Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are working to comply with Virginia legislative House Bill (HB) 139 that became effective July 1, 2018.  If you are a medical doctor (MD) or doctor of Osteopathy (DO) under review to be credentialed for participation in provider networks offered by Anthem and HealthKeepers, Inc., HB 139 will allow you to see Anthem patients and retroactively receive payments if you are ultimately credentialed. 

This means that on or after July 1, 2018, and you are a MD or DO who submits a credentialing application to us, Anthem and HealthKeepers, Inc. will adhere to the requirements specified in HB 139.  Requirements in the bill do not apply to credentialing applications that were submitted BEFORE July 1 but which are still being processed after the July effective date.

Under the new law, we are required to establish protocols and procedures for reimbursing MDs and DOs – at the contracted in-network rate – for approved, covered health care services that are provided during the period in which a physician's credentialing application is pending.  Effective July 1 under HB 139, the credentialing period begins with the receipt of a fully completed credentialing application.  Incomplete credentialing applications and denied applications are excluded.

What lines of our business are impacted?

Members enrolled in the following health benefit plans are impacted by the new state legislation:

• Anthem’s PAR/PPO health benefit plans

• HealthKeepers, Inc.’s Anthem HealthKeepers (commercial, non-Medicaid) health benefit plans. This includes health plans members purchase on or off the Health Insurance Marketplace (commonly referred to as the exchange).

• Commonwealth of Virginia COVA Care and COVA HDHP health benefit plans, the Local Choice (TLC) health benefit plans, and the Line of Duty (LODA) health benefit plans.

• Medicare Supplement health benefit plans.

Those lines of business NOT impacted are:

• Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP).

• Administrative services only (ASO) health plans.

• HealthKeepers, Inc.’s Anthem HealthKeepers Plus/FAMIS (Medicaid) health plans

• Medicare Advantage health plans

Impact to physicians – call to action

Hold claims for Anthem members:  During the credentialing period, MDs and DOs should hold claims for our members until Anthem sends a final notification of a credentialing decision.  If you submit claims to Anthem during the credentialing period before receiving a credentialing decision, claims will be rejected indicating that the claims must be resubmitted upon a final credentialing decision.  Members will be protected from inappropriate billing and held harmless during this period.

Patient Financial Responsibility:  Upon receiving notice of Anthem’s final credentialing approval, MDs and DOs may collect any applicable member cost shares based on members’ health benefit plans as appropriate.  Physicians with approved credentialing applications are required to submit claims under their contract with Anthem and HealthKeepers, Inc.  Those with denied applications, while not obligated to so do, are encouraged to file claims to us on behalf of members to help speed claims processing and payments as appropriate.  As always, we encourage you to verify eligibility and benefits for members via our secure Web-based provider tool – Availity. 

Notify Anthem members as required by HB 139:  In order to submit claims pursuant to HB139, MDs and DOs are required to take the following actions regarding members enrolled in health benefit plans offered by Anthem and HealthKeepers, Inc.:

• Notify members – either in writing or electronically – stating that the physician’s credentialing application has been submitted to Anthem and is under review.

• Provide the notice in advance of providing treatment to members.

• Include in the notice to members certain credentialing information as outlined in HB 139. Please refer to the legislation for actual requirements and how they impact you.

Questions

At Anthem Blue Cross and Blue Shield in Virginia, we are committed to continuously improving the way we do business with our network participating providers in the community.  To that end, we have listened to your feedback and are pleased to announce that over the next month or so a new look and feel is coming to our Network Update provider newsletter and the Communications page on the Virginia section of the anthem.com provider website. The new design of Network Update will allow you to easily read and print individual articles that pertain to your practice or facility.

While the Communications page may look a little different in the coming months when you visit, we hope that the new design will allow you the flexibility to more easily find the specific Anthem communications that are important to you and your practice or facility.

On October 10, 2018, Anthem will offer our final provider education webinar for the year. Designed for our network-participating providers, the webinars address Anthem business updates and billing guidelines that impact your business interactions with us.

For your convenience, we offer these informative, hourly sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the last scheduled webinar for 2018 is:

• Wednesday, October 10, 2018, from 10 a.m. to 11 a.m. ET

Please take time to register today for the webinar using the attached registration form under "Article Attachments."  If you have already registered for the October webinar, please ensure you have received a fax confirmation or a confirmation from an Anthem representative to ensure we’ve received your registration form.  Please contact joyce.lindley@anthem.com if you need to confirm your registration.

By the end of 2018, members enrolled in health plans offered by Anthem Blue Cross and Blue Shield and HealthKeepers, Inc. will begin receiving a new explanation of benefits (EOB) that is designed to help members better understand their health care benefits and out-of-pocket expenses. The new design will look more like a health care summary. EOBs will continue to include important information about services rendered, the amount paid to the provider, and the member out-of-pocket expense. The new EOB will also include:

• Ways members can save on health care expenses
• A preventive care checklist, sharing important screenings that were missed
• A summary of the member’s most recent claims

Learn more about our newly designed EOB.

In the June edition of our Network Update provider newsletter, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. announced the introduction of a streamlined member identification (ID) card coming July 1, 2018, to help reduce confusion about members’ cost shares.  The updated member ID cards maintain the current style, but specific cost share information (such as copayments, deductibles and coinsurance) will be absent from cards.  In addition, there may be alpha prefix and other changes to members’ ID cards, so please check members’ ID cards carefully.  The new simpler and easier to read ID cards are available to groups over time as they renew coverage with Anthem and HealthKeepers, Inc. 

