For the most up-to-date information from Anthem about COVID-19, please bookmark Provider News Home and check back often.  The most recent articles will be displayed in the Provider Spotlight section.

 

For a repository of all COVID-19 related articles in one location, please reference the COVID-19 Information - Nevada under Articles by Publication. 

444-0520-PN-CONV

Diabetes is a complex chronic illness requiring ongoing patient monitoring. NCQA includes diabetes in its HEDIS® measures on which providers are rated annually. Since diabetes HbA1c testing is a key measure to assess for future medical conditions related to complications of undiagnosed diabetes, the National Committee for Quality Assurance (NCQA) requires health plans to review claims for diabetes in patient health records.  The findings contribute to health plan stars ratings for Commercial and Medicare plans and the Quality Rating System (QRS) measurement for Marketplace plans. A systematic sample of patient records is pulled annually as part of the HEDIS® medical record review to assess for documentation.

 

Which HEDIS measures are Diabetes Measures?

The diabetes measures focus on members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following assessments:

 

• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (>9.0%)
• HbA1c control (<8.0%)
• Dilated Retinal exam
• Medical attention for nephropathy

 

The American College of Physicians’ guidelines for people with type 2 diabetes recommend the desired A1c blood sugar control levels remain between 7 to 8 percent.¹

 

In order to meet the HEDIS measure “HbA1c control <8”, you must document the date the test was performed and the corresponding result. For this reason, report one of the four Category II codes and use the date of service as the date of the test, not the date of the reporting of the Category II code.

 

To report most recent hemoglobin A1c level	Use
HbA1c level less than 7.0%	3044F
HbA1c level greater than or equal to 7.0% and less than 8.0%	3051F
HbA1c level greater than or equal to 8.0% and less than or equal to 9.0%	3052F
HbA1c level greater than 9.0%	3046F
HbA1c level ≤9.0%	3044F, 3051F, 3052F2

 

NOTE: Multiple dates of service may be associated with a single lab test (e.g., a collection date, a reported date and a claim date). For a laboratory test CPT II code to count toward HEDIS, the Category II date of service and the test result date must be no more than seven days apart.

 

Continued management and diverse pathways to care are essential in controlling blood glucose and reducing the risk of complications. While it is extremely beneficial for the patient to have continuous management, it also benefits our providers. As HEDIS rates increase, there is potential for the provider to earn maximum or additional revenue through Pay for Quality, Value Based Services, and other pay-for-performance models.³

 

Sources include:

• Diabetes Prevalence: 2015 state diagnosed diabetes prevalence, cdc.gov/diabetes/data; 2012 state undiagnosed diabetes prevalence, Dall et al., ”The Economic Burden of Elevated Blood Glucose Levels in 2012”, Diabetes Care, December 2014, vol. 37.
• Diabetes Incidence: 2015 state diabetes incidence rates, cdc.gov/diabetes/data
• Cost: American Diabetes Association, “Economic Costs of Diabetes in the U.S. in 2017”, Diabetes Care, May 2018.
• Research expenditures: 2017 NIDDK funding, projectreporter.nih.gov; 2017 CDC diabetes funding, www.cdc.gov/fundingprofiles

 

¹ https://www.medicalnewstoday.com/articles/321123#An-A1C-of-7-to-8-percent-is-recommended

² https://www.ama-assn.org/system/files/2020-01/cpt-cat2-codes-alpha-listing-clinical-topics.pdf

³  https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.html

 

 

402-0520-PN-CONV

This is a reminder to ensure that you are referring Anthem members to participating labs. LabCorp is our preferred lab provider and offers a Single Source Solution to your testing needs.  The relationship with LabCorp does not affect network hospital-based lab service providers, contracted pathologists, or contracted independent laboratories.  Physicians may continue to refer to all par providers as they have in the past.

 

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, and select Providers.  Select your state if you haven’t done so already.  Under the Provider Resources heading, select Find a Doctor.  Select your state if you haven’t done so already.

