• Medical Policy and Clinical Guidelines Updates – April 2019*

• Specialty Pharmacy Prior Authorization List Updates*

• AIM Clinical Appropriateness Guidelines Updates*

• Reimbursement Policy Updates*

• Medicare and Medicaid Updates*

In February, Anthem Blue Cross and Blue Shield introduced a new feature on Interactive Care Reviewer (ICR) that lets you request a clinical appeal for denied authorizations. Now instead of making a phone call or sending a fax, you can save time making your request online! This feature is available for authorization requests that were submitted through ICR, phone or fax.

Here’s how easy it is to request a clinical appeal using ICR:

Logon to ICR from the Availity Portal and locate the case from ICR’s dashboard – My Organization Requests or through Check Case Status if the case was submitted by phone or fax.

• Select the Request Tracking ID link to open the case. If the case is eligible for an appeal you will see the Request Appeal menu option on the Case Overview screen.
• Select Request Appeal to open the Appeal Details screen and complete the required fields on the appeal template. (You also have the option of uploading attachments and images to support your request.)
• Select Submit.

Want to check the status of your clinical appeal?

The Check Appeal Status feature was added to ICR in December 2018.

• Select Check Appeal Status from the ICR top menu bar.
• Type the Appeal Case ID and Member ID in the allocated fields (do not include the alpha/numeric prefix).
• Select Submit.

The appeal status and detail of the decision will open on the bottom of the screen.

Additionally, you will be able to access letters associated with the appeal.

Need more information on how to navigate the new ICR Appeals features?

Download the ICR Clinical Appeals Reference Guide located on the Availity Portal. Select: Payer Spaces > Applications > Education and Reference Center > Communication and Education. Find the link to the reference guide below the ICR menu.

Additional Training

If you are new to ICR or want to get a refresher please attend our monthly ICR webinar.

Register here for the April webinar.

With both our Prospective and Retrospective approaches, accurate documentation and coding are what we are encouraging physicians to achieve. As a physician for our members with ACA compliant plans, you play a vital role in the success of our CRA reporting processes and ACA compliance. When members visit your office, we encourage you to document ALL of the members’ health conditions, especially chronic diseases on the claim. As a result, there will be ongoing documentation that indicates these conditions are being properly assessed and managed. Additional benefits of accurate coding include:

• Reduced volume in medical chart requests in the future due to the increased level of specificity in documentation and coding, as part of our Retrospective approach; and 

• Reduced volume of health assessment requests by ensuring your patients with our ACA compliant plans are seen for their annual exams each and every year, as part of our Prospective approach.

Please Note: It’s important to ensure that all diagnosis codes captured in your EMR system are included on the claims, and are not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes, but a claim system may only have the ability of capturing 4. If your claim system is truncating some of the listed diagnosis codes, please work with your vendor/clearing house to ensure all codes are being captured.

Reminder about ICD-10 CM coding

As you may be aware, the ICD-10 CM coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits. Additionally, Anthem uses ICD-10 CM codes submitted on health care claims to monitor health care trends and costs, disease management and clinical effectiveness of medical conditions.

We encourage you to follow the principles below for diagnostic coding to properly demonstrate medical necessity and complexity:

• Code the primary diagnosis, condition, problem or other reason for the medical service or procedure in the first diagnosis position of the claim whether on a paper claim form or the 837 electronic claim transaction, or point to the primary diagnosis by using the correct indicator/pointer.
  
  
• Include any secondary diagnosis codes that are actively managed during a face-to-face, provider-patient encounter, or any condition that impacts the provider’s overall management or treatment of that patient in the remaining positions. 
  
  
• Include all chronic historical codes, as they must be documented each year under the ACA (e.g. an amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).

You want what’s best for your patients’ health. So, it's challenging when a patient doesn't follow your prescribed treatment plan.  Why do approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed1? What can be done differently? The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg—the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline—the Titanic-sized, often invisible, patient self-talk that may not get discussed—can create a misalignment between patient and provider.

