As a reminder, we will update our claim editing software for professional services throughout 2023, with most updates occurring at a minimum quarterly. These updates apply to any provider, provider group (tax identification number) and/or across providers and claim type (professional/facility) and include, but are not limited to:

• The addition of new, and revised codes (for example, CPT^®, HCPCS, ICD-10, modifiers) and associated edits such as:
  • ICD-10 laterality
  • Add-on procedures (indicated by + sign)
  • Code book parenthetical statements and other directives about appropriate code use (for example, separate procedure, do not report, list separately in addition to, etc.)
• Updates to editing for multiple procedure reduction calculations based on relative value unit (RVU) as designated and updated by the Centers for Medicare & Medicaid (CMS) in the physician fee schedule relative value (PFSRV) files
• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to incidental, mutually exclusive, and unbundled (re-bundle) edits
• Updates to code edits associated with reimbursement policies including, but not limited to, updates to the edits that allow/disallow for assistant surgeon/co-surgeon/team surgeon, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by CMS

As a reminder, we will update our claim editing software for outpatient facility services throughout 2023 with most updates occurring at a minimum quarterly. These updates will include, but are not limited to:

• The addition of new and revised codes (for example, CPT^®, HCPCS, ICD-10, modifiers, revenue codes) and associated edits.
• Updates related to the appropriate use of various code combinations, which can include, but are not limited to, CPT/HCPCS code to revenue code, type of bill to procedure code, type of bill to CPT/HCPCS code, and CPT/HCPCS code to modifier.
• Updates to National Correct Coding Initiative edits (NCCI) and Facility Outpatient Hospital Services Medically Unlikely Edits (MUEs).
• Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC) and the Centers for Medicare & Medicaid Services (CMS).

Beginning with dates of service on or after April 1, 2023, or the end of the public health emergency (PHE), whichever is later, reimbursement for COVID-19 laboratory service codes may be reduced for participating providers contracted with Anthem.

New COVID-19 laboratory service codes were implemented and reimbursed at rates to meet the needs of providers during the PHE. Reimbursement will now be revised to Anthem's standard reimbursement methodology for the following codes:

 If you have any questions regarding this notice, please contact Provider Services or use Availity* Live Chat, which is available during normal business hours. Go to www.availity.com and select Anthem from the payer spaces drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

HEDIS^® measurement year 2023 documentation for Childhood Immunization Status (CIS)

Measure description:The percentage of children who turn 2 years of age in the measurement year who had the following vaccines on or before their second birthday:

• Four DTaP (diphtheria, tetanus, and acellular pertussis)
• Three IPV (polio)
• One MMR (measles, mumps, and rubella)
• Three HiB (haemophilus influenza type B)
• Three hep B (hepatitis B)
• One VZV (chicken pox)
• Four PCV (pneumococcal conjugate)
• One hep A (hepatitis A)
• Two or three RV (rotavirus)
• Two flu (influenza)

The measure calculates a rate for each vaccine and three combination rates.

HEDIS measurement year 2023 documentation for Lead Screening in Children (LSC)

Measuredescription: The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday.

In provider medical records, we look for the following:

• Immunization records from birth (Department of Health immunization records are acceptable).
• If available, newborn inpatient records documenting hepatitis B.
• For immunizations not recorded on the immunization record, provide progress notes for:
  • Immunizations administered.
  • Patient’s history of disease (chickenpox, hep A, hep B, measles, mumps, rubella).
• Lead testing results and date (capillary or venous) on or before the second birthday.
• Evidence of hospice services in 2023.
• Evidence patient expired in 2023.

Helpful hints:

• Childhood immunizations and lead blood tests must be completed by child’s second birthday.
• Assess immunization needs at every clinical encounter and, when indicated, immunize.
• Ensure immunization records include all vaccines that were ever given including hospitals, health departments, and all former providers, including refusals and contraindications.
• FluMist (LAIV) vaccination (only approved for ages 2 to 49) may be used for the second vaccination; however, it must be given on the child’s second birthday to be compliant.

