As we continue our efforts to help ensure our members enrolled in Affordable Care Act (ACA) compliant plans have their chronic conditions assessed and documented each year, we are engaging Matrix, a vendor, to help encourage members – on our behalf – to schedule a mobile health clinic assessment. Matrix operates the largest fleet of mobile medical centers nationwide and has conducted more than 1,000,000 patient assessments since 1998 – providing convenient access to comprehensive health assessments. 

The mobile clinic provides members with additional options to help them close any gaps in care that they may have. In late July, Matrix began reaching out to members on our behalf by letter and phone. Our outreach efforts will continue until the end of this year.

Matrix works with hospitals and health plans like Anthem to deliver preventive health testing to the communities Matrix serves. Each mobile clinic has a reception area and private screening rooms. Matrix also helps members with scheduling follow-up appointments with their PCPs at the end of the assessments and forwards the PCPs a copy of any results from the health assessment.

Matrix in-home assessments

Matrix will perform in-home assessments where possible. The in-home assessments offer a board-certified nurse practitioner to come to a member’s home to provide a general exam, suggestions for important screenings or other tests, a full review of the medicines they take, answers to health-related questions and a personal health summary detailing their health information. A copy of the assessment will be sent to members’ PCPs to ensure continuity of care.

The overall goals of the mobile clinic program and the in-home program are to provide convenient, comprehensive appointments that are designed to complement the care provided by our network of physicians. These mobile clinic or in-home visits do not replace any active treatment plans members currently have with their physicians and are not considered wellness visits or a substitute for members’ annual physical examinations. 

We’re including information about the program in this edition of Provider News should patients contact you about the program. Please refer members directly to Matrix if they have questions or need more information:

Mobile bus: 888-822-3247I

In-home: 855-403-0967

Continuing our 2019 CRA updates, we request your assistance in helping us to accurately report our member’s health status to the Centers for Medicare & Medicaid Services (CMS).

2019 retrospective chart request

Retrospective medical chart collection begins in November and it is the most significant and largest volume of our requests.  We appreciate your collaboration as we work through the requests and submit to your medical records department in a timely manner.

Electronic options for chart collections

We have 4 electronic options for chart collections:

1. Remote/direct Anthem access
2. Electronic medical record (EMR) Interoperability with 4 EMR systems
3. Inovalon virtual visit or onsite
4. Secure FTP

Submitting medical charts can be time consuming for your staff. Utilizing an electronic option can help alleviate the constraints on your staff’s resources and time. 

The most efficient electronic option is to allow the Anthem medical coder team to have direct connection access to your EMR system (Option 1), so that we may retrieve the records ourselves. Our team has collaborated with several providers and facilities to have direct access to their EMR systems to collect the charts. This allows for no vendor interventions and fewer handoffs of the records. To address compliance concerns, please note that as a health plan, Anthem is a covered entity under the HIPAA Privacy Rule and is bound to protect PHI. 

If you are interested in any of these electronic options, or you would like to grant Anthem medical coders direct access to your EMR system, please contact Alicia.Estrada@anthem.com, our Commercial Risk Adjustment Representative who supports your area.

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

The National Accounts 2020 precertification list has been published. Please note, providers should continue to verify member eligibility and benefits prior to rendering services.

U.S. Antibiotic Awareness Week is a one week observance that gives organizations and providers an opportunity to raise awareness on the appropriate use of antibiotics and reduce the threat of antibiotic resistance. The Centers for Disease Control and Prevention (CDC) has many tools for providers on their website. Posters, prescriptions pads, social media posts, patient education pieces, sticker and counter clings, and more can be found on the CDC website.

During U.S. Antibiotic Awareness Week and throughout the year, the CDC promotes Be Antibiotics Aware, an educational effort to raise awareness about the importance of safe antibiotic prescribing and use. Be Antibiotics Aware has resources to help healthcare professionals (in outpatient and inpatient settings) educate patients and families about antibiotic use and risks for potential side effects. For more information visit the CDC’s website.

Exciting new changes are on the horizon for the public provider site at anthem.com. These next wave of updates include:

• New Contact Us page that gives providers easy access to important contact information
• Redesigned Medicare Advantage page with an improved, effortless user experience
• New Enhanced Personal Health Care (EPHC) page that provides a more prominent and easier access to information that communicates Anthem’s role in transforming health care. (EPHC is a program designed to advance and support a patient-centered approach to care delivery.)

