The Provider Digital Engagement Supplement is another example of how [Anthem Blue Cross and Blue Shield (Anthem)] is using digital technology to improve the health care experience. The Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits all in one comprehensive resource. We want providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.

 

Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:

• File claims
• Check statuses
• Verify eligibility and benefits
• Submit prior authorizations

 

Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website.

 

Get payments faster

• Electronic Funds Transfer (EFT) eliminate the need for paper checks. Payments are deposited directly to your bank account. It is safe, secure and you receive payments faster.

 

Eliminate paper remittances

• Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.

 

Member IDs go digital

Having a member email their ID card directly to you for file upload eliminates the need for you to scan or print, making it easier for you and the member. Member ID cards can also be accessed from the Availity. Save time by accepting the digital member ID cards when presented by the member via their App or email.

 

Read more about going digital with Anthem in the Provider Digital Engagement Supplement available online.  Go to anthem.com, select Providers, under the Provider Resources heading select Forms and Guides.  Pick your state if you haven’t done so already.  From the Category drop down, select Digital Tools, then Provider Digital Engagement Supplement.

 

 

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Through predictive analytics, health care teams can now receive real-time solutions to claim denials

 

Anthem is committed to providing digital first solutions. Our providers’ health care 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 completion. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOB.

 

Access Claims Status Listing from Payer Spaces from our secure provider portal through anthem.com using the Log In button or through the Availity Portal. 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 has 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 health care experience.

 

 

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New health plans built around Anthem’s Blue High Performance Network will take effect January 1, 2021.

 

As employers across the country host open enrollment periods for their employees, many will offer a new option this fall: plans built around a Blue High Performance Network.

 

Blue High Performance Network® plans offer access to providers with a record of delivering high-quality, efficient care. These networks will go live January 1, 2021 in more than 50 cities across the country, including Las Vegas. 

 

The Blue High Performance Network is a national network designed from our local market expertise, deep data and strong provider relationships, and aligned with local networks across the country. These local networks are then connected to the national chassis to form a national Blue High Performance Network. In Nevada, the Pathway HMO network is our Blue High Performance Network. Providers participating in the Pathway HMO will be in-network for any members with High Performance Network plans.

 

If you are not sure whether your practice is part of the Pathway HMO network and therefore the Blue High Performance Network, ask your office manager or business office, or contact your Anthem network representative. Blue High Performance Network participation will be displayed in provider profiles in our provider directory January 1, 2021.

 

Beginning January 1, you may see patients accessing this network through either a national employer plan, Blue High Performance Network, or large group employer plans with access to the Pathway HMO network. Under these plans, out of network benefits are limited to emergency or urgent care. Members must select a primary care provider, but PCP referrals are not required for specialty care.

 

Large group BlueHPN health plans sold in Nevada will have a plan prefix of H8N, but keep in mind that other prefixes may be part of HPN plan member IDs. The Member ID card sample below has the “HPN” indicator in the suitcase icon are the most reliable indicators that a member is enrolled in an HPN plan.

 

Note: The High Performance Network acronym HPN is not used in conjunction or affiliated with any other local organizations known by the same acronym.

 

 

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The providers listed below are participating air ambulance providers with Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada (Anthem).  That means, for Members picked up in Nevada, these participating providers have contractually agreed to accept the Anthem Rate as payment in full for approved and medically necessary transport, and will bill those Members for cost-shares only.

 

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

• These air ambulance providers may, and often do, charge members rates that are significantly higher than the Anthem contracted provider rates.
• These non-contracted air ambulance providers, with the assistance of their billing agents, attempt to collect from Anthem Members the difference between Anthem’s allowed amount and their costly billed amount.

To help Anthem members avoid the burden of the high costs of air transportation imposed by non-contracted providers, we ask that, whenever possible, you choose a participating air ambulance provider for your patients who are Anthem members.  Utilizing participating providers:

 

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

 

To schedule fixed wing or rotary wing air ambulance services, please

1. Contact Anthem for precertification for all non-emergent transports, using the number on the back of the member’s ID card, then
2. Call one of the phone numbers listed in the table below.

