Beginning in May 2019, Anthem Blue Cross and Blue Shield will enhance our claims editing systems to include outpatient facility editing.

These edits will: 

• Help ensure correct coding and billing practices are being followed
• Help ensure compliance with industry standards such as American Medical Association (AMA), National Uniform Billing Committee (NUBC), and national specialty and academy guidelines
• Reinforce compliance with standard code edits and rules (such as CPT, HCPCS, ICD-10, NUBC)

Our provider newsletter is our primary source for providing important information to health care providers and professionals. The newsletter is published 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 email 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 email

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.

On April 10, 2019, Anthem will offer our first provider education webinar for the year. Designed for our network-participating providers, the webinars address Anthem business updates and billing guidelines that impact your business interactions with us.

For your convenience, we offer these informative, hourly sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the first scheduled webinar for 2019 is:

• Wednesday, April 10, 2019, from 10 a.m. to 11 a.m. ET

Please take time to register today for the webinar using the registration form to the right under the “Article Attachments” section. If you have already registered for the April webinar, please ensure you have received a fax confirmation or a confirmation from an Anthem representative to ensure we’ve received your registration form.  Please contact stacey.marsh@anthem.com if you need to confirm your registration.

To help ensure the accurate processing of submitted claims, keep in mind ICD-10-CM Coding Guidelines, when selecting the most appropriate diagnosis for patient encounters.  Remember ICD-10-CM has two different types of excludes notes and each type has a different definition.  In particular, one of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 Notes. 

An Excludes 1 Note is used to indicate when two conditions cannot occur together (Congenital form versus an acquired form of the same condition). An Excludes 1 Note indicates that the excluded code identified in the note should not be used at the same time as the code or code range listed above the Excludes 1 Note. These notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note applies to all codes in the section.

As a reminder, the physician office lab (POL) lists include one list for primary care providers (PCPs) and one for specialist care providers (SCPs).  These lists include services for office-based tests for members enrolled in Anthem HealthKeepers and Anthem HealthKeepers Plus (Medicaid) – health benefit plans offered by Anthem’s affiliate HealthKeepers, Inc.  PCPs and SCPs who provide these services during an office visit for a covered member can submit claims for these services directly to HealthKeepers, Inc. for reimbursement. Lab tests not shown on these lists are not reimbursable to providers and must be handled by our exclusive arrangement with laboratory provider, LabCorp.  

POL list for SCPs expands to include CPT 87631 effective January 1

In this notice, HealthKeepers, Inc. is announcing that our POL list for SCPs has been expanded to include CPT 87631. [CPT code 87631 is defined as respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.]  

This change became effective January 1, 2019.  For the complete POL list, visit anthem.com and select providers and then “Find Resources for Virginia.”  On the Provider home page, select the “Answers@Anthem” tab at the top and then the “Provider Office Lab Lists” link.

Anthem Blue Cross and Blue Shield has identified that providers often bill a duplicate evaluation and management (E/M) service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group tax identification number or TIN) recently billed a service or procedure which included an E/M for the same or similar diagnosis. The use of modifier 25 to support separate payment of this duplicate service is not consistent with correct coding or Anthem’s policy on use of modifier 25. 

Beginning with claims processed on or after March 1, 2019, Anthem may deny the E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.

If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant, and separately identifiable E/M service, please submit those medical records for consideration.

Anthem Blue Cross and Blue Shield conducts an annual satisfaction survey of our members’ behavioral health outpatient service experience.  The random survey is conducted based on receipt of claims.  We have recently reviewed the 2018 survey experience results and wanted to share highlights with our network of behavioral health providers.  The survey inquires about members’ satisfaction with timeliness of treatment, practitioner service/attitude and office environment, care coordination (among members’ various providers), prescriptions/medication management process (if applicable), financial and billing process, and their perceived clinical improvement.   Our members are also asked to give an overall rating of the experience.  The 2018 overall practitioner rating was 88% in Virginia based on the survey results.

