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.

A new Sandata Mobile Connect (SMC) application was released in app stores in July 2023 for electronic visit verification (EVV) care providers. This is an enhanced app with a focus on the end user experience. In addition to an updated look and feel that simplifies navigation, the update includes a simplified login process and efficient reset password process. For care providers using their own devices, the old app will be available until June 30, 2024. Between now and then, no updates will be available for the old app, so be sure to download the new one.

The new SMC app can be downloaded in either Android or Apple stores. Information on the new SMC app is available online at Sandata on Demand.

Please reach out to the Ohio Department of Medicaid at odmevv@sandata.com if you have EVV questions or suggestions for future EVV newsletter articles.

When using or billing air ambulance services, please remember:

• To facilitate timely and accurate claim processing of air ambulance services, include the facility’s record (emergency department record, or if an inpatient, the discharge or transfer summary) along with your run sheet. Providing this information will greatly facilitate timely review of medical necessity.
• Regarding the practice of using air ambulance services solely because use of ground transport would temporarily deplete local area Emergency Medical Services (EMS) availability, while EMS availability is always a local EMS concern, please understand that this reason alone does not meet medical necessity criteria for our members.
• Lastly, excess miles flown to keep a patient within the sending facility’s health system, when another closer capable receiving hospital has capacity, does not meet medical necessity criteria. Determination of medical necessity, including mode of transportation, is determined in accordance with Anthem’s clinical guidelines and medical necessity criteria. These determining guidelines include only approving the distance to the closest capable facility with capacity.

Taking the above into consideration will result in faster processing and lower denials of your air ambulance service claims. For your reference, see CG-ANC-04 Ambulance Services: Air and Water.

If you have questions, contact your local provider relationship management representative.

We look forward to working together to achieve improved outcomes.

Effective January 1, 2024, Northrop Grumman Corporation will contract with Quantum Health to perform health care navigation and care coordination services for their active member population only. As part of this contract, Quantum Health will support member healthcare and benefit needs, including member and care provider services and medical utilization review and submission to Anthem. Northrup Grumman Corporation active members may be identified by the group number beginning with 174022 on the member ID card. A sample ID card is below.

Anthem will remain responsible for claims adjudication and certain services as described below. Anthem will also remain the administrator of Behavioral Health Utilization Management, inclusive of retrospective reviews, and Case Management.

Quantum Health is the point of contact for member and care provider inquiries.

Quantum Health will be the point of contact for members and healthcare providers to verify:

• Benefit coverage information.
• Eligibility inquiries.
• Prior-authorization submission and review (as stated above).

Anthem will remain the point of contact for care providers for the following:

• Behavioral Health Utilization Management, inclusive of retrospective reviews and Case Management.
• Quantum Health will redirect care provider questions/inquiries to Anthem or local Blue for Medical and Behavioral Health Services for the following:
  • Care provider contracting.
  • Remittances.
  • Fee schedule.
  • Value Based Programs.
  • Network status.
  • Demographic information updates.

Sample Member ID card

Based on the information outlined above, there are changes in the Member Services and Provider Services/pre-certification phone numbers. These two new phone numbers are located on the back of the Medical Member ID card.

If you have any questions, please contact your provider relationship management representative. We are committed to a future of shared success.

Maintaining your online provider directory information is essential for members and healthcare partners to connect with you when needed. Please review your information frequently and let us know if any of your information we show in our online directory has changed.

Submit updates and corrections to your directory information by following the instructions on our Provider Maintenance webpage. Online update options include:

• Adding/changing an address location.
• Changing a name.
• Changing a phone/fax number.
• Provider leaving a group or a single location.
• Closing a practice location.

The Consolidated Appropriations Act (CAA) of 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Reviewing your information helps us ensure your online provider directory information is current.

According to ICD-10-CM guidelines for coding and reporting, it is inappropriate to bill certain diagnosis codes as a primary or first listed diagnosis. Instead, these codes should always be sequenced as a secondary or subsequent diagnosis. Effective for claims processed on or after April 1, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny:

• Professional claims submitted on a CMS-1500 form that report inappropriate primary diagnosis codes as the only diagnosis on the claim or claim line; and facility claims submitted on a CMS-1450 form that report inappropriate primary diagnosis codes as the principal diagnosis or only code on the claim.

