Virginia House Bill 1640 requires payers to offer provider contracting opportunities to nurse practitioners who meet payer terms and conditions effective October 1, 2019.  Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. are now directly contracting and credentialing nurse practitioners (NPs) and physician assistants (PAs).  We are contracting with NPs and PAs who are licensed by the Virginia Board of Nursing and/or the Virginia Board of Medicine.

 

Previously, licensed NPs and PAs could only bill for covered services under the supervision of the employing/supervising participating physician using that physician’s name and National Provider Identifier (NPI) number. Direct contracting means NPs and PAs must bill Anthem directly for their services, and the “incident to” guidelines will no longer apply.  Direct contracting and credentialing of NPs and PAs also allows us to include NPs and PAs in our provider directories as independent providers, and our members – your patients – can easily search our Provider Finder tool for NPs and PAs who participate with their health plan.

 

In addition, direct contracting with NPs and PAs will allow easier handling of Medicare crossover claims. Medicare crossover claims for services provided by NPs and PAs to our members with a secondary group coverage policy will process under the participating NP or PA record, all without any re-billing by the group under the physician’s NPI.

 

In order to be participating providers in our networks, NPs and PAs will need to sign agreements and be credentialed by Anthem. NPs and PAs must complete the online credentialing application process through CAQH.  [To contact CAQH, dial 888-599-1771 (Monday -Thursday 7 a.m. - 9 p.m. ET; Friday 7 a.m. - 7 p.m. ET), or visit the CAQH website at http://www.caqh.org/ucd_physician_register.php.]

 

Effective March 1, 2020, we will no longer allow NP and PA services to be billed incident to physician services. So providers should take action right away to initiate contracting and credentialing.

 

If you or other providers in your organization meet the aforementioned requirements, please utilize our online provider enrollment application through the provider portal on Availity at https://www.availity.com/. Or, you may reach out to your designated network manager directly. Contact information can be found at https://www.anthem.com/provider/contact-us/

Anthem Blue Cross and Blue Shield is collaborating with leading organizations on a new school-based initiative called Shine Light on Depression to help tackle the issue of teen depression and suicide in middle and high school youth nationwide. The Shine Light on Depression e-toolkit (e.g., website) will provide school communities with free, ready-to-use tools designed to raise awareness of depression and suicide prevention in a positive, fact-based, and inclusive manner.

 

This approach will help build a community in which there is open discussion and appropriate vocabulary about the subject of depression and places it in the broader context of good mental health. The e-toolkit features customizable classroom lessons to empower educators to lead effective depression awareness programs, family-community workshop materials to help adults and families talk about how to support teens, and teen club resources that empower students to lead activities and help each other by talking and listening. With 24,053 secondary schools in the United States, the Shine Light on Depression e-toolkit has the potential to impact large numbers of individuals who are at risk of depression and suicide and support schools in meeting state teaching mandates. Visit Shine Light on Depression to learn more.

 

 

Shine Light on Depression is a unique collaboration of organizations committed to raising awareness of depression and suicide prevention among young people: American School Health Association, Anthem, Inc., Erika’s Lighthouse, JetBlue Airways Corporation, and the National Parent Teachers Association.

Effective for dates of service on and after May 17, 2020, the following updates will apply to the AIM Musculoskeletal Program: Joint Surgery and Spine Surgery Clinical Appropriateness Guidelines.

 

Joint surgery updates by section: 

 

Shoulder arthroplasty

 

• Added steroid injection for all joints exclusion based on panel recommendation

 

• Added exclusions for use of xenografts or biologic scaffold for augmentation or bridging reconstruction, use of platelet rich plasma or other biologics and concomitant subacromial decompression

 

• Removed indication for subacromial impingement with rotator cuff tear  

 

Hip arthroplasty

 

• Added exclusion for steroid injection for joint being replaced within the past 6 weeks

 

• Added labral tear indication

 

Knee arthroscopy and open procedures

 

• Added chondroplasty indication

 

• Narrowed use of lateral release to lateral compression as a cause for anterior knee pain or chondromalacia patella

 

• Added a conservative management and advanced osteoarthritis exclusion to patellar compression syndrome section

 

Code changes

 

• Added CPT codes 27425, 27570

 

Spine surgery updates by section:

 

No criteria changes

 

Code changes only

 

• Added CPT codes 0200T, 0201T

 

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

 

• Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.

 

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

 

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

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 and upcoming guidelines.

 

Effective for dates of service on and after May 17, 2020, the following updates will apply to the AIM Advanced Imaging:  Vascular Imaging Clinical Appropriateness Guidelines.

