Our Escalation Process documents outline the appropriate steps that must be taken prior to escalating claim issues to your Provider Relations Representative. All inquiries related to claims payment must be directed to the Provider Service Call Center first.  Network Relations is not able to accept claim inquiries that have not been discussed with the Provider Service Call Center.  Below are the links to the documents on our website for each provider type. 

Please review the appropriate document in its entirety and follow the steps listed prior to escalating issues to Provider Relations.  

• Provider Resources - Professional CMS 1500
• Provider Resources - Facility UB
• Provider Resources - Behavioral Health

Centauri Health Solutions is the contracted vendor to gather member medical records on behalf of the Blue Cross and Blue Shield Federal Employee Program. We value the relationship with our providers, and ask that you respond to the detailed requests in support of risk adjustment, HEDIS and other government-required activities within the requested timeframe. Centauri Health will work with you to obtain records via fax, mail, remote electronic medical record (EMR) access, or onsite scanning/EMR download (as necessary).

We ask that you please promptly comply within five (5) business days of the record requests. If you have any questions, please contact Ify Ifezulike with Blue Cross and Blue Shield Federal Employee Program at 202-626-4839 or Mary Kay Sander with Centauri at 636-333-9145.

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways is through Anthem’s value-based programs such as Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, and so on – called the “Programs.”  Certain providers (“Value-Based Program Providers” also known as “Payment Innovation Providers”) in Anthem’s various value-based programs receive quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value-Based Program Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in the provider getting more referrals from Value-Based Program Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

Providing this type of data, including comparative cost information, to Value Based Program Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Value Based Program Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant.

CMS requires that we ensure that the information in our provider directories is accurate; therefore, we conduct quarterly verifications of provider demographic and participation information. You may receive a fax, email or letter requesting that this information be confirmed. We appreciate your continued cooperation with this initiative.

Upon receipt of your verification form, please validate your demographic information for the specific location identified indicate if changes are required and fax back a revised form to the number indicated in your communication. If we need to verify information for your other locations or plans, we will contact you separately.

For reference, we will ask you to submit any changes to the information listed below. Upon receipt, we will include those changes in the provider directory within 30 days.

• Provider Name
• Provider Specialty
• Street Address
• Phone number
• Accepting New Patients
• NPI
• Fax Number
• Email    
• Handicap Accessibility

As a participating provider, please be reminded of your contractual obligation to help ensure our members have prompt access to services. Please visit anthem.com to access our Provider Manual for our guidelines for access to care for primary care practitioners (PCPs), specialty care practitioners (SCPs) and behavioral health practitioners (BHPs).

We use several methods to monitor adherence to these standards. Monitoring is accomplished by:

1. Assessing the availability of services via phone calls by our staff or designated vendor to the provider’s office
2. Analysis of member complaint data
3. Analysis of member satisfaction

Providers are expected to make best efforts to meet these access standards for all members.

Here’s a quick reminder of our guidelines for PCPs:

• Preventive care – members scheduling periodic routine exams (well care/preventive visits). Appointments should be available within 45 calendar days of a member’s call. Care provided to prevent illness or injury; examples include, but are not limited to routine physical examinations, immunizations, mammograms and pap smears.
• Urgent care services with acute symptoms – appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, non-resolving headache.   
• Routine check-up – members must have access to care within 10 business days of their call. Care provided for non-symptomatic visits for health check.
• After-hours access – members must have access to care 24 hours a day, 7 days a week, 365 days a year. PCPs must arrange after-hours care to provide 24 hour coverage for our members by a network provider during non-business office hours. Members should have the ability to reach a recorded message or a live voice providing instructions on how to access care for emergencies and conditions requiring urgent attention.

Although it is important for members to have the continuity of receiving care from their PCPs, there are occasions when you may not be available at a time that meets their scheduling needs. As a reminder, we now contract with walk-in centers and urgent care facilities which are listed in our directory.

Here’s a quick reminder of our guidelines for SCP’s.  At this time, these guidelines apply to certain specialties but will expand to other specialties in the near future.  To view those current impacted specialties, please view the access standards on anthem.com.

• Urgent care services with acute symptoms – appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, non-resolving headache.  
• Routine check-up – members must have access to care within 30 calendar days of their call. Care provided for non-symptomatic visits for health check.