As provided by ICD-10-CM guidelines, inappropriate primary diagnosis codes include but are not limited to:

• External Cause Codes of Morbidity (V, W, X, or Y codes [ICD-10-CM]) describes an environmental event causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. These codes are intended to be supplemental to the principal or primary diagnosis code indicating the nature of the condition. In addition, based on this guideline, a diagnosis code of external causes cannot be the only diagnosis on the claim.
• Manifestation Codes: Certain conditions contain both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD Manual coding guidelines have established a coding convention that requires the underlying condition to be sequenced first followed by the manifestation. According to the ICD Manual coding guidelines, the primary, first listed, or principal diagnosis cannot be a manifestation code. In addition, based on this guideline, a manifestation code cannot be the only diagnosis on the claim.
• Sequela Codes: a sequela (7th character "S") code cannot be listed as the primary, first listed, or principal diagnosis on a claim. Coding of a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by the sequela (7th character "S") code. In addition, based on this guideline, a sequela (7th character "S") code cannot be the only diagnosis on a claim.
• Secondary Diagnosis: According to ICD guidelines, a secondary diagnosis code can only be used as a secondary diagnosis. Since these codes are only for use as supplemental codes, any procedure or service received with a secondary diagnosis code as the principal or primary diagnosis will be denied as incorrectly coded.

EOB Message: We denied this service since it was reported incorrectly. Per CMS (Federal) correct coding guidelines, specific Supplementary Classification ICD-10 codes cannot be used as the primary diagnosis or as the only diagnosis on the claim.

According to ICD-10-CM guidelines for coding and reporting, it is inappropriate to bill certain diagnosis codes as a primary or first listed diagnosis. Instead, these codes should always be sequenced as a secondary or subsequent diagnosis. Effective for claims processed on or after February 1, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny:

• Professional claims submitted on a CMS-1500 form that report inappropriate primary diagnosis codes as the only diagnosis on the claim or claim line; and facility claims submitted on a CMS-1450 form that report inappropriate primary diagnosis codes as the principal diagnosis or only code on the claim.

As provided by ICD-10-CM guidelines, inappropriate primary diagnosis codes include but are not limited to:

• External Cause Codes of Morbidity (V, W, X, or Y codes [ICD-10-CM]) describes an environmental event causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. These codes are intended to be supplemental to the principal or primary diagnosis code indicating the nature of the condition. In addition, based on this guideline, a diagnosis code of external causes cannot be the only diagnosis on the claim.
• Manifestation Codes: Certain conditions contain both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD Manual coding guidelines have established a coding convention that requires the underlying condition to be sequenced first followed by the manifestation. According to the ICD Manual coding guidelines, the primary, first listed, or principal diagnosis cannot be a manifestation code. In addition, based on this guideline, a manifestation code cannot be the only diagnosis on the claim.
• Sequela Codes: a sequela (7th character "S") code cannot be listed as the primary, first listed, or principal diagnosis on a claim. Coding of a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by the sequela (7th character "S") code. In addition, based on this guideline, a sequela (7th character "S") code cannot be the only diagnosis on a claim.
• Secondary Diagnosis: According to ICD guidelines, a secondary diagnosis code can only be used as a secondary diagnosis. Since these codes are only for use as supplemental codes, any procedure or service received with a secondary diagnosis code as the principal or primary diagnosis will be denied as incorrectly coded.

EOB Message: We denied this service since it was reported incorrectly. Per CMS (Federal) correct coding guidelines, specific Supplementary Classification ICD-10 codes cannot be used as the primary diagnosis or as the only diagnosis on the claim.

Ex-Codes: 00V16 and v16

If you have questions about this communication or need assistance, contact Provider Services at 844-912-1226.

Effective January 1, 2024, most specialty prescriptions will transfer to BioPlus, CarelonRx specialty pharmacy that services Anthem members. This migration is taking place in multiple waves throughout the next year.

What happens next?

• If you have patients affected by this pharmacy change, BioPlus will contact you to request new prescriptions, refills, or prior authorizations. You will also receive a letter from CarelonRx.
• Current specialty prescriptions with open refills will automatically transfer to BioPlus.
• Impacted patients will receive a letter and a phone call, explaining this transition.
• There is nothing you or your patients need to do except speak with BioPlus when they call.

What is the benefit to you and your patients?

CarelonRx and BioPlus work together to deliver patients an unparalleled level of high-tech, high-touch service that focuses on their whole health.

As a care provider, you will receive fast and easy benefit confirmation and prior authorizations for expedited time to therapy. BioPlus also offers comprehensive infusion services that include dedicated nurse concierges, patient advocates, and disease-specific education and clinical reminders.

If you have any questions, please call your Anthem representative. We’re here to help.