 

Please have the following information ready when you call one of the contracted air ambulance providers:

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

 

Should you have questions regarding the air ambulance network, including providers contracted for air ambulance pickups outside of Colorado, please contact your Provider Network Manager.

 

Note:  All Providers listed below service Nevada even if Location Address indicates out of state.

First, call Anthem for precertification for all non-emergent transports. 

Then call one of the following:

 

Fixed Wing (Airplane) Providers (HCPCS Codes: A0430 & A0435)

 

Provider Name	Phone#	Location Address	Web site
AeroCare Medical Transport Systems	630-466-0800	43W 752 Hwy 30 Sugar Gove, IL 60554	www.aerocare.com
AirCare 1 International	505-2472-7760	5345 Wyoming Blvd. NE Ste 105 Albuquerque, NM 87109	www.aircareone.com
Air Med International	800-356-4840	950 22nd St. N. Suite 800  Birmingham, AL 35203	www.airmed.com
Classic Air Medical, Classic Lifeguard	800-444-9223	1010 North 500 east #200 Salt Lake, UT 84054	www.classicairmedical.com
Helinet Aviation Service	818-902-0229	16308 Waterman Drive, Van Nuys, CA 91406	www.helinet.com

 

Rotary Wing (Helicopter) Providers (HCPCS Codes: A0431 & A0436)

 

Provider Name	Phone#	Location Address	Web site
Air Methods (Rocky Mountain/Mercy Air Service	909-915-2305	7211 South Peoria, Englewood, CO 80112-4133	www.airmethods.com
Classic air Medical, Classic Lifeguard	800-444-9223	1010 North 500 east #200 Salt Lake, UT 84054	www.classicairmedical.com
Helinet Aviation Services	818-902-0229	16308 Waterman Drive Van Nuys, CA 91406	www.helinet.com
REMSA	775-858-5700	450 Edison Way, Reno, NV 89502	www.remsa-cf.com

 

To arrange air transport originating outside the U.S., U.S. Virgin Islands, and Puerto Rico:

Call 800-810-BLUE for BCBS Global Core, formerly BlueCard Worldwide.

 

 

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In November we introduced our new Authorization Rules Lookup tool that you can access through Availity from Payer Spaces. This new self-service application displays prior authorization rules so you can quickly verify if the outpatient services are required for members enrolled in Anthem’s commercial plans.

 

In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:

 

• Medical Policies and Clinical Guidelines
• Third Party Guidelines, if applicable (such as AIM Specialty Health, IngenioRx)

 

Steps to access the Authorization Rules Lookup application through Availity Payer Spaces:

 

Access to the tool does not require an Availity role assignment.

1. Select Payer Spaces
2. Select the Anthem Blue Cross Blue Shield tile from the Payer Spaces menu
3. Select the Applications tab
4. Select the Authorization Rules Lookup tile

 

Once you are in the tool you will need to provide the following information to display the service’s prior authorization rules:

 

• Tax ID
• National Provider Identifier (NPI)
• Member ID and birth date
• Member’s Group number or Contract Code
  (This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)

• CPT/HCPCS code

 

Give this new tool a try and discover how much this will improve the efficiency of your authorization process.

 

Please note: If a prior authorization is required for outpatient services, you can submit the case through Interactive Care Reviewer Anthem’s online authorization tool which you can also access through the Availity Portal from Patient Registration > Authorization & Referrals.

 

 

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Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form (PMF).  Access the PFM online at anthem.com.  Select Providers, and your state.  Under the Provider Resources heading, select Provider Maintenance Form.

 

The impact of COVID-19 in 2020 prohibited Anthem from conducting the annual appointment access studies to assess how well practices meet appointment access requirements for medical care. We will resume the survey in second quarter 2021 and expect when your office is contacted, you will be able to accommodate a member’s needs in a timely manner.