We were pleased to see overall improvement in the survey results.  In particular, two areas of focus over the last year are access and coordination of care.  Members responding to the survey indicated that obtaining an appointment was fairly easy, and many respondents indicated that care was being coordinated among their providers, including medical.  Care coordination and collaboration, particularly medical-behavioral integration, is a key focus at Anthem.   We also encourage ongoing understanding of an individual’s cultural, spiritual and religious beliefs while in treatment.

While we are pleased with our members’ experience with our participating provider network, and thank you for your network participation and the services you provide, we’d like to remind you of two key areas to maintain and improve satisfaction:

Members’ access to behavioral health care

As a participating provider please be reminded of Anthem’s expectation, based on NCQA definitions, of access to behavioral healthcare to help ensure our members have prompt access to behavioral health care:

• Non-Life Threatening Emergency Needs – must be seen, or have appropriate coverage directing the member, within 6 hours. When the severity or nature of presenting symptoms is intolerable but not life threatening to the member.

• Urgent Needs – must be seen, or have appropriate coverage directing the member, within 48 hours. Urgent calls concern members whose ability to contract for their own safety, or the safety of others may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. Urgent needs have the potential to escalate into an emergency without clinical intervention.

• Routine office visit – must be within 10 business days. Routine calls concern members who present no immediate distress and can wait to schedule an appointment without any adverse outcomes.

We use several methods to monitor adherence to these standards.   Monitoring is accomplished by a) assessing the availability of appointments via phone calls and surveys by our staff or designated vendor to the provider’s office; b) analysis of member complaint data; and c) analysis of member satisfaction.  Providers are expected to make best efforts to meet these access standards for all members.  Anthem continues to look at gaps, barriers and alternative options to improve access to behavioral health care including tele-health services.

Members held harmless

As participating providers in Anthem’s behavioral health provider network, providers shall look solely to Anthem for compensation for covered services and under no circumstances shall render a bill or charge to any member except for applicable co-payments, deductibles and coinsurance and for services that are not medically necessary or are otherwise not covered, provided that the provider obtains the consent of the member before providing such service. We recommend that consent be in writing and dated in order to protect our members and providers from disputes.

In addition, Anthem also reminds our participating providers that Anthem members must be advised of missed or cancelled appointment policies at the onset of treatment.  We also recommend that the advisement be acknowledged by the member in writing, and that acknowledgement is dated. 

Thank you again for the services that you provide to our members.

Effective for dates of service on and after May 18, 2019, the following updates will apply to the AIM Specialty Health Musculoskeletal Program Clinical Appropriateness Guidelines. 

Spine Surgery - Enhancements as indicated by section below:

General Requirements
-Reporting of symptom severity: expanded to include IADLs as functional impairment

-Tobacco Cessation: removed nicotine-free documentation requirement

Cervical Decompression with or without Fusion
-Added exclusion of cervical/thoracic laminectomy if criteria not met

Lumbar Discectomy, Foraminotomy, and Laminotomy

-Added criteria to define radicular pain for Lumbar herniated intervertebral disc

Lumbar Fusion and Treatment of Spinal Deformity (including scoliosis and Kyphosis)

-Added indication and criteria for Flat back Deformity

-Added criteria for Isthmic spondylolisthesis

-Added indication and criteria for Scheuermann’s Kyphosis

Lumbar Laminectomy

-Added exclusion of lumbar laminectomy if criteria not met

Noninvasive Electrical Bone Growth Stimulation

-Added risk factor criteria for cervical non-invasive bone growth stimulation

Interventional Pain Guidelines - Enhancements as indicated by section below: 

General Requirements

-Reporting of symptom severity: expanded to include IADLs as functional impairment

Therapeutic Epidural Steroid Injection

-Updated time period of initial advanced imaging

-Definition and frequency of repeat therapeutic epidural steroid injection

-Updated maximum number of annual injections

-Added criteria for subsequent injection after suboptimal initial response

Paravertebral Facet Injection/Nerve Block/Neurolysis

-Updated injection frequency limitations

Diagnostic Intraarticular Sacroiliac Joint Injections

-Updated pain reduction from initial injection

Spinal Cord Stimulators

-Added criteria for revision/removal of spinal cord stimulator

-Separated criteria of trial stimulation and permanent stimulator implantation

-Added exclusion of dorsal root ganglion stimulation

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

• Access AIM’s ProviderPortal_SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com.
• Call the AIM Contact Center toll-free number:   866-789-0397;  8 a.m. to 5 p.m. ET.