Use Availity and EDI to verify eligibility, members’ cost shares and benefits at time of service

Since the cost share information will no longer display on many of our ID cards, we urge providers to access Availity (our secure Web-based provider tool) and the Electronic Data Interchange (EDI) to verify member benefits and eligibility to obtain the most up-to-date cost share information in order to collect the applicable deductibles and coinsurance amounts at the time of service as appropriate.  If a member presents an older ID card with outdated benefits at the provider office, it can create confusion about the member’s cost share.

As always, please request that members enrolled in our health benefit plans present their most current ID cards at the time of service.  When filing claims to Anthem and HealthKeepers, Inc., enter members’ ID numbers exactly as the numbers appear on the card – including the alpha prefix – to help speed claims processing and reimbursement.

As the streamlined ID cards are adopted over time, it will help reduce misunderstandings around cost shares since real-time information is readily available via Availity about members’ benefits and cost shares.  Additionally, members will be encouraged to learn more about their benefits through Anthem’s digital and online tools. Members can retain their cards for as long as they remain in the same product plan, regardless of changes to cost share information.

Electronic ID cards

As a reminder, members can now view, download, email, and fax an electronic version of their member ID cards using the Anthem Anywhere mobile app. And because our electronic ID cards look just like our physical ID cards, members can show either an electronic or physical ID card when obtaining services.

Please note, this notice does NOT apply to National Accounts, the Federal Employee Program® (FEP), Medicaid or Medicare plans.

For questions, please contact the provider service number on the back of members’ ID cards. We’ve included two examples of our simplified ID cards under "Article Attachments."

Samples of simplified member ID cards (front and back) are provided for illustration purposes only.

To better assess measures of quality for our members, Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. will begin requiring documentation of a newborn’s gestational age at the time of delivery for all physician delivery claims.

Beginning with dates of service on and after November 1, 2018, all professional delivery claims (59400, 59409, 59410, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620 and 59622) will require an ICD-10 Z3A code indicating the newborn’s gestational age at the time of delivery. If the code is not found on the claim, the claim will be denied with the following reason:

 “Delivery diagnoses incomplete without report of pregnancy weeks of gestation. You may resubmit the corrected claim with the appropriate ICD-10 code for payment.”

Anthem will accept HCPCS code C9257 – when a physician is reporting Avastin – for Intravitreal Treatment for Retinal Vascular Conditions. Non-ophthalmologic indications should not be billed under C9257.

Professional billing of HCPCS code C9257 will ensure that the appropriate reimbursement is paid for this specific treatment. Physicians should no longer report codes J3490, J3590, J9035, or J9999 for Avastin used in intravitreal injections. Anthem has established a professional reimbursement allowance for code C9257 and will allow a maximum of five units per injection, per eye, per date of service. This reporting and reimbursement change impacts members enrolled in our commercial PAR/PPO and Anthem HealthKeepers plans only (excludes Medicaid).

Effective for professional claims (CMS-1500) processed on or after November 18, 2018, Anthem Blue Cross and Blue Shield will enhance our editing systems to automate edits supported by correct coding guidelines, as documented in industry sources such as CPT, HCPCS Level II, and International Classification of Diseases 10 (ICD-10).  As a result, there will be greater focus on identifying incorrect or inappropriate billing of services by multiple providers within the same tax identification number for the same patient on the same day. This 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.

Below are examples of claim edits that will be automated:

• Accurate reporting of modifiers, including LT, RT, 54, 55, 56, 62,76, 77, 78, 79, 80, 81, 82, and AS, which are often reported for the billing of services rendered by the same provider or multiple providers.

• Ensuring global, professional (modifier 26) and technical components (modifier TC) are billed appropriately by one or more providers in facility and office settings.

• Assessing whether services considered once in a lifetime have been billed more than once.

• Ensuring the reporting of procedures and the associated diagnosis codes are correctly reported together.

The Affordable Care Act (ACA) requires many health plans to cover recommended preventive care services without member cost sharing when the services are rendered by an in-network provider and/or facility. Screening colonoscopies (even when polyps are removed) are included as a covered preventive care service. Since colonoscopies are rendered for both screening and diagnostic purposes, it is very important for providers to use appropriate coding guidelines when reporting colonoscopies. When inappropriate CPT and ICD-10 codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.

The following services are covered with no member cost share:

• The colonoscopy screening procedure.

• Anesthesia charges when anesthesia is billed with the appropriate screening CPT code (even when polyps are removed).

• Other associated facility charges when the colonoscopy is billed with an appropriate screening diagnosis code.

• When polyps are removed during a screening colonoscopy – the removal, examination and analysis of the polyps.

Anthem Blue Cross and Blue Shield and our affiliate Healthkeepers, Inc. would like to remind all participating providers of their contractual obligation to ensure our members have prompt access to care and services. We use several methods to monitor adherence to these standards, and those methods include:

a.  Assessing the availability of appointments via phone calls by our staff or designated vendor to providers’ offices.

b.  Analysis of members’ complaint data.

c.  Analysis of members’ satisfaction.

Providers are expected to make best efforts to meet these access standards for all members.  

