Moving Toward Equity in Asthma Care
Anthem Blue Cross and Blue Shield is committed to achieving health equity in asthma outcomes with diverse populations. As part of this commitment, we offer an online training, Moving Toward Equity in Asthma Care. This course is accessible from any mobile device or computer and provides one continuing medical education credit at no cost to you. Visit www.mydiversepatients.com.

 Asthma Medication Ratio (AMR) HEDIS^® measure
The National Committee for Quality Assurance (NCQA) is also working to identify and reduce disparities in care. As part of this effort, race and ethnicity stratifications were added to the AMR HEDIS metric this year. The AMR metric measures the percentage of members 5 to 64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.5 or greater during the measurement year.

 Did you know: 

• Hispanics and African Americans with asthma are less likely to take daily controllers and are more likely to visit the ER and be hospitalized for asthma-related conditions than non-Hispanic whites? ¹
• Asian Americans are more likely to die from asthma than non-Hispanic whites?²
• Appropriate medication management for patients with asthma could reduce the need for rescue medication — as well as the costs associated with ER visits, inpatient admissions, and missed days of work or school?

 Helpful tips:  

• Ensure at least half of the medications dispensed to treat asthma are controller medications throughout the measurement period. 
• Talk to the patient about the importance of controller medication compliance, and not to use rescue medications on a regular basis, unless part of asthma action plan.
• Encourage patients to fill their prescriptions on a regular schedule rather than waiting till they are symptomatic.
• Create a written asthma action plan in language the patient understands, and schedule follow-up appointments with patients. Ask patients questions to assess asthma control, adherence to the action plan, and identify
• Utilize evidence-based asthma assessment tools to assess asthma control, adherence to the action plan, and identify triggers.
• Take the Moving Toward Equity in Asthma Care CME course at no cost for more helpful tips.

Additional resources
Also available is the Asthma & Me training. Do your patients have asthma? Show them the pathophysiology of asthma in their preferred language.

References:

1. Asthma and Allergy Foundation of America & National Pharmaceutical Council. (2005). Ethnic Disparities in the Burden and Treatment of Asthma. Retrieved from http://www.aafa.org/media/Ethnic-Disparities-Burden-Treatment-Asthma-Report.pdf
2. U.S. Department of Health & Human Service, Office of Minority Health. (2016, May 9). Asthma and Asian Americans. Retrieved August 8, 2016, from https://www.minorityhealth.hhs.gov
3. Asthma and Allergy Foundation of America. (2020). Asthma Disparities in America: A Roadmap to Reducing Burden on Racial and Ethnic Minorities. Retrieved from: https://aafa.org/wp-content/uploads/2022/08/asthma-disparities-in-america-burden-on-racial-ethnic-minorities.pdf

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 under Provider Overview, select Find Care.

Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:

• Add/change an address location
• Name change
• Provider leaving a group or a single location
• Phone/fax number changes
• Closing a practice location

Once you submit the form, we will send you an email acknowledging receipt of your request.

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’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes.

Engagement Hub objectives:

• Learn strategies to help you and your care team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
• Offer care providers a convenient way to earn CME credits at a time that works best for you.

Register here for our free CME clinical quality webinars!                   

Note: Sessions in this series are approved for one American Academy of Family Physicians credit each.

Join this CME webinar to learn best practices to preventing falls of your older patients Wednesday June 7, 2023.

Skilled Nursing Facility (SNF) providers: Fall prevention and patient safety

*Notice of Material Amendment to Contract and/or Change to Prior Authorization Requirements

As part of ongoing review and maintenance of CPT^® code changes, we have identified codes in our CT/MRI/Mammogram standard code set that need to be added and or deleted due to annual maintenance. These code sets will be updated effective August 1, 2023.

Reimbursement for these codes will be made according to the terms of the provider agreement. If you have questions, please reach out to your Provider Relationship Account Manager.

Mammogram:

CT:

Going forward, any code added within the following code ranges will automatically be added to the CT category:

MRI:

Going forward, any code added within the following code ranges will automatically be added to the MRI category:

Providers can submit corrected claims for Federal Employee Program, (FEP), members using Availity Essentials* or through Electronic Data Interchange (EDI). The FEP member ID number start with the letter R, followed by eight numerical digits.

