 Provider News VirginiaJuly 2020 Anthem Provider News - VirginiaPursuant to Virginia House Bill No.1057 (HB No. 1057 Health Insurance, Clinical Nurse Specialists), effective July 1, 2020, a clinical nurse specialist (CNS) may contract and be paid directly for covered health care services provided to Anthem members. Currently, Anthem contracts directly with clinical nurse specialists who provide behavioral health services.
Effective July 1, 2020, clinical nurse specialists can contract with Anthem to receive direct payment for services rendered for any covered medical service, not just behavioral health, within their scope of license. Digital Onboarding through Availity is not yet available for clinical nurse specialists outside of behavioral health. As such, please contact your Anthem network manager directly for further details.
Watch for upcoming editions of Provider News for more information.
550-0720-PN-VA The Custom Learning Center in the Availity portal offers an array of learning opportunities where you can access required training, recommended/elective trainings and view additional learning resources. Access to the Custom Learning Center is via Payer Spaces in the Availity Portal.
Highlights of the Custom Learning Center
- All the learning is in one place
- You can filter topics of interest
- View all your completed training
- Course resources may include links to a job aid
Your required courses are easily accessible and the available content is specific to your region. You may track your accomplishments, and view or download your training history via the Custom Learning Center Dashboard.
Select Access Your Custom Learning Center from the Applications tab in Payer Spaces.
Examples of trainings offered in the Custom Learning Center:
- Recommended administrative support courses
In addition, illustrated reference guides are located on Custom Learning Center - Resources. Select Resources from the menu located on the upper left corner of the screen. Usually, you may download or print reference guide materials.
Current Reference Guide topics include:
- Interactive Care Reviewer – Request Appeals Reference Guide
- Interactive Care Reviewer – Inquiries Reference Guide
Be sure to visit the Custom Learning Center in the Availity Portal often. New content is regularly added to the site.
For questions regarding the Availity Portal, please contact Availity Client Services at 1-800-282-4548.
526-0720-PN-VA We are targeting August 15, 2020, to introduce Interactive Care Reviewer (ICR) – Anthem Blue Cross and Blue Shield’s online authorization tool for members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® or FEP). You will access ICR through the Availity Portal. At this time, ICR will become your exclusive online tool for all new FEP medical and behavioral health inpatient and outpatient authorization requests and inquiries.
You may already be using ICR for your patients enrolled in Medicare Advantage and Anthem HealthKeepers Plus (Medicaid). Additionally, we plan to introduce ICR for our members enrolled in Anthem’s Commercial lines of business. (This includes Commercial plans offered by our affiliate, HealthKeepers, Inc.) The ability to request and check case status of your medical and behavioral health authorizations using one online application should further streamline your authorization workflow process.
In the coming months, please continue to check Point of Care and Availity News and Announcements for new updates we may post regarding this transition to ICR.
Are you new to ICR?
Get a head start now and ask your Availity administrator to grant you the required ICR role assignment.
Do you create and submit prior authorization requests?
Authorization and Referral Request role assignment
Do you check the status of the case or results of the authorization request?
Authorization and Referral Inquiry role assignment
Beginning on August 15, follow these steps to navigate to ICR through Availity:
Select Patient Registration from Availity’s home page
Select Authorizations & Referrals
Select Authorizations (for requests) | Select Auth/Referral Inquiry (for inquiries)
ICR training is offered monthly
Register for one of our free webinars created to familiarize new users with ICR features and navigation.
Can’t make it to the webinar?
Follow the steps outlined below to access self-paced videos located on the Custom Learning Center. From Availity’s home page, select Payer Spaces | Anthem tile | Applications | Your Custom Learning Center
- Select Catalog from the menu located on the upper left corner of the Custom Learning Center screen
- Use the catalog filter and select Interactive Care Reviewer-Online Authorizations or Authorizations from the Category menu
- Click Apply then enroll for the courses (videos) you want to view.
Illustrated reference guides that you can print are located on Custom Learning Center Resources. Select Resources from the menu located on the upper left corner of the screen. Use the catalog filter and select Authorizations or Interactive Care Reviewer-Online Authorizations from the Category menu. Select Download to view and/or print the reference guide.
551-0720 -PN-VA
On November 12, 2020, Anthem will offer a provider education webinar. Designed for our network-participating providers, the webinar addresses Anthem business updates and billing guidelines that impact your business interactions with us.
For your convenience, we offer these informative, hour-long sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the fall webinar is:
- Thursday, November 12, 2020, from 11 a.m. to noon 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 November webinar, please ensure you have received a fax confirmation or a confirmation from an Anthem representative to ensure we’ve received your registration form. Contact joyce.lindley@anthem.com if you need to confirm your registration.
