On April 1, 2024, Carelon Post Acute Solutions, LLC (formerly known as myNexus) began operating as Carelon Medical Benefits Management, Inc.

Provider materials that formerly included the Carelon Post Acute Solutions name, such as determination letters and provider forms, have adopted the new name. However, there will be no changes in the way you submit a case nor to the contact information you use for checking case status.

Please see below for a list of FAQ. Additional questions can be directed to our Health Care Networks team using the contact information below:

• Home health providers: HHprovider_relations@carelon.com
• Post-acute institutional management (PAC-IM) providers: PACprovider_relations@carelon.com
• Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers: DMEprovider_relations@carelon.com

Thank you for your continued partnership.

Carelon Medical Benefits Management transition FAQ

Q: Will there be any changes to the Carelon Post Acute Solutions provider website?

A: The name of our website has been updated to reflect Carelon Medical Benefits Management branding. Additionally, the web address you use today will automatically redirect to a new Carelon Medical Benefits Management site. There will be no changes to the case submission process.

Q: Are any phone number changes planned as part of this transition?

A: No, our inbound phone numbers will not change. The reference to Carelon Post Acute Solutions in recorded scripting will use the Carelon Medical Benefits Management name.

Q: How will third party websites, such as Availity, be impacted?

A: There will be no change to the way you access these websites. Within the sites, any reference to Carelon Post Acute Solutions will be replaced with the new name. This may take some time to fully complete.

Q: Will references to Carelon Post Acute Solutions on health plan websites and other materials be changed?

A: Yes, while you may continue to see the Carelon Post Acute Solutions company name on health plan websites for some time, these references will be updated over time through scheduled content update cycles. If your office includes the Carelon Post Acute Solutions name in any materials or web properties, we encourage you to update them to Carelon Medical Benefits Management during your next update cycle.

Q: Will information about Carelon Post Acute Solutions continue to be found on the corporate website?

A: Yes, post-acute care will be part of the Carelon Medical Benefits Management portfolio of solutions. You can learn more at careloninsights.com.

Q: Will provider resources, such as key documents and the provider finder, be impacted?

A: Our provider resources will continue to be available through our corporate website and our Provider Resources site.

Q: Does this impact provider agreements with Carelon Post Acute Solutions? Will I need to sign a new agreement?

A: No, there is no impact to provider agreements. You do not need to sign a new agreement regardless of whether your current contract is with MyNexus, Inc. or Carelon Post Acute Solutions.

Q: Do I need to complete credentialing again through Carelon Medical Benefits Management?

A: No, providers will not need to re-credential until their normal credentialing cycle.

Q: Will my claims be impacted?

A: No, claims are not impacted. Payer IDs will remain the same.

Q: Will I need to update my W-9?

A: Providers may need to update their W-9. If you need an updated W-9 from Carelon Medical Benefits Management, please contact the Carelon Provider Relations department at HHprovider_relations@carelon.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/provider, 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, reach out to Availity Client Services at 800-AVAILITY.

Providers must code their claims to the highest level of specificity in accordance with industry standard coding guidelines such as ICD-10-CM coding guidelines and reporting. When an ICD-10-CM diagnosis code has a specified laterality within the code description, the modifier that is appended to a CPT^® or HCPCS code must correspond to the laterality within the ICD-10 description.

For CMS 1500 form claims processed on or after May 30, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny claim lines that have a laterality diagnosis submitted with a CPT or HCPCS modifier that does not correspond to the diagnosis.      

Example one:

Example two:

Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT, HCPCS code(s), and/or modifiers billed.

Anthem will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex Code: 00W19

If you have questions about this communication or need assistance, contact your provider relationship management associate.

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.

Providers must code their claims to the highest level of specificity in accordance with industry standard coding guidelines such as ICD-10-CM coding guidelines and reporting. When an ICD-10-CM diagnosis code has a specified laterality within the code description, the modifier that is appended to a CPT^® or HCPCS code must correspond to the laterality within the ICD-10 description.