 

To be compliant, per the Provider Manual, providers should meet the following access standards:

 

Medical Appointment Type	Compliance
Emergency Care	24/7 access   Immediate access at a facility, ER, 911 as appropriate
Urgent Care appointment With acute symptoms	Within same day or 1 day ·         Patient can be seen in the office by their Practitioner, another participating Practitioner in the practice or a covering Practitioner within the timeframe; or ·         If appointment is unavailable, patient is directed to Urgent Care Center of ER, as appropriate.
Routine / Check-up appointment Without symptoms	Within 10 business days Patient can be seen in the office by their Practitioner, another participating Practitioner in the practice or a covering Practitioner within the timeframe.
After Hours access Urgent instructions	24x7x365 phone access to PCP outside regular business hours ·         Live person connects caller to their Practitioner or on-call Practitioner. ·         Recording or live person directs patient to Urgent Care Center, 911 or ER   In addition to, but not in place if above criteria, caller is prompted to contact a live health care Practitioner (via transfer, cell phone page, etc.) or an opportunity to get a call back for urgent questions or instructions.
Specialty Urgent Care appointment With acute symptoms	Within 24 hours ·         Patient can be seen in the office by their Specialist, another participating Practitioner in the practice or a covering Practitioner within the timeframe; or ·         If appointment is unavailable, patient is directed to Urgent Care Center of ER, as appropriate.
Specialty Routine / Check-up appointment Without symptoms	Within 30 calendar days Patient can be seen in the office by their Specialist, another participating Practitioner in the practice or a covering Practitioner within the timeframe.

 

 

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Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral.  Anthem Blue Cross and Blue Shield (Anthem) would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

 

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner.  Anthem Blue Cross urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between Behavioral Health and other health care practitioners at the time treatment begins.

 

We expect all health care practitioners to:

 

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
   • Diagnosis
   • Treatment plan
   • Referrals
   • Psychopharmacological medication (as applicable)

 

In an effort to facilitate coordination of care, Anthem has several tools available on the Provider website including a Coordination of Care Form and Coordination of Care Letter Templates for both Behavioral Health and other Medical Practitioners.* Behavioral Health tools are available, which includes forms, brochures, and screening tools for Substance Abuse, ADHD, and Autism. Please refer to the website for a complete list.**

 

*Access to the forms and template letters are available at www.anthem.com/provider/forms/

**Access to the Behavioral Health tools are www.anthem.com/provider/forms/

 

 

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The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement.

 

It can be found on our website, under the FAQ question about “Laws and Rights that Protect You.”  To access, go to anthem.com and select Provider.  Under the Provider Resources heading, select Policies, Guidelines & Manuals, and select your state. Under More Resources, scroll down to Member Rights and Responsibilities.  Select the Read about member rights link.  Practitioners may access the FEP member portal at www.fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

 

 

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Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits.  In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization.  Anthem’s medical policies are available on Anthem’s website at anthem.com.

 

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below. 

UM criteria are also available on our website at anthem.com.  Select Providers │ under the Provider Resources heading, select Policies and Guidelines │ select your state │ View Medical Policies & UM Guidelines.

 

We work with providers to answer questions about the utilization management process and the authorization of care.  Here’s how the process works:

 

• Call us toll free from 8:30 a.m. - 5 p.m. Monday through Friday (except on holidays). More hours may be available in your area.  Federal Employee Program hours are 8:00 a.m. -- 7 p.m. Eastern.

 

• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day.  Calls received after midnight will be returned the same business day. 

 

• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

 

The following phone lines are for physicians and their staffs.  Members should call the customer service number on their health plan ID card.

 

To discuss UM Process and Authorizations	To Discuss Peer-to-Peer UM Denials w/Physicians	To Request UM Criteria	TTY/TDD
Phone 800-336-7767 FAX - 800-763-3142   Transplant 888-574-7215   Autism 844-269-0538   FEP Phone 800-860-2156 FAX 800-732-8318 (UM) FAX 877-606-3807(ABD)	Local:  303-764-7227 Toll-free: 866-287-1654   No fax number to request Peer-to-Peers.   Adaptive Behavioral Treatment 844-269-0538   FEP Phone 800-860-2156	800-797-7758   No fax number. Providers leave message with: provider name, provider phone number, member’s name, member ID, and reference number.   FEP Phone 800-860-2156 FAX 800-732-8318 (UM) FAX 877-606-3807(ABD)	711 or  TTY / Voice 800-326-6868 (TTY/ASCII/HCO) /  800-326-6888 (Voice)

 

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.

