Digital Request for Additional Information (Digital RFAI) is the fastest and easiest way to get us the documents we need to process your claim. Now, it is even better! We’ve added filter, sort, and search features for greater productivity. 

New filtering functions are ideal for organizations where more than one person is responsible for submitting claim attachments. Another great feature: your filters are saved (locked) – so you can see your desired filter view each time you log on but easily clear them when your search criteria changes. 

We are committed to shared success and reporting is just another way we are giving Digital RFAI users a productivity boost. We’ve added reporting fields that can be used for both History and Inbox reports.

Fields available for History and Inbox reports

Expanded reporting fields are downloadable! Use the download option to meet your specific reporting requirements.

We’re here to help! 

Want to know more about receiving digital notifications for faster claims processing? Visit the Digital RFAI learning microsite or reach out to your Provider Relations Account Manager.

Description/Approach 

Provider performance can vary widely in relation to efficiency and quality. Our goal as your Medicare health plan partner is to ensure our members receive high-quality care that leads to improved member health outcomes across a wide range of variables. 

We will add a new sorting option on the Find Care tool for members to leverage when they are searching for a non-PCP specialist provider. This sorting option, called Personalized Match Phase 1, is based on each provider’s score relative to their peers in the patient’s preferred mileage search radius. Providers will be listed in order of their total score, though no individual scores will appear within the tool or be visible to the covered patients. The Personalized Match Phase 1 algorithm will be based on quality and efficiency criteria to assist members in making more informed choices about their medical care. Other sorting options will still be available on Find Care for our members. Members should consider a variety of factors when making decisions for choosing a specialist provider to manage their care. 

We evaluate provider groups and individual providers annually, using updated quality and efficiency methodologies and data.

Continue reading the rest of this article

We understand that providing the information needed to process a claim can cause payment delays, and the manual methods associated with mailing letters and returning information non-digitally is costly and inefficient.

We’re changing that by implementing a new process: Digital Request for Additional Information (Digital RFAI), and we’re inviting you to participate.

Digital requests for additional information are 50% faster than returning documentation any other way — making it the most efficient way to receive and return information — resulting in faster claim payments. 

Participation in Digital RFAI is easy

1. Registration:
   • Your organization’s Availity* administrator will register for Medical Attachments:
     • This enables you to receive digital notices (instead of paper) and to attach the requested documents directly to your claim.
     • Ensure all of your billing NPIs/TINs are registered.
2. User roles:
   • Your Availity administrator will also update or add new users with these specific role assignments through Availity Essentials:
     • Claims Status
     • Medical Attachments
   • This enables the users to view the Availity Attachment Dashboard.
3. Ready to go:
   • After the registration and user roles are completed on Availity, the Digital RFAI process is ready to go. 
   • Requests will automatically appear on the Attachments Dashboard each morning (when documents are needed).

Additional support

You, your organization’s Availity administrator, or other members of your team may need additional support – and we’re to help:

• For Availity Administrators: Take this training to ensure your NPIs are registered properly. 
• For those sending attachments: Take this user training to learn about accessing notifications, sorting and filtering, and other enhancements that improve your experience. 

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partner. For additional resources, visit the Digital RFAI webpage or contact your Provider Relations Account Manager. 

AMH Health, LLC is transitioning to the Availity Essentials* Authorization application.

You may already be familiar with the Availity multi-payer Authorization app because thousands of providers are already using it for submitting prior authorizations for other payers. AMH Health is eager to make it available to our providers, too. In September, you can begin using the same authorization app you use for other payers for AMH Health.

Interactive care reviewer (ICR) is still available

If you need to refer to an authorization that was submitted through ICR, you will still have access to that information. We’ve developed a pathway to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization app. To make it even more convenient, you can pin your authorizations from the ICR application to your Availity Authorization app dashboard.

Innovation in process

While we grow the Availity Authorization app to provide you with AMH Health -specific information, you will still need to access ICR for:

• Appeals.
• Behavioral health authorizations and inquiries.
• Federal Employee Program^® authorizations and inquiries.
• HealthLink authorizations and inquiries.
• Medical specialty prescription authorizations and inquiries.

Notices in the Availity Authorization app will guide you through the process for accessing ICR for alternate authorization and appeals functions.

Training is available

If you aren’t already familiar with the Availity Authorization app, training is available. Visit the training site to enroll for an upcoming live webcast or to access an on-demand recording at the Availity Authorization training site.

Now, give it a try

Accessing the Availity Authorization app is easy. Ask your organization’s Availity administrator to ensure you have the Authorization role assignment. Without the role assignment, you will not be able to access the Authorization application. Then, just log onto Availity.com to access the app through the Patient Registration tab by selecting Authorizations and Referrals. 

Starting mid-September, search for patient information in Availity Essentials* Eligibility and Benefits without having a member ID. We’ve updated and streamlined the process to eliminate the need for the member ID while maintaining the highest HIPAA standards. Easily search for patient eligibility and benefits details using the Patient Search option of patient last name, patient first name, date of birth, and patient zip code.

Find Eligibility and Benefits Inquiry on Availity’s top menu bar under Patient Registration. Once it becomes available, make sure to use the new search feature when you need to find member information and do not have access to the member ID.

Need the member ID for another capability in Availity Essentials? When you use the new search option in Eligibility and Benefits Inquiry and see the eligibility and benefits details, the member’s current ID details will be available and allow you to transact within other digital capabilities where the member ID is required. 

