 Provider News VirginiaAugust 2022 Anthem Provider News - Virginia Contents State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2022 Chlamydia screening
Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. would like to remind you of the procedures to follow for inpatient claim denials for our Commercial lines of business:
- If claim is billed as inpatient bill type in error, a replacement bill xx7 is a replacement of the same type of bill (ex. x11 and x17, or x31 and x37; you may not use a x37 to replace a x11 or a x17 to replace a x31).
- If you are changing the bill type from inpatient to outpatient or outpatient to inpatient, the original claim will need to be voided by using a frequency type 8 (void).
- The void request must be submitted first by the provider, or in conjunction with a frequency type 1 (original) inpatient or outpatient claim before the outpatient bill type claim will be processed.
- This can be done electronically or with a provider adjustment request (PAR) form.
- Further instructions are included in the provider manual.
It is inappropriate to re-bill an outpatient claim when receiving a denial/upheld appeal response for ancillary services rendered in the inpatient setting for commercial polices. This includes, but is not limited to, emergency department, imaging, laboratory services, specialty pharmacy, and surgeries.
Claims should be coded and billed based on the medical record and the physician order.
For complete information on electronic claims processing procedures, visit the Electronic Data Interchange (EDI) page on our website.
Note: This update does not apply to Medicaid or Medicare Advantage.
According to the American Medical Association (AMA) Current Procedural Terminology® (CPT) guidelines, a new patient is defined as one who has not received any professional services, i.e., face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
By contrast, AMA CPT guidelines state that an established patient is one that has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional in the same group and of the same specialty and subspecialty within the prior three years.
Effective with claims processed on or after September 1, 2022, Anthem Blue Cross and Blue Shield will add rigor to its existing review of professional provider claims for new patient evaluation and management (E/M) services submitted for the same patient within the last three years to align with the AMA CPT guidelines. Claims that do not meet these criteria will be denied.
Providers who believe their medical record documentation supports a new patient E/M service for the same patient within the last three years should follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual or resubmit the claim with an established patient E/M.
If you have questions on this program, contact your contract manager or Provider Experience representative.
Submitting your updates promptly helps ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information we show in our online directory has changed.
If updates are needed, you can use our online Provider Maintenance Form. Using this form, you can update:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging that we received your request. See the Provider Maintenance Form for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).
Effective July 1, 2022, Anthem recognizes and accepts qualifying claims for acute Hospital in Home (HiH) services through the newly established revenue code 0161. We encourage hospitals or other entities that meet the HiH requirements to reach out to their Anthem contractor to get an appropriate participation agreement in place, which will ensure more streamlined processing of HiH claims.
The new code enables hospitals to distinguish acute inpatient care in the home for qualifying patients. The code will follow the same guidelines and policies associated with any services performed in an inpatient setting, including but not limited to utilization management. Facilities must comply with all requests from Anthem for any information and data related to the HiH services and be an approved, active participant of the CMS Acute Hospital Care at Home Program for Medicare products. All services are subject to the Covered Individual Health Benefit Plan coverage and, if a covered benefit, the benefit will follow the inpatient hospital benefits that apply to services that are performed in a traditional hospital setting, which includes, but is not limited to, any applicable deductibles, copays, and coinsurance.
The following Anthem benefit plans are in scope for participation in HiH:
- Anthem Commercial
- Medicare Advantage (Individual and Group)
- Medicare Advantage Special Needs plans, including Dual-Eligible Special Needs (D-SNP)
The following Anthem plans are out of scope for participation in HiH:
- Federal Employee Program (FEP)
- Medicaid
Note:
- Be advised that while you may submit an electronic transaction to verify a Blue Plan member’s benefits and eligibility, Anthem suggests that you call the member’s Blue Plan to definitively determine whether the member has HiH benefits, since the electronic eligibility inquiry may not yield an answer specific to HiH eligibility. We suggest calling because if the member does not have this as a covered benefit, HiH services would then be the member’s financial responsibility.
- Covered individuals must express preference for and consent to treatment in the home setting for the HiH program and must be 18 years of age or older. This consent must be documented through a signed consent form. (Sample form available upon request.)
- Covered individuals may be admitted to the program from the emergency department (for a patient that needs the inpatient level of care) or transferred from the inpatient hospital setting.
- Facility shall not bill Anthem or the covered individual for any items or services provided by the facility in the home setting that typically would not be billed during an inpatient hospitalization.
