Effective January 1, 2019, the American Medical Association will be replacing the temporary CPT codes used by ABA (Applied Behavior Analyst) treatment services with new permanent CPT codes.  As with all annual CPT coding changes, Anthem Blue Cross and Blue Shield and our affiliate Healthkeepers, Inc. will make the necessary updates to all claims and operational systems by the effective date.  All participating ABA providers will receive an additional notice, advising them of any changes to reimbursement or billing as a result of the new CPT codes once the final and official AMA documentation along with any CMS updates have been made available to health plans and providers.

In our company’s ongoing efforts to streamline and simplify our payment recovery process, we continue to consolidate our internal systems and will begin transitioning our National Accounts membership to a central system in 2019. While this is not a new process, we are transitioning the National Accounts membership to align with the payment recovery process across our other lines of business.

Currently, our recovery process for National Accounts membership is reflected in the EDI PLB segment on the electronic remittance advice (835).  This segment will show the negative balance associated with the member account number.  Monetary amounts are displayed at the time of the recovery adjustment.

As National Accounts membership transitions to the new system and claims are adjusted for recovery, the negative balances due to recovery are held for 49 days to allow ample time for you to review the requests, dispute the requests and/or send in a check payment. During this time, the negative balances due are reflected on paper remits only within the “Deferred Negative Balance” sections. 

After 49 days, the negative balances due are reflected within the 835 as a corrected and reversed claim in PLB segments. 

If you have any questions or concerns, please contact the E- Solutions Service Desk toll free at (800) 470-9630.

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

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

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

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

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

Electronic ID cards

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

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

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

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

Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. have designated Availity to operate and serve as your electronic data interchange (EDI) entry point or also called the EDI Gateway.  The EDI Gateway is a no-cost option to our direct trading partners.  With this change, Anthem continues our efforts to ensure consistency between your provider portal and the EDI Gateway.

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway.  Availity is well known as a Web portal and claims clearinghouse.  In addition, Availity functions as an EDI Gateway for multiple payers and is the single EDI connection for our company.

Your organization can submit and receive the following electronic transactions through Availity’s EDI Gateway:

• 837- Institutional Claims
• 837- Professional Claims
• 837- Dental Claims
• 835 - Electronic Remittance Advice
• 276/277- Claim Status
• 270/271- Eligibility Request

If you wish to become a direct a trading partner with Availity, the setup is easy. Use the Availity Welcome Application  to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions. 

If you prefer to use your clearinghouse or billing company, please work with them to ensure connectivity.

Need Assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

835 Electronic Remittance Advice (ERA)

Effective June 1, 2018, please use Availity to register and manage account changes for ERA.

If you were previously registered to receive ERA, you must register using Availity to manage account changes.

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

If you were previously registered to receive EFT only, you must register using EnrollHub to manage account changes. No other action is needed.

Contacting Availity

If you have any questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 7:30 p.m. Eastern Time.

The Education and Reference Center (ERC) offers the Communication and Education section where you can find training materials, important policy information, commonly used forms and reference guides on Anthem’s proprietary tools. When you visit the ERC, you can efficiently navigate to all available electronic resources using only the Availity Portal.

The Communication and Education section includes a new category – Payer Spaces – to help make it easier for you to find what you need.

With an Availity log in, you can easily view any new content added to the ERC. There is no additional role assignment needed.  

Find the ERC on the Availity Portal under Payer Spaces > Anthem> Applications. If you are having trouble locating the Education and Reference Center, type Education and Reference Center in the Availity Search option located on the top navigation menu. Select the heart next to the application to save it to your favorites.

As a reminder, our claim editing software will be updated monthly throughout 2019 with the most common updates occurring quarterly in February, May, August and November of 2019. These updates will:

• Reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
• Include updates to National Correct Coding Initiative (NCCI) edits
• Include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
• Include assistant surgeon eligibility in accordance with the policy
• Include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

This coding tip is based on recent findings for claims processed with modifier 79 during a postoperative period.  Current Procedural Terminology (CPT®) specifically states modifier 79 should be reported by the same individual when reporting unrelated procedures or services during the postoperative period. For example, this modifier is used when a patient presents with a problem that is unrelated to a previous surgery (yet within the postoperative period) and requires additional services by the same provider/individual.  When modifier 79 is appended for a different provider during the postoperative period, the claim line will deny.

In addition to modifier 79, modifiers 58 and 78 are also based on Same Physician or Other Qualified Health Care Professional as documented below:

• 58:  Staged/Related Procedure/Service by the Same Physician/Other Qualified Health Care Professional during the Postoperative Period.

• 78:  Unplanned Procedure/Service by Same Physician/Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure during the Postoperative Period.