 

Updates by section: 

 

Aneurysm of the abdominal aorta or iliac arteries

 

• Added new indication for asymptomatic enlargement by imaging

 

• Clarified surveillance intervals for stable aneurysms as follows:

 

1. Treated with endografts, annually
2. Treated with open surgical repair, every 5 years

 

Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified

 

• Added surveillance indication and interval for surgical bypass grafts

 

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

 

• Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.

 

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

 

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

 

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 and upcoming guidelines.

Anthem’s Commercial Risk Adjustment (CRA) area contracts with Inovalon – an independent company that provides secure, clinical documentation services – to help us comply with provisions of the Affordable Care Act (ACA).  These provisions require us to assess members’ relative health risk level and report to the Centers for Medicare & Medicaid Services (CMS) on those conditions.  Your offices have been receiving health assessment packets from Inovalon called Subjective, Objective, Assessment, and Plan (SOAP) notes all year long as part of our risk adjustment cycle, asking for your help with completing these health assessments for some of your patients who are our members.

 

Incentives for submitting SOAP notes/health assessments

 

Should you receive a request from Inovalon, SOAP notes submitted as paper are eligible for a $50 incentive. SOAP notes submitted electronically through Inovalon’s ePASS system are eligible for a $100 incentive. 

 

Submission deadline and important reminder

 

While the dates of service for the patient visits must have been by December 31, 2019, the SOAP notes/health assessments can be submitted up until February 15, 2020.  We will still offer the incentive payments for these submissions through February 15, 2020.

 

Questions or assistance with SOAP notes

 

Need help with ePASS or have questions? Simply email your inquiry to Inovalon at ePASSsupport@inovalon.com with your name, organization, contact information, and any questions that you might have. Trained representatives are available to assist you.  If you prefer to reach Inovalon by phone, please call 1-877-448-8125, Monday - Friday, 8 a.m. - 9 p.m. ET; Saturday - Sunday, 10 a.m. - 6 p.m. ET.

 

If you have any questions regarding our risk adjustment process, please contact our CRA Network Education Representative who supports your area:

 

• Alicia.Estrada@anthem.com

Category:  Medicaid


As patient panels grow more diverse and needs become more complex, providers and office staff need more support to help address the needs of Anthem HealthKeepers Plus patients. HealthKeepers, Inc. wants to help.

 

Cultural competency resources

 

We have cultural competency resources available on our provider website. Leveraging content created by the Industry Collaboration Effort (ICE) Cultural and Linguistic Workgroup, the Cultural Competency Training and the Caring for Diverse Populations Toolkit have enhanced content.

 

Cultural Competency Training includes:

 

• Enhanced content regarding culture including language and the impact on health care.

 

• A cultural competency continuum that can help providers assess their level of cultural competency.

 

• Guidance on working effectively with interpreters.

 

• Comprehensive content on serving patients with disabilities.

Caring for Diverse Populations Toolkit includes:

 

• Comprehensive information on working with diverse patients and effectively supporting culture, language and disabilities in health care delivery.

 

• Tools and resources to help mitigate barriers including materials that can be printed and made available for patients in your office.

 

• Guidance on regulations and standards for cultural and linguistic services.

 

In addition, providers can access https://mydiversepatients.com for tools and resources that are accessible from any smartphone, tablet or desktop. Providers will find free continuing medical education courses that cover topics relevant to providing culturally competent care and services for diverse individuals.

 

Prevalent non-English languages (based on population data)

 

Like you, HealthKeepers, Inc. wants to effectively serve the needs of diverse patients. It’s important for us all to be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the prevalent non-English languages spoken by 5 percent or 1,000 individuals in Virginia.

 

(Source: American Community Survey, 2016 American Community Survey 5-Year Estimates, Table B16001, generated 10/03/2018)

 

Prevalent non-English languages in Virginia

Spanish

 

Language support services

 

As a reminder, HealthKeepers, Inc. provides language support services for our members with limited English proficiency (LEP) or hearing, speech or visual impairments. Please see the provider manual at https://mediproviders.anthem.com/va for details on the available services and how to access them.

 

Category:  Medicaid


Per the Department of Medical Assistance Services (DMAS), effective November 1, 2019, HealthKeepers, Inc. will 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, providers are required to include billing taxonomy codes. 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.

 

For claims submitted:

 

• 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.

 

• For paper claims submissions, on a CMS-1500 form, include the taxonomy codes in box 33b.

 

• For paper claims submissions, on a UB-04 form, include the taxonomy code in box 57 or in box 81.

 

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

Category:  Medicaid


Policy update

Split-Care Surgical Modifiers

(Effective 05/01/20)

 

Currently, HealthKeepers, Inc. allows reimbursement of surgical codes for Anthem HealthKeepers Plus members appended with split-care modifiers unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

 

Reimbursement is based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure. The percentage is determined by which modifier is appended to the procedure code:

 

• Modifier 54 (surgical care only): 70%

 

• Modifier 55 (postoperative management only): 20%

 

• Modifier 56 (preoperative management only): 10%

The global surgical package consists of preoperative services, surgical procedures and postoperative services.