- Notify Anthem immediately through the utilization management nurse assigned to the HiH case when:
- An applicable member is admitted to the HiH program
- A member in the program is transferred back to hospital inpatient care or has any other status change in their care plan
- As with other claims, participating facilities and/or providers may not bill the member for any denied HiH-related charges. Providers who disagree with the claim denial may request a review of the denial using the reconsideration and appeal process outlined in your Anthem Agreement and/or as outlined in the applicable Anthem provider manual.
- We will continue to update billing guidance as these programs evolve.
Now open for learning
Access to training for Availity Essentials can be helpful when trying to master applications like claims attachments, authorizations and eligibility and benefits. The Provider Learning Hub on Anthem.com is not only a new way to access training, it also offers a new learning experience.
Short, easy to follow training videos with supporting resources are available on the Provider Learning Hub – no username and password required. Access it at your convenience and share your learnings with others on your teams. Handy filtering options enable you to quickly find what you are looking for including an option to save trainings to a Favorites folder for easy access later. You will register for the Provider Learning Hub once. On future visits your preferences are populated, eliminating the need for any additional logon information.
Get started today
Access the Provider Learning Hub or from Anthem.com under Important Announcements on the home page.
Digital claims attachments expedite claims processing and payment. That’s why we have been hard at work making the digital attachment process easier, more intuitive and streamlined. Now you can add attachments directly to your claim by using the new Send Attachments feature from the Claims Status application on Availity.com.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time because there is no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and personal health information.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the Attachment Control Number, there are three options for submitting attachments:
|
OPTION
|
ACTION
|
|
1
|
Through the Attachments Dashboard Inbox:
From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox
|
|
2
|
Through the 275 attachment:
Important: You must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment
|
|
3
|
Through the Availity.com application:
From Availity.com, select the Claims & Payments tab to run a Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
|
If you submitted your claim through the Availity Essentials application:
- Simply submit your attachment with your claim.
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and run a Claims Status to locate your claim. When you have found your claim, use the Send Attachments button.
Learn more about the Send Attachments feature
In collaboration with Availity Essentials, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status workflow. Sign up for a live webinar today:
Reductions in missed appointments are significant
Telehealth visits are having a significant impact on missed appointments according to a study published in Counselling Psychology Quarterly. Prior to transitioning to telehealth, clinicians in the study “Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice,i” experienced a 14.25% missed appointment rate. After transitioning to telehealth, the missed appointment rate fell to 5.63%.
Rate of missed appointments before and after transitioning to telehealth
The graph below illustrates the changes in the average rate of missed appointments (cancellations and no-show) for each of the eight clinicians in the study between the periods before and after the transition to telehealth.
https://www.tandfonline.com/doi/full/10.1080/09515070.2020.1777390
“While there are a number of limitations to consider regarding this data, [which is further discussed in the study], the statistically significant reduction in missed appointments pre-and-post [digital] transition is striking,” cited in the study report.
Telehealth and telephone visits with members after a behavioral health inpatient stay meet HEDIS® criteria for the measure: Follow-up after Hospitalization for Mental Illness (FUH). With transportation being one of the barriers to after hospitalization follow-up, telehealth visits could be an ideal solution.ii
The FUH HEDIS measure evaluates:
- Members (6 years and older) who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.
Two areas of importance for this HEDIS measure are:
- The percentage of behavioral health inpatient discharges for which the member received follow-up within seven days after discharge.
- The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.
These two consecutive follow-up appointments are paramount to positive outcomes as well as meeting this HEDIS measure. Telehealth visits can greatly increase the likelihood of keeping follow-up appointments leading to reduced numbers of rehospitalization and more favorable outcomes for these patients. To learn more about the FUH HEDIS measure, visit the National Committee for Quality Assurance (NCQA) website.
Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will implement the following new and revised coverage guidelines effective November 1, 2022. These guidelines impact all our products – with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP®). Furthermore, the guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on May 12, 2022.
The services addressed in these coverage guidelines here and in the attachment under "Article Attachments" to the right will require authorization for all of our HealthKeepers, Inc. products – with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan. A pre-determination can be requested for our PPO products. Please note that FEP is excluded from this requirement as well.
