Digital Request for Additional Information (RFAI) is the easiest way to submit attachments requested by your payer using Availity Essentials. There is no need to fax or mail paperwork to complete your claim submissions anymore; just use the digital channels provided for your organization.

Availity Essentials notification center

The notification center is located on the top of the Availity Essentials home page. If your payer has requested documentation, there will be a message stating there are requests in your work queue. Simply select the hyperlink to be navigated to the Attachment Dashboard to view the request.

Availity Essentials Attachment Dashboard

The Attachment Dashboard is where all attachment requests are displayed. You can use the hyperlink in the notification center or navigate to Claims & Payments > Attachments New.

To locate a specific RFAI request, the request number will begin with RFAI. If you notice multiple requests in your dashboard, take advantage of the filters. You have the option to search, filter, and sort for multiple values, such as tax ID, NPI, and request type.

Select Upload Attachment to view the type of document requested. Your uploaded requests will be visible in the History tab once accepted. Select the Record History icon on the right side of the request to view the Availity Transaction ID for specific Availity Essentials questions or Health Plan Transaction ID if you need to contact your payer for questions.

Digital RFAI progress dashboard

This dashboard, located in Payer Spaces, allows your organization to understand how many digital requests have been sent, how many finalized claims there are based on your attachment submissions, and the average turnaround time from the initial payer request to the claim finalization. To view your Digital RFAI Progress Dashboard application, select Payer Spaces from the drop-down menu and choose your payer tile.

Get trained

Availity Essentials has training on-demand. This includes a pre-check for administrators and a Learn How to Submit Digital Requests for Additional Information training. Log in to Availity Essentials > Help & Training > Get Trained > Enter RFAI in the keyword search.

Visit the Provider Learning Hub to take Availity on-demand training.

If you have questions, call Availity Client Services at 800-Availity (800-282-4548). Availity Client Services is available Monday to Friday, 8 a.m. to 8 p.m. ET.

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

As part of our ongoing efforts to optimize and enhance the Claims Status application in Availity Essentials, we recently launched the ability for non-medical/atypical care providers — such as providers of non-emergency transportation, case management, or environmental modifications — to use the Dispute functionality in the enhanced Claims Status app. This new functionality allows atypical care providers to be more efficient and accurate in their dispute submission process.

Below are a few simple and important steps and reminders to follow for the best experience and results.

First step

Register with Availity Essentials

Non-medical/atypical care providers can submit a dispute using Availity Essentials. Care providers need to first register an organization with Availity Essentials, ensuring an administrator is chosen and their provider information — including tax ID — is added to Manage My Organization.

Once the organization is set up as Non-Medical/Atypical on Availity Essentials, it can use various functions, such as submitting disputes. Atypical care providers do not use an NPI to bill claims; therefore, it's important that the setup is completed.

Second step

Go to the Claims Status app:

• Navigate from the home page to Claims & Payments > Claim Status > select your organization and payer > Claim Status Inquiry page will open.
• When Manage My Organization has been completed, you can select the care provider from the drop-down menu and the tax ID field will display.
• Complete an inquiry by entering the required fields and selecting Submit for requested claims to display.

Third step

Select Dispute

To complete a dispute:

• Locate the claim and, if there is an option to appeal, select Dispute to initiate.
• Select Go to details to be navigated to the Appeals Application.
• Locate your initiated dispute and select the action menu to complete the dispute request.
• Choose the request reason, upload supporting documents, and submit the request.

Once completed, your progress will appear in the Notifications Center on the Availity Essentials home page when Web is selected in the contact field.

Explore training and resources

We are here to support you along the way through on-demand training and resources.

Availity Essentials offers keyword search assistance with the option to attend live or recorded demos:

• On the Availity Essentials home page, select Help & Training, then select Get Trained to register for upcoming live and recorded training demos for all Availity Essentials capabilities.
• Use the search bar to locate specific appeals training.
• The Availity Learning Center user guide will assist with how to locate training.