Watch for more information on the Availity Essentials home page under News and Announcements to notify you when this feature is available. 

Get access to Availity Essentials now

If you and your organization aren’t currently registered for Availity Essentials, now is the time to make that happen. Availity Essentials offers secure online access for working together and is free to our providers. To register, visit the availity.com Registration Information page.

Effective December 1, 2023, prior authorization (PA) requirements will change for the following code(s).  The medical code(s) listed below will require PA by AMH Health, LLC for Medicare members. 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 precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com.* Providers may also call the number on the back of the member’s ID card for assistance with PA requirements.

The following services will be added to precertification for the effective dates listed below.

To obtain precertification, providers can access Availity Essentials* (Availity.com) or call Anthem Blue Cross and Blue Shield’s Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved. Precertification can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider.

Effective for dates of service on and after December 1, 2023, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.* (formerly AIM Specialty Health_®).

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

• Access Carelon’s ProviderPortal_SM directly at www.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 Carelon via the Availity Essentials* website at www.availity.com.

Note: This update does not apply to the Federal Employee Program^®.

If you have any questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Beginning with dates of service on or after December 1, 2023, Anthem Blue Cross and Blue Shield will expand the current Documentation Standards for Episodes of Care — Professional reimbursement policy to apply to facility providers. This policy outlines how and what elements must be documented for an episode of care.

The policy will be retitled Documentation Standards for Episodes of Care — Professional and Facility.

Effective as of June 14, 2023, Anthem Blue Cross and Blue Shield updated the Documentation and Reporting Guidelines for Evaluation and Management (E/M) Services reimbursement policy to include the 2021 American Medical Association (AMA) CPT^® Level of Medical Decision Making (MDM) table to align with the 2021-2023 Centers for Medicare & Medicaid Services (CMS) and AMA-CPT code changes. This table will be listed under the policy section titled Selecting a Level of Medical Decision Making for Coding an E/M Service. When determining the level of E/M service using MDM, this table will be used instead of the 1995/1997 CMS risk tables and the Marshfield Clinic tables.

Additional updates to this reimbursement policy are as follows:

• Documentation submitted in accordance with this reimbursement policy will remain subject to signature and other requirements as stated in the related Documentation for Episodes of Care reimbursement policy. Therefore, the policy was updated to include the following note: All documents are subject to the Documentation Requirements for Episodes of Care policy.
• The Related Coding section was expanded to include “other” E/M services, as defined in the policy.

For specific policy details, visit the corresponding reimbursement policy page from the list below:

• Colorado
• Connecticut
• Georgia
• Indiana
• Kentucky
• Maine
• Missouri
• Nevada
• New Hampshire
• Ohio
• Wisconsin

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

Effective June 14, 2023, Anthem Blue Cross and Blue Shield’s split care surgical modifier language was removed from the Global Surgical Package — Professional reimbursement policy and added to a new standalone reimbursement policy titled Split Care Surgical Modifiers — Professional. This policy allows reimbursement based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure. The percentage is determined by the modifier that is appended to the procedure code. The Related Coding section of the policy identifies the applicable modifiers and standard reimbursement percentages.

For specific policy details, visit the reimbursement policy page at anthem.com.

Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Anthem's Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.^*, a separate company.  

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Including the National Drug Code (NDC) code on your claim may help expedite claim processing of drugs billed with a not otherwise classified (NOC) code. 

Prior authorization updates

Effective for dates of service on and after December 1, 2023, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process. 

Access our Clinical Criteria to view the complete information for these site of prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Quantity limit updates

Effective for dates of service on and after December 1, 2023, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

The following Clinical Criteria documents were endorsed at the June 12, 2023, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

New Clinical Criteria effective December 1, 2023

The following Clinical Criteria are new:

•    CC-0241 Elfabrio (pegunigalsidase alfa-iwxj)*

•    CC-0242 Epkinly (epcoritamab-bysp)*

•    CC-0243 Vyjuvek (beremagene geperpavec)*

Revised Clinical Criteria effective December 1, 2023

The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:

•    CC-0015 Infertility and HCG Agents*

•    CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications*

•    CC-0062 Tumor Necrosis Factor Antagonists*

•    CC-0177 Zilretta (triamcinolone acetonide extended-release)*

* The applicable policy is attached to this article in PDF format.

Effective April 5, 2023, Sublocade^® can no longer be filled at Accredo Specialty Pharmacy.* Members currently filling through Accredo Specialty Pharmacy will need to switch to CVS Specialty Pharmacy.*   A member of the CVS Specialty Pharmacy Care team will be contacting prescribers to obtain a new prescription. Prescribers can contact CVS Specialty Pharmacy at 877-254-0015.

The following Part B medications from the current Clinical Criteria Guidelines are included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below. 

There are no clinical changes to Clinical Criteria CC-005, Hyaluronan Injections. Based on feedback, the table listing the preferred and non-preferred products has been updated to present the information in a more useful manner. The updated table identifies preferred alternatives based on injection series. 

Clinical Criteria Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

**This collateral ran originally in the July 1, 2023, newsletter and was also posted on the provider portal with an October 1, 2023, effective date. The new date of service will begin on November 1, 2023.** 

Effective for dates of service on and after November 1, 2023, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.  

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.