Anthem Blue Cross and Blue Shield and Availity Electronic Data Interchange (EDI) are excited to announce the X12 275 5010 version of electronic attachments transactions for claims functionality is now available.

 

The X12 275 5010 version of electronic attachments transactions for claims will:

 

• Bring value to you by eliminating the need for mailing paper records.

 

• Provide a transaction audit trail via an electronic acknowledgment – proof of delivery/receipt.

 

• Reduce administrative costs associated with manual processing.

 

• Save time waiting for paper correspondents.

 

This new functionality includes both solicited and unsolicited attachments.

 

• Solicited Attachment - Documentation submitted in response to a specific request.

 

• Unsolicited Attachment - Documentation is known to be needed and submitted at the same time as the claim.

 

How to send a 275 transaction

 

Your practice management software or billing service/clearinghouse must have the ability to send a 275 transaction. We encourage you to have a conversation with them to determine their ability to set up the X12 275 attachment transaction capabilities.

 

Where to find help

 

The new EDI batch process, X12 275 5010v Companion Guide, assists with specific attachment requirements and enables providers to electronically submit attachments based on your business needs.

The companion guide can be downloaded at: (Anthem at www.anthem.com/edi)

 

Availity documentation can be found at:   www.availity.com

 

Use the “Availity Welcome Application” below to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions.

 

EDI Welcome App:   https://apps.availity.com/web/welcome/#/  

 

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday - Friday 8 a.m. - 7 p.m. ET.

 

587-0820-PN-VA

There is no doubt the coronavirus (COVID-19) crisis has taken a toll on all of us. The pandemic has led to immeasurable challenges, but we are here to help you ease back into business. We want to remind you, as the Availity migration continues, Anthem Blue Cross and Blue Shield will guide you to make it a smooth transition.  The Availity EDI migration has a target closing date of September 15, 2020.

 

Take action today: Availity setup is simple and at no cost for you

 

Use this “Welcome” link to get started today: https://apps.availity.com/web/welcome/#/

 

All EDI transmissions currently sent or received today via the Anthem gateway are now available on the Availity EDI gateway. 

 

• 837 Institutional and Professional

 

• 837 Dental

 

• 835 Electronic Remittance Advice

 

• 276/277 Claim Status

 

• 270/271 Eligibility Request

 

• 275 Medical Attachments

 

• 278 Prior Authorization/Referrals

 

• 278N Inpatient Admission and Discharge Notification

 

Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:

 

• Migrate your direct connection with Anthem and become a direct submitter with Availity.

 

• Use your existing clearinghouse or billing company for your EDI transmissions. (Work with them to ensure connectivity to the Availity EDI Gateway).

 

• Use Direct Single Claim entry through the Availity Portal.

 

Learn more about Availity by taking courses at no charge

 

Enroll in one of Availity’s free courses and training demos at your convenience. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.

 

Follow these steps to register at www.Availity.com :

 

1. Log in to the Availity Portal and select Help & Training | Get Trained to access the Availity Learning Center (ALC).

 

2. Select Sessions from the menu under the search catalog field.

 

3. Scroll Your Calendar to locate your webinar.

 

4. Select View Course and then Enroll. The ALC will email you instructions to attend.

 

If you and your clearinghouse have already migrated over to Availity, thank you and you are a step ahead.  If not, start the process now to make the transition before September 15, 2020.

 

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday - Friday 8 a.m. - 7 p.m. ET.

 

585-0820-PN-VA

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 – and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well.  The current health crisis illuminates this quite clearly.  It is imperative to offer care that is tailored to the unique needs of patients, and Anthem Blue Cross and Blue Shield is committed to supporting our providers in this effort. 

 

MyDiversePatients.com offers education resources to help you support the needs of your diverse patients and address disparities, including:

 

• Free Continuing Medical Education (CME) learning experiences about disparities, potential contributing factors and opportunities for providers 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.

 

Stronger Together offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.

 

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

 

Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted health care partner by visiting these resources today.

 

My Diverse Patients

 

 

Stronger Together Health Equity Resources

584-0820-PN-VA

Later this month, on August 15, 2020, you can begin using Interactive Care Reviewer (ICR) to request and check the status of medical and behavioral health inpatient and outpatient authorizations for members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® or FEP).

 

• You will be able to view FEP historical cases submitted through Point of Care prior to August 15, 2020, through ICR and Point of Care.