The guidelines addressed in this edition of Provider News are:
- Intermittent abdominal pressure ventilation devices (DME.00046)
- Rehabilitative devices with remote monitoring (DME.00047)
- Virtual reality-assisted therapy systems (DME.00048)
- Gene expression profiling of melanomas and cutaneous squamous cell carcinoma (GENE.00023)
- Hybrid personalized molecular residual disease testing for cancer (GENE.00059)
- Pain management biomarker analysis (LAB.00048)
- Electrical impedance scanning for cancer detection (MED.00139)
- Portable normothermic organ perfusion system (TRANS.00039)
- Cryosurgical, radiofrequency or laser ablation to treat solid tumors outside the liver (CG-SURG-61)
For providers who provide physical, occupational or speech therapy services, the AIM Rehabilitation Program effective date is delayed until September 1, 2022. A prior authorization will not be required for therapy services until that date.
Several months ago, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. shared with you our plans to transition medical necessity review of physical, occupational and speech therapy services to AIM Specialty Health® (AIM),* a separate company, effective August 1, 2022. Recently, we informed you that we were experiencing a technical issue related to Anthem’s Commercial members in Virginia.
Therefore, we have decided it would be best to postpone the prior authorization requirement for the AIM Rehabilitation Program until September 1, 2022. We will continue to work on resolving our technical issues.
Once implemented, the new rehabilitation program will review certain treatment plans against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine. In Virginia, Anthem will be utilizing the AIM outpatient rehabilitative and habilitative services Clinical Guidelines. Any qualified providers acting within the scope of their license who intend to provide therapy services are required to obtain a prior authorization from AIM.
Note: Chiropractors performing therapy services are not required to obtain prior authorization from AIM due to the current American Specialty Health (ASH) chiropractor utilization management program.
For therapy services that are scheduled to begin on or after September 1, 2022, all providers must contact AIM to obtain prior authorization for the following non-emergency modalities:
- Physical therapy
- Occupational therapy
- Speech therapy
For more information
The AIM provider website helps you learn more about the program and provides access to useful information and tools such as order entry checklists, clinical guidelines, and FAQs. To learn more about AIM, please visit www.aimspecialtyhealth.com.
August 11 webinar postponed
Anthem and AIM will continue to host live Q&A webinar sessions in advance of the September 1 implementation. However, the session originally scheduled for August 11 has been postponed until further notice. We are working to schedule additional webinar dates and will share those dates when available.
The webinars are designed for providers and office staff who will be requesting prior authorizations. If you have not yet attended a training session, please consider registering to attend a training opportunity when the new schedule is available. We highly encourage facilities to attend an AIM training opportunity.
AIM solution-specific training content will be made available to you upon completion of registration and prior to attending the webinar session. Reviewing the material ahead of the training will allow your facility to bring relevant questions to be addressed during the training.
How to submit a request for review
As a reminder, providers can submit requests for review or verify order numbers using one of the following methods.
Online
The AIM ProviderPortalSM is available 24/7, fully interactive, and processes requests in real-time using Clinical Criteria. To register, go to https://aimspecialtyhealth.com/providerportal.
By phone
Call AIM Specialty Health toll free at 866-789-0158, Monday through Friday from 8 a.m. to 5 p.m. ET.
At Anthem, we value your business and understand the seriousness of this implementation delay. Please know that we regret any inconvenience or disruption this situation may have caused you and your staff.
Specialty pharmacy updates for Anthem Blue Cross and Blue Shield (Anthem) and our affiliate HealthKeepers, Inc. are listed below.
Anthem’s medical specialty drug review team manages prior authorization clinical review of non-oncology use of specialty pharmacy drugs. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health®. This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
Important to note
Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of the National Drug Code (NDC) on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code. The Health Plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code, for the injected substance. This requirement is consistent with CMS guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.
Prior authorization updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0072
|
Alymsys (bevacizumab-maly)
|
C9399, J3490, J3590
|
|
ING-CC-0107*
|
Alymsys (bevacizumab-maly)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0216*
|
Opdualag (nivolumab and relatlimab-rmbw)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0118*
|
Pluvicto (lutetium lu 177 vipivotide tetraxetan)
|
A9699
|
|
ING-CC-0002*
|
Releuko (filgrastim-ayow)
|
C9096
|
* Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0107*
|
Non-preferred
|
Alymsys
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0002*
|
Non-preferred
|
Releuko
|
C9096
|
*Oncology use is managed by AIM.