As a reminder, providers and facilities are required to review all member information received from Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. to help ensure no misrouted PHI is included. Misrouted PHI includes information about members that a provider or facility is not currently treating. PHI can be misrouted to providers and facilities by mail, fax or e-mail. Providers and facilities are required to immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are providers or facilities permitted to misuse or re-disclose misrouted PHI. If providers or facilities cannot destroy or safeguard misrouted PHI, providers and facilities must contact Anthem’s provider services area to report receipt of misrouted PHI.

Our provider newsletter is our primary source for providing important information to health care providers and professionals. The newsletter is published bi-monthly and is posted to our website on the Virginia provider section of anthem.com for easy 24/7 access.

Note that in addition to this newsletter and our website, we also use our e-mail service – Network eUPDATE – to communicate new information. If you are not yet signed up to receive Network eUPDATEs, we encourage you to enroll now so you’ll be sure to receive all information we will be sending about billing, upcoming changes, coverage guidelines and other pertinent topics.

Reminder notifications sent via e-mail

Effective January 1, 2019, Anthem Blue Cross and Blue Shield will offer three new Exclusive Provider Organization (EPO) plans in the Virginia Small Group market. The new EPO plans will use our KeyCare network which is currently also used by our PPO plans. The alpha prefix will be “VLX.”  One new EPO plan will be offered in each of the Bronze, Gold and Platinum metal levels of our health benefit plans. No Silver EPO plans will be offered at this time.

The notable difference from our standard PPO plans will be the exclusion of out-of-network benefits – except in medical emergencies and for certain authorized services. As such, the plans will be referred to as “open access” and will accordingly have the letters “OAEPO” in their names. The plans will not have gatekeeper referral requirements, and like our PPO and Point of Service (POS) plans, will have a PCP assignment requirement and only be sold OFF the exchange. The authorization process and reimbursement fee schedule will also follow what we have in place for PPO plans.

If you have questions, please contact our customer service area using the phone number on the back of the member’s ID card.

Department of Corrections eligibility update

You may have recently received notice from the Virginia Department of Corrections (DOC) regarding billing and payment for inpatient hospitalization services provided to the DOC offender population.  The passage of HB5001 expanded eligibility of Medicaid benefits for individuals in the Commonwealth in accordance with the Patient Protection and Affordable Care Act (PPACA).  With this change, a significant portion of the DOC population will become newly eligible for medical assistance benefits. 

Therefore, for most of the inpatient hospitalization services administered on or after January 1, 2019. Medicaid should be the primary payer on the claims.  The DOC is proactively working with the Virginia Department of Medical Assistance Services (DMAS) and the Virginia Department of Social Services (VDSS) to enroll all eligible offenders into the Inpatient Hospitalization Medicaid aid category.

Effective January 2, 2019, DOC Inpatient Hospitalization claims should be filed directly to Medicaid, as they will automatically deny if submitted to Anthem.  If the claim is denied by Medicaid, it should be filed to Anthem for payment, following your standard process.  

Effective immediately for offenders covered by Anthem’s Inmate Services Program, claims for Covered Services rendered to Anthem Covered Individuals must be submitted within 12 months of the date of service.  Claims that have been denied by Medicaid and must be resubmitted to Anthem may be reviewed on a case by case basis if outside of the timely filing period.

If you have questions, please reach out to your Anthem representative.

Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) commercial data collection project for 2018, impacting members enrolled in our Anthem PPO and Anthem HealthKeepers (excluding Medicaid) commercial products.  You play a central role in promoting the health of our members. By documenting services in a consistent manner, it is easy for you to track care that was provided and identify any additional care that is needed to meet the recommended guidelines.  Consistent documentation and responding to our medical record requests in a timely manner eliminates follow-up calls to your office and also helps improve HEDIS scores, both by improving care itself and by improving our ability to report validated data regarding the care you provided. The records that you provide to us directly affect the HEDIS results that are listed in the attachment.

Each year, our goal is to improve our process for requesting and obtaining medical records for our HEDIS project.  In order to demonstrate the exceptional care that you have provided to our members and in an effort to improve our scores, you and your office staff can help facilitate HEDIS process improvement by:

• Responding to our requests for medical records within five days if at all possible

• Providing the appropriate care within the designated timeframes

• Accurately coding all claims

• Documenting all care clearly in the patient’s medical record

Select the attachment to the right to view HEDIS information including 2018 HEDIS results

In addition to the information in the attachment, further information regarding documentation guidelines and administrative codes can be found on the HEDIS page of our Provider Portal.  More information on HEDIS can be found by visiting the provider portal at: www.anthem.com > Provider > Choose Virginia > Find Resources > Health & Wellness (top blue bar) > Quality Improvement and Standards > HEDIS Information. You will find reference documents entitled “HEDIS 101 for Providers” and “HEDIS Physician Documentation Guidelines and Administrative Codes”.