It’s time for some of your patients to renew their Medicaid benefits. As states begin to recommence Medicaid renewals, we want to ensure you have the information needed to help your Medicaid patients renew their healthcare coverage. Some patients have never had to renew their coverage at all, while other patients may have forgotten the process entirely.

We’re here to help.

What steps do my patients need to take?

• Ready: Patient gets their documents ready.
• Set: Patient ensures their form is all set.
• Renew: Patient sends renewal form:
  • Via web: benefits.ohio.gov
  • Via phone: 844-640-6446
  • Via mail: Mail to your local CDJFS office

What if I need assistance?

Availity Chat with Payer 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.

The Health Care Networks team for Anthem Blue Cross and Blue Shield (Anthem) will host provider orientations during the winter of 2024. These orientations will cover everything providers need to know about working with Anthem.

Orientation dates:

• Wednesday, January 17, 2024, at 3 p.m. ET
• Tuesday, March 26, 2024, at 11 a.m. ET

To register for any of the dates above, select here.

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

We’re committed to ensuring every eligible member receives an Annual Planned Visit (APV) this year and appreciate your help to make this happen.

Tips to help your practice boost APV rates early in the year:

• Members do not need to wait a full calendar year between wellness visits. Coverage resets on January 1 and we encourage all eligible members to schedule wellness visits with their care provider.

• Outreach to members within their first year of Medicare to schedule their Welcome to Medicare Exam (or Initial preventive physical exam, IPPE) and explain its importance.
• Know who your hard-to-engage members are and start contacting them earlier in the year.
• The Provider News Quality Management page is a great resource to learn more about optimizing your quality scores and staying up to date on our latest communications.
• While everyone is eligible for an annual wellness visit, some of the topics discussed during the visit may require additional follow-up to close a care gap. Be aware of scheduling lead times with other facilities for certain visit types, like mammograms, DEXA scans, and colonoscopies. Try to prioritize these patients who need these services for wellness visits.
• The AWV is a hands-off appointment that can be conducted via telehealth. This may be a great option for patients with mobility or access issues or compromised immune systems. See our guide for how to facilitate these exams via telehealth here.

APV coding guidelines:

*Verify member’s benefits and eligibility prior to scheduling

HEDIS^® 2023 documentation for Blood Pressure Control for Patients With Diabetes (BPD)

Measure description

The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose blood pressure (BP) was adequately controlled (< 140/90 mm Hg) during the measurement year.

What we are looking for in provider records:

• Last BP documented in 2023 regardless of reading

• Evidence of hospice or palliative services in 2023
• Evidence patient expired in 2023
• Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes

Helpful hints:

• Take a second BP at the end of the office visit if initial BP was > 140/90 and document new BP.
• Consider taking BP at every visit.

• Remind medical staff not to round results. Results must be precise (such as, 139/89).
• Compliance is less than 140/90.

• Counsel on healthy habits for managing high blood pressure.
• Encourage antihypertensive and other medication adherence.
• Member reported BPs during a telehealth visit are acceptable and should be documented in the members health record
• Review diabetic services needed at each office visit.
• For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).

HEDIS 2023 documentation for Hemoglobin A1c Control for Patients With Diabetes (HBD)

Measure description

The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose hemoglobin A1c (HbA1c) was at the following levels during the measurement year:

• HbA1c control (< 8.0%)
• HbA1c poor control (> 9.0%)

What we are looking for in provider records:

• Last HbA1c documented in 2023 regardless of result

• Evidence of hospice or palliative services in 2023
• Evidence patient expired in 2023
• Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes

Helpful hints:

• Counsel on healthy habits for managing diabetes.
• If appropriate, set an HbA1c goal of less than 7%.

• Encourage timely HbA1c testing.

• Encourage medication adherence.
• Encourage continuous glucose monitoring.

• In progress notes when documenting HbA1c value include date the test was performed.
• Review diabetic services needed at each office visit.

• For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).

HEDIS 2023 documentation for Eye Exam for Patients With Diabetes (EED)

Measure description

The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) who had a retinal eye exam.

What we are looking for in provider records:

• Evidence of a retinal eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or year prior with results
• Bilateral eye enucleation any time during the member’s history

• Evidence of hospice or palliative services in 2023
• Evidence patient expired in 2023
• Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes

Helpful hints:

• Refer patients to an optometrist or ophthalmologist for a dilated or retinal eye exam annually.
• Fundus/retinal photography is considered imaging and is eligible for use, must be dated and interpreted by an eye care professional.
• Counsel on healthy habits for managing diabetes.
• In progress notes when documenting a retinal eye exam include the name of eye care provider or optometrist/ophthalmologist credentials, date performed, and result.
• Encourage medication adherence.
• Review diabetic services needed at each office visit.
• For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).

