As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway.  Availity is well known as a Web portal and claims clearinghouse.  In addition, Availity functions as an EDI Gateway for multiple payers and is the single EDI connection for our company.

Your organization can submit and receive the following electronic transactions through Availity’s EDI Gateway:

• 837- Institutional Claims
• 837- Professional Claims
• 837- Dental Claims
• 835 - Electronic Remittance Advice
• 276/277- Claim Status
• 270/271- Eligibility Request

If you wish to become a direct a trading partner with Availity, the setup is easy.

Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions. 

If you prefer to use your clearinghouse or billing company, please work with them to ensure connectivity.

Need Assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

835 Electronic Remittance Advice (ERA)

Effective June 1, 2018, please use Availity to register and manage account changes for ERA.

If you were previously registered to receive ERA, you must register using Availity to manage account changes.

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

If you were previously registered to receive EFT only, you must register using EnrollHub to manage account changes. No other action is needed.

Contacting Availity

If you have any questions, contact Availity Client Services at 1-800-Availity

Requesting a clinical appeal is easy:

Logon to ICR from the Availity Portal and locate the case using one of the search options, or from your ICR dashboard.

• Select the Request Tracking ID link to open the case. If the case is eligible for an appeal you will see the Request Appeal menu option on the Case Overview screen.
• Select Request Appeal to open the Appeal Details screen and complete the required fields on the appeal template. (You also have the option of uploading attachments and images to support your request.)
• Select Submit

Take the steps below to check the status of a clinical appeal:

Logon to ICR from the Availity Portal

• Select Check Appeal Status from the ICR top menu bar
• Type the Appeal Case ID and Member ID in the allocated fields
• Select Submit

The appeal status and detail of the decision will open on the bottom of the screen.

Need more information on how to navigate the new ICR Appeals feature?

Download the ICR Clinical Appeals Reference Guide located on the Availity Portal. Select: Payer Spaces | Applications | Education and Reference Center | Communication and Education. Find the link to the reference guide below the ICR menu.

Additional Training:

Currently, our recovery process for National Accounts membership is reflected in the EDI PLB segment on the electronic remittance advice (835).  This segment will show the negative balance associated with the member account number.  Monetary amounts are displayed at the time of the recovery adjustment.

As National Accounts membership transitions to the new system and claims are adjusted for recovery, the negative balances due to recovery are held for 49 days to allow ample time for you to review the requests, dispute the requests and/or send in a check payment. During this time, the negative balances due are reflected on paper remits only within the “Deferred Negative Balance” sections. 

After 49 days, the negative balances due are reflected within the 835 as a corrected and reversed claim in PLB segments. 

If you have any questions or concerns, please contact the E- Solutions Service Desk toll free at (800) 470-9630.

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

Unfortunately, there are certain non-participating labs that are offering to waive or cap co-payments, coinsurance or deductibles to our members in order to increase their overall revenue. These practices undermine member benefits and may encourage over-utilization of services.

These billing practices are also questionable in their legality.  Such a practice may present violations under state or federal anti-kickback laws.

For a listing of Anthem participating laboratories, please check our online directory. Go to anthem.com.  Choose Select Providers, and Providers Overview.  Select Find Resources in Your State, and pick Nevada.   From the Provider Home tab, select the enter button from the blue box on the left side of page titled Find a Doctor. 

Note:  When searching for laboratory, pathology, or radiology services, under the field “I am looking for a:” select Lab/Pathology/Radiology; and then under the field “Who specializes in:”, select Laboratories, Pathology, or Radiology as appropriate for your inquiry.

LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs:

LabCorp is capable of providing services that range from routine testing, such as basic blood counts and cholesterol tests, to highly complex diagnosing of genetic conditions, cancers, and other rare diseases.  LabCorp has specialized laboratories which cover the following areas of testing:

Note:  This relationship with LabCorp does not affect network hospital-based lab service providers, or contracted pathologists. 

Engagement methods vary by the individual’s risk level but can include:

• Education about their condition through mailings, email newsletters, telephonic outreach, and/or online tools and resources.
• Round-the-clock phone access to registered nurses.
• Guidance and support from Nurse Care Managers and other health professionals.

Physician benefits:

• Save time by answering patients’ general health questions and responding to concerns, freeing up valuable time for the physician and their staff.
• Support the doctor-patient relationship by encouraging participants to follow their doctor’s treatment plan and recommendations.
• Inform the physician with updates and reports on the patient’s progress in the program.

Please visit our website to find more information about the program such as program guidelines, educational materials and other resources. Go to anthem.com.  Select Providers, and Providers Overview.  Select Find Resources for Your State and pick Nevada.  From the Health & Wellness tab, select the Condition Care link. Also on our website find the Referral Form, which you can use to refer other members you feel may benefit from our program.

