 Provider News NevadaAugust 1, 2022 August 2022 Anthem Provider News - NevadaAccording to the American Medical Association (AMA) Current Procedural Terminology® (CPT) guidelines, a new patient is defined as one who has not received any professional services, i.e. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after 30-day notice, Anthem Blue Cross and Blue Shield will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.
Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual or resubmit the claim with an established patient E/M.
If you have questions on this program, contact your contract manager or Provider Experience representative.
Material adverse change (MAC)
As a reminder, Anthem Blue Cross and Blue Shield’s current Outpatient Prepay Itemized Bill Review Program reviews outpatient claims more than $100,000 billed at a percent of charge prior to reimbursement to ensure items and services included on the claim are reimbursable. We are expanding the prepay program launched in 2021 requiring an itemized bill review for all outpatient services as follows:
- Effective with dates of service on or after July 1, 2022, we will add HOST and ambulatory surgery centers (ASCs) in scope.
- Effective with dates of service on or after November 1, 2022, the threshold for requiring an itemized bill for outpatient claims will decrease from $100,000 to $50,000.
Anthem Blue Cross and Blue Shield would like to remind you of the procedures to follow for inpatient claim denials:
- If claim is billed as inpatient bill type in error, a replacement bill xx7 is a replacement of the same type of bill (ex. x11 and x17, or x31 and x37; you may not use a x37 to replace a x11 or a x17 to replace a x31).
- If you are changing the bill type from inpatient to outpatient or outpatient to inpatient, the original claim will need to be voided by using a frequency type 8 (void).
- The void request must be submitted first by the provider, or in conjunction with a frequency type 1 (original) inpatient or outpatient claim before the outpatient bill type claim will be processed.
- This can be done electronically or with a provider adjustment request (PAR) form.
- Further instructions are included in the provider manual.
It is inappropriate to re-bill an outpatient claim when receiving a denial/upheld appeal response for ancillary services rendered in the inpatient setting for commercial polices. This includes, but is not limited to, emergency department, imaging, laboratory services, specialty pharmacy, and surgeries.
Claims should be coded and billed based on the medical record and the physician order.
For complete information on electronic claims processing procedures, visit the Electronic Data Interchange (EDI) page on our website.
Note: This update does not apply to Medicaid or Medicare Advantage.
As of today, the new provider manual is available online. Go to anthem.com, and select For Providers. Under the Provider Resources heading, select Policies, Guidelines & Manuals. Select Nevada.
- To access the manual effective November 1, 2022: Under the Provider Manualheading, select Download the Manual under the banner. This version is effective beginning November 1, 2022, but available for review as of August 1, 2022.
- To access the manual still effective until October 31, 2022: Select the link titled Access previous versions and other manuals. See the appropriate historical version using the effective dates listed with each manual.
Changes were made to the following sections:
- Insurance requirements
- Credentialing
- Claims submission
- Medical records submission (solicited and unsolicited)
- Electronic Data Interchange (EDI)
- Claim payment disputes
- Clinical appeals
- Reimbursement requirements and policies
- Medical Policies and Clinical Utilization Management (UM) Guidelines
- Utilization Management
- AIM Specialty Health®*
- Quality Improvement Program
- Member rights and responsibilities
- Overview of HEDIS®
- Centers of Medical Excellence
- Audit and review
- Fraud, waste and abuse detection
Submitting your updates promptly helps ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information shown in our online directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Using this form, you can update:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging that we received your request. See the Provider Maintenance Form for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
Digital claims attachments expedite claims processing and payment. That’s why we have been hard at work making the digital attachment process easier, more intuitive and streamlined. Now you can add attachments directly to your claim by using the new Send Attachments feature from the Claims Status application on Availity.com.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time because there is no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and personal health information.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the Attachment Control Number, there are three options for submitting attachments:
- Through the Attachments Dashboard Inbox: From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox
- Through the 275 attachment: Important: You must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment
- Through the Availity.com application: From Availity.com, select the Claims & Payments tab to run a Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
If you submitted your claim through the Availity Essential Claims application:
- Simply submit your attachment with your claim
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments: From Availity.com, select the Claims & Payments tab and access a Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
Learn more about the Send Attachment feature
In collaboration with Availity Essentials, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status workflow. Sign up for a live webinar today:
Now open for learning!
Introducing the Anthem Blue Cross and Blue Shield Provider Learning Hub.
Access to training for Availity Essentials can be helpful when trying to master applications like claims attachments, authorizations and eligibility and benefits. The Provider Learning Hub on Anthem.com is not only a new way to access training, it also offers a new learning experience.
