The Ohio Department of Medicaid (ODM) resumed Provider Revalidations in June 2023. It is imperative that providers who are due for revalidation take immediate action as terminations will resume on January 23, 2024.

All providers are subject to either three (3) or five (5) year time-limited provider agreements. Prior to termination, letters are both mailed and emailed 120 days, 90 days, 60 days, and a final notice at 30 days. Providers who do not submit their revalidation could experience termination at the state level, which would cascade to the Managed Care Entities (MCEs) causing claim denials as a non-participating provider. Emails will come from OHPNM@maximus.com.

Revalidations notices are posted in the Provider Network Management (PNM) module and can be accessed in the Correspondence folder. Providers will also see a “Begin Revalidation” option in the PNM Enrollment Action Selection 120 days prior to the Medicaid Agreement end date. Providers can locate this under the “Manage Application” then “Enrollment Actions” option within the provider file. Click the Revalidation/Reenrollment Quick Reference Guide for step-by-step instructions.

Providers who need technical assistance can contact ODM’s Integrated Help Desk at 800-686-1516 and follow the prompts for Provider Enrollment or email IHD@medicaid.ohio.gov.

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website.

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, then at the top of the webpage, select Find Care.

Submit updates and corrections to your directory information by following the instructions on the Provider Maintenance Form online. Update options include:

• add/change an address location
• name change
• phone/fax number change
• provider leaving a group or a single location
• closing a practice location

The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current.

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

Anthem providers who administer vaccines to children through 18 years of age should enroll in the VFC program. Anthem will reimburse only the administration fee for any vaccine available through the VFC program.

When submitting claims for vaccines and/or toxoids covered under the VFC program:

• Providers should bill CPT^® 90460 for the administration.
• When administering more than one vaccine, providers should bill the number of vaccines as units:
  • For example, if two vaccines are administered the claim should be billed with an E/M code, two individual vaccines and/or toxoids, and two units of 90460.
• Anthem does not require the SL modifier to be appended.

If you have questions regarding Vaccines for Children, visit the following:

• Ohio Department of Health’s website:
  • Vaccines for Children (VFC) | Ohio Department of Health
• ODM Guidance:
  • Microsoft Word - MAL VFC Policy v2.docx (ohio.gov)
• Anthem VFC policy:
  • OH_CAID_RP_VaccinesforChildren(VC)Program.pdf (anthem.com)

Per the Ohio Department of Medicaid, all hospice claims billed on the UB04 form must be billed with the appropriate county code to be reimbursed correctly. Failure to include the correct county code will result in denial of the claim.

The county code should be entered in the Value Code section of the UB04 form. The list of correct county codes can be found here. For additional information regarding hospice reimbursement, please refer to OAC 5160-56-06.

As of November 1, 2023, Anthem’s system configuration has been updated to allow providers who bill on the UB04 form to bill type of bill 81x or 82x for HCPCS codes T2042-T2045, based on the type of hospice provider billing these services.

If you have questions regarding hospice billing, please reach out to your Provider Relationship Account Management consultant at Ohiomedicaidprovider@anthem.com or refer to our provider website for additional information.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value 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.

Effective June 1, 2024, Anthem will transition from CG-BEH-02 (Adaptive Behavioral Treatment) and MCG W0153 (Behavioral Health Care Applied Behavioral Analysis), to MCG B-806-T Behavioral Health Care Applied Behavioral Analysis (Original MCG Guideline), for medical necessity/clinical appropriateness reviews.

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

Summary

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.

Effective April 1, 2024, Anthem will transition to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for medical necessity/clinical appropriateness reviews for requested interventions:

• Genetic Testing Guidelines:
  • Carrier Screening in the Prenatal Setting and Preimplantation Genetic Testing
  • Cell-free DNA Testing for the Management of Cancer
  • Chromosomal Microarray Analysis
  • Genetic Testing for Inherited Conditions
  • Hereditary Cancer Testing
  • Pharmacogenomic Testing
  • Polygenic Risk Scores
  • Prenatal Testing using cell-free DNA
  • Somatic Tumor Testing
  • Whole Exome Sequencing and Whole Genome Sequencing

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross and Blue Shield patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes. Select here for our conversation guide for tips on how to engage patients who may be from a culture different from your own.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

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 associate or call Provider Services on the back of your patient’s member ID card.

Through our efforts, we can help deliver high quality, equitable healthcare.

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross and Blue Shield patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

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 associate or call Provider Services at 844-912-1226.

Through our efforts, we can help deliver high quality, equitable healthcare.

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross and Blue Shield patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes. Select here for our conversation guide for tips on how to engage patients who may be from a culture different from your own.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

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 associate or call Provider Services on the back of your patient’s member ID card.

Through our efforts, we can help deliver high quality, equitable healthcare.