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We encourage providers to utilize the online Provider Maintenance Form to notify us about your telehealth services and we will add a telehealth indicator to your online provider directory profile.

Visit anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.

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Change Notification to Provider and Facility Manual effective July 1, 2021

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Contact your Anthem representative if you need additional information or visit anthem.com/coronavirus/providers.

COVID-19 testing coding guidelines

• For a new or established patient, CPT code 99211 would be appropriate if patient is being seen for no other services besides a specimen collection.
• For a patient assessment in addition to a specimen collection it is appropriate to bill the applicable E&M service, CPT codes 99202-99215. Specimen collection is a component of the E&M service and not separately reimbursable.
• Effective 04/01/2021, CPT codes G2023 and G2024 are appropriate when billed by clinical laboratories only and are not appropriate for provider practices.

Refer patients to anthem.com/coronavirus to find convenient testing locations

If an Anthem member requests a COVID-19 test, you may refer them to anthem.com or the Sydney Health mobile app to find testing locations near them. Our test-site finder gives members important information about each site, including days and hours of operation, and if they offer:

• Appointments or walk-ins.
• Drive-through service.
• Rapid test results.  
• Antibody testing.
• Testing for children

Send swab tests to Anthem-contracted laboratories

When providing COVID-19 molecular testing services to our members, consider utilizing the following additional in-network, high-quality labs to assist in helping to ensure that our members are receiving high value health care.

Consider Antigen testing when rapid test results are needed

Antigen tests can be a quicker way to detect COVID-19 than nucleic acid amplification tests (NAAT), e.g. PCR. Antigen tests offer a reasonable and lower cost alternative when screening asymptomatic or low-risk patients and may be most useful for individuals within the first five to seven days of symptoms when virus replication is at its highest.

Antigen tests can be used to detect current infection, are relatively easy to use, and most can provide point-of-care testing results. The Centers for Disease Control and Prevention (CDC) notes that proper interpretation of antigen test results (and confirmatory testing with NAAT when indicated) is important for accurate clinical management of patients with suspected COVID-19; more information can be found here.

The CDC notes that when molecular tests are unavailable or rapid turnaround time is needed, antigen tests can generally be used for diagnosis of COVID-19.

Antigen tests are typically less sensitive and clinicians should interpret negative results carefully.  When symptoms are present or a high clinical suspicion exists, negative antigen tests should be confirmed with a molecular test.

When antigen tests are used in symptomatic patients, positive antigen tests can be interpreted as indicative of SARS-CoV-2 infection and do not usually require follow-up testing.

Consider using COVID-19 and flu combination testing when appropriate

According to the CDC, clinicians should consider testing for other causes of respiratory illness, including infections such as influenza, when clinically appropriate.

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We’re changing!

The Information Center is replacing the Education and Reference Center application in Payer Spaces on the Availity Portal. There you’ll find important policies, forms and helpful resources.

If you’re looking for Anthem specific education materials, we invite you to visit the Custom Learning Center in Availity, which was designed to offer education/training content and to be a learning environment.  Content previously posted in the Communication & Education tab have now migrated there. Find the Custom Learning Center tool in Payer Spaces > Applications > Custom Learning Center.

Locate the Information Center in Payer Spaces > Applications > Information Center. Depending on your market, the Information Center contains a number of sections:

• Administrative Support
• Behavioral Health
• Clinical Resources
• Medicaid
• Medicare
• Federal Employee Program (FEP)

To view content in both of these valuable tools, visit Payer Spaces today.

What EDI roles do I need?

EDI Management: This role consists of the following permissions available under EDI File Management in the Availity menu:

• EDI Reporting Preferences– Specify the EDI batch report files you want users at your organization to receive, along with file formats and other reporting preferences.
• EDI Send and Receive Files– Review EDI batch report files for batch files submitted using Availity's EDI File Management feature.  In addition, review payer responses to Availity Web-based claim forms submitted to payers that process claims in batches.
• File Restore– Restore archived EDI files to your ReceiveFiles

Set up EDI Reporting Preferences

Availity's batch EDI processing generates response files for each batch file that you submit. The administrator for an organization can set reporting preferences that specify which response files are generated. In the Availity Portal menu, click Claims & Payments > EDI Reporting Preferences.