 

• Updates to existing FEP cases will continue through Point of Care until September 30, 2020.  If there are any services past September 30, 2020, those will be transitioned and can be updated through ICR.

 

Next month, we are targeting September 12 to launch ICR to request new authorizations for our members enrolled in Anthem’s Commercial lines of business. (This includes Commercial plans offered by our affiliate, HealthKeepers, Inc.) Look for additional details in upcoming communications, as we begin to make this transition from Point of Care to ICR.

 

ICR is currently available to request prior authorizations for your patients enrolled in Medicare Advantage and Anthem HealthKeepers Plus (Medicaid).

 

Once fully launched, Interactive Care Reviewer will be your exclusive self-service online authorization tool for all new medical and behavioral health prior authorization requests. Using one application for your patients enrolled in all Anthem plans will further streamline your authorization workflow process.

 

Access ICR through the Availity Portal

 

Be prepared early and ask your Availity administrator to grant you the required ICR role assignment now.

 

Do you create and submit prior authorization requests?

Authorization and Referral Request role assignment

 

Do you check the status of the case or results of the authorization request?

Authorization and Referral Inquiry role assignment

 

Beginning August 15, follow these steps to navigate to ICR through Availity to request and check the status of prior authorizations for FEP members

• Select Patient Registration from Availity’s home page

• Select Authorizations & Referrals

• Select Authorizations (for requests) | Select Auth/Referral Inquiry (for inquiries)

 

Register for our August ICR webinar

 

We offer training every month to familiarize new users with ICR features and navigation of the tool. Our next webinar is taking place on August 18.  Register Here

 

Additional ICR resources are available through the Custom Learning Center

 

Follow the steps outlined below to access self-paced videos located on the Custom Learning Center. From Availity’s home page, select Payer Spaces | Anthem tile | Applications | Custom Learning Center

 

• Select Catalog from the menu located on the upper left corner of the Custom Learning Center screen.

 

• Use the catalog filter and select Interactive Care Reviewer-Online Authorizations or Authorizations from the Category

 

• Click Apply then enroll for the courses (videos) you want to view.

 

Illustrated reference guides that you can print are located on Custom Learning Center Resources. Select Resources from the menu located on the upper left corner of the screen.  Use the catalog filter and select Authorizations or Interactive Care Reviewer-Online Authorizations from the Category menu. Select Download to view and/or print the reference guide.           

 

593-0820-PN-VA

 

Anthem continues to offer provider education webinars with our fall webinar scheduled for November 12, 2020. Designed for our network-participating providers, the webinar addresses Anthem business updates and billing guidelines that impact your business interactions with us.

 

For your convenience, we offer these informative, hour-long sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the fall webinar is:

 

• Thursday, November 12, 2020, from 11 a.m. to noon ET

 

Please consider registering today for the webinar using the registration form to the right under the “Article Attachments” section. If you have already registered for the November webinar, please ensure you have received a confirmation from an Anthem representative to ensure we’ve received your registration form.  Contact joyce.lindley@anthem.com if you need to confirm your registration.

 

557-0820-PN-VA

Quality health care requires standard documentation requirements to ensure consistency for the care of our members. These standards are reviewed annually to ensure they align with our current policies. These standards ensure effective medical record documentation and provide clear and consistent guidelines to ensure that providers maintain records in a current, organized, and effective manner. The medical record criteria that are encouraged for our network of independently contracted providers are outlined below.

 

1. Every page in the medical record contains the patient name or ID number.

 

2. Allergies/No Known Drug Allergies (NKDA) and adverse reactions are prominently displayed in a consistent location.

 

3. All presenting symptom entries are legible, signed and dated, including phone entries. Dictated notes should be initialed to signify review.  Signature sheet for initials are noted.

 

4. The important diagnoses are summarized or highlighted.

 

5. A problem list is maintained and updated for significant illnesses and medical conditions.

 

6. A medication list or reasonable substitute is maintained and updated for chronic and ongoing medications.

 

7. History and physical exam documentation identifies appropriate subjective and objective information pertinent to the patient’s presenting symptoms, and treatment plan documentation is consistent with findings.

 

8. Laboratory tests and other studies are ordered, as appropriate, with results noted in the medical record. (The clinical reviewer should see evidence of documentation of appropriate follow-up recommendations and/or non-compliance to care plan).

