Medical Policies and Clinical Guidelines

• Clinical Guidelines Updates – May 2019*

• Anthem MCG Care Guidelines – 23rd Edition*

Reimbursement Policies

• Update: Drug Screen Testing – Professional*

Pharmacy Updates

• Anthem expands specialty pharmacy medical step therapy drug list for agents for hereditary angioedema

• Anthem specialty pharmacy medical step therapy drug list clarification about non oncology colony stimulating factor agents

Other Important Updates

• Medicare and Medicaid News

Have you had more patients present with their ID card on their smartphone? We want to remind you of the ways you can access your own copy of their ID card.

In the October 2017 issue of Network Update, Anthem informed you about our mobile app called Anthem Anywhere that allows members to manage their benefits on their smart phones, including the option of an electronic only version of their ID cards.  We want to ensure a member’s electronic only ID card meets your needs. 

Based on member requests and growing trends, we anticipate that by the year 2020, nearly 50% of our Local Plan members may choose the electronic ID card option, so we urge you to start using the available retrieval tools today. 

Provider options for obtaining a copy of an electronic Member ID card

• Online through the Availity Portal
  
  Providers also have the option to view Anthem Member ID Cards online (and print if needed) from the Availity Portal at availity.com.  When conducting an Eligibility and Benefits (E&B) Inquiry -- from the E&B Results page, select the blue button titled View Member ID Card.  (Currently excludes BlueCard^®, Federal Employee Program^® (FEP) and some health plans’ Medicare Advantage and Medicaid members.)
  
  
  
  Note: As with all E&B Inquiries on Availity, providers must have the member ID number (including the three-character prefix) and one or more search options of date of birth, first name and last name.
  

• Email or Fax
  
  Members can email/fax the card from his/her phone.  When members are viewing their ID Card on their phone, they will select the email or fax icon to forward their ID card.
  
  
  

These options are available for your patients who are members covered by our affiliated health plans in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, New York, Nevada, Ohio, Wisconsin, and Virginia.

Members are still required to have a copy of their card in one format or another, whether hard copy or electronic, in order for services to be rendered.  See our Quick Reference Guide for further details.

Quick Reference Guide

See our Electronic Member ID Cards – Quick Reference Guide for more details and information on:

• Frequently Asked Questions
• Details on provider options for obtaining a copy of an electronic Member ID card
• Sample electronic Member ID cards

Anthem will request documentation for identified claims, and level 5 ER professional reviews will evaluate the appropriate use of the level 5 ER code based on the AMA CPT coding manuals, and Anthem guidelines. Reimbursement will be based on the ER E/M code the submitted documentation supports.

Please note, these coding reviews are not related to any prior notifications of reviews which examine the appropriate use of ERs for non-emergencies, nor do they include the examination of emergent versus non-emergent reasons patient utilize emergency room services.

As a reminder, there are two approaches that we take (Retrospective and Prospective) to improve risk adjustment reporting accuracy. We are focusing on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), to close the documentation and coding gaps that we are seeing with our members enrolled in our Affordable Care Act (ACA) compliant plans.

This month we’d like to focus on the Prospective approach, and the request to our Providers.

Anthem network providers – usually primary care physicians – may receive letters from our vendor, Inovalon, requesting that physicians:

1. Schedule a comprehensive visit with patients identified to confirm or deny if previously coded or suspected diagnoses exists, and

2. Submit a Health Assessment documenting the previously coded or suspected diagnoses (also called a SOAP Note – Subjective, Objective, Assessment and Plan).

• $100 for assessments submitted electronically
  
  
• $50 for assessments submitted via fax

Health Assessment requests through Inovalon

We have engaged Inovalon – an independent company that provides secure, clinical documentation services – to help us comply with provisions of the ACA that require us to assess members’ relative health risk level.  In the coming weeks and months, Inovalon will be sending letters to providers as part of our risk adjustment cycle, asking for their help with completing health assessments for some of our members.

This year will bring a new round of assessments. As a reminder, chronic conditions must be coded every year, and we encourage you to code to the greatest level of specificity on all Anthem claim submissions.  If you have questions about the requests you receive, you can reach Inovalon directly at 1-866-682-6680.

Maximize your Incentive opportunity: submit electronically via Inovalon’s ePASS^® tool

Join an ePASS webinar to learn how to submit a Health Assessment electronically and maximize your incentive opportunities. They are offered every Wednesday from 3:00 – 4:00pm EST. Register by sending an email to ePASSProviderRelations@inovalon.com with your name, organization, contact information and the date of the webinar you wish to attend.

• Teleconference: Dial 1-415-655-0002 (US Toll) and enter access code: 736 436 872
• WebEx: Visit https://inovalonmeet.webex.com and enter meeting number: 736 436 872
• Once you join the call, live support is available at any time by dialing *0

Alternative reporting engagement

ePASS is our preferred method for submission for the Prospective approach. However to improve engagement and collaborate with our Providers who are not submitting via ePASS, we have identified other alternatives which may be helpful and provide more flexibility with your current processes.

