Beginning with claims processing on or after December 1, 2024, we will update our outpatient facility claims editing process to deny claim lines when an add-on code is reported without a primary procedure code.

An add-on code is a specific type designated by the HCPCS or CPT^®. These codes describe additional procedures or services performed with a primary procedure.

According to CPT guidelines, add-on codes must be reported with a primary procedure code.

If you believe you have received a claim denial in error, please follow our claim dispute process.

With your help, we can continually build towards a future of shared success.

The Department of Health & Human Services (HHS) requires health plans to report whether or not our in-network providers offer telehealth services.

If you provide telehealth services, please tell us by submitting your information to us through Availity.com. Updating your telehealth status will not affect your participation with us. We will add a telehealth indicator to your online provider directory profile, allowing our members to know you offer telehealth services.

If you have questions about submitting your information, please see the instructions below.

If your organization is not currently registered with Availity, you will need to create an account. The person(s) designated as your administrator(s) should go to Availity.com and select Get Started in the upper right corner of the webpage. You may also navigate directly to Availity’s registration website by selecting here.

Begin your application here. To update your application:

1. Log in to Availity Essentials.
2. Select My Providers.
3. Select Provider Data Management.

Please update your telehealth information at the service location.

In July, we announced an enhancement to the 277CA to notify you of submission errors discovered during claims processing.  

As of November 1, 2024, the 277CA will include additional corrective action types for your review. As communicated in July, these errors will still be sent through physical mailing.

With these added error types, there is no reduction to the services we already provide.

Through our efforts, we are committed to reducing administrative burden, improving communication, and ensuring timely payments because we value you, our care provider partners.

Find Care, the doctor finder and transparency tool in the Anthem online directory, provides Anthem members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options such as sorting providers based on distance, alphabetical order, and provider name.

In our November 2022 newsletter, we provided an update regarding Personalized Match, an additional Find Care sorting option for Commercial members. We informed you that this provider sorting option was based on provider efficiency and quality outcomes described in a methodology document linked in the newsletter article, in addition to member search radius.

We want to inform you that, beginning in December 2024 or later, we will be enhancing Personalized Match. This will expand upon the existing program. Newer components of the provider personalization metrics will contain up to 10 times as many features as compared to existing metrics such as gaps in care and additional types of service cost and utilization. Personalized Match will continue to display providers with the highest overall ranking within the member’s search radius, first. Members will continue to have the ability to sort based on distance, alphabetical order, and provider name.

Helpful resources on Availity

You may review a copy of the Personalized Match methodology that has been posted on Availity, our secure web-based provider tool, using the following navigation:

• Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.

If you have general questions regarding these upcoming changes, please submit an inquiry via the web at Availity.com. If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.com.

Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.

We are excited to announce the release of an Applied Behavior Analysis (ABA) Provider Resource Guide designed to assist with proper billing and documentation practices. This essential guide simplifies the complexities of ABA coding and requirements, ensuring that you can navigate these processes with ease.

Refer to attached ABA Provider Resource Guide.

As respiratory syncytial virus (RSV) season approaches, we would like to remind providers about available RSV immunizations to help prevent severe RSV related disease in infants. According to a report from the CDC (March 2024), infant preventive antibodies showed 90% effectiveness against the need for hospitalization for RSV in babies. Two immunizations are available to prevent RSV lower respiratory tract infections in infants:

• Pfizer's Abrysvo, a maternal vaccine given during pregnancy
• Nirsevimab (Beyfortus), a monoclonal antibody administered to the baby

The maternal vaccine, Abrysvo, is recommended for those who are 32 to 36 weeks pregnant during RSV season, which generally falls between October and March. The vaccine can provide protection for infants up to six months if the mother receives it at least two weeks prior to delivery.

Nirsevimab (Beyfortus) provides up to five months of protection against RSV and is approved for infants under 8 months during their first RSV season, and certain children between 8 and 19 months at increased risk of severe RSV disease. In some cases where a mother received an RSV vaccine, Nirsevimab can still be considered for the child if there is a substantial risk for severe RSV disease or if the maternal immune response to the vaccination is inadequate.

Nirsevimab is covered under the Vaccines for Children Program. Additional information about RSV prevention and Nirsevimab (Beyfortus) can be found at cdc.gov/rsv.

We look forward to sharing resources and working with you to achieve improved outcomes for children in our communities.

As a contracted provider for a special needs plan (SNP) from Anthem, you are required to participate in an annual Model of Care training for providers, per CMS regulations. This training includes a detailed overview of Anthem special needs plans and program information, highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Please remember this training is specific to our plans and delivery of care for members, ensuring their specific care needs are met. Your participation is critical for improved quality and health outcomes.