 

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:

                                                                         

· Allergy Program · Cancer Testing · Cardiovascular Disease · Companion Diagnostics · Dermatology · Diabetes · DNA Testing · Endocrine Disorders · Esoteric Coagulation · Gastroenterology

· Genetic Testing · Genetic Counseling · Genomics · HLA Lab for National Marrow Donor Program · Hematopathology · Infectious Disease · Immunology · Liver Disease · Kidney Disease

· Medical Drug Monitoring · Molecular Diagnostics · Newborn Screening · Pain Management · Pathology Expertise w/range of Subspecialties · Pharmacogenomics · Preimplantation Genetic Diagnosis · Reproductive Health

· Obstetrics / Gynecology · Oncology · Toxicology · Whole Exome Sequencing · Virology · Women’s Health · Urology

 

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

 

 

409-0520-PN-CONV

We understand the increased risk and strain on the health care system during the fight against COVID-19, and we support you in the response and treatment of your patients. Telehealth is now an option to assess your patients with risk adjustable conditions.  Anthem’s Prospective Risk Adjustment program works to improve risk adjustment accuracy and focus on performing appropriate interventions for patients with undocumented Hierarchical Condition Categories (HCC), in order to help you close your patients’ gaps in care.  This program involves:

 

• Member outreach encouraging primary care physicians (PCP) in-person or telehealth visits
• Refer to Anthem’s COVID-19 FAQ in Provider News for updates about telehealth reimbursement guidance.
• Provider outreach sharing previously coded and suspected conditions, and encouraging member visits
• PCP alternatives to complete Health Assessments

 

Inovalon Requests

Consistent with 2019, we have again engaged a vendor, Inovalon – an independent company that provides secure, clinical documentation services – to help us comply with the provisions of the Affordable Care Act that require us to assess members’ relative health risk levels.  In the coming weeks and months, Inovalon will begin sending letters to providers as part of a new risk adjustment cycle, asking for your help with completing Health Assessments for some of our members.

 

If you worked with Inovalon in 2019, many thanks for your help. This year will bring a new round of assessments because chronic conditions must be assessed and coded each and every year. As always, if you have questions about the requests you receive, you can reach Inovalon directly at 1-877-448-8125.

 

Prospective Program ask of Providers:

 

• Anthem network providers – usually PCPs – receive letters from Inovalon, requesting that they:
  
  
  1. Schedule a comprehensive in-person or telehealth visit with patients identified by Inovalon to confirm or deny if previously coded or suspected diagnoses exists, and;
  2. Submit a Health Assessment documenting the previously coded or suspected diagnoses (also called SOAP Notes - Subjective, Objective, Assessment and Plan).
• Incentives for properly submitted Health Assessments (these incentives are in addition to the office visit reimbursement):
  
  
  • $100 for each Health Assessment properly submitted electronically
  • $50 for each Health Assessment properly submitted via fax

 

• Submit electronically via Inovalon’s ePASS tool:
  
  
• Inovalon ePASS^® Training Webinars
  • Every Wednesday - 3:00 - 4:00 PM EST
• Join an ePASS webinar:
  • Register by sending an email to ePASSProviderRelations@inovalon.com with your name, organization, contact information and the date of the webinar you wish to attend.

 

Alternative Engagement

ePASS® is our preferred method for submission. However to improve engagement and collaborate with our providers who are not submitting via ePASS®, we have identified other tools which may be helpful. If in 2019 your practice utilized some of these alternative options for prospective member outreach, we thank you for continuing on these alternative forms of program participation into 2020. 

 

For those providers not familiar with our alternative options, they are listed here. Telehealth visits are also an acceptable form of a patient visit for these alternative engagement options. Any questions your office has on these can be directed to either your local Provider Representative, or the Anthem CRA Network Education Representative listed below.

• EPHC Providers using PCMS - Providers participating in our Enhanced Personal Health Care (EPHC) program can use member reports from our PCMS tool to schedule members for comprehensive visits. PCMS does have a link to take you directly to the Inovalon ePASS® tool where completed Health Assessments will result in a $100 incentive payment per submitted Health Assessment.
• List of Members to be scheduled - Anthem CRA provides member/patient reports for providers to schedule members for comprehensive visits. Providers use normal gap closure through claims submission.  No Health Assessment needed. Not eligible for additional incentive.
• EPIC Patient Assessment Form (PAF) - Providers with EPIC as their electronic medical record (EMR) system can fax the EPIC PAF to Inovalon at 1-866-682-6680 with a coversheet indicating "see attached Anthem Progress Note,” which is eligible for a $50 incentive payment.
• Providers Existing Patient Assessment Form (PAF) - Utilize providers existing EMR system and applicable PAF. Must be submitted to Inovalon at 1-866-682-6680 with coversheet indicating, "see attached Anthem Progress Note,“ which is eligible for a $50 incentive payment.