 

Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls.  They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.

 

 

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Are you looking for creative ways to talk to your patients about certain preventive care services such as breast cancer screening and adolescent vaccinations including the HPV vaccination?  As flu season approaches, do you want a way to educate your patients about the dangers of antibiotic resistance?  Short educational videos, approximately two minutes in length, are available on anthem.com > Providers > Forms and Guides > under the Category heading, select Patient Care. 

 

By providing education and addressing common fears and concerns, these brief videos offer an alternative approach to patient engagement on these important topics.  Take a look today!

 

 

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Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form (PMF).  Access the PFM online at anthem.com.  Select Providers, and your state.  Under the Provider Resources heading, select Provider Maintenance Form.

 

The impact of COVID-19 in 2020 prohibited Anthem from conducting the annual after-hours access studies to assess phone messaging for our members for perceived emergency or urgent situations after regular office hours.  We will resume the survey in the second quarter of 2021 and expect when your office is contacted, you will be able to accommodate a member’s urgent concerns after hours.

 

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, such as:

 

Emergency situations:

The compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects the caller directly to the doctor.  

 

Urgent situations:

The compliant response for urgent needs would direct the caller to Urgent Care or ER, to call 911 or connect the caller to their doctor or the doctor on call. 

 

Messaging that only gives callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions is not complaint, as there is no direct connection to their health care practitioner. This prompt can be used in addition to, but not in place of, the emergency and urgent instructions. 

 

Is your practice compliant?

 

 

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Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form (PMF).  Access the PFM online at anthem.com.  Select Providers, and your state.  Under the Provider Resources heading, select Provider Maintenance Form.

 

The impact of COVID-19 in 2020 prohibited Anthem from conducting the annual appointment access studies to assess how well practices meet appointment access requirements for our members for behavioral healthcare (BH). We will resume the survey in second quarter 2021 and expect when your office is contacted, you will be able to accommodate a member’s needs in a timely manner.

 

To be compliant, per the Provider Manual, providers should meet the following access standards:

 

• Non-life-threatening emergency – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or a covering Practitioner within 6 hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate.
  • Explanation - These calls concern members in acute distress, whose ability to conduct themselves for their own safety, or the safety of others, may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. The situation has the potential to escalate into an emergency without clinical intervention.

• Urgent – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or by a covering Practitioner within 48 hours.   
• Explanation - These calls are non-emergent with significant psychological distress, when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
• Initial Routine office visit – A new patient must be seen in the office by a designated BH Practitioner or another equivalent Practitioner in the practice within 10 business days.  It can be after the Practitioner intake assessment or a direct referral from a treating Practitioner. 
• Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms, which present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
• Routine office visit – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or by a covering Practitioner within 30 calendar days.
• Explanation - These calls concern existing members, to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.

• BH follow-up appointment after discharge – The patient must be seen in the office by their Practitioner or another Practitioner in the practice within 7 calendar days.
  • Explanation – These calls concern members being released from inpatient psychiatric hospital care, requesting a follow-up appointment to evaluate what has taken place since release, including med management.

• •  

 

Methods used to monitor adherence to these standards consist of assessing the accessibility of appointments via phone calls from North American Testing Organization, a vendor working on Anthem’s behalf, and analysis of member complaint and member experience data.

 

 

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For participating Anthem commercial ASO plans, we have expanded our hospice benefit to align with our previous expansion for commercial fully insured members. These expanded hospice benefits allow members with a life expectancy of up to 12 months (increased from 6 months) and allow disease modifying treatments to continue alongside hospice services. If you have a patient with an advanced illness and life expectancy of less than 12 months, now is the time to talk about hospice. Hospice is a powerful support resource for patients that can work in tandem with their treatment.

