 Provider News MissouriFebruary 2025 Provider NewsletterAs a crucial part of our commitment to providing the highest quality care and ensuring accuracy and timelines in the processing of claims, please remember to obtain prior authorization for neonatal intensive care unit (NICU) services at the level you intend to provide services. Obtaining prior authorization helps us: - Ensure timely and appropriate care for our smallest and most vulnerable patients.
- Streamline the claims process, thereby reducing delays and potential denials.
- Facilitate accurate and efficient billing, which saves time and resources for everyone involved.
Please ensure all nonemergent NICU services are prior authorized before the commencement of treatment and continue to provide updates concurrently. This proactive step is essential for maintaining smooth and efficient operations. Prior authorization is not required for emergent NICU services or NICU services provided in the first 48 hours following birth for vaginal delivery and 96 hours following birth for cesarian delivery. Should you have any questions or need further assistance with the authorization process, please do not hesitate to contact Provider Services via the number on the back of our member ID card. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-073281-24-CPN73119 To help ensure inpatient claims are processed quickly and accurately, and consistent with our Claims Requiring Additional Documentation reimbursement policy, starting May 1, 2025, inpatient claims with billed charges over $100,000, reimbursed partly or fully based on a percentage of charges, must include the full medical record upon submission. There is no impact to a member's ability to receive care. The claim and medical record may be reviewed prior to claim payment or audited after claim payment. If claims meeting the above criteria are received without medical records, the claim will not be eligible for reimbursement until submitted with the appropriate documentation. To view the full reimbursement policy, please visit our website: anthem.com/provider Submit medical records with initial claim filingFacilities can proactively submit medical records digitally with the initial claim filing via our preferred clearinghouse, Availity Essentials (https://Availity.com), through the Claim Status application. For additional options on claim and medical record submission, consult the provider manual at anthem.com/provider. If your facility is not already registered for Availity Essentials or the Medical Attachments application, complete registration at https://Availity.com. Registering for the application allows facilities to receive digital notifications if documentation is required to complete a claim. Training resources on submitting medical records attachments are available on our Digital Solutions Learning Hub. Trainings that begin with Attachments in the title provide education on this topic. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-075012-24-CPN74936 In March, we will add new functionality to the provider enrollment and network management tool hosted on Availity Essentials to improve the correspondence experience. We will start posting letters related to your credentialing directly in the Communication Center and you will be able to download the correspondence as a PDF.
How will this help you:
- Convenience — reduced time spent sorting through mailed documents
- Faster access — no need to wait for mail service delivery
- Ease of access — access your correspondence 24/7 digitally
- Environmental benefits — saving paper and printing costs helps you and the planet
Before you begin
If your organization is not currently registered for Availity Essentials, the person in your organization designated as the Availity administrator should go to https://Availity.com and select Get Started. If you need assistance registering with Availity Essentials, visit https://www.availity.com/customer-support.
For organizations already using Availity Essentials, your administrator(s) will automatically be granted access to the provider enrollment tool.
Staff using the provider enrollment tool need to be granted the user role Provider Enrollment by an administrator. To find yours, go to My Account Dashboard >My Account > Organization(s) > Administrator Information.
At this time, Carelon Behavioral Health is out‑of-scope for this implementation.
Accessing the Communication Center
1. Log in to https://Availity.com.
2. Select your market.
3. Select Payer Spaces in the top menu.
4. Select the brand that corresponds to your market.
5. Accept the User Agreement (once every 365 days).
6. On the Applications tab, select Provider Enrollment and Network Management.
7. Select the Communication Center link under the My Communications option on the side menu.
8. Enter your TIN and NPI to access the letters. Carelon Behavioral Health, Inc. is an independent company providing utilization management services on behalf of the health plan.