IMPORTANT NOTE: 

The information in the attachment pertains only to our Anthem PPO and Anthem HealthKeepers commercial lines of business and does NOT include results for Anthem HealthKeepers Plus [Medicaid and Commonwealth Coordinated Care Plus (Anthem CCC Plus)], Medicare Advantage, or the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP®).

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

Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a health care puzzle that for some, are frightening and complex issues to handle.

Anthem is available to offer assistance in these difficult moments with our Case Management Program.  Our case managers are part of an interdisciplinary team of clinicians and other resource professionals who are there to support members, families, primary care physicians and caregivers.  The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  They will be transferred to a team member based on the immediate need.  Physicians can also refer by contacting us telephonically or through electronic means.  No issue is too big or too small.  We can help with transitions across level of care so that patients and caregivers are better prepared and informed about health care decisions and goals.

How do you contact us?

Members enrolled in our health plans offered by Anthem and affiliate HealthKeepers, Inc. have additional resources available to help them better manage chronic conditions. 

The ConditionCare program helps members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. A team of registered nurses with added support from other health professionals such as dietitians, pharmacists and health educators work with members to help them understand their condition(s), their physician’s orders and how to become a better self-manager of their condition. 

Engagement methods vary by the individual’s risk level but can include:

• Education about their condition through mailings, email newsletters, telephonic outreach, and/or online tools and resources.
• Round-the-clock phone access to registered nurses.
• Guidance and support from Nurse Care Managers and other health professionals.

Physician benefits:

• Save time by answering patients’ general health questions and responding to concerns, freeing up valuable time for the physician and their staff.
• Support the doctor-patient relationship by encouraging participants to follow their doctor’s treatment plan and recommendations.
• Inform the physician with updates and reports on the patient’s progress in the program.

Please visit the anthem.com website to find more information about the program such as program guidelines, educational materials and other resources. Go to anthem.com.  Also on our website is the Patient Referral Form, which you can use to refer other patients you feel may benefit from our program.

If you have any questions or comments about the program, call 877-681-6694.  Our nurses are available Monday-Friday, 8 a.m. to 9 p.m., and Saturday, 9 a.m. to 5:30 p.m.

An Integrated Care Model affords members with plans purchased on the Health Insurance Marketplace (also called the exchange) the ability to have continuity of care with each care management case.  A single Primary Care Nurse provides case and disease assessment and management.  This continuity provides opportunity for the member to get assistance working through an acute phase of an illness and then work with their nurse on the necessary behavioral changes needed to improve their health   and enhance their well-being. The program is based on nationally recognized clinical guidelines and serves as an excellent adjunct to physician care.

The Integrated Care Model helps exchange members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease.  Our nurse care managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. 

Nurse Care Managers encourage participants to follow their physician’s plan of care; not to offer separate medical advice. In order to help ensure that our service complements the physician’s instructions, we collaborate with the treating physician to understand the member’s plan of care and educate the member on options for their treatment plan. 

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  How do you contact Case Management?

Virginia

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral.  Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. would like to take this opportunity to stress the importance of communicating with your patients’ other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner.  Anthem urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between Behavioral Health and other health care practitioners at the time treatment begins.

We expect all health care practitioners to:

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:

• Diagnosis
• Treatment plan
• Referrals
• Psychopharmacological medication (as applicable)
  
  

In an effort to facilitate coordination of care, Anthem has several tools available on the Provider website including a Coordination of Care template and cover letters for both behavioral health and other health care practitioners.* In addition, there is a provider toolkit on the website with information about alcohol and other drugs that contains brochures, guidelines and patient information.**

*Access to the forms and cover letters are available at anthem.com>Providers> Provider Home>Answers@Anthem

**Access to the Toolkit is available at anthem.com>Providers>Provider Home> Health and Wellness

Our utilization management (UM) decisions are based on written criteria, the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits.  In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization.  Anthem’s coverage guidelines are available on Anthem’s website at anthem.com.

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below.  UM criteria are also available on the web. Just select “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” from the Provider home page at anthem.com.

We work with providers to answer questions about the utilization management process and the authorization of care.  Here’s how the process works:

• Call us toll free from 8:30 a.m. - 5 p.m., Monday through Friday (except on holidays). More hours may be available in your area.  Federal Employee Program hours are 8 a.m. – 7 p.m. Eastern.
• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day.  Calls received after midnight will be returned the same business day. 
• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

The following phone lines are for physicians and their staffs.  Members should call the customer service number on their health plan ID card.

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.

Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls.  They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement.