Enroll for the Direct Data Entry Transaction

You must be assigned the Claims role to submit professional claims or encounters. If you cannot access the claim form, contact your administrator to assign the Claims role to you. Submit transactions through manual data entry in Availity Portal. In the Availity Portal menu, click Claims & Payments > Professional Claim/Facility Claim/Dental Claim < Confirm which organization and payer you would like to submit claims for and continue to complete the fields to be directed to the simple and time saving claim form to enter claim information.

Need More Help?

The EDI Connection Services Startup Guide is a helpful resource to help you get started, set up your EDI reporting preferences and submit transactions through manual data entry in Availity Portal.

Availity Support

• Select Help & Training > Get Trained to display the Availity Learning Center (ALC) in a new browser tab. Search the catalog to locate and enroll in courses. Based on your needs.
• Select Help & Training > Find Help to display Availity Help in a new browser window. Use Contents to display topics. Depending on your needs, consider exploring these topics:
  • Administrator
  • Claim Submission
  • Electronic Data Interchange (EDI)
  • Glossary

• Select Help & Training > Availity Support to:
• Open a ticket to request support
• Get support via Chat

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Authorization and Referral Request (278)
 

Use this transaction to electronically submit authorization and referral requests. You have the option to transmit this transaction in real-time or batch mode, and you will receive confirmation numbers to validate receipt of request.

• An authorization is a review and approval of specific services
• A referral is used to refer a patient to a specialty provider

Hospital Admission Notification (278N)

Use this transaction to electronically submit hospital admission notifications between your facility and health plan.  The EDI 278N is the easiest, most efficient way to communicate facility admissions.  Just like the 278, you can also transmit in either batch or real-time format which includes the ability to update a previously submitted date.

What are your benefits for using these transactions?

• Streamline administrative tasks and increase productivity
• Reduce administrative costs through automation
• Increase data accuracy by reducing manual errors
• Confirm a notification of admission is on file in the form of a service reference number that is generated upon registration
• Submit notification of discharge
• Accomplish more with less ‒ fewer phone calls, faxes or keying

Getting Started

• If you use a clearinghouse or vendor work with them to ensure they have the capability to exchange these transactions.
• If you use practice management software have your Availity administrator use the following path to enroll:
  • My Providers > Enrollment Center > Transaction Enrollment

Useful Documents

• Availity EDI Companion Guide communicates Availity-specific requirements and other information that supplements requirements and information already provided in standard EDI and HIPAA communications.
• Anthem specific companion guide communicates requirements for submitting these transactions. These are located on the company website at anthem.com/edi.
• The Availity Quick Start Guidewill assist you with any EDI connection questions you might have.

If you need assistance, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 8 p.m. Eastern Time.

Anthem Blue Cross and Blue Shield (Anthem)’s Clinical Data Acquisition Group has integrated Admission, Discharge and Transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange can help Anthem:

• Better support members with care coordination and discharge planning – leading to healthier outcomes for our members – your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings to better manage out-of-pocket expenses.

Anthem would like to digitally exchange HLT ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real time HL7 ADT messaging data, or at least within 24-hours of admission, discharge or transfer, enables Anthem to most effectively manage care transitions.

Contact the Clinical Data and Analytics team to get started today. Email ADT_Intake@Anthem.com

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If you have questions about prior authorizations (PA), you now have a new option to have them answered quickly and easily. With Anthem’s Chat, providers can have a real-time, online discussion with a PA specialist.

• Faster access to PA provider services experts
• Real-time answers to your questions about PA and live help for submissions, similar to the call experience
• Access to denial information and clinical team for resolution
• The same high level of safety and security you have come to expect with Anthem

Chat is one example of how Anthem is using digital technology to improve the healthcare experience, with a goal to save you valuable time. To start, access the service through Payer Spaces on Availity.

To access chat: log on to Availity at www.Availity.com. Select Payer Spaces, select Anthem, and from Applications select Chat with Payer.

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We can impact the injustice of racism together.

Anthem has partnered with Motivo*, the first HIPAA-compliant digital platform that connects mental health therapists and clinical supervisors, to take on the challenge of facilitating conversations on racial injustice, trauma, and inequality among our providers and associates.

We are hosting Racial Equity forums on a quarterly basis to keep the conversation going. Please register for the next forum, Deconstructive Bias, to learn more about the impact of racism on healthcare and the people we serve, and what we can do about it.  

In Pursuit of Racial Equity: Deconstructing Bias

Wednesday, June 9th, 2021
4:00 pm – 5:30 pm Eastern, (1:00 pm – 2:30 pm Pacific)

Register today!

