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

Submit updates and corrections to your online directory information by using our online Provider Maintenance Form. Once you submit the form, we will send you an email acknowledging receipt of your request. 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

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. Reviewing your information helps us ensure your online provider directory information is current.

The Statin Therapy Exclusions for Patients With Cardiovascular Disease (SPC) HEDIS^® measures examines the percentage of patients with atherosclerotic cardiovascular disease (SPC) or with diabetes who received and adhered to statin therapy throughout the measurement year. However, statin therapy does not work for everyone, and alternative therapies are necessary to minimize their risk for future complications. If you have patients who cannot tolerate statin therapy, it is important that you document and notify us annually so we can exclude the patients from your list of open care gaps. Refer to NCQA guidelines for a complete listing of exclusion criteria.

How to submit exclusion data:

• Indicate the appropriate ICD-10 code for encounters.
• Use standard data file submission or EMR/EHR access for supplemental data collection.

Exclusions are applied based on diagnosis codes on the date of service provided on the claim or through supplemental data collection. Based on the timing of your data submission and when reports are generated, it may take several weeks for exclusions to be reflected on your reports.

Please note, if exclusions are not coded properly or given to HealthKeepers, Inc. in the proper format, the care gap will remain open until the failure reason is corrected. Patients listed on the open care gap report are assumed to tolerate statin therapy and will have their care gaps closed after claims for moderate to high intensity statins are adjudicated by HealthKeepers, Inc.

Tips for implementing best practices and improving your quality scores:

• Educate your patients on the importance of adhering to their statin therapy regime and on potential side effects. If they start to experience muscle pain or weakness, have them contact you to discuss their options.
• Statin therapy should also be accompanied by lifestyle modifications, such as a healthy diet and exercise. Work with your patients to proactively identify and overcome any barriers that may prevent lifestyle modifications. Discuss creating a realistic, individualized exercise routine based on the patient’s ability and interests. Encourage a healthy diet based on the patient’s culture and locally available produce, stores, and resources.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at (800) 901-0020. 

On July 1, 2022, we communicated that HealthKeepers, Inc. would begin to implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service is billed with a problem-oriented E/M service and appended with modifier 25 (Provider News article). We have since decided to limit this review for claims for members aged 22 and older. Subsequently, we have updated the impacted CPT^® codes. For your convenience, we are including an updated communication below:

HealthKeepers, Inc. will implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service (CPT codes 99385-99387 or 99395-99397) is billed with a problem-oriented E/M service (CPT codes 99202-99215) and appended with modifier 25 (for example, CPT code 99395 billed with CPT® code 99213-25). This review is limited to claims for members aged 22 and older.

According to the American Medical Association (AMA) CPT Guidelines, E/M services must be significant and separately identifiable in order to appropriately append modifier 25. Based upon review of the submitted claim information, if the problem-oriented E/M service is determined not to be a significant, separately identifiable service from the preventive service, the problem-oriented E/M service will be bundled with the preventive service.

Providers who believe their medical record documentation supports a significant and separately identifiable E/M service should follow the claims payment dispute process (including submission of such with the dispute) outlined in the provider manual.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at  800-901-0020.

Effective for dates of service on and after July 1, 2023, the following codes will require prior authorization through Carelon Medical Benefits Management (formerly AIM Specialty Health_®).*

As a reminder, ordering and servicing providers may submit prior authorization requests for Commercial consumers to Carelon in one of several ways:

• Access Carelon’s ProviderPortal_SM directly at providerportal.com:
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

If you have questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Make sure your correspondence includes one of these elements

The best way to send supporting documents when disputing, appealing, or sending us additional information about a claim is to use the digital applications available on Availity.com.* Using Availity.com to send attachments, such as medical records or an itemized bill, is:

• We’ll receive the documents needed faster than through the mail.
• Less expensive. No need to pull records, copy them, and then mail them. Digital submissions can be uploaded directly to the claim.
• Submitting attachments digitally is the easiest way to send them and the best way for us to receive them.
• More accurate. The information needed to identify the claim is automated, so the risk associated with submitting incorrect information on paper is eliminated.

However, if you choose to send documentation through the mail, it is important that you include at least one of the three following elements; otherwise, we will not be able to match the document to the claim and the correspondence will be returned to you, causing further delays:

1. Valid claim number and valid member ID
   or

2. Valid member ID with prefix and correct dates of service
   or

3. Valid member ID with prefix and billed charges

For a clinical appeal, ensure these elements are included:

1. Valid claim number and valid member ID
   or

2. Valid member ID with prefix and correct dates of service
   or

3. Valid member ID with prefix and billed charges
   or

4. Member name, member date of birth, and correct dates of service
   or

5. Member name, member date of birth, and authorization or reference number

This is important: We cannot match the attachment to the correct claim or member if these elements are not included with your non-digital (fax or mail) submission.