It can be found on our Web site.  To access, go to the "Provider" home page at anthem.com.  From there, select “Provider,” “Providers Overview,” select your state, “Find Resources,” > then Health & Wellness> Quality Improvement Standards > Member Rights & Responsibilities.  Practitioners may access the FEP member portal at www.fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

As part of our commitment to provide you with the latest clinical information, we have posted a Vaginal Birth after Cesarean (VBAC) shared decision making aid to our provider portal. This is a tool for you to discuss with your patients to aid in making a decision regarding their treatment options.   This has been reviewed and certified by the Washington Health Care Authority (HCA) and is available on our website.  To access the aid, go to anthem.com and select "Provider" from the top menu.  From there, click on “Providers Overview,” select your state and scroll down and choose “Find Resources in your state.”  From the Health & Wellness page, choose “Practice Guidelines,” then “Shared Decision Making Aid.”

HealthKeepers, Inc. reminds providers that Anthem HealthKeepers Plus authorization requirements are the responsibility of the provider and should be renewed and validated prior to service. Precertification requests should be made, at a minimum, three days before the scheduled/elective procedure/request. HealthKeepers, Inc. will also authorize services retroactively up to 10 calendar days after service. In the Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) rollout, we have been lenient with that requirement. Effective October 15, 2018, HealthKeepers, Inc. will actively enforce these timelines to ensure timely processing and adequate care for our members. 

Failure to obtain precertification for a scheduled/elective procedure/request may result in an administrative review and a denial of services.

HealthKeepers, Inc. does not require precertification for treatment of emergency medical conditions and will cover emergency and post-stabilization services. HealthKeepers, Inc. will not retroactively deny a claim for an emergency screening examination because the condition was a nonemergency.

To determine whether precertification is needed, use the Precertification Lookup Tool at https://mediproviders.anthem.com/va > Precertification > Precertification Lookup Tool.

Use one of the following methods to request precertification:

• Web: Interactive Care Reviewer tool via https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-901-0200

The Precertification Request Form is located at https://mediproviders.anthem.com/va > Precertification > How to Request Precertification > Forms & Other Resources. To get the fastest response on an authorization request:

• Complete the form online, then print and fax it. Doing so will ensure legibility.
• Fill out the form completely. Unanswered questions typically result in delays.

HealthKeepers, Inc. revises forms periodically. Outdated forms can delay a request.

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

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

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

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

Policy Update

Claims Requiring Additional Documentation

(Policy 06-031, effective 03/01/19)

HealthKeepers, Inc. requires Anthem HealthKeepers Plus professional providers and facilities to submit additional documentation for adjudication of applicable types of claims. If the required documentation is not submitted, the claim may be denied. HealthKeepers, Inc. may request additional documentation or notify the provider or facility of additional documentation required for claims, subject to contractual obligations.

Effective March 1, 2019, if an itemized bill is requested and/or required, then it must include the appropriate revenue code for each individual charge.

For additional information, please review the Claims Requiring Additional Documentation reimbursement policy at https://mediproviders.anthem.com/va.

Substance use disorders can affect a person’s brain and in turn their behavior. Substance use can start with the experimental use of a drug in a social situation or exposure to prescribed medications. Eventually it can lead to an inability to control the use of the legal or illegal drug or medication. When a patient is diagnosed with an alcohol- or drug-use disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations and comorbidities. This article will provide you with the information you need to provide high-quality care to patients struggling with substance use as well as how to code for the services provided to them.

Drug and substance addiction in the U.S.

The U.S. Department of Health and Human Services declared a public health emergency in 2017 due to an unprecedented opioid epidemic. Drug overdose deaths and opioid-involved deaths continue to increase in the U.S.¹

Smoking is the leading preventable cause of death in the United States. According to the Centers for Disease Control (CDC), 15.5 % of all adults (37.8 million people) were current cigarette smokers in 2016.²

Health risks of drug use and smoking

Drugs can have significant and damaging short-term and long-term effects, including psychotic behavior, seizures or death due to overdose. Dependence on drugs can create a number of dangerous and damaging complications, such as accidents, suicide, family/work/school problems and legal issues.

Smoking diminishes overall health and is a known cause of multiple cancers, heart disease, stroke, complications of pregnancy, chronic obstructive pulmonary disease (COPD) and many other diseases. There are also health dangers of involuntary exposure to (second-hand) tobacco smoke. Smoking increases risks for preterm delivery.³

Diagnosis and treatment

Diagnosing substance use disorders requires a thorough evaluation and includes an assessment by a psychiatrist or a psychologist or an independently licensed behavioral health practitioner that has met the state requirements to render a diagnosis. Blood, urine or other lab tests are used to assess drug use.