 

Provider benefits:

• Improved communication: By removing obstacles to hospice care, providers can introduce hospice benefits earlier while empowering patients to express their goals, values and care preferences.

 

• Centralized care: The treating physician remains at the center of the patient’s overall treatment plan – supported by the entire hospice team. Patients get the benefit of expert medical care, pain management, and emotional and spiritual support all working together.

 

• Planning resource: Hospice professionals are a useful resource for physicians to help aid in discussions with patients and families related to: caregiver stress, fears of the future, end-of-life discussions and bereavement planning.

 

Patient benefits:

• More patient and caregiver support, earlier: Relaxing the previous benefit life expectancy maximum and treatment limitations will help patients with advanced illnesses access hospice services earlier, ultimately choosing the care that fits their personal needs.
  
  
• Coordinated team: Patients will have a dedicated hospice team that coordinates access to medication, medical supplies, and equipment. Patients can depend on hospice services for their care needs rather than emergency room and intensive care professionals who are unfamiliar with their histories, goals, and preferences.

 

• Improved quality of life: Patients receive help sooner, manage their pain and symptom relief better, and families are able to discuss planning of personal needs more effectively.

 

Note: This update does not apply to Federal Employee Program® (FEP®), Medicare and

Medicaid. Providers should continue to verify eligibility and benefits for all Anthem members prior to rendering services or referring members for hospice care.

 

 

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Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.

 

Anthem is available to offer assistance in these difficult moments with our Case Management (CM) Program.  Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers.  The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

 

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  They will be transferred to a team member based on the immediate need.  Physicians can also refer by contacting us telephonically or through electronic means.  No issue is too big or too small.  We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

 

How do you contact us?

 

CM Email Address	CM Telephone Number	CM Business Hours
Case.management@anthem.com	1-888-613-1130	Monday-Friday, 7am-6pm PT
National NationalWest-CM@anthem.com	1-877-783-2756   1-888-574-7215 (Transplant)	Monday-Friday, 8am-9pm PT, Saturday 9am-4:30pm PT Monday-Friday 5:30am-2pm PT (Transplant)
Federal Employee Program (FEP) No email	1-800-711-2225	5am-4pm PT

 

 

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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).

 

Introducing the Anthem Provider Digital Engagement Supplement to the provider manual

Using our secure provider portal or EDI submissions (via Availity*), administrative tasks can be reduced by more than 50% when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, just go here for EDI or here for the secure provider portal (Availity).

 

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and will deliver payments to you faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the Availity Provider Portal or the EDI 835 remittance, which meets all HIPAA mandates — eliminating the need for paper remittances.

 

Member ID cards go digital

Members who are transitioning to digital member ID cards, will find it is easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

 

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available by going to https://mediproviders.anthem.com/nv/Pages/manuals-directories-training.aspx > Manuals, Directories & Training > Tutorials, Reference Guides and Other Resources > Provider Digital Engagement, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid, including medical, dental and vision benefits.

 

The Provider Digital Engagement Supplement to the provider manual is another example of how Anthem is using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now by going to https://mediproviders.anthem.com/nv/Pages/manuals-directories-training.aspx > Manuals, Directories & Training > Tutorials, Reference Guides and Other Resources > Provider Digital Engagement. Go digital with Anthem.

 

 

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

 

ANV-NU-0168-20

Consumer Assessment of Healthcare Providers and Systems (CAHPS)^® is an annual standardized survey conducted to assess consumer experience with their health care services and health plan. Providers and their staff play a key role in the member experience. Several questions specific to the member’s experience with their provider are included in the CAHPS survey. Education about the CAHPS survey, the importance of focusing on the patient experience and ways to improve the patient experience are included in the Provider Orientation and available by visiting https://mediproviders.anthem.com/nv.

 

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

 

ANV-NU-0155-20

Effective for dates of service on and after January 1, 2021, 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. Step therapy review will apply upon precertification initiation or renewal in addition to the current medical necessity review of all drugs noted below. Bevacizumab (under brand names: Avastin, Mvasi, and Zirabev) is preferred for the indication of wet age-related macular degeneration.