On a CMS 1500 form, for professional submitted claims processed on or after June 1, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny claim lines that have a laterality diagnosis submitted with a CPT or HCPCS modifier that does not correspond to the diagnosis.

See examples below:

Reported diagnosis: E11.3593 (Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral):

• Billed CPT code: 67228-RT Treatment of extensive or progressive retinopathy (for example, diabetic retinopathy), photocoagulation.
• Determination: It is not appropriate to report the RT modifier when the laterality of bilateral is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied.

Reported diagnosis: S91.011A (Laceration without foreign body, right ankle, initial encounter):

• Billed CPT code: 27786-LT (Closed treatment of distal fibular fracture: lateral malleolus; without manipulation)
• Determination: It is not appropriate to report a LT modifier when the laterality of right is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied.

Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT, HCPCS code(s), and/or modifiers billed.

Anthem will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

EOB message

Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex codes: v19 and 00V19

If you have questions about this communication or need assistance, contact your provider relationship account manager. We are committed to a future of shared success.

We are updating our process for reviewing readmissions. As you may know, our current process is performed post-payment via coding and claims analysis.

Our revised process will move this review to our Utilization Management team, pre-payment, and will occur at the time of the admission. This will allow for an immediate review and notification to facility of an admission that meets our contractual requirements for a readmission. This updated process also provides the opportunity for a peer-to-peer in the event it is determined to be a readmission.

This is an update to our processing to allow for more efficient processes. This is not a medical necessity review and does not change or replace that process. It is not a change to our policies or your contract.

Our updated review process for readmissions will begin on May 1, 2024, unless you have been notified otherwise by Anthem.

We continue to work towards identifying simplified ways to access care.

What are three things everyone should know about you?

I am from Peytona, a small coal mining town in southern West Virginia. I am a true “coalminer’s daughter” and did not move to Ohio until 2004.

I am an avid sports fan! I am a season ticketholder to the Columbus Blue Jackets and enjoy the game of hockey. I love college football and both Ohio NFL teams.

I am the mom of two boys and one grandson. My oldest, Logan, is a senior network administrator at a credit union in Gahanna, and my youngest, Hayden, is a pharmacist at a home infusion pharmacy in Dublin. Adler, my 2-year-old grandson, can do no wrong in my eyes and totally rules my world.

One thing you never leave home without.

The one thing I cannot leave home without is the same answer that most people give: my cellphone. The main reason is without my driving directions, I would always be lost. I have the worst sense of direction, and at this point I wonder how I got to destinations before cellphones.

Who has been most influential in your life? 

The most influential person would be my husband, Jeff. He understands me, listens to me, is a shoulder to cry on, and, most importantly, he believes in me. His support has helped mold me into the person that I am today. No matter the situation, Jeff’s words and actions make me rise when I fall and he brings out the best person I can be. He continually shows me how much a positive attitude can help with my outlook on everything. I am a much better person all around since he came into my life, and I will be forever grateful.

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.

Anthem updates the provider manuals annually so that our care provider partners have the current information they need to work with us. The provider manual serves as a reference document and is reviewed internally each year to reflect changes to our processes and policies.

The provider manual incorporates information for both professional and hospital/facility providers. The next update will be available on the website May 1, 2024, and will become effective August 1, 2024.

To view the updated manual, please visit anthem.com. Select For Providers, then Policies, Guidelines & Manuals. Change the state to Ohio, scroll to the Provider Manual area, and select Download the Manual to view and/or download the provider manual as well as the BlueCard and Medicare Advantage manuals.

Archived copies of the professional and hospital/facility manual will remain available at the same location.

Use the information below to help complete required patient information on donor claims. Correct completion of the form is needed to process the claim.