523-0720-PN-VA Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. are offering outpatient network providers an opportunity to participate in the 2020 Virginia Behavioral Health Pay for Performance (VBH-P4P) program. This program provides Behavioral Health providers an opportunity to earn incentive payment for performing at or above target on a set of quality care measures.
Year 2020 will be the last year we will be offering our current Virginia Behavioral Health Pay for Performance program to outpatient network providers. We are making changes for 2021 and will be presenting new and exciting opportunities for the coming year.
Beginning in 2021, providers who have participated in the previous Virginia program will be invited to participate in the BH Provider Collaboration Value-Based Payment program. Lauren Sims, BHH PC Program Director, presented at the May 13, 2020, Virginia BH Provider P4P bi-annual meeting. If you have any questions, please contact her at lauren.sims@anthem.com. Additional overview training will be offered the beginning of fourth quarter. Communications will be sent directly to providers interested in participating in the BH Provider Collaboration program.
The remainder of 2020 will continue as previous years with the VBH-P4P program incentives sent to providers in June, and the last bi-annual meeting held in October. For specifics related to the current VBH-P4P program, please contact Deborah.bell@anthem.com.
508-0720-PN-VA As you know, AIM Specialty Health® (AIM) administers the musculoskeletal program, which includes the medical necessity review of certain surgeries of the spine and joints and interventional pain treatment. For certain surgeries, the review also includes a consideration of the level of care for Commercial fully insured Anthem members and some administrative services only (ASO) groups.
According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures, it is generally appropriate to perform joint codes (CPT codes 27130, 29871, 29892) and 4 spine codes (CPT codes 22633, 22634, 63265 and 63267) in a hospital outpatient setting. To avoid additional clinical review for these procedures, providers requesting prior authorization should either choose “hospital observation” admission as the site of service or Hospital Outpatient Department (HOPD). If the provider determines that an inpatient stay is necessary due to post-operative care requirements, they can initiate a concurrent review request for inpatient admission with the health plan by contacting the number on the back of the member ID card.
Total hip arthroplasty (CPT code 27130) is currently reviewed for medical necessity and level of care. Effective October 1, 2020, four spine codes (CPT codes 22633, 22634, 63265 and 63267) and two joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:
- Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
- Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.
Peer-to-peer conversations are available to a provider at any time to discuss the applicable clinical criteria and to provide information about the circumstances of a specific member.
Providers should continue to submit pre-service review requests to AIM using one of the following ways:
- Access AIM 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 Portal at availity.com.
- Call the AIM toll-free number at 866-789-0397, Monday through Friday, 8 a.m. to 5 p.m. ET.
For questions, please contact the provider number on the back of the member ID card.
553-0720-PN-VA Effective July 1, 2020, we will begin using the new acute viral illness guidelines that have been added to the 24th edition of MCG. Based on the presenting symptoms or required interventions driving the need for treatment or hospitalization, these guidelines are not a substantive or material change to existing MCG guidelines we use now, such as systemic or infectious condition, pulmonary disease, or adult or pediatric pneumonia guidelines.
Inpatient & Surgical Care (ISC)
- Viral Illness, Acute – Inpatient Adult (M-280)
- Viral Illness, Acute – Inpatient Pediatric (P-280)
- Viral Illness, Acute – Observation Care (OC-064)
Recovery Facility Care (RFC)
- Viral Illness, Acute – Recovery Facility Care (M-5280)
For questions, please contact the provider service number on the back of the member's ID card.
521-0720-PN-VA Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will implement the following new and revised coverage guidelines effective October 1, 2020. These guidelines impact all our products – with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan, and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). Furthermore, the guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on May 14, 2020.
The services addressed in these coverage guidelines in this section and in the attachment under "Article Attachments" on the right will require authorization for all of our HealthKeepers, Inc. products with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, and the Anthem CCC Plus plan. Please note that FEP is excluded from these requirements as well. A pre-determination can be requested for our PPO products.
If applicable, services related to specialty pharmacy drugs (non-cancer related) require a medical necessity review, which includes site of care criteria, as outlined in the applicable coverage or clinical UM guideline.
Guidelines addressed in this edition of Provider News are:
- Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting (CG-DME-46)
- Analysis of RAS Status (CG-GENE-02)
- Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation) (CG-MED-64)
- Therapeutic Apheresis (CG-MED-68)
546-0720-PN-VA
As a provider, you are committed to providing the best care for our members which now involves telehealth visits. Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions.