Why is this important?

Each year, a random sample of enrolled members receive a CAHPS* Survey or a Qualified Health Plan Enrollee Survey asking them to evaluate their experiences with healthcare. The surveys ask members to rate their experiences with:

1. Their health plan.
2. Their personal provider.
3. Their specialist.

Several responses are combined and evaluated for the following:

• Getting needed care
• Receiving care quickly
• Communicating with providers
• Sharing in the decision-making process

The responses give us an idea of how your patients and our members perceive us and provide opportunities for us to improve the way we deliver services. Our engagement and interaction with patients and members are critical. Together, we can provide positive experiences for our shared members and patients.

Members receive the survey either by mail or phone between February and May. Some of the questions they are asked include:

• In the last six¹ months, how often did your personal provider explain things in a way that was easy to understand?
• In the last six¹ months, how often did your personal provider listen carefully to you?
• In the last six¹ months, how often did your personal provider show respect for what you had to say?
• In the last six¹ months, how often did your personal provider spend enough time with you?
• Using any number from zero to 10, where zero is the worst personal provider possible, and 10 is the best personal provider possible, what number would you use to rate your personal doctor?
• We want to know your rating of the specialist you saw most often in the last six¹ months. Using any number from zero to 10, where zero is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate the specialist?

Every interaction with a patient is an opportunity to make their healthcare experience positive.

We thank you for striving to provide quality care for our members and for the continued focus on improving our member experience.

Additional information

Continuing medical education (CME) education opportunities: http://www.mydiversepatients.com.

¹ The commercial survey asks the same questions, but for the last [12 months vs. 6 months and] language on the Medicaid Child Survey is slightly different to reflect asking a parent/guardian about their child’s experience.

The following services will be added to precertification for the effective dates listed below.

Precertification responsibility: The ordering or rendering provider of service is responsible for completing the precertification process.

HMO plans: Services that require precertification will be denied if rendered without the appropriate precertification for in-network providers. HMO members may not have benefits for non-emergency services rendered outside of the network and are subject to review and may be denied.

PPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement.

EPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement. No out-of-network benefit is available with the exception of ER/urgent care and authorized services.

Requesting precertification with the Virginia plan 

To obtain precertification, providers can access Availity* at www.availity.com or call the Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.

The following services will be added to precertification for the effective dates listed below.

Precertification responsibility: The ordering or rendering provider of service is responsible for completing the precertification process.

HMO plans: Services that require precertification will be denied if rendered without the appropriate precertification for in-network providers. HMO members may not have benefits for non-emergency services rendered outside of the network and are subject to review and may be denied.

PPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement.

EPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement. No out-of-network benefit is available with the exception of ER/urgent care and authorized services.

Requesting precertification with the Virginia plan 

To obtain precertification, providers can access Availity* at www.availity.com or call the Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.

In November 2022, we shared information about updates to claim status inquiries denial descriptions. You should now see these expanded descriptions on your explanation of payment remittance advice. These simplified descriptions should make it easier to understand why your claim denied and how to update your claim with the information needed for processing.

We’re phasing in clear, concise, and simplified denial descriptions that explain in greater detail why the claim or claim line has denied and what to do next. We’ve even included details about how to provide us with information digitally, to move the claim further along in the claims process.

Continuing to improve

The new denial descriptions will be phased in over the next few months. We’re starting with those claims or claim lines that have caused the most confusion based on your feedback. If new denial reasons are added, those descriptions will be expanded, as well.

Save time. Increase efficiency. Go digital! If you’re not enrolled in Availity* Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity.com.

The annual after-hours access studies performed by our vendor, North American Testing Organization* based in California, were resumed and fielded in the third quarter of 2022. This was to assess adequate phone messaging for our members with perceived emergency or urgent situations after regular office hours.

Unfortunately, most of the Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. plans assessed fell short of the expectation of having a live person or a directive in place after hours. We will resume the survey in the second quarter of 2023 and expect when your office is contacted, you will be able to accommodate a member’s urgent concerns after hours.

