We will begin publishing new indicators in our online provider directories to help members easily identify facilities and physicians designated as medication assisted treatment (MAT) providers for opioid use disorder.

These directory indicators fall into four categories related to MAT:

• Facility that provides MAT
• Physician who provides MAT
• Facility with a certified opioid treatment program
• Facility that provides counseling for opioid use disorders

We encourage facilities and individual providers who provide these services to update their demographic information so these MAT indicators can be added to our directories. To submit updated demographic information, please visit anthem.com and locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.

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On August 15, 2020, we introduced Interactive Care Reviewer (ICR), Anthem’s online authorization tool for members enrolled in an Anthem Plan. ICR is also available for members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (Federal Employee Program® or FEP). ICR is accessed through the Availity Portal and can be used for many of your medical and behavioral health prior authorization requests. You will be able to submit authorization requests, check case status, update cases and request clinical appeals using one tool and one secure portal. 

Ask your Availity administrator to grant you the required ICR role assignment now so you can begin using the tool immediately.

• Do you create and submit prior authorization requests?

You’ll need the Authorization and Referral Request role assignment.

• Do you check the status of the case or results of the authorization request?

You’ll need the Authorization and Referral Inquiry role assignment

Once you have the role assignment, follow these steps to navigate to ICR through Availity.

• Select Patient Registration from Availity’s home page
• Select Authorizations & Referrals
• Select Authorizations (for requests) | Select Auth/Referral Inquiry (for inquiries)

Register for our September ICR webinars.

We offer training every month to familiarize new users with ICR features and navigation of the tool. Our next webinars are taking place on September 2 and September 16. Register Here

Can’t make it to the webinar?

Follow the steps outlined below to access self-paced videos located on the Custom Learning Center.
From Availity’s home page, select Payer Spaces | Anthem tile | Applications | Your Custom Learning Center.

1. Select Catalog from the menu located on the upper left corner of the Custom Learning Center screen
2. Use the catalog filter and select Interactive Care Reviewer-Online Authorizations or Authorizations from the Category menu
3. Click Apply then enroll for the courses (videos) you want to view.

Illustrated reference guides that you can print are located on Custom Learning Center Resources. Select Resources from the menu located on the upper left corner of the screen. Use the catalog filter and select Authorizations or Interactive Care Reviewer-Online Authorizations from the Category menu. Select Download to view and/or print the reference guide.

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Migrate your EDI transactions to Availity today! We want to remind you, as the Availity migration continues full speed ahead, we will guide you to make it an effortless transition without having to rush.

If you, your clearinghouse or vendor have already migrated over to Availity, thank you and you are a step ahead! If not, start the process today to make the transition before September 15, 2020.

Take action now! Availity setup is simple and at no cost for you!

Use this link to learn about Availity to get started today. 

All EDI transmissions currently sent or received today via the Anthem gateway are now available on the Availity EDI Gateway. 

• 837 Institutional and Professional
• 837 Dental
• 835 Electronic Remittance Advice
• 276/277 Claim Status
• 270/271 Eligibility Request
• 275 Medical Attachments
• 278 Prior Authorization/Referrals
• 278N Inpatient Admission and Discharge Notification

Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:

• Transition your existing connection with Anthem and become a direct submitter with Availity.
• Use your existing Clearinghouse or Billing Company for your EDI transmissions. (Work with them to ensure connectivity to the Availity EDI Gateway).
• Use Direct Single Claim entry through the Availity Portal with the new attachment function

Share with your team what you learn

Enroll in one of Availity’s free courses and training demos at your convenience. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.

Follow these steps to register with Availity:

1. Log in and select Help & Training | Get Trained to open the Availity Learning Center in a new tab Search Catalog field and choose. It is your dedicated ALC account.
2. Search by keyword (Medical Attachments/Attachments) to find on-demand and live training options.
3. Click Enroll to enroll for a course and then go to your Dashboard to access it any time.

For questions, contact Availity Client Services at 1-800-Availity (800-282-4548) for assistance Monday – Friday, 8:00 a.m. – 7:00 p.m.

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Patient360 is a real time dashboard you can access through the Availity Portal that gives you a full 360° view of your Anthem patient’s health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.

What’s new: 

Medical providers now have the option available to include feedback for Anthem members who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.

Once you have completed the required fields on the Availity Portal to access Patient360, you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

First, you need to be assigned to the Patient360 Role which your Availity Administrators can locate within the Clinical Roles options.

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

Do you need a job aid to help you get started?

The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal, and instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center.