Here’s a quick reminder of our guidelines for BHPs:

• Non-life threatening emergency services - must be seen, or have appropriate coverage directing the member, within six (6) hours. Emergent behavioral health care provided when a member is in crisis, experiencing acute distress and/or other symptoms and needs immediate attention; no risk of loss of life.
• Urgent services - must be seen, or have appropriate coverage directing the member, within 24 hours. Non-emergent behavioral health services that requires immediate care; member is experiencing significant psychological distress with symptoms that impairs daily functioning; no risk of loss of life.  
• Initial routine services - must be seen within 10 business days. New patient non-urgent appointment scheduled after intake assessment or a direct referral from a treating practitioner.
• Follow-up routine services – must be seen within 30 calendar days. Non-urgent behavioral health care; member has been scheduled for a non-urgent consultation or requires services including, but not limited to, follow-up and existing medication management.
• BH follow-up appointment after discharge (inpatient psychiatric hospital release) – this standard is currently used for HEDIS® measures. Members must be seen within 7 calendar days. Members can be seen in office by their practitioner or another practitioner in the practice within the same timeframe.
• After-hours access - members must have access to care 24 hours a day, 7 days a week, 365 days a year. Must have arrangement for after-hours care to provide 24 hour coverage for our members by a network provider during non-business office hours. Members should have the ability to reach a recorded message or a live voice providing instructions on how to access care for emergencies and conditions requiring urgent attention.

After-hours urgent access coverage

After-hours coverage, which is required by the Participating Provider Agreement, consists of an attendant or recording assisting the member in accessing urgent instructions outside of regular office hours. Note that telephone answering machines and voice mail are not acceptable means of providing urgent access for members if the answering machine or voice mail message only refers members to the emergency room or to call 911.

Compliance requires that a recording or live person directs callers to urgent care, 911, the ER, or connects the call to the caller’s doctor or the doctor on call.  In addition to these measures but not in place of them, the messaging can give callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or an opportunity to ask for a call back for urgent questions or instructions.

Timely access to physicians is a major priority of our members and employer groups. The requirements adopted reflect not only their expectations, but market norms. We will be assessing physicians against these requirements through our customer satisfaction surveys and provider surveys as well as follow-up on any members’ complaints received. However, we are sensitive to problems related to seasonal services, the varying nature of practice specialties, and the challenges faced by busy practices. If your office routinely fails to meet these access and after-hours standards, it is important that you document and we understand the reasons that the requirements are not met.

Effective July 1, 2020, we will upgrade to the 24th edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC), Recovery Facility Care (RFC), and Behavioral Health Care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

Goal Length of Stay (GLOS) Changes for Inpatient & Surgical Care (ISC) and Behavioral Health Care (BHC)

New Optimal Recovery Guidelines (ORGs) for Inpatient & Surgical Care (ISC) and New Behavioral Health Care (BHC) New Guidelines

Anthem Customizations to MCG care guideline 24th Edition

Effective July 1, 2020, the following MCG care guideline 24th edition customizations will be implemented.

• Carotid Artery Stenting (W0165) – Clinical Indications were customized to reference CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
• Deep Brain Stimulation (W0164) – Clinical Indications were customized to refer to SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation.
• Vagus Nerve Stimulation, Implantable (W0166) – Clinical Indications were customized to refer to SURG.00007 Vagus Nerve Stimulation.

To view a detailed summary of customizations, scroll down to other criteria section and select Customizations to MCG Care Guidelines 24th Edition.

For questions, please contact the provider service number on the back of the member's ID card.

Effective January 1, 2020, many New Hampshire group members were enrolled in a new benefit design called Preferred Primary Care (PPC). When these members receive care from a designated PPC provider, their copayment is $5. PPC providers are those who have been identified as top performers in Anthem’s Enhanced Personal Health Care value-based model, and can be identified on our ‘Find a Doctor’ tool on anthem.com. Simply choose the plan information and choose PPC in the “Sort by” box for primary care.

We have become aware that many primary care providers who have not been designated as a PPC provider are collecting the PPC copayment of $5, instead of the correct member copayment as indicated on the member’s ID card. If you are not listed as a PPC on our Find a Doctor tool, you should be collecting the other copayment or cost share indicated on the member’s ID card.

As always, it is important that providers are verifying member eligibility and benefits using the ID number on the member’s ID card. This can be done using Availity.com or by calling Provider Service. 

We continue to make changes to our public provider website to make it easier for you to find the information you need. The end of Q1 brings a few updates for the site at anthem.com:

• Information has been added to our website regarding Patient Centered Specialty Care (PCSC) – our value-based payment program for cardiology, endocrinology and obstetrics/gynecology providers. You can find this information online as an extension of our Enhanced Personal Health Care (EPHC) program – our broad patient-centered, value-based care program.
• Documents listed on the Prior Authorization page can be conveniently accessed via online links.
• Medicare Advantage will be live in the coming days. You will be able to view updated Medicare Advantage pages on the commercial public sites.
• Medical Policies and Clinical Utilization Management Guidelines now display on our newly designed web pages.