Guidelines for primary care physicians (PCPs):

• Preventive care – Members scheduling periodic routine exams (well care/preventive visits), appointments should be available within 60 calendar days of a member’s call. Care provided to prevent illness or injury.

• Urgent care appointment with acute symptoms – Appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care.

• Routine check-up – Members must have access to care within 10 business days of their call. Care provided for non-symptomatic visits for health check.

• After-hours access – Members must have access to care 24 hours a day, 7 days a week, 365 days a year. PCPs must arrange after-hours care to provide 24-hour coverage for our members by a network provider during non-business office hours. Members should have the ability to reach a recorded message or a live voice providing instructions on how to access care for emergencies and conditions requiring urgent attention.

Guidelines for specialists:

• Urgent care appointment with acute symptoms – Appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care.

• Routine check-up – Members must have access to care within 30 calendar days of their call. Care provided for non-symptomatic visits for health check.

Guidelines for behavioral health practitioners (BHPs):

• Non-life threatening emergency needs – Members must be seen, or have appropriate coverage directing the member, within six (6) hours. Emergent behavioral health care provided when a member is in crisis, experiencing acute distress and/or other symptoms and needs immediate attention; no risk of loss of life.

• Urgent needs – Members must be seen, or have appropriate coverage directing the member, within 24 hours. Non-emergent behavioral health illness that requires immediate care; member is experiencing significant psychological distress with symptoms that impairs daily functioning; no risk of loss of life.

• Initial routine office visit – Members must be seen within 10 business days. New patient non-urgent appointment scheduled after intake assessment or a direct referral from a treating practitioner.

• Follow-up Routine visit – Members must be seen within 30 calendar days. Non-urgent behavioral health care; member has been scheduled for a non-urgent consultation or requires services including, but not limited to, follow-up and existing medication management.

• After-hours access – Members must have access to care 24 hours a day, 7 days a week, 365 days a year. Must have arrangement for after-hours care to provide 24-hour coverage for our members by a network provider during non-business office hours. Members should have the ability to reach a recorded message or a live voice providing instructions on how to access care for emergencies and conditions requiring urgent attention.

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines that are available to providers on our website.  The guidelines – which are used for our quality programs – are based on reasonable medical evidence.  In addition, the guidelines are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

Visit anthem.com for updates, as we continue to post information on our dedicated web pages regarding health care reform and the health plans HealthKeepers Inc. is offering on and off the exchange.   Click either of these Web pages Health Care Reform or Health Insurance Exchange for more information, and refer back to these pages often. 

As previously communicated in the December 2017 Network Update provider newsletter, Anthem Blue Cross and Blue Shield has established a contractual relationship with Alliant Health Solutions to assist us in validating provider compliance with applicable reimbursement guidelines and to identify instances of incorrect billing for behavioral health services.  Alliant – a behavioral health audit and review company – will examine Anthem’s outpatient behavioral health claims data.  Alliant has initiated the work, and your compliance is required should you receive a request for information. 

Utilizing systematic sampling methodology and a broad range of algorithms, the audits and findings will be customized to support Anthem’s expectations as outlined in the Anthem Provider Manuals and related guidelines and procedures.  Alliant’s findings may result in provider audits and record reviews, education and other direct outreach. 

Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. have designated Availity – a secure Web-based provider tool – to become our Electronic Data Interchange (EDI) gateway.  This effort is currently underway, and we are committed to providing transparency throughout this process.

All EDI submissions currently received today via the Anthem EDI gateway can now start to transition to the Availity gateway. All Anthem EDI claims submitted will adjudicate the same way; it’s just the entry point (EDI gateway) which is changing to Availity.  With this new process, there is no impact to your participation status with Anthem and no impact on how your claims adjudicate.

If you currently use a clearinghouse to submit your claims and other transactions electronically, you can contact your clearinghouse to validate the transition dates to the Availity gateway. If your clearinghouse notifies you of changes regarding connectivity, workflow, or the financial cost of EDI transactions, you have the option of submitting directly through Availity at no cost.

Your organization can register with Availity to submit the following transactions:

• 837 – Institutional

• 837 – Professional

• 837 – Dental

• 835 – Electronic Remittance Advice

• 276/277 – Claim Status – real-time

• 270/271 – Eligibility – real-time

Next steps:

• Anthem and Availity will continue to communicate and provide assistance with this transition going forward.

• Availity will work directly with all trading partners to help ensure a smooth transition.

• You may utilize Availity to transmit your electronic claims and other EDI transactions as a fully subsidized option – at no charge to you.

How to register with Availity:

• If your organization is not already registered with Availity, you can go to availity.com. Click REGISTER and then follow the steps to register.

• Look for emails from Availity containing your log-in credentials.

• If your organization is already registered with Availity, you can log in and click My Providers | Enrollments Center if you need to complete a new 835 enrollment or make changes.