Our racial equity forums focus on:

• Exploring how racism takes shape in healthcare.
• Discussing how to identify racism in your practice and how to be an ally to your patients.
• Understanding the impact of prolonged exposure to racism on people of .
• Providing you with actionable resources to put an end to racism in your practice.

Since October 2020, Anthem has sponsored two virtual forums featuring healthcare professionals from Anthem and Motivo: Racial Trauma in America and The Road to Allyship: Playing Your Part in Racial Equity.

We know we are on the right track because the Racial Equity Forum participants say so.

• 90% received meaningful information about the influence that racism and white privilege may have on their perspectives and gained an understanding on what actions they can take to make a difference and be an ally.
• 86% obtained useful information and resources that will enhance their ability to serve patients.
• 75% agreed that the forum helped them understand a different perspective.
• 76% had some of their perspectives and beliefs challenged.

Systematic racism is a part of today’s healthcare system.

• US physicians underestimate the pain level of Black patients 47% of the time vs. 33.5% of the time for white patients (PNAS).
• Black women die from pregnancy or childbirth 243% more often than white women (CDC).

The first step to addressing racism is to recognize its existence, subtle or otherwise.

These conversations can be uncomfortable, but this is how you can do something about racial injustice now.

At Anthem, we are determined to reduce racism in our communities with your support and participation.

*Motivo is an independent company providing a virtual forum on behalf of Anthem.

Millennials with behavioral health conditions were at twice the risk of having a chronic physical condition.

The study included the analysis of millennials’ medical claims over a five year period. Those with ongoing behavioral health conditions were twice as likely to have a chronic physical condition as their peers without a behavioral health diagnosis.

Behavioral health conditions driving adverse health for millennials

Reprinted from Blue Cross Blue Shield Association’s 2019 report on the Health of Millennials

It’s important to follow-up with your patients - millennial, Gen X, Gen Z or baby boomer, who are prescribed antidepressant medications or who have been hospitalized for mental illness or substance use disorders. Not only will patients have better behavioral health outcomes, their physical health could be significantly impacted as well. Follow these HEDIS® measures for additional guidance in closing the gaps in behavioral health conditions for all ages.

A note about telehealth

NCQA now accepts telehealth codes for behavioral health and some physical health measures. The modifiers 95 and GT are defined as telehealth services rendered via interactive audio and video telecommunications system.  CPT Codes 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 98960-98962, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99406-99409 and 99495-99496 may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95.

AMM - Antidepressant Medication Management (AMM): The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported:

• Effective Acute Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
• Effective Continuation Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).

AIM Billing Codes:

• BH Outpatient CPT: 99078, 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411-99412, 99510 HCPCS: G0155, G0176-G0177, G0409, G0463, H0002, H0004, H0031, H0034-H0037, H0039-H0040, H2000, H2001, H2010-H2011, M0064, T1015
• Emergency Department CPT: 99281-99285 UB Rev: 0450-0452, 0456, 0459, 0981
• Major Depression ICD-10 CM: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9
• Telephone Visits CPT: 98966-98968, 99441-99443
• Telephone Modifier Value Set: 95 GT POS: 02
• Telehealth: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
• Telehealth modifier: 95 or GT
• Telehealth POS: 02

FUH - Follow-Up After Hospitalization for Mental Illness (FUH) - The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are reported:

• The percentage of discharges for which the member received follow-up within 30 days after discharge.
• The percentage of discharges for which the member received follow-up within 7 days after discharge.

The follow-up visits, within 7 days and 30 days after hospitalization can both be telehealth visits. Telephone visits alone do not meet this criterion.

FUH Billing Codes:

• Follow-Up Visits CPT: 90791-2, 90832-40, 90845, 90847, 90849, 90853, 90875-6, 98960-2, 98966-8, 99078, 99201-5, 99211-5, 99217-23, 99231-3, 99238-9, 99241-5, 99251-5, 99341-5, 99347-50, 99381-7, 99391-7, 99401-4, 99411-2, 99441-3, 99483, 99495-6, 99510 HCPCS: G0155, G0176-7, G0409, G0463, H0002, H0004, H0031, H0034, H0036-7, H0039-40, H2000, H2010-1, H2013-20, M0064, T1015
• Mental Illness Diagnosis Codes ICD-10: F03.9x, F20-F25.xx, F28-F34.xx, F39-F45.xx, F48.xx, F50-F53.xx, F59-F60.xx, F63-F66.xx, F68-F69.xx, F80-F82.xx, F84.xx, F88-F93.xx, F95.xx, F98-F99.xx
• Telehealth visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
  Telehealth modifier: 95 or GT
  Telehealth POS: 02

FUM - Follow-Up After Emergency Department Visit for Mental Illness (FUM) - The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness. Two rates are reported:

• The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
• The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.

