 Provider News NevadaJanuary 1, 2019 January 2019 Anthem Provider Newsletter - NVWe invite you to go to anthem.com to learn about the many ways health care reform and health insurance marketplace / affordable care act information may impact you. New information is added regularly. To view the latest articles on health care reform and/or health insurance marketplace / affordable care act, and all achieved articles, go to anthem.com. Select Providers, and Providers Overview. Select Find Resources in Your State, and pick Nevada. Select the Provider Home tab at the top of the page. Under the Communications and Updates heading, choose Health Care Reform Updates and Notifications or Health Insurance Exchange Marketplace / Affordable Care Act information. The Prefix Reference List has been updated. Access the updated list online. Please go to anthem.com. Select Menu, and under the Support heading, select Providers. Select Find Resources for Your State, and pick Nevada. From the Provider Home page, under the Self Service and Support heading, choose Contact Us (Escalation Contact List & Prefix List), and then Escalation Contact List. Your contract with Anthem requires that your practice provide timely access to care for our members. Listed below are the Appointment Access standards for both Medical and Behavioral health Providers.
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Medical Appointment Type
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Compliance
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Emergency Care
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24/7 access
Immediate access at a facility, ER, 911, as appropriate.
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Urgent Care appointment
Non-emergent care with significant. Calls are urgent when the severity or nature of presenting symptoms is intolerable, but not life threatening to the member.
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Within 24 hours
- Patient can be seen in the office by their PCP or another participating provider in the practice or a covering provider; and
- If appointment is unavailable, patient is directed to Urgent Care Center, 911 or ER, as appropriate.
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Preventive visit/well visits
Patients can get an appointment for preventive visit or well visits.
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Within 30 calendar days
Patient can be seen in the office by their PCP or another participating provider in the practice within the timeframe.
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Specialty urgent care
Contacting a specialist for urgent care
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Within 24 hours
Patient can be seen in the office by their specialty provider in the practice within the timeframe.
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Specialty care routine visits
Patients can get an appointment for routine specialty visit
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Within 30 calendar days
Patient can be seen in the office by their specialty provider in the practice within the timeframe.
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After Hours Urgent Access
Contacting Primary Care Provider for emergency and urgent instructions.
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24X7 phone access
- Live person connects caller to their Practitioner or on-call Practitioner.
- Recording or live person; instructs the caller to hang up and go to ER or call 911 for emergencies or Urgent Care Center, 911 or ER, for urgent, as appropriate.
In addition to, but not in place if above criteria, caller is offered to contact their PCP or on-call provider (via cell, pager, beeper, transfer system) or get a call back for urgent questions or instructions.
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Behavioral Health Access Standards
Behavioral Health: Note that Anthem may use prescribing nurse practitioners for availability, if they are in the scope of credentialing, as licensed independent practitioners. These same professionals will be included in the access assessment.
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Behavioral Health Appointment Type
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Compliance
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Emergency Care
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24x7 phone access to BH practitioner.
Recording or live person instructs the caller to hang up and call 911, go to ER or Crisis Center for emergencies.
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Non-life threatening Emergent appointment
Members under 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. Situation has the potential to escalate into an emergency without clinical intervention.
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Within 6 hours
- Patient can be seen in the office by their BH Practitioner, another participating Practitioner in the practice or a covering Practitioner; or
- If appointment is unavailable, patient directed to 911, ER or 24 hour crisis services, as appropriate.
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Urgent Care appointment
Non-emergent care with significant psychology distress and symptoms. Calls are urgent when the severity or nature of presenting symptoms is intolerable, but not life threatening to the member.
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Within 48 hours
- Patient can be seen in the office by their BH Practitioner, another participating Practitioner in the practice or a covering Practitioner; or
- If appointment is unavailable, patient directed to 911, ER or 24 hour crisis services, as appropriate.
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Routine initial appointment
New patient non-urgent appointment.
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Within 10 calendar days
New patient can be seen in the office by a designated BH Practitioner or another appropriate participating Practitioner in the practice.
(After the intake assessment or a direct referral from a treating Practitioner.)
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Routine follow-up appointment
New or existing patient
Evaluation of progress or members who present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
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Within 30 calendar days
Patient can be seen in the office by their BH Practitioner, another participating Practitioner in the practice or a covering Practitioner within the timeframe.
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After Hours Urgent Access
Contacting BH Practitioners for emergency and urgent instructions.
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24X7 phone access
- Live person connects caller to their Practitioner or on-call Practitioner
- Recording or live person refers patient to ER / 911 / 24- hour crisis services;
In addition to, but not in place if above criteria, caller is offered to contact a BH professional (via cell, pager, beeper, transfer system) or get a call back for urgent instructions or consultation.
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Anthem uses several methods to monitor adherence to these standards, including:
- assessing the availability of appointments via phone calls and surveys by our designated vendor to the provider’s office;
- analysis of member complaint data; and
- analysis of member satisfaction. Providers are expected to make best efforts to meet these access standards for all members.