So we’ve created an online learning experience for the skills and techniques that may help you navigate these uncharted patient waters.  After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust, and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence—and you’ll earn CME credit along the way.

Take the next step. To enhance your skills, go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

^{1 Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions.  Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm}

Effective July 1, 2019, Anthem Blue Cross and Blue Shield (Anthem) will transition medical necessity review of rehabilitative (restoring function) and habilitative (enhancing function) services for fully insured members to AIM Specialty Health® (AIM). Currently, OrthoNet LLC is performing medical necessity reviews for physical and occupational therapy services for Anthem. These reviews will transition to AIM in addition to adding speech therapy service reviews.

AIM will manage Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) medical necessity reviews using the following Anthem Clinical Utilization Management (UM) Guidelines:

• CG-REHAB-04 Physical Therapy
• CG-REHAB-05 Occupational Therapy
• CG-REHAB-06 Speech-Language Pathology Services.

Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis. The clinical criteria to be used for these reviews can be found on the Anthem Provider website on the Clinical UM Guidelines webpage. A complete list of CPT codes requiring prior authorization for the AIM Rehabilitative program is available on the AIM Rehabilitation microsite. There you can learn more about the program and access helpful information and tools such as order entry checklists and FAQs.

AIM will begin accepting prior authorization requests on June 17, 2019 for dates of service on and after July 1, 2019. To determine if prior authorization review is needed for an Anthem member, please check online or call the pre-service review number located on the back of the member ID card. As of July 1, 2019, self-funded accounts (ASO) that currently have the OrthoNet program will also be offered the AIM Rehabilitative program. The program will also be offered to new local self-funded accounts (ASO) to add to their members’ benefit package as of July 1, 2019.

Ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortal^SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number at (800) 554-0580, Monday through Friday, 8:30 a.m. to 7:00 p.m. ET.

AIM Rehabilitation training webinars

Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM.  Go to the AIM Rehabilitation microsite to register for an upcoming webinar. If you have previously registered for other services managed by AIM, there is no need to register again. The training will be recorded and can be viewed at a time convenient for you! 

Beginning with claims processed on or after May 1, 2019 Anthem may deny the E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.

If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant and separately identifiable E/M service, please submit those medical records for consideration.

• Billed in the procedure code field in the same way as CPT Category I codes.
• Used to describe clinical components usually included in evaluation, management or clinical services.
• Billed with a $0 billable charge amount since they are not usually associated with any relative value.

Under this new incentive program, Anthem will reimburse contracted Medicare Advantage providers for submitting select HEDIS®-related CPT Category II codes for eligible members.

Using these CPT Category II codes for Medicare Advantage members will:

• Help providers address clinical care opportunities.
• Facilitate timely and accurate claims payments.

Detailed information about this program, including a list of applicable codes, will be sent to providers.

Non-contracted providers may continue treating Ozarks Schools Benefits Association members and will be reimbursed 100% of Medicare’s allowed amount for covered services, less any member cost share.

Ozarks Schools Benefits Association members’ copay or coinsurance percentage will be the same. For all services provided locally or nationwide by doctors or hospitals for in- or out-of-network treatment, the member’s cost share does not change.

The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers. The plan also covers additional benefits that Medicare does not, such as hearing, LiveHealth Online and SilverSneakers.

The prefix on the Medicare Advantage ID cards is ZMX.

Call Provider Services at 1-833-848-8730 for eligibility, prior authorization requirements and any questions about the Ozarks Schools Benefits Association member benefits or coverage.

Detailed prior authorization requirements are also available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com.

Providers will follow their normal claim filing procedures for Ozarks Schools Benefits Association member claims.

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

• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ

• Group Retiree members and National Access Plus
  
  
• 2019 risk adjustment provider training
  
  
• New provider learning opportunity: Put the AIM Provider Portal to work for you
  
  
• New provider service phone number beginning January 1, 2019