Anthem Blue Cross and Blue Shield is working with Accordant Health Services to provide targeted disease management services for members with rare medical conditions, including: 

• Epilepsy (Seizures)
• Rheumatoid Arthritis (RA)
• Human Immunodeficiency Virus (HIV)
• Multiple Sclerosis (MS)
• Crohn's Disease (CD)
• Ulcerative Colitis (UC)
• Parkinson's Disease (PD)
• Systemic Lupus Erythematosus (SLE or Lupus)
• Myasthenia Gravis (MG)
• Sickle Cell Disease (SCD)
• Cystic Fibrosis (CF)
• Hemophilia
• Scleroderma
• Polymyositis
• Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
• Amyotrophic Lateral Sclerosis (ALS)
• Dermatomyositis
• Gaucher Disease

Members in your care who may benefit from additional outreach and information may receive letters or phone calls from AccordantCare and Anthem. In the course of performing these activities, a nurse may contact you or your facility to obtain member information and/or AccordantCare may request medical information about Anthem members. AccordantCare and Anthem also will let you know of any health changes that may require your attention.

If you would like to refer a member to this program, please contact AccordantCare at:

• Phone or Fax: 1-866-247-1150

• Web: https://referral.accordant.com

Anthem Blue Cross and Blue Shield’s Care and Cost Finder tool provides many Anthem members with the ability to search and compare cost and quality measures for in-network providers using the secure member portal at anthem.com. The Care and Cost Finder tool currently offers multiple sorting options, such as sorting providers based on distance or name.

Beginning October 14, 2018, Care and Cost Finder will have a new sorting option called “Personalized Match.” The sorting option is based on algorithms which will use a combination of provider location, quality, cost results and member information to intelligently sort and display results for a member’s search. The sorting results will take into account member factors such as the member’s medical conditions, and medications as well as provider factors such as areas of specialty, quality and efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures.

These member and provider features will be combined to generate a unique ranking of providers for each member conducting the search. Providers with the highest overall ranking within the search radius will be displayed first with other providers displayed in descending order based on overall rank and proximity to the center of the search radius.

Members will continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology will have no impact on member benefits.

• Providers may review a copy of the new sorting methodology here.

• If you have general questions about the Care and Cost Finder tool or this new sorting option, please contact Provider Customer Service.

• If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-5250.

Last year, Anthem Blue Cross and Blue Shield shared information about the authorization process for home sleep testing.  Once again, we are including a reminder about the process in this edition of the Network Update.  The authorization process for home sleep testing (HST) with NovaSom is designed to be simple for ordering physicians. NovaSom is a network participating provider of home sleep testing equipment and interpretation. 

Anthem delegates the management of sleep testing and treatment services to AIM Specialty Health® (AIM) on our behalf. To request an authorization for HST with NovaSom, just contact AIM toll free at 1-866-789-0158 (weekdays, 8 a.m. to 5 p.m. EST) or via Availity (see below).

If your authorization request is approved, an order is automatically sent to NovaSom for you. There is no need to contact or fax an order form to NovaSom on your patient’s behalf.

Home sleep testing with NovaSom

Anthem members suspected of having noncomplicated obstructive sleep apnea have the ability to test at home using NovaSom’s AccuSom® wireless HST device. AccuSom wireless sleep studies are performed in the patient’s home and self-administered, which may be more comfortable and reflective of typical sleep behaviors than those provided in a lab.

NovaSom provides telephonic clinical support. All data is wirelessly transmitted from the AccuSom sleep testing device to the NovaSom secure portal during the test process. Data is reviewed by sleep technicians to help promote quality.  Daily clinical telephonic support is provided to coach the patient throughout the testing process. Once the study is complete, a board-certified sleep physician interprets the study and provides a report with treatment recommendations. The goal is to provide reports within 48 hours of study completion to the ordering practitioner.

Please note that this notice impacts claims for members enrolled in our Anthem PPO, Anthem HealthKeepers, Anthem HealthKeepers Plus (Medicaid), Commonwealth Coordinated Care Plus (Anthem CCC Plus), and Anthem Medicare Advantage health benefit plans.  If you have any questions about NovaSom or the authorization process, please contact your local Anthem network manager.

Accessing AIM via Availity

A key goal of Anthem’s provider transparency efforts is to improve quality while controlling health care costs. One of the ways this is done is by giving primary care physicians (PCPs) in the Enhanced Personal Health Care (EPHC) Program quality and/or cost information about the health care providers to which the PCPs refer their Attributed Members (the “Referral Providers”). If a Referral Provider is higher quality and/or lower cost, this component of the program should result in their getting more referrals from PCPs.

The converse should be true if Referral Providers are lower quality and/or higher cost. Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost information so that they can better understand how their health care dollars are being spent. This will give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

Cost Opportunity Report

• The Cost Opportunity Report is available for EPHC providers to access via Provider Care Management Solutions (PCMS).

• The report was created to help users quickly identify meaningful and actionable opportunities to optimize costs and help achieve shared savings targets within the EPHC Program.

• By providing a standard set of potential cost opportunity metrics, the Cost Opportunity Report can be used to help evaluate the relative success of providers within the EPHC Program.

• Metrics are selected based on size of financial opportunity, ability of PCPs to affect changes, mix of impacted service types, mix of utilization and unit price impact.

• Metrics are reviewed on a periodic basis and may be added, changed or removed.

We’ve heard it all our lives:  To be fair, you should treat everybody the same.  But the challenge is that everybody is not the same.  These differences can lead to critical disparities not only in how patients access health care, but their outcomes as well.

The reality is burden of illness, premature death, and disability disproportionately affects certain populations. 1  MyDiversePatient.com features robust educational resources to help support you in addressing these disparities.  You will find:

• Learning experiences about disparities, potential contributing factors and opportunities for you to enhance care while earning continuing medical education (CME) credits.