HEDIS^® 2023 documentation for Blood Pressure Control for Patients With Diabetes (BPD)

Measure description

The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose blood pressure (BP) was adequately controlled (< 140/90 mm Hg) during the measurement year.

What we are looking for in provider records:

• Last BP documented in 2023 regardless of reading

• Evidence of hospice or palliative services in 2023
• Evidence patient expired in 2023
• Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes

Helpful hints:

• Take a second BP at the end of the office visit if initial BP was > 140/90 and document new BP.
• Consider taking BP at every visit.

• Remind medical staff not to round results. Results must be precise (such as, 139/89).
• Compliance is less than 140/90.

• Counsel on healthy habits for managing high blood pressure.
• Encourage antihypertensive and other medication adherence.
• Member reported BPs during a telehealth visit are acceptable and should be documented in the members health record
• Review diabetic services needed at each office visit.
• For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).

HEDIS 2023 documentation for Hemoglobin A1c Control for

Patients With Diabetes (HBD)

Measure description

The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose hemoglobin A1c (HbA1c) was at the following levels during the measurement year:

• HbA1c control (< 8.0%)
• HbA1c poor control (> 9.0%)

What we are looking for in provider records:

• Last HbA1c documented in 2023 regardless of result

• Evidence of hospice or palliative services in 2023
• Evidence patient expired in 2023
• Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes

Helpful hints:

• Counsel on healthy habits for managing diabetes.
• If appropriate, set an HbA1c goal of less than 7%.

• Encourage timely HbA1c testing.

• Encourage medication adherence.
• Encourage continuous glucose monitoring.

• In progress notes when documenting HbA1c value include date the test was performed.
• Review diabetic services needed at each office visit.

• For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).

HEDIS 2023 documentation for

Eye Exam for Patients With Diabetes (EED)

Measure description

The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) who had a retinal eye exam.

What we are looking for in provider records:

• Evidence of a retinal eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or year prior with results
• Bilateral eye enucleation any time during the member’s history

• Evidence of hospice or palliative services in 2023
• Evidence patient expired in 2023
• Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes

Helpful hints:

• Refer patients to an optometrist or ophthalmologist for a dilated or retinal eye exam annually.
• Fundus/retinal photography is considered imaging and is eligible for use, must be dated and interpreted by an eye care professional.
• Counsel on healthy habits for managing diabetes.
• In progress notes when documenting a retinal eye exam include the name of eye care provider or optometrist/ophthalmologist credentials, date performed, and result.
• Encourage medication adherence.
• Review diabetic services needed at each office visit.
• For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).

With the New Year, people often make resolutions or set goals for themselves. Let this be the year that you see all your patients for their annual preventive care visit.

As you know, annual visits are mutually beneficial to both you and your patients. These visits help establish a strong provider-patient relationship, which is essential in achieving the best healthcare outcomes. Establishing baseline measurements, knowing family history, and understanding unique risk factors and concerns can help you provide appropriate and culturally sensitive guidance on reducing risk for disease. Patients who report positive interactions with their healthcare providers demonstrate greater self-management and quality of life, as well as a reduction in emergency room visits and inpatient admissions.

Start the new year on the right foot:

• If you are seeing a patient for the first time, ask them to have their previous provider send their medical records.
• Begin reaching out to harder to engage patients early in the year.
• Reach out to patients at least [two months] prior to their birthday to schedule an appointment.
• Remind patients of their upcoming appointment via phone, text, and/or email as it approaches to avoid no shows.
• Remember to verify your patient’s benefits and eligibility prior to scheduling appointments.
• Screen for social needs that may be a barrier for care.
• If you need to refer a patient for a test or to a specialist, manage their expectations and follow-up with both the patient and provider.

Make sure to get the credit you deserve by reporting all services provided and use all appropriate billing codes:

• The annual visit service is coded based on the patient’s age.
• Use CPT^® Category II codes with your claims encounters to maximize HEDIS^® data collection and reduce the burden of HEDIS medical record review. Go to the American Medical Association website at ama-assn.org for a complete list of CPT codes.
• If you are using an electronic medical record system, consider electronic data sharing with the health plan to capture all coded elements to facilitate HEDIS data collection and more accurate gap in care reports.