The main challenges the vendor has encountered while attempting to collect this required, essential data are related to an inability to reach the provider and/or the lack of after-hours messaging altogether. The challenges include:

• Inaccurate provider information in the Anthem demographic database to allow assessment of the after-hours messaging.
• No voicemail or messaging at all.
• Voicemail not reflecting the practitioner’s name.
• Calls being automatically forwarded with no identification, no voicemail, or messaging.

To help your patients and Anthem reach your practice, we ask that you update your office information using the online Provider Maintenance Form and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, such as:

• Emergency situations:
  • The compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to the emergency room (ER) or connects the caller directly to the physician.
• Urgent situations:
  • The compliant response for urgent needs would direct the caller to urgent care or ER, to call 911, or connect the caller to their physician or the physician on call.

Members must have access to care 24 hours a day, 7 days a week, 365 days a year. Primary care physicians (PCPs) must have arrangements for after-hours care to provide 24-hour coverage for members by a network provider during non-business office hours. Compliance requires that a recording or live person directs callers to urgent care, 911, the ER, or connects the call to the caller’s physician or physician on call.

In addition to these measures, but not in place of them, the messaging can give callers the option of contacting their healthcare practitioner (via transfer, cell phone, pager, text, email, or voicemail) or an opportunity to ask for a call back for urgent questions or instructions.

Is your practice compliant?

The following service will be added to the precertification list for the effective date listed below.

Precertification responsibility: The ordering or rendering provider of service is responsible for completing the precertification process.

HMO plans: Services that require precertification will be denied if rendered without the appropriate precertification for in-network providers. HMO members may not have benefits for non-emergency services rendered by out of network providers and are subject to review which could result in a denial.

PPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement.

EPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement. No out-of-network benefit is available with the exception of ER/Urgent Care and authorized services.

Requesting precertification for Anthem Blue Cross and Blue Shield members in Virginia

To obtain precertification, providers can access Availity Essentials* at Availity.com. To submit the authorization, select Authorizations from the home page. Calling the Utilization Management department using the number on the back of the member’s identification card can cause delays and digital submissions are recommended. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed.

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_® (AIM)* Musculoskeletal — Interventional Pain Management Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Interventional pain management — updates by section:

• Epidural steroid injections:
  • For nerve root compression due to herniated disc, specified that the MRI/CT showing this finding must have been done within 18 months instead of 12 months.
• Selective nerve root block:
  • Included a second session for cases requiring evaluation of more than one level.
• Therapeutic intra-articular facet injections:
  • Included criteria for repeat injections in patients who met criteria for an initial injection.
• Conservative management requirements:
  • Aligned definitions with joint surgery, spine surgery, spine, and extremity imaging guidelines.
  • More rigorous definition of the supervised home physical therapy requirement and removed cognitive behavioral therapy as a conservative care modality.
  • Included activity modification and a trial of rest.
• Epidural steroid injections:
  • Specified that only one spinal region may be treated per date of service.
  • For repeat injection, prior injection must have provided improvement for three months instead of three weeks.
• Diagnostic medial branch block:
  • Specified that up to four diagnostic sessions may be done in a rolling 12-month period (previously three).
  • Reduced the number of unilateral levels that may be done in a session from three to two.
• Thermal medial branch radiofrequency neurotomy:
  • Reduced the number of unilateral levels that may be done in a session from three to two.
  • Specified a maximum of two radiofrequency sessions per rolling 12-month period.
• Regional sympathetic nerve block:
  • Specified that procedure must be performed using imaging guidance.
  • Specified that the procedure must be performed unilaterally.
  • Specified a lifetime maximum of six blocks.
  • Removed exclusions that referred to procedures which are no longer performed.

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM:

• Through 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.

If you have 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 online.

Why is this important?

