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.

Maintaining your online provider directory information is essential for member and healthcare partners to connect with you when needed. Access your online provider directory information by visiting anthem.com then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information we show 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.
• For Roster Automation Standard Template and Roster Automation Rules of Engagement specific training, listen to our recorded webinar here.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your 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, contact Availity Client Services at 800‑AVAILITY.

Please be advised Anthem follows the Ohio Department of Medicaid (ODM) billing guidelines. To ensure accurate reimbursement of all behavioral health claims, Anthem requires the appropriate rendering practitioner modifier. If the rendering practitioner modifier is incorrect or omitted, the claim may be denied or paid at the incorrect rate.

For more information on the billing guidelines, please see the most recent Behavioral Health Provider Reimbursement Manual at medicaid.ohio.gov/resources-for-providers/bh.

If you have any additional questions, please reach out to your provider relationship account management associate or email OhioMedicaidProvider@anthem.com.

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.

Problem: Incidence of Congenital Syphilis (CS) is increasing exponentially nationwide:

• In 2021, a total of 2,677 cases were reported rising to a rate of 74.1 per 100,000 live births.
• From 2012-2021, the number of cases increased 701.5% from 334 to 2,677 cases.

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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.

Patient panels are increasingly diverse, and needs are becoming more complex. It is important for providers to have the knowledge, resources, and tools to offer culturally competent and linguistically appropriate care. Anthem wants to help, as we all work together to achieve health equity.

Cultural competency resources

Here is an overview of the cultural competency resources available on our provider website:

• Cultural Competency and Patient Engagement:
  • A training resource to increase cultural and disability competency to help effectively support the health and health care needs of your diverse patients.
• Caring for Diverse Populations Toolkit:
  • A comprehensive resource to help providers and office staff increase effective communication by enhancing knowledge of the values, beliefs, and needs of diverse patients.
• My Diverse Patients:
  • Offers resources, information, and techniques to help provide the individualized care every patient deserves regardless of their diverse backgrounds. The site also includes learning experiences on topics related to cultural competency and disparities that offer free continuing medical education (CME) credit.
  • Free accessibility from any device (desktop computer, laptop, phone, or tablet), no account or log in required:

To access these resources, go to Serving Diverse Populations | Anthem Blue Cross and Blue Shield > Training Academy > Cultural competency resources

In addition, providers can access Stronger Together, which offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities:

Prevalent non-English languages (based on population data)

Like you, Anthem wants to effectively serve the needs of diverse patients. It’s important for us all to be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the top fifteen non-English languages spoken by 5 percent or 1,000 individuals in Ohio. (Source: American Community Survey, 2023 American Community Survey 1-Year Estimates, Table B16001, generated July 2023.)

Language support services

As a reminder, Anthem provides language assistance services for our members with limited English proficiency (LEP) or hearing, speech, or visual impairments. Please see the Provider Manual for details on the available resources and how to access them. In addition, the cultural competency resources shared above provide guidance on communicating and serving diverse populations effectively.

Effective May 1, 2024, Anthem will upgrade to the 28th edition of MCG Care Guidelines for the following modules:

• Behavioral Health Care (BHG)
• Inpatient & Surgical Care (ISC)
• General Recovery Care (GRG)
• Recovery Facility Care (RFC)
• Chronic Care (CCG)
• Ambulatory Care (AC)
• Home Care (HC)

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

Measure description: The purpose is to document the percentage of adults, 66 years and older, who had each of the following during the measurement year:

• Medication Review
• Functional Status Assessment
• Pain Assessment

What we are looking for in provider records:

• Medication Review: Members with both of the following during the same visit in the measurement year:
  • At least one medication review by a prescribing practitioner, or clinical pharmacist, and the date it was performed, along with the presence of a medication list in the medical record.
  • Notation that the member is not taking any medication, and the date it was noted.
• Functional Status Assessment: Members who had at least one Functional Status Assessment during the measurement year (2024):
  • Notation of Activities of Daily Living (ADL) were assessed, or that at least five of the following were assessed (bathing, dressing, eating, transferring, toileting, walking).
  • Notation that Instrumental Activities of Daily Living (IADL) were assessed, or at least four of the following were assessed (shopping for groceries, driving or using public transportation, using the telephone, cooking or meal prep, housework, home repair, laundry, taking medicines, handling finances).
  • Result of assessment using a standardized functional status assessment tool.
• Pain Assessment: Members who had at least one Pain Assessment during the measurement year:
  • Documentation that the patient was assessed for pain (positive or negative).
  • Result of an assessment using a standardized pain assessment tool or scale.
• Evidence of hospice services in 2024.
• Evidence patient expired prior to January 1, 2025.

