For the most up-to-date information from Anthem about COVID-19, please bookmark Provider News Home and check back often.

As recently communicated in the February 2020 edition of Anthem’s Provider News, the AIM Rehabilitative program for Anthem’s Commercial Membership will relaunch April 1st.  AIM Specialty Health® (AIM), a separate company, will perform prior authorization review of physical, occupational and speech therapy services.  Requests may be submitted via the AIM ProviderPortal for dates of service April 1, 2020 and after.   

 

The AIM Rehab Program follows the Anthem Clinical Guidelines that state the services must be delivered by a qualified provider of therapy services acting within the scope of their licensure. Qualified providers acting within the scope of their license, including chiropractors, who intend to provide PT, OT or ST services should request prior authorization for those services through AIM. 

 

Please note that if you are providing PT/OT/ST services to an Anthem Commercial member whose state of issuance is part of the AIM Rehab Program, you will be required to obtain an authorization.

 

Anthem is also transitioning vendors for review of Rehabilitative Services for our *Medicare members to include out-patient PT, OT, and SLP, to AIM Specialty Health April 1, 2020 for dates of service April 1, 2020 and after.  *This does not apply to members in the states of FL, NJ and NY for whom prior authorization will still be required. Please review the update in an upcoming notice for more information about the AIM Rehabilitative Program for Medicare members.

 

CMS average sales price (ASP) second quarter fee schedule with an effective date of April 1, 2020 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on May 1, 2020. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.

Laboratory Medicine Consultants became a non-participating provider with Anthem.  This is a reminder to ensure that you are referring Anthem members to participating labs. LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs.  The relationship with LabCorp does not affect network hospital-based lab service providers, contracted pathologists, or contracted independent laboratories.  Physicians may continue to refer to all participating providers as they have in the past.

 

Not only does your Anthem agreement obligate you to refer to participating labs where available, but members will only receive their full benefits from participating providers.  As a result, referring your patient and our member to a non-participating lab may expose them to a greater financial responsibility.  

 

For a listing of Anthem participating laboratories, please check our online directory. Go to anthem.com.  Choose select Providers.  When prompted, choose Nevada as your state if you haven’t done so already. Under the Provide Resources heading, select Find a Doctor.

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways is through Anthem’s value-based programs such as Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, and so on – called the “Programs.”  Certain providers (“Value-Based Program Providers” also known as “Payment Innovation Providers”) in Anthem’s various value-based programs receive quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value-Based Program 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 may result in the provider getting more referrals from Value-Based Program 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 Value Based Program 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 Value Based Program 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 refer to your local Market Representative or Care Consultant.  

Anthem completed its acquisition of Beacon Health Options, a large behavioral health organization that serves more than 36 million people across the country. The company will operate as a wholly owned subsidiary of Anthem.

 

Bringing together our existing solid behavioral health business with Beacon’s successful model and support services creates one of the most comprehensive behavioral health networks in the country. It’s also an opportunity to offer best-in-class behavioral health capabilities and whole person care solutions in new and meaningful ways to help people live their best lives.

 

From the standpoint of our customers and providers at this time, it’s business as usual:

 

• Members should continue to call the customer service number on the back of their membership card or access their health plan’s website for online self-service.
• Providers should continue to use the provider service contact information, websites and online self-service portals as part of their agreement with either Anthem or Beacon.
• There will be no immediate changes to the way Anthem or Beacon manage their respective provider networks, contracts and fee arrangements. Anthem and Beacon provider networks, contracts and fee arrangements will remain separate at this time.

 

We know our providers continue to expect more of their healthcare partner, and at Anthem, we aim to deliver more in return.

 

For more details, please see the press release.

 

At Anthem, we continue to make changes to our public provider website to make it easier for you to find the information you need. The end of first quarter brings a few updates for the site at anthem.com:

 

• Information has been added to our website regarding Patient-Centered Specialty Care (PCSC) – Anthem’s value-based payment program for cardiology, endocrinology and obstetrics/gynecology providers. You can find this information online as an extension of our broader patient-centered, value-based care program – Enhanced Personal Health Care (EPHC).
• Documents listed on the Prior Authorization page can be conveniently accessed via online links.
• Medicare Advantage will be live in the coming days. You will be able to view updated Medicare Advantage pages on the commercial public sites.
• Medical Policies (MP) and Clinical Utilization Management Guidelines (CUMG) now display on our newly designed Web pages.

 

If you have any questions, please contact Michelle Fraser at michelle.fraser@anthem.com or Nick Kizirnis at nick.kirzinis@anthem.com.

