To help ensure accuracy and eliminate delays in the adjudication of your claims, the itemized bill must be included with qualifying claim submissions. Submitting an itemized bill (unsolicited* medical attachment) for a high dollar claim just got easier!

 

To submit an itemized bill (unsolicited medical attachment):

1. Log in to Availity Portal
2. Select Claims & Payments | Attachments – New
3. Select Send Attachment
4. Under Request for Information, select No, if you are including the supplemental information/attachment for an 837 claim PWK. (see example below)

 

 

 

 

Providers can also submit a claim attachment using the Availity Portal for solicited** medical attachments.

 

To submit supporting documentation in response to a formal (solicited) request from the payer:

• Log in to Availity Portal
• Select Claims & Payments | Attachments – New
• Select Send Attachment
• Under the Request for Information, select Yes, if you are responding to a request from the health plan or need to submit documentation for a specific claim number (see example below)
• Add supporting documentation and reason
• Submit

Additionally, if you attended a previous webinar, we have updated information on submitting an EDI 837 batch that includes a PWK segment in loops 2300/2400. The update is regarding the linkage between the electronic claim and your supplemental documentation that can be submitted through the Availity portal.

 

What does this mean for you?

You may now submit attachments electronically (EDI) using the PWK segment to specify that documents are being submitted in support of the claim and no additional face sheet or coversheet is needed.

 

Here are the steps:

• Log in to Availity Portal
• Select Claims & Payments I Attachments - New
• From the Inbox tab, select the appropriate claim or open the request in your work queue
• Add files with supporting documentation
• Submit

 

Get Trained

• Attend an Availity-hosted webinar to learn more about all capabilities. You can register for an upcoming live webinar hosted by Availity here, or
• Log into Availity.com and select Help & Training | Get Trained to open the Availity Learning Center in a new tab (it is your dedicated ALC account).

• Search by keyword (Medattach) to find on-demand and live training options
• Select Enroll to enroll for a course and then go to your Dashboard to access it any time

 

Get started today with these wide-ranging capability enhancements to transform your business operations to a quick, secure, paperless and simple process to fulfill medical records requests electronically through Availity.

 

*Unsolicited attachment: Documentation submitted without a formal request from the payer

**Solicited attachment: Documentation submitted in response to a specific request from payer

 

 

1017-0321-PN-CONV

Material Adverse Change (MAC)

Site of Care medical necessity reviews for long-acting colony-stimulating factors begin June 1, 2021

 

 

1019-0321-PN-CONV

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 upon 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-0167	Ruxience (Q5119) Truxima (Q5115)	Rituxan (J9312)

 

The clinical criteria is publicly available on our provider website.

 

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-0164-20

Revised measures:

• The former Well-Child Visits in the First 15 Months of Life (W15) measure was revised to Well‑Child Visits in the First 30 Months of Life (W30). It includes two indicators:
  • Well-child visits in the first 15 months — children who turned 15 months during the measurement year with six or more well-child visits
• Well-child visits for ages 15 to 30 months — children who turn 30 months during the measurement year with two or more well-child visits
• The former Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) and Adolescent Well-Care Visits (AWC) measures have been combined into Child and Adolescent Well-Care Visits (WCV):
  • The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year

Key measure changes:

• Controlling High Blood Pressure (CBP and CDC-CBP)
  Telephone visits, e-visits and virtual check-ins are now acceptable settings for blood pressure (BP) readings. Digital BP readings reported by the member are considered numerator compliant.
• Telehealth updates
  NCQA has updated telehealth guidance in 40 HEDIS^® measures for HEDIS measurement years 2020 and 2021. The purpose of these changes is to:
  • Support increased use of telehealth caused by the pandemic.
  • Align with guidance from Centers for Medicare & Medicaid Services and other stakeholders.

A list of the 40 measures can be found on the NCQA COVID-19 website at www.ncqa.org/covid.

 

New Medicaid measures:

Kidney Health Evaluation for Patients With Diabetes (KED) — The percentage of members 18 to 85 years of age with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a uACR identified by both a quantitative urine albumin test and a urine creatinine test with service days four or less days apart during the measurement year

 

Cardiac Rehabilitation (CRE) — The percentage of members 18 years and older who attended cardiac rehabilitation following a qualifying cardiac event, including myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, heart and heart/lung transplantation, or heart valve repair/replacement; four rates are reported:

• Initiation — The percentage of members who attended two or more sessions of cardiac rehabilitation within 30 days after a qualifying event
• Engagement 1 — The percentage of members who attended 12 or more sessions of cardiac rehabilitation within 90 days after a qualifying event
• Engagement 2 — The percentage of members who attended 24 or more sessions of cardiac rehabilitation within 180 days after a qualifying event
• Achievement — The percentage of members who attended 36 or more sessions of cardiac rehabilitation within 180 days after a qualifying event

 

Retired Medicaid measures:

• Comprehensive Diabetes Care (CDC) retired sub-measures —
  • Medical Attention for Nephropathy (retired for Commercial and Medicaid)
  • HbA1c control (< 7.0%) for a selected population
• Adult BMI Assessment (ABA)
• Medication Management for People With Asthma (MMA)
• Children’s and Adolescents’ Access to Primary Care Practitioners (CAP)
  
  

Measure change summary:

For a complete summary, go to https://tinyurl.com/NCQA-measures.