The Integrated Care Model helps exchange members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease.  Our nurse care 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. 

Nurse Care Managers encourage participants to follow their physician’s plan of care; not to offer separate medical advice. In order to help ensure that our service complements the physician’s instructions, we collaborate with the treating physician to understand the member’s plan of care and educate the member on options for their treatment plan. 

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  How do you contact Case Management (CM)?

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 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 template and cover letters for both Behavioral Health and other Healthcare Practitioners.* In addition, there is a Provider Toolkit on the website with information about Alcohol and Other Drugs which contains brochures, guidelines and patient information.**

*Access to the forms and cover letters are available at anthem.com > Providers > Providers Overview > Find Resources for Your State > Nevada > Provider Home > Answers@Anthem

**Access to the Toolkit is available at anthem.com > Providers > Providers Overview > Find Resources for Your State > Nevada > Provider Home > Health and Wellness

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 the web. Just select “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” from the Provider home page at anthem.com.

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.

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.

FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. 

AllianceRX Walgreens Prime is the specialty pharmacy program for the Federal Employee Program.  You can view the Specialty Drug List or call us at 1-888-346-3731 for more information.

It can be found on our website.   Go to anthem.com, and select the Providers, and Providers Overview.   Select Find Resources for Your State, and pick Your State.  From the Health & Wellness tab, select the link titled Quality Improvement and Standards, and then the link titled “Member Rights & Responsibilities”.  Practitioners may access the FEP member portal at www.fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website. To access the guidelines, go to anthem.com, and select the Providers, and Providers Overview.   Select Find Resources for Your State, and pick Your State.  From the Health & Wellness tab, select the link title “Practice Guidelines”. You can then choose from Clinical Practice Guidelines, Preventive Health Guidelines, or Behavioral Health Clinical Practice Guidelines.

Anthem is available to offer assistance in these difficult moments with our Case Management 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?

The credentialing process must be completed before a practitioner begins seeing members and enters into a contractual relationship with a health care insurer. As part of our credentialing process, practitioners have certain rights as briefly outlined below.

Practitioners can request to:

• Review information submitted to support their credentialing application.
• Correct erroneous information regarding a credentialing application.
• Be notified of the status of credentialing or recredentialing applications.

The Council for Affordable Quality Healthcare (CAQH®) universal credentialing process is used for individual providers who contract with Amerigroup Community Care. To apply for credentialing with Amerigroup, go to the CAQH website at https://www.caqh.org and select CAQH ProView™. There is no application fee.

We encourage practitioners to begin the credentialing process as soon as possible when new physicians join a practice. Doing so will help minimize any disruptions to the practice and members’ claims.

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

ANV-NL-0015-18 March 2018

Effective January 1, 2019, Medicare providers will have toll free phone numbers specifically designated for their service inquiries. These new provider numbers will be listed separately on the back of the member ID cards and should be used beginning January 1, 2019. The associates answering your provider service calls are trained to answer your questions and resolve your issues as quickly as possible. To ensure you receive the most efficient service, please refrain from using the member services line and use only 844-421-5662 or the provider services phone number listed on the back of the member ID card for individual Medicare Advantage calls beginning January 1, 2019.

• CO 2019 Annual Notice of Change
• NV 2019 Annual Notice of Change
• Prior authorization requirements for Colonoscopy and Upper Gastrointestinal Endoscopy
• Medicare Advantage Reimbursement Policy October Provider Bulletin
• Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila
• July Medicare Advantage reimbursement policy
• Submit PA medication requests electronically; new phone number for MA prescription PAs
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective January 1, 2019
• Inpatient Readmissions
• Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective September 1

Log in to our provider website (https://mediproviders.anthem.com/nv) to access our Formulary, Prior Authorization forms, Preferred Drug List and process information.

Have questions about the Formulary or need a paper copy?

Call Provider Services at 1-844-396-2330.

Our Member Services representatives serve as advocates for our members. To reach Member Services, please call 1-844-396-2329 (TTY 711).

Effective March 1, 2019, if an itemized bill is requested and/or required, then it must include the appropriate revenue code for each individual charge.

For additional information, please review the Claims Requiring Additional Documentation reimbursement policy at https://mediproviders.anthem.com/nv.

ANV-NL-0024-18 September 2018

Here’s how to access the remittance inquiry tool:

1. Log in to the Availity Portal.
2. From the Availity home page, select Payer Spaces.
3. Select Anthem from the list of payer options.
4. Select Applications and then Remittance Inquiry.