Click here for more information about the COVID-19 Virus Talking Points

 

 

ABSCARE-0434-20 March 2020          508967MUPENMUB

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting November 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

ABSCRNU-0124-20 February 2020          507833MUPENMUB

 

On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting December 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.*

 

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0130-20          508037MUPENMUB

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

 

Medicare Risk Adjustment and Documentation Guidance (General)

 

• When: The trainings will be offered the first Wednesday of each month from 1 p.m. to 2 p.m. ET (from January 8, 2020, to December 2, 2020).
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity has been reviewed and is acceptable for up to 1 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:

 

Medicare Risk Adjustment and Documentation Guidance (General)

 

Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (Condition Specific)

 

• When: The trainings will be offered on the third Wednesday of every other month from noon to 1 p.m. ET (from January 15, 2020, to November 18, 2020).
• Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
• Credits: This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

 

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

 

1. Red Flag HCCs Part 1 (January 15, 2020) — register for a recording of the session: Training will cover HCCs most commonly reported in error as identified by CMS (Chronic Kidney Disease Stage 5, Ischemic or Unspecified Stroke, Cerebral Hemorrhage, Aspiration and Specified Bacterial Pneumonias, Unstable Angina and Other Acute Ischemic Heart Disease, End-Stage Liver Disease).
   • Link: Red Flag Hierarchical Condition Categories (HCCs), part one
     
     
2. Red Flag HCCs Part 2 (March 18, 2020): Training will cover HCCs most commonly reported in error as identified by CMS (Atherosclerosis of the Extremities with Ulceration or Gangrene, Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome, Drug/Alcohol Psychosis, Lung and Other Severe Cancers, Diabetes with Ophthalmologic or Unspecified Manifestation)
   • Link: Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 2
     
     
3. Neoplasms (May 20, 2020)
   • Link: Neoplasms
     
     
4. Acute, Chronic and Status Conditions (July 15, 2020)
   • Link: Acute, Chronic and Status Conditions
     
     
5. Diabetes Mellitus and Other Metabolic Disorders (September 16, 2020)
   
   • Link: Diabetes Mellitus and Other Metabolic Disorders
     
     
6. TBD — This Medicare risk adjustment webinar will cover the critical topics and updates that surface during the year (November 18, 2020):
   • Link: Topic TBD

 

ABSCRNU-0125-20 February 2020          507941MUPENMUB

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

 

• Coding tip for psychological and neuropsychological testing
• New MA Opioid Treatment Program benefit
• Medical Policies and Clinical Utilization Management Guidelines update
• Prior authorization requirements: new 2020 codes for coverage and precertification

Click here for more information about the COVID-19 Virus Talking Points.

 

ANVPEC-1155-20 March 2020

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield Healthcare Solutions. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting November 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.*

 

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield Healthcare Solutions.

 

ANV-NU-0111-20 February 2020

The HEDIS® measure, Use of Imaging Studies for Low Back Pain (LBP), analyzes the percentage of patients 18 to 50 years of age during the measurement year with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. The measure is used to determine whether imaging studies are overused to evaluate members with low back pain. The measure is an inverted rate. A higher score indicates appropriate treatment of low back pain.

 

Clinical guidelines for treating patients with acute low back pain recommend against the use of imaging in the absence of red flags (in other words, indications of a serious underlying pathology such as a fracture or tumor). Unnecessary or routine imaging is problematic because it is not associated with improved outcomes and exposes patients to unnecessary harms such as radiation exposure and further unnecessary treatment.

Measure exclusions:

• Cancer
• HIV
• Intravenous drug abuse
• Major organ transplant
• Neurological impairment
• Prolonged use of corticosteroids
• Recent trauma
• Spinal infection

Helpful tips:

Hold off on doing imaging for low back pain within the first six weeks, unless red flags are present.

 

Consider alternative treatment options prior to ordering diagnostic imaging studies, such as:

• Nonsteroidal anti-inflammatory drugs.
• Nonpharmacologic treatment, such as heat and massage.
• Exercise to strengthen the core and low back or physical therapy.

 

Other available resources:

• National Committee for Quality Assurance — NCQA.org
• Choosing Wisely — Choosingwisely.org
• American Academy of Family Physicians — AAFP.org

 

 

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

ANVPEC-1082-19 February 2020

This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).

 

Anthem provides benefits for covered services rendered by nurse practitioners (NPs) and physician assistants (PAs) when operating within the scope of their license. Our policy states that these mid-level practitioners are required to file claims using their specific NPI number — not that of the medical doctor.

 

We will continue to monitor this area of concern through medical chart review and data analysis. Billing noncompliance can be considered a contract breach.

 

Anthem recognizes the quality of care delivered to our members can be improved by the proper use of NPs and PAs. This notice is in no way intended to discourage their proper use, but rather to clearly define how services should be appropriately billed.