The corrected claims process begins when a claim has already been adjudicated. Multiple types of errors that occur can typically be corrected quickly with the options below. As a reminder, the corrected claim must be received within the timely filing.

Availity Essentials corrected claim submission

You can recreate a claim and submit it as a replacement or cancellation (void) of the original claim if Anthem has already accepted the original claim for processing. Follow these steps:

• In the Availity Essentials menu, select Claims & Payments, and then select Professional Claim or Facility Claim, depending on which type of claim you want to correct.
• Enter the claim information, and set the billing frequency and payer control number as follows:
  • Replacement of Prior Claim or Void/Cancel of Prior Claim.
  • Billing Frequency (or Frequency Type) field, in the Claim Information section (for professional and facility claims) or Ancillary Claim/Treatment Information section (for dental claims). Use 7 for replacement claims and 8 for voided claims.
  • Set the Payer Control Number (ICN / DCN) (or Payer Claim Control Number) field to the claim number assigned to the claim by Anthem. You can obtain this number from the 835 ERA or Remittance Inquiry on Payer Spaces.
• Submit the claim.

EDI corrected claim submission

Corrected claims submitted electronically must also have the applicable frequency code and payer control number.

Frequency code:

• For corrected professional (837P) claims, use one of the following frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
  • 7 — Replacement of prior claim\corrected claim
  • 8 — Void/cancel prior claim
• For corrected institutional (837I) claims, use bill type frequency codes to indicate a correction was made to a previously submitted and adjudicated claim:
  • 0XX7 — Replacement of prior claim
  • 0XX8 — Void/cancel prior claim

Payer claim control number:

• Use the original claim number assigned to the claim by Anthem.

Required EDI segments:

• CLM05-3: Frequency Code (7,8)
• REF: Payer Claim Control Number (original claim number)

Please confirm with your practice management software vendor and billing service or clearinghouse for full details and information on submitting corrected claims.

We encourage you and your staff to use the digital methods available to submit corrected claims to save costs in mailing, paper, and your valuable time.

A decision-making tool for patients navigating the Medicaid renewal process.
During the COVID-19 public health emergency, nearly all Medicaid and Children’s Health Insurance Program (CHIP) members were able to stay enrolled in their current health coverage regardless of changes in eligibility or status. As Medicaid renewal starts again, your patients will have to take additional steps to keep their current coverage or find a new health plan. Many will be doing this for the first time and may need advice and support to feel confident throughout the process.

The need for reliable direction in this changing landscape
If your patients who have a Medicaid or CHIP plan don’t renew their benefits, or if they no longer qualify, they are at risk of losing their health coverage and the ability to stay with their current doctors and healthcare providers. 

To help your patients stay covered and remain in your care, Anthem developed a benefits eligibility tool that helps those enrolled in Medicaid or CHIP check if they qualify to renew their coverage. If they no longer qualify, it directs them to coverage and benefits information.

How the decision-making tool works
Patients can visit www.myhealthbenefitfinder.com/anthem. After they fill out information such as their age, ZIP code, annual household income, and number of household members, they select Results. The next page is customized based on their responses:

• Patients who may still qualify for Medicaid or CHIP health benefits are directed to their state agency website to verify their eligibility.
• Patients who no longer qualify for Medicaid or CHIP are directed to other health plan options.

The tool also provides information on additional benefits they may qualify for, such as programs that help with food, housing, and transportation costs.

We encourage you to share the www.myhealthbenefitfinder.com/anthem website with those impacted by Medicaid renewal. The tool offers reassurance for those who continue to qualify for coverage, and for those who no longer qualify, guidance on other health coverage, including a Health Insurance Marketplace plan, Medicare, or employer-sponsored coverage.

Additional resources to guide your patients
To support your patients through the Medicaid renewal process, we’ve developed two additional resources you can share with them:

• A patient-facing sheet — https://bit.ly/3obeMca
• An educational Medicaid renewal destination — anthem.com/staycovered

You and your staff can also support your patients by using the Availity Essentials* platform at Availity.com to identify your Medicaid and CHIP patients. For a step-by-step video tutorial that walks you through how to find this information, visit https://bcove.video/3TEFG7W. 