People with behavioral disorders are more likely to experience a substance use disorder and people with a substance use disorder are more likely to have behavioral health issues when compared to the general population. According to the National Survey of Substance Abuse Treatment Services, about 45% of Americans seeking treatment of substance use/abuse have also been diagnosed with behavioral health problems.⁴

When diagnosing a substance use disorder, most mental health professionals use criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Treatment depends on the type of substance used and any related medical or behavioral health disorders that the patient may have. Some treatment options include:

• Chemical dependence treatment programs
• Detoxification
• Behavioral therapy
• Self-help groups

There are a lot of treatments to support tobacco cessation, including behavioral therapies and FDA-approved medications. Some treatment options to help ensure tobacco cessation include:

• Nicotine replacement therapy (NRT), as well as bupropion and varenicline
• Combination of behavioral treatment and cessation medications
• Mobile devices and social media help to boost tobacco cessation
• Tobacco cessations are not recommended for adolescents due to lacking high-quality studies
• Behavioral counseling can be provided either in person or by telephone and a variety of approaches are available such as Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), telephone support lines, text messaging, web-based services and social media.⁵

HEDIS® quality measures

Initiation and Engagement of Alcohol and Other Drug Abuse Dependence Treatment (IET) is a measure that assesses the percentage of plan members’ ages 13 years and older with the new episode of alcohol or other drug (AOD) abuse or dependence who received the following: initiation of AOD and engagement of AOD.

Initiation of treatment is the percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.

Engagement of treatment is the percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days after the initiation visit.⁶ This measure now includes medication-assisted treatment (MAT) as an appropriate treatment for people with alcohol and opioid dependence. This measure also adds telehealth to treatment options.

Use of Opioids at High Dosage (UOD) is a first year quality measure that assesses the number of members 18 years and older per 1,000 beneficiaries receiving prescription opioids for ≥ 15 days during the measurement year at a high dosage (average morphine equivalent dose > 120 mg).⁷

Use of Opioids from Multiple Providers (UOP) is a first year quality measure that assesses the number of members 18 years and older per 1,000 receiving a prescription for opioids for ≥ 15 days during the measurement year who received opioids from multiple providers. Three rates are reported:

• Multiple prescribers – the rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers during the measurement year
• Multiple pharmacies – the rate per 1,000 members receiving prescriptions for opioids from four or more different pharmacies during the measurement year
• Multiple prescribers and multiple pharmacies – the rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year.⁷

Unhealthy Alcohol Use Screening and Follow-Up (ASF) is a measure that assess the percentage of health plan members 18 years and older who were screened for unhealthy alcohol use using a standardized tool and, if screened positive, received appropriate follow-up care.

• Unhealthy alcohol use screening – the percentage of members who had a systematic screening for unhealthy alcohol use
• Counseling or other follow-up – the percentage of members who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within 2 months of a positive screening.

The intent of the measure: alcohol misuse is a leading cause of illness, lost productivity and preventable death in the U.S.⁷

Medical Assistance with Smoking and Tobacco Use Cessation (MSC) is a survey measure that assesses different facets of providing medical assistance with smoking and tobacco use cessation. There are three components of the survey:

• Advising Smokers and Tobacco Users to Quit: Adults 18 years of age and older who are current smokers or tobacco users and who received cessation advice during the measurement year
• Discussing Cessation Medications: Adults 18 years of age and older who are current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year
• Discussing Cessation Strategies: Adults 18 years of age and older who are current smokers or tobacco users who discussed or were provided cessation methods or strategies during the measurement year.

ICD-10-CM: general coding information

When a patient is diagnosed with an alcohol- or drug-related disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations, and comorbidities.

Details are required from the documentation to identify use, abuse or dependence of the substance.

Based on ICD-10-CM Coding Guidelines, when use, abuse or dependence of the same substance are documented in the medical record, only one code should be assigned based on the following hierarchy:

• If both use and abuse are documented, the code for abuse should be assigned
• If both abuse and dependence are documented, the code for dependence should be assigned

• If use, abuse and dependence are documented, the code for dependence should be assigned
• If both use and dependence are documented, the code for dependence should be assigned.⁸

Alcohol dependence and abuse

• Alcohol related disorders are classified to category F10-. An additional code for blood alcohol level (Y90.-) may be assigned, if applicable

• Alcohol abuse is classified under subcategory F10.-, Alcohol abuse

• Alcohol dependence is classified under subcategory F10.2-, Alcohol dependence
• Both categories alcohol abuse and alcohol dependence, are further subdivided to specify the presence of intoxication or intoxication delirium. Additional characters are also provided to specify alcohol-induced mood disorder, psychotic disorder, and other alcohol-induced disorders