The preferred method for submitting supporting documentation is digitally because the documents are attached directly to the claim. This reduces the possibility that incorrect information is included on the paper submission.

To attach documents to your claim digitally, go to Availity.com and use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim and use the Submit Attachments button to upload your supporting documentation.

For a claim dispute or an appeal, from Availity.com, use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim, use the Dispute button, and upload your supporting documentation. If the Dispute button capability is not available, refer to the provider manual for information about how to file a claim dispute/appeal.

If you do send supporting documentation through the mail or fax, you must include the elements noted above. It is preferrable that you include this information on the first page of the correspondence you send to us. If this information is not included on your paper correspondence, we will return the correspondence to you because we are not able to validate the documentation.

For information about submitting attachments digitally, use this link to access Availity: Learn about the new claim attachments workflow.

Effective August 1, 2023, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem Blue Cross and Blue Shield (Anthem) members as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management cardiology, genetic testing, and radiology programs. The clinical guidelines and medical policies that have been adopted by Anthem to be used for medical necessity review are in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on July 17, 2023, for dates of service August 1, 2023, and after.

Members included in the new program

All fully insured (FI), self-funded (ASO) and national members currently participating in the Carelon Medical Benefits Management programs listed below are included. For self-funded (ASO) groups that currently do not participate in the Carelon Medical Benefits Management programs, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of August 1, 2023.

Members of the following products are excluded: Medicare Advantage, Medicaid, original Medicare, Medicare supplement, Medicare Advantage Group Retiree Solutions, Federal Employee Program® (FEP®).

Pre-service review requirements

For procedures that are scheduled to begin on or after August 1, 2023, all care providers must contact Carelon Medical Benefits Management to obtain pre-service review for the following nonemergency modalities. Please refer to the program microsite resource pages for complete code lists.

To determine if prior authorization is needed for a member on or after August 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. (Note: Providers cannot use the Interactive Care Reviewer (ICR) tool on Availity Essentials* to pre-certify an outpatient procedure or any requests for services administered by Carelon Medical Benefits Management)

Providers should continue to submit pre-service review requests to Carelon Medical Benefits Management using the convenient online service via the Carelon Medical Benefits Management ProviderPortal_SM. ProviderPortal is available 24 hours a day, seven days a week, processing requests in real-time using Clinical Criteria. Go to Carelon Medical Benefits Management to register.

For more information

Visit the resources below to help your practice get started with the radiology, cardiology, and genetic testing programs.

Our special websites help you learn more and access helpful information and tools such as order entry checklists, clinical guidelines, and FAQ.

You can also reach out to your local Network Relations representative.

Resources:

• Carelon Medical Benefits Management, Inc. genetic testing program
• Carelon Medical Benefits Management, Inc. cardiology program
• Carelon Medical Benefits Management, Inc. radiology program

Effective July 1, 2023, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are implementing a new guideline related to submission of certain clinical data that builds upon our 2021 guideline regarding sharing of admission, discharge, and transfer (ADT) notifications.

When requested by Anthem, providers shall submit clinical data (such as discharge summaries, consult notes, and medication lists) and ADT data to Anthem for certain healthcare operations functions. We collect this data to improve the quality and efficiency of healthcare delivery to our members. Providers shall submit:

• ADT data to Anthem or state-designated Health Information Exchange on a near real-time basis (no later than 24 hours) from time of admission, discharge, or transfer of a member.
• Clinical data for a member on a daily, weekly, or monthly basis, based on the provider's electronic medical record (EMR) or other electronic data sharing capabilities.

Anthem permitted uses of the data with respect to clinical data requests include:

• Utilization management.
• Case management.
• Identification of gaps in care.
• Conducting clinical quality improvement.
• Risk adjustment.
• Documentation in support of HEDIS^® and other regulatory and accrediting reporting requirements, and for any other purpose permitted under HIPAA.

Anthem has determined the data requested is the minimum necessary for Anthem to accomplish our intended purpose. The data will be provided in accordance with data layout and format requirements defined by Anthem. 

We value you as our partner in providing quality care and appreciate your continued participation in our networks.

On March 26, 2023, Carelon Medical Benefits Management Inc. (formerly AIM Specialty Health)* released operational enhancements to the ProviderPortal_SM for the Medical Oncology Program for Anthem Blue Cross and Blue Shield. These enhancements are geared towards creating an easier intake process for users. You may notice the clinical intake screens look and function differently.