As we reported in the May and June editions of Provider News, we are completing our prospective and retrospective reviews for 2020 for Anthem’s Commercial Risk Adjustment (CRA) program. The retrospective program focuses on medical chart collection. The prospective program focuses on member health assessments for patients with undocumented Hierarchical Condition Categories (HCC’s), in order to help close patients’ gaps in care.
What’s in it for you
First, monthly you will receive a list of your patients who are Anthem members enrolled in Affordable Care Act (ACA) compliant coverage. We encourage you to reach out to these patients who may have gaps in care to come in for office visits earlier.
Second, we’ve heard resoundingly from providers that participation in these programs helps them better evaluate their patients and, as a result, perform more strongly in population health management and gain sharing programs. Many providers cite that they now ask different questions today that allow them to better manage treatment options for their patients end to end.
Finally, when you see Anthem ACA members and submit health assessments, we pay incentives of $100 for each properly completed electronic submission and $50 for a paper submission. For additional details on how to earn these incentives and the options available, please contact the CRA Network Education Representative listed below.
What’s in it for your patients
Anthem is completing monthly postcard campaigns to members with ACA compliant coverage when we suspect a high-risk condition with messaging to encourage members to call their Primary Care Provider (PCP) and schedule an annual checkup. The goal is to get the members to have a visit with their PCPs, so the PCPs have an overall picture of their patients’ health and schedule any screenings that may be needed. Telehealth visits have become very flexible formats for patients and doctors to meet, so we encourage telehealth visits to be scheduled if that is what the patient is most comfortable with at this time.
We will continue these monthly postcard mailings throughout the remainder of 2020 to encourage the members to schedule an annual checkup, which supplements any patient outreach you may be doing.
If you have any questions regarding our reporting processes, please contact the CRA Network Education Representative via email at Alicia.Estrada@anthem.com.
We applaud your continued commitment to delivering quality care to our members.
527-0720-PN-VA Prior authorization updates
Effective for dates of service on and after October 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
The Health Plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code (NDC), for the injected substance. This requirement is consistent with the Centers for Medicare & Medicaid Services (CMS) guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.
Please note, inclusion of NDC code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Access the Clinical Criteria information.
For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
|
|
ING-CC-0038
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J3110
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Bonsity
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|
ING-CC-0162
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J3490
J3590
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Tepezza
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|
ING-CC-0163
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J3490
C9399
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Durysta
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Step therapy updates
Effective for dates of service on and after October 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
Access the Clinical Criteria information with step therapy(ies).
For Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).
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Clinical Criteria
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Status
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Drug(s)
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HCPCS Codes
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ING-CC-0072
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Preferred
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Avastin
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J9035, C9257
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ING-CC-0072
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Preferred
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Mvasi
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Q5107
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|
ING-CC-0072
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Preferred
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Zirabev
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Q5118
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|
ING-CC-0072
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Preferred
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Eylea
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J0178
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|
ING-CC-0072
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Non-preferred
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Lucentis
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J2778
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|
ING-CC-0072
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Non-preferred
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Macugen
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J2503
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|
ING-CC-0072
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Non-preferred
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Beovu
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J0179
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CORRECTION: June 2020 step therapy update on clinical criteria ING-CC-0003:
Panzyga has been non-preferred for ING-CC 0003 since 2018.
In the June 2020 Provider News edition, we published information regarding Panzyga to be effective September 1, 2020. This was published in error.
540-0720-PN-VA Beginning July 1, 2020, most of Anthem Blue Cross and Blue Shield’s Affordable Care Act compliant, non-grandfathered health plans will cover pre-exposure prophylaxis (PrEP) medication at 100% with no member cost share, when used for prevention of HIV and dispensed at an in-network pharmacy with a prescription.
Since medications used for PrEP can also be used to treat HIV, Anthem will review medical and pharmacy claims data to determine if a member has been diagnosed and prescribed treatment for HIV or prescribed PrEP for preventive purposes. When prescribed for prevention of HIV, this drug is covered with no member cost share. When prescribed for treatment of HIV, member cost shares apply based on the member’s benefit plan. Coverage includes Truvada (200-300 mg), and its generic components, Emtriva 200mg and tenofovir 300mg. When medically necessary, a prior authorization process is available for Descovy to be covered with no member cost share when used for prevention of HIV.
Providers can contact the provider service number on the back of the member ID card to determine if a member’s plan includes this benefit.
515-0720-PN-VA On November 15, 2019, and February 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the Anthem HealthKeepers Plus medical drug benefit for HealthKeepers, Inc. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting February 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
AVA-NU-0247-20 In this Anthem HealthKeepers Plus coding spotlight, we will focus on several cardiovascular conditions; codes from Chapter 9 of the ICD-10-CM are listed in the table below.