FUM Billing Codes:

• Outpatient Follow-Up Visits CPT: 90791-2, 90832-4, 90836-40, 90845, 90847, 90849, 90853, 90875-6, 98960-2, 98966-8, 99078, 99201-5, 99211-5, 99217-23, 99231-3, 99238-9, 99241-5, 99251-5, 99341-5, 99347-50, 99381-7, 99391-7, 99401-4, 99411-2, 99441-3, 99483, 99495-6, 99510
• HCPCS: G0155, G0176-7, G0409, G0463, H0002, H0004, H0031, H0034, H0036-7, H0039-40, H2000, H2010-1, H2013-20, M0064, T1015
• Mental Illness Diagnosis Codes ICD-10:9x, F20-25.xx, F28-34. xx, F39-45.xx, F48.xx, F50-53.xx, F59-60.xx, F63-66.xx, F68-69.xx, F80-82.xx, F84.xx, F88-93.xx, F95.xx, F98-99.xx
• Intentional Self-Harm Diagnosis Codes ICD-10 example:92XA
• Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 98960-98962
• Telehealth modifier: 95 or GT
• Telehealth modifier POS: 02

FUA - Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA) - The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up visit for AOD. Two rates are reported:

• The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
• The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

The follow-up visits, within 7 days and 30 days after hospitalization, can both be telehealth visits. Telephone visits alone do not meet this criterion.

FUA Billing Codes:

• Initiation, Engagement and Treatment Follow-Up Visits CPT: 98960-2, 99078, 99201-5, 99211-5, 99241-5, 99341-50, 99384-7, 99394-7, 99401-4, 99408-9 99411-2, 99483, 99510
  Alcohol Counseling or Other Follow-Up Visits CPT: 99408-9 HCPCS: G0396-7, G0443, H0005, H0007, H0016, H0022, H0050, H2035-6, T1006, T1012 AOD
• Medication Treatment HCPCS: G2067-77, G2080, G2086-7, H0020, H0033, J0570, J0571-5, J2315, Q9991-2, S0109
• Substance Use Disorder Diagnosis Codes ICD-10: F10-16.xx, F18-19.xx
• Telehealth modifier: 95 or GT
• Telephone visits: 98966 - 98968, 99441- 99443
• Other visits: 90791-90792, 90832-90834, 90836-90838, 90845, 90847, 99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99408-99409, 98960-98962
• Telehealth modifier POS: 02

FUI – Follow-Up After High-Intensity Care for Substance Use Disorder (FUI) - The percentage of acute inpatient hospitalizations, residential treatment or detoxification visits for a diagnosis of substance use disorder among members 13 years of age and older that result in a follow-up visit or service for substance use disorder. Two rates are reported:

• The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 30 days after the visit or discharge.
• The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 7 days after the visit or discharge.

FUI Billing Codes:

• Opioid Abuse and Dependence ICD-10:10; F11.120; F11.121; F11.122; F11.129
• Other Drug Abuse and Dependence ICD-10:10; F12.120; F12.121; F12.122; F12.129
• Alcohol Abuse and Dependence ICD-10:10; F10.120; F10.121; F10.14; F10.150
• Telephone Visits CPT: 98966-98968; 99411-99443
• Online Assessments CPT: 98969-98972; 99421-99423; 99444; 99458
• IET Stand Alone Visits CPT: 98960-98962; 99201-99205; 99211-99215

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

¹Millennial Health: Trends in Behavioral Health Conditions. https://www.bcbs.com/the-health-of-america/reports/millennial-health-trends-behavioral-health-conditions

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Having the common goal of reaching all Latinos in the US, Anthem, Inc., the Beckman Research Institute of City of Hope, the National Hispanic Medical Association, and Pfizer, Inc., announce the launch of Tomando Acción por Nuestra Salud/Taking Action for Our Health, a free interactive bilingual website aimed at eliminating health disparities in the Latino community. The website encourages preventive health screenings for cancer, emotional health, heart health, and prediabetes. It also provides tools to help people care for the emotional health of their families and themselves in the language of their preference.