 

9. Documentation of Advance Directive/Living Will/Power of Attorney discussion (including copies of any executed documents) in a prominent part of the medical record for adult patients is encouraged.

 

10. Documentation of continuity and coordination of care between the PCP, specialty physician (including BH specialty) and/or facilities if there is reference to referral or care provided elsewhere. The clinical review will look for a summary of findings or discharge summary in the medical record. Examples include progress notes/report from consultants, discharge summary following inpatient care or outpatient surgery, physical therapy reports, and home health nursing/ provider reports.

 

11. Age appropriate routine preventive services/risk screening is consistently noted, i.e. childhood immunizations, adult immunizations, mammograms, pap tests, etc., or the refusal by the patient, parent or legal guardian, of such screenings/immunizations in the medical record.

 

582-0820-PN-VA

We appreciate the role you play in managing the health of our members.  As the physician of a patient who has coverage compliant with the Affordable Care Act (ACA), you play a vital role in accurately documenting the health of the patient to help ensure compliance with ACA program reporting requirements. When patients visit your practice, we encourage you to document ALL of their health conditions, especially chronic diseases.  Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.

 

Please ensure that all codes captured in your electronic medical record (EMR) system are also included on the claim(s), and are not being truncated by your claims software management system.  For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing four.  If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.

 

Reminder about ICD-10 coding

 

The ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits.  Additionally, Anthem uses ICD-10 codes submitted on claims to monitor health care trends, cost, and disease management. Additionally, the Centers for Medicare & Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a patient’s health.

 

Using specific ICD-10 diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.

• Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.

• Include any secondary diagnosis codes that are actively being managed.

• Include all chronic historical codes, as they must be documented each year pursuant to the ACA.  (Such as an amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).

Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions.   ICD-10 coding guidelines still apply, so please ensure coding on a telehealth visit claim is to the highest specificity with all diagnosis codes.  Previous Anthem Provider News editions provide telehealth reimbursement guidance to follow for claims submission.

 

If you are interested in a coding training session specific to risk adjustable conditions, please contact the Commercial Risk Adjustment network education representative: Alicia.Estrada@anthem.com

 

567-0820-PN-VA

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)

 

More than 20 million Americans age 13 and older are classified as having a substance use disorder involving alcohol and other drug use (AOD). Treatment has been shown to reduce AOD-associated morbidity and mortality; improve health, productivity and social outcomes; and reduce health spending. Despite these benefits, less than 20% of individuals with substance use disorders receive treatment. To ensure these positive outcomes, it’s important to remember the following for your Anthem HealthKeepers Plus members 13 and older who are newly diagnosed with a substance use disorder in any level of care:

 

• Ensure that your patient is seen by a mental health practitioner within 14 days for initiation of AOD treatment. Treatment can be through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, or medication-assisted treatment (MAT).

 

• Following that visit, at least two additional visits are recommended within 34 days of the initial visit.

 

All visits must be documented with a substance use diagnosis.

 

Follow-up after Emergency Department visit for alcohol and other drug Abuse or dependence (FUA)

 

Millions of Americans age 13 and older are classified as having a substance use disorder involving alcohol and other drug use (AOD). High ED use for individuals with AOD may signal a lack of access to care or issues with continuity of care. Timely follow-up care for individuals with AOD who were seen in the ED is associated with a reduction in substance use, future ED use, hospital admissions and bed delays.

 

Do the following to ensure the best outcome for your members age 13 and older discharged from an emergency room visit with a primary diagnosis of alcohol or other drug use or dependence: Make sure they are seen by an outpatient provider (any practitioner) and have a principal diagnosis of AOD use. This follow-up visit may occur on the date of discharge.

 

Two rates are reported:

 

• ED visits for which the member received follow-up within 30 days of the ED visit (31 total days)

 

• ED visits for which the member received follow-up within seven days of the ED visit (eight total days)

Follow-up is key.  Make sure your members are seen within the seven- and 30-day window.

 

Follow-up after Emergency Department Visit for Mental Illness (FUM)

 

Mental illness can affect people of all ages. In the United States, 18% of adults and 13% to 20% of children under 18 years of age experience mental illness. Research suggests that follow-up care for people with mental illness is linked to fewer repeat ED visits, improved physical and mental function and increased compliance with follow-up instructions.