Is your practice compliant? In early 2018, Anthem Blue Cross and Blue Shield (Anthem) became one of the first major insurers to reimburse Emergency Medical Service (EMS) providers for appropriate and medically necessary care billed under HCPCS code A0998 (Ambulance response and treatment, no transport). The code, which has been active since January 2018 for most standard Anthem benefit plans, allows EMS providers to receive reimbursement for treatment rendered in response to an emergency call to a member’s home or scene, when transportation to the hospital emergency room (ER) was not provided. Previously, Anthem reimbursed EMS providers for treatment rendered only when a patient was transported to the ER.
Important reminders:
- The code is currently active and available for EMS use.
- If an EMS provider responds to an emergency call and provides appropriate treatment at-home or on-site without transporting to the ER, code A0998 can be used.
- The EMS provider must render treatment to the patient per EMS protocols which are approved by the medical director at the local or state level.
- Billing of A0998 when treatment is not rendered is not appropriate.
- Anthem will apply medical necessity review to A0998 using coverage guideline CG-ANC-06.
- HCPCS code A0998 applies to all of Anthem’s commercial health plans, and reimbursement will be made in accordance with the member’s benefits.
Questions?
- For contract questions, please reach out to your contract representative.
- For questions about using code A0998, please reach out to Jay Moore, Senior Clinical Director for Anthem, Inc.
Anthem continues to work with Inovalon - an independent company that provides secure, clinical documentation services - to help ensure that members who have purchased health care plans on or off the Health Insurance Marketplace (also called the exchange) get their diagnoses confirmed, corrected, and updated every year, as well as have potential preventive care gaps addressed. To accomplish this goal, as a network provider with Anthem (usually primary care physicians) you may receive letters from Inovalon on our behalf, asking you to perform patient outreach to identified Anthem patients so that patients can schedule an in-office visit with your practice.
Submission Deadline and Important Reminder
While the date of service for the must be form a visit in the 2018 calendar year, the SOAP note/Health Assessment can be submitted up until February 15, 2019.
Questions or assistance
Need help with ePASS or have questions? Simply email your inquiry to Inovalon at ePASSsupport@inovalon.com with your name, organization, contact information, and any questions that you might have. Trained representatives are available to assist you. If you prefer to reach Inovalon by phone, please call 1-877-448-8125, Monday - Friday, 8 am - 8 pm ET; Saturday - Sunday, 10 am - 6 pm ET.
For a practical overview of ePASS, please refer to Inovalon’s online document: Frequently Asked Questions.
Join a Live Weekly Webinar
Available every Wednesday from 3 pm - 4 pm ET, we encourage you to register in advance by sending an email to ePASSProviderRelations@inovalon.com with your name, organization, contact information and the date of the webinar you wish to attend. Remaining webinar sessions to help you meet the 2018 submission deadline:
- January 2
- January 9
- January 16
- January 23
- January 30
How to Join Webinar:
The following information can be used to join all webinars scheduled in 2018
- Teleconference: Dial 1-415-655-0002 (US Toll) and enter access code: 736 436 872
- WebEx: Visit https://inovalonmeet.webex.com and enter meeting number: 736 436 872
- Once you join the call, live support is available at any time by dialing *0
GO TO ePASS WEBSITE
To help easily identify members with Affordable Care Act plans, and the aligned networks, please see our Affordable Care Act - Quick Reference Guide. In the October 2018 Provider newsletter, we communicated some enhancements to the claim payment dispute process, allowing for electronic submission through Availity at availity.com. To ensure deployment of a successful provider experience, we’ve pushed out the implementation of the new functionality until early March. When the new functionality becomes available, you’ll receive notification through the Availity portal, as well as a future article in our Provider Newsletter.
To learn more about the claim dispute tool, register for a live webinar:
- Log in to Availity and select Help & Training | Get Trained
- Select Sessions and go to Your Calendar to locate a webinar
- Select View Course and then select Enroll
The Availity Learning Center will email you with instructions to attend.
Scheduled live webinars:
- January 3, 2019, 2-3 p.m. EST
- January 10, 2019, 2-3 p.m. EST
- January 24, 2019, 2-3 p.m. EST
Additional live webinars are being scheduled for 2019. Please follow the steps outlined above to find additional training opportunities as they become available. CMS average sales price (ASP) first quarter fee schedule with an effective date of January 1, 2019 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on February 1, 2019. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/. Anthem Blue Cross and Blue Shield (Anthem) is committed to investing in primary care, rewarding coordinated, patient-centered care, and promoting proactive chronic care management. In recognition of the time-intensive nature of this work, Anthem will reimburse chronic care management and advance care planning services for Commercial health plans effective for claims processed on or after February 23, 2019.
- Chronic care management (CCM) is care rendered by a physician or non‐physician health care provider and their clinical staff, once per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Only one practitioner can bill a CCM service per service period (month). Three CCM codes are included in this reimbursement policy change: 99490, 99487and 99489.