Each year, a random sample of enrolled members receive a CAHPS* Survey or a Qualified Health Plan Enrollee Survey asking them to evaluate their experiences with healthcare. The surveys ask members to rate their experiences with:

1. Their health plan.
2. Their personal provider.
3. Their specialist.

Several responses are combined and evaluated for the following:

• Getting needed care
• Receiving care quickly
• Communicating with providers
• Sharing in the decision-making process

The responses give us an idea of how your patients and our members perceive us and provide opportunities for us to improve the way we deliver services. Our engagement and interaction with patients and members are critical. Together, we can provide positive experiences for our shared members and patients.

Members receive the survey either by mail or phone between February and May. Some of the questions they are asked include:

• In the last six¹ months, how often did your personal provider explain things in a way that was easy to understand?
• In the last six¹ months, how often did your personal provider listen carefully to you?
• In the last six¹ months, how often did your personal provider show respect for what you had to say?
• In the last six¹ months, how often did your personal provider spend enough time with you?
• Using any number from zero to 10, where zero is the worst personal provider possible, and 10 is the best personal provider possible, what number would you use to rate your personal doctor?
• We want to know your rating of the specialist you saw most often in the last six¹ months. Using any number from zero to 10, where zero is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate the specialist?

Every interaction with a patient is an opportunity to make their healthcare experience positive.

We thank you for striving to provide quality care for our members and for the continued focus on improving our member experience.

Additional information

Continuing medical education (CME) education opportunities: http://www.mydiversepatients.com.

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 855‑323‑4687.

¹The commercial survey asks the same questions, but for the last 12 months vs. 6 months and language on the Medicaid Child Survey is slightly different to reflect asking a parent/guardian about their child’s experience.

HEDIS^® measurement year 2023 documentation for Childhood Immunization Status (CIS)

Measure description: The percentage of children who turn 2 years of age in the measurement year who had the following vaccines on or before their second birthday:

• Four DTaP (diphtheria, tetanus, and acellular pertussis)
• Three IPV (polio)
• One MMR (measles, mumps, and rubella)
• Three HiB (haemophilus influenza type B)
• Three hep B (hepatitis B)
• One VZV (chicken pox)
• Four PCV (pneumococcal conjugate)
• One hep A (hepatitis A)
• Two or three RV (rotavirus)
• Two flu (influenza)

The measure calculates a rate for each vaccine and three combination rates.

HEDIS measurement year 2023 documentation for Lead Screening in Children (LSC)

Measure description: The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday.

In provider medical records, we look for the following:

• Immunization records from birth (Department of Health immunization records are acceptable).
• If available, newborn inpatient records documenting hepatitis B.
• For immunizations not recorded on the immunization record, provide progress notes for:
  • Immunizations administered.
  • Patient’s history of disease (chickenpox, hep A, hep B, measles, mumps, rubella).
• Lead testing results and date (capillary or venous) on or before the second birthday.
• Evidence of hospice services in 2023.
• Evidence patient expired in 2023.

Helpful hints:

• Childhood immunizations and lead blood tests must be completed by child’s second birthday.
• Assess immunization needs at every clinical encounter and, when indicated, immunize.
• Ensure immunization records include all vaccines that were ever given including hospitals, health departments, and all former providers, including refusals and contraindications.
• FluMist (LAIV) vaccination (only approved for ages 2 to 49) may be used for the second vaccination; however, it must be given on the child’s second birthday to be compliant.

Background

Providers are a trusted resource for patients when it comes to vaccine advice. As information on the monkeypox outbreak changes and vaccination and testing guidance is released, we’re committed to keeping you informed.

Some providers may have seen a message on their provider Explanation of Payment (EOP) stating that HealthKeepers, Inc. does not recognize the vaccine product codes for monkeypox and smallpox that became effective July 26, 2022. We’re updating the provider fee schedules to reflect the new vaccine product codes as quickly as possible. The EOP message did not impact payment for administration of the vaccines, which is reimbursable; however, since the monkeypox and smallpox vaccines are provided by the government at no charge, the vaccine products are non-reimbursable.