 

It’s important to remember that your patients ages 6 and older discharged from an emergency department visit with a primary mental health diagnosis must be seen by an outpatient provider. The visit may occur on the date of discharge.

 

Two rates are reported:

 

• ED visits for which the member received follow-up within 30 days of the ED visit (31 total days)

 

• ED visits for which the member received follow-up within seven days of the ED visit (eight total days)

Follow-up is key. Make sure your members are seen within the seven- and 30-day window.

If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

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

 

AVA-NU-0254-20

HealthKeepers, Inc. partners with AIM Specialty Health_®* (AIM), a leading specialty benefits management company that provides services for radiology, cardiology, genetic testing, oncology, musculoskeletal, rehabilitation, sleep management, and additional specialty areas. We require that Anthem HealthKeepers Plus provider demographic information (group or practice name, additional providers added to the group/practice, location) is current and accurate to eliminate provider and member abrasion.

 

In the event the provider's demographic information has not been updated in the Anthem HealthKeepers Plus system, the data will also be missing from the provider data that goes to AIM. Therefore, providers may not be able to locate the requested record in AIM's system. While the provider's information can be manually entered to build a case, the record will appear to be out-of-network, and the case will adjudicate accordingly.

 

Anthem HealthKeepers Plus provider data updates flow to AIM via the provider data extract, but the data flow does not work in the reverse back to HealthKeepers, Inc. It is important that providers make the following changes or updates with HealthKeepers, Inc., not AIM:

 

• Group or practice name

 

• Tax Identification Number (TIN)

 

• National Provider Identifier (NPI)

 

• Address (add/remove location(s), corrections)

 

• Phone numbers

 

• Fax numbers

 

• Any additional changes

 

If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of HealthKeepers, Inc.

 

AVA-NU-0255-20

It is believed that behaviors established during childhood or adolescence, such as eating habits and physical activity, often extend into adulthood. Well‐care visits provide an opportunity for providers to influence health and development. For members enrolled in Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus), these visits are a critical opportunity for screening and counseling. The Adolescent Well-Care Visits (AWC) HEDIS^® measure looks for at least one comprehensive well‐care visit for members 12 to 21 years of age with a PCP or OB/GYN type provider.

An adolescent well-care visit should include the following:

 

• A health history – covers past illnesses (or lack of illness), hospitalizations, chronic health conditions, allergies, and the child’s emotional and social development. It also includes a family history of health problems. The health history highlights any special concerns about the adolescent.

 

• Physical developmental history – includes developmental milestones and an assessment of whether the adolescent is developing skills to become a healthy adult. Examples: Tanner score, onset of menstrual cycle, participation in a team sport.

 

• Mental developmental history – includes developmental milestones and assessment of whether the adolescent is developing skills to become a healthy adult. Examples: making good grades, good circle of friends, seems depressed or detached from family and/or friends, career development, smoking/ETOH/drug use.

 

• Physical exam – a comprehensive head to toe exam with vital signs; it must consist of more than one body system to meet criteria.

 

• Anticipatory guidance – given in anticipation of emerging issues that member may face; injury and illness prevention, nutrition, promotion of constructive family relationships and developing social skills. Preprinted forms or checklists may be used, but the check boxes must be checked off or initialed by the provider at the time of the visit.

Don’t miss an opportunity to perform a well‐child exam. Well-child preventive services count toward the measure, regardless of the primary intent of the visit (for example, GYN type visit or sick visit), but services that are specific to an acute or chronic condition do not count towards the measure.

 

If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

Childhood Immunization Status HEDIS measure

Immunizations are essential for disease prevention and are a critical aspect of preventive care for children. Vaccination coverage must be maintained in order to prevent a resurgence of vaccine‐preventable diseases. Childhood immunizations are to be completed by a child’s second birthday for HEDIS® compliance. If the CDC immunization schedule is followed, immunizations can actually be completed by 18 months of age for Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members.

 

What is measured for Childhood Immunization Status (CIS)? The percentage of children 2 years of age in the measurement year who had the following:

4 – Dtap	3 – IPV (polio)
1 – MMR	3 – HiB (haemophilus influenza type B)
3 – Hep B	1 – VZV (chicken pox)
4 – PCV (pneumococcal)	1 – Hep A
2 or 3 – RV (rotavirus)	2 – influenza

 

Children also need a lead screen (by a capillary or venous blood test) on or before their second birthday.  Unfortunately, there has been an increase in the number of parents that are refusing to vaccinate their children. This is causing a growing concern for the recurrence of vaccine-preventable diseases. It is imperative to talk with the parents to allay their fears and dispel any misbeliefs they may have about vaccinations.