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!

We announced in July that the AIM Rehabilitative Program for Anthem’s Commercial membership was delayed. The AIM Rehabilitative Program for prior authorization for physical, speech and occupational therapy services is scheduled to relaunch on November 1, 2019. Prior authorization requests for dates of service on or after November 1 may be submitted beginning October 21 via the AIM ProviderPortal_SM.

Coverage for physical, speech and occupational therapy services with dates of service July 1, 2019 through October 31, 2019 will not require prior authorization; processes have been created to allow providers to continue to provide treatment and to allow claims to adjudicate for those dates of service.  Claims that were denied for no authorization in error for dates of service after July 1, 2019 are being reprocessed. The OrthoNet program is no longer active in applicable markets.

We invite you to take advantage of an informational webinar that will introduce you to the Rehabilitative Program and the capabilities of the AIM ProviderPortal_SM. Visit the AIM Rehabilitation microsite to register for an upcoming training session.

Visit our website for information about how you can assist your patients in managing the “Donut Hole.”

Visit our website for information about the prior authorization requirements for continuous positive airway pressure supplies.

Visit our website for information about lowering health risks with no-cost statins.

Visit our website for information about the clinical laboratory improvement amendments for Anthem Blue Cross and Blue Shield.

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. 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.

To view a guideline, visit the provider website at www.anthem.com/medicareprovider.

Notes/updates

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

• *DME.00037 - added devices that combine cooling and vibration to the investigational and not medically necessary statement
• *LAB.00027 - added Mediator Release Test to investigational and not medically necessary statement
• *LAB.00033 - clarified investigational and not medically necessary statement to include 4Kscore and AR-V7
• *OR-PR.00003:
  • Clarified medically necessary position statement criteria 2 through 4
  • Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered investigational and not medically necessary for all indications
• *SURG.00011:
  • Added new medically necessary and investigational and not medically necessary statements addressing amniotic membrane-derived products for conjunctival and corneal indications, including KeraSys and Prokera
  • Added new products to investigational and not medically necessary statement
• *SURG.00045:
  • Added erectile dysfunction, Peyronie’s disease and wound repair to the investigational and not medically necessary statement
  • Revised title
• *SURG.00121 - added investigational and not medically necessary statement to address use of transcatheter tricuspid valve repair or replacement for all indications

• The following AIM Specialty Health® updates were approved on June 6, 2019:
  • Advanced imaging:
    • Imaging of the heart
    • Oncologic imaging
    • Vascular imaging
  • Proton beam therapy
  • Rehabilitative therapies - physical therapy, occupational therapy and speech therapy (new)

View the PDF attachment to this article for the list of medical policies and clinical UM guidelines that were approved on June 6, 2019 by the Anthem Medical Policy and Technology Assessment Committee (MPTAC). 

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On February 22, 2019 and March 14, 2019, the Anthem Pharmacy and Therapeutics (P&T) Committee approved changes to clinical criteria applicable to the medical drug benefit. These policies were developed, revised or reviewed to support clinical coding edits.

The clinical criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Q1 web posting. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.

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Effective November 1, 2019, we will require prior authorization (PA) for Anthem Medicare Advantage members for the following services. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions), take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following codes:

• 0026U - Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
• 0533T - Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
• 0534T - Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
• 0535T - Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
• 0536T - Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
• 0546T - Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
• 33270 - Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
• 33271 - Insertion of subcutaneous implantable defibrillator electrode
• 77299 - Unlisted procedure, therapeutic radiology clinical treatment planning
• 81205 - BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., Maple syrup urine disease) gene analysis, common variants (e.g., R183P, G278S, E422X)
• 81219 - CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9
• 81250 - G6PC (glucose-6-phosphatase, catalytic subunit) (e.g., Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (e.g., R83C, Q347X)
• 81302 - MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis
• 81303 - MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant
• 81304 - MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants 
• 81331 - SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81332 - SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81400 - Molecular pathology procedure, Level 1 (e.g., identification of single germline variant e.g., SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (e.g., medium chain acyl dehydrogenase deficiency)
• 81401 - Molecular pathology procedure, Level 2 (e.g., 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (e.g., acquired imatinib resistance)
• 81402 - Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81402 - Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (e.g., congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (e.g., IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81407 - Molecular pathology procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (e.g., generalized epilepsy with febrile seizures), full gene sequence
• 81408 - Molecular pathology procedure, Level 9 (e.g., analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (e.g., Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (e.g., neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (e.g., malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (e.g., von Willebrand disease types 1 and 3), full gene sequence
• 97033 - Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
• C9042 - Injection, bendamustine hcl (belrapzo), 1 mg
• C9043 - Injection, levoleucovorin, 1 mg
• C9141 - Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
• D9130 - Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
• D9920 - or management, by report
• J9999 - Not otherwise classified, antineoplastic drugs
• S3850 - Genetic testing for sickle cell anemia

To request PA, you may use one of the following methods:

• Web: https://www.Availity.com
• Phone: Call the Provider Services number on the back of the member’s ID card for PA requirements.

Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.Availity.com. Contracted and noncontracted providers who are unable to access Availity may call the Provider Services number on the back of the member’s ID card for PA requirements.

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Our Medicare Risk Adjustment Regulatory Compliance team developed two provider training programs regarding Medicare risk adjustment guidelines. Information for each training is provided below:

Medicare risk adjustment and documentation guidance (general)

• When - offered the first Wednesday of each month from December 5, 2018, to November 6, 2019 at 1:00 p.m. to 2:00 p.m. Eastern time
• Learning objective - This training will provide an overview of Medicare Risk Adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) Model, with guidance on medical record documentation and coding.
• Credit - This activity has been reviewed and is acceptable for up to one prescribed credit by the American Academy of Family Physicians.

If you are interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register here for one of the monthly training sessions.

Medicare risk adjustment, documentation and coding guidance (condition specific)

• When - offered on the fourth Wednesday of every other month from January 23, 2019 to November 27, 2019 from noon to 1:00 p.m. Eastern time
• Learning objective - This is a collaborative learning event with Enhanced Personal Health Care (EPHC) to provide in-depth disease information pertaining to specific conditions including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
• Credit - This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians.

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

• Red flag HCCs, part one – Register here for recording of live session. Training will cover HCCs most commonly reported in error as identified by CMS: chronic kidney disease (stage 5), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease. Recording will play upon registration.

• Red Flag HCCs, part two – Register here for recording of live session. Training will cover HCCs most commonly reported in error as identified by CMS: atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, and diabetes with ophthalmologic or unspecified manifestation. Recording will play upon registration.

• Opioids and more: substance abuse and dependence – Register here. Recording will play upon registration.

• Acute, chronic and status conditions – Register here. Recording will play upon registration.

• Behavioral health – Register here. November 27, 2019

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The Aspire Health Telehealth Palliative Care program provides an additional layer of telephonic support to members facing a serious illness. Aspire Health is an independent company providing telephonic palliative care on behalf of Anthem. The program is focused on:

• Helping patients understand their diagnosis
• Facilitating conversations with patients and their families around their goals of care
• Helping to ensure patients receive care aligned with their goals and values

The program begins with an initial 30 to 60 minute telephonic assessment by a specially trained Aspire Health social worker. The conversation in this initial call focuses on building rapport and completing a comprehensive assessment. This assessment includes understanding the patient's perception of their illness and current treatment plan. Follow-up calls occur every 2 to 4 weeks, typically lasting 15 to 45 minutes, with the exact frequency based on a patient's individual need.

Aspire Health's social workers are supported by a full interdisciplinary team of board-certified palliative care physicians, nurses, and chaplains who provide additional telephonic support to patients and their families as needed. Patients enrolled in the telehealth program have access to 24/7 on-call support. The average patient is enrolled in the program for 6 to 8 months with some of the key goals being the ability for patients to teach-back their current medical situation, articulate their health and quality-of-life goals, and establish a future care plan through either the completion of advanced care planning documents and/or a transition to hospice when appropriate.

More information is available at www.aspirehealthcare.com or by calling the 24/7 Patient & Referral Hotline at 844-232-0500.

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On January 1, 2020, Anthem will implement a preferred edit on Medicare-eligible continuous glucose monitors (CGMs). Currently, there are two CGM systems covered by the Centers for Medicare & Medicaid Services (CMS) under the Medicare Advantage Part D (MAPD) benefit; these are Dexcom and Freestyle Libre. The preferred CGM for MAPD individual members covered by Anthem will be Freestyle Libre. This edit will only affect members who are newly receiving a CGM system. Members will need to obtain their CGM system from a retail or mail order pharmacy – not a durable medical equipment (DME) facility. For Dexcom coverage requests, call 833-293-0661.

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