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-075633-24-CPN75180 We’re excited to introduce two new Payment Integrity trainings available on our Digital Solutions Learning Hub: - Payment Integrity: Emergency Dept Evaluation and Management Services
- Payment Integrity: Outpatient Evaluation and Management Services
With an initial focus on these two key educational initiatives, our purpose is to amplify your billing and coding accuracy. More trainings will be announced throughout the year. Discover what our Digital Solutions Learning Hub has to offer. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. KYBCBS-CRCM-072244-24-CPN72085, MULTI-BCBS-CRCM-072264-24-CPN72085, MULTI-BCBS-CRCM-075953-24-CPN75258, MULTI-BCBS-CRCM-077839-25-CPN77515, MULTI-BCBS-CRCM-080188-25-CPN79720 Beginning with dates of service on or after May 1, 2025, Anthem will update the Diagnostic Radiopharmaceuticals and Contrast Materials — Professional and Facility reimbursement policy to remove the code list located in the Related Coding section. Providers should continue to follow the policy guidelines that identify the services eligible for reimbursement. Providers can refer to the AMA CPT Manual or HCPCS Level II Manual for correct coding. For specific policy details, visit the reimbursement policy page. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-075363-24 As of December 10, 2024, we retired the reimbursement policy titled Place of Service — Professional C‑09001 and replaced it with a new policy titled Place of Service — Professional C‑24004. Under this policy, we require the appropriate place of service code to be billed on a CMS‑1500 claim form to be eligible for reimbursement. The place of service is determined by the following: - CPT® or HCPCS Level II code description
- CPT coding guidelines
For specific policy details, visit the Missouri Reimbursement Policies page. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MOBCBS-CM-076127-24-CPN75910 Our digital first approach enables providers to submit EDI corrected claims through Availity Essentials or the electronic data interchange (EDI). Corrected claim guidanceWhen submitting a corrected claim, include all previous information along with any corrections or additions. To correct a claim billed to us in error, submit the entire claim as a void/cancel. A new claim may be required if we identify missing or incorrect information based on the guidelines in the Claims Submission section. Providers will receive written or electronic notification indicating the missing data. The provider manual at https://tinyurl.com/44xzzz3a offers guidance on submitting corrected claims, helping to prevent issues with reimbursement. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-075755-24 For services beginning on January 1, 2025, prior authorization requests for admission to or concurrent stay requests in an inpatient acute rehab facility (ARF) or long‑term acute care hospital (LTACH) will be handled by the FEP Case Management team to review for medical necessity and care coordination. This change impacts members of the Anthem Blue Cross and Blue Shield Federal Employee Program® (FEP®), including Federal Employee Health Benefit (FEHB) and Postal Service Health Benefit (PSHB), The FEP Case Management team may be contacted by phone at 800‑711-2225 for FEHB members or 833‑277-5220 for PSHB members. Clinical information should be faxed to 866‑862-4288. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-074100-24 Visit the Drug List page on our website for more information about: - 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 the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed. Federal Employee Program pharmacy updates and other pharmacy‑related information may be accessed at fepblue.org > Pharmacy Benefits. Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access. Through our efforts, we are committed to reducing the administrative burden because we value you, our care provider partner. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-076188-24 Effective with dates of service on and after January 1, 2025, and in accordance with the CarelonRx, Inc. pharmacy and therapeutics (P&T) process, we updated our drug lists that support commercial health plans. Updates include changes to drug tiers and the removal of medications from the formulary. Please see the attachment here for more information. CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-075572-24-CPN75351 ATTACHMENTS (available on web): Key formulary updates: effective January 1, 2025_Blue Cross Blue Shield (pdf - 0.19mb) Anthem has a policy requiring facilities to acquire certain select specialty pharmacy medications administered in the hospital outpatient setting through our contracted medical specialty pharmacy. UpdatesEffective for dates of service on and after April 1, 2025, the HCPCS code J2796 for Nplate (romiplostim), which is presently on the Designated Medical Specialty Pharmacy Drug List, will be replaced with HCPCS code J2802. Additionally, effective for dates of service on and after April 1, 2025, the following specialty pharmacy medications will be removed from the Designated Medical Specialty Pharmacy Drug List and will no longer need to be obtained from our contracted medical specialty pharmacy: HCPCS | Description | Brand name | J1950 | INJ LEUPROLIDE ACETATE PER 3.75 MG | LUPRON DEPOT | J9217 | LEUPROLIDE ACETATE 7.5 MG | ELIGARD/LUPRON DEPOT | J9218 | LEUPROLIDE ACETATE, PER 1 MG | LUPRON |
To access the current Designated Medical Specialty Pharmacy Drug List, please visit anthem.com/provider, select Providers, select Forms and Guides (under the Provider Resources column), select Missouri, scroll down, and select Pharmacy in the Category dropdown. The Designated Medical Specialty Pharmacy Drug List may be updated periodically by Anthem. If you have questions or would like to discuss the terms and conditions for providing certain specialty medications, please contact your contract manager with Anthem. Thank you for your continued participation in the Anthem networks and the services you provide to our members. We are committed to a future of shared success. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MOBCBS-CM-074999-24 We are excited to announce our 2025 Clinical Quality in Practice, a continuing education webinar series. This comprehensive series will cover a diverse range of critical topics designed to equip clinicians with the latest strategies and best practices in patient care. The webinar series will explore essential areas, such as: - Clinical strategies to care for patients with diabetes.