If you are interested in any of these alternative options, please contact our CRA Network Education Representative at Natalie.Wilder@anthem.com.

As a contracted provider with Anthem Blue Cross and Blue Shield (Anthem) in Indiana, Kentucky, Missouri, Ohio and/or Wisconsin, please remember that you are obligated when medically appropriate to refer Anthem members to in-network providers.  This includes physicians and all provider types including, but not limited to, ambulance transport (ground and air), ambulatory surgical centers, behavioral health services, physical medicine providers and ancillary providers.  Referring to in-network providers allows members to receive the highest level of benefits under their Health Benefit Plan.  As a reminder, call Anthem first for pre-certification if required by the member’s policy.

Ground Ambulance Providers

You can search for participating ground providers using our online tool, Provider Finder, located at www.anthem.com. Search parameters include distance from your location (zip code, address or county). To use the tool, go to www.anthem.com and follow these steps in our “Find a Doctor” tool:

Air Ambulance Providers

Attached is the list of particlpating air ambulance providers with Anthem in Indiana, Kentucky, Missouri, Ohio and/or Wisconsin. This means that these providers have contractually agreed to accept the Anthem Rate as payment in full for covered services, and they will bill members only for allowable benefit cost-share obligations when transporting members who are picked up in your state. 

Some air ambulance providers choose not to participate with payers like Anthem. 

• These air ambulance providers may charge member rates that are much higher than the Anthem contracted provider rates.
• Depending on their benefits, members who utilize non-participating air ambulance providers can be left with significant out-of-pocket expenses, which the ambulance providers and their billing agents may seek to collect.

To avoid these situations, we ask that, whenever possible, you use a participating air ambulance provider for your patients who are our members.  Utilizing participating providers:  

• Protects the member from balance billing for what may be excessive amounts,
• Assures the most economical use of the member’s benefits, and
• Is consistent with your contractual obligations to refer to in-network providers where available.

To schedule fixed wing or rotary wing air ambulance services, please contact Anthem for pre-certification if required by the member’s policy, then call one of the phone numbers listed below. Please have the following information ready when you call:

• Basic medical information about the patient, including the patient’s name and date of birth or age. If the service was not pre-certified with Anthem, the air ambulance provider will also need to receive a full medical report from the attending facility.
• Current location of the patient, the name of the hospital or facility caring for the patient and its address (city and state).
• Location where patient is to be transported, including the name of the destination hospital/facility and address.
• Approximate transport date or time frame.
• Special equipment or care needs.

Should you have questions regarding the air ambulance network, including providers contracted for air ambulance pickups outside of your state, please contact your Provider Network Manager.  To arrange air transport originating outside the U.S., U.S. Virgin Islands and Puerto Rico, call 800-810-BLUE for BCBS Global Core (formerly Bluecard Wordwide).

• File size – each attachment can be up to 10 MB with a maximum of 30 MB as the file size limit
• The addition of logos in your dashboard make it easy to quickly identify each payer
• The Medical Attachment tool will be retired from the Availity Portal soon, so we encourage you to start utilizing the ‘Attachment – New’ option now. We will announce the retirement date for the Medical Attachment tool soon.

Other features of the updated medical attachment include:

• The ability to submit an itemized bill
• A different link tilted “Attachment – New” where you will now submit medical records when Anthem has requested additional information to process a claim
• A new link on the attachment page called “Send Attachment” will allow you to start the process
• A record history of each entry provides you increased visibility of your submission

The Medical Attachment tool makes the process of submitting an electronic documentation in support of a claim, 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.

NOTE: We will continue to keep you informed of upcoming changes to the ‘Attachment – New’ platform as we progress toward streamlining our electronic documentation functionality.

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

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 and select Help & Training | Get Trained to open the Availity Learning Center (ALC) Catalog in a new browser tab. It is your dedicated ALC account.
2. Search the Catalog by keyword (attachments) to find training demo and on-demand courses.
3. Select Enroll to enroll for a course and then go to your Dashboard to access it any time.

• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ
  
  
• Group Retiree members and National Access Plus
  
  
• Prior authorization requirements for DME repair and portable oxygen concentrator
  
  
• Update: Evaluation and management with Modifier 25 update
  
  
• Latest updates to Electronic Data Interchange Gateway migration
  
  
• New incentive program for reimbursement for select CPT Category II codes
  
  
• Fall prevention tips
  
  
• Medical records request for risk adjustment
  
  
• Medicare Advantage reimbursement policy provider bulletin for Modifier 63: Procedure Performed on Infants Less Than 4 kg
  
  
• Partial hospitalization services - Highlights
  
  
• New provider learning opportunity: Put the AIM ProviderPortal to work for you
  
  
• Skilled nursing facility QIO appeal documentation reminder (Ohio only)