The Department of Health & Human Services (HHS) requires health plans to report whether or not our in-network providers offer telehealth services.

If you provide telehealth services, please tell us by submitting your information to us through Availity.com. Updating your telehealth status will not affect your participation with us. We will add a telehealth indicator to your online provider directory profile, allowing our members to know you offer telehealth services.

If you have questions about submitting your information, please see the instructions below.

If your organization is not currently registered with Availity, you will need to create an account. The person(s) designated as your administrator(s) should go to Availity.com and select Get Started in the upper right corner of the webpage. You may also navigate directly to Availity’s registration website by selecting here.

Begin your application here. To update your application:

1. Log in to Availity Essentials.
2. Select My Providers.
3. Select Provider Data Management.

Please update your telehealth information at the service location.

In today's rapidly evolving healthcare landscape, the accuracy of provider data is a critical component of ensuring operational efficiency, regulatory compliance, and overall patient satisfaction. A recent survey suggests there is opportunity for providers to correct their data with us.

Ohio Medicaid Managed Care providers maintain their data on Ohio’s Provider Network Management (PNM) module. Providers should ensure that all data is correct, paying particular attention to addresses, phone numbers, and office hours.

Accurate data in the PNM in critical so that your patients — our members — can reach you and access the services they need.

To learn more about the PNM module and centralized credentialing, visit PNM & Centralized Credentialing (ohio.gov).

If you have questions, send an email to ohiomedicaidprovider@anthem.com. You may also locate your dedicated provider relationship account associate on the territory map.

Note: This communication does not apply to outpatient hospital services.

Providers who administer vaccines to children through 18 years of age should enroll in the Immunizations Covered by Vaccines for Children (VFC) program. We will reimburse only the administration fee for any vaccine available through the VFC program.

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

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

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

• Ohio Department of Health’s website
• ODM guidance
• The VFC policy

Beginning with claims processing on or after December 1, 2024, we will update our outpatient facility claims editing process to deny claim lines when an add-on code is reported without a primary procedure code.

An add-on code is a specific type designated by the HCPCS or CPT^®. These codes describe additional procedures or services performed with a primary procedure.

According to CPT guidelines, add-on codes must be reported with a primary procedure code.

If you believe you have received a claim denial in error, please follow our claim dispute process.

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

What are three things everyone should know about you?

I was born and raised in Cincinnati, Ohio. I am a single father now raising three amazing children of my own — one boy and two girls. I have always held big dreams and look forward to living on top of a mountain coastline one day. I enjoy broadening my children’s perspective on life and taking them to enjoy new places and learning unique facts about the world.

I am a creative type. In my personal time I enjoy writing music and designing sound for independent projects in the film, television, and game space. I am a self-taught pianist with an inclination toward classical styles. I have a passion for all types of music and consider myself eclectic in music I enjoy and music I create. Following my dreams, I have earned a bachelor’s degree in music production and a master’s degree in business. I have utilized my passion to open a home production studio where I discover new talent, manage artists, produce, and license music for use in a variety of projects.

While I chased a passion for music, I do enjoy following my heart for creative writing with poetry and short stories being among my favorites. As weird as it may sound, I also have a love for technical, business, and legal writing.

What is one thing you never leave home without?

My Frisbees! I always keep a backpack full of disc golf gear in my trunk in case I want to stop at a park and throw a few holes.

Who has been the most influential in your life?

I have found in life that the deepest and most impactful influences on me have come from people’s stories.

Tell me your story, and I am certain to find both wisdom and inspiration.

In July, we announced an enhancement to the 277CA to notify you of submission errors discovered during claims processing.  

As of November 1, 2024, the 277CA will include additional corrective action types for your review. As communicated in July, these errors will still be sent through physical mailing.

With these added error types, there is no reduction to the services we already provide.

Through our efforts, we are committed to reducing administrative burden, improving communication, and ensuring timely payments because we value you, our care provider partners.

There are new resources available for providers to complete the Pregnancy Risk Assessment Form electronically, or ePRAF (Electronic Pregnancy Risk Assessment Form). To access this form, log in to the NurtureOhio website where you will find information on how to use the ePRAF.