Helpful hints:

• Encourage at least yearly visits. Older adults, many of whom have multiple, complex chronic conditions, require regular care addressing their physical, mental, cognitive, and behavioral needs.
• Most older adults take multiple drugs. A medication review to check safety and potential savings is recommended.
• Many older adults believe that pain is a normal part of aging. Regular screening for pain is recommended. Utilization of a standardized pain tool may assist in evaluating and adjusting care.
• Document, at least annually, ADL or IADL assessment:
  • Use the appropriate codes for Medication Review, Functional Status Assessment, and Pain Assessment whenever possible.

HEDIS^® (Healthcare Effectiveness Data Information Set) is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

HEDIS 2024 documentation for Controlling High Blood Pressure (CBP)

Measure description: The percentage of members 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose BP (blood pressure) was adequately controlled (< 140/90 mm Hg) during the measurement year.

What we are looking for in provider records:

• Last BP documented in 2024 regardless of reading

Documentation below could be used to exclude the patient:

• Evidence of hospice or palliative services in 2024
• Evidence patient expired in 2024
• Documentation of pregnancy any time during 2024
• Documentation of end stage renal disease, dialysis, nephrectomy, or kidney transplant any time in the member’s history on or prior to December 31, 2024

Helpful hints:

• Take BP at every visit.
• Take a second BP before the end of the office visit if the BP was ≥ 140/90.
• Counsel on healthy habits for managing high blood pressure.
• BP's cannot be taken:
  • On the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests.
  • From member-reported BPs if taken with a non-digital device such as with a manual blood pressure cuff and a stethoscope.

HEDIS 2024 documentation for Statin Therapy for Patients with Cardiovascular Disease (SPC)

Measure description: The percentage of males 21 to 75 years of age and females 40 to 75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and received statin therapy and remained on the statin for at least 80% of the treatment period.

What we are looking for in provider records

Documentation in the medical record indicating the date the patient was dispensed at least one high-intensity or moderate-intensity statin medication during the measurement year.

All of the following must be present with a dispensed medication:

• Name of the drug (generic or brand name)
• Strength/dose
• Route
• Date when the medication was dispensed, filled, or shipped to the patient

Documentation below could be used to exclude the patient:

• Evidence of hospice services in 2024
• Evidence patient expired in 2024
• Evidence patient received palliative care in 2024
• Evidence patient was pregnant or underwent IVF treatment in 2023 or 2024
• Evidence of ESRD or dialysis in 2023 or 2024
• Evidence of cirrhosis in 2023 or 2024
• Evidence of a dispensed prescription for Clomiphene in 2023 or 2024
• History of myalgia, myositis, myopathy, muscle pain or rhabdomyolysis documented in 2024

Helpful hints:

• Recommended that if the patient has a reaction to statins, record the specific reaction (myalgia, myositis, myopathy, muscle pain or rhabdomyolysis) in the patient’s chart annually.
• Recommended to also include drug quantity and directions with the dispensed medication so that days’ supply can be calculated for the measure.

HEDIS^® (Healthcare Effectiveness Data Information Set) is a widely used set of performance measures developed and maintained by NCQA (National Committee for Quality Assurance). These are used to drive improvement efforts surrounding best practices.

HEDIS 2024 Documentation for Cervical Cancer Screening (CCS)

Measure description: The percentage of women 21 to 64 years of age who were screened for cervical cancer using either of the following criteria:

• Women 21 to 64 years of age who had cervical cytology performed within the last 3 years.
• Women 30 to 64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
• Women 30 to 64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) co-testing within the last 5 years.

What we are looking for in provider records:

• Documentation in the medical record indicating the date when the cervical cytology was performed and result or finding (2022 to 2024)
• Documentation in the medical record indicating the date when the hrHPV test was performed and result or finding (2020 to 2024)
  • Documentation of HPV test can be counted as hrHPV testing along with result or finding
• Documentation of complete, total, or radical hysterectomy (abdominal, vaginal, or unspecified anytime in the member’s history through 12/31/2024).
• Documentation of vaginal hysterectomy (anytime in the member’s history through 12/31/2024).
• Evidence of hospice services in 2024
• Evidence patient expired in 2024

Please note: Documentation of hysterectomy alone does not meet the criteria, because it is not sufficient evidence that the cervix was removed.

