Care providers have the opportunity to initiate member screenings and lab work without delay. To help detect and manage health conditions in a timely manner, set a proactive course for member wellness throughout the year. Early and routine screenings align with our commitment to comprehensive, preventive healthcare, contributing to better health outcomes for all.

Broader access for members and more options for care providers

Both our preferred national labs, LabCorp and Quest Diagnostics, are in-network for our Commercial and Medicare plans. This expansion not only broadened the spectrum of diagnostic options available but also enhanced convenience for members through increased specimen draw locations.

Our expanded network benefits members and care providers through:

• Increased convenient testing locations and appointment scheduling: online appointment scheduling, conveniently located patient service centers, and timely access to results
• Expanded testing options, including specialty testing expertise: broad menu of routine and specialized tests, including molecular, genetic, and genomic testing
• Streamlined workflow and enhanced efficiency: easy-to-use lab management services for ordering tests and supplies, scheduling a specimen pickup, and tracking order status

We encourage you to share this update with your patients and leverage the expanded network for efficient and effective care delivery.

We are committed to helping patients more easily access the care they need. You can find our participating laboratories — including LabCorp and Quest Diagnostics — in our online provider directory at Find Care.

We are required to adjust rates in accordance with the acute Diagnosis-Related Groups (DRGs), exempt hospitals, and exempt hospital unit services payment methodology, retroactive to the effective date of those rates as determined by the New York State Division of Budget. As a result, rates issued by the state in September 2024 will be applied retroactively to all claims submitted with dates of discharge on or after April 1, 2024.

Accordingly, we will reconcile the affected claims and determine the adjusted reimbursement amounts based on the new rates. If, based on our reconciliation efforts, you are due additional reimbursement, we will issue payment at that time. If the adjusted net reimbursement results in an amount due from you to us, we will commence recovery of such amounts through an offset against future claims payments.

We appreciate your continued participation in our network. If you have any questions, contact Provider Services at 800‑450‑8753.

To align with the Centers for Medicare & Medicaid Services (CMS) guidance, we are updating our claims editing system regarding claim submissions for global surgical procedures. This update will ensure that reimbursements are accurately processed for clearly distinct surgical procedures performed during the postoperative period, excluding re‑operations or complications from treatment. These changes will be effective for dates of service starting on July 1, 2025.

Updated reimbursement eligibility criteria for global surgical procedures

• Claim lines will not be eligible for reimbursement when a 0-day, 10-day, or 90-day global surgical procedure is submitted during the postoperative period of a prior 10-day or 90-day procedure by the same provider for the same member unless it is a distinct procedure.
• The logic reviews the diagnoses reported to the seventh digit.
  If the diagnoses are different, the claim line will be allowed; if the diagnoses are the same, the claim line will not be allowed.
• Modifiers 58, 78, and 79 or site modifiers E1‑E4, F1‑F9, FA, T1‑T9, TA, LM, RI, LC, LD, RC, RT, and LT are appropriate to identify unrelated procedures.

Example

The provider reports procedure code 68761‑E2 and diagnosis code H04.123 with the date of service of January 10, 2025. If the same provider reports procedure code 68760‑E2 and diagnosis code H04.123 with a date of service of January 16, 2025, the claim line for January 16, 2025, will not be allowed since the same site modifier and diagnosis are present as the procedure 10 days prior.

How to Initiate a Claims Payment Dispute

If you believe a claim reimbursement decision should be reviewed, follow the claims payment dispute process outlined in your provider manual, which is available at https://www.anthem.com/provider/individual-commercial/reimbursement.

Contact us

In accordance with CMS guidelines, contracted Medicare Advantage care providers for special needs plans (SNP) must complete our annual Model of Care training. Providing a detailed overview of SNP, this training highlights cost sharing; data sharing; participation in the Interdisciplinary Care team; where to access the member’s health risk assessment results; plan of care and benefits coordination; and ensures the specific care needs of your patients, our members, are met.

To access the training, go to the link below:
https://www.anthem.com/content/dam/digital/docs/provider/commercial/ma/train/ABCBS-CR-070929-25.pdf

Did you know 40% to 50% of patients are non‑adherent to their medications for chronic conditions, leading to 100,000 preventable deaths and $100 to $300 billion in avoidable medical costs per year?

Medications are the primary intervention in treating and preventing disease. For most conditions, medications need to be taken 80% or more of the time to see an improvement in clinical outcomes.

Understanding the potential challenge

Medication adherence is not just about patients remembering to take their pills. Adherence is a multifaceted issue influenced by several factors, which can include:

• Adherence challenges such as cognitive impairment, history of non‑adherence, and confusion or misunderstandings.
• Concerns for the fear of side effects, perceived lack of benefit, and complex medication regimens.
• Logistical or financial Issues such as transportation difficulties or high medication costs.

Implementing solutions

Identifying patients with adherence issues can be challenging. We recommend incorporating the following strategies into your practice:

• Discuss adherence with patients at each appointment using open‑ended questions.
• Analyze claims or non‑adherence reports to find at‑risk patients.
• Use electronic health records for proactive identification of at‑risk patients.

Tailored and proactive approaches

Once identified, it is essential to tailor solutions to each patient’s unique needs:

• Simplify regimens using once‑daily doses and 90‑day supplies with refills.
• Educate patients by clearly explaining medication benefits and risks.
• Streamline prescribing with real‑time prescription benefits.
• Reduce pharmacy visits using e‑prescribe to CarelonRx for home delivery.

Spotlight on success

When patients struggle with controlling their condition, consider medication non‑adherence as a potential reason. Care providers can significantly improve patient outcomes and reduce healthcare costs by employing these strategies.

