Do you and your staff want to know what’s new at Anthem in 2019?
Attend an upcoming Provider Webinar to learn about networks, ID cards, electronic tools, Availity, medical record requests and more. These are live meetings which allow providers to ask questions to Anthem’s MO Network Consultant Team.

When joining a webinar be sure to sign into both the specific webinar link for the meeting and dial into the conference call number (866) 308-0254 (conference call code: 3148733284).

 

 

-> Join Webinar

 

-> Join Webinar

 

 

For questions on the webinar contact Lynn Schleper at (314) 873-3284. We hope to see you there!

 

Missouri Provider Solutions

Have you been using the Medical Attachment tool on the Availity Portal to submit solicited medical records in support of a claim filed with Anthem Blue Cross and Blue Shield (Anthem)?

 

You will find these changes that were recently introduced:

• Select the “Attachment – New” option to submit medical records when Anthem has requested additional information to process a claim
• To send a solicited attachment, see the “Send Attachment” link on the top, right side of the page
• Expanded file size – each attachment can be up to 40 MB with a total of 80 MB as the file size limit
• Ability to submit an itemized bill

 

If you have not tried the Medical Attachment tool to submit electronic documentation in support of a claim, now is the time to give it a try! This tool makes the process of submitting requested medical records simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Anthem) medical record attachments through the Availity Portal.

 

The existing Medical Attachment tool will not be removed from the Availity Portal immediately but users are encouraged to connect to the “Attachment – New” option for greater capabilities.

 

How to Access solicited Medical Attachments for Your Office

Availity Administrator, complete these steps:

From My Account Dashboard, select Enrollments Center>Medical Attachments Setup, follow the prompts and complete the following sections:

1. Select Application>choose Medical Attachments Registration
2. Provider Management > Select Organization from the drop-down. Add NPIs and/or Tax IDs (Multiples can be added separated by spaces or semi-colons)
3. Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name

 

Using Medical Attachments tool

Availity User, complete these steps:

1. Log in to www.availity.com
2. Select Claims and Payments > Attachments-New > Send Attachment Tab
3. Complete all required fields of the form
4. Attach supporting documentation
5. Submit

 

Need Training?

To access additional training for this Availity feature:

1. Log in to the Availity Portal at www.availity.com
2. At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
3. In the new window a list of available topics will open. Locate and click Medical Attachments
4. Under the Recordings section, click View Recording

 

Claim Status Updates
You will now see updates to the claim status screens on the Availity Portal. Use the Go To menu on the patient eligibility and benefit detail page to navigate seamlessly to the new look. The new claim status look includes color coded patient ID cards and easy to read claim detail.

Secure Messaging Changes

A new Actions menu on the updated Claim Status page will be used to access the Secure Provider Messaging tool. The link “Do you have a question about this claim?” will no longer be available with the new claim screen. You can also use the Actions menu to edit or print the claim screen.

 

More information is now available in the Availity Learning Center. Access the training demo through Help & Training > Get Trained from the Availity Portal. Type Claim Status – Training Demo in the Learning Center’s search field to locate the course and enroll.

 

Anthem Blue Cross and Blue Shield (Anthem) has designated Availity to operate and serve as your electronic data interchange (EDI) entry point or also called the EDI Gateway. The EDI Gateway is a no-cost option for our providers that choose to submit their own EDI claims to Anthem. If you prefer to use a clearinghouse or billing company, please work with them to ensure connectivity.

 

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway. 

 

Do you already have an Availity User ID and Login? You can use the same login for your Anthem EDI transactions.

Log in to the Availity Portal and select Help & Training > Get Trained. In the Availity Learning Center, search the Catalog by keyword “SONG” for live and on-demand resources created especially for you. 

 

If you wish to become a direct a trading partner with Availity, the setup is easy.

Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions. 

 

Need Assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

 

835 Electronic Remittance Advice (ERA)

Please use Availity to register and manage account changes for ERA.

If you were previously registered to receive ERA, you must register using Availity to manage account changes. Log into the Availity Portal and select My Providers > Enrollments Center > ERA Enrollment to enroll for 835 ERA delivery.