Helpful Hints:

• Educate patient on importance of regular cervical cancer screening.
• OB/GYN and PCP should share cervical cancer screening results.
• Document date and result of member reported cervical cancer or HPV screenings.

HEDIS 2024 Documentation for Prenatal and Postpartum Care (PPC)

Measure description: The percentage of deliveries of live births on or between October 8 of the year prior to the measurement year (2023) and October 7 of the measurement year (2024). For these women, the measure assesses the following facets of prenatal and postpartum care.

• Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment with the Healthy Blue plan.
• Postpartum Care. A postpartum visit on or between 7 and 84 days after delivery.

What we are looking for in provider records for a prenatal care visit with a PCP or OB/GYN or other prenatal practitioner:

• Documentation in the medical record for deliveries of live births on or between October 8 of the year prior to the measurement year (2023) and October 7 of the measurement year (2024) must include a note indicating the date when the prenatal care visit occurred and evidence of one of the following:
  • Documentation indicating the woman is pregnant or references to the pregnancy for example:
    • Documentation in a standardized prenatal flow sheet
    • Documentation of LMP, EDD, or gestational age
    • Documentation of a positive pregnancy test result
    • Documentation of gravidity and parity
    • Documentation of complete obstetrical history
    • Documentation of prenatal risk assessment and counseling/education
  • Documentation of a basic physical obstetrical examination that includes auscultation for fetal heart tone, or pelvic exam with obstetric observations, or measurement of fundus height (a standardized prenatal flow sheet may be used).
  • Evidence that a prenatal care procedure was performed such as:
    • Screening test in the form of an obstetrical panel (must include all the following: hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing)
    • Torch antibody panel alone
    • A rubella antibody test/titer with an Rh incompatibility (ABO/blood typing)
  • Ultrasound of a pregnant uterus
  • Evidence of nonlive birth
  • Evidence of hospice services in 2024
  • Evidence patient expired in 2024

What We Are Looking For In Provider Records For A Postpartum Care Visit With A PCP Or OB/GYN or other prenatal practitioner:

• Documentation in the medical record must include a note indicating the date when a postpartum visit occurred and one of the following:
  • Pelvic exam
  • Evaluation of weight, BP, breasts, and abdomen
  • Notation of postpartum care
  • Perineal or cesarean incision/wound check
  • Screening for depression, anxiety, tobacco use, substance use disorder, or preexisting mental health disorders
  • Glucose screening for women with gestational diabetes
  • Documentation of any of the following: Infant care or breastfeeding, resumption of intercourse, birth spacing or family planning, sleep/fatigue, resumption of physical activity, attainment of healthy weight
• Evidence of nonlive birth
• Evidence of hospice services in 2024
• Evidence patient expired in 2024

Helpful Hints:

• Educate members on the importance of timely prenatal care.
• Schedule postpartum visit during final prenatal appointment or prior to discharge from hospital.
• Reach out to members to remind them of scheduled prenatal and postpartum appointments.

Cervical cancer is one of the most preventable and successfully treatable forms of cancer if it is detected and diagnosed early. Although Cervical Cancer Screening (CCS) has dramatically reduced new cases and deaths from the disease over the past 50 years, a National Cancer Institute study found that the percentage of people who are overdue for screening has increased from 14% in 2005 to 23% in 2019.¹  

What can I do?

One of the most important things you can do is to recommend a routine CCS for your patients, per preventive care guidelines published by the U.S. Preventive Services Task Force and the National Institutes of Health: every three years for people 21 to 64 years with a cervical cytology (Pap test) and every five years for people 30 to 64 years of age with a cervical high-risk human papillomavirus (hrHPV) test or hrHPV and Pap co-testing. People who have been vaccinated against HPV should still be screened for cervical cancer.

How can I encourage my patients to get a CCS?