For questions, contact Availity Client Service:

• Online: Help & Training > Availity Support > Contact Support > Create a case or Chat with Support
• By phone: Call 800-AVAILITY (282-4548) Monday through Friday from 8 a.m. to 8 p.m. Eastern time

In our previous communications about the Authorizations and Referrals application on Availity Essentials, we mentioned the Preference Center where you can select your preferred method of communication for authorization cases. Below, find details on how to easily access the Preference Center and set your communication preference. The Preference Center, which can be accessed by your Availity administrator or their assistant, will be available on Availity Essentials within Payer Spaces by the end of April 2024.

Access the Preference Center

After logging in to Availity Essentials, your Availity administrator, or their assistant, will select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Preference Center application tile. The Preference Center will prompt them to select your organization.

Set your preferred communication mode for authorization cases

After selecting your organization, select the preference option for Authorization and Referrals to see the preferred communication mode for authorization cases and adjust the preference (Digital Access (Default) or Digital + Mail) based on your business needs.

Once in the preference setting for Authorizations and Referrals, all tax IDs and NPIs for your organization registered with Availity Essentials will be displayed on the screen. The default communication mode for authorization cases will be set to Digital Access for all organizations, including all combinations of tax IDs and NPIs.

You can change the mode of communication to Digital + Mail for any combination of tax ID and NPI. There is no need to manually enter the tax IDs and/or NPIs to set this preference. Instead, use the search bar to focus on the tax IDs and NPIs you want to make changes to. Additionally, you can add more NPIs to your current registration and set the preferred communication mode for the new NPIs under the selected tax IDs.

Manage preferences (Availity administrators)

Availity administrators can learn more about managing preferences related to Authorization Decision letters in the Custom Learning Center, available in Payer Spaces on Availity Essentials.

After logging in to Availity Essentials, select Payer Spaces from the top menu bar, then select the Anthem payer tile. Once in Payer Spaces, select the Custom Learning Center application, then select the Resources section to view or download the Reference Guide on managing receipt of Authorization Decision letters.

Through our shared health vision, we can affect real change.

Roster Automation is our technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel template.

On March 29, we introduced a new Roster Automation functionality on the Upload Roster File page of Availity PDM. With this enhancement, you can view:

• Date received and status of rosters submitted in the last 12 months.
• Errors in submitted rosters that result in the need of manual intervention to process. The types of issues included in the error report will be incorrectly formatted data and required data elements that are missing from the roster.

Understanding the errors made when completing a roster allows you to ensure subsequent submissions do not contain those issues. Error-free rosters reduce the need for manual intervention, which improves data accuracy and processing time.

As you learn how to use the information available in the new error reports, we will continue to correct issues on your behalf.

In the future, you will need to correct any errors submitted in a roster (for example, missing data, incorrectly formatted data). Rows in a roster that contain an error will not be processed and the addition, change, or termination will not be updated in our systems. More information about when you will need to correct errors, and how to do so, will be sent in future communications and covered in future virtual webinars.

Utilize the Roster Submission Guide

Find it online: On Availity.com > Payer Spaces > Select Payer Tile > Resources > Roster Submission Guide using Provider Data Management.

Soon, you will be able to submit all your authorizations in one application on Availity.com.

You may already be submitting your physical health authorizations through the Availity Essentials multi-payer Authorization application — taking advantage of the time savings and speed to care through digital authorization submissions. You will soon be able to submit both your physical health and behavioral health authorizations through one Authorization application on Availity.com.

Using the Availity Authorization application to submit your behavioral health authorizations will not be much different from the process you follow today. You may enjoy more intuitive screens or learn sooner if an authorization is required, but the digital submission process is still the best way to submit your authorization requests and the fastest way to care for our members.

You will continue to use Interactive Care Reviewer (ICR) to submit an appeal or authorization for medical specialty prescriptions.

Accessing the Availity Authorization application is easy. Ask your organization’s Availity administrator to ensure you have the Authorization role assignment. Without the role assignment, you will not be able to access the Authorization application. Then, log on to Availity.com to access the app through the Patient Registration tab by selecting Authorizations and Referrals.