Short, easy to follow training videos with supporting resources are available on the Provider Learning Hub – no username and password required. Access it at your convenience and share your learnings with others on your teams. Handy filtering options enable you to quickly find what you are looking for including an option to save trainings to a Favorites folder for easy access later. You will register for the Provider Learning Hub once. On future visits your preferences are populated, eliminating the need for any additional logon information.
Get started today! Access the Provider Learning Hub using this link or from Anthem.com under Important Announcements on the home page.
Anthem Blue Cross and Blue Shield appreciates the feedback you shared about the Availity* Essentials multi-payer authorization application. The insight you provided about your user experience has enabled enhancements that we hope will further improve your experience:
- Easier to track your authorization requests: Case numbers are being returned following your authorization submission, making it easier to track your authorization requests.
- Expanded procedure code options: You can now submit your procedure codes by visits and hours, in addition to days and units.
- Error code improvements: Recognizing that error codes can be difficult to understand, we have rewritten them to be more clear, concise, and actionable.
- Enhancements to the admissions dropdown menu: For outpatient submissions, an enhancement to the level of service improves turnaround time for case decision. For inpatient and outpatient submissions, urgent requests receive a confirmation message.
- Update to Add Attachment feature: We have added a reminder notification that enables you to double check that the attachments are connected to the correct member for the correct
Become an Availity user today
If you aren’t registered to use Availity, signing up is easy and 100% secure. There is no cost for our providers to register or to use any of the digital applications. Start by logging onto availity.com and selecting the Register icon at the top of the home screen, or you can use this link to access the registration page.
Reductions in missed appointments are significant.
Telehealth visits are having a significant impact on missed appointments according to a study published in Counselling Psychology Quarterly. Prior to transitioning to telehealth, clinicians in the study “Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice,[i]” experienced a 14.25% missed appointment rate. After transitioning to telehealth, the missed appointment rate fell to 5.63%.
Rate of missed appointments before and after transitioning to telehealth
The graph below illustrates the changes in the average rate of missed appointments (cancellations and no-show) for each of the eight clinicians in the study between the periods before and after the transition to telehealth.
https://www.tandfonline.com/doi/full/10.1080/09515070.2020.1777390
“While there are a number of limitations to consider regarding this data, [which is further discussed in the study], the statistically significant reduction in missed appointments pre-and-post [digital] transition is striking,” cited in the study report.
Telehealth and telephone visits with members after a behavioral health inpatient stay meet HEDIS® criteria for the measure: Follow-up after Hospitalization for Mental Illness (FUH). With transportation being one of the barriers to after hospitalization follow-up, telehealth visits could be an ideal solution.[ii]
The FUH HEDIS measure evaluates:
- Members (6 years and older) who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.
Two areas of importance for this HEDIS measure are:
- The percentage of behavioral health inpatient discharges for which the member received follow-up within seven days after discharge
- The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.
These two consecutive follow-up appointments are paramount to positive outcomes as well as meeting this HEDIS measure. Telehealth visits can greatly increase the likelihood of keeping follow-up appointments leading to reduced numbers of rehospitalization and more favorable outcomes for these patients. To learn more about the FUH HEDIS measure, visit the National Committee for Quality Assurance (NCQA) website.
ATTACHMENTS (available on web): Picture1.jpg (jpg - 0.02mb) All members on a product with referral management will have an attributed PCP within the product parameters:
- Nevada utilizes PMG designation for member attribution.
- Nevada uses PMG assignment, or member selection happens at the PMG level when there is a group practice in place.
Application for all products within:
- Guided Access HMO
- Pathway X Guided Access HMO
- Convenient Care HMO (launching January 2023)
Referral parameters:
- Referral orders must be created by the system attributed PCP of the member.
- Referrals must be limited to an in-network provider only. If PCP is seeking a referral for an
out-of-network (OON) provider, then all OON authorization processes must be followed.
- Specialist claims require a referral or will be denied, except as noted below.
- Exceptions: The following specialties do not require referrals when in-network (procedure codes listed in Exhibit 1):
- Optometry
- Mental:
- Behavioral health
- Substance use disorder (SUD) providers
- Gynecology
- Dental
- Addiction medicine
- Emergent or urgent services
- Pediatric PCP services
- Maximum of three visits to specialist per PCP referral. After the third visit, member must return to PCP to obtain a new referral. If a PCP believes additional referrals are required, then the PCP must contact Anthem Blue Cross and Blue Shield directly for a referral.
- All referrals expire in 90 days.
Please see the attached table titled Referral Exclusion List and Procedure Codes (Exhibit 1 – as of June 9, 2022).
Material adverse change (MAC)
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) are listed below.
Anthem’s medical specialty drug review team manages prior authorization clinical review of non-oncology use of specialty pharmacy drugs. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Important to note
Currently, your patients may be receiving these medications without prior authorization. Effective November 1, 2022, you may be required to request prior authorization review for your patients’ continued use of these medications.