You and your patients can count on us for support
Your patients may have questions about the Medicaid renewal process. We want you to feel confident you have the answers and resources to guide them.

Together, we can ease your patients’ potential concerns and help make sure there are no gaps in coverage or care.

If you would like more information, contact your Provider Relationship Management representative, or call the number on the back of the member’s ID card.

*Notice of Material Amendment to Contract and/or Change to Prior Authorization Requirements

One of the greatest responsibilities Anthem Blue Cross and Blue Shield (Anthem) has to our members is to administer their benefits accurately. We conduct prepay itemized bill reviews for inpatient and outpatient services to ensure member cost shares are correctly applied. We have recently made the determination that our members would be best served if we were to require itemized bills for inpatient services billed in excess of $50,000 and outpatient services billed in excess of $20,000.

On August 1, 2023, you will be required to make a change when submitting itemized bills for Anthem inpatient and outpatient member claims:

• For inpatient services, submit an itemized bill for member claims in excess of $50,000.
• For outpatient services, submit an itemized bill for member claims in excess of $20,000.
• The itemized bill should be equal to the amount billed in order for us to process the claim.

At this time, this change only applies to fully insured members. 

We want to reduce the impact to your billing area as much as possible, so we have introduced a process that will:

• Reduce the time needed to identify a fully insured member.
• Eliminate the need to submit itemized bills when not needed.
• Integrate with your existing workflows to enable electronic submission.

Anthem’s Digital Request for Additional Information (Digital RFAI) process enables you to submit itemized bills electronically through Availity.com.*

The most efficient way to submit itemized bills is through the Digital RFAI process. This is how it works:

1. You submit your claim through either EDI or the Availity.com Claims & Payments application.
2. If an itemized bill is needed, we send a notification to your Attachments Dashboard on Availity.com each morning by 8 a.m. Eastern.
3. You retrieve the notification and upload the itemized bill directly to your claim as an attachment.

If an itemized bill is not required for the claim, you will not receive a notification, and the claim will continue through processing.

Another benefit of the Digital RFAI process is the claim will pend (rather than deny), allowing up to 30 days for you to supply the requested itemized bill.

Access the Digital RFAI webpage for learning resources, pre-recorded demonstrations, and more.

1. Start by viewing the Digital Request for Additional Information Training session.
2. For help with Availity medical attachment setup, access this video for additional instructions.
3. Not registered with Availity Essentials?* Here’s a link to get started with Availity.

For more information, view the Digital RFAI webpage online.

Save the date! Upcoming webinars will take place on June 28, July 12, and July 19.

The Connections app webinar: A free solution to support your Ohio Medicaid Managed Care members with substance use disorder covers how you can provide the Connections app (created by CHESS Health *) at no cost to you or your Anthem Blue Cross and Blue Shield (Anthem) members. The Connections app is an evidence-based smartphone app that helps individuals adhere to their treatment plan and stay in recovery. The goal is to ensure that individuals with substance use disorder (SUD) have access to the support they need, wherever and whenever they need it —including between their appointments with you.

Connections helps patients build healthy habits, reduce isolation, and celebrate achievements. The Connections app includes:

• An existing robust virtual community with 24/7 support.
• Moderation of lively discussion groups.
• Video support meetings to create meaningful engagement.
• Trained and professional staff of certified peer recovery specialists who have lived experience with SUD and mental health.

Anthem has contracted with CHESS Health to make the Connections App free to both you and your Anthem members.

Speakers: Stephanie Romney, senior customer success consultant and Dwayne Blair, certified peer, from CHESS Health.

Dates and times:

• June 28 at 12:30 p.m.
• July 12 at 8:30 p.m.
• July 19 at 3 p.m.

Register here.

Anthem Blue Cross and Blue Shield invites providers to participate in our Provider Advisory Council. The meeting’s intent is to collaborate with our provider community to gather input, discuss trends, identify challenges, and remove barriers, ultimately improving the healthcare delivery system. If you are interested in participating, please sign up by selecting this link: https://bit.ly/3FywQ5M.