To aid in processing claims for the monkeypox and smallpox vaccine products, providers must include these three elements on claims, even if vaccine products were received from the federal government at no charge:

1. Product code (90611 or 90622)
2. Applicable ICD-10-CM diagnosis code
3. Administration code

More detail on codes and cost-sharing

Providers are encouraged to use:

• Product code 90611 for smallpox and monkeypox vaccine.
• Product code 90622 for vaccinia (smallpox) virus vaccine.
• Code 87593 for laboratory testing.

When billing the monkeypox and smallpox vaccine products, providers should submit those codes with a $0.01 charge.

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 855‑323‑4687. You can read more information on monkeypox online.

Notification regarding reimbursement changes to COVID-19 laboratory services codes

Beginning with dates of service on or after January 12, 2023, or the end of the public health emergency (PHE), whichever is the latter, reimbursement for COVID-19 laboratory services codes will be reduced for providers contracted as independent laboratory (ancillary) providers and participating in an Anthem HealthKeepers Plus independent laboratory provider network.

New COVID-19 laboratory service codes were implemented and reimbursed at rates to meet the needs of providers during the PHE. HealthKeepers, Inc. will revise reimbursement to standard reimbursement methodology for independent laboratory providers for the following codes:

The revised standard fee schedule for the COVID-19 laboratory services codes outlined above can be viewed on www.Availity.com* beginning January 12, 2023.

If you have any questions regarding this notice, please contact your designated Provider Network Manager. Please incorporate this notice into your Anthem HealthKeepers Plus provider agreement folder.

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 855‑323‑4687.

Prior authorizations submitted digitally can reduce denials associated with manual submission errors. The interactive care reviewer (ICR) prior authorization application makes it easy to submit, review, and check authorization status – all in one place.

Learn how by attending our January 2023 ICR webcast.

Tuesday, January 17, 2023

Noon Eastern time

Register here

Learn how to use ICR to: 

• Create an authorization request.
• Inquire on a previously submitted authorization.
  Update a case.
• Copy a case.
  View letters associated with a case.
• Request and check the status of an authorization appeal.

Visit the ICR target page to register and to access self-service learning and to view recorded learning sessions. Download ICR user guides and other job aides from theICR target page too. You can also register from the Provider Learning Hub by selecting the ICR live webinar learning icon.

This is an important message for all providers contracted with the Anthem HealthKeepers Plus network. 

Virginia’s Department of Medical Assistance Services (DMAS) will implement Cardinal Care effective January 1, 2023, which combines the two managed care programs — Medallion 4.0 and Commonwealth Coordinated Care Plus (CCC Plus) — to create a single identity for all members receiving services through Medicaid. 

Medallion 4.0 serves children, pregnant individuals and adults. CCC Plus serves older adults, disabled children and adults, and individuals receiving long-term services and supports (LTSS). Cardinal Care will continue to offer members the same programs and services and will not reduce or change any existing coverage.

While new Cardinal Care-branded ID cards will be issued during the first quarter of 2023, providers should continue to accept the member’s current ID card.

We will be consolidating customer service phone numbers for Medallion 4.0 and CCC Plus into one customer service phone number to provide seamless service to both members and providers. Please note these Cardinal Care customer service phone numbers:

Providers will continue to follow the same processes that currently exist to submit claims, verify eligibility, and verify benefits. Providers do not need to take any action at this time. HealthKeepers, Inc. and DMAS will continue to provide updates as needed.

If you have any questions about this communication, call Provider Services at 800‑901‑0020 or your Provider Experience representative.

• This is Quitting: Helping teens and young adults quit vaping
• HEDIS measure for prenatal and postpartum care
• Prior authorization requirement changes updated effective January 1, 2023
• AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT Code List update
• Change to vaccine age limitations

• Prior authorization requirement changes
• New specialty pharmacy medical step therapy requirements
  
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list
  
• Updates to AIM Specialty Health Radiation Oncology Clinical Appropriateness Guidelines