Donor claims

There are two patients involved in an organ donation — the donor and the recipient. The insurance plan for the recipient is responsible for paying the donor claim. The recipient can be the subscriber or a dependent to the subscriber (Note: Plans are instructed to include living donor charges on the recipient claims).

When billing for services rendered to the transplant donor, the care provider enters the recipient’s name, date of birth, sex, and Anthem ID number.

Completing forms

Review the information outlined below for billing instructions needed to process donor claims.

CMS-1450 (UB-04 Uniform Bill):

• UB box 8b — recipient’s name*
• UB box 10 — recipient’s birthdate
• UB box 11 — recipient’s sex
• UB box 42 — donor ICD-10-CM codes and revenue codes
• UB box 58 — subscriber’s name
• UB box 59 — relationship code of 39 or 40
• UB box 60 — subscriber ID number
• UB box 66 — donor diagnosis codes
• UB box 80 — note this is a donor claim submission with donor’s name

CMS-1500 (Health Insurance Claim Form):

• HCFA box 1a — subscriber’s ID number
• HCFA box 2 — recipient’s name*
• HCFA box 3 — recipient’s date of birth and gender
• HCFA box 4 — subscriber’s name
• HCFA box 6 — relationship to subscriber, other (Complete with 39 or 40.)
• HCFA box 19 — note, this is a donor claim submission with donor’s name
• HCFA box 21 — donor diagnosis code
• HCFA box 53 (electronic claim) — will list the donor’s name:
• Example: Claim note ref code: ADD Claim note Text: 39-Jones, Sally

* The recommendation is that the recipient’s name be billed. However, the care provider can bill with the donor’s name. If the claim is billed with the recipient’s name, it has a better chance at adjudication upon initial submission.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

When determining transportation to an alternative hospital and to help avoid medical necessity denials for rotary wing air ambulance transports to another hospital, please remember the criteria below.

The use of air and water ambulance services is considered medically necessary when all the following criteria are met:

1. The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
2. The individual’s condition must be such that any form of transportation other than by ambulance would be medically contraindicated; and
3. The individual’s condition is such that the time needed to transport by land poses a threat to the individual’s survival or seriously endangers the individual’s health*; or the individual’s location is such that accessibility is only feasible by air or water transportation; and
4. There is a medical condition that is life threatening, or first responders deem to be life threatening, including, but not limited to, the following:

1. Intracranial bleeding; or
2. Cardiogenic shock; or
3. Major burns requiring immediate treatment in a burn center; or
4. Conditions requiring immediate treatment in a hyperbaric oxygen unit; or
5. Multiple severe injuries; or
6. Transplants; or
7. Limb-threatening trauma; or
8. High risk pregnancy; or
9. Acute myocardial infarction; if this would enable the individual to receive a more timely medically necessary intervention (such as percutaneous transluminal coronary angioplasty [PTCA] or fibrinolytic therapy).

* Air transportation may be appropriate if the time between identification of the need for transportation until arrival at the intended destination for ground ambulance would be at least 30 minutes longer than air transport.

For additional details on Clinical UM Guideline CG-ANC-04 Ambulance Services: Air and Ground please visit the Anthem provider site.

Clinical UM Guidelines are subject to change. Administrative services only (ASO) accounts may utilize alternate criteria. All terms and conditions of the member’s benefit plan apply.

For more information, please contact Provider Services at 844-912-1226.

Digital Request for Additional Information (RFAI) is the easiest way to submit attachments requested by your payer using Availity Essentials. There is no need to fax or mail paperwork to complete your claim submissions anymore; just use the digital channels provided for your organization.

Availity Essentials notification center

The notification center is located on the top of the Availity Essentials home page. If your payer has requested documentation, there will be a message stating there are requests in your work queue. Simply select the hyperlink to be navigated to the Attachment Dashboard to view the request.

Availity Essentials Attachment Dashboard

The Attachment Dashboard is where all attachment requests are displayed. You can use the hyperlink in the notification center or navigate to Claims & Payments > Attachments New.