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Diseases of the circulatory system
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Category codes
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Acute rheumatic fever
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I00-I02
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|
Chronic rheumatic heart diseases
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I05-I09
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|
Hypertensive diseases
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I10-I16
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|
Ischemic heart diseases
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I20-I25
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|
Pulmonary heart disease and diseases of pulmonary circulation
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I26-I28
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|
Other forms of heart disease
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I30-I52
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|
Cerebrovascular diseases
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I60-I69
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|
Diseases of arteries, arterioles and capillaries
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I70-I79
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|
Diseases of veins, lymphatic vessels and lymph nodes, not elsewhere classified
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I80-I89
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|
Other and unspecified disorders of the circulatory system
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I95-I99
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Hypertension
ICD-10-CM classifies hypertension by type as essential or primary (categories I10 to I13) and secondary (category I15).
Categories I10 to I13 classify primary hypertension according to a hierarchy of the disease from its vascular origin (I10) to the involvement of the heart (I11), chronic kidney disease (I12), or heart and chronic kidney disease combined (I13).1
Elevated blood pressure versus hypertension
A diagnosis of elevated blood pressure reading, without a diagnosis of hypertension, is assigned code R03.0. This code is never assigned on the basis of a blood pressure reading documented in the medical record; the physician must have specifically documented a diagnosis of elevated blood pressure.
The postoperative hypertension is classified as a complication of surgery, and code I97.3, postprocedural hypertension, is assigned. When the surgical patient has pre-existing hypertension, only codes from categories I10 to I13 are assigned.
Hypertensive heart disease
ICD-10-CM presumes a causal relationship between hypertension and heart involvement and classifies hypertension and heart conditions to category I11 — hypertensive heart disease — because the two conditions are linked by the term with in the alphabetic index of the ICD-10-CM. These conditions should be coded as related even in the absence of provider documentation linking them. First, code I11.0, hypertensive heart disease with heart failure as instructed by the note at category I50, heart failure. If the provider specifically documents different causes for the hypertension and the heart condition, then the heart condition (I50.-, II51.4-I51.9) and hypertension are coded separately.1
Other heart conditions that have an assumed causal connection to hypertensive heart disease
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Code
|
Description
|
|
I51.4
|
Myocarditis, unspecified
|
|
I51.5
|
Myocardial degeneration
|
|
I51.7
|
Cardiomegaly
|
|
I51.81
|
Takotsubo syndrome
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|
I51.89
|
Other ill-defined heart diseases
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|
I51.9
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Heart disease, unspecified
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Hypertension, secondary
Two codes are required: one to identify the underlying etiology and one from category I15 to identify the hypertension. For example:
- Hypertension due to systemic lupus erythematosus, M32.10 + I15.8.
Hypertensive crisis
A code from category I16, hypertensive crisis, is assigned for any documented hypertensive urgency (I16.0), hypertensive emergency (I16.1), or unspecified hypertensive crisis (I16.9). Report two codes, at a minimum, for hypertensive crisis. The crisis code is reported in addition to the underlying hypertension code (I10-I15).1
Pulmonary hypertension
Pulmonary hypertension is classified to category I27, other pulmonary heart diseases. For secondary pulmonary hypertension (I27.1, I27.2-), any associated conditions or adverse effect of drugs or toxins should be coded.2
Ischemic heart disease
Category I25, chronic ischemic heart disease, includes coronary atherosclerosis, old myocardial infarction, coronary artery dissection, chronic coronary insufficiency, myocardial ischemia, and aneurysm of the heart.
ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are I25.11, atherosclerotic heart disease with angina pectoris and I25.7, atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris.
When using one of these combination codes, it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates that angina is due to a condition other than atherosclerosis.2
Heart failure
Systolic heart failure is coded as I50.2 and diastolic heart failure is coded as I50.3-; combined systolic and diastolic heart failure is assigned code I50.4. Fifth characters further specify whether the heart failure is unspecified, acute, chronic or acute on chronic.
Other classifications of heart failure include:
- Right heart failure, unspecified (I50.810)
- Acute right heart failure (I50.811)
- Chronic right heart failure (I50.812)
- Acute on chronic right heart failure (I50.813)
- Right heart failure due to left heart failure (I50.814)
- Biventricular heart failure (I50.82)
- High output heart failure (I50.83)
- End-stage heart failure (I50.84)
- Other heart failure (I50.89)
For a diagnosis of left ventricular, biventricular and end-stage heart failure, two codes are required to completely describe the condition: one to report the left, biventricular or end-stage heart failure, and one to identify the type of heart failure.