Courtesy notice
Effective for dates of service on and after October 1, 2022, updated step therapy criteria for immunoglobulins found in clinical criteria document ING-CC-0003 will be implemented. The preferred product list is being expanded. Please refer to clinical criteria document for details.
Quantity limit updates
Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0072
|
Alymsys (bevacizumab-maly)
|
C9399, J3490, J3590
|
Effective for dates of service on and after November 1, 2022, the following Clinical Criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
For Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc., prior authorization of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of oncology will still require prior authorization by AIM Specialty Health®* (AIM). This applies to members with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
Access the Clinical Criteria document information.
|
ING-CC-0068
|
Growth Hormone
|
|
ING-CC-0087
|
Gamifant (emapalumab)
|
|
ING-CC-0107
|
Bevacizumab for Non-Ophthalmologic Indications
|
|
ING-CC-0118
|
Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin)
|
|
ING-CC-0119
|
Yervoy (ipilimumab)
|
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
|
ING-CC-0153
|
Adakveo (crizanlizumab)
|
|
ING-CC-0215
|
Ketamine injection (Ketalar)
|
|
ING-CC-0216
|
Opdualag (nivolumab and relatlimab-rmbw)
|
Visit the Drug Lists page at https://www.anthem.com for more information on:
- Copayment/coinsurance requirements and their applicable drug classes.
- Drug lists and changes.
- Prior authorization criteria.
- Procedures for generic substitution.
- Therapeutic interchange.
- Step therapy or other management methods subject to prescribing decisions.
- Any other requirements, restrictions, or limitations that apply to using certain drugs.
The Commercial and Exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.
To locate Exchange Select Formulary and pharmacy information, scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2022 HEDIS 2022: Summary of changes from the National Committee for Quality AssurancePlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
The National Committee for Quality Assurance (NCQA) has changed, revised, and retired HEDIS® measures for measurement year 2022. Below is a summary of some of the key changes.
Diabetes measures
NCQA has separated the Comprehensive Diabetes Care indicators into stand-alone measures:
- Hemoglobin A1c Control for Patients with Diabetes (Two rates reported: HbA1c Control (< 8%) and Poor Control HbA1c) (> 9%) (HBD)
- Eye Exam for Patients with Diabetes (EED)
- Blood Pressure Control for Patients with Diabetes (BPD)
The process measure Comprehensive Diabetes HbA1c testing was retired as the goal is to move toward more outcome-based measures.
Race/ethnicity stratification
An important step to address healthcare disparities is reporting and measuring performance. Given this, NCQA has added race and ethnicity stratifications to the following HEDIS measures:
- Colorectal Cancer Screening (COL)
- Controlling High Blood Pressure (CBP)
- Hemoglobin A1c Control for Patients with Diabetes (HBD)
- Prenatal and Postpartum Care (PPC)
- Child and Adolescent Well Care Visits (WCV)
NCQA plans to expand the race and ethnicity stratifications to additional HEDIS measures over several years to help identify and reduce disparities in care among patient populations. This effort builds on NCQA’s existing work dedicated to advancing health equity in data and quality measurements.
Measure changes
Colorectal Cancer Screening (COL): Measures the percentage of members 45 to 75 years of age who had appropriate screening for ectal cancer. The Medicaid product was added to the administrative data collection method for this measure and the age range was changed to 45 to 75 years of age. Any of the following meet criteria:
- Fecal occult blood test during the measurement year
- Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year
- Colonoscopy during the measurement year or the nine years prior to the measurement year
- CT colonography during the measurement year or the four years prior to the measurement year
- Stool DNA (sDNA) with FIT test during the measurement year or the two years prior to the measurement year
This measure can also be reported as an Electronic Clinical Data Reporting System measure: Colorectal Cancer Screening (COL-E).
Antibiotic Utilization for Respiratory Conditions (AXR): A newly added metric which measures the percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event. This measure was added because antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse.
Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic use. Given this new measure, the broader Antibiotic Utilization measure has been retired.
Use of Imaging Studies for Low Back Pain (LBP): This measure was expanded to the Medicare line of business, and the upper age limit for this measure was expanded to age 75. Additional exclusions to the measure were also added.
