 Provider News MissouriAugust 2022 Anthem Provider News - MissouriIn April 2022, AIM Specialty Health® (AIM)® launched new phone numbers for prior authorization requests for Anthem Blue Cross and Blue Shield.
Effective August 15, 2022, the old phone number for AIM will no longer be available for requests. Please use these new numbers to submit AIM prior authorization requests.
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State
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AIM phone number
effective April 1, 2022
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Indiana
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(833) 775-1952
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Kentucky
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(833) 419-1357
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Missouri
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(833) 305-1807
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Ohio
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(833) 404-1678
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Wisconsin
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(833) 342-1253
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The best way to reach AIM is to use the ProviderPortalSM for:
- Self-service
- Available 24/7
- Customizable with physician information
- Easy to use and allows real-time determinations
The ProviderPortal is a fast and efficient way to start a case. It also allows your team to:
- Check order status and view order history
- Print/save PDF of order summary
- Use multiple staff members to enter/view the practice’s orders
- Increase payment certainty
- Reference desk training and tutorials, including clinical criteria and CPT lists
Your first step is to register your practice in ProviderPortal. If you are not already registered, go to providerportal.com to register.
As a reminder, Anthem Blue Cross and Blue Shield’s current Outpatient Prepay Itemized Bill Review Program reviews outpatient claims more than $100,000 billed at a percent of charge prior to reimbursement to ensure items and services included on the claim are reimbursable. We are expanding the prepay program launched in 2021 requiring an itemized bill review for all outpatient services as follows:
- Effective for dates of service on or after July 1, 2022, we will add host claims and ambulatory surgery centers (ASCs) in scope.
According to the American Medical Association (AMA) Current Procedural Terminology® (CPT) guidelines, a new patient is defined as one who has not received any professional services, i.e. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after 30-day notice, Anthem Blue Cross and Blue Shield will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.
Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual or resubmit the claim with an established patient E/M.
If you have questions on this program, contact your contract manager or Provider Experience representative.
Submitting your updates promptly helps ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information we show in our online directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Using this form, you can update:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging that we received your request. See the Provider Maintenance Form for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
Digital claims attachments expedite claims processing and payment. That’s why we have been hard at work making the digital attachment process easier, more intuitive and streamlined. Now you can add attachments directly to your claim by using the new Send Attachments feature from the Claims Status application on Availity.com.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time because there is no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and personal health information.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the Attachment Control Number, there are three options for submitting attachments:
- Through the Attachments Dashboard Inbox:
- From availity.com select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox
- Through the 275 attachment:
- Important: You must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment
- Through the Availity.com application:
- From Availity.com, select the Claims & Payments tab to access Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
If you submitted your claim through the Availity Essentials application:
- Simply submit your attachment with your claim
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and access Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
Learn more about the Send Attachment feature
In collaboration with Availity Essentials, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status workflow.
Sign up for a live webinar today:
Now open for learning!
Access to training for Availity Essentials can be helpful when trying to master applications like claims attachments, authorizations and eligibility and benefits. The Provider Learning Hub on Anthem.com is not only a new way to access training, it also offers a new learning experience.
Short, easy to follow training videos with supporting resources are available on the Provider Learning Hub – no username and password required. Access it at your convenience and share your learnings with others on your teams. Handy filtering options enable you to quickly find what you are looking for including an option to save trainings to a Favorites folder for easy access later. You will register for the Provider Learning Hub once. On future visits your preferences are populated, eliminating the need for any additional logon information.
Get started today
Access the Provider Learning Hub using this link or from Anthem.com under Important Announcements on the home page.
Reductions in missed appointments are significant.
Telehealth visits are having a significant impact on missed appointments according to a study published in Counselling Psychology Quarterly. Prior to transitioning to telehealth, clinicians in the study “Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice,1” experienced a 14.25% missed appointment rate. After transitioning to telehealth, the missed appointment rate fell to 5.63%.
Rate of missed appointments before and after transitioning to telehealth
The graph below illustrates the changes in the average rate of missed appointments (cancellations and no-show) for each of the eight clinicians in the study between the periods before and after the transition to telehealth.
“While there are a number of limitations to consider regarding this data, which is further discussed in the study, the statistically significant reduction in missed appointments pre-and-post digital transition is striking,” cited in the study report.
Telehealth and telephone visits with members after a behavioral health inpatient stay meet HEDIS® criteria for the measure: Follow-up after Hospitalization for Mental Illness (FUH). With transportation being one of the barriers to after hospitalization follow-up, telehealth visits could be an ideal solution.2
The FUH HEDIS measure evaluates:
- Members (6 years and older) who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.
Two areas of importance for this HEDIS measure are:
- The percentage of behavioral health inpatient discharges for which the member received follow-up within seven days after discharge
- The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.
These two consecutive follow-up appointments are paramount to positive outcomes as well as meeting this HEDIS measure. Telehealth visits can greatly increase the likelihood of keeping follow-up appointments leading to reduced numbers of rehospitalization and more favorable outcomes for these patients. To learn more about the FUH HEDIS measure, visit the National Committee for Quality Assurance (NCQA) website.
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Anthem’s medical specialty drug review team manages prior authorization clinical review of non-oncology use of specialty pharmacy drugs. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Important to note
Currently, your patients may be receiving these medications without prior authorization. Effective November 1, 2022, you may be required to request prior authorization review for your patients’ continued use of these medications.
By including National Drug Code (NDC) on your claim, you will 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 November 1, 2022, 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 prior authorization updates.
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Clinical Criteria
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Drug
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HCPCS or CPT Code(s)
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ING-CC-0072
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Alymsys (bevacizumab-maly)
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C9399, J3490, J3590
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ING-CC-0107*
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Alymsys (bevacizumab-maly)
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C9399, J3490, J3590, J9999
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ING-CC-0216*
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Opdualag (nivolumab and relatlimab-rmbw)
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C9399, J3490, J3590, J9999
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ING-CC-0118*
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Pluvicto (lutetium lu 177 vipivotide tetraxetan)
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A9699
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ING-CC-0002*
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Releuko (filgrastim-ayow)
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C9096
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Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Access our Clinical Criteria to view the complete information for these step therapy updates.
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Clinical Criteria
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Status
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Drug
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HCPCS or CPT Code(s)
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ING-CC-0107*
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Non-preferred
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Alymsys
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C9399, J3490, J3590, J9999
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ING-CC-0002*
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Non-preferred
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Releuko
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C9096
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*Oncology use is managed by AIM.
Courtesy notice
Effective for dates of service on and after October 1, 2022, updated step therapy criteria for immunoglobulins found in clinical criteria document ING-CC-0003 will be implemented. The preferred product list is being expanded. Please refer to clinical criteria document for details.
Quantity limit updates
Effective for dates of service on and after November 1, 2022, 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.
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Clinical Criteria
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Drug
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HCPCS or CPT Code(s)
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ING-CC-0072
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Alymsys (bevacizumab-maly)
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C9399, J3490, J3590
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Visit the Drug Lists page at anthem.com for more information on:
- Copayment/coinsurance requirements and their applicable drug classes.
- Drug lists and changes.
- Prior authorization criteria.
- Procedures for generic substitution.
- Therapeutic interchange.
- Step therapy or other management methods subject to prescribing decisions.
- Any other requirements, restrictions, or limitations that apply to using certain drugs.
The Commercial and Exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.
To locate Exchange Select Formulary and pharmacy information, scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.
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