• From Availity’s home page select Payer Spaces | Anthem payer tile| Applications | Custom Learning Center
• Select Resources from the menu located on the upper left corner of the page
  • (To use the catalog filter to narrow the results select Payer Spaces from the Category menu.)

• Select Download to view and/or print the reference guide

Anthem now offers a full suite of options to assist with medical record submissions. To ease your administrative burden and recognizing your staff may be working remotely, we have increased the intake channels for required medical records supporting claim submissions.

Leverage any of the following Availity-hosted channels for electronic claim attachment transmission:

• EDI Transaction: X12 275 Patient Information (version 5010)
  • Anthem supports the industry standard X12 275 transaction for electronic transmission of supporting claims documentation including medical records (pdf, jpeg, tif file types). Access your X12 275 Companion Guide for more details.
  • Electronic Integrated Submission – Submit the claim via EDI 837 batch file and supporting documentation via x12 275.
• Availity Secure Provider Portal Options
  • Direct Data Entry (DDE) – The direct data entry claim application allows you to upload supporting documentation for a defined claim (unsolicited process).
  • Attachments - New tool - Submit solicited or unsolicited supporting documentation for your claims

Attend an Availity hosted webinar to learn more about all capabilities.

Start your transition today!

Start now to adopt these new processes and experience the many advantages to using an electronic option for claim attachment submission. You may find you are able to use these new processes to replace your more manual processes of submitting supporting documentation via fax or US Mail.

Advantages:

• Easy submission of medical documentation to include but not limited to:
  • itemized bills
  • medical records
  • discharge summaries
• Less administrative burden – medical records submitted electronically save an average of 4 minutes per record for staff vs. faxing or mailing your records in
• Electronic acknowledgment with a transaction audit trail – confirm delivery/receipt
• Comprehensive history – view past medical record submissions by your organization
• Administrative savings – reduce your mailing expense and/or fax related expenses

Want to learn more? 
Register for an upcoming webinar session.

1. In the Availity Portal select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options.
• In the Catalog, search by webinar title or keyword (medattach).
• Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you’ll receive emails with instructions to join the session.

September and October webinars

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We are offering providers using Change Healthcare for revenue cycle management an opportunity to have a streamlined in-workflow solution native to Relay Assurance application.

Starting September 1, 2020, we will launch the use of Change Healthcare’s Medical Attachment functionality for electronic communications as an additional digital option. This new functionality allows providers to upload medical records and itemized bill documents electronically instead of through traditional paper communications. This functionality can improve communications and increase transparency for medical record requests and will not otherwise impact the audit program.

Important facts regarding this change:

• This change only affects providers who use Assurance Reimbursement Management™ from Change Healthcare and have opted in to using the Attach Assist functionality.
• The new functionality is only for medical record requests for postpay claims for the Payment Integrity Quality Claims Review (Provider Audit) department only.
• There will be no duplicate requests (either paper or electronic). If you opt to use this method, paper requests for medical records will not be sent.
• In Assurance Reimbursement Management™, requests for additional documentation will be displayed to the user on the History tab of the claim. Assurance will be configured such that these requests drive workflow to help ensure they are brought to the user’s attention.
  • The original letter, historically sent via paper, is accessible as a PDF electronic copy in the provider’s downloads folder in Assurance for review. The letter content is exactly the same as it was in paper format.
  • Each request letter (first, second and final attempt) will have a timeframe for responding to the request. After the timeframe has passed for that letter, you will not be able to respond to that letter. If you wish to upload medical records after the response time has expired, please refer to the Change Healthcare training referenced below.
  • Providers can respond to the request by uploading records in Assurance Attach Assist. The attachments are received in almost real time and are delivered electronically to the payer’s systems through secure means. Records can be accessed through a hyperlink in Assurance Attach Assist for the particular claim the record is associated.
• The following is out of scope or not impacted:
  • Vendor requests for medical records on behalf of the payer
  • Providers who do not use Assurance Reimbursement Management™ Attach Assist from Change Healthcare or have not configured Attach Assist within Assurance Reimbursement Management™
  • The request timing of request letter and the verbiage in the request letter
  • The Program Integrity Special Investigations Unit postpay review is not included at this time.

Resources

Training is available on the Change Healthcare Connect Center.

Can I start using the functionality earlier?

Yes, you can. If you chose to opt in earlier, please ensure you are configured within Assurance Reimbursement Management™. Reach out to your Provider Solutions contact or request early access via email at dl-Prod-ChangeHealthcare-Provider-Support@anthem.com.

For additional information, see the attached PDF Change Healthcare Medical Attachment Functionality FAQ.