Training is available

Training is available for the Availity Authorization application. Once registered with the authorization role assignment, visit the training site to enroll for an upcoming live webcast or to access an on-demand recording at the Availity Authorization Training Site.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

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.

We previously introduced you to Personalized Match, an additional Find Care sorting option for Medicare Advantage members, which was based on provider efficiency and quality outcomes, in addition to member search radius. Personalized Match was initially limited to PCP searches and was later expanded to include certain specialists.

Beginning in June 2024 or later, we will further enhance Personalized Match. Provider availability and STARS rating scores will now more directly influence provider rankings. Additionally, provider recommendations will be driven in part by knowledge about member history derived from claims and other available clinical data. Personalized Match will continue to display providers with the highest overall ranking within the member’s search radius at the top of search results. Members may continue to sort based on distance, alphabetical order, and provider name:

• A copy of the Personalized Match phase two methodology will be posted in Availity in the coming weeks.
• If you have general questions regarding this new sorting option, please submit an inquiry via the web at Availity.
• 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.

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 committed to helping patients more easily access the care they need.

These updates list the new and/or revised Medical Policies and Clinical Guidelines for Anthem. The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised Medical Policy or Clinical Guideline is effective for all claims processed on and after the specified implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the changes. If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and Clinical Guidelines (and Medical Policy takes precedence over Clinical Guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the service is rendered must be used. This document supplements any previous Medical Policy and Clinical Guideline updates that may have been issued by Anthem. Please include this update with your provider manual for future reference.

Please note that Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Anthem’s Medical Policies and Clinical Guidelines are available at anthem.com. Select For Providers. Under the Provider Resources heading, select Policies, Guidelines & Manuals. Select your state. Then, select View Medical Policies & Clinical UM Guidelines.

Note: These updates may not apply to all administrative services only accounts as some accounts may have nonstandard benefits that apply.

To view Medical Policies and Clinical Utilization Management (UM) Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program FEP^®), visit fepblue.org > Policies & Guidelines.

Medical Policy updates

New Medical Policies effective August 17, 2024

The following policies are new:

• OR-PR.00008 Osseointegrated Limb Prostheses

• SURG.00162 Implantable Shock Absorber for Treatment of Knee Osteoarthritis

Revised Medical Policies effective August 1, 2024

The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• SURG.00135 Renal Sympathetic Nerve Ablation

Revised Medical Policy effective August 3, 2024

The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• LAB.00039 Combined Pathogen Identification and Drug Resistance Testing

Revised Medical Policy effective August 17, 2024

The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck

Coding Updates effective August 17, 2024

As a result of coding updates in the claims system, the claim system edits for the policies listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary and/or investigational determination for certain services:

• MED.00140 Gene Therapy for Beta Thalassemia
• MED.00146 Gene Therapy for Sickle Cell Disease

In the March 2024 issue of Provider News, we announced that language was inadvertently removed from the Modifier 26 comment in Section II. The policy has been updated to include the following statement:

• When a professional provider has reported modifier 26 to procedure codes designated with NPFSRVF PC/TC indicators 3 or 9, the procedure will not be eligible for reimbursement.

Upon further review, no claims were impacted by this omission. If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual.  

HEDIS^® is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

What vaccines are included in the HEDIS Adult Immunization Status (AIS-E) measure?

Influenza: The percentage of members 19 years of age and older who are up to date on recommended routine vaccines for influenza.

Td/Tdap: The percentage of members 19 years of age and older who are up to date on recommended routine vaccines for tetanus and diphtheria (Td) or tetanus, diphtheria, and acellular pertussis (Tdap).

Zoster: The percentage of members 50 years of age and older who are up to date on recommended routine vaccines for zoster.

Pneumococcal: The percentage of members 66 years of age and older who are up to date on recommended routine vaccines for pneumococcal.

Using correct codes can help your practice improve HEDIS AIS-E results.

Using the correct code to capture the vaccine given, or identifying anaphylaxis code to reflect the contraindications, can help your practice with performance rates.