• Real life stories about diverse patients and the unique challenges they face.

• Tips and techniques for working with diverse patients to promote improvement in health outcomes.

While there’s no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com is to start reversing these trends…one patient at a time.

Accelerate your journey to becoming your patients’ trusted health care partner by visiting MyDiversePatient.com today.  Use a smartphone to scan the quick response (QR) code below and be routed directly to MyDiversePatient.com.

1 Centers for Disease Control and Prevention. (2013, Nov 22). CDC Health Disparities and Inequalities Report — United States, 2013.  Morbidity and Mortality Weekly Report. Vol 62(Suppl 3); p3.

Beginning with dates of review on and after November 1, 2018, the following updates will apply to AIM Level of Care Musculoskeletal Surgery Clinical Appropriateness Guidelines: 

Addition of criteria for observation in surgical settings, ambulatory surgical centers, and hospital outpatient departments

Addition of staff, equipment, and resource capabilities in outpatient surgery

Modifications to the inpatient admission criteria

Ordering and servicing providers may submit pre-certification requests to AIM in one of the following ways:

Access AIM ProviderPortalSM 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.

Access AIM via the Availity Web Portal at availity.com.

Call the AIM Contact Center toll-free number:  866-789-0397, Monday–Friday, 8 a.m. to 5 p.m. ET.

Effective for dates of service on and after November 1, 2018, AIM Specialty Health® (AIM), a separate company, will apply AIM’s Radiation Oncology Clinical Appropriateness Guidelines to prior authorization requests for the services noted below. These guidelines will replace certain Anthem’s radiation oncology coverage and clinical guidelines, which are being archived. This update applies to Anthem plans with radiation oncology services medically managed by AIM.

• Proton beam radiation therapy

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

• Access AIM’s ProviderPortalSM 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.

• Access AIM via the Availity Web Portal at availity.com.

• Call the AIM Contact Center toll-free number: 866-789-0397, Monday – Friday, 8 a.m. to 5 p.m. ET.

Please note, this program does not apply to the Federal Employee Program (FEP) or National Accounts.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

Archived coverage guideline

Anthem’s coverage guideline, THER-RAD.000002 Proton Beam Radiation Therapy will be archived effective November 1, 2018. This policy will be applied as a part of AIM Clinical Guidelines beginning November 1, 2018.

Beginning with dates of service on and after October 29, 2018, the following updates will apply to AIM Advanced Imaging Clinical Appropriateness Guidelines:                                                                                                                        

CT Chest guideline:

• Expanded list of diagnostic testing abnormalities that may be followed up with CT to include endoscopy, fluoroscopy, and ultrasound in addition to specific chest radiography findings

• Lengthening of timeframe required prior to imaging for chronic cough from 3 to 8 weeks, and more specifics of preliminary workup required prior to imaging

• Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging

• Allowance for use of imaging in the staging of malignancy prior to biopsy confirmation

• Allowance for imaging of suspected pulmonary embolism in pregnancy

• New criteria for appropriate imaging of chest wall mass

CT Angiography (CTA) Chest guideline:

• Allowance for imaging of suspected pulmonary embolism in pregnancy

CT Abdomen/CT Pelvis/CT Abdomen & Pelvis guideline:

• Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging

MRI Chest guideline:

• Inclusion of imaging of suspected pectoralis muscle tear

• New criteria for appropriate imaging of chest wall mass

MRI Abdomen guideline:

• Addition of hemochromatosis as an indication for imaging in pediatric patients

Ordering and servicing providers may submit pre-certification requests to AIM in one of the following ways:

• Access AIM ProviderPortalSM 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.

• Access AIM via the Availity Web Portal at com.

• Call the AIM Contact Center toll-free number: 866-789-0397, Monday – Friday, 8 a.m. to 5 p.m. ET.

As you know, Anthem Blue Cross and Blue Shield (Anthem) and our affiliate HealthKeepers, Inc. offer pregnant women several services and benefits through the Future Moms program. It is our goal to try to ensure all pregnant members are identified early in their pregnancy so they can take full advantage of the education, support, resources and incentives Anthem provides throughout the prenatal and postpartum period.

We’ve partnered with Availity – the vendor supporting the benefit look-up tool you may currently use in your obstetrics/gynecology (OB/GYN) office – to send us information about newly identified pregnant women. With a few simple steps, this new reporting process – including the HEDIS® Maternity Attestation form – helps connect patients with additional benefits as soon as possible.

How the process works for women enrolled in Anthem and HealthKeepers, Inc.’s health plans

When female members of childbearing age visit an OB/GYN’s office, the office associate is prompted to answer the question “Is the member pregnant?” during the eligibility and benefits inquiry process. If the response is “yes,” the system asks about the due date, and a HEDIS Maternity Attestation form is generated for the OB/GYN office to complete. On this electronic form, physicians are asked to provide other important information including the date of the first prenatal care visit, delivery date and postpartum visit date.  This new, user-friendly process generates timely information that aids members, providers, Anthem and HealthKeepers, Inc. in improving birth outcomes with early intervention.

We are working hard to support physicians and their staffs throughout Virginia in receiving the necessary training for the new Availity maternity attestation process. If you have specific questions about the new process, please feel free to reach out to our customer service area toll free using the telephone number on the back of members’ Anthem or HealthKeepers, Inc. ID cards.