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

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

Policy Update

Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

(Policy 06-003, effective 04/01/2019)

HealthKeepers, Inc.’s Modifier 25 reimbursement policy for Anthem HealthKeepers Plus members provides the criteria for reimbursement for a significant, separately identifiable evaluation and management (E&M) service performed by the same provider on the same day of the original service or procedure. Effective September 1, 2018, HealthKeepers, Inc. does not allow separate reimbursement for E&Ms performed on the same day as a major surgery (90-day global period).

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

2019 risk adjustment provider training  

New provider learning opportunity: Put the AIM ProviderPortal to work for you  

New provider service phone number beginning January 1, 2019  

Medicare Advantage reimbursement policy provider bulletin  

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

75560MUPENMUB 12/28/2018

Effective for dates of service beginning January 1, 2019, the following Medicare Part B devices will be preferred to support cost-effective benefits. During precertification initiation or renewal, providers requesting a nonpreferred device will be encouraged to switch to a preferred product. The preferred and nonpreferred products are listed below.

75557MUSENMUB 12/20/18

Refractions and routine eye exams are not covered under medical insurance for Anthem members. These benefits may be available through the member’s supplemental insurance. These services must be billed to the supplemental vendor. Check your patient’s Anthem ID card for the name of the vendor.

Additional information, including billing modifiers and documentation requirements, will be available at www.anthem.com/medicareprovider under Important Medicare Advantage Updates.

AIM Specialty Health® groups CPT codes on authorizations so they can be reviewed together to support a procedure or therapy. Grouped codes are used for radiology, cardiology, and sleep and radiation therapy programs. The groupings can be found at http://aimspecialtyhealth.com/ClinicalGuidelines.html by selecting the appropriate solution and then the exam or therapy being performed. Additional information is available at www.anthem.com/medicareprovider under Important Medicare Advantage Updates.

Anthem is required to follow all clinical and reimbursement policies established by Original Medicare in the processing of claims and determining benefits. Anthem follows all Original Medicare local coverage determinations, national coverage determinations, Medicare rulings, code editing logic and the Social Security Act. 

Anthem may offer additional benefits that are not covered under Original Medicare. Certain benefits are only covered when provided by a vendor selected by Anthem. More information can be found at www.anthem.com/medicareprovider. You may also contact Provider Services at the phone number on the back of the member ID card.

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

If you have questions or feedback, please use this email link.

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

The goal of the postpartum outreach initiative is to increase patient compliance, improve health outcomes for our members and to encourage our network providers to collaborate with us in maintaining the highest possible postpartum quality measures. HEDIS® determines a postpartum appointment as one that takes place 21-56 days after delivery. Follow-up appointments that occur 1-2 weeks or greater than 56 days after delivery are not recognized as reportable postpartum visits by HEDIS.

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

We look forward to working with you to improve the health outcomes and the quality of life for our postpartum members. If you have questions regarding our postpartum outreach initiative, please contact your Provider Relations representative or Anthem HealthKeepers Plus Provider Services at 1-800-901-0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 1-855-323-4687.

Summary of change: Effective April 1, 2019, HealthKeepers, Inc. will require all wound care requests to include current clinical documentation for Anthem HealthKeepers Plus members. This must include clear documentation of medical necessity including history, effectiveness of treatment and plan of care (POC). This affects home health wound care providers, including private duty nurses and skilled home health professionals.

What does this mean to me?

Requests for wound care services submitted without the documentation listed below may result in delayed or rejected precertification requests.

What documentation is required?