For a complete summary of 2022 HEDIS changes, visit: https://www.ncqa.org/hedis/measures/.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2022 Using screening, brief intervention, and referral to treatment to address opioid and substance use disordersPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
COVID-19 impact on opioid and substance use disorders
As a result of the COVID-19 pandemic, there has been a 20% increase in substance use nationwide, and nearly 100,000 opioid overdose related deaths between 2020 and 2021.1 Black Americans have been disproportionately affected by this increase in overdoses.2 Increasing screening, brief intervention, and referral to treatment (SBIRT) may help provide an opportunity to engage those with emerging and existing substance use disorders through proactive identification and connection to professional services when indicated.
SBIRT Resources for providers
A provider toolkit for SBIRT is available on the Anthem HealthKeepers Plus provider portal. This toolkit includes SBIRT collateral materials for your use, which outline recommended screening tools, a guided SBIRT process, and resources to help identify appropriate referrals.
More about the SBIRT approach
SBIRT is a “comprehensive, integrated public health approach to the delivery of early intervention and treatment services for persons with substance use disorders (SUD), as well as those who are at risk of developing these disorders,” according to the Substance Abuse and Mental Health Service Administration (SAMHSA). The goal of SBIRT is to reduce the potential consequences of SUDs.3
SBIRT encounters include a brief screening and intervention that identifies:
- One or more behaviors related to risky alcohol or drug use.
- Right type and amount of treatment.
The screening is a brief set of questions that identify the patient’s risk of SUD-related problems. The brief intervention is a short (15 to 30 minutes) counseling session to raise awareness of the risks. By leveraging motivation enhancement techniques, this seeks to work with the patient where they are at and with what they are ready and willing to do to address identified substance misuse. Referral to treatment helps the patient access specialized treatment when indicated.
The purpose of the encounter is to facilitate change with the patient’s immediate behavior or thoughts about a risky behavior. In addition, SBIRT results help those with higher levels of need to obtain long-term care, including referrals to specialty providers. This evidence-based program (EBP) has been shown to result in a $2 to 4 healthcare savings for every $1 spent.4
Healthcare providers who encounter an at-risk member have an opportunity for early intervention and referral to appropriate treatment. The core goal is to reduce and prevent problematic use, abuse, and dependence on alcohol, opioids, and other substances. SBIRT has been proven effective regardless of age, gender, race, and culture in children, adolescents, and adults.
Encounters with patients in need of SBIRT may occur in public health, non-substance use treatment settings including primary care centers, hospital emergency rooms, trauma centers, and community health settings. Primary care providers (MD/DOs, PAs, ARNPs), behavioral health providers (therapists, counselors, psychiatrists, clinical social workers), and nurses may provide SBIRT.
Recommended screening tools include:
- Alcohol use disorder identification test (AUDIT)5 for adults with alcohol risk.
- Drug abuse screening test (DAST-10)6 for adults with drug risk.
- Car, relax, alone, forget, family or friends, trouble (CRAFFT)7 for children and adolescents.
- Tolerance, worried, eye opener, amnesia, k/cut down (TWEAK)8 for pregnant people.
Below is the SBIRT process flow.
If you need assistance connecting patients to SUD treatment, or have questions about implementing SBIRT in your practice, call Provider Services at 800-901-0020 or Anthem CCC Plus Provider Services at 855-323-4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2022 The cost of alcohol use disorderPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
The total economic cost of alcohol use disorder (AUD) was estimated to be $249 billion as of 2019, according to the CDC1 with $27 billion coming from healthcare costs.2 The CDC projected the total AUD economic impact on society to be $807 per person, per year.3
AUD and healthcare spending
Alcohol contributes to the highest amount of health plan spending related to substance use. 36% of Medicaid substance use claims were related to alcohol in 2020, accounting for over $129 million — an increase of 16% from 2019. Additionally, people with AUD are more likely to be high-cost claimants. In government and commercially insured patients across the country, the top 5% of high-cost claimants have either an existing AUD or health conditions resulting from alcohol use.4
AUD and the workforce
AUD also has a significant economic effect on the workforce by way of tardiness, absenteeism, employee turnover, and conflict. It causes a reduction in potential employees, customer base, and the taxpayer base.5
AUD and mortality
Alcohol use was directly tied to 95,000 deaths annually between 2011 and 2015, according to the CDC. This was more than all other illicit substances combined including opioids, heroin, fentanyl, and methamphetamines. The CDC estimates that alcohol-attributed disease resulted in almost 685,000 years of potential life lost (YPLL) for the same period. YPLL is the estimation of the average time a person would have lived had they not died prematurely.6
Below is the YPLL related directly or indirectly to AUD.
|
Cause
|
YPLL
|
|
Total YPLL
|
> 2.7 million
|
|
100% alcohol attributed disease
|
684,750
|
|
Suicide
|
334,058
|
|
Motor vehicle crashes
|
323,610
|
|
Liver disease
|
202,391
|
|
Heart disease
|
118,021
|
|
Cancer
|
88,729
|
Need assistance?