The Provider Manual, which incorporates information for both professional and hospital/facility providers, will be updated for an effective date of July 1, 2020. The manual will be available after May 1, 2020 on the provider portal of anthem.com.  Select Providers, then, under the Provider Resources heading, select Policies, Guidelines and Manuals.  Enter New Hampshire as state, scroll to Provider Manuals, and select Download Provider Manual. Archived copies of the professional and hospital/facility manual will remain available at the same location.

In addition, a new BlueCard® Provider Manual has also been published with an effective date of January 1, 2020. This manual is also available on anthem.com. Select Providers, then, under Provider Resources, select Policies, Guidelines and Manuals. Enter New Hampshire as state, scroll to Provider Manuals, and select Download Provider Manual. From here select Access previous versions and other manuals > BlueCard Provider Manual (effective January 1, 2020).

Anthem completed its acquisition of Beacon Health Options, a large behavioral health organization that serves more than 36 million people across the country. The company will operate as a wholly owned subsidiary of Anthem.

Bringing together our existing solid behavioral health business with Beacon’s successful model and support services creates one of the most comprehensive behavioral health networks in the country. It’s also an opportunity to offer best-in-class behavioral health capabilities and whole person care solutions in new and meaningful ways to help people live their best lives.

From the standpoint of our customers and providers at this time, it’s business as usual:

• Members should continue to call the customer service number on the back of their membership card or access their health plan’s website for online self-service.
• Providers should continue to use the provider service contact information, websites and online self-service portals as part of their agreement with either Anthem or Beacon.
• There will be no immediate changes to the way Anthem or Beacon manage their respective provider networks, contracts and fee arrangements. Anthem and Beacon provider networks, contracts and fee arrangements will remain separate at this time.

We know our providers continue to expect more of their healthcare partner, and at Anthem, we aim to deliver more in return.

For more details, please see the press release.

For the most up-to-date information from Anthem about COVID-19, please bookmark Provider News Home and check back often.

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

• COVID-19 Information from Anthem
• Coding tip for psychological and neuropsychological testing
• New MA Opioid Treatment Program benefit
• Medical Policies and Clinical Utilization Management Guidelines update
• Prior authorization requirements: new 2020 codes for coverage and precertification

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. 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.*

ABSCRNU-0130-20

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved clinical criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 November 2019. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.

ABSCRNU-0124-20

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

Medicare Risk Adjustment and Documentation Guidance (General)

• When: The trainings will be offered the first Wednesday of each month from 1:00 p.m. to 2:00 p.m. (through December 2, 2020).
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity has been reviewed and is acceptable for up to 1 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the following link: Medicare Risk Adjustment and Documentation Guidance (General).

Note: Dates may be modified due to holiday scheduling.

Medicare Risk Adjustment, Documentation and Coding Guidance (Condition Specific)

• When: The trainings will be offered on the third Wednesday of every other month from noon to 1 p.m. ET (from January 15, 2020, to November 18, 2020).
• Learning objective: This training series will provide in-depth disease information pertaining to specific conditions including an overview of their corresponding HCC, with guidance on documentation and coding.
• Credits: This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

1. Red Flag HCCs Part 1 (January 15, 2020): Register for a recording of the session: Training will cover HCCs most commonly reported in error as identified by CMS (Chronic Kidney Disease Stage 5, Ischemic or Unspecified Stroke, Cerebral Hemorrhage, Aspiration and Specified Bacterial Pneumonias, Unstable Angina and Other Acute Ischemic Heart Disease, End-Stage Liver Disease).

Link: Red Flag Hierarchical Condition Categories (HCCs), part one

2. Red Flag HCCs Part 2 (March 18, 2020): Training will cover HCCs most commonly reported in error as identified by CMS (Atherosclerosis of the Extremities with Ulceration or Gangrene, Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome, Drug/Alcohol Psychosis, Lung and Other Severe Cancers, Diabetes with Ophthalmologic or Unspecified Manifestation)

Link: Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 2

3. Neoplasms (May 20, 2020)

Link: Neoplasms

4. Acute, Chronic and Status Conditions (July 15, 2020)

Link: Acute, Chronic and Status Conditions

5. Diabetes Mellitus and Other Metabolic Disorders (September 16, 2020)

Link: Diabetes Mellitus and Other Metabolic Disorders

6. TBD — This Medicare risk adjustment webinar will cover the critical topics and updates that surface during the year (November 18, 2020):

Link: Topic TBD

ABSCRNU-0125-20