- Advance care planning (ACP) is a face-to-face service between a physician or other qualified health care professional and a patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document in which a patient appoints an agent and/or records the wishes of a patient pertaining to their medical treatment at a future time if they cannot decide for themselves at that time. No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary. Two ACP codes are included in the reimbursement policy change: 99497 and 99498
Anthem requires patient consent prior to CCM or ACP service(s) being provided. Please refer to the current Claims Requiring Additional Documentation policy for more information.
For more information, review our Bundled Services and Supplies policy dated February 23, 2019 available online from the Reimburse Policies - Professional page at anthem.com. On the date the new edit becomes effective, Clear Claim Connection, our web-based editing tool, will be updated to incorporate the new editing rules outlined above and will include an interface that will allow you to view the clinical rationale for the edit when you enter claim scenarios. If you have not used Clear Claim Connection previously, we would like to take this opportunity to encourage you to access this user-friendly tool to explore the ClaimsXten edits. Clear Claim Connection is located on the Availity Portal. Log into Availity.com. Once logged in, select Payer Spaces, and choose the Anthem icon. Under Applications, select Clear Claim Connection. Anthem Blue Cross and Blue Shield (Anthem) is committed to offering efficient and streamlined solutions for submitting prior authorizations (PAs). This helps reduce the administrative burden while improving the member experience for their patients.
Anthem’s Proactive PA process approves select drugs in real time, using an automated prior authorization (PA) process. Proactive PA uses integrated medical and pharmacy data to seamlessly approve medication prior authorization requests where diagnoses are required. Anthem’s prior authorization process helps to ensure clinically appropriate use of medications.
Providers can take advantage of the electronic prior authorization (ePA) submission process by logging in at covermymeds.com. Creating an account is FREE, and many prior authorizations are approved in real time. Read more about the ePA submission process from our December 2018 provider newsletter.
Additionally, providers may be able to access real-time, patient-specific prescription drug benefits information through their electronic medical record (EMR) system. To learn more about this feature, from our October 2018 provider newsletter article, Access patient-specific drug benefit information through EMR. Anthem Blue Cross and Blue Shield (Anthem) continually monitors and updates the list of drugs not approved by the Food and Drug Administration (FDA), which are considered non-covered under prescription drug benefits. When drugs are added to this list, Anthem notifies impacted members that the drug is not FDA approved and will no longer be covered.
Effective December 1, 2018, these drugs were added to our list of drugs not approved by the FDA.
For new members just beginning an Anthem plan or not yet having used one of these non-FDA-approved drugs, coverage for these drugs ended December 1, 2018.
Existing members who had been identified as already using at least one of the drugs added to the list received a letter to let them know their drug(s) will no longer be covered after December 31, 2018. However, if the patient had a prior authorization for a drug on this list, coverage for that drug continued until the prior authorization expired on December 31, 2018. Currently, providers can submit claim payment reconsiderations verbally, in writing or electronically. We are reaching out to notify you about some exciting new tools for electronic submission that will become available through the Availity Portal. You should soon see changes in the provider manual that will outline this new information regarding claim remediation tools through the Availity Portal.
Beginning March 7, 2019, providers will have the ability to submit claim reconsideration requests through the Availity Portal with more robust functionality. For you, this means an enhanced experience when:
- Filing a claim payment reconsideration.
- Sending supporting documentation.
- Checking the status of your claim payment reconsideration.
- Viewing your claim payment reconsideration history.
New Availity Portal functionality will include:
- Acknowledgement of submission at the time of submission.
- Notification when a reconsideration has been finalized by Anthem Blue Cross and Blue Shield Healthcare Solutions.
- A worklist of open submissions to check a reconsideration status.
With the new electronic functionality, when a claim payment reconsideration is submitted through the Availity Portal, we will investigate the request and communicate an outcome through the Availity Portal. Once an outcome has been determined, the Availity Portal user who submitted the claims payment reconsideration will receive notification informing him/her that the reconsideration review has been completed. If you are not satisfied with the reconsideration outcome, continue to follow the existing process to file an appeal, as outlined in your provider manual.
Look for announcements on the Availity Portal for upcoming training opportunities. Providers who have questions as they begin to use the new functionality should contact Provider Services at 1‑844‑396-2330. The holiday season is approaching and HEDIS audits shortly thereafter. You will be receiving medical record requests and on-site visits for record retrieval from an analytics vendor for Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem).
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.
Improving the Patient Experience, a provider continuing medical education program, offers a brief overview for understanding the provider/member relationship. It is live and available for viewing at www.patientexptraining.com. More educational information can be found by visiting https://mediproviders.anthem.com/nv > Provider Education & Support > Continuing Medical Education.
Anthem Blue Cross and Blue Shield (Anthem) recently introduced a redesigned monthly Explanation of Benefits (EOB) to Medicare Advantage members.
The new EOB includes:
- Personalized tips to help members save on health care expenses.
- A preventive care checklist - to point out opportunities for screenings or other care.
- Alerts when a claim needs immediate attention.
If you or your members have any questions about how to read the new EOB, please call the number on the back of the member ID card. |