Here’s how it works:

After selecting the organization, select the tax ID number from the drop-down menu. Then, select the provider under the Express Entry drop-down or enter the NPI (typically the group NPI). You have the option to sort your results by provider name, issue date, check/EFT number and check/EFT amount.

Do you need an imaged copy of the remittance for your files?

Select the View Remittance link associated with each remit and print or save.

Don’t see this valuable tool when you log in to the Availity Portal?

Contact your administrator to request claims status access, which includes the Remittance Inquiry tool. If you do not know who the administrator for your organization is, log in to Availity, go to your account and select My Administrators.

If you have questions about the features on the Availity Portal or need additional registration assistance, contact Availity Client Services at 1-800-282-4548.

If you have questions about the tools and resources available within Payer Spaces or on the Anthem website, contact Provider Services at 1-844-396-2330 or your local Provider Relations representative.

ANV-NL-0026-18 November 2018

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.

* The Washington Health Care Authority is recognized as a certifying body by NCQA.

ANV-NL-0040-18 October 2018

Providers should continue to call the phone number indicated on the back of the member ID card to request prior authorization review or for additional questions regarding physical and behavioral health benefits. If providers have access to Availity, they may initiate a request online at https://www.availity.com.

For more information, please contact the Provider Services at 1-844-396-2330.

ANV-NU-0001-18 October 2018

PA requirements will be added to the following:

• Interferon beta-1a — injection, 30 mcg (J1826)

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-844-396-2330

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-844-396-2330 for PA requirements.

Drug and substance addiction in the U.S.

The U.S. Department of Health and Human Services declared a public health emergency in 2017 due to an unprecedented opioid epidemic. Drug overdose deaths and opioid-involved deaths continue to increase in the U.S.1

Smoking is the leading preventable cause of death in the United States. According to the Centers for Disease Control (CDC), 15.5 % of all adults (37.8 million people) were current cigarette smokers in 2016.2

Health risks of drug use and smoking

Drugs can have significant and damaging short-term and long-term effects, including psychotic behavior, seizures or death due to overdose. Dependence on drugs can create a number of dangerous and damaging complications, such as accidents, suicide, family/work/school problems and legal issues.

Smoking diminishes overall health and is a known cause of multiple cancers, heart disease, stroke, complications of pregnancy, chronic obstructive pulmonary disease (COPD) and many other diseases. There are also health dangers of involuntary exposure to (second-hand) tobacco smoke. Smoking increases risks for preterm delivery.3

Diagnosis and treatment

Diagnosing substance use disorders requires a thorough evaluation and includes an assessment by a psychiatrist or a psychologist or an independently licensed behavioral health practitioner that has met the state requirements to render a diagnosis. Blood, urine or other lab tests are used to assess drug use.

People with behavioral disorders are more likely to experience a substance use disorder and people with a substance use disorder are more likely to have behavioral health issues when compared to the general population. According to the National Survey of Substance Abuse Treatment Services, about 45% of Americans seeking treatment of substance use/abuse have also been diagnosed with behavioral health problems.4

When diagnosing a substance use disorder, most mental health professionals use criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Treatment depends on the type of substance used and any related medical or behavioral health disorders that the patient may have. Some treatment options include:

• Chemical dependence treatment programs
• Detoxification
• Behavioral therapy
• Self-help groups

There are a lot of treatments to support tobacco cessation, including behavioral therapies and FDA-approved medications. Some treatment options to help ensure tobacco cessation include:

• Nicotine replacement therapy (NRT), as well as bupropion and varenicline
• Combination of behavioral treatment and cessation medications
• Mobile devices and social media help to boost tobacco cessation
• Tobacco cessations are not recommended for adolescents due to lacking high-quality studies
• Behavioral counseling can be provided either in person or by telephone and a variety of approaches are available such as Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), telephone support lines, text messaging, web-based services and social media.5

HEDIS® quality measures

Initiation and Engagement of Alcohol and Other Drug Abuse Dependence Treatment (IET) is a measure that assesses the percentage of plan members’ ages 13 years and older with the new episode of alcohol or other drug (AOD) abuse or dependence who received the following: initiation of AOD and engagement of AOD.

Initiation of treatment is the percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.

Engagement of treatment is the percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days after the initiation visit.6 This measure now includes medication-assisted treatment (MAT) as an appropriate treatment for people with alcohol and opioid dependence. This measure also adds telehealth to treatment options.

