Effective for all claims received on and after May 1, 2024, Anthem is updating its outpatient facility editing system to align with correct coding guidelines. As a result, claims billed with HCPCS/CPT^® codes 0373T, 0362T, 90853, 90887, 96121-96171, 97151-97158, 90785, 90791, 90792, 90832-90847, 90863, H0001-H2035, S0201, S9480, and an inappropriate revenue code(s) will be denied.

For assistance with coding guidelines, please refer to CPT Coding Guidelines or Encoder Pro. If you believe you have received a denial in error, please follow the standard claim payment dispute process outlined in the provider manual. To access, visit anthem.com/provider and select Change State, then select Providers, Guidelines & Manuals. Finally, select Download the Manual under the Provider Manuals ribbon.

Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com/provider, then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information in our online directory has changed.

Updating your information

Anthem uses the provider data management (PDM) capability available on Availity Essentials to update your provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate provider demographic data set by the Consolidated Appropriations Act (CAA).

PDM features include:

• Updating provider demographic information for all assigned payers in one location.
• Attesting to and managing current provider demographic information.
• Monitoring submitted demographic updates in real-time with a digital dashboard.
• Reviewing the history of previously verified data.

Accessing the PDM application

Log on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

PDM training

PDM training is available:

• Learn about and attend one of our training opportunities by visiting here.
• View the Availity PDM quick start guide here.
• Roster automation standard template and roster automation rules of engagement specific training:
  • Listen to our recorded webinar here.

Not registered for Availity Essentials yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account.

If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY.

We are excited for genuine collaboration with you, our care provider partners.

There are new resources available for providers to complete the Pregnancy Risk Assessment Form electronically, or ePRAF (Electronic Pregnancy Risk Assessment Form). To access this form, log in to the NurtureOhio website where you will find information on how to use the ePRAF.

Quality Enhancer Incentive Program for ePRAF

The Quality Enhancer Incentive Program provides increased payments to eligible providers who submit the ePRAF via the NurtureOhio website on behalf of their pregnant patients.

Technical Assistance Intervention Package for ePRAF

The Technical Assistance Intervention Package is a collection of resources, tools, and reporting that is designed to assist Providers in delivering high-quality pregnancy related care to their patients.

For more information on using the ePRAF, please contact us at ohiomedicaidprovider@anthem.com.

As a reminder, Anthem requires the documentation of PASRR (Preadmission Screening and Resident Review) form for initial and concurrent stay prior authorization requests to an in-network skilled nursing facility (SNF) for Ohio Medicaid Managed Care members.

Floor to in-network SNF inpatient prior authorization process requires that the nursing facility and provider must be in-network; member needs to have a 6-click score of 18 or below (physical and occupational therapy) and the member must not have any exclusions:

• Transfer from an acute rehab facility
• Transfer from a long-term acute care hospital (LTACH) facility
• Transfer from a psychiatric/geropsychiatric hospital unit
• Member whose prior level of function (PLOF) is non-ambulatory
• Member has been admitted to a hospital from a SNF or acute rehabilitation facility
• Member was denied an LTACH admission
• Member was denied a standard SNF precertification request

Referring provider/facility or SNF is required to submit the SNF/Rehab Worksheet and PASRR (Preadmission Screening and Resident Review) form in the initial 24 hr. therapy evaluation period and clinical information within three business days after the date of admission to aid in members’ care coordination, discharge planning, and member management. Documentation listed is required before final determination is made by Anthem.

If the member does not qualify for the Floor to SNF prior authorization, the referring provider/facility must go through the standard pre-certification process.

PASRR regulations (Ohio Administrative Code Rule 5160-3-14) require that all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payer source, be assessed for indications of serious mental illness and/or a developmental disability unless the member meets requirements for a Hospital Exemption.

For your convenience, the PASRR form can be downloaded here.

Anthem will conduct random audits and monitor trends to evaluate the effectiveness of this initiative.

Refer to the frequently asked questions (FAQ) below for more information.

Frequently asked questions

As a SNF provider, do I need to send information and notification to Anthem as I would normally do for a prior authorization?