A few updates will include:

• Improved look and feel of the case entry screens.
• Removal of unnecessary biomarker questions for specific clinical scenarios.
• Revised drug dosing screens for easier input of cycle ranges and days of administration.

Resources, training, and support 

To familiarize yourself with the enhanced medical oncology authorization request process, Carelon will be hosting a series of provider training sessions. Please register to receive a unique meeting invite.

 For more information 

Carelon has a designated email address for provider questions about the ProviderPortal and case entry process; please use MedicalOncologySolution@carelon.com. All member eligibility or claims questions should be directed to your health plan network representative. Thank you for your continued support of this program.

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: commonhelp.virginia.gov
  • Via phone: 833-522-5582
  • Via mail: Send to your local social service agency

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.

If your practice is looking for ways to improve your vaccination strategy and help protect the health of your patients through vaccines, we can help. Let’s Vaccinate provides ready-to-use resources and strategies to help your care team increase vaccination rates.

Let’s Vaccinate https://www.letsvaccinate.org/ was redesigned to help you increase vaccination rates among your patients through ready-to-use resources that focus on the two main strategies that most directly impact your vaccination rates: one) optimizing your office workflows and two) enhancing patient engagement.

Optimizing office workflows

Let’s Vaccinate can help your care team improve office workflows during and after office visits, as well as for proactive patient outreach. The website includes resources and strategies for:

• Leveraging electronic health record systems (EHR) to help with vaccine assessments, reminders, and documentation.
• Customizing outreach to influence your patients’ decisions to get vaccinated.
• Implementing recommended office workflows to help ensure that patients are getting the vaccines they need.

Enhancing patient engagement

Let’s Vaccinate can help your care team improve patient communication by allowing them to better understand the many social, geographic, political, economic, and environmental factors that create challenges to vaccination access, and address patients’ feelings about vaccine safety. The website includes resources and strategies for:

• Making strong recommendations.
• Addressing vaccine hesitancy and disparities.
• Using effective patient education handouts and toolkits.

Keeping your patients healthy and safe requires the collaboration of your entire care team. The power is in your hands. So, let’s get started!

Let’s Vaccinate is a collaboration of health plans, HealthyWomen, and Pfizer Inc.

Q: What is Pay Doctor Bill? 

A: Anthem contracted with a vendor to deliver options for consumers to view their claims and pay their out-of-pocket responsibility to doctors from the Sydney Health mobile app or from https://www.anthem.com/provider. This is not related to the payment of health insurance premiums.

Q: What is happening with the Pay Doctor Bill option? 

A: Anthem will stop offering this option to consumers effective March 31, 2023.

Q: Why is Pay Doctor Bill going away?

A: This was not a good overall consumer (and provider) experience. We are always committed to keeping consumers at the center of everything we do and will be exploring other options.

Q: What other options will consumers have to pay doctor bills? 

A: Even though this option will no longer be available, consumers still have other ways of paying doctors:

• Through a Health Savings Account (HSA) or Flexible Spending Account (FSA) if they have this type of account
• Through the consumer’s bank’s bill pay feature on a mobile app or website
• Directly through the doctor’s secure payment website or at the doctor’s office with a debit or credit card

Q: How will consumers be notified that the feature is going away? 

A: A month prior to the Pay Doctor Bill option being removed from the Sydney Health mobile app and the Anthem website, we will notify consumers within these applications.

Q: How will providers be notified that the feature is going away? 

A: Providers will be notified about these changes in the March 1, 2023, provider newsletter.

Q: Who is the vendor that provides consumers with access to this provider payment option?

A: InstaMed* is the name of the vendor.

To align with correct coding guidelines for HCPCS code G0463, HealthKeepers, Inc. is updating its outpatient facility editing system. For Medicaid claims processed on or after May 1, 2023, when HCPCS code G0463 is billed with an inappropriate revenue code, it will be denied. According to correct coding guidelines, HCPCS code G0463 is for hospital outpatient clinic visits or assessment and management of a patient and should only be billed with revenue codes that support the billing of clinic visits, assessments, and management services including the following:

• Clinic (0510 to 0517, 0519, 0520)
• ER urgent care (0456)
• Treatment room (0761)

For assistance with coding guidelines, please refer to the CPT^® coding guidelines. If you believe you have received a denial in error, please follow the Anthem HealthKeepers Plus standard claim payment dispute process as outlined in the provider manual.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.