 

If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

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

 

AVA-NU-0258

This HEDIS^® measure looks at the percentage of Anthem HealthKeepers Plus members ages 18 to 85 years who have had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (< 140/90 mm Hg).

 

Record your efforts:

 

Document blood pressure and diagnosis of hypertension.  Members whose BP is adequately controlled include:

 

• Members 18 to 85 years of age who had a diagnosis of HTN and whose BP was adequately controlled (< 140/90 mm Hg) during the measurement year.

 

• The most recent BP reading during the measurement year on or after the second diagnosis of HTN.

 

• If no BP is recorded during the measurement year, assume that the member is “not controlled.”

 

What does not count for this HEDIS measure?

 

• If blood pressure is taken on the same day as a diagnostic test or procedure or for a change in diet or medication regimen.

 

• If blood pressure is taken on or one day before the day of any test or procedure.

 

• Blood pressure taken during an acute inpatient stay or an emergency department visit.

 

Exclusions:

 

• End stage renal disease

 

• Nephrectomy or kidney transplant

 

• Pregnancy

 

• Nonacute inpatient stay

 

• Members aged 66 to 80 with frailty and advanced illness

 

• Members 81 years old and above with frailty

 

Helpful tips:

 

• Have your office staff recheck blood pressure for members with initial diagnosis of hypertension and record readings greater than 140 mm Hg systolic and 90 mm Hg diastolic during outpatient office visits. Educate your staff to record the recheck in member’s medical records.

 

• Refer high-risk members to our hypertension programs and other programs for additional education and support.

 

• Educate members and their spouses, caregivers or guardians about the elements of a healthy lifestyle such as:

 

• Heart-healthy eating and a low-salt diet.

 

• Smoking cessation and avoiding secondhand smoke.

 

• Adding regular exercise to daily activities.

 

• Home BP monitoring.

 

• Ideal BMI.

 

• The importance of taking all prescribed medications as directed.

 

• Remember to include the applicable Category II reporting code on the claim form to help reduce the burden of HEDIS medical record review.

 

How can we help?

 

We support you in helping members control high blood pressure by:

 

• Providing online Clinical Practice Guidelines on our provider website.

 

• Reaching out to our hypertensive members through our education and support programs.

 

Other available resources:

 

• National Heart, Lung, and Blood Institute

 

• CDC Blood Pressure educational materials

 

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

 

AVA-NU-0261-20

On November 15, 2019, February 21, 2020, and March 26, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the Anthem HealthKeepers Plus medical drug benefit for HealthKeepers, Inc. Please note, this does not affect the prescription drug benefit. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting March 2020. Visit Clinical Criteria to search for specific policies.

 

If you have questions or would like additional information, use this email.

 

AVA-NU-0262-20

Effective August 1, 2020, HealthKeepers, Inc. will use the new acute viral illness guidelines that have been added to the 24th edition of the MCG Care Guidelines for Anthem HealthKeepers Plus members. Based on the presenting symptoms or required interventions driving the need for treatment or hospitalization, these guidelines are not a substantive or material change to the existing MCG Care Guidelines we use now, such as systemic or infectious condition, pulmonary disease, or adult or pediatric pneumonia guidelines.

 

Inpatient Surgical Care (ISC):

 

• Viral Illness, Acute – Inpatient Adult (M-280)

 

• Viral Illness, Acute – Inpatient Pediatric (P-280)

 

• Viral Illness, Acute – Observation Care (OC-064)

 

Recovery Facility Care (RFC):

 

• Viral Illness, Acute – Recovery Facility Care (M-5280)

 

AVA-NU-0265-20

The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members.

 

Effective July 1, 2020, formulary changes, non-formulary changes and prior authorization requirements will apply.