Adult immunization

* Influenza live virus

Sources: 1. NCQA Health Plan Description AND ECDS: Adult Immunization Status, pages 643 to 650.
2. HEDIS MY 2024 Volume 2 Value Set Directory 2023-08-01: tabs Measures to Value Sets and Value Sets to Codes.

Exclusions:

• Members who use hospice services; or
• Members who elect to use a hospice benefit any time during the measurement period; or
• Members who die any time during the measurement period.
• Members with a history of at least one of the following contraindications any time during the measurement period.

Exclusions codes for anaphylaxis

Helpful tips

Immunization information obtained from the medical record:

• A note indicating the name of the specific antigen and the date of the immunization.
• A certificate of immunization prepared by an authorized healthcare provider or agency, including the specific dates and types of immunization administered.
• Document in the medical record of refusal or anaphylaxis reaction to the serum/vaccination.

Elevance Health, the parent company of our pharmacy benefit management partner, CarelonRx, Inc., has completed its acquisition of Paragon Healthcare, Inc., a company specializing in life-saving and life-giving infusible and injectable therapies.

Paragon Healthcare provides infusion services to members through its omnichannel model of ambulatory infusion centers, home infusion pharmacies, and other specialty pharmacy services. The company, headquartered in Plano, Texas, currently serves more than 35,000 members at over 40 ambulatory infusion centers across eight states, as well as in members’ homes.

The acquisition of Paragon Healthcare will deepen our capabilities around providing affordable, convenient access to specialty medications for those living with chronic and complex illnesses. Paragon Healthcare will operate as part of CarelonRx.

CarelonRx plans to expand Paragon Healthcare’s geographical footprint and operations while bolstering its therapeutic coverage to ensure members receive convenient, timely access to medications.

We share a health vision with our care providers that means real change for consumers.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the Medical Specialty Drug Review team of Anthem. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc.  

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Inclusion of a national drug code (NDC) code on your claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code. 

Prior authorization updates

Effective for dates of service on and after August 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria here view the complete information for these prior authorization updates.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Quantity limit updates

Effective for dates of service on and after August 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria here view the complete information for these quantity limit updates.

Site of care updates

Effective for dates of service on and after August 1, 2024, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our site of care review process.

Access our Clinical Criteria here view the complete information for these site of care updates.

The Anthem pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by the Medical Specialty Drug Review team of Anthem. Oncology drugs will be managed by Carelon Medical Benefits Management, Inc., a separate company.

The following Clinical Criteria documents were endorsed at the February 23, 2024, Clinical Criteria meeting. To access the Clinical Criteria information, visit this link.

New Clinical Criteria effective August 1, 2024

The following Clinical Criteria are new:

• CC-0258 iDoseTR (travoprost Implant)
• CC-0260 Nexobrid (anacaulase-bcdb)

Revised Clinical Criteria effective August 1, 2024

The following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CC-0011 Ocrevus (ocrelizumab)
• CC-0020 Natalizumab Agents (Tysabri, Tyruko)
• CC-0029 Dupixent (dupilumab)
• CC-0033 Xolair (omalizumab)
• CC-0041 Complement Inhibitors
• CC-0043 Monoclonal Antibodies to Interleukin-5
• CC-0047 Trogarzo (ibalizumab-uiyk)
• CC-0057 Krystexxa (pegloticase)
• CC-0062 Tumor Necrosis Factor Antagonists
• CC-0064 Interleukin-1 Inhibitors
• CC-0066 Monoclonal Antibodies to Interleukin-6
• CC-0067 Prostacyclin Infusion and Inhalation Therapy
• CC-0068 Growth Hormones
• CC-0078 Orencia (abatacept)
• CC-0088 Elzonris (tagraxofusp-erzs)
• CC-0090 Ixempra (ixabepilone)
• CC-0096 Asparagine Specific Enzymes
• CC-0099 Abraxane (paclitaxel, protein-bound)
• CC-0108 Halaven (eribulin)
• CC-0112 Xofigo (Radium Ra 223 Dichloride)
• CC-0115 Kadcyla (ado-trastuzumab)
• CC-0117 Empliciti (elotuzumab)
• CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)
• CC-0119 Yervoy (ipilimumab)
• CC-0123 Cyramza (ramucirumab)
• CC-0125 Opdivo (nivolumab)
• CC-0126 Blincyto (blinatumomab)
• CC-0131 Besponsa (inotuzumab ozogamicin)
• CC-0174 Kesimpta (ofatumumab)
• CC-0199 Empaveli (pegcetacoplan)
• CC-0208 Adbry (tralokinumab)
• CC-0212 Tezspire (tezepelumab-ekko)
• CC-0227 Briumvi (ublituximab)