It is required that a wound care POC includes:

Patient information:

• Date the patient was last seen by the PCP or specialist for the wounds
• The start date of wound treatment
• Accurate diagnostic information pertaining to the underlying diagnosis and condition
• Other medical diagnoses and conditions, if applicable, including the patient’s overall health status, for example:
  • Off-loading pressure and glucose control for a patient with a diabetic ulcer
  •  Adequate circulation for a patient who has an arterial ulcer

• Patient’s permitted current and prior functional limitations and activities
• Nutritional deficits or needs required for patient
• Dose and frequency of medications

Description of wound:

• Wound measurements including length, width, depth, tunneling and undermining
• Wound color, drainage (type and amount) and odor, if present

Wound treatment:

• Describe current prescribed wound care regimen including frequency, duration and supplies needed.
• Describe all previous wound care therapy regimens, if applicable.
• If an infection is present, describe the current treatment regimen.
• If wound debridement is prescribed, documentation must support the level and number of debridements. Documentation should indicate if the debridement involves muscle or bone.
• Provide evidence of maintaining a clean, moist bed of granulation tissue.

Equipment used for wound treatment:

• Pressure-reducing support surface, mattress and/or cushion
• Compression system (for example, if a patient has a venous ulcer)

A POC must be signed and dated by the physician or accompanied by the physician’s signed and dated orders. The patient must be seen by a physician within 30 days of the initial start of care and at least once every six months thereafter unless the patient’s condition changes.

A revised POC is required for every change request in home health visits. The revised POC must include all continuing and new orders. It must also be updated to document any changes in the patient’s condition or diagnosis.

What authorization form should I use?

The Precertification Request Form located on our provider website at https://mediproviders.anthem.com/va must be used for service requests. It is important that the form is complete with all supporting clinical documentation provided. Requests without the required documentation will be returned as incomplete. Fax requests with the required clinical information to fax number.

This PA can also be submitted electronically by logging in to the Availity Portal at https://www.availity.com. You can also view the status of the request after it is submitted.

Please note that form CMS 285 will not be accepted.

What will I receive after I submit the request?

We will fax responses to requests with a reference ID number and determination letter to the servicing provider within three business days of receipt of request.

What if I have questions?

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

The Department of Medical Assistance Services has asked us to implement some changes to Anthem HealthKeepers Plus claims payment requirements for certain early intervention (EI) claims. 

Effective January 1, 2019, HealthKeepers, Inc. will implement claims edits that will impact claims payments for EI claims if an Individual Family Service Plan (IFSP) is not on file with HealthKeepers, Inc. prior to submitting claims.

Please review the following information on the new EI claims payment requirements:

• We still do not require authorizations for EI services. 
• However, we now require an IFSP to be on file to serve as a notification authorization.
• Claims will only pay when an IFSP is on file and the services billed align with the services listed on the IFSP.
• Clean claims are processed within 14 days. If an IFSP is not on file, the claim will not be considered clean.
• Codes T2022 and T1023 do not require an IFSP, as these are for service coordination and assessment; these claims will not be impacted.
• All other codes require an IFSP to be on file with HealthKeepers, Inc.
• All revisions to an IFSP should be submitted directly to HealthKeepers, Inc. as soon as possible via fax to 1-866-920-4097 or email  to: wrkgp-EarlyInterventionServicesSupport@anthem.com.
• For issues pertaining to EI claims, please call Provider Services at 1-800-901-0020 or call the Anthem CCC Plus team at 1-855-323-4687.
• The Virginia Department of Behavioral Health and Developmental Services must certify servicing providers.

Note: Please contact your Anthem HealthKeepers Plus patient’s care coordinator to ensure that your patient’s IFSP is on file.

HealthKeepers, Inc. has started conducting monthly provider orientations and trainings covering information important for members enrolled in Anthem HealthKeepers Plus for the Medallion 4.0 Medicaid Managed Care Program; and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus).

These orientations/trainings are for all contracted and noncontracted providers. The goal of these orientations/trainings is to aid new providers in engaging with the health plan and give existing providers an opportunity to learn about any new initiatives. You can find a schedule of the orientations along with the registration links by visiting https://mediproviders.anthem.com/va > Provider Education > Communications & Updates > Provider Bulletins > 2018 > Provider Orientation Invite.