To locate a specific RFAI request, the request number will begin with RFAI. If you notice multiple requests in your dashboard, take advantage of the filters. You have the option to search, filter, and sort for multiple values, such as tax ID, NPI, and request type.

Select Upload Attachment to view the type of document requested. Your uploaded requests will be visible in the History tab once accepted. Select the Record History icon on the right side of the request to view the Availity Transaction ID for specific Availity Essentials questions or Health Plan Transaction ID if you need to contact your payer for questions.

Digital RFAI progress dashboard

This dashboard, located in Payer Spaces, allows your organization to understand how many digital requests have been sent, how many finalized claims there are based on your attachment submissions, and the average turnaround time from the initial payer request to the claim finalization. To view your Digital RFAI Progress Dashboard application, select Payer Spaces from the drop-down menu and choose your payer tile.

Get trained

Availity Essentials has training on-demand. This includes a pre-check for administrators and a Learn How to Submit Digital Requests for Additional Information training. Log in to Availity Essentials > Help & Training > Get Trained > Enter RFAI in the keyword search.

Visit the Provider Learning Hub to take Availity on-demand training.

If you have questions, call Availity Client Services at 800-Availity (800-282-4548). Availity Client Services is available Monday to Friday, 8 a.m. to 8 p.m. ET.

With your help, we can continually build towards a future of shared success.

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.

On May 19, 2023, August 18, 2023, and August 30, 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.

On February 24, 2023, and November 17, 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.

On December 11, 2023, and January 5, 2024, 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 for dates of service on and after April 14, 2024, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines for medical necessity review for Anthem:

• Musculoskeletal Guidelines:
  • Interventional Pain Management

Effective for dates of service on and after June 30, 2024, the following Carelon Medical Benefits Management Clinical Appropriateness Guideline updates for medical necessity review will apply for Anthem:

• Genetic Testing:
  • Hereditary Cancer Testing
  • Carrier Screening in the Prenatal Setting and Preimplantation Genetic Testing
  • Genetic Testing for Inherited Conditions

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

Estimates suggest that around 35 million American adolescents fail to receive at least one recommended vaccine.* The CDC and the American Academy of Pediatrics advise pre-teens between 10 and 12 years old receive three vaccines: (1) one dose for meningococcal; (2) one dose for tetanus, diphtheria, and pertussis (Tdap); and (3) two doses of human papillomavirus (HPV) given five months apart.

Encourage pre-teen immunizations

Take action to provide clear and specific guidance to your patients’ parents to get the recommended vaccines on time. Convey the importance by administering vaccines as part of routine visits and by offering vaccine clinics during non-traditional times when your patients and their parents might be more available. It is helpful to remind patients of their upcoming appointments, follow up to reschedule any missed appointments, and address any concerns or barriers. Although you should check your patients’ benefits, immunizations are generally a covered benefit.

Reporting and documenting for HEDIS

Take action to make sure that all vaccine doses given, including those administered in a pharmacy and an urgent care, are clearly documented in your electronic medical system, your patient’s medical record, and state Immunization Registry. Doses should be clearly reported on claim forms with the assistance of CPT® codes to maximize data collection and to reduce the burden of HEDIS® medical record review, especially since NCQA strongly encourages the electronic collection of Immunizations for Adolescents (IMA) HEDIS data. Contact your provider relationship management representative for additional information and assistance with establishing electronic data exchange.

Opportunities to learn more:

• An on-demand webinar  about the importance of the HPV vaccine and starting the conversation early with parents of 9-year-olds can be found on the Clinical Quality Webinars Hub. One continuing education unit is provided upon completion.
• Mydiversepatients.com includes free resources and courses that might help you with your diverse patient population.
• Letsvaccinate.org provides ready-to-use resources and strategies to help your care team increase vaccination rates.

 Through our shared health vision, we can affect real change.