Training for the SNP product is self-paced and available at Availity.com. The training must be completed by December 31, 2024.

How to access the Custom Learning Center:

1. Log in to the Availity website at Availity.com.
2. At the top of the Availity website, select Payer Spaces and select the appropriate payer.
3. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
4. In the Custom Learning Center, select Required Training.
5. Select Special Needs Plan and Model of Care Overview.
6. Select Enroll.
7. Select Start.
8. Once the course is completed, select Begin Attestation and complete.

Not registered for Availity Essentials?

Have your organization’s designated administrator register your organization for the Availity website:

1. Visit Availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

Refer to these PDF documents for complete registration instructions.

Effective on November 17, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.

You may access and download a copy of the current and upcoming guidelines here:

• Musculoskeletal:
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

The above guideline updates have a publish date of November 17, 2024.

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

In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here:

• Site of Care Guidelines:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

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

In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care, effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here.

Site of Care Guidelines:

• Site of Care for Advanced Imaging
• Rehabilitative Site of Care
• Surgical Site of Care

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

Summary: On June 10, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

At a glance:

• High Performing Providers will also be known as Anthem Diamond Providers.
• Providers receiving a designation based on the Blue National Physician Performance Dataset will also be known as Anthem Diamond Providers (National).

High Performing Provider program

Over the last several months, we have communicated with our providers about our High Performing Provider program. PCPs and specialists meeting certain criteria are designated High Performing Providers. High Performing Providers may also be referred to as Anthem Diamond Providers.

As a reminder, the following specialties may be designated High Performing Providers (aka Anthem Diamond Providers) from this program:

• PCP: family practice, general practice, geriatric medicine, internal medicine, pediatric medicine, and nurse practitioners
• Specialists: cardiology, endocrinology, nephrology, neurology, neurosurgery, obstetrics gynecology, orthopedic surgery, psychiatry, pulmonology, and rheumatology

If you have any questions about this program, contact Provider Services or your local provider relationship management representative.

Blue National Physician Performance Dataset

This is an Anthem designation program for providers in networks supporting Anthem national accounts and certain out-of-area providers.

As we previously communicated to you, effective January 1, 2025, Anthem may incorporate insights from the Blue National Physician Performance Dataset (Dataset) in various initiatives. For Anthem national accounts and certain out-of-area providers, Anthem will use data made available in the Dataset to assess individual physician’s performance at the NPI level. The individual physician’s performance is assessed across the three domains — cost of care/efficiency, quality of care, and appropriateness of care — for the following 16 primary care and specialty areas: cardiothoracic surgery, cardiovascular disease, endocrinology, neurology, ob/gyn, ophthalmology, orthopedics, pediatrics, primary care, pulmonology, surgery, urology, gastroenterology, otolaryngology, oncology, and radiation oncology.

The providers who qualify for the designation from this Dataset program will also be referred to as Anthem Diamond Providers (National).

If you have any questions regarding this, contact your local provider relationship management representative.

At a glance:

• Care providers must prepare for HEDIS^® medical record reviews starting January 2025.
• Care providers will submit records through Remote Electronic Medical Record (EMR) Access Service, website upload, fax, secure file transfer protocol (SFTP), mail, or on-site.

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

Background

Each year, we perform a review of a sample of our members’ medical records as part of the HEDIS quality study. HEDIS is part of a nationally recognized quality improvement initiative and is used by the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and several states to monitor the performance of managed care organizations.

We will begin requesting medical records in January 2025. No special authorization is needed for you to share member medical record information with us since quality assessment and improvement activities are routine parts of healthcare operations.

Ways to submit your records in our preferred order:

• Remote EMR Access Service: We offer the Remote EMR Access Service to care providers to submit member medical record information to us. If you are interested in more information, contact us at Centralized_EMR_Team@anthem.com.
• Upload: Medical records can be uploaded to our secure website using the instructions in the request document.
• Fax: Medical records can be faxed to us using the instructions in the request document.
• SFTP: Medical records can be uploaded via a secure website.
• U. S. Postal Service: Medical records can be mailed to us using the instructions in the request document.
• On-site: Medical records can be pulled by a representative at your local office where medical records are located.

HEDIS review is time sensitive, so submit the requested medical records within the timeframe indicated in the initial HEDIS request document.

We appreciate the care you provide our members. Your assistance is crucial to ensuring our data is statistically valid, auditable, and accurately reflects quality performance.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

The Consumer Assessment of Healthcare Providers and Systems^® (CAHPS) is an annual standardized survey conducted anonymously by a third-party vendor (Center for the Study of Services) to assess a random sample of consumers' experiences with their health plan, their personal provider, and healthcare services.

Refer to attachment to view full details.