Quality Enhancer Incentive Program for ePRAF

The Quality Enhancer Incentive Program provides increased payments to eligible providers who submit the ePRAF via the NurtureOhio website on behalf of their pregnant patients.

Technical Assistance Intervention Package for ePRAF

The Technical Assistance Intervention Package is a collection of resources, tools, and reporting that is designed to assist Providers in delivering high-quality pregnancy related care to their patients.

For more information on using the ePRAF, please contact us at ohiomedicaidprovider@anthem.com.

This guidance concerns:

• Claims payment disputes versus claims payment appeals
• Clinical appeals for adverse utilization management (UM) decisions.

Claims payment disputes versus claim payment appeals

Q: What is a claims payment dispute?

A: A claims payment dispute is the provider’s initial request for a review into the outcome of a claim once it is finalized.

Q: What is a claims payment appeal?

A: If a provider disagrees with the outcome of the claims payment dispute, the provider may request a second-level review, known as a claim payment appeal.

Q: When should providers file a claim payment dispute or claim payment appeal?

A: Claims payment disputes and claim payment appeals can be filed when claims are underpaid, overpaid, denied for no authorization (additional information below), or payment was denied for any reason other than medical necessity. Review our provider manual (PDF) for additional reasons a claim payment dispute or appeal may be filed.

We accept both claims payment disputes and appeal requests within 365 days from the date of service (DOS) or 60 calendar days from the date on the Explanation of Payment (EOP), whichever is later.

Q: How can providers file a claims payment dispute and claim payment appeal?

A: Both the claims payment dispute and claim payment appeal can be filed via the preferred method of Availity Essentials or by mail or phone; call Provider Service at 844-912-1226. The mailing address can be found in our provider manual (PDF).

Q: What documentation is required when filing a claims payment dispute or a claim payment appeal?

A:

• Your name, address, phone number, email, and either your National Provider Identifier or tax ID
• The member’s name and their Anthem or Medicaid ID number
• A listing of disputed claims, which should include the claim number and the date(s) of service(s)
• All supporting statements and documentation
• A detailed explanation of the reason for the appeal

Note: We cannot process a claim payment appeal without a claims payment dispute on file.

Clinical appeals for adverse utilization management (UM) decisions

Q: When should providers file a clinical reconsideration?

A: The clinical reconsideration process is available to providers following an adverse medical determination within 30 days from the initial denial and when there is new clinical information or information that was not already provided in the initial review.

Q: How do providers file a clinical reconsideration?

A:

• Physical health: Fax to 877-643-0671
• Behavioral health: Fax to 866-577-2184

Q: What is needed to file a clinical reconsideration?

A: During the clinical reconsideration process, providers have an opportunity to submit additional clinical information to substantiate medical necessity for a previously denied preservice or concurrent inpatient stay.

Providers should also include reconsideration on the cover sheet if submitting via fax.

Q: When can providers request a peer-to-peer consultation?

A: Providers who disagree with an adverse medical necessity decision can request a peer-to-peer by contacting Anthem within seven calendar days of the initial determination or seven days after the determination of clinical reconsideration. To request a peer-to-peer, call Provider Services:

• Behavioral health: 844-441-1506
• Physical health: 833-308-3035

When you request a peer-to-peer review, Anthem will acknowledge your request within 24 hours and offer a peer-to-peer conversation within a mutually agreed-upon time.

Q: When can providers file a preservice clinical appeal?

A: If an authorization is denied prior to the service being rendered to the member, the provider has the option to file a pre-service clinical appeal directly with Anthem and can do so without the member’s consent.

If filing without the member’s consent, appeals must be submitted within 30 calendar days of the initial determination. If filing on behalf of a member, providers have 60 calendar days from the initial determination to submit their preservice clinical appeal, along with the member’s consent. Additional information can be found in our Provider Manual (PDF).

Q: How do providers file a preservice clinical appeal?

A:

• Electronically using ICR in Availity Essentials; ICR training can be found on the Digital Solutions Learning Hub (on24.com)
• Fax directly to the Appeals department at 866-587-3316

Q: If a provider fails to request a prior authorization (PA) can the service be reviewed retrospectively?

A: Yes, providers who fail to obtain a PA can request that services already administered be reviewed for medical necessity via a claim payment dispute. The dispute should be submitted after the claim denies for no authorization.