• Codes in sub classification F10.23-, Alcohol dependence with withdrawal, provide additional detail regarding withdrawal symptoms such as delirium and perceptual disturbance

• Selection of codes “in remission” for categories F10-F19 requires the provider’s clinical judgement. The appropriate codes for “in remission” are assigned only on the basis of provider documentation, unless otherwise instructed by the classification
• Toxic effect of alcohol is not classified to category F10 but to subcategory T51.0- instead.⁹

Drug dependence and abuse

ICD-10-CM classifies drug dependence and abuse in the following categories according to the class of the drug:

• In most cases, fourth characters indicate whether the disorder is nondependent abuse (1), dependence (2), or unspecified use (9).
• Additional characters also provided to specify intoxication, intoxication delirium, and intoxication with perceptual disturbance.
• Patients with substance abuse or dependence often have related physical complications or psychotic symptoms. These complications are classified to the specific drug abuse or dependence, with the fifth or sixth characters providing further specificity regarding any associated drug-induced mood disorder, psychotic disorder, withdrawal, and other drug-induced disorders (such as sleep disorder).

Tobacco use and dependence

Category F17. - (nicotine dependence) codes are located in chapter 5 of the ICD-10-CM book.

The Excludes 1 note reminds that this is not the same diagnosis as tobacco use (Z72.0) nor the history of tobacco dependence (Z87.891). Therefore, the documentation will need to specifically discern between tobacco use and nicotine dependence.

The Excludes 2 note reminds to code tobacco use (smoking) during pregnancy, childbirth and the puerperium (O99.33-) and toxic effect of nicotine (T65.2-).

If the patient has been in contact with, or in close proximity to, a source of tobacco smoke, then Z77.22, Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic), need to be reported.

Tobacco abuse counseling is reported using code Z71.6 with the additional code for nicotine dependence (F17.-).

ICD-10-CM classifies nicotine dependence by substance:

• F17.20-, nicotine dependence, unspecified
• F17.21-, nicotine dependence, cigarettes
• F17.22-, nicotine dependence, chewing tobacco
• F17.29-, nicotine dependence, other tobacco product.⁹

Each category further breaks down the dependence using a sixth character to denote:

References:

1. Opioid overdose. Overview of an epidemic. https://www.cdc.gov/drugoverdose/data/index.htm
2. Current cigarette smoking among adults – United States, 2016. https://www.cdc.gov/mmwr/volumes/67/wr/mm6702a1.htm?s_cid=mm6702a1_w%20
3. CDC. Health effects of cigarette smoking. Retrieved on 1/18/2018 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
4. Treatment for co-occurring mental and substance use disorders. https://www.samhsa.gov/treatment
5. What are treatments for tobacco dependence? Retrieved on 1/18/2018 from https://www.drugabuse.gov/publications/tobacco-nicotine-e-cigarettes/what-are-treatments-tobacco-dependence
6. HEDIS Benchmarks and Coding Guidelines for Quality Care. Amerigroup RealSolutions in healthcare. Retrieved from https://providers.amerigroup.com
7. NCQA updates quality measures for HEDIS 2018. http://www.ncqa.org/newsroom/details/ncqa-updates-quality-measures-for-hedisreg-2018?ArtMID=11280&ArticleID=85&tabid=2659
8. ICD-10-CM Expert for Physicians. The complete official code set (2017). Optum 360
9. Leon-Chisen N. (2017). ICD-10-CM and ICD-10-PCS Coding Handbook 2018. American Hospital Association, Chicago, IL.

These links lead to third-party sites.  These organizations are solely responsible for the content on their sites.

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

Effective February 1, 2019, prior authorization (PA) requirements will change for the infusible/injectable drug Sublocade to be covered by HealthKeepers, Inc. for Anthem HealthKeepers Plus members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Sublocade (Buprenorphine) — implant (J0570)
• Sublocade — injectable (Q9991, Q9992)

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

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-901-0020

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

Effective February 1, 2019, prior authorization (PA) requirements will change for the Subcutaneous Implantable Defibrillator system to be covered by HealthKeepers, Inc. for members enrolled in Anthem HealthKeepers Plus. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Subcutaneous Implantable Defibrillator system:  Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation (33270)

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

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-901-0020

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

Did you know HealthKeepers, Inc. reviews quality of care (QOC) concerns? Our QOC team works with Anthem HealthKeepers Plus providers and members to uphold this initiative.

What does this mean to me?

When HealthKeepers, Inc. requests records for QOC reviews, they should be provided at no cost.

In order to ensure QOC reviews can be completed within 90 days, providers should respond to record requests within 30 days.

Our goals in working together include high-quality care for our members, strong relationships with our network providers and safety, which is our top priority.