Yes, notification is still required within 48 hours or next business day of admission. However, you can notify Anthem of the admission and may move a member to the SNF without authorization if they meet the six clicks and floor to SNF requirements. It will be important to verify member benefits and submit a PASRR form. For additional details on our Floor to SNF prior authorization process or visit our provider portal at Availity.com.

When do I need to submit clinical information?

For the initial SNF admission, submit the clinical information no later than three business days after the admission, and for continued stay, prior to the last covered day.

Does this apply to SNF, inpatient (IP) rehab, and long-term acute care (LTAC) admissions?

This process is only applicable to the initial SNF admission. Follow standard prior authorization process for IP rehab and LTAC.

For the SNF initial authorization of seven days, will Anthem assign a level of care?

Anthem utilization management will assign level of care once the PASRR and clinical information is received from the SNF.

If the physician and/or facility are out-of-network for the member, does this process apply?

No, the facility and physician both need to be in-network. All out-of-network facilities and providers must follow the standard prior authorization process.

Contact us

Availity Chat with Anthem 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 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 at the bottom of our provider website for the appropriate contact.

Anthem uses post-pay and prepayment review in certain circumstances to validate the appropriate level for facility emergency department (ED) claims. This process identifies the level of ED E&M code by intensity and/or complexity of resources or interventions a facility uses to furnish all services indicated on the claim. Providers must use appropriate HIPAA-compliant codes for all services rendered during the ED encounter. The highest intervention/resource used will determine the final facility ED level.

Anthem defines:

• Interventions: the staff the facility uses and their work performed
• Resources: facility building, equipment, and/or supplies used
• Note: Professional provider services are not considered facility interventions or resources.
• Intensity and/or complexity: quantity, type, or specialization of interventions and/or resources used and the nature of the presenting problem, member age, acuity, and diagnostic services performed, as indicated on the claim
• Emergency services: a medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care, could result in (a) placing the health of an individual in serious jeopardy, (b) serious impairment to bodily function, (c) serious dysfunction of any bodily organ or part, (d) serious disfigurement, or (e) in the case of a pregnant woman, serious jeopardy to the health of the woman or her unborn child

** In the event a determination cannot be made based on the guidance in this document, a referral to a medical director for a determination will be made.

For specific administrative policy details, visit anthem.com/provider/forms and select your state. Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

We strive to advance health equity so everyone has a fair opportunity to be at their healthiest. As we reduce barriers to whole health — physical, behavioral, and social — and personalize the healthcare journey, we can more effectively advance health equity. While focusing on understanding member needs, we actively develop educational tools for care providers.

In recognition of the American Heart Association designating April as National Minority Health Month and Stress Awareness Month, we are featuring two Continuing Medical Education (CME) courses offered in a comprehensive repository of resources on My Diverse Patients. The site is designed to help care providers support the needs of diverse patients and address healthcare disparities.

For the month of April, our featured eLearning experiences are:

• Reducing Health Care Stereotype Threat — course benefits:
  • Understand Health Care Stereotype Threat (HCST) and its implications for multicultural patient groups.
  • Learn to recognize when patients may be experiencing HCST.
  • Explore shifts that you can make to reduce the likelihood that patients from diverse groups will experience HCST.
  • Identify the benefits of reducing HCST to both your patients and your practice.
• Medication Adherence — course benefits:
  • Recognize potential barriers to medication adherence and what influences your patients’ thoughts and emotions.
  • Understand the importance of meeting your patients where they are, and not where you want them to be.
  • Learn how to navigate and break through barriers with C.A.R.E.

These courses are designed for: doctors (CME credit provided); nurses; health professionals; and medical office staff.

Providers can view these courses on their smartphone, tablet, or computer.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

When we receive a corrected claim and it doesn’t have the original claim number, or the original claim number is not correctly entered, we are not able to process it because we’re not able to connect it to the original claim.