Upon receipt of the claim payment dispute, Anthem will review the service retrospectively for medical necessity. When submitting a claim payment dispute, the provider must submit medical documentation and provide the extenuating circumstances for not submitting the PA.

Claim payment disputes are to be submitted within 365 days from the DOS or 60 calendar days from the date on the Explanation of Payment, whichever was later.

Q: How do providers file postservice clinical appeals?

If there is an adverse determination of medical necessity, a post-service clinical appeal can be submitted (guidance above).

Q: When can providers file an external medical review (EMR)?

A: Providers who have exhausted appeal rights can request an EMR within 30 calendar days of Anthem’s decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity. The EMR is available at no cost to providers.

The request for EMR must be submitted to Permedion (gainwelltechnologies.com) within 30 calendar days of the written notification that the internal appeals process has been exhausted. Providers must complete the Ohio Medicaid MCE External Medical Review Request (PDF), which is available on Permedion.

Providers need to upload the request form and all supporting documentation to the HMS eCenter (hmsy.com). If the provider is a new user, the provider can send documentation by secure email to imr@gainwelltechnologies.com to establish website access.

Services denied for reasons other than lack of medical necessity are not subject to EMR. Examples include noncovered services and timely denials.

Trainings available:

• Availity Essentials offers both live and on-demand trainings.
• Digital Solutions Learning Hub (on24.com)

If you have questions, contact your provider relationship account manager or send an email to ohiomedicaidprovider@anthem.com. View this map (PDF) to identify your provider relationship account manager.

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 resumed January 23, 2024.

All providers are subject to either three- or five-year, time-limited Provider Agreements. Letters are mailed and emailed 120 days, 90 days, and 60 days prior to termination, and a final notice is sent 30 days prior to termination. Providers who do not submit their revalidation could experience a termination at the state level — which would cascade to the managed care entities (MCEs) and cause claim denials as a non-participating provider. Emails will come from OHPNM@maximus.com.

Revalidation 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 Manage Application > Enrollment Actions within the provider file. Refer to the Quick Reference Guide: Revalidation/Reenrollment (maximus.com) 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 providers can email IHD@medicaid.ohio.gov.

To learn more about the PNM module and centralized credentialing, visit the PNM & Centralized Credentialing page (ohio.gov) on the Next Generation Program website (ohio.gov).

Find Care, the doctor finder and transparency tool in the Anthem online directory, provides Anthem members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options such as sorting providers based on distance, alphabetical order, and provider name.

In our November 2022 newsletter, we provided an update regarding Personalized Match, an additional Find Care sorting option for Commercial members. We informed you that this provider sorting option was based on provider efficiency and quality outcomes described in a methodology document linked in the newsletter article, in addition to member search radius.

We want to inform you that, beginning in December 2024 or later, we will be enhancing Personalized Match. This will expand upon the existing program. Newer components of the provider personalization metrics will contain up to 10 times as many features as compared to existing metrics such as gaps in care and additional types of service cost and utilization. Personalized Match will continue to display providers with the highest overall ranking within the member’s search radius, first. Members will continue to have the ability to sort based on distance, alphabetical order, and provider name.

Helpful resources on Availity

You may review a copy of the Personalized Match methodology that has been posted on Availity, our secure web-based provider tool, using the following navigation:

• Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.

If you have general questions regarding these upcoming changes, please submit an inquiry via the web at Availity.com. If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.com.

Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.

We are excited to announce the release of an Applied Behavior Analysis (ABA) Provider Resource Guide designed to assist with proper billing and documentation practices. This essential guide simplifies the complexities of ABA coding and requirements, ensuring that you can navigate these processes with ease.

Refer to attached ABA Provider Resource Guide.

As respiratory syncytial virus (RSV) season approaches, we would like to remind providers about available RSV immunizations to help prevent severe RSV related disease in infants. According to a report from the CDC (March 2024), infant preventive antibodies showed 90% effectiveness against the need for hospitalization for RSV in babies. Two immunizations are available to prevent RSV lower respiratory tract infections in infants:

• Pfizer's Abrysvo, a maternal vaccine given during pregnancy
• Nirsevimab (Beyfortus), a monoclonal antibody administered to the baby

The maternal vaccine, Abrysvo, is recommended for those who are 32 to 36 weeks pregnant during RSV season, which generally falls between October and March. The vaccine can provide protection for infants up to six months if the mother receives it at least two weeks prior to delivery.