Stay tuned for the latest QOC updates in the next newsletter.

How do I contact the QOC team?  

Mail:  Anthem HealthKeepers Plus

          2015 Staples Mill Road

          Mail Drop VA2002-N600

          Customer # 2013422

          Richmond, VA 23230

Fax: 1-855-273-6831

QOC manager: Dana DeLucia, dana.delucia@anthem.com

The Coverage Guidelines and Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

Note:

• Effective November 1, 2018, AIM Specialty Healthâ (AIM) Musculoskeletal Level of Care Guidelines, Sleep Study Guidelines and Radiology Guidelines will be used for clinical reviews.

• When requesting services for a patient (including medical procedures and medications), the Precertification Look-Up Tool may indicate that precertification is not required, but this does not guarantee payment for services rendered; a Medical Policy or Clinical UM Guideline may deem the service investigational or not medically necessary. In order to determine if services will qualify for payment, please ensure applicable clinical criteria is reviewed prior to rendering services.

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

To search for specific guidelines, visit https://mediproviders.anthem.com/va/Pages/medical.aspx.

Coverage Guidelines

On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to HealthKeepers, Inc.

Clinical UM Guidelines

On July 26, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on August 31, 2018.

Need up-to-date pharmacy information?

Log in to our provider website (https://mediproviders.anthem.com/va) to access our Formulary, Prior Authorization form, Preferred Drug List and process information.

Have questions about the Formulary or need a paper copy?

Call Provider Services at 1-800-901-0020.

Our Member Services representatives serve as advocates for our members. To reach Member Services, please call 1-800-901-0020 (TTY 711).

The credentialing process must be completed before a practitioner begins seeing Anthem HealthKeepers Plus members and enters into a contractual relationship with a health care insurer. As part of our credentialing process, practitioners have certain rights as briefly outlined below.

Practitioners can request to:

• Review information submitted to support their credentialing application.
• Correct erroneous information regarding a credentialing application.
• Be notified of the status of credentialing or recredentialing applications.

The Council for Affordable Quality Healthcare (CAQH®*) universal credentialing process is used for all providers who contract with HealthKeepers, Inc. To apply for credentialing with HealthKeepers, Inc., go to the CAQH website at https://www.caqh.org and select CAQH ProView™. There is no application fee.

We encourage practitioners to begin the credentialing process as soon as possible when new physicians join a practice. Doing so will help minimize any disruptions to the practice and members’ claims.

* CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Commonwealth Coordinated Care Plus (Anthem CCC Plus) patients. These changes were reviewed and approved at the first quarter 2018 Pharmacy and Therapeutics Committee meeting.

Effective August 1, 2018, formulary changes applied.

EFFECTIVE FOR ALL PATIENTS ON AUGUST 1, 2018
SECOND NOTICE:  ADDITIONAL INFORMATION PROVIDED
(PREFERRED NDC'S LISTED)

What action do I need to take?

Please review these changes and work with your Anthem HealthKeepers Plus and 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 Anthem HealthKeepers Plus patient cannot be converted to a formulary alternative, call our Pharmacy department at 1‑800‑901‑0020 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.

If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at:

• 1-800-901-0020 (Anthem HealthKeepers Plus).
• 1-855-323-4687 (Anthem CCC Plus).

HealthKeepers, Inc. has designated Availity as a no-cost option to operate and service your Anthem HealthKeepers Plus electronic data interchange (EDI) entry point (or EDI gateway). This designation will ensure greater consistency and efficiency in EDI submission.

Who is Availity?

Availity is well known as a Web portal and claims clearinghouse, but they are much more. Availity also functions as an EDI gateway for multiple payers and serves as the single EDI connection.

Your organization can submit and receive the following transactions through Availity’s EDI gateway:

• 837:  Institutional claims
• 837:  Professional claims
• 837:  Dental claims
• 835:  Electronic remittance advice (ERA)
• 276/277:  Claim status
• 270/271:  Eligibility request

Get started with Availity:

• If you wish to submit directly to Availity, setup is easy. Go to the Availity Welcome Application and begin the process of connecting to the Availity EDI Gateway for your EDI transmissions.
• If you wish to use a clearinghouse or billing company, please work with them to ensure connectivity.

Need assistance?

The Availity Quick Start Guide will assist you with any EDI connection questions.

Availity payer IDs

You can access the Availity Payer List here.

Electronic funds transfer (EFT) registration

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at a time.

If you were previously registered to receive EFT only, you must register using EnrollHub to manage account changes.

ERA registration

Use Availity to register and manage account changes for ERA. If you were previously registered to receive ERA, you must register using Availity to manage account changes.

Manage your paper remittance vouchers suppression (turn off) here.