 

Please contact our Commercial Risk Adjustment Network Education Representative if you have any questions: 

Socorro.Carrasco@anthem.com.

Thank you for your continued efforts with our CRA Program.

 

 

416-0520-PN-CONV

Effective August 1, 2020, Anthem Blue Cross and Blue Shield will continue to allow reimbursement for unlisted, unspecified or miscellaneous codes. Unlisted, unspecified or miscellaneous codes should only be used when an established code does not exist to describe the service, procedure or item rendered. Reimbursement is based on review of the unlisted, unspecified or miscellaneous codes on an individual claim basis. Claims submitted with unlisted, unspecified or miscellaneous codes must contain specific information and/or documentation for consideration during review.

 

For additional information, please review the Unlisted, Unspecified or Miscellaneous Codes reimbursement policy here.

 

 

ABSCRNU-0105-19 March 2020         507050MUPENMUB

Background: Anthem Blue Cross and Blue Shield wants to make multi-dose packaging available to your patients to help support medication adherence. It’s a simpler, safer way for your patients to manage their medications. Multi-dose packaging is a free service available to members at select network pharmacies.

 

What is multi-dose packaging?

Multi-dose packaging (MDP) involves organizing prescription and over-the-counter products to provide ease to patients when taking their routine medications. Each MDP dispenser provides patients with a personalized roll of pre-sorted medication packs, labeled with the date and time of the patient's next scheduled dose. MDP helps reduce the stress of determining which medications to take, when to take them and how much of them to take.

 

Who provides these services?

MDPs can be shipped to the CVS* retail pharmacy of choice or directly to a patient’s home at no additional charge. The MDP Care team is available 24/7 to address patient questions and concerns. The team also coordinates mid-month prescription changes with local CVS pharmacies. CVS MDP is licensed in all states and the District of Columbia.

 

If CVS isn't the right fit based on geography, PillPack* can provide MDP services for your patients. Packages can include prescription medication, over-the-counter medication and vitamins, and will include a date and time stamp on each packet to help your patients remember to take their medications. Patient copays should be the same; in some cases, it may be cheaper.

 

How do I refer my patients to MDP providers?

For CVS: Patients can enroll online at https://www.CVS.com/multidose or call 1-800-753-0596. Patients residing in the District of Columbia, Georgia or South Carolina should call 1-844-650-1637 (due to remote practice restrictions). Members may also enroll at their local CVS pharmacy.

 

For PillPack: Patients interested in PillPack can enroll online at https://www.pillpack.com/blue or via phone by calling 1-866-282-9462.

 

 

ABSCRNU-0137-20 March 2020          509073MUPENMUB

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

 

• Prior Authorization requirements
• New behavioral health Medicare Advantage individual and Group Retiree Solutions provider fax

ABSCRNU-0133-20

ABSCRNU-0132-20

Effective August 1, 2020, Anthem Blue Cross and Blue Shield Healthcare Solutions will continue to allow reimbursement for unlisted, unspecified or miscellaneous codes. Unlisted, unspecified or miscellaneous codes should only be used when an established code does not exist to describe the service, procedure or item rendered. Reimbursement is based on review of the unlisted, unspecified or miscellaneous codes on an individual claim basis. Claims submitted with unlisted, unspecified or miscellaneous codes must contain specific information and/or documentation for consideration during review.

 

For additional information, please review the Unlisted, Unspecified or Miscellaneous Codes reimbursement policy here.

 

 

ANV-NU-0100-19 March 2020

Disease Management programs are designed to assist PCPs and specialists in caring for members with chronic health care needs. Anthem Blue Cross and Blue Shield Healthcare Solutions provides members with continuous education on self-management, assistance in connecting to community resources, and coordination of care by a team of highly qualified professionals whose goal is to create a system of seamless health care interventions and communications for members.

 

Who is eligible?

Disease Management case managers provide support to members with:

• Behavioral health conditions such as depression, schizophrenia, bipolar disorder and substance use disorder.
• Diabetes.
• Heart conditions such as congestive heart failure, coronary artery disease and hypertension.
• HIV/AIDS.
• Pulmonary conditions such as asthma and chronic obstructive pulmonary disease.