Cardiomyopathy
Cardiomyopathy is coded as I42- with the third character describing:
- I42.0 Dilated cardiomyopathy, which includes congestive cardiomyopathy
- I42.1 Obstructive hypertrophic cardiomyopathy, including idiopathic hypertrophic subaortic stenosis
- I42.2 Other hypertrophic cardiomyopathy, including nonobstructive hypertrophic cardiomyopathy
- I42.3 Endomyocardial (eosinophilic) disease, including endomyocardial (tropical) fibrosis and Loffler’s endocarditis
- I42.4 Endocardial fibroelastosis, including congenital cardiomyopathy and elastomyofibrosis
- I42.5 Other restrictive cardiomyopathy, including constrictive cardiomyopathy not otherwise specified
- I42.6 Alcoholic cardiomyopathy due to alcohol consumption: a code for alcoholism (F10.-) is also assigned if present
- I42.7 Cardiomyopathy due to drug and external agent: code first the poisoning due to drug or toxin; if applicable (T36-T65 with fifth or sixth character 1-4 or 6); if the condition is caused by an adverse effect, use an additional code, if applicable, to identify the drug (T35-T50 with fifth or sixth character)
- I42.8 Other cardiomyopathies
Two codes may be required for cardiomyopathy due to other underlying conditions; for example, cardiomyopathy due to amyloidosis is coded E85.4, organ-limited amyloidosis, and I43, cardiomyopathy in diseases classified elsewhere. The underlying disease, amyloidosis, is sequenced first.2
Status Z codes
ICD-10-CM provides several Z codes to indicate that the patient has a health status related to the circulatory system, such as the following:
- Z94.1 Heart transplant status
- Z95.0 Presence of cardiac pacemaker
- Z95.1 Presence of aortocoronary bypass graft
- Z95.810 Presence of automatic (implantable) cardiac defibrillator
- Z95.811 Presence of heart assist device
- Z95.828 Presence of other vascular implants and grafts
These codes are assigned only as additional codes and are reportable only when the status affects the patient’s care for a given episode.
Resources
AVA-NU-0250-20The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus members (FAMIS and Medallion) and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members. These changes were reviewed and approved at the fourth quarter 2019 pharmacy and therapeutics committee meeting.
Effective May 1, 2020, formulary changes, non-formulary changes and prior authorization (PA) requirements will apply.
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Effective for all members on May 1, 2020
|
|
Therapeutic class
|
Medication
|
Formulary status change
|
Potential alternatives
(preferred products)
|
|
PEDIATRIC MULTIPLE VITAMINS
|
(BRAND)
POLY-VI-SOL DROPS
POLY-VI-SOL WITH IRON DROPS
|
PREFERRED
|
N/A
|
ADDITIONAL UM EDITS, EFFECTIVE NO LATER THAN AUGUST 1, 2020,
CAN BE FOUND ON THE EXTENDED VERSION ON OUR PROVIDER PAGE
|
What action do I need to take?
Please review these changes and work with your Anthem HealthKeepers Plus patients and/or 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 PA to continue coverage beyond the applicable effective date.
What if I need assistance?
We recognize the unique aspects of patient cases. If your patients cannot be converted to a formulary alternative, call our Pharmacy department at 1-800-901-0020 (Anthem HealthKeepers Plus members) or 1-855-323-4687 (Anthem CCC Plus members) and follow the voice prompts for pharmacy PA. You can find the Preferred Drug List (formulary) on our provider website at https://mediproviders.anthem.com/va > Pharmacy > Medicaid Common Core Formulary > Common Core Preferred Drug List.
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.
AVA-NU-0253-20 In March 2020, HealthKeepers, Inc. informed Anthem HealthKeepers Plus providers that the plan was aligning incontinence benefit limits with those of the Department of Medical Assistance Services (DMAS). This policy only affected members 21 and over. However, these limits did not go into effect on May 1, 2020, as scheduled.
On June 1, 2020, HealthKeepers, Inc. removed all benefit/quantity limits for incontinence supplies for all Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members of all ages (see DMAS Appendix B for impacted codes).
HealthKeepers, Inc. will reimburse DME providers for all quantities prescribed by the member’s physician and for services documented on a Certificate of Medical Necessity. HealthKeepers, Inc. will perform periodic reviews of all incontinence services to ensure that members are receiving the appropriate amount of supplies.
Reminder: Medicaid does not reimburse for incontinent briefs or incontinent under pads for children under the age of 3 years.