 

Effective for all members on July 1, 2020
Therapeutic class	Medication	Formulary status change	Potential alternatives (preferred products)
ADHD AGENTS	DYANAVEL XR 2.5 MG/ML SUSPENSION	NON-PREFERRED	Vyvanse capsules/chewable tablet Adderall XR capsules Dextroamphetamine tablet
ADHD AGENTS	QUILLIVANT XR 25 MG/5 ML SUSPENSION QUILLICHEW ER 40 MG CHEW TABLET QUILLICHEW ER 20 MG CHEW TABLET QUILLICHEW ER 30 MG CHEW TABLET	NON-PREFERRED	Focalin XR capsules Daytrana transdermal patch Concerta tablet methylphenidate IR capsules/tablet
ANDROGENS	ANDROGEL 1.62%(1.25G) GEL PACKET	NON-PREFERRED WITH PA	testosterone pump (genric androgel) PA required
ANTIDIABETIC COMBINATIONS	INVOKAMET 50-500 MG TABLET INVOKAMET 50-1,000 MG TABLET INVOKAMET 150-500 MG TABLET INVOKAMET 150-1,000 MG TABLET XIGDUO XR 2.5 MG-1,000 MG TAB XIGDUO XR 5 MG-500 MG TABLET XIGDUO XR 5 MG-1,000 MG TABLET XIGDUO XR 10 MG-500 MG TABLET XIGDUO XR 10 MG-1,000 MG TAB	PREFERRED WITH MIN AGE LIMIT OF 18 YEARS AND OLDER	N/A
INSULIN	HUMALOG JR HUMALOG MIX 50/50 HUMALOG 100/ML VIAL	PREFERRED	N/A
INSULIN	INSULIN LISPRO KWIKPEN ADMELOG SOLOSTAR	NON-PREFERRED	HUMALOG KWIK INJ 100/ML
INSULIN	NOVOLIN N FLEXPEN	NON-PREFERRED	HUMULIN N KWIKPEN
INSULIN	NOVOLIN 70/30 FLEXPEN	NON-PREFERRED	HUMULIN 70/30 KWIKPEN
URINARY ANTISPASMODICS	SOLIFENACIN 5 MG TABLET SOLIFENACIN 10 MG TABLET	PREFERRED	N/A
URINARY ANTISPASMODICS	VESICARE 5 MG TABLET VESICARE 10 MG TABLET	NON-PREFERRED	SOLIFENACIN 5 MG TABLET SOLIFENACIN 10 MG TABLET

 

Edits effective July 1, 2020 No changes in preferred/nonpreferred status revision or addition to UM edit only
Therapeutic class	Medication	Formulary status change
ALLERGENIC EXTRACTS	PALFORZIA CAPSULES	PA REQUIRED
ANALGESICS - ANTI-INFLAMMATORY	OLUMIANT 1 MG TABLET OLUMIANT 2 MG TABLET	ADD QTY LIMIT 30 PER 30 DAYS
ANALGESICS - ANTI-INFLAMMATORY	OTEZLA 30 MG TABLET	ADD QTY LIMIT 60 PER 30 DAYS
ANTIRHEUMATIC ANTIMETABOLITES	OTREXUP INJECTIONS RASUVO INJECTIONS	ADD QTY LIMIT 4 PER 28 DAYS
HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS	WAKIX  4.45MG TABLET WAKIX  17.8MG TABLET	PA REQUIRED
INTERLEUKIN-1 RECEPTOR ANTAGONIST	KINERET INJ	ADD QTY LIMIT 30 PER 30 DAYS
MIGRAINE PRODUCTS	REYVOW TABLET UBRELVY  TABLET	PA REQUIRED

 

 What action do I need to take?

 

Please review these changes and work with your Anthem HealthKeepers Plus and/or Anthem CCC Plus patients to transition them to formulary alternatives. If you determine formulary alternatives are not clinically appropriate for specific patients, you will need to obtain prior authorization to continue coverage beyond the applicable effective date.

 

What if I need assistance?

 

We recognize the unique aspects of patients’ cases. If your patients cannot be converted to a formulary alternative, call our Pharmacy department at 1-800-901-0020 (Anthem HealthKeepers Plus members) or 1-855-323-4687 (Anthem CCC Plus members) and follow the voice prompts for pharmacy prior authorization. You can find the Preferred Drug List (formulary) on our provider website at https://mediproviders.anthem.com/va > Pharmacy > Medicaid Common Core Formulary > Common Core Preferred Drug List.