Use of Opioids at High Dosage (UOD) is a first year quality measure that assesses the number of members 18 years and older per 1,000 beneficiaries receiving prescription opioids for ≥ 15 days during the measurement year at a high dosage (average morphine equivalent dose > 120 mg).7

Use of Opioids from Multiple Providers (UOP) is a first year quality measure that assesses the number of members 18 years and older per 1,000 receiving a prescription for opioids for ≥ 15 days during the measurement year who received opioids from multiple providers. Three rates are reported:

• Multiple prescribers – the rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers during the measurement year
• Multiple pharmacies – the rate per 1,000 members receiving prescriptions for opioids from four or more different pharmacies during the measurement year
• Multiple prescribers and multiple pharmacies – the rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year.7

Unhealthy Alcohol Use Screening and Follow-Up (ASF) is a measure that assess the percentage of health plan members 18 years and older who were screened for unhealthy alcohol use using a standardized tool and, if screened positive, received appropriate follow-up care.

• Unhealthy alcohol use screening – the percentage of members who had a systematic screening for unhealthy alcohol use
• Counseling or other follow-up – the percentage of members who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within 2 months of a positive screening.

The intent of the measure: alcohol misuse is a leading cause of illness, lost productivity and preventable death in the U.S.7

Medical Assistance with Smoking and Tobacco Use Cessation (MSC) is a survey measure that assesses different facets of providing medical assistance with smoking and tobacco use cessation. There are three components of the survey:

• Advising Smokers and Tobacco Users to Quit: Adults 18 years of age and older who are current smokers or tobacco users and who received cessation advice during the measurement year
• Discussing Cessation Medications: Adults 18 years of age and older who are current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year
• Discussing Cessation Strategies: Adults 18 years of age and older who are current smokers or tobacco users who discussed or were provided cessation methods or strategies during the measurement year.

ICD-10-CM: general coding information

When a patient is diagnosed with an alcohol- or drug-related disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations, and comorbidities.

Details are required from the documentation to identify use, abuse or dependence of the substance.

Based on ICD-10-CM Coding Guidelines, when use, abuse or dependence of the same substance are documented in the medical record, only one code should be assigned based on the following hierarchy:

• If both use and abuse are documented, the code for abuse should be assigned
• If both abuse and dependence are documented, the code for dependence should be assigned

• If use, abuse and dependence are documented, the code for dependence should be assigned
• If both use and dependence are documented, the code for dependence should be assigned.8

Alcohol dependence and abuse

• Alcohol related disorders are classified to category F10-. An additional code for blood alcohol level (Y90.-) may be assigned, if applicable

• Alcohol abuse is classified under subcategory F10.-, Alcohol abuse

• Alcohol dependence is classified under subcategory F10.2-, Alcohol dependence
• Both categories alcohol abuse and alcohol dependence, are further subdivided to specify the presence of intoxication or intoxication delirium. Additional characters are also provided to specify alcohol-induced mood disorder, psychotic disorder, and other alcohol-induced disorders

• Codes in sub classification F10.23-, Alcohol dependence with withdrawal, provide additional detail regarding withdrawal symptoms such as delirium and perceptual disturbance

• Selection of codes “in remission” for categories F10-F19 requires the provider’s clinical judgement. The appropriate codes for “in remission” are assigned only on the basis of provider documentation, unless otherwise instructed by the classification
• Toxic effect of alcohol is not classified to category F10 but to subcategory T51.0- instead.9

Drug dependence and abuse

ICD-10-CM classifies drug dependence and abuse in the following categories according to the class of the drug:

• In most cases, fourth characters indicate whether the disorder is nondependent abuse (1), dependence (2), or unspecified use (9).
• Additional characters also provided to specify intoxication, intoxication delirium, and intoxication with perceptual disturbance.
• Patients with substance abuse or dependence often have related physical complications or psychotic symptoms. These complications are classified to the specific drug abuse or dependence, with the fifth or sixth characters providing further specificity regarding any associated drug-induced mood disorder, psychotic disorder, withdrawal, and other drug-induced disorders (such as sleep disorder).

Tobacco use and dependence

Category F17. - (nicotine dependence) codes are located in chapter 5 of the ICD-10-CM book.

The Excludes 1 note reminds that this is not the same diagnosis as tobacco use (Z72.0) nor the history of tobacco dependence (Z87.891). Therefore, the documentation will need to specifically discern between tobacco use and nicotine dependence.

The Excludes 2 note reminds to code tobacco use (smoking) during pregnancy, childbirth and the puerperium (O99.33-) and toxic effect of nicotine (T65.2-).

If the patient has been in contact with, or in close proximity to, a source of tobacco smoke, then Z77.22, Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic), need to be reported.

Tobacco abuse counseling is reported using code Z71.6 with the additional code for nicotine dependence (F17.-).