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.
AVA-NU-0256-20AIM Specialty Health® (AIM)* currently performs utilization management review for bi-level positive airway pressure (BiPAP) equipment and all associated supplies. Beginning July 1, 2020, the following codes will require prior authorization with Anthem Blue Cross and Blue Shield (Anthem) rather than with AIM.
Line of business: Individual Medicare Advantage, Group Retiree Solutions, and Medicare-Medicaid Plans
|
E0470
|
Respiratory assist device, bi-level pressure capability, without back-up rate feature, used with noninvasive interface, such as a nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
|
|
E0471
|
Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, such as a nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
|
AIM will continue to manage the supply codes for automatic positive airway pressure (APAP) and continuous positive airway pressure (CPAP) requests.
Anthem will continue to follow the COVID-19 Public Health Emergency orders from CMS until the waivers no longer apply. If the Public Health Emergency Orders are no longer in place beginning July 1, 2020, the following codes will require prior authorization with Anthem rather than with AIM when used in combination with the BiPAP codes above.
Precertification requests
Submit precertification requests via:
- Telephone – Dial the customer service number on the back of the member’s card; identify yourself as a provider and follow the prompts to reach the correct precertification team. There are multiple prompts. Select the prompt that fits the description for the authorization you plan to request.
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A4604
|
Tubing with heating element
|
|
A7046
|
Water chamber for humidifier, replacement, each
|
|
A7027
|
Combination Oral/Nasal Mask used with positive airway pressure device, each
|
|
A7030
|
Full Face Mask used with positive airway pressure device, each
|
|
A7031
|
Face Mask Cushion, Replacement for Full Face Mask
|
|
A7034
|
Nasal Interface (mask or cannula type), used with positive airway pressure device, with/without head strap
|
|
A7035
|
Headgear
|
|
A7036
|
Chinstrap
|
|
A7037
|
Tubing
|
|
A7039
|
Filter, non-disposable
|
|
A7044
|
Oral Interface for Positive Airway Pressure Therapy
|
|
A7045
|
Replacement Exhalation Port for PAP Therapy
|
|
A7028
|
Oral Cushion, Replacement for Combination Oral/Nasal Mask, each
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A7029
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Nasal Pillows, Replacement for Combination Oral/Nasal Mask, pair
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A7032
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Replacement Cushion for Nasal Application Device
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A7033
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Replacement Pillows for Nasal Application Device, pair
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A7038
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Filter, disposable
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* AIM Specialty Health® is an independent company providing utilization management services on behalf of Anthem Blue Cross and Blue Shield.
ABSCARE-0535-20 510502MUPENMUB On November 15, 2019, and February 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem). These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the Anthem provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting February 2020. Visit Clinical Criteria to search for specific policies.
For questions or additional information, use this email.
ABSCRNU-0144-20 509512MUPENMUB Anthem Blue Cross and Blue Shield (Anthem) is proud to offer the 2020 Optum* In-Office Assessment (IOA) Program, formerly known as the Healthcare Quality Patient Assessment Form/Patient Assessment Form (HQPAF/PAF) program. The name change reflects significant advancements in technology over the past few years, evolving from a paper form-based program to a program that securely exchanges clinical information digitally through multiple digital modalities.
If you are interested in learning about the electronic modalities available, please contact your Optum representative or the Optum Provider Support Center at 1-877-751-9207 from 8 a.m. to 7 p.m. Eastern time, Monday through Friday.
The IOA Program is designed to help participating providers ensure chronic conditions are addressed and documented to the highest level of specificity at least once per calendar year for all of our participating Medicare Advantage plan members. The IOA Program is designed to help overall patient quality of care (preventive medicine screening, chronic illness management and trifurcation of prescriptions for monitoring of high-risk medications and medication adherence) and care for older adults when generated for a Special Needs Plan (SNP) member.
Success stories
Below are some achievements Optum has accomplished with provider groups through the IOA Program:
- As a result of incorporating technology and/or different types of resources offered under the IOA Program, numerous provider offices demonstrated an increase in productivity, documentation and coding accuracy.
- Providers have taken advantage of the IOA Program resources to help alleviate some of the burden for their staff and office resources.
COVID-19 update
Anthem knows this is a difficult time for everyone. We will continue to adapt and evolve our practices to fully address the changing dynamics of these unprecedented events. Anthem is following the CDC guidelines on social distancing; thus, all nonessential IOA Program personnel are to work telephonically/electronically with the provider groups until further notice.