The interactive website highlights the importance of health screenings, addresses barriers and provides information on access to low and no cost healthcare services in the community. The easy to use website, guides participants through four programs where they can learn about risk factors, take action to get screened, monitor their progress, and share their results with their doctors, health care teams or family and friends to let them know they are taking steps to protect their health and help encourage others to participate as well.

The website is not exclusive for Anthem members. Health care providers are encouraged to share the website with all of their Latino patients.

The website identifies four major targets of undue poor health outcomes for Latinos. In response, Tomando Acción por Nuestra Salud/Taking Action for Our Health strives to help increase cancer screening, screening for depression/anxiety-risk, heart diseases and prediabetes and provides tools to address emotional health. The website includes a 4-part workshop series “Compartiendo el Café y el Chocolate/Coffee and Chocolate” to help people care for the emotional health of their family and themselves. This is a program, specifically for Hispanics, which uses a holistic approach to emotional stability. It builds on cultural strengths to balance four key items—community, body, mind, and spirit.

To access Tomando Acción por Nuestra Salud/Taking Action for Our Health visit: Taking Action for Our Health.

To encourage well-visits and vaccinations, here are some extra steps you can take, if you haven’t already, to make visits as safe as possible for both patients and staff. They include:

• Scheduling sick visits and well-child visits during different times of the day.
• Asking patients to remain outside until it’s time for their appointment to reduce the number of people in waiting rooms.
• Offering sick visits and well-child visits in different locations.

It’s important to identify those children who have missed immunizations and well-child visits to schedule these essential in-person appointments. To help, the CDC has published vaccine catch-up guidance on their website.

Helpful information for keeping babies and children healthy

Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:

• Four DTaP (diphtheria, tetanus and acellular pertussis)
• Three IPV (polio)
• One MMR (measles, mumps, rubella)
• Three HiB (H influenza type B)
• Three HepB (hepatitis B)
• One VZV (chicken pox)
• Four PCV (pneumococcal conjugate)
• One HepA (hepatitis A)
• Two or Three RV (rotavirus)
• Two Influenza (flu)

Billing codes:

• MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
• Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
• Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
• Rubella CPT: 90706
• Rubella antibody CPT: 86762
• Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
• Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
• HCPCS: G0008
• Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)

Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:

• 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
• 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
    10 to 13 years of age
• 2 or 3 HPV vaccines between 9 to 13 years of age

Billing Codes:

• Meningococcal CPT: 90734
• Tdap CPT: 90715
• HPV CPT: 90649, 90650, 90651

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

For a complete list of HEDIS® measures, descriptions and coding tips, visit Anthem.com.

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UPDATE--Site of Care medical necessity reviews for long-acting colony-stimulating factors begin August 1, 2021

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Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.

Anthem is committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem has the answers before you ask the questions. With an initial focus on claim-level insights, Anthem has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOP.

Access the Claims Status Listing on Payer Spaces from https://mediproviders.anthem.com/nv or using the Log In button or through the secure provider portal via Availity.* We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.

Anthem made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem is using digital technology to improve the healthcare experience. If you have questions, please reach out to your Provider Relations representative.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

ANV-NU-0182-20

Changes are meant to simplify code selection criteria, make coding more clinically relevant and to reduce documentation overload for office-based evaluation and management (E/M) services, while continuing to differentiate payment based on complexity of care.

Key elements of major revisions for 2021:

• Physicians may choose their documentation based on medical decision making (MDM) or total time (including non-face-to-face services).
• History and exam are still important parts of the notes and may contribute to both time and MDM, but they will no longer be scored for determining the level of the E/M visit.
• MDM criteria has moved away from simply adding up tasks to instead focusing on tasks that affect the management of a patient’s condition.
• Code 99201 was deleted.
• Codes 99202 to 99215 were revised.

Changes to time documentation

Time will now be defined as the total time spent by the provider (both face-to-face and time spent on
non-face-to-face activities related to this patient’s visit performed on the same day as the visit). This may include the services listed below but should not include time spent on separately billable services (such as X-ray interpretation).

Effective January 1, 2021:

• The total time spent must be documented clearly by the provider for the E/M level to be determined by time and does not include ancillary staff time.
• Time will no longer need to be dominated by counseling.
• All time used for leveling the E/M must be on the same day as the face-to-face visit.

