The Escalation Contact List  has been updated. Access the updated list online. Please go to anthem.com.  Select Providers.  Under the Communcations heading, select Contact Us.  Choose Nevada, then select Escalation Contact List.

• Submit a refund check with supporting documentation outlined below, or
• Submit the Provider Refund Adjustment Request Form with supporting documentation to have claim adjustment/recoupment done off a future remittance advice

When voluntarily refunding Anthem on a Claim overpayment, please include the following information:

• Provider Refund Adjustment Request Form (see directions below for how to access online)
• All documents supporting the overpayment including EOBs from Anthem and other carriers as appropriate
• Covered Individual ID number
• Covered Individual’s name
• Claim number
• Date of service
• Reason for the refund (as indicated on the form of common overpayment reasons)

Please be sure the copy of the provider remittance advice is legible and the Covered Individual information that relates to the refund is circled. By providing this critical information, Anthem will be able to expedite the process, resulting in improved service and timeliness to Providers and Facilities.

Important Note: If a Provider or Facility is refunding Anthem due to coordination of benefits and the Provider or Facility believes Anthem is the secondary payer, please refund the full amount paid. Upon receipt and insurance primacy verification, the Claim will be reprocessed and paid appropriately.

How to access the Provider Refund Adjustment Request Form online:

To download the “Provider Refund Adjustment Request Form” directly from anthem.com.  Select Providers, and Providers Overview.  Select Find Resources in Your State, and pick Nevada.  From the Provider Home page, Under the Self Service and Support heading, choose Download Commonly Requested Forms and select Provider Refund Adjustment Request Form.

Please utilize the proper address noted in the grid below to return payment:

We were pleased to see overall improvement in the survey results.  In particular, two areas of focus over the last year, access and coordination of care.  Members responding to the survey, indicated that obtaining an appointment was fairly easy and many respondents indicated that care was being coordinated among their providers, including medical.  Care coordination and collaboration, particularly medical-behavioral integration, is a key focus at Anthem.   We also encourage ongoing understanding of an individual’s cultural, spiritual and religious beliefs while in treatment.

While we are pleased with our member’s experience with our participating provider network and thank you for your network participation and the services you provide, we’d like to remind you of two key areas to maintain and improve satisfaction:

• Member’s Access to Behavioral Health Care

As a participating provider please be reminded of Anthem’s expectation, based on NCQA definitions, of access to behavioral healthcare to help ensure our members have prompt access to behavioral health care:

• Non-Life Threatening Emergency Needs - must be seen, or have appropriate coverage directing the Member, within 6 hours. When the severity or nature of presenting symptoms is intolerable but not life threatening to the member.

• Urgent Needs - must be seen, or have appropriate coverage directing the Member, within 48 hours. Urgent calls concern members whose ability to contract 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. Urgent needs have the potential to escalate into an emergency without clinical intervention.

• Routine office visit - must be within 10 business days. Routine calls concern members who present no immediate distress and can wait to schedule an appointment without any adverse outcomes.

We use several methods to monitor adherence to these standards.   Monitoring is accomplished by a) assessing the availability of appointments via phone calls and surveys by our staff or designated vendor to the provider’s office; b) analysis of member complaint data and c) analysis of member satisfaction.  Providers are expected to make best efforts to meet these access standards for all members.   Anthem continues to look at gaps, barriers and alternative options to improve access to behavioral healthcare including tele-health services. 

• Members Held Harmless

As a participating provider in Anthem’s behavioral health provider network, a participating provider shall look solely to Anthem for compensation for covered services and under no circumstances shall render a bill or charge to any member except for applicable co-payments, deductibles and coinsurance and for services that are not medically necessary or are otherwise not covered, provided that the Provider obtains the consent of the Member before providing such service. We recommend that consent be in writing and dated, in order to protect our members and providers from disputes.

In addition, Anthem also reminds our participating providers that Anthem members must be advised of missed or cancelled appointment policies at the onset of treatment.  We also recommend that the advisement be acknowledged by the member in writing, and that acknowledgement is dated. 

Anthem may offer additional benefits that are not covered under Original Medicare. Certain benefits are only covered when provided by a vendor selected by Anthem. More information can be found at anthem.com/medicareprovider. You may also contact Provider Services at the phone number on the back of the member ID card.

Additional information, including billing modifiers and documentation requirements, will be available at anthem.com/medicareprovider under Important Medicare Advantage Updates.

Effective for dates of service beginning January 1, 2019, the following Medicare Part B devices will be preferred to support cost-effective benefits. During precertification initiation or renewal, providers requesting a nonpreferred device will be encouraged to switch to a preferred product. The preferred and nonpreferred products are listed below.

75557MUSENMUB 12/20/18

• 2019 risk adjustment provider training
• New provider learning opportunity: Put the AIM ProviderPortal to work for you
• New provider service phone number beginning January 1, 2019  
• Medicare Advantage reimbursement policy provider bulletin
• CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019

75560MUPENMUB 12/28/2018

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

To search for specific policies or guidelines, use this link.

Medical Policies

On September 13, 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 September 13, 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 September 27, 2018.

The clinical criteria below have been updated to include the requirement of a preferred agent effective May 1, 2019.

The clinical criteria is publicly available on our provider website. Visit our Clinical Criteria web page to search for specific clinical criteria.

PA requirements will be added to the following:

• Sublocade (Buprenorphine) - implant (J0570)
• Sublocade - injectable (Q9991, Q9992)

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

We’ve heard it all our lives: in order to be fair, you should treat everybody the same. But the challenge is that everybody is not the same — and these differences can lead to critical disparities not only in how patients access health care, but in their outcomes as well.

The reality is that the burden of illness, premature death and disability disproportionately affects certain populations.1 My Diverse Patients features robust educational resources to help support you in addressing these disparities, such as:

• Continuing medical education about disparities, potential contributing factors and opportunities for you to enhance care.
• Real life stories about diverse patients and the unique challenges they face.
• Tips and techniques for working with diverse patients to promote improvement in health outcomes.

Accelerate your journey to becoming your patients’ trusted health care partner by visiting https://mydiversepatients.com today.

[1] Centers for Disease Control and Prevention. (2013, Nov 22). CDC Health Disparities and Inequalities Report — United States, 2013. Morbidity and Mortality Weekly Report. Vol 62 (Suppl 3); p3.

PA requirements will be added to the following:

• Subcutaneous Implantable Defibrillator system — Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation (33270)

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.

If you have any questions or need additional information, please contact Provider Services at 1‑844‑396‑2330.

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.