If you need assistance connecting your patients to AUD or substance use treatment, please contact Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2022 Prior authorization requirement changes updated effective November 1, 2022Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Effective November 1, 2022, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by HealthKeepers, Inc. Federal and state law, as well as state contract language, and CMS 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:
- 0214U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O
- 0215U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O
- 81415: Exome (such as unexplained constitutional or heritable disorder or syndrome); sequence analysis
- 81416: Exome (such as unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (such as parents, siblings) (List separately in addition to code for primary procedure)
- 81417: Exome (such as unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (such as updated knowledge or unrelated condition/syndrome)
- L6026: Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device
- L6715: Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement
To request a PA, you may use one of the following methods:
- Availity:* Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then select Authorizations or Auth/Referral Inquiry, as appropriate.
- Fax: 800-964-3627
- Phone: 800-901-0020
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://providers.anthem.com/va. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 800-901-0020 for assistance with PA requirements.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2022 Chlamydia screening
Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Chances are, one of these teenagers has chlamydia. According to the Centers for Disease Control and Prevention (CDC), one of the largest growing populations for chlamydia are teens and young adults. Chlamydia infection is often asymptomatic, and screening for asymptomatic infection is a cost-effective strategy to reduce transmission and prevent pelvic inflammatory disease among females.
Talking to a teenager about sexual health issues like chlamydia can be difficult. But, left untreated, an affected individual may develop conditions such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. To help get the conversation started, visit the National Chlamydia Coalition website at http://chlamydiacoalition.org for a free Chlamydia How-To Implementation Guide for Healthcare Providers.
Facts about chlamydia
- The United States Preventive Services Task Force (USPSTF) recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at risk for infection.
- Chlamydia is the most commonly reported sexually transmitted disease (STD) with over 1.8 million cases reported in 2019.
- Young women account for 43% of reported cases and face the most severe consequences of an undiagnosed infection.
- It is estimated that undiagnosed STDs cause infertility in more the 20,000 women each year.
Chlamydia Screening in Women (CHL) HEDIS® Measure
This HEDIS measure looks at the percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year, including teens and women who:
- Made comments or talked to you about sexual relations.
- Had a pregnancy test.
- Were prescribed birth control (even if used for acne treatment).
- Received gynecological services.
- Have a history of sexually transmitted diseases.
- Have a history of sexual assault or abuse.
|
Description
|
CPT® codes
|
|
Chlamydia tests
|
87110, 87270, 87320, 87490, 87492, 87810
|
|
Pregnancy test exclusion
|
81025, 84702, 84703
|
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2022 Billing taxonomy code requirementsPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
As a reminder, the Department of Medical Assistance Services (DMAS) and HealthKeepers, Inc. require all Anthem HealthKeepers Plus providers to include their respective billing taxonomy codes on paper and electronic claims. This is in addition to their billing National Provider Identifier (NPI). Ensuring the taxonomy codes are included will prevent adverse impacts on Anthem HealthKeepers Plus claims submissions to the Commonwealth of Virginia.
Additionally, for any claims submitted to Medicare for dual members, the taxonomy code with the appropriate qualifier is required to ensure accurate claims processing. HealthKeepers, Inc. has confirmed that even though Medicare does not require the billing taxonomy codes, Medicare will accept and transfer them to HealthKeepers, Inc. when the claims cross over.
Below are some tips for filing a complete and correct professional and institutional claim:
- For electronic claims submissions, consult the Commonwealth of Virginia’s encounter processing solution (EPS) claims submission rules, which dictate that the billing provider NPI is included in loop 2010AA, segment NM109, and taxonomy is included in loop 2000A, segment PRV03:
- Taxonomy code qualifier PXC is required with electronic submissions.
- For paper claims submissions, on a CMS-1500 form, the billing providers taxonomy code is required in box 33b in addition to the taxonomy code qualifier ZZ:
- Enter the two-digit ZZ qualifier directly followed by the taxonomy code. Do not enter a space, hyphen, or other separator between the qualifier and taxonomy.