- Clinical strategies to care for patients with cardiovascular disease and hypertension.
- Post acute care management.
- Motivating patients to adhere to cancer prevention and screenings.
- Clinical strategies to increase flu vaccinations.
- Clinical strategies for screening and preventive care.
- Enhancing coordination of care.
Participants will have the opportunity to engage with experienced practitioners and thought leaders, gaining valuable insights that can be immediately applied in clinical settings. For a detailed schedule of live events and a full listing of available on‑demand webinars that you can start viewing now, visit our Engagement Hub. Don’t miss this chance to advance your clinical expertise and enhance patient outcomes. In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CRCM-075332-24-CPN74850 The National Committee Quality Assurance (NCQA) develops and collects Healthcare Effectiveness Data and Information Set (HEDIS®) measurements to set performance and drive improvement in quality‑of-care outcomes. The AAB measure is one of the priority measures that have many opportunities to optimize antibiotic prescribing.
The Federal Employee Program (FEP) is continuously working toward improving clinical quality of care and performance outcomes. To improve HEDIS AAB compliance, the FEP takes this opportunity to ask for your commitment to promote the appropriate use of antibiotic prescription in protecting your patients from harmful side effects and possible resistance to antibiotics over time.
According to the CDC, in U.S. doctors’ offices and emergency departments, at least 28% of antibiotic prescriptions each year are unnecessary, and an estimated 80 to 90% of antibiotic prescriptions occur in the outpatient setting, which makes improving antibiotic prescribing and use a national priority. The national guidelines recommend against prescribing antibiotics bronchitis/bronchiolitis for healthy people.
What is the HEDIS AAB measure?
The AAB measure looks at the percentage of episodes for members ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.
If a patient is diagnosed with an acute bronchitis/acute bronchiolitis and medically requires an antibiotic prescription due to comorbid conditions at the time of the visit, it is important to document the comorbid conditions/diagnosis by using the appropriate ICD‑10-CM on the same visit claim which will remove the patient from the HEDIS AAB measure.
The table below lists the common ICD‑10-CM diagnosis codes for outpatient visits that trigger patients to be included in the HEDIS AAB measure:
|
Code
|
Description
|
|
J20.3, J20.4, J20.5, J20.6, J20.7, J20.8, J20.9
|
Acute bronchitis
|
|
J21.x, J21.0, J21.1, J21.8, J21.9
|
Acute bronchiolitis
|
Common ICD‑10-CM codes that exclude patients from the HEDIS AAB measure are:
|
Code
|
Description
|
|
J02.x
|
Acute pharyngitis
|
|
J03.x
|
Acute tonsillitis
|
|
H66.xxx
|
Suppurative otitis media
|
|
J01.xx
|
Acute sinusitis
|
|
J18.xx
|
Pneumonia
|
|
J32.xx
|
Chronic sinusitis
|
|
J35.xx
|
Chronic tonsillitis; hypertrophy tonsils
|
|
J39.x
|
Disease upper respiratory tract
|
|
L03.xx
|
Cellulitis/acute lymphangitis
|
|
N39.xx
|
UTI
|
Note: These lists are not all‑inclusive. This information is not about a change in policy but a reference to quality improvement activities.
The CDC is an excellent source for antibiotic information and awareness. In fact, the CDC leads in the Antibiotics Stewardship Training. We encourage you to take advantage of these continuing education opportunities:
Helpful tips:
- If a patient insists on an antibiotic:
- Refer to the illness as a chest cold rather than bronchitis; patients tend to associate the label with a less‑frequent need for antibiotics.
- Write a prescription for symptom relief, such as an over‑the-counter medicine.
- Reiterate the CDC’s recommendation that antibiotics do not work against viruses that cause most chest colds or bronchitis.
- Treat with antibiotics if the patient has a competing diagnosis listed above.
- Document accurately and use the correct ICD‑10-CM diagnosis codes.
- Use correct exclusion codes when appropriate.
- Maintain timely submission of claims and encounter data.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-074661-24 |