• All Ohio Medicaid claims with Anthem Blue Cross and Blue Shield (Anthem) must be submitted electronically through the Ohio Department of Medicaid’s (ODM) Fiscal Intermediary (FI) via an ODM authorized electronic data interchange (EDI) trading partner using EDI payer ID# 0002937.
• Providers can submit their ODM claims electronically to Availity Essentials^* by submitting with the payer ID# 0002937.
• If a provider does not use an ODM authorized EDI trading partner, claims must be entered on the Availity Essentials website via Direct Data Entry at Availity.com. Once the claim is entered, Availity will route the claim through ODM’s Fiscal Intermediary (FI) for processing.
• If a provider uses the Ohio Commercial EDI payer ID# for Ohio Medicaid claims with Anthem, the claim will be rejected.
• Paper claims will not be accepted.

For the most up-to-date information, please visit our provider website at https://providers.anthem.com/oh.

If you have any additional questions, please reach out to our dedicated Health Care Networks team at OhioMedicaidProvider@anthem.com.

The fax number on the previous communication was incorrect and has been corrected here. The correct fax number is 833-678-0223.

For services beginning on July 1, 2023, prior authorization requests for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) services will be reviewed by Carelon Post Acute Solutions, LLC.* The goal of this program is to ensure members receive the right product for the right duration of time in the home. This change will be applicable to the following markets: Colorado, Connecticut, Georgia, Indiana, Kentucky, Missouri, New Hampshire, Nevada, Ohio, Virginia, and Wisconsin.

How to submit or check a prior authorization request
For DMEPOS services, Carelon Post Acute Solutions will begin receiving requests on Tuesday, June 20, 2023, for dates of service July 1, 2023, and after.  

Providers are encouraged to request authorization using the website. Go here to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. If you are unable to use the link or website, you can call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to Carelon Post Acute Solutions at 833-678-0223.

Please note: Carelon Post Acute Solutions will not review authorization requests for products/services that do not fall under Medicare-covered products/services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras.

To learn more about Carelon Post Acute Solutions and upcoming training webinars, visit the website or email.

If you have additional questions, please call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622.

Who is affected
For women ages 67 to 85 who sustained a recent fracture, it is important to obtain a bone density scan to assess for osteoporosis.

How can we collaborate?
We can help your patients complete this scan in the comfort of their home through Quest HealthConnect™.*

In home resources
We are working with Quest HealthConnect, a Quest Diagnostics service, to provide this service at no added cost to you. Quest HealthConnect will call your patient to arrange a visit. Patients may also call them directly at 888-306-0615 between 8:30 a.m. to 4 p.m. Eastern Time. The result(s) of the screening test(s) will be sent to both the patient and your office after the visit.

For professional claims submitted on a CMS-1500 form processed on or after June 1, 2023, Anthem Blue Cross and Blue Shield will enhance our editing systems to automate edits and simplify remittance messaging. These edit enhancements are supported by correct coding guidelines as documented in industry sources such as Correct Procedural Terminology (CPT^®) guidelines and Centers for Medicare & Medicaid Services (CMS). Additionally, these edit enhancements will promote faster claim processing and reduce follow-up audits and/or record requests for claims that are not consistent with correct coding guidelines. As a result of these edit enhancements, there will be greater attention on identifying inappropriate billing of genetic testing services.

Below are examples of claim edits focused on identifying inappropriate billing of genetic testing services that will be automated:

• Multianalyte Assays with Algorithmic Analyses (MAAA) — CPT 81507: This edit will deny laboratory provider claims submitted with the proprietary laboratory analysis code for the associated proprietary harmony prenatal test when the laboratory provider is not an affiliated proprietary laboratory.
• Panel testing: This edit will deny laboratory provider claims submitted with codes for individual components of a panel test (for example, tumors, inherited conditions, and hematologic malignancy) when a single panel code exists.
  Providers who believe their medical record documentation supports services billed should follow the claims payment dispute process (including submission of all supporting documentation with the dispute) as outlined in the provider manual.

If you have questions on this program, contact your Provider Relationship Account Manager.

Please continue to read the latest Medicare Advantage information, including:

• Itemized bill review program
• Medical Policies and Clinical Utilization Management Guidelines update