Understanding how to update claims to bill inpatient and outpatient services accurately ensures prompt reimbursement, improves quality reporting, and increases patient satisfaction by mitigating unexpected costs. Please use the guidance below.

Replacement of inpatient bill types

When a claim is mistakenly billed as an inpatient bill type, it must be replaced using the ‘replacement bill type’ xx7. To correctly replace an inpatient bill type, the replacement must match the same bill type category:

• Replace x11 with x17
• Replace x31 with x37
• Do not replace x11 with x37, or x17 with x31.

Changing between inpatient and outpatient bill types

To change billing from inpatient to outpatient or from outpatient to inpatient, follow these steps:

1. Void the incorrect claim using ‘frequency type 8’ to avoid errors and overlaps.
2. Create a new claim submission labeled ‘frequency type 1’ to represent the correct billing type.

Contact your network manager or provider relationship management representative with any questions.

We are excited to announce two new interactive training courses for uploading rosters through the Availity platform. Dive into these two 20‑minute sessions and master the roster upload process with confidence.

The Provider Roster Upload via Availity course will guide you through uploading rosters, troubleshooting errors, and downloading your data. The Roster Automation Standard Template course offers training on using a roster template to enhance compatibility and streamline the submission process.

Don't miss this opportunity to unlock valuable insights. Visit https://Availity.com and navigate to Payer Spaces > Payer Tile > Resources to access the latest Roster Automation Standard Template and Roster Submission Guide.

Access all training courses on the Digital Solutions Learning Hub.

We are excited to announce the launch of the Availity Essentials Provider Overpayments application in July 2025. The Provider Overpayments application is a robust tool for improving digital communication in managing claim overpayments. It offers care providers a streamlined and efficient way to handle notifications, inquiries, disputes, and resolutions of overpayments directly through the Availity website.

Benefits of the Availity Overpayments application:

• Comprehensive management: Access a user‑friendly platform to help you efficiently oversee overpayment processes, from initiation to resolution.
• Intuitive interface: Navigate easily through five overpayment statuses: Action Required, Inquired, Disputed, Resolved, and Closed, with overpayment details displayed as unique cards.
• Enhanced communication: Benefit from integrated messaging functions and document uploads to facilitate clear communication and documentation.
• Training and support: Training resources and support are available to assist you in maximizing the use of this tool. All application documentation/demos are available after logging into Availity Essentials.

If you experience technical issues while logging in or using Essentials, contact Availity Client Services at 800‑AVAILITY for immediate assistance.

The original Availity Essentials Overpayments Application training and demonstration schedule has been updated.

Webinars, training resources, and support are available to help you maximize the use of this tool.

For access to Availity Essentials learning resources, follow these two easy steps:

1. Log in to Availity Essentials.
2. Select the Help and Training menu.

We look forward to helping you enhance operational efficiencies and improve claim overpayment management.

Thank you for your continued partnership.

Summary: The Pharmacy and Therapeutics (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 our Clinical Criteria page to find specific policies. If you have questions or need additional information, please email us.

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

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

Note:

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

Managing illness can be a daunting task for our members. It is not always easy to understand test results, obtain essential resources for treatment, or know whom to contact with questions and concerns.

Anthem is available to offer assistance in these difficult moments with our Complex Case Management program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals available to support members, families, providers, and caregivers. Our Care Coordination team uses their expertise to educate and empower members by increasing self‑management skills.

The complex case management process can help members understand their illnesses and learn about their options to ensure they have access to quality, efficient healthcare. We can also help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

Members or caregivers can refer themselves or family members by calling the Member Services number located on their ID card. They will be transferred to a team member based on the immediate need.

Physicians can refer their patients by visiting our provider website. You can also contact us by phone at 833‑869‑5890. Case management business hours are Monday to Friday from 8 a.m. to 5 p.m.

Quality healthcare requires cooperation between patients, their care providers, and their healthcare benefit plan. To support these relationships, your provider manual includes a Members’ Rights and Responsibilities section. Please review at https://providers.anthem.com/ny > Resources > Provider manuals, policies & guidelines.

As a healthcare provider, staying informed about the utilization management (UM) process is crucial for optimizing patient care and streamlining administrative functions and claims submissions. This comprehensive guide details submission methods, necessary documentation, and contact information, ensuring you have the resources to facilitate approvals efficiently.

Support and communication

We have staff available to help with UM issues Monday through Friday, during regular business hours for inbound collect or toll‑free calls. We can also receive fax communications after regular business hours. Phone and fax number options are detailed below. Messages will be returned within one business day. When initiating or returning calls, our staff will identify themselves by name, title, and organization name. TDD/TTY and language assistance services are available for members as needed at no cost.

You can request a free copy of our UM criteria from Provider Services at 800‑450‑8753. You can also call this number to discuss a UM denial decision with a physician reviewer. Our Medical Policies and UM criteria are available on our provider website.

Preapprovals

You can submit preapproval requests by:

• Using the Availity Essentials Authorization application. Log in to Availity Essentials and select Patient Registration > Authorizations and Referrals. You can also access information previously mailed or faxed anytime in Availity Essentials.
• Faxing 800‑964‑3627.
• Calling 800‑450‑8753.

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept preapprovals. Secure voicemail is available outside of business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues.

Our UM decisions are based on the appropriateness of care and service and existence of coverage. We do not specifically reward practitioners or other individuals for not approving coverage. We also do not offer financial incentives for UM decision‑makers to encourage decisions resulting in underutilization.

What if I need assistance?

If you have questions about utilization decisions or the UM process, call Provider Services at 800‑450‑8753, Monday through Friday from 8:30 a.m. to 5:30 p.m. ET. You can also use Chat with Payer from Payer Spaces on Availity Essentials.