For easy reference, we've included some common questions and responses in the attached frequently asked questions (FAQs) document under "Articles Attachments."  Please refer to the  FAQs as needed.

In July, Anthem Blue Cross and Blue Shield (Anthem) added new functionality to Virginia’s provider enrollment tool on the Availity Portal to further automate and improve your online enrollment experience. You can now use the online enrollment application for new groups and new solo professional providers applying for the Anthem network. 

When you use this efficient online tool to submit new provider information to Anthem, a contract will be generated and sent back to you digitally for an electronic signature. This eliminates the need for paper applications or paper contracts.  As a reminder, you can continue to access the new provider enrollment application on the Availity Portal to enroll additional providers under your existing group/practice participation agreement.

Here’s a review of how the online enrollment application works:

The system automatically accesses CAQH to pull in all updated information you’ve already included in your CAQH application.  The CAQH information automatically populates the information Anthem needs to complete the enrollment process – including credentialing and loading your new provider to our database.  Please ensure that your provider information on CAQH is updated and is in a complete or re-attested status.

Availity’s online application will guide you throughout the enrollment process, providing status updates using a dashboard.  As a result, you know where each provider is in the process without having to call or email for a status. 

Please note: For any changes to your practice profile and demographics, continue to use the new online provider maintenance form that allows you to electronically submit to Anthem any changes to your practice profile and demographics. Availity administrators and assistant administrators can access the form on Availity>Payer Spaces>Resources.

Accessing the provider enrollment application

Log on to the Availity Portal and select Payer Spaces > Anthem Blue Cross Blue Shield >Applications>Provider Enrollment to begin the enrollment process.

If your organization is not currently registered for the Availity Portal, the person in your organization designated as the Availity administrator should go to www.availity.com and select Register. 

For organizations already using the Availity Portal, your organization's Availity administrator should go to My Account Dashboard from the Availity home page to register new users and update or unlock accounts for existing users. Staff who need access to the provider enrollment tool need to be granted the role of “provider enrollment.”

(Availity administrators and User Administrators will automatically be granted access to provider enrollment.)

If you are using Availity today and need access to provider enrollment, please work with your organization’s administrator to update your Availity role. To determine who your administrator is, you can go to My Account Dashboard > My Administrators.

Need assistance with registering for the Availity Portal?

Are you an Anthem provider who needs help transitioning to using Availity’s gateway solutions? Are you looking for SFTP or other batch upload options? If yes, check out a one-hour webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session.

Webinar:  Introduction to Availity EDI gateway services for Anthem provider organizations

During this fast-paced hour, you’ll learn how to:

• Understand Availity’s EDI gateway and Clearinghouse workflow.

• Enroll for and manage 835 ERA delivery with Availity.

• Use the Availity portal to manage file transfers, set up EDI reporting preferences, and more.

• Access and navigate the Availity EDI Guide.

…and more.

Webinar schedule

Enroll for an upcoming webinar (and check back again later for additional dates and times).

Date                                                     Time

Monday, August 20, 2018                       3 p.m. to 4 p.m. Eastern time

Thursday, August 23, 2018                     1 p.m. to 2 p.m. Eastern time

Tuesday, September 25, 2018                Noon to 1 p.m. Eastern time

Thursday, September 27, 2018               3 p.m. to 4 p.m. Eastern time

Registration

1. Log in to the Availity portal.

2. Click Help & Training | Get Trained.

4. Scroll through Your Calendar to view upcoming live events.

Tip: You can also search the ALC Catalog by a special keyword set up just for you. The keyword is song.

Additional training

Obesity is a serious issue in the United States. The obesity rate is rising. Obesity has significant health consequences, contributing to increased incidence of several diseases, including metabolic syndrome, high blood pressure, diabetes, heart disease, high blood cholesterol, sleep disorders and cancers.

For detail information on obesity HEDIS® measurements and coding, please view the full update at:

https://mediproviders.anthem.com/Documents/VAVA_CAID_ObesityCodingSpotlight.pdf.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

The following section addresses one reimbursement policy update:  Medical Recalls 

Policy Update:  Medical Recalls

(Policy 06-111, effective 11/01/2018)

In applicable circumstances, the appropriate modifier, condition code or value code (identified below) should be used to identify a medically recalled item for Anthem HealthKeepers Plus members. This will assist HealthKeepers, Inc. in identifying medically recalled items and support correct coding guidelines.

Applicable condition codes are 49 and 50. Condition code 49 signifies products replaced within the product lifecycle due to the product not functioning properly, and condition code 50 is used for product replacement for known recall of a product.

When a credit or cost reduction is received by the provider for the replacement device, applicable modifiers are FB and FC. Modifier FB is used when items are provided without cost to the provider, supplier or practitioner, and modifier FC is used when a partial credit is received by the provider, supplier or practitioner for the replacement device.

NOTE: In circumstances where we have reimbursed the provider for repair or replacement of items or procedures related to items due to a medical recall, we are entitled to recoup or recover fees from the manufacturer and/or distributor as applicable. In circumstances where we have reimbursed the provider the full or partial cost of a replaced device and the provider received a full or partial credit for the device, we are entitled to recoup or recover fees from the provider.

