COVID-19

• Information from Anthem for Care Providers about COVID-19

 

Material Changes/Amendments to Contract and/or Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements starred (*) below.

• Anthem prior authorization updates for specialty pharmacy are available – April 2020*
• UPDATE: Notice of changes to the AIM Musculoskeletal Program prior authorization requirements*
• MCG Care Guidelines 24th Edition*

 

Other Important Updates

• Medicare and Medicaid News – COVID-19 Updates

 

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

At Anthem Blue Cross and Blue Shield (Anthem), 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) – Anthem’s value-based payment program for cardiology, endocrinology and obstetrics/gynecology providers. You can find this information online as an extension of our broader patient-centered, value-based care program – Enhanced Personal Health Care (EPHC).
• 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 (MP) and Clinical Utilization Management Guidelines (CUMG) now display on our newly designed Web pages.

If you have any questions, please contact Michelle Fraser at michelle.fraser@anthem.com or Nick Kizirnis at nick.kirzinis@anthem.com. 

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 Network Representative or Care Consultant.

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.

 

Click here for more information about the COVID-19 Virus Talking Points for Medicare Advantage.

 

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

 

• Coding tip for psychological and neuropsychological testing
• Medical Policies and Clinical Utilization Management Guidelines update
• New Medicare Advantage opioid treatment Program benefit
• Prior authorization requirements: new 2020 codes for coverage and precertification

 

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.

 

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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.*

 

^{* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield.}

 

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The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield (Anthem) 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 p.m. to 2 p.m. ET (from January 8, 2020, to 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 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 link below:

• 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 is a collaborative learning event with Enhanced Personal Health Care (EPHC)* to 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

 

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Effective, January 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) entered into a provider collaboration agreement with Physician’s Group of Southeast Ohio Physicians in the southeastern Ohio market called Trusted Senior Care Advantage. Anthem delegated responsibility for medical claims payment, prior authorizations, case management, provider credentialing, and inpatient and outpatient utilization management to each of these groups for individual Medicare Advantage HMO members in Fairfield, Guernsey, Morgan, Muskingum, Noble and Perry counties who are attributed to Physician’s Group of Southeast Ohio Physicians. The delegation was effective January 1, 2020. Members under this arrangement will have Trusted Senior Care Advantage on their member ID card.

Please see the frequently asked questions and answers below for additional information. You may also call Trusted Senior Care Advantage Provider Services at 1-833-440-5652.

 

Frequently Asked Questions (FAQ)

 

When did this relationship start?

This relationship started January 1, 2020.

 

What changes can I expect?

Certain services historically performed by Anthem have been delegated to Trusted Senior Care Advantage. Trusted Senior Care Advantage will provide services for payment of medical claims, provider credentialing and utilization management. As a result of these administrative changes, providers can expect increased interaction and collaboration between Anthem and Trusted Senior Care Advantage.

 

What number should I call if I have questions?

For provider inquiries, call Trusted Senior Care Advantage Provider Services at 1-833-440-5652.

 

What service area is Trusted Senior Care Advantage handling?

The service area includes the following counties: Fairfield, Guernsey, Morgan, Muskingum, Noble and Perry counties.

 

To what address do I submit claims?

Claims for routine vision services should be submitted to EyeMed (also known as Blue View Vision). All other medical claims should be submitted to the following address for payment:

Attn: Core Care Select

P.O. Box 70032

Anaheim, CA 92825

 

Electronic claims can be sent to Office Ally or Change Healthcare:

• Office Ally payer ID: AGL02
• Change Healthcare payer ID: 52352

 

For claim submission questions, contact Trusted Senior Care Advantage Provider Services at 1-833-440-5652.

 

Whom do I contact if I have questions about or need assistance with electronic data interchange?

Contact Trusted Senior Care Advantage Provider Services at 1-833-440-5652 for inquiries related to your electronic claims submission. They will assist in identifying, testing and correcting any issues.

 

Will there be a separate provider directory?

No, members will be able to refer to their Anthem provider directory as usual.

 

Where should I direct my patients if they have questions about their insurance plan?

Members should contact Anthem’s Member Services at the phone number on the back of their ID card.

 

Will prior authorization be required for admissions and/or certain services?

Yes, prior authorization is required for all nonemergency admissions and certain other services. For emergency admissions, please call Trusted Senior Care Advantage Provider Services at 1-833-440-5652 within 24 hours of admission or fax a face sheet to 1-614-259-0287.

 

How do I contact the Utilization and Quality Management departments?

• Provider Services phone: 1-833-440-5652
• Direct fax: 1-614-259-0293
• Inpatient and Outpatient Case Management department fax: 1-614-259-0287

 

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Effective January 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) entered into a provider collaboration agreement with PriMed Physicians in the Dayton, Ohio, market called Greater Dayton Senior Care Advantage. Anthem delegated responsibility for medical claims payment, prior authorizations, case management, provider credentialing, and inpatient and outpatient utilization management to each of these groups for individual Medicare Advantage HMO members in Clark, Greene, Miami, Montgomery, Preble and Warren counties who are attributed to PriMed Physicians. Members under this arrangement will have Greater Dayton Senior Care Advantage on their member ID card.

Please see the frequently asked questions and answers below for additional information. You may also call Greater Dayton Senior Care Advantage Provider Services at 1-833-440-5652.

 

Frequently Asked Questions (FAQ)

 

When did this relationship start?

This relationship started January 1, 2020.

 

What changes can I expect?

Certain services historically performed by Anthem have been delegated to Greater Dayton Senior Care Advantage. Greater Dayton Senior Care Advantage will provide services for payment of medical claims, provider credentialing and utilization management. As a result of these administrative changes, providers can expect increased interaction and collaboration between Anthem and Greater Dayton Senior Care Advantage.

 

What number should I call if I have questions?

For provider inquiries, call Greater Dayton Senior Care Advantage Provider Services at 1-833-440-5652.

 

What service area is Greater Dayton Senior Care Advantage handling?

The service area includes the following counties: Clark, Greene, Miami, Montgomery, Preble and Warren counties.

 

To what address do I submit claims?

Claims for routine vision services should be submitted to EyeMed (also known as Blue View Vision). All other medical claims should be submitted to the following address for payment:

Attn: Core Care Select

P.O. Box 70032

Anaheim, CA 92825

           

Electronic claims can be sent to Office Ally or Change Healthcare:

• Office Ally payer ID: AGL02
• Change Healthcare payer ID: 52352

 

For claim submission questions, contact Greater Dayton Senior Care Advantage Provider Services at

1-833 440 5652.

 

Whom do I contact if I have questions about or need assistance with electronic data interchange?

For inquiries related to your electronic claim submission to Greater Dayton Senior Care Advantage, contact Greater Dayton Senior Care Advantage Provider Services at 1-833-440-5652. They will assist in identifying, testing and correcting any issues.

 

Will there be a separate provider directory?

No, members will be able to refer to their Anthem provider directory as usual.

 

Where should I direct my patients if they have questions about their insurance plan?

Members should contact Anthem’s Member Services at the phone number on the back of their ID card.

 

Will prior authorization be required for admissions and/or certain services?

Yes, prior authorization is required for all nonemergency admissions and certain other services. For emergency admissions, call Greater Dayton Senior Care Advantage Provider Services at 1-833-440-5652 within 24 hours of admission or fax a face sheet to 1-614-259-0287.

 

How do I contact the Utilization and Quality Management departments?

• Provider Services phone: 1-833-440-5652
• Direct fax: 1-614-259-0293
• Inpatient and Outpatient Case Management department fax: 1-614-259-0287

 

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