 

If you have any questions about this communication, call our Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

AVA-NU-0266-20

In accordance with the Commonwealth of Virginia’s 2020 Appropriation Act, HealthKeepers, Inc. will be implementing the following new reimbursement policy for emergency room payments, effective July 1, 2020. This policy, together with reimbursement specifications, will also be added to the Anthem HealthKeepers Plus provider manual.

 

The 2020 Appropriation Act (Chapter 1289) includes the following changes in emergency room facility and physician reimbursement.

 

Item 313.AAAAA The Department of Medical Assistance Services shall amend the State Plan for Medical Assistance Services to allow the pending, reviewing and the reducing of fees for avoidable emergency room claims for codes 99282, 99283 and 99284, both physician and facility. The department shall utilize the avoidable emergency room diagnosis code list currently used for Managed Care Organization clinical efficiency rate adjustments. If the emergency room claim is identified as a preventable emergency room diagnosis, the department shall direct the Managed Care Organizations to default to the payment amount for code 99281, commensurate with the acuity of the visit. The department shall have the authority to implement this reimbursement change effective July 1, 2020, and prior to the completion of any regulatory process undertaken in order to effect such change.

 

If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

AVA-NU-0268-20

In accordance with the Commonwealth of Virginia’s 2020 Appropriation Act, HealthKeepers, Inc. will implement the following new reimbursement policy for inpatient readmissions, effective July 1, 2020. This policy, together with reimbursement specifications, will also be added to the Anthem HealthKeepers Plus provider manual.

 

The 2020 Appropriation Act (Chapter 1289) includes the following change in hospital readmission reimbursement.

 

Item 313.BBBBB. The Department of Medical Assistance Services shall amend the State Plan for Medical Assistance Services under Title XIX to modify the definition of readmissions to include cases when patients are readmitted to a hospital for the same or a similar diagnosis within 30 days of discharge, excluding planned readmissions, obstetrical readmissions, admissions to critical access hospitals, or in any case where the patient was originally discharged against medical advice. If the patient is readmitted to the same hospital for a potentially preventable readmission then the payment for such cases shall be paid at 50 percent of the normal rate, except that a readmission within five days of discharge shall be considered a continuation of the same stay and shall not be treated as a new case. Similar diagnoses shall be defined as ICD diagnosis codes possessing the same first three digits. The department shall have the authority to implement this reimbursement change effective July 1, 2020, and prior to the completion of any regulatory process undertaken in order to effect such change. The department shall report quarterly on the number of hospital readmissions, the cost, and the primary diagnosis of such readmissions to the Joint Subcommittee for Health and Human Resources Oversight.

 

If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

AVA-NU-0269-20

Please continue to check our website https://mediproviders.anthem.com for the latest Medicaid information for members enrolled in HealthKeepers, Inc.’s Anthem HealthKeepers Plus and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) benefit plans. Here is the topic we’re addressing in this edition:

 

Prior authorization requirements for angiographic evaluation of stenotic or thrombosed dialysis circuits

 

AVA-NU-0259-20

On November 15, 2019, February 21, 2020, and March 26, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting March 2020. Visit Clinical Criteria to search for specific policies.

 

If you have questions or would like additional information, use this email.

 

ABSCRNU-0156-20                   510564MUPENMUB

Effective August 1, 2020, Anthem Blue Cross and Blue Shield will use the new acute viral illness guidelines that have been added to the 24th edition of the MCG Care Guidelines. Based on the presenting symptoms or required interventions driving the need for treatment or hospitalization, these guidelines are not a substantive or material change to the existing MCG Care Guidelines we use now, such as systemic or infectious condition, pulmonary disease, or adult or pediatric pneumonia guidelines.

 

Inpatient Surgical Care (ISC):

 

• Viral Illness, Acute – Inpatient Adult (M-280)

 

• Viral Illness, Acute – Inpatient Pediatric (P-280)

 

• Viral Illness, Acute – Observation Care (OC-064)

 

Recovery Facility Care (RFC):

 

• Viral Illness, Acute – Recovery Facility Care (M-5280)

 

ABSCRNU-0157-20                   511106MUPENMUB

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

 

Medicare Risk Adjustment and Documentation Guidance (general)

 

When: This training is offered the first Wednesday of each month from 1 p.m. to 2 p.m. ET.

 

Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model with guidance on medical record documentation and coding.