ICD-10-CM classifies nicotine dependence by substance:

• F17.20-, nicotine dependence, unspecified
• F17.21-, nicotine dependence, cigarettes
• F17.22-, nicotine dependence, chewing tobacco
• F17.29-, nicotine dependence, other tobacco product.9

Each category further breaks down the dependence using a sixth character to denote:

References:

1. Opioid overdose. Overview of an epidemic. https://www.cdc.gov/drugoverdose/data/index.htm
2. Current cigarette smoking among adults – United States, 2016. https://www.cdc.gov/mmwr/volumes/67/wr/mm6702a1.htm?s_cid=mm6702a1_w%20
3. CDC. Health effects of cigarette smoking. Retrieved on 1/18/2018 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
4. Treatment for co-occurring mental and substance use disorders. https://www.samhsa.gov/treatment
5. What are treatments for tobacco dependence? Retrieved on 1/18/2018 from https://www.drugabuse.gov/publications/tobacco-nicotine-e-cigarettes/what-are-treatments-tobacco-dependence
6. HEDIS Benchmarks and Coding Guidelines for Quality Care. Amerigroup RealSolutions in healthcare. Retrieved from https://providers.amerigroup.com
7. NCQA updates quality measures for HEDIS 2018. http://www.ncqa.org/newsroom/details/ncqa-updates-quality-measures-for-hedisreg-2018?ArtMID=11280&ArticleID=85&tabid=2659
8. ICD-10-CM Expert for Physicians. The complete official code set (2017). Optum 360
9. Leon-Chisen N. (2017). ICD-10-CM and ICD-10-PCS Coding Handbook 2018. American Hospital Association, Chicago, IL.

These links lead to third-party sites. These organizations are solely responsible for the content on their sites.

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

Note:

• Effective November 1, 2018, AIM Specialty Healthâ (AIM) Musculoskeletal Level of Care Guidelines, Sleep Study Guidelines and Radiology Guidelines will be used for clinical reviews.
• When requesting services for a patient (including medical procedures and medications), the Precertification Look-Up Tool may indicate that precertification is not required, but this does not guarantee payment for services rendered; a Medical Policy or Clinical UM Guideline may deem the service investigational or not medically necessary. In order to determine if services will qualify for payment, please ensure applicable clinical criteria is reviewed prior to rendering services.

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

To search for specific policies or guidelines, visit http://www.anthem.com/cptsearch_shared.html.

Medical Policies

On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem).

Clinical UM Guidelines

On July 26, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on August 31, 2018.

Payment for these services may not be accurate because the service is not a covered benefit. To ensure accurate processing of claims in the future, any procedure code billed that is not listed on the applicable fee schedule(s) will be denied. Please ensure you are billing with the most current, applicable procedure code.

Claims billed in line with the fee schedule will be processed accordingly. If you have questions about this communication or need help with any other item, contact your local Provider Relations representative or call Provider Services at 1-844-396-2330.

ANV-NU-0016-18 November 2018

What action do I need to take?

Please review these changes and work with your patients to transition them to formulary alternatives. If you determine preferred formulary alternatives are not clinically appropriate for specific patients, you will need to obtain prior authorization to continue coverage beyond the applicable effective date.

What if I need assistance?

We recognize the unique aspects of patients’ cases. If for medical reasons your patient cannot be converted to a formulary alternative, call our Pharmacy department at 1-844-396-2330 and follow the voice prompts for pharmacy prior authorization. You can find the Preferred Drug List on our provider website at https://mediproviders.anthem.com/nv.

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

ANV-NU-0004-18 December 2018

If you haven’t already taken the continuing medical education Improving Your CAHPS, visit the training site at www.patientexptraining.com.

The health plan is offering clinic day events called Anthem Healthy Connections (AHC) Days that also assist in capturing last-minute members and help increase your HEDIS scores. For more information, call 702-228-1308.

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

CAHPS is a registered trademark of the Agency for Healthcare Research and Quality.

What does this mean to you as a provider?

All EDI submissions currently received are now available on Availity. Please note, there is no impact to provider participation statuses and no impact on how claims adjudicate.

Next steps

Contact your clearinghouse to validate their transition dates to Availity. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you — You can submit claims directly through Availity!

Register with Availity

If you wish to submit directly through Availity for your 837 (claim), 835 (electronic remittance advice) and 27X (claim status and eligibility) transactions, please visit https://www.availity.com to register.

We look forward to delivering a smooth transition to the Availity EDI Gateway.

If you have any questions please contact Availity Client Services at 1-800-282-4548, Monday to Friday, 8 a.m. to 7:30 p.m. Eastern time.

ANV-NU-0008-18 September 2018