Nirsevimab (Beyfortus) provides up to five months of protection against RSV and is approved for infants under 8 months during their first RSV season, and certain children between 8 and 19 months at increased risk of severe RSV disease. In some cases where a mother received an RSV vaccine, Nirsevimab can still be considered for the child if there is a substantial risk for severe RSV disease or if the maternal immune response to the vaccination is inadequate.

Nirsevimab is covered under the Vaccines for Children Program. Additional information about RSV prevention and Nirsevimab (Beyfortus) can be found at cdc.gov/rsv.

We look forward to sharing resources and working with you to achieve improved outcomes for children in our communities.

As a contracted provider for a special needs plan (SNP) from Anthem, you are required to participate in an annual Model of Care training for providers, per CMS regulations. This training includes a detailed overview of Anthem special needs plans and program information, highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Please remember this training is specific to our plans and delivery of care for members, ensuring their specific care needs are met. Your participation is critical for improved quality and health outcomes.

Training for the SNP product is self-paced and available at Availity.com. The training must be completed by December 31, 2024.

How to access the Custom Learning Center:

1. Log in to the Availity website at Availity.com.
2. At the top of the Availity website, select Payer Spaces and select the appropriate payer.
3. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
4. In the Custom Learning Center, select Required Training.
5. Select Special Needs Plan and Model of Care Overview.
6. Select Enroll.
7. Select Start.
8. Once the course is completed, select Begin Attestation and complete.

Not registered for Availity Essentials?

Have your organization’s designated administrator register your organization for the Availity website:

1. Visit Availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

Refer to these PDF documents for complete registration instructions.

Anthem invites our Medicaid care providers in Ohio to participate in our Provider Advisory Council. The meeting’s intent is to collaborate with our provider community and gather input, discuss trends, identify challenges, and remove barriers — ultimately improving the healthcare delivery system.

If you are interested in participating, sign up by visiting the link below.

Provider Advisory Council sign-up (chkmkt.com)

All hospice providers are invited to attend a hospice education webinar.

The Ohio Medicaid Provider Relationship Account Management team webinar will provide education on Anthem’s billing guidelines.

If you have any questions, please email ohmedicaidencpesupport@elevancehealth.com.

Through genuine collaboration, we can help solve real needs in a sustainable way.

Our Provider Relationship Management team will host our next behavioral health provider orientation on November 13th, 2024, at 9 a.m. ET. Please join us to learn more about working with us and supporting your patients and our members.  

If you have questions, please contact your provider relationship manager or email OhioMedicaidProvider@anthem.com.

Through genuine collaboration, we can work to achieve improved outcomes in patients’ health.

Orientation happening soon

The Ohio Medicaid Provider Relationship Account Management team will be hosting our next provider orientation in November. The orientation will cover everything you need to know to work with Anthem members enrolled in Medicaid in Ohio.

Register

Visit https://us.mar.medallia.com/?e=412439&d=l&h=87C2D15D588CFE7&l=en

We’re here to answer any questions

If you have questions, contact your provider relationship account manager or email ohiomedicaidprovider@anthem.com.

Through genuine collaboration, we can work to achieve improved outcomes in patients’ health.

In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care, effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here.

Site of Care Guidelines:

• Site of Care for Advanced Imaging
• Rehabilitative Site of Care
• Surgical Site of Care

Please share this notice with other members of your practice and office staff.

Effective on November 17, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.

You may access and download a copy of the current and upcoming guidelines here:

• Musculoskeletal:
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

The above guideline updates have a publish date of November 17, 2024.

Please share this notice with other members of your practice and office staff.

Effective on November 30, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

You may access and download a copy of the current and upcoming guidelines here.

• Radiology:
  • Oncologic Imaging

The above guideline updates have a publish date of April 14, 2024.