 

Credits: This live activity, Medicare Risk Adjustment and Documentation Guidance, from January 8, 2020, to December 2, 2020, has been reviewed and is acceptable for up to one prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at: Training Registration.

 

* Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (condition specific)

 

When: This training is offered on the third Wednesday of every other month from noon to 1 p.m. ET.

 

Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.

 

Credits: This live series activity, Medicare Risk Adjustment Documentation and Coding Guidance, from January 15, 2020, to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

 

Session 1: Red Flag HCCs, part one: Training will cover HCCs most commonly reported in error as identified by CMS, including chronic kidney disease (stage five), ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, and end-stage liver disease.

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 1

Password: sDBNERC3

 

Session 2: Red Flag HCCs, part two: Training will cover HCCs most commonly reported in error as identified by CMS, including atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and guillain-barre syndrome, drug/alcohol psychosis, lung and other severe cancers, diabetes with ophthalmologic or unspecified manifestation.

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC’s Part 2

Password: PnPAF4py

 

Session 3: Neoplasms

Recording will play upon registration.

2020 Medicare Risk Adjustment Documentation and Coding Guidance: Neoplasms

Password: PfUWPcs6

 

Session 4: Acute, Chronic and Status Conditions

Recording link will be provided after October 1, 2020.

 

Session 5: Diabetes Mellitus and Other Metabolic Disorders - September 16, 2020

DM and other Endocrine, Nutritional and Metabolic Disorders

 

Session 6: Coinciding Conditions in Risk Adjustment Models - November 18, 2020

Medicare Risk Adjustment Documentation and Coding Guidance: Coinciding Conditions in Risk Adjustment Models

 

ABSCRNU-0158-20                   510874MUPENMU

Effective November 1, 2020, AIM Specialty Health_® (AIM)*, a specialty health benefits company, will expand the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joint for Medicare Advantage patients, as further outlined below.

 

AIM will follow the Anthem Blue Cross and Blue Shield (Anthem) clinical hierarchy for medical necessity determination. For Medicare Advantage (MA) products AIM makes clinical appropriateness based on CMS National Coverage Determinations, Local Coverage Determinations, other coverage guidelines, and instructions issued by CMS and legislative benefit changes. Where the existing CMS guidance provides insufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.

 

Prior authorization requirements

 

For services scheduled on or after November 1, 2020, providers must contact AIM to obtain prior authorization for the services detailed below. Providers are strongly encouraged to verify they have received a prior authorization before scheduling and performing services.

 

Detailed prior authorization requirements are available to contracted providers by accessing the Availity Portal* at www.availity.com. Contracted and non-contracted providers may call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements or additional questions as needed.

 

Small joint replacement (including all associated revision surgeries)

 

• Total joint replacement of the ankle

 

• Correction of hallux valgus

 

• Hammertoe repair

The expanded musculoskeletal program will review certain lower extremity small joint surgeries for clinical appropriateness of the procedure and the setting in which the procedure is performed (Level of Care review). Procedures performed as part of an inpatient admission are included. The clinical guidelines that have been adopted by Anthem to review for medical necessity and level of care are located at:

 

• AIM Small Joint Surgery Guideline

 

• AIM Level of Care Guidelines for Musculoskeletal Surgery and Procedures

How to place a review request

 

You may place a prior authorization request online via the AIM ProviderPortal_SM. This service is available 24/7 to process requests using Clinical Criteria. Go to www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday to Friday 7 a.m. to 7 p.m. Central time.

 

For more information

 

For resources to help your practice get started with the musculoskeletal program, go to www.aimprovider.com/msk.

 

This provider website will help you learn more and provide useful information and tools such as order entry checklists, clinical guidelines, and FAQs.

 

For questions related to guidelines, please contact AIM via email at im.guidelines@aimspecialtyhealth.com.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0159-20       511046MUPENEBS

Please continue to check Important Medicare Advantage Updates for the latest Medicare Advantage information, including:

 

Medicare Advantage Submit behavioral health authorizations via our online Interactive Care Reviewer tool

ABSCARE-0488-20       509678MUPENMUB

 

Medicare Advantage Waived copays, deductibles and coinsurance for CCM, complex CCM and TCM

ABSCRNU-0155-20        510548MUPENMUB

 

Updates to AIM musculoskeletal program clinical appropriateness guidelines

ABSCRNU-0149-20        509715MUPENMUB