Contacting Availity

A website to support your diverse patients

Treating everyone the same is a value we have all grown up with. But the challenge is that not everyone is the same, and these differences can lead to critical disparities in how our Anthem HealthKeepers Plus patients receive their care. That is why we want to introduce you and your staff to MyDiversePatients.com, which has educational resources you can use to help address these disparities.

In the United States:

• About three times more African Americans die from hypertension than their white counterparts.¹
• Black women with a Master’s degree have a higher infant mortality rate than White women who did not finish high school.²
• Hispanics are 51 percent more likely to have diabetes-related deaths than the general population.³
• LGBT youth are up to three times more likely to attempt suicide than their non-LGBT counterparts.⁴

MyDiversePatients.com features resources to help you address disparities in health care, such as:

• Continuing medical education 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.

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

Visit MyDiversePatients.com today to embrace the knowledge, skills, ideals, strategies and techniques to continue enhancing the quality of care for your diverse patients.  

FOOTNOTES:               

¹ American Heart Association. (2010). Heart Disease and Stroke Statistics – A 2010 Update. pp116-117. DOI: 10.1161/CIRCULATIONAHA.109.192667.  Retrieved from http://circ.ahajournals.org/content/circulationaha/121/7/e46.full.pdf?download=true

² Center for Disease Control and Prevention. (2017). CDC Wonder. Retrieved from https://wonder.cdc.gov/welcomet.html

³ Center for Disease Control and Prevention. (2015, May 8). Vital Signs: Leading Causes of Death, Prevalence of Diseases and Risk Factors, and Use of Health Services Among Hispanics in the United States — 2009–2013. Morbidity and Mortality Weekly Report (MMWR).  Vol. 64(17);469-478.  Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6417a5.htm?s_cid=mm6417a5_w

⁴ Center for Disease Control and Prevention. (2016, Aug 12). Sexual Identity, Sex of Sexual Contacts, and Health-Related Behaviors Among Students in Grades 9–12 — United States and Selected Sites, 2015.  Morbidity and Mortality Weekly Report (MMWR). Vol. 65 No. 9. Retrieved from https://www.cdc.gov/mmwr/volumes/65/ss/pdfs/ss6509.pdf

Effective January 1, 2019, Medicare providers will have toll-free phone numbers specifically designated for their service inquiries. These new provider numbers will be listed separately on the back of the member ID cards and should be used beginning January 1, 2019. The associates answering your provider service calls are trained to answer your questions and resolve your issues as quickly as possible. To ensure you receive the most efficient service, please refrain from using the member services line and use only 844-421-5662 or the provider services phone number listed on the back of the member ID card for individual Medicare Advantage calls beginning January 1, 2019.

Summary of benefits, evidence of coverage and formularies for 2019 individual Medicare Advantage plans will be available at anthem.com/medicareprovider. An overview of notable 2019 benefit changes also is available at Important Medicare Advantage Updates at anthem.com/medicareprovider.  Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider  for the latest Medicare Advantage information.

The U.S. Centers for Medicare and Medicaid Services (CMS) and Medicare Advantage and Part D organizations, including Anthem, will implement a new initiative, the Preclusion List, to protect the integrity of the Medicare Trust Funds. Beginning April 1, 2019, Medicare Advantage and Part D organizations will deny payment for items and services furnished by providers that CMS has placed on the Preclusion List. For more information, visit www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/PreclusionList.html.

When a claim must be corrected beyond the initial claim timely filing limit of one year from the date of service, a normal adjustment bill is not allowed. Providers must use the re-opening process to correct the error. To learn when and how to initiate re-openings and adjustments, check Important Medicare Advantage Updates at anthem.com/medicareprovider.

CMS updated its guidance to allow Medicare Advantage plans the option of implementing step therapy for Part B drugs as part of a patient-centered care coordination program beginning January 1, 2019.  The goal is to lower drug prices while maintaining access to covered services and drugs for beneficiaries. Anthem will implement step therapy edits to promote clinically appropriate and cost effective drug options for our members. A patient-centered care coordination program will be created to ensure member access to necessary drugs, provide medication reviews and reconciliations, educate members regarding their medications, encourage medication adherence, and provide incentives to members who complete care coordination programs.

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

VA 2019 provider annual notice of change

Prior authorization requirements for Colonoscopy and Upper Gastrointestinal Endoscopy

Medicare Advantage Reimbursement Policy October Provider Bulletin  

Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila  

July Medicare Advantage reimbursement policy  

Submit PA medication requests electronically; new phone number for MA prescription PAs 

CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019  

Inpatient Readmissions   

Submit PA medication requests electronically; new phone number for MA prescription prior authorizations effective Sept. 1   

74837MUPENMUB 10/25/2018