Effective June 1, 2024, the following medication codes will require prior authorization.

Please note, inclusion of a National Drug Code (NDC) on your medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

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 800-450-8753.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Effective for dates of service on and after August 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines — including definitions and specific contract provisions/exclusions — take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

We look forward to working together to achieve improved outcomes.

Visit the Drug Lists page on our website at anthem.com/ms/pharmacyinformation/home.html for more information about:

• Copayment/coinsurance requirements and their applicable drug classes.
• Drug lists and changes.
• Prior authorization criteria.
• Procedures for generic substitution.
• Therapeutic interchange.
• Step therapy or other management methods subject to prescribing decisions.
• Any other requirements, restrictions, or limitations that apply to using certain drugs.

The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.

To locate the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.

Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.

Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access.

Through our efforts, we are committed to reducing administrative burden because we value you, our care provider partner.

Summary of change

The formulary changes listed in the table below were reviewed and approved at our fourth quarter 2023, Pharmacy and Therapeutics Committee meeting.

Effective May 1, 2024, the changes outlined below apply to all members of Anthem.

Don’t forget to read the footnotes at the bottom of the tables.

Please work with your Anthem patients to transition to formulary alternatives. If you determine preferred formulary alternatives are not clinically appropriate for specific patients, you must obtain prior authorization to continue coverage beyond the applicable effective dates.

We recognize the unique aspects of patients’ cases. If for medical reasons your Anthem patient cannot be converted to a formulary alternative, call Provider Services at 800-450-8753 and follow the voice prompts for pharmacy prior authorization. You can find the Preferred Drug List on our provider website at providers.anthem.com/new-york-provider/home.

If you need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 800-450-8753.

Prior authorization updates

Effective for dates of service on and after May 1, 2024, the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization.

Please note, inclusion of a national drug code on your medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Step therapy updates

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy code from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon prior authorization initiation or renewal in addition to the current medical necessity review of the drug noted below.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 800-450-8753.

CarelonRx mail service pharmacy changed to CarelonRx Pharmacy on January 1, 2024.

This pharmacy change does not affect the way CarelonRx works with care providers. There are no changes to the prior authorization process, how claims are processed, or level of support.

This change does not impact your patients’ benefits, coverage, or how their medications are filled.

When e-prescribing orders to the mail service pharmacy:

Prescribers will need to choose CarelonRx Pharmacy, not CarelonRx Mail, if searching by name.

If searching by NPI (National Provider Identifier), the NPI is changing to 1568179489.

We are taking steps to ensure a smooth transition to our new home delivery pharmacy for your patients:

• Patients will receive a letter to alert them of their new pharmacy.
• If a patient has refills left, we will move them to CarelonRx Pharmacy.
• If a patient does not have any refills left of their medication(s), CarelonRx Pharmacy will contact you to obtain a new prescription.
• If a patient is taking a controlled substance, CarelonRx Pharmacy will contact you to obtain a new prescription.
• All prior authorizations will be transitioned to CarelonRx Pharmacy.

CarelonRx Pharmacy delivers an enhanced, digital-first solution to your patients to improve adherence and lower costs, while removing barriers associated with traditional retail and mail order pharmacy models. Some highlights include:

• 24/7 text or chat (digitally) directly with our pharmacists at any time.
• Enhanced end-to-end order status tracking from prescription order to delivery.
• Free delivery of their 90-day supply, directly to a patient’s door.