The American College of Obstetricians and Gynecologists (ACOG) recommends having a conversation with your patient in their third trimester regarding immediate postpartum placement of long-acting reversible contraception (LARC) as an effective option for postpartum contraception. There are few contraindications to postpartum intrauterine devices and implants.¹

The reimbursement from HealthKeepers, Inc. is the same for immediate postpartum placement and outpatient placement of LARC. Please follow the American Academy of Pediatrics guidance and provide additional counseling and support to your teenage and young patients (ages 13 to 19), as this group is at the greatest risk for early discontinuation of these methods.² Additional information about postpartum placement of LARC can be found at acog.org.

How this benefit works

During an inpatient facility admission, you can implant the covered device of your patient’s choice and receive the same reimbursement from HealthKeepers, Inc. as if the device was implanted in an outpatient setting. The inpatient facility will provide the device. Please work closely with your OB unit to understand the logistics of obtaining devices.

LARC FAQ

Q: When should providers insert an intrauterine device (IUD) or Nexplanon^® postpartum?

A: Providers can insert IUDs in the postpartum period:

• Within 10 minutes after delivery of the placenta.
• Up to 48 hours after delivery.
• At the time of cesarean delivery.

Q: When should patients avoid postpartum IUD placement?

A: Immediate post-placenta insertion should be avoided in patients with a fever. Additionally, patients with rupture of membranes greater than 36 hours before delivery, a postpartum hemorrhage, or extensive genital lacerations should be referred for interval insertion.

Q: What are the CPT^® codes associated with IUD and Nexplanon insertion in the hospital setting?

A: The CPT and associated ICD-10-CM codes are unchanged for the hospital setting:

• 11981 — insertion, nonbiodegradable drug delivery implant
• 58300 — insertion of an IUD

Q: Does placement of an IUD in the postpartum period increase a woman’s chance of infertility in the future?

A: No, there is no data to suggest that there is any adverse effect on future fertility. Baseline fecundity has been shown to return rapidly after IUD removal.

Q: Is there a greater rate of IUD expulsion with postpartum placement of an IUD?

A: “Expulsion rates for immediate postpartum IUD insertions are higher than for interval or postabortion insertions, vary by study, and may be as high as 10 to 27%. Research is underway to determine whether levonorgestrel IUDs have different expulsion rates than copper devices in the immediate postpartum setting. Women should be counseled about the increased expulsion risk, as well as signs and symptoms of expulsion. Replacement cost may vary by insurance plan, and a woman who experiences or suspects expulsion should contact her obstetrician-gynecologist or other obstetric care provider and use a back-up contraceptive method.”³

Q: When should patients be seen in follow-up?

A: Patients should be seen between 7 to 84 days after delivery. For a complicated pregnancy or birth, the patient should be seen sooner rather than later. Many patients resume intercourse before their postpartum checkup. To prevent unintended pregnancies, it is important to confirm that the device is still in place.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at  800-901-0020.

1 Immediate Postpartum Long-Acting Reversible Contraception. Committee Opinion No. 670. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016; 128:e32–7.

2 Contraception for Adolescents. Committee On Adolescence. Pediatrics Oct 2014, 134 (4) e1244-e1256; DOI: 10.1542/peds.2014-2299

3 The American College of Obstetricians and Gynecologist Committee Opinion. Immediate Postpartum Long-Acting Reversible Contraception Number 670, August 2017.

acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/08/immediate-postpartum-long-acting-reversible-contraception

• Clinical Criteria updates
• Prior authorization requirement changes
• Provider orientation and training
• Change to vaccine age limitations

Medicare Advantage allows coverage of online evaluation and management services for an established patient when all requirements have been met. The communication between patient and doctor is a cumulative of seven days and with at least the minimum of the minutes for the CPT^® code being billed. Any services amounting to less than five minutes would not be appropriate to bill as an e-visit

Here is a communication by CMS to help with further questions,

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.

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 NexLync. Go to https://providers.carelonmedicalbenefitsmanagement.com/postacute/provider-materials/anthem-provider-resources/ to get started. You can upload clinical information and check the status of your requests through this online tool 24 hours a day, seven days a week. 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 from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to Carelon Post Acute Solutions at 833-311-2986.

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 https://providers.carelonmedicalbenefitsmanagement.com/postacute/provider-materials/anthem-provider-resources/ or email provider_network@carelon.com.

* Carelon Post-Acute Solutions, LLC is an independent company providing services on behalf of the health plan.
MULTI-BCBS-CR-019705-23 

• Clinical Criteria updates
• Clinical Criteria updates
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list
• Blue Cross and Blue Shield expands specialty pharmacy precertification list
• New specialty pharmacy medical step therapy requirements
• Genetic testing CPT code list update for Carelon Medical Benefits Management (formerly AIM Specialty Health)