• Cardiology:
  • Imaging of the Heart
• Genetic Testing:
  • Pharmacogenomic Testing
  • Predictive and Prognostic Polygenic Testing
  • Chromosomal Microarray Analysis
  • Whole Exome Sequencing and Whole Genome Sequencing
  • Somatic Tumor Testing
• Musculoskeletal:
  • Spine Surgery
  • Sacroiliac Joint Fusion
• Radiology:
  • Vascular Imaging
  • Imaging of the Brain

The above guideline updates have a publish date of October 20, 2024.

• Genetic Testing:
  • Cell-free DNA Testing for the Management of Cancer
  • Prenatal Testing using cell-free DNA
  • Somatic Tumor Testing
• Musculoskeletal:
  • Joint Surgery

The above guideline updates have a publish date of November 17, 2024.

Please share this notice with other providers in your practice and office staff.

At a glance:

• High Performing Providers will also be known as Anthem Diamond Providers.
• Providers receiving a designation based on the Blue National Physician Performance Dataset will also be known as Anthem Diamond Providers (National).

High Performing Provider program

Over the last several months, we have communicated with our providers about our High Performing Provider program. PCPs and specialists meeting certain criteria are designated High Performing Providers. High Performing Providers may also be referred to as Anthem Diamond Providers.

As a reminder, the following specialties may be designated High Performing Providers (aka Anthem Diamond Providers) from this program:

• PCP: family practice, general practice, geriatric medicine, internal medicine, pediatric medicine, and nurse practitioners
• Specialists: cardiology, endocrinology, nephrology, neurology, neurosurgery, obstetrics gynecology, orthopedic surgery, psychiatry, pulmonology, and rheumatology

If you have any questions about this program, contact Provider Services or your local provider relationship management representative.

Blue National Physician Performance Dataset

This is an Anthem designation program for providers in networks supporting Anthem national accounts and certain out-of-area providers.

As we previously communicated to you, effective January 1, 2025, Anthem may incorporate insights from the Blue National Physician Performance Dataset (Dataset) in various initiatives. For Anthem national accounts and certain out-of-area providers, Anthem will use data made available in the Dataset to assess individual physician’s performance at the NPI level. The individual physician’s performance is assessed across the three domains — cost of care/efficiency, quality of care, and appropriateness of care — for the following 16 primary care and specialty areas: cardiothoracic surgery, cardiovascular disease, endocrinology, neurology, ob/gyn, ophthalmology, orthopedics, pediatrics, primary care, pulmonology, surgery, urology, gastroenterology, otolaryngology, oncology, and radiation oncology.

The providers who qualify for the designation from this Dataset program will also be referred to as Anthem Diamond Providers (National).

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

At a glance:

• Care providers must prepare for HEDIS^® medical record reviews starting January 2025.
• Care providers will submit records through Remote Electronic Medical Record (EMR) Access Service, website upload, fax, secure file transfer protocol (SFTP), mail, or on-site.
  

Background

Each year, we perform a review of a sample of our members’ medical records as part of the HEDIS quality study. HEDIS is part of a nationally recognized quality improvement initiative and is used by the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and several states to monitor the performance of managed care organizations.

We will begin requesting medical records in January 2025. No special authorization is needed for you to share member medical record information with us since quality assessment and improvement activities are routine parts of healthcare operations.

Ways to submit your records in our preferred order:

• Remote EMR Access Service: We offer the Remote EMR Access Service to care providers to submit member medical record information to us. If you are interested in more information, contact us at Centralized_EMR_Team@anthem.com.
• Upload: Medical records can be uploaded to our secure website using the instructions in the request document.
• Fax: Medical records can be faxed to us using the instructions in the request document.
• SFTP: Medical records can be uploaded via a secure website.
• U. S. Postal Service: Medical records can be mailed to us using the instructions in the request document.
• On-site: Medical records can be pulled by a representative at your local office where medical records are located.

HEDIS review is time sensitive, so submit the requested medical records within the timeframe indicated in the initial HEDIS request document.

We appreciate the care you provide our members. Your assistance is crucial to ensuring our data is statistically valid, auditable, and accurately reflects quality performance.

Contact us

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 https://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 of our provider website for the appropriate contact.

The Consumer Assessment of Healthcare Providers and Systems® (CAHPS) is an annual standardized survey conducted anonymously by a third-party vendor (Center for the Study of Services) to assess a random sample of consumers' experiences with their health plan, their personal provider, and healthcare services.

Refer to attachment to view full details.