 

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

 

 

ANV-NU-0181-20

New: additional benefit detail

Now, you can select Additional Benefit Notes, on the Availity Portal* Eligibility and Benefits results screen to find more descriptive benefit information.

 

Benefits are listed in alphabetical order, making it easier to search for specific benefits. Capabilities include full benefit descriptions, vendor information associated with the benefit and the option for the provider to print out the benefit information.

 

Digital member ID cards

The digital member ID card allows easy, low-touch access to view additional information or confirm basic membership details.

 

When conducting an eligibility and benefits inquiry for Nevada Medicaid members, simply select View Member ID Card on the Eligibility and Benefits results page. Note: The Availity Portal requires you to enter the member’s ID number, as well as a date of birth or the member’s first and last name into the search options in order to submit an eligibility and benefits inquiry.

 

Try both of these valuable tools today!

 

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

 

 

ANV-NU-0190-20

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

 

• Updates to AIM Clinical Appropriateness Guidelines for Advanced Imaging
• Provider notification for Utilization Management Authorization Rule Operations Workgroup Item 1326
• Ocrevus/Vyepti Medical Step Therapy Notice
• Provider Spotlight: H.O.P.E. Counseling Services

 

 

ANV-NU-0171-20

ANV-NU-0183-20

ANV-NU-0193-20

ANV-NU-0195-20

Anthem Blue Cross and Blue Shield will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.

 

We encourage providers who offer telehealth services to use the online Provider Maintenance Form to notify us, and we will add a telehealth indicator to your online provider directory profile.

 

Visit http://www.anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.

 

• Nevada Provider Maintenance Form

 

 

ABSCRNU-0203-20

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 note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

 

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

 

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

 

Notes/updates:

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

*GENE.00055 – Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity

Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications

*LAB.00037 – Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and

anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered investigational and not medically necessary for screening, diagnosis or management of irritable bowel syndrome, and for all other indications

*DME.00011 – Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

Revised scope to only include non-implantable devices and moved content addressing implantable devices to SURG.00158

Added “non-implantable” to bullet point on percutaneous neuromodulation therapy

Added percutaneous electrical nerve field stimulation (PENFS) as investigational and not medically necessary for all indications

*SURG.00062 – Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele

Expanded scope to include percutaneous testicular vein embolization for varicocele and added embolization of the testicular (spermatic) veins as investigational and not medically necessary as a treatment of testicular varicocele

*CG-LAB-15 – Red Blood Cell Folic Acid Testing

RBC folic acid testing is considered not medically necessary in all cases

*CG-LAB-16 – Serum Amylase Testing

Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions

*CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules

Added the Afirma Xpression Atlas as not medically necessary

SURG.00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

A new Medical Policy was created from content contained in DME.00011.

There are no changes to the policy content.

Publish date is December 16, 2020.

CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing

A new Clinical Guideline was created from content contained in GENE.00026.

There are no changes to the guideline content.

Publish date is December 16, 2020.

 

Medical Policies

On November 5, 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 March 8, 2021.

 

Publish date	Medical Policy number	Medical Policy title	New or revised
12/16/2020	*GENE.00055	Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity	New
12/16/2020	*LAB.00037	Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)	New
11/12/2020	ANC.00009	Cosmetic and Reconstructive Services of the Trunk and Groin	Revised
12/16/2020	*DME.00011	Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices	Revised
11/12/2020	GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	Revised
11/12/2020	MED.00129	Gene Therapy for Spinal Muscular Atrophy	Revised
12/16/2020	SURG.00011	Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
12/16/2020	*SURG.00062	Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele	Revised

 

Clinical UM Guidelines

On November 5, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on November 19, 2020. These guidelines take effect March 8, 2021.

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
12/16/2020	*CG-LAB-15	Red Blood Cell Folic Acid Testing	New
12/16/2020	*CG-LAB-16	Serum Amylase Testing	New
11/12/2020	CG-DME-42	Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices	Revised
12/16/2020	*CG-GENE-04	Molecular Marker Evaluation of Thyroid Nodules	Revised
12/16/2020	CG-GENE-18	Genetic Testing for TP53 Mutations	Revised
12/16/2020	CG-GENE-20	Epidermal Growth Factor Receptor (EGFR) Testing	Revised
11/12/2020	CG-MED-87	Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications	Revised

 

 

ABSCRNU-0206-21

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

 

• MCG Care Guidelines 24th edition customization
• DME checklist of information needed from providers

 

 

ABSCRNU-0201-20

ABSCRNU-0205-21