Dates and tips to remember:
- Anthem strongly encourages participating providers to review their patient population as soon as possible. This will help get patients scheduled for an appointment if they have not already scheduled an in-office visit. This will also help the provider manage chronic conditions, which impact the health status of the patient.
- At the conclusion of each office visit with a patient, providers participating in the IOA Program are asked to complete and return an In-Office Assessment The form should be completed based on information regarding the patient’s health collected during the office visit. Participating providers may continue to use the 2020 version of the In-Office Assessment form for encounters that take place on or before December 31, 2020. Anthem will accept the 2020 version of the form for 2020 encounters until midnight January 31, 2021.
- Participating providers are required to submit an Account Setup Form, W9 and completed direct deposit enrollment by March 31, 2021. Participating providers should call 1-877-751-9207 if they have any questions regarding this requirement. Participating providers who fail to comply with this requirement will result in forfeiture of the provider payment for submitted 2020 In-Office Assessment forms if applicable.
If you have any questions regarding the IOA Program, please call Optum at 1-877-751-9207, Monday through Friday from 9:30 a.m. to 7:30 p.m. Eastern time.
* Optum is an independent company providing medical chart review services on behalf of Anthem Blue Cross and Blue Shield.
ABSCRNU-0150-20 509687MUPENMUEffective July 1, 2020, Henry County and Henry County Public Schools will offer an Anthem Medicare Preferred (PPO) Medicare Advantage Plan with Part D (MAPD). Retirees with Medicare Parts A and B are eligible to enroll in the MAPD plan. The plan includes the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. The MAPD plan offers the same hospital and medical benefits that original Medicare covers and also covers additional benefits that original Medicare does not, such as an annual routine physical exam, hearing, LiveHealth Online* tool and SilverSneakers®.*
The prefix on Henry County and Henry County Public Schools member ID cards will be VAY. The cards will also show the Henry County and Henry County Public Schools name and National Access Plus icon.
Providers may submit claims electronically using the electronic payer ID for the Anthem Blue Cross and Blue Shield (Anthem) plan in their state or submit a UB-04 or CMS-1500 form to the Anthem plan in their state. Do not file claims with original Medicare. Contracted and non-contracted providers may call the provider services number on the back of the member ID card for benefit eligibility, prior authorization requirements and any questions about Henry County and Henry County Public Schools member benefits or coverage.
Detailed prior authorization requirements also are available to contracted providers by accessing the Availity Portal* at https://www.availity.com.
* LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Anthem Blue Cross and Blue Shield.
ABSCRNU-0153-20 509934VAPENABS Introduction
Anthem Blue Cross and Blue Shield (Anthem) is offering Dual Special Needs Plans (D-SNPs) to people eligible for both Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. D-SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These include supplemental benefits such as hearing, dental, vision and transportation to medical appointments. Some D-SNP plans include a card or catalog for purchasing over-the-counter items. D-SNPs do not charge premiums.
D-SNP members under Anthem benefit from a model of care that is used to assess needs and coordinate care. Within 90 days of enrollment and annually thereafter, each member receives a comprehensive health risk assessment (HRA) that covers physical, behavioral and functional needs, and a comprehensive medication review. The HRA is used to create a member Care Plan. Members with multiple or complex conditions are assigned a health plan case manager.
D-SNP HRAs, Care Plans and case managers support members and their providers by helping to identify and escalate potential problems for early intervention, ensuring appropriate and timely follow-up appointments, and providing navigation and coordination of services across Medicare and Medicaid programs.
Provider training required
Providers contracted for D-SNP plans are required to complete an annual training to stay up-to-date with plan benefits and requirements, including details on coordination of care and model of care elements. Every provider contracted for D-SNP is required to complete an attestation, which states they have completed their annual training. These attestations are located at the end of the self-paced training document.
To take the self-paced training, go to the Model of Care Provider Training link on the Availity Portal.*
How to access the Custom Learning Center on the Availity Portal
- Log in to the Availity Portal.
- At the top of Availity Portal, select Payer Spaces and select the appropriate payer.
- On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
- In the Custom Learning Center, select Required Training.
- Select Special Needs Plan and Model of Care Overview.
- Select Enroll.
- Select Start.
- Once the course is completed, select Attestation and complete.
Not registered for Availity?
Have your organization’s designated administrator register your organization for Availity.
- Visit https://www.availity.com to register.
- Select Register.
- Select your organization type.
- In the Registration wizard, follow the prompts to complete the registration for your organization.
Q&A
What does it mean to be dual-eligible? What is a D-SNP?