By including National Drug Code (NDC) on your claim, you will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
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Clinical criteria
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Drug
|
HCPCS or CPT® Code(s)
|
|
ING-CC-0216*
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Opdualag (nivolumab and relatlimab-rmbw)
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C9399, J3490, J3590, J9999
|
|
ING-CC-0002*
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Releuko (filgrastim-ayow)
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C9096
|
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ING-CC-0118*
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Pluvicto (lutetium lu 177 vipivotide tetraxetan)
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A9699
|
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ING-CC-0107*
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Alymsys (bevacizumab-maly)
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C9399, J3490, J3590, J9999
|
|
ING-CC-0072
|
Alymsys (bevacizumab-maly)
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C9399, J3490, J3590
|
* Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Access our Clinical Criteria to view the complete information for these step therapy updates.
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Clinical Criteria
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Status
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Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0002*
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Non-preferred
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Releuko
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C9096
|
|
ING-CC-0107*
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Non-preferred
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Alymsys
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C9399, J3490, J3590, J9999
|
*Oncology use is managed by AIM.
Courtesy notice
Effective for dates of service on and after October 1, 2022, updated step therapy criteria for immunoglobulins found in clinical criteria document ING-CC-0003 will be implemented. The preferred product list is being expanded. Please refer to clinical criteria document for details.
Quantity limit updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
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Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0072
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Alymsys (bevacizumab-maly)
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C9399, J3490, J3590
|
Visit the Drug Lists page at https://www.anthem.com for more information on:
- Copayment/coinsurance requirements and their applicable drug classes.
- Drug lists and changes.
- Prior authorization criteria.
- Procedures for generic substitution.
- Therapeutic interchange.
- Step therapy or other management methods subject to prescribing decisions.
- Any other requirements, restrictions, or limitations that apply to using certain drugs.
The Commercial and Exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.
To locate Exchange Select Formulary and pharmacy information, scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
Medicaid
Effective November 1, 2022, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by Anthem Blue Cross and Blue Shield Healthcare Solutions. Federal and state law, as well as state contract language, and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.
PA requirements will be added to the following:
- 0214U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O.
- 0215U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O.
- L6026: Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device.
To request a PA, you may use one of the following methods:
- Availity:* Once logged in to Availity.com, select Patient Registration > Authorizations & Referrals, then select Authorizations or Auth/Referral Inquiry, as appropriate.
- Fax: 800-964-3627
- Phone: 844-396-2330
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://providers.anthem.com/nv. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 844-396-2330 for assistance with PA requirements.
Medicaid
Please continue to check Medicaid Provider Communications & updates at anthem.com/nvmedicaiddoc for the latest Medicaid information, including:
Medicaid
The total economic cost of alcohol use disorder (AUD) was estimated to be $249 billion per year as of 2019, according to the CDC1 with $27 billion coming from healthcare costs.2 The CDC projected the total AUD economic impact on society to be $807 per person, per year.3
AUD and healthcare spending
Alcohol contributes to the highest amount of health plan spending related to substance use. 36% of Medicaid substance use claims were related to alcohol in 2020, accounting for over $129 million — an increase of 16% from 2019. Additionally, people with AUD are more likely to be high-cost claimants. In government and commercially insured patients across the country, the top 5% of high-cost claimants have either an existing AUD or health conditions resulting from alcohol use.4
AUD and the workforce
AUD also has a significant economic effect on the workforce by way of tardiness, absenteeism, employee turnover, and conflict. It causes a reduction in potential employees, customer base, and the taxpayer base.5
AUD and mortality
Alcohol use was directly tied to 95,000 deaths annually between 2011 and 2015, according to the CDC. This was more than all other substances combined including opioids, heroin, fentanyl, and methamphetamines. The CDC estimates that alcohol-attributed disease resulted in almost 685,000 years of potential life lost (YPLL) for the same period. YPLL is the estimation of the average time a person would have lived had they not died prematurely.6
Below is the YPLL related directly or indirectly to AUD.
|
Cause
|
YPLL
|
|
Total YPLL
|
> 2.7 million
|
|
100% alcohol attributed disease
|
684,750
|
|
Suicide
|
334,058
|
|
Motor vehicle crashes
|
323,610
|
|
Liver disease
|
202,391
|
|
Heart disease
|
118,021
|
|
Cancer
|
88,729
|
What if I need assistance?
If you need assistance connecting your patients to AUD or substance use treatment, please contact Provider Services at 844-396-2330.