1. For providers and their vendors (clearinghouses or billing services) submitting a corrected claim through EDI, we will send you a 277CA EDI Response Report acknowledging that we’ve received the submission, but are not able to process it:

1. In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
2. It is important that you submit proof of timely filing when resubmitting the correction or the original claim so we can ensure the claim is processed according to the timely filing guidelines.
   

2. For providers using Claims Status application on Availity.com, you will not be able to access the corrected claim if it was rejected on the 277CA EDI Response Report:

1. In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
2. It is important that you submit proof of timely filing when resubmitting the correction or the original claim so we can ensure the claim is processed according to the timely filing guidelines.

We’ve also developed a training video that can help you reduce duplicate claims along with a training guide called Making the Claims Process Work for You to help you properly submit a corrected claim. Access the video and download the guide here. Provider information is required to view this training; however, you will only be prompted to enter this information the first time viewing this training.

If you have questions about submitting a corrected claim, reach out to your provider representative or work with your EDI vendor to ensure you are receiving the 277CA Response Report.

Blue High Performance Network^SM (BlueHPN^SM) plans offer access to providers with a record of delivering high-quality, efficient care. Since January 2021, we’ve been collaborating with select healthcare providers across the U.S. to make BlueHPN available to members. Anthem’s mission is to provide affordable, quality healthcare benefits to its members. This in-network only plan helps keep members’ healthcare costs more predictable and manageable.

It is important to know that only in-network care is covered in the BlueHPN. Members in the BlueHPN cannot go to out-of-network doctors or hospitals, except in an urgent and/or emergent situation. If they see a provider for routine or non-urgent care outside the BlueHPN, they will not have coverage.

If you are not participating in the Blue Connection network, you are also not participating in the BlueHPN.

Recognizing BlueHPN members

You and your staff can identify patients enrolled in BlueHPN plans by their member ID card. The BlueHPN name will be prominently displayed on the front of the member ID card, along with the BlueHPN suitcase logo, as shown below:

Eligibility and benefits

BlueHPN does not offer coverage for out-of-network care with the exception of urgent and/or emergent services. This means that BlueHPN patients will receive full benefits from in-network BlueHPN providers.

You can check BlueHPN plan member eligibility and benefits the same way you do today for Blue Connection members — Either submit a HIPAA 270 eligibility and benefit request transaction or contact Provider Services at the number on the back of the member’s ID card.

Referrals to BlueHPN providers

BlueHPN is a comprehensive network that includes a full range of providers, from primary care doctors and specialists to hospitals. Not all healthcare providers are included. To ensure your BlueHPN patients will have full benefits when they need to see a specialist or another healthcare provider, it’s important that you only recommend other BlueHPN healthcare providers. You can use the Find a Doctor/Find Care tool at https://anthem.com/find-care to identify BlueHPN healthcare providers by searching by the member’s ID or alpha prefix. This will help ensure your patients will be receiving care from healthcare providers who are also committed to providing high quality, cost-efficient care. Please make sure you and your office staff are checking network status when referring members to new providers.

Formal physician-to-physician referrals are not required under BlueHPN plans, but out-of-network benefits are limited to urgent and/or emergent services only. That means referrals for non-emergency care to providers outside the BlueHPN network, including durable medical equipment and laboratory services, may be costly for your patients.

Additional network information

More than 60 large metropolitan areas have their own high-performance networks sponsored by local Anthem plans across the country, which gives national employers access to high quality, cost-efficient providers in these geographic areas. The Ohio BlueHPN uses the existing Blue Connection network; therefore, you may see both local patients who have access to Blue Connection through the Anthem plan and patients traveling from other cities where BlueHPN products are offered. Ohio-based employer-sponsored health plans with access to our Ohio High Performance Network refer to the BlueHPN as Blue Connection.

If you are not sure whether your practice is part of the Ohio BlueHPN or Blue Connection, ask your office manager or business office or contact your provider relationship account manager.

Anthem is thrilled to announce ON24^®, a new platform for provider coding education and learning! As a valued Anthem network provider, we invite you to experience the new digital learning platform. You’ll simply register once to gain access to all the following:

• Live webcasts: Learn from instructors and earn continuing education credits.
• On-demand videos: Watch past webcasts at your convenience.
• Interactive modules: Engage in learning activities and practice coding skills at your own pace.
• Coding guides: Download handy references for accurate and complete coding.