 

Our case managers use member-centric motivational interviewing to identify and address health risks such as tobacco use and obesity to improve condition-specific outcomes. Interventions are rooted in evidence-based clinical practice guidelines from recognized sources. We implement continuous improvement strategies to increase evaluation, management and health outcomes.

 

We welcome your referrals. To refer a member to Disease Management:

• Call 1-888-830-4300 to speak directly to one of our team members.
• Fill out the Disease Management Referral Form located on the provider website and fax it to 1-888-762-3199 or submit electronically via the Availity Portal.

 

Your input and partnership are valued. Once your patient is enrolled, you will be notified by the assigned Disease Management case manager. You can also access your patient’s Disease Management care plan, goals and progress at any time via the Availity Portal through Patient360.

 

We are happy to answer any questions. Our registered nurse case managers are available Monday to Friday from 8:30 a.m. to 5:30 p.m. local time, and our confidential voicemail is available 24 hours a day, 7 days a week.

 

 

ANV-NU-0107-20 March 2020

On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield Healthcare Solutions. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting December 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

 

ANV-NU-0114-20 March 2020

Did you know that you can earn extra incentives for helping us keep new moms healthy? Since

November 1, 2011, we’ve offered our participating providers additional reimbursements for ensuring our members receive quality postpartum care.

 

How does the program work?

We will reimburse the CPT^® Category II (CPT II) code 0503F for a postpartum care visit only when billed in conjunction with the CPT code for the postpartum visit. This code will help with HEDIS^® data collection.

 

An example of billing for postpartum care:

The member has a vaginal delivery on January 1, 2018, so bill CPT code 59400 for vaginal delivery global care. On February 1, 2018, the member has a postpartum visit. For this visit, bill 0503F (postpartum care visit). In this scenario, you would be reimbursed the global maternity care fee plus $20 for submitting the claim for the postpartum visit.

 

To earn the additional $20 postpartum care reimbursement:

1. Complete a postpartum visit between 7 and 84 days after delivery.
2. Bill using the appropriate delivery code with your patient’s date of delivery (be sure not to bill using the date of admission or date of discharge).
3. Submit your claim with the CPT II code 0503F.

If you have any questions about this program, please contact your local Provider Relations representative. Thank you for participating in our network and for working with us to improve the health and clinical outcomes for our members.

 

Sincerely,

 

Provider Relations

Anthem Blue Cross and Blue Shield Healthcare Solutions

 

 

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

 

 

ANV-NU-0117-20 March 2020

We know you work hard to ensure our members receive the care they need. Anthem Blue Cross and Blue Shield Healthcare Solutions added two additional billing codes in order to more accurately reflect the services our members are receiving. Beginning March 1, 2017, CPT^® Category II (CPT II) procedure codes were introduced to be used in addition to obstetric codes for verified live births. CPT II codes are nonreimbursable codes used for tracking obstetrical care.

 

Why is this change necessary?

Women’s health is important to us as well as to the state of Nevada. As a provider, you play an important role in ensuring our members obtain the care they need.

 

How does this impact me?

• Members should have a prenatal visit within the first trimester, on or before the enrollment start date or within 42 days of enrollment.
• Your office should schedule a postpartum visit on or between 7 and 84 days after delivery.

 

Prenatal and postpartum care
CPT II codes
0500F	Initial prenatal care visit — report at first prenatal encounter with health care professional providing obstetrical care, also report date of visit; in a separate field, report the date of the last menstrual period.
0501F	If Prenatal Care flow Sheet documented in medical record by first prenatal visit.
0502F	Subsequent prenatal care visit
0503F	Postpartum visit — to be completed from 7 to 84 days after delivery
CPT codes (CPT II codes must be billed with one of these global billing codes.)
59400	Routine obstetric care (ROC) including antepartum care (AC), vaginal delivery (VD) and postpartum care (PC)
59510	ROC including AC, cesarean delivery (CD) and PC
59610	ROC including AC, VD and PC after previous CD
59618	ROC including AC, CD and PC after attempted VD following previous CD
If a member does not qualify for global obstetrical billing, the CPT II codes should still be used to reflect prenatal and postpartum visits.

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your Provider Relations representative or call Provider Services toll-free at 1-844-396-2330.

 

ANV-NU-0118-20 March 2020

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

 

• Prior authorization requirements: new 2020 codes for coverage and precertification
• Clinical edit for obstetric services implementation

 

 

ANV-NU-0110-20

ANV-NU-0121-20