Services included in total time:

• Preparing for the visit (for example, reviewing test results)
• Obtaining and/or reviewing separately obtained history
• Performing a medically necessary examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering tests, medications, prescriptions or procedures after the visit
• Referring and communicating with other health care professionals (when not reported separately)
• Documenting clinical information in the patient’s medical record
• Independently interpreting results (not separately reportable) and communicating results to the patient/family/caregiver
• Care coordination (not separately reportable)

Prolonged office services

2021 changes include addition of a new add-on code (currently labeled 99417) for prolonged office visits when time is used for code level selection, including face-to-face and non-face-to-face provider time of at least 15 additional minutes on the same date of service for level five office visits (99205, 99215).

Medical decision making (MDM)

Using the new MDM table, medical decision making for office/outpatient visits will be based on meeting (or exceeding) two out of three categories: 

Number and complexity of problems addressed at the encounter:

• Straightforward: One self-limited or minor problem
• Low: Two or more self-limited or minor problems; one stable chronic illness, one acute, uncomplicated illness or injury
• Moderate: One or more chronic illnesses with exacerbation, progression or side effects of treatments; two or more stable chronic illnesses; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; one acute complicated injury
• High: One or more chronic illnesses with severe exacerbation, progression or side effects of treatment; one acute or chronic illness or injury that poses a threat to life or bodily function.

Amount and/or complexity of data to be reviewed and analyzed

The 2021 guidelines list three categories for data:

1. Tests, documents or independent historians.
2. Independent interpretation of tests
3. Discussion of management or test interpretation.

• Straightforward: Minimal or none
• Low (one category required):
  • Two tests/documents or independent historian
• Moderate (one category required):
  • Three tests, documents and/or independent historian
  • Independent interpretation of a test
  • Discussion of management or test interpretation
• High (two categories required):
  • Three items between documents and independent historian
  • Independent interpretation of a test
  • Discussion of management or test interpretation

Risk of complications and/or morbidity or mortality of patient management

For the purposes of MDM, level of risk is based upon the consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization:

• Minimal: Rest, gargle, elastic bandages, superficial dressings
• Low: OTC drugs, physical therapy, minor surgery with no identified risk factors, IV fluids without additives
• Moderate: Management of a prescription drug, minor surgery with identified risk factors, decision regarding major surgery without identified risk factors, diagnosis or treatment
• High: Need to discuss higher risk problems that could happen for which physician or other qualified health care professional will watch or monitor.

Tips to prepare your practice for E/M office visit changes:

• Identify project lead
• Schedule team preparation time
• Update practice protocols
• Consider coding support
• Review business liability coverage
• Guard against fraud/abuse
• Update compliance plan
• Check with your electronic health record (EHR) vendor
• Assess financial impact
• Understand medical liability coverage

Resources:

1. CPT^® Professional Edition, 2021. AMA
2. AMA Elements of Medical Decision Making. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
3. AMA Press Release 2021 CPT code set. https://www.ama-assn.org/press-center/press-releases/ama-releases-2021-cpt-code-set
4. Major E/M Changes Coming Soon. Are you prepared? https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx

ANV-NU-0191-20

Please note, inclusion of the National Drug Code (NDC) on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Visit the Clinical Criteria website to search for specific clinical criteria.

ANV-NU-0197-20

The Clinical Criteria is publicly available on our provider website. Visit https://www.anthem.com/ms/pharmacyinformation/Agents-for-Iron-Deficiency-Anemia.pdf for the specific Clinical Criteria.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-844-396-2330.

ANV-NU-0198-21

Visit the Clinical Criteria website to search for specific clinical criteria. Please note, these codes are specific to Agents for Iron Deficiency Anemia. The Clinical Criteria indicated below can be found at: https://www.anthem.com/ms/pharmacyinformation/Agents-for-Iron-Deficiency-Anemia.pdf.

If you have questions about this communication or need further assistance, contact your local Provider Relations representative or call Provider Services at 1-844-396-2330.

• MCG Care Guidelines 24th edition customization
• Clinical Criteria Updates Notification November 2020
• DHCFP COVID-19 covered services, vaccines, and vaccination prioritization lanes information for members

ANV-NU-0187-20

ANV-NU-0202-21

ANV-NU-0209-21

Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.