 

The clinical criteria below will be updated to include the requirement of a preferred agent effective

January 1, 2021.

 

Clinical Criteria	Status	Drug(s)	HCPCS Codes
ING-CC-0072	Preferred	Avastin	J9035, C9257
ING-CC-0072	Preferred	Mvasi	Q5107
ING-CC-0072	Preferred	Zirabev	Q5118
ING-CC-0072	Non-preferred	Eylea	J0178
ING-CC-0072	Non-preferred	Lucentis	J2778
ING-CC-0072	Non-preferred	Macugen	J2503
ING-CC-0072	Non-preferred	Beovu	J0179

 

The clinical criteria is publicly available on our website at https://mediproviders.anthem.com/nv.

 

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-0162-20

Effective for dates of service on and after January 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria will be included in our medical step therapy precertification review process. Step therapy review will apply on precertification initiation or renewal in addition to the current medical necessity review of all drugs noted below.

 

The clinical criteria below will be updated to include the requirement of a preferred agent effective

January 1, 2021.

 

Clinical criteria	Preferred drug	Nonpreferred drug
ING-CC-0107	Mvasi (Q5107), Zirabev (Q5118)	Avastin (J9035)

 

The Clinical Criteria is publicly available on https://mediproviders.anthem.com/nv.

 

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 toll free at 1-844-396-2330.

 

 

ANV-NU-0166-20

 

Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) appreciates the recent improvements seen in early elective delivery (EED) rates across the country. These improvements have been brought about through the collaborative efforts of state Medicaid agencies, the March of Dimes, CMS, the Joint Commission, the American College of Obstetricians and Gynecologists (ACOG), and many others. The implementation of hospital hard stop policies describing the review of clinical indications and scheduling approval for EED has also increased awareness of the harm that can be caused by non-medically necessary EED and encouraged discussion on the topic between patients, their care providers and hospitals. Voluntary efforts combined with payment reform have been found to further decrease EED rates while increasing gestational age and birth weight for the covered population.¹

 

Early elective delivery is defined as a delivery by induction of labor without medical necessity followed by vaginal or caesarean section delivery or a delivery by caesarean section before 39 weeks gestation without medical necessity. Vaginal or caesarean delivery following non-induced labor is not considered an early elective delivery regardless of gestational weeks.

 

What does this mean for providers?

To improve birth outcomes for our members and further reduce EED, Anthem requires a Z3A code indicating gestational age, the appropriate code to indicate the outcome of delivery and supporting medical necessity diagnosis codes on all professional delivery claims for all EED. Anthem will apply Milliman Care Guidelines, which defines medically necessary criteria for EED.

 

All professional delivery claims (59400, 59409, 59410, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622) with dates of service January 1, 2018, or after, will require a Z3A code indicating gestational age at the time of delivery. If the code is not present on the claim, the claim will deny with the explanation code e02: Delivery diagnoses incomplete without report of pregnancy weeks of gestation. You may resubmit the claim with the appropriate Z3A code.

• Professional delivery claims with dates of service January 1, 2018, or after, with gestational age dates of 37 and 38 weeks will require a supporting medically necessary diagnosis code for the early delivery.
• If a professional delivery claim is submitted without evidence of medical necessity for the early delivery, the claim will deny with code k34: Delivery is not medically indicated. You may resubmit the claim with the appropriate supporting diagnosis code or appeal with medical records.

 

Should you have questions about this communication, received this communication in error or need assistance with any other item, contact your local provider relations representative or call provider services toll-free at
1-844-396-2330. Thank you for being a valued partner. We appreciate your commitment to the health of our members.

 

¹ Dahlen, Heather M., J. Mac Mccullough, Angela R. Fertig, Bryan E. Dowd, and William J. Riley. Texas Medicaid Payment Reform: Fewer Early Elective Deliveries and Increased Gestational Age And Birthweight. Health Affairs 36.3 (2017): 460-67. Print.

 

 

ANV-NU-0167-20

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).

 

Patient360 is a real-time dashboard you can access through the Availity Portal* that gives you a full 360° view  of your Anthem patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.