Please refer to CMS and/or the Commonwealth of Virginia’s guidelines, and the Medical Recalls reimbursement policy for additional details at https://mediproviders.anthem.com/va.

Effective November 1, 2018, HealthKeepers, Inc. will update the claims processing system to ensure accurate payment of newborn claims in accordance with Virginia normal newborn diagnosis-related group (DRG) requirements and Anthem HealthKeepers Plus inpatient authorization requirements.

All newborn inpatient stays must have sufficient documentation provided to support an admission to an area beyond the newborn nursery, such as a neonatal intensive care unit (NICU) or for the higher level of care associated with the more complex newborn DRG. Documentation to support the higher level admission includes authorization or medical records.

Failure to provide the appropriate documentation will result in the claim being processed based on the normal newborn rate. Please note that current authorization guidelines for normal newborn and higher level of care baby inpatient stays will be applied.

For more information about this update, please go to: https://mediproviders.anthem.com/Documents/VAVA_CAID_DRGCPUNormalNewborn.pdf.

Effective September 1, 2018, prior authorization (PA) requirements will change for injectable drug Cabazitaxel (Jevtana) to be covered by HealthKeepers, Inc. for Anthem HealthKeepers Plus members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

Cabazitaxel (Jevtana) — injection, 1 mg (J9043)

To request PA, you may use one of the following methods:

• Web: https://www.availity.com

• Fax: 1-800-964-3627

• Phone: 1-800-901-0020

HealthKeepers, Inc. would like to inform providers of the following prior authorization (PA) change affecting Anthem HealthKeepers Plus members.

Effective September 1, 2018, PA requirements will change for injectable/infusible drugs mepolizumab (Nucala®) and reslizumab (Cinqair®). Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/ exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Mepolizumab (Nucala) — injection, 1 mg (J2182)

• Reslizumab (Cinqair) — injection, 1 mg (J2786)

To request PA, you may use one of the following methods:

• Web: https://www.availity.com

• Fax: 1-800-964-3627

• Phone: 1-800-901-0020

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-800-901-0020.

As you know, HealthKeepers, Inc. offers pregnant Anthem HealthKeepers Plus members several services and benefits through the New Baby, New LifeSM program. It is our goal to ensure all pregnant members are identified early in their pregnancy so they can take full advantage of the education, support, resources and incentives HealthKeepers, Inc. provides throughout the prenatal and postpartum period.

We’ve partnered with Availity, the vendor supporting the Benefit Look-Up tool you may currently use in your OB office, to send us information about newly identified pregnant women. This new process, including the HEDIS® Maternity Attestation form, helps connect patients with additional benefits as soon as possible. The reporting process includes a few simple steps.

How it works

When an Anthem HealthKeepers Plus member of childbearing age visits the OB office, the office associate asks if the member is pregnant during the eligibility and benefits inquiry process. If the member is pregnant, the system asks about the due date, and a HEDIS Maternity Attestation form is generated for the OB office to complete. On this electronic form, providers are asked to provide other important information, including the date of the first prenatal care visit, delivery date and postpartum visit date.

This new, user-friendly workflow generates timely information that aids members, providers and HealthKeepers, Inc. in improving birth outcomes with early intervention.

We are working hard to support providers throughout Virginia in receiving necessary training for this new workflow. If you have specific questions regarding the new Availity maternity attestation process, please feel free to call Provider Services at 1-800-901-0020.  For easy reference, we've included some frequently asked questions (FAQs) and responses in the attached document under "Article Attachments."  

HealthKeepers, Inc. now conducts monthly provider orientations and training sessions for Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) and Medallion 4.0 programs.

These orientations and trainings are for both contracted and noncontracted providers, giving new providers information about engaging the Medicaid health plan and presenting existing providers an opportunity to learn about new initiatives.

You can find a schedule of the orientations on the provider website at https://mediproviders.anthem.com/va/pages/manuals-directories-training.aspx.

Anthem HealthKeepers Plus utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://mediproviders.anthem.com/va/Pages/medical.aspx.

You can request a free copy of our UM criteria from our Medical Management department. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below. To access UM criteria online, go to https://mediproviders.anthem.com/va/Pages/medical.aspx.

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title and organization name when initiating or returning calls regarding UM issues.

You can submit precertification requests by:

• Calling us at 1-800-901-0020

• Faxing to 1-800-964-3627

• Submitting online at https://www.availity.com

Have questions about utilization decisions or the UM process?

Call our Clinical team at 1-800-901-0020 Monday to Friday, 8:30 a.m. to 5:30 p.m. Eastern time.

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, HealthKeepers, Inc. has adopted a Member’s Rights and Responsibilities Statement, which is located in your Provider Manual.

At HealthKeepers, Inc., we recognize that the relationship between the patient and the health care provider can lead to improved compliance with routine postpartum care. With this in mind, we are requesting our Anthem HealthKeepers Plus network providers assist us in our postpartum outreach initiative. This initiative targets providers and their patients who are due for postpartum follow-up appointments.

The goal of the postpartum outreach initiative is to increase patient compliance, improve health outcomes for our members and to encourage our network providers to collaborate with us in maintaining the highest possible postpartum quality measures. HEDIS® determines a postpartum appointment as one that takes place 21 to 56 days after delivery. Follow-up appointments that occur one to two weeks or greater than 56 days after delivery are not recognized as reportable postpartum visits by HEDIS.