 

Effective May 1, 2020, HealthKeepers, Inc. will no longer allow reimbursement of surgical codes appended with split-care modifiers unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. The global surgical package consists of preoperative services, surgical procedures and postoperative services.

 

For additional information regarding percentages and reimbursement criteria, view the Split-Care Surgical Modifiers reimbursement policy at https://mediproviders.anthem.com/va.

 

Category:  Medicaid


HealthKeepers, Inc. communicated to you on June 1, 2019, that we were initiating post-payment reviews for professional emergency room (ER) claims billed with level 5 ER evaluation and management (E/M) codes 99285 and G0384 for Anthem HealthKeepers Plus members.

 

A link to this communication can be found here: http://anthem.ly/2rptejN

 

The implementation of this policy has been postponed.

 

This update relates only to the policy announced June 1, 2019. All other current policies applicable to you, including but not limited to other audit or reimbursement policies pertaining to ER claims, are unaffected by this update. We will keep you informed about the initiation of the review process; however, we require proper coding and billing to ensure prompt and accurate payment.

 

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

 

Category:  Medicaid


Effective February 1, 2020, HealthKeepers, Inc. will require prior authorization (PA) for certain durable medical equipment for Anthem HealthKeepers Plus members.

 

Codes requiring PA as of February 1, 2020:

 

E0983

E0986

E2300

E2311

E2312

E2313

E2331

E2609

E2617

We recommend providers visit https://mediproviders.anthem.com/va > Precertification to review the list of services and service categories that currently require PA. Should a provider need clarification regarding whether a specific code or service requires PA, they should use the Utilization Management contact numbers below.

 

The list of services requiring PA will be updated as needed.

 

Providers are responsible for verifying eligibility and benefits for Anthem HealthKeepers Plus members before providing services. Except for an emergency, failure to obtain PA for the services requiring PA may result in denial of reimbursement.

 

Requesting PA

 

To request PA, report a medical admission or ask questions regarding PA, contact the Utilization Management department at the following:

 

• Fax: 1-800-964-3627

 

• Phone: 1-855-661-2028

Regardless of PA requirement, all services must be medically necessary to be covered. To access our medical necessity criteria, visit https://www.anthem.com/home-providers.html > Select a State > choose Virginia > scroll down and select See Policies and Guidelines > choose View Coverage & UM Guidelines.

 

Questions

 

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

 

Category:  Medicaid


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

 

Reimbursement Policy Update Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

 

Reimbursement Policy Update Multiple and Bilateral Surgery: Professional and Facility Reimbursement

Category:  Medicare


CMS requires that all hospitals and critical access hospitals (CAHs) provide written notification and an oral explanation to individuals receiving observation services as outpatients for more than 24 hours.

 

Hospitals should use the OMB-approved standardized Medicare Outpatient Observation Notice (MOON), form CMS-10611. All hospitals and CAHs are still required to provide this statutorily required notification. The notice and accompanying instructions are available at https://go.cms.gov/391jZH9.

 

The MOON was developed to inform all Medicare beneficiaries, including Anthem Blue Cross and Blue Shield members, when they are an outpatient receiving observation services, and are not an inpatient of the hospital or CAH. The notice must include the reasons the individual is an outpatient receiving observation services and the implications of receiving outpatient services, such as required Medicare cost-sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility services.

 

Hospitals and CAHs must deliver the notice no later than 36 hours after observation services are initiated or sooner if the individual is transferred, discharged or admitted.

 

506979MUPENMUB

 

Category:  Medicare


Policy update

Modifier 62: Co-Surgeons

(Effective 05/01/2020)

Effective May 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) has updated the Modifier 62: Co‑Surgeons reimbursement policy to expand the current policy’s language, adding that Anthem does not consider surgeons performing different procedures during the same surgical session as co-surgeons, and Modifier 62 is not required.

 

Assistant surgeon and/or multiple procedures rules and fee reductions apply if a co-surgeon acts as an assistant in performing additional procedure(s) during the same surgical session.

 

Please note that assistant surgeon rules do not apply to procedures appropriately billed with Modifier 62.

 

Please visit www.anthem.com/medicareprovider to view the Modifier 62: Co-Surgeons reimbursement policy for additional information regarding percentages and reimbursement criteria.

 

501926MUPENMUB

Category:  Medicare


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

 

Reimbursement Policy Update Multiple and Bilateral Surgery: Professional and Facility Reimbursement

 

 504986MUPENMUB

2020 Medicare risk adjustment provider trainings

 

 506264MUPENMUB

Introducing a new Medicare Advantage special needs plan for 2020 (VA only)

 

 506285MUPENMUB