below:

*Rosuvastatin (Crestor) is a preferred brand medication on the Medicare formulary. 

**Available for a $0 co-pay for most plans in 2018.

Per guidance established by the Comprehensive Addiction and Recovery Act of 2016, the Centers for Medicare & Medicaid Services has established provisions to develop a pharmacy and prescriber home program for opioid medications. Beginning January 1, 2019, we will work with beneficiaries and providers to help to reduce the risk of opioid dependency by streamlining access to opioid medications. If a beneficiary is exhibiting at-risk opioid medication utilization, the plan sponsor will work with the beneficiary and provider to select a pharmacy home and prescriber home for the beneficiary’s opioid medications. At risk is defined by CMS as:

1. More than 90 mg per day cumulative morphine milligram equivalent (MME)
2. More than three (3) opioid prescribers and more than three (3) opioid dispensing pharmacies, or
3. More than five (5) opioid prescribers, regardless of the number of pharmacies

• Cancer, long term care (LTC) and hospice are exempt.
• Beneficiaries will have the choice of which pharmacy or prescriber to select as their home.
• Plan sponsors will request agreement from the provider selected as the home.
• At this time, only opioid and benzodiazepine medications will be delegated to a home pharmacy or prescriber.
• Both beneficiaries and providers will receive letters to explain what is happening and how it will happen.
• Beneficiaries retain the right to request a coverage determination and may choose to change their home pharmacy or prescriber at any time.

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

• Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila 
• July Medicare Advantage reimbursement policy
• Submit PA medication requests electronically; new phone number for MA prescription PAs 
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective January 1, 2019
• Inpatient Readmissions 
• Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective September 1 
• Introducing the Interactive Care Reviewer