 

What’s new: Medical providers now have the option to include feedback for Anthem patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.

 

Once you have completed all the required fields on the Availity Portal to access Patient360 you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.

 

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

 

First, you need to be assigned to a Patient360 role, which your Availity administrators can locate within the Clinical Roles options.

 

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

                                                                                                                

Do you need a job aid to help you get started?

The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center:

1. From the Availity home page, select Payer Spaces > Anthem payer tile > Applications > Custom Learning Center
2. Select Resources from the menu located on the upper left corner of the page
   (To use the catalog filter to narrow the results, select Payer Spaces from the Category )
3. Select Download to view and/or print the reference guide

 

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

 

ANV-NU-0149-20

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

 

• Prior authorization requirements for HCPCS code 55899
• Provider transparency update

ANV-NU-0151-20

ANV-NU-0161-20

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).

 

Introducing the Anthem Provider Digital Engagement Supplement to the provider manual

Using our secure provider portal or EDI submissions (via Availity*), administrative tasks can be reduced by more than 50% when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, just go here for EDI or here for the secure provider portal (Availity).

 

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and will deliver payments to you faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the Availity Provider Portal or the EDI 835 remittance, which meets all HIPAA mandates — eliminating the need for paper remittances.

 

Member ID cards go digital

Members who are transitioning to digital member ID cards, will find it is easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

 

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available by going to https://mediproviders.anthem.com/nv/Pages/manuals-directories-training.aspx > Manuals, Directories & Training > Tutorials, Reference Guides and Other Resources > Provider Digital Engagement, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid, including medical, dental and vision benefits.

 

The Provider Digital Engagement Supplement to the provider manual is another example of how Anthem is using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now by going to https://mediproviders.anthem.com/nv/Pages/manuals-directories-training.aspx > Manuals, Directories & Training > Tutorials, Reference Guides and Other Resources > Provider Digital Engagement. Go digital with Anthem.

 

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

 

ANV-NU-0168-20

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).

 

Patient360 is a real-time dashboard you can access through the Availity Portal* that gives you a full 360° view  of your Anthem patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.

 

What’s new: Medical providers now have the option to include feedback for Anthem patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.

 

Once you have completed all the required fields on the Availity Portal to access Patient360 you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.

 

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

 

First, you need to be assigned to a Patient360 role, which your Availity administrators can locate within the Clinical Roles options.

 

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

                                                                                                                

Do you need a job aid to help you get started?

The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center:

1. From the Availity home page, select Payer Spaces > Anthem payer tile > Applications > Custom Learning Center
2. Select Resources from the menu located on the upper left corner of the page
   (To use the catalog filter to narrow the results, select Payer Spaces from the Category )
3. Select Download to view and/or print the reference guide

 

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

 

ANV-NU-0149-20

How do I check eligibility and benefits for these members?

 

Online — Eligibility, benefits, claims, links to secure messaging, commonly used forms and remit information are all available through the Availity* Portal at https://www.availity.com. For questions on access and registration, call Availity Client Services at 1-800-AVAILITY (1-800-282-4548). Availity Client Services is available Monday through Friday, 8 a.m. to 7 p.m. ET (excluding holidays) to answer your registration questions.

 

Phone — Call the Provider Service number on the back of the member’s ID card. You may also verify a member’s eligibility by calling the BlueCard Eligibility Line at 1‑800‑676‑BLUE (2583) and providing the member’s three-digit alpha prefix located on the ID card.

 

As new members enroll in Group Retiree Medicare Advantage plans under Anthem Blue Cross and Blue Shield, they will receive new ID cards. Additionally, existing members may receive new ID cards as a result of benefit changes. Please continue to check member ID cards to ensure you have the most up-to-date eligibility and benefit information.

 

Please note that we are experiencing an unusually high volume of changes for an effective date of January 1, 2021. Many of the changes do not affect member prefix, member ID or benefits, but some changes will. Because of this, we encourage providers to request a copy of the member’s ID card, particularly at the beginning of the year when members may have new ID cards.