As an added incentive, HealthKeepers, Inc. offers providers $50 for every member provided with postpartum follow-up care within the HEDIS time frame. For details on this incentive, please contact your Provider Relations representative or Anthem HealthKeepers Plus Provider Services at 1-800-901-0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 1-855-323-4687.

Associates from HealthKeepers, Inc. may contact your office to schedule and/or confirm members’ postpartum appointments during the 21- to 56-day period. In addition, we will continue to educate our members about the necessity and importance of keeping their postpartum appointments. It is our hope that these efforts will improve patient compliance for postpartum follow-up visits.

HealthKeepers, Inc. is pleased to introduce Edgepark®, a national distributor of medical supplies, which will be providing quality standard electric breast pumps to Anthem HeathKeepers Plus members.

What this means

Providers can refer Anthem HeathKeepers Plus members to Edgepark for standard electric breast pumps. Members can go online or call Edgepark to order a standard electric breast pump. As a provider, you can also complete the order form with your patient and fax it in. It is important to note that members with specific needs or concerns have other options. Their provider should be notified on these needs, and other pumps/models can be ordered.

Referrals to Edgepark

To place a breast pump order for a member, use the breast pump order form located on the provider website at: https://mediproviders.anthem.com/va>Medical>Provider Forms>Electric, Nonhospital Grade Breast Pump Request Form and fax it in. The member can also call or go online to place her order:

• Online: edgepark.com/breastpumps

• Phone: 1-800-321-0591

• Fax: 1-330-425-3355

Need additional copies of the order form?

Additional copies of the breast pump order form can be found on our provider website at https://mediproviders.anthem.com/va under Medical: Provider Forms.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-800-901-0020.

Effective with dates of service on and after May 7, 2018, HealthKeepers, Inc. began using the 22nd edition of the MCG care guidelines for Anthem HealthKeepers Plus members.

Recently, HealthKeepers, Inc. partnered with Availity as our designated Electronic Data Interchange (EDI) gateway and E-Solutions Service Desk.  HealthKeepers, Inc. will not renew existing contracts with clearinghouse vendors. As a result, beginning January 1, 2019, Availity will manage all EDI trading partner relationships on behalf of HealthKeepers, Inc. This new partnership will not interrupt your current Anthem HealthKeepers Plus services.

Transmitting 837 claims

If you currently transmit 837 claims using a clearinghouse, you should contact your clearinghouse as soon as possible to confirm your EDI submission path for HealthKeepers, Inc. transactions has not changed. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you. You can submit claims directly through Availity.

Direct submitters can also use Availity for their 837 transmissions.

Registering with Availity

If you choose to submit directly through Availity but are not yet a registered user, go to https://www.availity.com and select REGISTER. The registration wizard will lead you through the enrollment process. Once complete, you will receive an email with your login credentials and next steps for getting started. If you have any questions or concerns please contact Availity at 1-800-AVAILITY (1‑800-282-4548).

To help our members receive the durable medical equipment (DME) equipment they need and help ensure no disruption in care, it is important to document that the physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. Additional details on this requirement and other information that will help ensure that your prior authorization request for a wheelchair is processed efficiently will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider.

Anthem accepts electronic medication prior authorization (PA) requests for Medicare plans. This feature reduces processing time and helps determine coverage more quickly. Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.

Electronic prior authorization (ePA) offers many benefits:

• More efficient review process 

• Ability to identify if a prior authorization is required 

• Able to see consolidated view of ePA submissions in real time

• Faster turnaround times

• A renewal program that allows for improved continuity of care for members with maintenance medication

• Prior authorizations are preloaded for the provider before the expiration date

Submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.

While ePA helps streamline the prior authorization process, if you must initiate a new PA request by fax or phone, please note that the contact numbers for Medicare Prior Authorization will change September 1, 2018.

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

MyDiversePatients.com features robust educational resources to help providers address health care disparities.  You will find:

• CME learning experiences about disparities, potential contributing factors and opportunities for you to enhance care.

• Real life stories about diverse patients and the unique challenges they face.

• Tips and techniques for working with diverse patients to promote improvement in health outcomes.

Visit MyDiversePatients.com today to learn more.

The Centers for Medicare & Medicaid Services recently issued regulations related to opioid analgesics to help improve patient safety and reduce the misuse of opioid analgesics:

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf

Beginning January 1, 2019, all short- and long-acting opioids will reject at the point of sale if prescribed for more than seven days.  This edit applies to members who do not have an opioid prescription in the previous 60 days.  The edit excludes members with cancer or members in hospice. 

Please continue to check Important Medicare Advantage Updates at http://www.anthem.com/medicareprovider for the latest Medicare Advantage information, including:

• July Medicare Advantage reimbursement policy provider bulletin 
• Inpatient readmissions Medicare Advantage update
• Prior authorization requirements for Part B drugs Retacrit, Damoctocog and Ilumya  
• Medical policy update
• Prior authorization requirements for Part B drugs: Azedra and Poteligeo  
• Prior authorizations required for new group-sponsored MA membership 
• Contracted provider responsibility and liability for Issuance of Notice of Medicare Non Coverage to a skilled nursing facility
• Improve Medicare Advantage members’ medication adherence with 90-day prescriptions

72598MUPENMUB 06/18/2018