 

Thank you for your continued participation. Should you have any questions, please call Provider Services:

• Anthem Blue Cross and Blue Shield Healthcare Solutions (Medicaid): 1-844-396-2330
• Medicare Advantage: Call the number on the back of members’ ID cards.

 

ANV-NU-0106-19 February 2020

 

Code only confirmed cases
According to ICD-10-CM coding guidelines for Chapter One, code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H. In this context, ‘confirmation’ does not require documentation of positive serology or culture for HIV. The provider’s diagnostic statement that the patient is HIV positive or has an HIV-related illness is sufficient.

Status	ICD-10-CM code
Asymptomatic HIV	Assign code Z21 — Asymptomatic human immunodeficiency virus [HIV] infection status when the patient without any documentation of symptoms is listed as being ‘HIV positive’, ‘known HIV’, ‘HIV test positive’ or similar terminology. Assign code B20 — Human immunodeficiency virus [HIV] disease on the claim when the term AIDS is used, when the patient is being treated for HIV-related illness or when the patient is described as having any active HIV-related condition.
Patients with inconclusive HIV serology	Assign code R75 — Inconclusive laboratory evidence of human immunodeficiency virus [HIV] when the patient’s record is documented with inconclusive HIV serology, but there is no definitive diagnosis or manifestations of the illness.
Previously diagnosed HIV-related illness	Code B20 if you document a patient as having had any known prior diagnosis of an HIV-related illness — Z21 is no longer reported. If the patient develops an HIV-related illness, they should be assigned code B20 on every subsequent admission/encounter.
HIV infection in pregnancy, childbirth and the puerperium	Assign code O98.7 — Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium first when a patient presents for treatment of an HIV-related illness during pregnancy, childbirth or the puerperium followed by code B20. Also assign additional code(s) for HIV-related illness(es). Keep in mind that codes from Chapter 16 take priority when sequencing codes on the claim. If a patient with asymptomatic HIV infection status presents for a routine visit during pregnancy, childbirth or the puerperium, the correct code assignment would be O98.7 followed by code Z21.

Assign code B20 for all types of HIV infections, which may be described by a variety of terms including:

• AIDS.
• Acquired immune deficiency syndrome.
• Acquired immunodeficiency syndrome.
• AIDS-related complex (ARC).
• AIDS-related conditions.
• HIV infection, symptomatic.

 

Testing for HIV:

• Assign code Z11.4 — Encounter for screening for human immunodeficiency virus [HIV] when seeing a patient with no prior diagnosis of HIV infection or positive HIV-status to determine their HIV status.
• Code the signs and symptoms when seeing a patient with signs or symptoms for HIV testing. If you provide counseling during the encounter, assign additional code Z71.7 — Human immunodeficiency virus [HIV] counseling.

• Assign code Z71.7 if a patient’s test results are negative for HIV.
• Assign code Z72.8 if a patient is known to be in a high-risk group for HIV infection. Other problems related to lifestyle can be assigned as an additional code.

Major HIV-related conditions
HIV-related condition	ICD-10-CM code
Pneumonia, unspecified organism	J18.9
Tuberculosis of other sites	A18.89
Sepsis, unspecified organism	A41.9
Candida stomatitis (thrush)	B37.0
Herpes zoster (any site)	B02.9
Encephalopathy, unspecified	G93.40

Other HIV-related conditions
Tinea cruris	B35.6
Anemia, unspecified	D64.9
Underweight	R63.6
Acute lymphadenitis	L04.9
Arthropathy, unspecified	M12.9
Splenomegaly, not elsewhere classified	R16.1
Weakness	R53.1

HIV/AIDS prevention

The CDC works with other federal agencies, state and local health departments, national organizations, and other entities to reduce the spread of HIV in the United States. This work covers several components:

• Behavioral interventions — These interventions ensure people have the information, motivation and skills necessary to reduce the risk of infection.
• HIV testing — Testing is critical to prevent the spread of HIV.
• Treatment and care — Treatment and care enable individuals with HIV to live longer, healthier lives.

 

The CDC remains on the forefront of pursuing high-impact prevention. This approach is designed to maximize the impact of prevention efforts for all Americans at risk for HIV infections and the CDC is aligning its efforts with the first National HIV/AIDS Strategy for the United States (NHAS). The Division of HIV/AIDS Prevention has developed a strategic three-year plan for 2017 to 2020 with the goal of one day achieving a future free of HIV.

 

Resources:

1. ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2019.
2. http://www.cdc.gov: HIV/AIDS.

ANV-NU-0105-19 February 2020

Please continue to check Medicaid Provider Communications & Updates at anthem.com/mediproviders for the latest Medicaid information.

 

• Coding tip for psychological and neuropsychological testing