Anthem is committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem has the answers before you ask the questions. With an initial focus on claim-level insights, Anthem has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOP.

Access the Claims Status Listing on Payer Spaces from https://mediproviders.anthem.com/nv or using the Log In button or through the secure provider portal via Availity.* We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.

Anthem made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem is using digital technology to improve the healthcare experience. If you have questions, please reach out to your Provider Relations representative.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

ANV-NU-0182-20

If you are interested in learning about the electronic modalities available, please contact your representative or the Optum* Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time.

Success stories

Below are some achievements that Anthem Blue Cross and Blue Shield (Anthem) was able to accomplish with provider groups through the IOA program:

• As a result of leveraging different types of resources offered by the IOA program (for example, technology), providers’ offices were able to see an increase in staff productivity.
• Providers who have taken advantage of the IOA program resources have seen an increase in their documentation and coding accuracy.

COVID-19 update

Anthem knows this is a difficult time for everyone, as the situation continues to evolve each day. Anthem has considered the severity of the situation and is following CDC Guidelines. For the IOA program, all nonessential personal are required to work with provider groups telephonically/electronically until further notice.

Anthem continues to evaluate the situation and guidelines, and will keep you notified of any changes. If you have any questions or concerns about the IOA program and COVID-19 updates, please call the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time.

Dates and tips to remember:

• To review their population as soon as possible, Anthem strongly encourages participating providers to deliver and continually maintain proper care management, as well as care coordination of their patient population. This will further ensure the current and active conditions that impact patient care, treatment and/or management are continually addressed.
• At the conclusion of each office visit with the patient, providers participating in the IOA program are asked to complete and return a patient assessment. The assessment should be completed based on information regarding the patient’s health collected during the office visit. Participating providers may continue to use the 2021 version of the assessment for encounters that take place on or before December 31, 2021; Anthem will accept the 2021 version of the assessment for 2021 encounters until midnight January 31, 2022.
• If not already submitted, participating providers are required to submit an Account Setup Form, W-9 and completed direct deposit enrollment by March 31, 2022. Participating providers should call the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time, if they have any questions regarding this requirement. Failure to comply with this requirement will result in forfeiture of the provider payment for submitted 2021 assessments, if applicable.

Questions

If you have questions about this communication or the IOA program, please contact your representative or the Optum Provider Support Center at 1-877-751-9207, Monday through Friday, from 8 a.m. to 7 p.m. Eastern time.

ABSCRNU-0210-21

Effective for dates of service on or after July 1, 2021, providers for our Medicare Advantage plan members covered by Anthem will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications, listed below. Reviews for these oncology drugs will continue to be administered by the reviewing company, either AIM Specialty Health_®* or IngenioRx.* 

Providers will be asked whether or not they will accept the dose reduction at the initial review point in the prior authorization process. Within the provider portal, a pop-up question will appear related to dose reduction. If the patient is considered unable to have his or her dose reduced, then a second question will appear asking for the provider’s clinical reasoning. For requests made outside of the provider portal (for example, called-in or faxed-in prior authorization requests), the same questions will be asked by the registered nurse or medical director who is reviewing the request. Since this program is voluntary, the decision made regarding dose reduction will not affect the final decision on the prior authorization.

The dose reduction questions will appear only if the originally requested dose is within 10% of the nearest whole vial. This threshold is based on current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) that it is appropriate to consider dose rounding within 10%. HOPA recommendations can be found here.

The Voluntary Dose Reduction Program only applies to specific oncology drugs, listed below. Providers can view prior authorization requirements for Anthem members on the Medical Policy and Clinical Utilization Management Guidelines page at https://www.anthem.com/medicareprovider.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

Note: In some plans, dose reduction to nearest whole vial or waste reduction may be the term used in benefit plans, provider contracts or other materials instead of or in addition to dose reduction to nearest whole vial. In some plans, these terms may be used interchangeably. For simplicity, we have uses dose reduction (to nearest whole vial).

ABSCRNU-0211-21

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other members of your practice and office staff.

Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other members of your practice and office staff.

Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

ABSCRNU-0213-21

Beginning in April 2021, our online directories will identify professional providers who offer telehealth services in their practice.

We encourage providers to use the online Provider Maintenance Form to notify us about your telehealth services, and we will add a telehealth indicator to your online provider directory profile.

Visit http://www.anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.

• Nevada Provider Maintenance Form

ABSCRNU-0208-21