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We understand you are committed to providing the best care for our members, which may now include telehealth visits. Telehealth visits are an acceptable form for seeing your patients, and assessing if they have risk adjustable conditions in support of the Anthem Commercial Risk Adjustment (CRA) prospective program. The prospective program is well under way for 2020, and focuses on member health assessments for patients with undocumented Hierarchical Condition Categories (HCC’s), in order to help close patients’ gaps in care. We continue to provide updates regarding the prospective program to solicit your help getting patients in for a wellness visit before the calendar year ends, and we offer incentives to recognize your efforts (see details below.)

Inovalon requests

Inovalon – an independent company that provides secure, clinical documentation services – helps us comply with the provisions of the Affordable Care Act (ACA) that require us to assess members’ relative health risk levels. Please submit health assessments to Inovalon when completed and if you have questions, 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:

1. 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;
2. Submit a Health Assessment documenting the previously coded or suspected diagnoses (also called SOAP Notes - Subjective, Objective, Assessment and Plan).

Incentives offered for properly submitted Health Assessments:

• $100 for each Health Assessment properly submitted electronically via Inovalon’s ePASS® tool
• $50 for each Health Assessment properly submitted via fax

ePASS® training is available to ensure health assessment completion accuracy:

• Training webinars every Wednesday - 3:00 p.m. - 4:00 p.m. 
• 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. Information will be provided on how to join the webinar.

Alternative engagement

Inovalon’s ePASS® tool is our preferred method for submission. However, we offer alternate options to be flexible and meet your needs. If in 2019 your practice utilized these alternative options for prospective member outreach, we thank you for continuing to utilize these alternative forms of program participation in 2020.

For those providers not familiar with alternative options, they are listed here. Telehealth visits are also an acceptable form of a patient visit for these alternative engagement options.  

• 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. No health assessment needed. Not eligible for additional incentive because CRA will get the diagnosis for gap closure through claims submission.
• EPIC Patient Assessment Form (PAF) - Providers with EPIC as their electronic medical record (EMR) system can fax the EPIC PAF to Anthem CRA at 855-244-0926 with a coversheet indicating "see attached Anthem Progress Note,” which is eligible for a $50 incentive payment.
• Providers Existing Patient Assessment Form (PAF) - Utilizes providers’ existing EMR system and applicable PAF. Must be submitted to Anthem CRA at 855-244-0926 with coversheet indicating, "see attached Anthem Progress Note“ which is eligible for a $50 incentive payment.

If you have any questions please contact Alicia Estrada, the Commercial Risk Adjustment Network Education Representative, at Alicia.Estrada@anthem.com.

Thank you for your commitment to assessing your patient’s health and closing possible gaps in care.

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On May 15, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield and AMH Health, LLC. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting May 2020 (Anthem) Clinical Criteria Web Posting May 2020 (AMH Health). Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

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As you know, AIM Specialty Health_® (AIM) administers the musculoskeletal program for Medicare Advantage members, which includes the medical necessity review of certain surgeries of the spine, joints and interventional pain treatment. For certain surgeries, the review also includes a consideration of the level of care.

Effective December 1, 2020, two joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM guideline, it is generally appropriate to perform these two procedures in a hospital outpatient setting. To avoid additional clinical review for these surgeries, providers requesting prior authorization should either choose hospital observation admission as the site of service or hospital outpatient department (HOPD).

We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:

• Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
• Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.

On January 1, 2020, CMS removed total hip arthroplasty as well as six spine codes from the inpatient only (IPO) list making these procedures eligible for payment by Medicare in the hospital outpatient setting in addition to the hospital inpatient setting. The two-midnight rule should guide providers on the expected reimbursement. The codes that were removed from the inpatient only list and are also in the AIM Musculoskeletal program are 27130, 22633, 22634, 63265 and 63267. CMS has established a two year grace period (ending December 31, 2021) for site of service reviews of these codes in order to facilitate provider transition to compliance with the two-midnight rule. To this end, it is recommended that providers choose hospital observation or HOPD during the prior authorization process when clinically appropriate to the respective patient. Choosing hospital observation still allows for the surgery to be performed and recovered in the main hospital, so long as discharge is planned for less than two midnights. Alternatively, the provider may choose to perform the procedure in the HOPD. However, the inpatient setting will still be approved should the provider decide it is the optimal setting for the member.

Providers should continue to submit prior authorization requests to AIM using one of the following ways:

• Access AIM ProviderPortal_SM directly at http://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 Portal at http://www.availity.com.
• Call the AIM toll-free number at 800-714-0400, Monday – Friday, 8:00 a.m. to 8:00 p.m.

If you have questions, please contact the provider number on the back of the member’s ID card.

AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is and independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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

• AIM Musculoskeletal program expansion