 Provider News MissouriFebruary 2022 Anthem Provider News - MissouriThe 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. We are asking you to review your online provider directory information to help ensure Anthem Blue Cross and Blue Shield (Anthem) members can locate the most current information for in-network providers and facilities.
You can help us ensure your online provider directory information is current by:
- Reviewing your online provider directory information on a regular basis to ensure it is correct. You can check your directory listing on Anthem’s Find Care Consumers, members, brokers, and providers use the Find Care tool to identify in-network physicians and other healthcare providers supporting member health plans. To ensure we have your most current and accurate information, please take a moment to access Find Care. Go to anthem.com, select Providers, then under Provider Overview, choose Find Care.
- Submitting updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:
- 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 receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
AIM Specialty Health® (AIM)® has created a new AIM contact center phone number for providers to use to call in prior authorization requests for Anthem Blue Cross and Blue Shield (Anthem). The new phone numbers are listed below and will go into effect on April 1, 2022. Please use this new number to submit new prior authorization AIM requests or get an update on an existing request after April 1, 2022.
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State
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New 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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As always, the best way to reach AIM is to use the ProviderPortalSM:
- Self-service
- Available 24/7
- Customizable with physician information
- Easy to use and allows real-time determinations
The ProviderPortalSM is a fast and efficient way to submit and monitor requests. It also allows you 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 ProviderPortalSM to register.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is an annual standardized survey conducted starting February 2022 through May 2022 to assess consumers’ experience with their provider and health plan. A random sample of your adult or child patients may get the survey. Over half of the questions used for scoring are directly impacted by providers. These questions are:
- When you needed care right way, how often did you get care as soon as you needed?
- How often did you get an appointment for a check-up or routine care as soon as you needed?
- How often was it easy to get the care, tests, or treatment you needed?
- How often did you get an appointment to see a specialist as soon as you needed?
- How often did your personal doctor seem informed and up-to-date about the care you got from other doctors or other health providers?
- How would you rate your personal doctor?
- How would you rate the specialist you see most often?
- How would you rate all your health care in the last 6 months?
Interested in how you can improve CAHPS performance? Anthem Blue Cross and Blue Shield (Anthem) offers an online course for providers and office staff designed to learn how to improve communication skills, build patient trust and commitment, and expand your knowledge of the CAHPS survey. The Improving the Patient Experience course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. It can be accessed at https://www.mydiversepatients.com/le-ptexp.html.
Filing claim payment disputes for our commercial members is now available on availity.com
When you have additional information to share about a claim that has been denied, filing the dispute electronically is a cost-effective and time-saving alternative to paper and fax. This application enhancement enables a fast, efficient streamlined process for filing claim disputes:
- Supporting documentation can be digitally uploaded
- Dispute inquiries are digitally available on your dashboard
- Retrieve correspondence related to your dispute digitally through your dashboard
- A digital history for electronically filed disputes is conveniently located in one place on your dashboard
Two-step claim payment dispute process
There are two steps to the claim payment dispute process, and both can be accomplished in one place – through availity.com:
- Claim payment reconsideration. This is your initial request asking us to investigate the outcome of a claim. Most issues are resolved during reconsideration, which we try to resolve within 30 days. In those instances when additional documentation is needed, the determination may go beyond 30 days. If this occurs, we will notify you. You can access notifications about delays and determinations conveniently from your dashboard.
- Claim payment appeal. If you disagree with the outcome from the reconsideration determination, you may request an additional review. When submitting a claim payment appeal, include the additional information needed to help us understand why the claim requires additional review. If a claim payment appeal requires clinical expertise, it will be reviewed by the appropriate Anthem clinical professionals. We make every effort to resolve the claim payment appeals within 60 days. If additional information is required to make a determination, notification will be available on your dashboard.
Receive determination electronically
Anthem will review the claim payment dispute and communicate an outcome on availity.com. Check the status of a claim payment dispute at any time from your dashboard.
Attend a Training Webinar
For step-by-step instructions on how to submit a claim payment dispute through Availity, attend one of these convenient live webinars:
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Tuesday, February 1, 2022
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2 p.m. ET
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Thursday, February 3, 2022
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1 p.m. ET
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Tuesday, February 15, 2022
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1 p.m. ET
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Thursday, February 17, 2022
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2 p.m. ET
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Register for training by logging onto availity.com, select Help & Training, Get Trained and choose the session most convenient for you. Self-guided training is also available through Get Trained.