 

What are the alpha prefixes for Group Retiree Medicare Advantage PPO members?

 

Group Retiree Medicare Advantage PPO member alpha prefixes
AFJ	CBH	MEW MBL	VAY	VGD	WSP	WZV
XLU	XNS	YVK YGZ	ZDX	ZMX	ZVR	ZVZ

 

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

 

 

ABSCRNU-0183-20

 

Summary of benefits, evidence of coverage and formularies for 2021 individual Medicare Advantage plans will be available at anthem.com/medicareprovider. An overview of notable 2021 benefit changes will be available at anthem.com/medicareprovider> Read News and Updates. Please continue to check anthem.com/medicareprovider for the latest Medicare Advantage information.

 

 

ABSCRNU-0182-20

Effective December 8, 2020, Anthem Blue Cross and Blue Shield will transition the clinical criteria for medical necessity review of certain outpatient rehabilitative services from our clinical guidelines for physical therapy CG-REHAB-04, occupational therapy CG-REHAB-05 and speech language pathology CG-REHAB-06 to AIM Specialty Health_®* Rehabilitative Service Clinical Appropriateness Guidelines. These reviews will continue to be completed by the NV utilization management team.

 

Access and download a copy of the current and upcoming guidelines here.*

 

 

ABSCRNU-0189-20

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

 

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

 

To view a guideline, visit https://www11.anthem.com/search.html.

 

Updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• 00134 — Noninvasive Heart Failure and Arrhythmia Management and Monitoring System:
  • Revised Investigational and Not Medically Necessary indications
• 00156 — Implanted Artificial Iris Devices:
  • Revised Investigational and Not Medically Necessary indications
• 00157 — Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis:
  • Revised Investigational and Not Medically Necessary indications
• CG-DME-07 — Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output:
  • Revised Medically Necessary and Not Medically Necessary indications
• 00052 — Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling:
  • Revised Medically Necessary indications
• 00077 — Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques:
  • Expanded scope and revised Investigational and Not Medically Necessary indications
• 00112 — Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures):
  • Revised scope, and Investigational and Not Medically Necessary indications
• CG-REHAB-12 — Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology:
  • A new clinical UM Guideline was created from content contained in CG-REHAB-04,
    CG-REHAB-05, CG-REHAB-06.
  • There are no changes to the guideline content.
  • Publish date is scheduled for December 8, 2020.
• The following AIM Specialty Health_®* Clinical Appropriateness Guidelines have been revised and will be effective on December 6, 2020. To view AIM guidelines, visit the AIM Specialty Health page:
  • Interventional Pain Management (See August 16, 2020, version.)*
  • Chest Imaging (See August 16, 2020, version.)*
  • Oncologic Imaging (See August 16, 2020, version.)*
  • Sleep Clinical Guidelines (See August 16, 2020, version.)*

 

Medical Policies

 

On August 13, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect December 6, 2020.

 

Publish date	Medical Policy #	Medical Policy title	New or revised
10/7/2020	*MED.00134	Non-invasive Heart Failure and Arrhythmia Management and Monitoring System	New
10/7/2020	*SURG.00156	Implanted Artificial Iris Devices	New
10/7/2020	*SURG.00157	Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis	New
9/1/2020	*GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	Revised
10/7/2020	*SURG.00077	Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques	Revised
10/1/2020	*SURG.00112	Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)	Revised

 

Clinical UM Guidelines

 

On August 13, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for Medicare Advantage members on
September 24, 2020. These guidelines take effect December 6, 2020.

 

Publish date	Clinical UM Guideline #	Clinical UM Guideline title	New or revised
10/7/2020	*CG-DME-07	Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output	Revised
10/7/2020	CG-DME-25	Seat Lift Mechanisms	Revised
8/20/2020	CG-GENE-03	BRAF Mutation Analysis	Revised
8/20/2020	CG-SURG-83	Bariatric Surgery and Other Treatments for Clinically Severe Obesity	Revised

 

 

ABSCRNU-0190-20

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

 

• Policy Update - Emergency Department: Leveling of Evaluation and Management Services

 

 

ABSCARE-0693-20