 

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

 

If you have any questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday, 8 a.m. to 7:30 p.m. ET.

 

A key goal of Anthem Blue Cross and Blue Shield (Anthem)’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways this is done is by giving certain providers (Payment Innovation Providers) in Anthem’s various Payment Innovation Programs, such as the Enhanced Personal Health Care, Bundled Payments, Medical Home programs, etc., (the Programs) quality, utilization and/or cost information about the health care providers (Referral Providers) to whom the Payment Innovation Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in their getting more referrals from Payment Innovation Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

 

Providing this type of data, including comparative cost information, to Payment Innovation Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Payment Innovation Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers, including any opportunities for improvement. For questions or support, please contact your local Provider Representative or Care Consultant.

 

In March, anthem.com will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms, as seen below. This first version of the new Provider Forms will keep growing and evolving in the coming months. 

 

We will continue to keep you informed of upcoming changes to the public provider site as we progress toward streamlining our Web platform and other business processes.

 

Each year, Anthem Blue Cross and Blue Shield (Anthem) requests your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs, Retrospective and Prospective, that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), in order to document and close the coding gaps.

 

The CRA Program is specific to our Affordable Care Act (ACA) Members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the Exchange).

 

With our Retrospective Program we focus on medical chart collection. We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS). This particular effort is part of Anthem’s compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership. The members’ medical record documentation helps support this data requirement.

 

Analytics are performed internally on claims which do not have the ICD-10 code for which we suspect a chronic condition. These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.

 

Anthem network providers (such as PCPs, specialists, facilities, behavioral health, ancillary, etc.) may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review. These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf. The vendors’ web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management.

 

We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2019 at the latest). While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.

 

Electronic options that may make medical chart collection easier for providers:

• EMR Interoperability

• o Allscripts (Opt in – signature required)
• o NextGen (Opt out – auto-enrolled)
• o Athenahealth (Opt out – auto-enrolled)
• o MEDENT

• Remote/Direct Anthem access
• Vendor virtual or onsite visit
• Secure FTP

 

The goal of these electronic options is to both improve the medical record data extraction and the experience for Anthem’s network-participating hospitals, clinics and physician offices. If you are interested in this type of set up or any other remote access options, please contact our Commercial Risk Adjustment Network Education Representative at Natalie.Wilder@anthem.com.

 

Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests.

In 2019, Anthem Blue Cross and Blue Shield (Anthem) is offering Dual Eligible Special Needs Plans (D-SNPs) to people who are eligible for both Medicare and Medicaid benefits or qualified Medicare beneficiaries (QMBs). D-SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These plans are $0 premium plans. Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments. Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.  

 

Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in the first quarter of 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.

 

Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.

 

For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.

 

Anthem Blue Cross and Blue Shield (Anthem) updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433.

 

The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:

 

• Group code patient responsibility (PR) will be assigned.
  
  
• Claim adjustment reason codes (CARCs) will include the following:
  • 1 — deductible amount (professional claim)
  • 2 — coinsurance amount (professional claim)
  • 3 — copay amount (professional and facility claim)
  • 247 — deductible for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
  • 248 — coinsurance for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
    
    
• Remittance advice remark codes (RARCs) will include the following:
  • N781 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
  • N782 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
  • N783 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected copay. This amount may be billed to a subsequent payer.

 

Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.

 

The following revised clinical criteria will be effective May 1, 2019. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.

 

Clinical criteria effective date	Clinical criteria number	Clinical criteria	Clinical criteria (new/revised)
May 1, 2019	ING-CC-0001	Erythropoiesis Stimulating Agents	Revised
May 1, 2019	ING-CC-0004	H.P. Acthar Gel®(repository corticotropin injection)	Revised
May 1, 2019	ING-CC-0072	Selective Vascular Endothelial Growth Factor (VEGF) Antagonists	Revised

 

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

 

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

 

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

 

If you have questions or feedback, please email us at druglist@anthem.com.

 

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

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