- For paper claims submissions, on a UB-04 form, include the taxonomy code in box 81:
- Box 81-Code Field/Qualifiers:
- Enter the B3 as the qualifier directly followed by the taxonomy code if locations 76-79 contain an NPI. Enter the corresponding provider taxonomy code that is required for the provider’s NPI entered in locations:
- 76a – 81CCa
- 77b – 81CCb
- 78c – 81CCc
- 79d – 81CCd
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2022 Service facilitation visit authorization and limit reminderPlease note, this communication applies to Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
HealthKeepers, Inc. would like to remind Anthem CCC Plus providers of the visit limitations and a change to the authorization requirements for the Commonwealth Coordinated Care Plus Waiver Consumer Directed Service Facilitation visits.
There are several different management visits allowed to be billed by Service facilitators, as part of the Consumer Direction program. Service facilitators can review these visit types and defined expectation in the Commonwealth Coordinated Care Plus Waiver Services Provider Manual, as well as utilize the How to Do Business Chart on the Virginia Department of Medical Assistance Services (DMAS) website.
What is the change?
Effective September 1, 2022, prior authorization will be required for the following service:
- Code: (99509) Routine visit – authorization required.
HealthKeepers, Inc. will initiate the first round of authorizations for 99509, so no initial action is needed from the provider. However, they will be required to request renewal yearly as needed.
Defined below are the visit limitations allowed by HealthKeepers, Inc. as well as the authorization requirements.
|
Service code
|
Visit limits
|
Authorization required?
|
|
H2000 – Initial Comprehensive Visit
|
One visit per member per lifetime
|
Authorization required
|
|
S5109 – Consumer Training Visit
|
One visit per Employer of Record (EOR)
|
Authorization required
(also required if service is requested due to change in EOR)
|
|
99509 – Routine visit
|
Five visits per rolling calendar year
|
Authorization required
|
|
S5116 – Management Training Hours
|
Two visits per rolling calendar year
|
Authorization required for any visits over the allowable limit
|
|
T1028 – Reassessment Visit
|
Two visits per rolling calendar year
|
Authorization required for visits over allowable limit
|
How do I request authorization?
Requests may be submitted by calling Provider Services at 855-323-4687, ext. 1061035152 or faxing the requests to one of the fax lines indicated below. All requests must include clinical documentation showing a medical reason why the member needs to have the service. As a reminder, we allow requests for authorizations to be submitted retroactively up to 10 calendar days after the service, however, approval is based on utilization review.
Documentation requirements
- For 99509- Routine visit: The service facilitator should supply DMAS 99 to coincide with visit.
Example: If frequency of visit is necessary due to a change in level of care, it should be documented appropriately on DMAS 99.
- For S5116- Management training hours: The service facilitator should supply DMAS 99 to coincide with visit.
Example: If management training hours are provided upon the request of the individual/EOR, the service facilitator should document what training was provided and discussed. This service is for EOR training only, as attendant training is the responsibility of the EOR.
- For T1028- Reassessment visit: The service facilitator should supply DMAS 99 to coincide with visit.
Example: If reassessment visit needed after hospital discharge, should be documented appropriately on DMAS 99.
- For S5109 – Consumer training visit: The service facilitator should supply the Fiscal Agent Request Form (FARF) that shows proof in the change of the EOR, when requesting any additional visits outside of the standard one visit.
Fax lines
|
Anthem CCC Plus Waiver standard requests
|
844-864-7853
|
|
Anthem CCC Plus Waiver expedited requests
|
888-235-8390
|
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2022 Treatment involving prescription of opioidsPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus offered by HealthKeepers, Inc.
Effective as of July 1, 2022, providers accepting Medicaid reimbursement may not request or require a Medicaid member to pay any out-of-pocket cost for the provision of opiates for pain management or medications approved for the treatment of opioid addiction. Providers not accepting Medicaid must inform their Medicaid members via writing that they do not participate with Medicaid, but that in-network Medicaid providers do not charge for the provision of opiates for pain management or medications approved for the treatment of opioid addiction.
Additional information is available.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | August 1, 2022 Keep up with Medicaid news: August 2022Please continue to check our website https://providers.anthem.com/virginia-provider/home 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 a topic we’re addressing in this edition:
 |