Medicaid
COVID-19 impact on opioid and substance use disorders
As a result of the COVID-19 pandemic, there has been a 20% increase in substance use nationwide and nearly 100,000 opioid overdose-related deaths between 2020 and 2021.1 Black Americans have been disproportionately affected by this increase in overdoses.2 Increasing screening, brief intervention, and referral to treatment (SBIRT) may help provide an opportunity to engage those with emerging and existing substance use disorders (SUDs) through proactive identification and connection to professional services when indicated.
SBIRT resources for providers
A provider toolkit for SBIRT is available on the Anthem Blue Cross and Blue Shield Healthcare Solutions provider website. This toolkit includes SBIRT collateral materials for your use, which outline recommended screening tools, a guided SBIRT process, and resources to help identify appropriate referrals.
More about the SBIRT approach
SBIRT is a “comprehensive, integrated public health approach to the delivery of early intervention and treatment services for persons with SUDs, as well as those who are at risk of developing these disorders,” according to the Substance Abuse and Mental Health Service Administration (SAMHSA). The goal of SBIRT is to reduce the potential consequences of SUDs.3
SBIRT encounters include a brief screening and intervention that identifies:
- One or more behaviors related to risky alcohol or drug use.
- Right type and amount of treatment.
The screening is a brief set of questions that identify the patient’s risk of SUD-related problems. The brief intervention is a short (15 to 30 minutes) counseling session to raise awareness of the risks. By leveraging motivation enhancement techniques, this seeks to work with the patient where they are at and with what they are ready and willing to do to address identified substance misuse. Referral to treatment helps the patient access specialized treatment when indicated.
The purpose of the encounter is to facilitate change with the patient’s immediate behavior or thoughts about a risky behavior. In addition, SBIRT results help those with higher levels of need to obtain long-term care, including referrals to specialty providers. This evidence-based program (EBP) has been shown to result in a $2 to $4 healthcare savings for every $1 spent.4
Healthcare providers who encounter an at-risk member have an opportunity for early intervention and referral to appropriate treatment. The core goal is to reduce and prevent problematic use, abuse, and dependence on alcohol, opioids, and other substances. SBIRT has been proven effective regardless of age, gender, race, and culture in children, adolescents, and adults.
Encounters with patients in need of SBIRT may occur in public health, non-substance use treatment settings including primary care centers, hospital emergency rooms, trauma centers, and community health settings. Primary care providers (MD/DOs, PAs, ARNPs), behavioral health providers (therapists, counselors, psychiatrists, clinical social workers), and nurses may provide SBIRT.
Recommended screening tools include:
- Alcohol Use Disorder Identification Test (AUDIT)5 for adults with alcohol risk.
- Drug Abuse Screening Test (DAST-10)6 for adults with drug risk.
- Car, Relax, Alone, Forget, Family Or Friends, Trouble (CRAFFT)7 for children and adolescents.
- Tolerance, Worried, Eye Opener, Amnesia, K/Cut Down (TWEAK)8 for pregnant people.
Below is the SBIRT process flow.
If you need assistance connecting patients to SUD treatment or have questions about implementing SBIRT in your practice, call Provider Services at 844-396-2330.
ATTACHMENTS (available on web): Picture3.png (png - 0.11mb) Medicaid
Chances are one of these teenagers has chlamydia. According to the Centers for Disease Control (CDC), one of the largest growing populations for chlamydia are teens and young adults. Chlamydia infection is often asymptomatic, and screening for asymptomatic infection is a cost-effective strategy to reduce transmission and prevent pelvic inflammatory disease among females.
Talking to a teenager about sexual health issues like chlamydia can be difficult. But, left untreated, an affected individual may develop conditions such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. To help get the conversation started, visit the National Chlamydia Coalition website at http://chlamydiacoalition.org for a free Chlamydia How-To Implementation Guide for Healthcare Providers.
Facts about chlamydia:
- The United States Preventive Services Task Force (USPSTF) recommends screening for chlamydia in all sexually active women [24] years or younger and in women [25] years or older who are at risk for infection.
- Chlamydia is the most commonly reported sexually transmitted disease (STD) with over 1.8 million cases reported in 2019.
- Young women account for 43% of reported cases and face the most severe consequences of an undiagnosed infection.
- It is estimated that undiagnosed STDs cause infertility in more the 20,000 women each year.
Chlamydia Screening in Women (CHL) HEDIS® measure
This HEDIS measure looks at the percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year, including teens and women who:
- Made comments or talked to you about sexual relations.
- Had a pregnancy test.
- Were prescribed birth control (even if used for acne treatment).
- Received gynecological services.
- Have a history of sexually transmitted diseases.
- Have a history of sexual assault or abuse.
|
Description
|
CPT® codes
|
|
Chlamydia tests
|
87110, 87270, 87320, 87490, 87492, 87810
|
|
Pregnancy test exclusion
|
81025, 84702, 84703
|
|