Join us on the new digital platform today and take your learning to the next level!

To ensure the best experience, please copy and paste the following registration link into a Google Chrome browser and use the Chrome browser when you access the ON24 platform:

Patient panels are growing more diverse, and needs are becoming more complex. It is important for providers to have the knowledge, resources, and tools to offer culturally competent care. 

Join our Health Equity Director, Angela Abenaim, for a webinar on provider cultural competency and patient engagement on April 4, 2024, at noon ET. 

To register, select the following link:  http://tinyurl.com/mr478xuh

If you have questions about this communication, contact your provider relationship account manager or email ohiomedicaidprovider@anthem.com.

Through genuine collaboration, we can help solve real needs in a sustainable way.

On September 21, 2023, and October 4, 2023, 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. For questions or 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.

Only Electronic Clinical Data Systems (ECDS) reporting will be used for this measure.

Measure description

The percentage of members 45 to 75 years of age who had appropriate screening for colorectal cancer (revised the age range from 50 to 75 years of age to 45 to 75 years of age).

What we are looking for in provider records

Documentation in the medical record indicating the date when the colorectal cancer screening was performed and result or finding of one or more of the following:

• A pathology report that indicates the type of screening (for example, colonoscopy, flexible sigmoidoscopy) and the date the screening was performed
• Documentation of a Fecal Occult Blood Test (FOBT) during the measurement year (2024)
• Documentation of a flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year (January 1, 2020, to December 31, 2024)
• Documentation of a colonoscopy during the measurement year or the nine years prior to the measurement year (January 1, 2015, to December 31, 2024)
• Documentation of a CT colonography during the measurement year or the four years prior to the measurement year (January 1, 2020, to December 31, 2024)
• Documentation of Stool DNA (sDNA) with FIT test during the measurement year or two years prior to the measurement year (January 1, 2022, to December 31, 2024)
• Documentation of members who are diagnosed with colorectal cancer on or before December 31, 2024
• Documentation of a total colectomy on or before December 31, 2024 (documentation must state total, not partial)
• Evidence of hospice services in 2024
• Evidence patient expired prior to January 1, 2025

Helpful hints:

• Recommend colorectal cancer screening to all patients 45 to 75 years of age.
• If a patient is hesitant, discuss different screening options.
• Educate that screening is recommended, even if there is no family history of colon cancer.

Only Electronic Clinical Data Systems (ECDS) reporting will be used for this measure.

Measure description

The percentage of members 45 to 75 years of age who had appropriate screening for colorectal cancer (revised the age range from 50 to 75 years of age to 45 to 75 years of age).

What we are looking for in provider records

Documentation in the medical record indicating the date when the colorectal cancer screening was performed and result or finding of one or more of the following:

• A pathology report that indicates the type of screening (for example, colonoscopy, flexible sigmoidoscopy) and the date the screening was performed
• Documentation of a Fecal Occult Blood Test (FOBT) during the measurement year (2024)
• Documentation of a flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year (January 1, 2020, to December 31, 2024)
• Documentation of a colonoscopy during the measurement year or the nine years prior to the measurement year (January 1, 2015, to December 31, 2024)
• Documentation of a CT colonography during the measurement year or the four years prior to the measurement year (January 1, 2020, to December 31, 2024)
• Documentation of Stool DNA (sDNA) with FIT test during the measurement year or two years prior to the measurement year (January 1, 2022, to December 31, 2024)
• Documentation of members who are diagnosed with colorectal cancer on or before December 31, 2024
• Documentation of a total colectomy on or before December 31, 2024 (documentation must state total, not partial)
• Evidence of hospice services in 2024
• Evidence patient expired prior to January 1, 2025

Helpful hints:

• Recommend colorectal cancer screening to all patients 45 to 75 years of age.
• If a patient is hesitant, discuss different screening options.
• Educate that screening is recommended, even if there is no family history of colon cancer.