Share information with patients about taking an active role in their heart health
National Wear Red Day is a great way to keep heart aware. It is also a great opportunity to have a conversation with your patients about their heart health. The Centers for Disease Control and Prevention (CDC) has information you can share with your patients, including a helpful Know the Facts about Heart Disease flyer that’s free for health care professionals.
Controlling high blood pressure, diabetes, extra weight and unhealthy diets are heart disease contributors that you can help your patients recognize. For information about these heart disease risks to share with your patients, use the CDC website for toolkits, flyers and give-a-ways.
Measure Up: Controlling High Blood Pressure (CBP)
Known as the “silent killer,” high blood pressure or hypertension increases the risk of heart disease.
The HEDIS® measure CBP looks at the percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (140/90) in the measurement year. Record all blood pressure readings and the dates they were taken being sure to record the exact reading. Blood pressure readings captured during a telehealth, virtual care, telephone or e-visit should also be recorded.
Measure Up: Statin Therapy for Patients with Cardiovascular Disease and Diabetes (SPC/SPD)
Statins are effective at lowering cholesterol and protecting against a heart attach and stroke. Patients with diabetes also have elevated cardiovascular risk.
- Statin therapy for patients with cardiovascular disease (STC). HEDIS measure assesses males 21-75 years of age and females 40-75 years of age who have clinical atherosclerotic cardiovascular disease and who received and adhered to statin therapy.
- Statin therapy for patients with diabetes (STD) assesses adults 40-75 years of age who have diabetes and who do not have clinical ASCVD, who received and adhered to statin therapy.
Adherence to prescribed medication is key to patient care and SPC/SPD measure success.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
The following Anthem Blue Cross and Blue Shield (Anthem) medical polices and clinical guidelines were reviewed on November 11, 2021.
Determine if prior authorization is needed for an Anthem member by going to anthem.com > select “Providers” > under “Claims” > select “Prior Authorization”, then select your state. Or, you may call the prior authorization phone number on the back of the member’s ID card.
Below are the new medical policies that have been approved.
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Title
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Information
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Effective date
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DME.00044
Wheelchair Mounted Robotic Arm
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• The use of a wheelchair mounted robotic arm is considered Investigational & not medically necessary (INV&NMN) for all uses.
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5/1/2022
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MED.00138
Wearable Devices for Stress Relief and Management
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• Wearable devices for management, monitoring or prevention of stress and stress-related conditions are considered INV&NMN for all indications
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5/1/2022
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Below are changes to the medical policies that have been approved.
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Title
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Information
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Effective Date
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SURG.00010 Treatments for Urinary Incontinence
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• Added new criterion to INV&NMN statement on endovaginal cryogen-cooled, monopolar radiofrequency remodeling
• Added “as treatments for urinary incontinence” to Investigational & not medically necessary (INV&NMN) statement and removed wording on urinary incontinence.
New CPT category III code 0672T effective 01/01/2022 for Viveve procedure for urinary incontinence, considered INV&NMN; added CPT codes 53451-53454 effective 01/01/2022 for ProAct considered INV&NMN, replacing 0548T-0551T deleted 12/31/2021
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5/1/2022
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SURG.00097 Scoliosis Surgery
Previously titled: Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
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• Revised title
• Added “minimally invasive deformity correction system” to the Scope and Position Statement
No specific CPT code for ApiFix procedure, 22899 NOC already listed; added ICD-10-PCS codes for ApiFix considered INV&NMN
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5/1/2022
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MED.00099 Navigational Bronchoscopy
Previously titled: Electromagnetic Navigational Bronchoscopy
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• Revised title
• Removed the word “Electromagnetic” in the Position Statement
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5/1/2022
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To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines.
Please note that the following information applies to Anthem Blue Cross and Blue Shield (Anthem) local Commercial health plans in Missouri.
In the October 2021 edition of Provider News, we announced that effective August 1, 2021, Anthem would allow a five-day initial length of stay upon notification of an admission to an in-network skilled nursing facility (SNF) facility for members in local Commercial plans.
This pilot was to end on December 31, 2021. After reviewing the outcomes of the pilot period, we have decided to continue this process until further notice.
Reminders regarding the program:
- This program applies to hospital inpatient transfers to skilled nursing facility (SNF) only.