When encouraging your patients to get their cervical cancer screening, be sensitive and use culturally appropriate messaging. Regardless of a person’s background, many people might be sensitive or embarrassed to discuss or have the screening. High levels of modesty among some people might create barriers in their interactions, especially when there is a lack of cultural congruence. As a result, encouraging your patients to be screened for cervical cancer may be part of a continued conversation conducted with your patients in their preferred language and in simple terms until they feel more comfortable and understand the benefits of completing the screening.

It is important to start these conversations early in the year so the appropriate screenings can be completed in a timely manner before the end of the calendar year.

How can I report data for HEDIS?

NCQA strongly encourages the electronic collection of CCS HEDIS^® data. Data sources for HEDIS Electronic Clinical Data System (ECDS) may come from the electronic health record (EHR)/personal health record (PHR) and administrative data from claims. ECDS reporting can reduce the measurement and data exchange burden on your practices and can be more efficient and more sensitive. Contact your Healthy Blue provider relationship management representative for additional details and questions.

Cervical cancer screening HEDIS data may also be collected through medical record review. As you review and screen your patients based on the guidance and their personal risk factors, be sure to clearly document the screening in your patient’s medical chart and in submitted claims. Additionally, be sure to clearly document any applicable exclusions such as an absence of a cervix, a hysterectomy, or assignment of male at birth.

In addition, it is becoming increasingly important to identify the population served by race, ethnicity, preferred language, and socioeconomic status to help measure and address health disparities.

Background

The U.S. Preventive Services Task Force (USPSTF) has joined other medical organizations in recommending that members of average risk for breast cancer begin routine screening at 40 years of age. Breast cancer screening in the form of screening mammography is recommended by the USTPSTF every other year beginning at age 40 and continuing until the age of 74.

Research has shown that more members are being diagnosed with breast cancer in their 40s.¹ Members who are diagnosed with early-stage breast cancer may be cured with fewer and/or less intense treatment and surgeries.

African American/Black members and members of Ashkenazi Jewish ancestry are at higher risk and are more likely to be diagnosed in their 40s with more aggressive breast cancer as referenced by the Breast Cancer Research Foundation (BCRF) and the American College of Radiology. However, there is a risk of more false positives among younger members who might have more dense breast tissue, making it harder to distinguish between normal and suspicious breast tissue on a screening mammogram.²

One option for members with dense breasts and others with a higher-than-normal risk for breast cancer is 3D mammography. Studies have found that 3D mammography reduces the chances of needing to return for more images when compared to a standard 2D mammogram. It also appears to find more breast cancers, and several studies have shown it can be helpful in members with more dense breasts.

How will NCQA collect data for HEDIS?

NCQA requires Breast Cancer Screening (BCS) HEDIS® data to be collected electronically. Data sources for HEDIS Electronic Clinical Data System (ECDS) may come from the electronic health record (EHR)/personal health record (PHR) and administrative data from claims. ECDS reporting can reduce the measurement rate and data exchange burden on your practices and may be more efficient and sensitive. Contact your provider relationship management representative for more information and assistance with establishing this connection.

As you review and screen your patients based on the guidance and their personal risk factors, be sure to clearly document the screening in your patient’s medical chart and in submitted claims, as well as clearly document any applicable exclusions such as bilateral or unilateral mastectomy or care-prohibitive conditions like living in a long-term care institution or advanced illnesses.

In addition, it is becoming increasingly important to identify the population served by race, ethnicity, preferred language, and socioeconomic status to help measure and address health disparities. MyDiversePatients.com and communityresources.elevancehealth.com are free resources that might help you with your diverse patient population.

Impact to patients

Unequal access to and utilization of screening mammography often leads to delays in the detection, diagnosis, and treatment, thus amplifying disparities in patient outcomes.³ Therefore, it is important to meet your patients where they are when discussing screening options; addressing barriers to care including beliefs, concerns, and issues of access and availability; and scheduling timely appointments and follow-ups.

Questions?

We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities. Contact your provider relationship management representative for additional details and questions.

As you know, annual visits help establish and enhance a strong partnership with your patients which is essential in getting the best healthcare outcomes. Preventive care visits give you an opportunity to:

• Check in with your patients when they are not sick.
• Establish a baseline and monitor health.
• Learn about your patient’s family history, unique risk factors, and concerns.
• Ensure that appropriate screenings and tests are completed.
• Understand social and cultural factors that might impact their physical and mental health and subsequent disease management.
• Educate, counsel, and address health issues and manage chronic conditions.

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