- This program does not apply to:
- Transfers from Acute IP Rehab, LTAC to SNF, or SNF to SNF
- Admissions to out-of-network SNF facilities
- Facility and physician must be in-network for the member.
- Anthem will require notification of the SNF admission, which includes sending demographics and verification of benefits, via the usual channels to aid in our members’ care coordination and management.
- Anthem will approve an initial five-day length of stay without the need to provide clinical information.
- SNF providers will need to submit the clinical information within two business days after the admission to aid in our members’ care coordination, discharge planning and member management. Note that prior authorization is still required but we allow the transfer to SNF, and then allow provider to send clinical within two days after the admission and prior to the last covered day for concurrent review.
- Concurrent review will be required starting on day five of the SNF stay.
- Anthem may apply monetary penalties such as a reduction in payment, for failure to provide timely notice of admission.
- We will continue this process until further notice. We may conduct random audits and monitor trends to evaluate the effectiveness.
Members in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)) are excluded from this program. To view medical policies and utilization management guidelines applicable to members enrolled in FEP®, please visit fepblue.org > Policies & Guidelines.
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 Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Please note, inclusion of National Drug Code (NDC) code on your claim 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 May 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 step therapy 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-0204
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Tivdak
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J3490, J3590, J9999
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ING-CC-0072
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Byooviz
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J3590
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ING-CC-0068
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Skytrofa
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J3490
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* Oncology use is managed by AIM.
Note: 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 May 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-0072
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Non-Preferred
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Byooviz
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J3590
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Quantity limit updates
Effective for dates of service on and after May 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 step therapy 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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Byooviz
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J3590
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Visit the Drug Lists page on 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 marketplace drug lists are posted to the website quarterly on the first day of the month in January, April, July and October.
To locate Marketplace formularies 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 www.fepblue.org > Pharmacy Benefits.
In April 2022, Anthem Blue Cross and Blue Shield (Anthem) will replace its current internal provider demographic management system with a new Strategic Provider System (SPS). This investment in advanced technology will significantly improve provider data accuracy and transparency, enhancing the overall provider experience. New system features will strengthen our ability to match submitted claims for more accurate pricing and processing.
System upgrades special notice
During the first phase of our improvements, Anthem will implement system upgrades April 1, 2022 through April 8, 2022. Provider updates submitted during this period will be processed after April 8, 2022. We appreciate your patience as we upgrade our systems.
Next steps: new Provider Data Management coming soon
Beginning in June 2022, the second phase of our improvement initiative will be integration with Availity’s* Provider Data Management (PDM) functionality, which will roll out in phases. This single, easy-to-use portal, will allow providers to view, maintain, update, and attest to the accuracy of provider demographic information for Anthem. The Availity portal will enable providers to complete required verifications online via a simplified quick verification procedure – eliminating the need to fax, email, or use separate online forms. This service will replace the way you currently send Anthem your demographic updates.
Get ready for the change today
If your organization is not already registered on the Availity Portal, we strongly encourage you to get started right away. Your organization’s designated administrator can go to availity.com to register and find other helpful information about using Availity. Availity is Anthem’s secure provider portal platform where providers can enjoy the convenience of digital transactions, including prior authorization submissions, claims submission and benefit and eligibility look-up.
For questions about Availity, call 800-AVAILITY (800-282-4548).
*Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.
Effective November 1, 2021, EnrollSafe* at https://enrollsafe.payeehub.org replaced Enrollhub® from the Council for Affordable Quality Healthcare, Inc. (CAQH) as the electronic funds transfer (EFT) enrollment website at no cost to Anthem Blue Cross and Blue Shield (Anthem) providers.
EnrollSafe is safe, secure, and available 24-hours a day
Log onto the EnrollSafe enrollment hub at https://enrollsafe.payeehub.org to enroll in EFT. You will be directed through the EnrollSafe secure website to the Registration page, where you will provide the required information to create an account and then Enroll to supply your banking information.
Already enrolled in EFT through CAQH Enrollhub?
If you were previously enrolled in EFT through CAQH Enrollhub, no action is needed unless you are making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, use https://enrollsafe.payeehub.org to update your account.
For more information or additional questions regarding the EnrollSafe Enrollment Hub portal, the provider can contact the Support team by calling 877-882-0384, Monday through Friday, 9 a.m. to 8 p.m. ET.
* EnrollSafe is a tool developed by Zelis Payments, an independent organization offering electronic fund transfer services on behalf of Anthem Blue Cross and Blue Shield.
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