The term dual eligible refers to people with Medicare coverage who also qualify for some type of state Medicaid
benefit — meaning that these members are eligible for both Medicaid and Medicare. These individuals may have higher incidence of chronic conditions, cognitive impairments and functional limitations. D-SNPs are special Medicare Advantage plans that enroll only dual-eligible people, providing them with more intensive coordination of care and services than those offered by traditional Medicare and Medicare Advantage plans.
What is a D-SNP model of care?
CMS requires Dual Special Needs Plans (D-SNPs) to have a model of care that describes how the D-SNP will administer key components of care management programs, including assessments and training. The model of care describes the unique needs of the population being served and how Anthem will meet these needs. Each D-SNP model of care is evaluated and scored by the NCQA and approved by CMS.
How does the model of care help physicians?
The three major components of the model of care, 1) the HRA, 2) Care Plan and 3) case manager, support providers in serving D-SNP members. Each member receives a comprehensive HRA that covers physical, behavioral and functional needs, and a comprehensive medication review. Health plan staff use the HRA information to create a Care Plan. Members with multiple or complex conditions may be assigned to a case manager.
These key model of care components identify and escalate potential problems for early intervention, ensure appropriate and timely follow-up, and help coordinate services across Medicare and Medicaid programs. Through the provider website, providers have access to review the Care Plan, the results of the HRA and other information to help manage care.
How are transitions of care managed?
Anthem case managers are involved in transitions of care (for example, discharge from hospital to home for those at high risk of readmission). Such transitions may trigger a reassessment and updates to the member’s Care Plan as needed. Following a discharge, case managers help ensure that D-SNP members see their PCP within a week and work through barriers that members experience in adhering to post-discharge medication regimens.
Who makes up the Interdisciplinary Care Team (ICT)?
Members of the ICT include any of the following: nurses, physicians, social workers, pharmacists, the member and/or the member’s caregiver, behavioral health specialists, or other participants as determined by the member, the member’s caregiver, or a relative of the member.
Providers who care for Anthem members are considered participants in the ICT and may be contacted by a case manager to discuss the member’s needs. The case manager may present recommendations concerning care coordination or other needs. The goal of the ICT is to assist providers in managing and coordinating patient care.
Do I have to become a Medicaid provider?
You are not required to become a Medicaid provider, but we recommend that you do. Even if you are only providing services covered by Medicare Part A or Part B to D-SNP members, we recommend that you attain a Medicaid ID because the state Medicaid agency may require this for the Medicare cost share.
Do I need a separate agreement or contract to see D-SNP members under Anthem?
No, if you see Medicare Advantage HMO members under Anthem, you are considered contractually eligible to see D-SNP members under Anthem.
How do I file claims for D-SNP members?
Claims for services to D-SNP members are filed the same way claims are filed for Medicare Advantage members under Anthem who are not part of D-SNP. Providers should ensure that the claim has the correct member ID (including the prefix).
How is the D-SNP member’s cost sharing handled?
D-SNP benefits are administered similarly to Medicare fee-for-service benefits. Upon receiving an explanation of payment (EOP) from Anthem, you should bill the state Medicaid agency or the applicable Medicaid MCO contracted with the state for processing of any Medicare cost sharing applied.
Medicare cost sharing is paid according to each state’s Medicaid reimbursement logic. Some states do not reimburse for Medicare cost sharing if the payment has already met or exceeded Medicaid reimbursement methodology.
Do I have to file claims twice for D-SNP members?
Yes, when you treat D-SNP members under Anthem, you will file the initial claim with Anthem and then bill the state Medicaid agency or the applicable Medicaid MCO contracted with the state for Medicare cost sharing processing. Please use the same electronic claim submission or address you currently use for Anthem claims filing.
Do D-SNP members have access to the same prescription drug formulary as other Medicare Advantage members under Anthem?
Yes, D-SNP members have coverage for the same prescription drugs listed on the Medicare Advantage prescription drug formulary for Anthem.
Please note that in California the tier placement may vary. Be sure to review the plan’s specific formulary for details on California D-SNPs as the formulary depends on the market.
What are D-SNP benefits for Anthem?
The D-SNP for Anthem members covers all Medicare Part A and Part B services and includes full Part D prescription coverage. Anthem also covers a range of preventive services with no cost sharing for the member. In addition, the D-SNP includes coverage for supplemental benefits that may include routine dental, vision and nonemergency medical transportation. A summary of the D-SNP benefits is posted on the provider website for Anthem members.
Any Medicaid benefits available to the member will be processed under their Medicaid coverage directly with the state or the Medicaid organization in which the member is enrolled.
Does the D-SNP use the same procedure codes and EDI payer codes?
Yes, the D-SNP uses the same procedure and payer codes and electronic filing procedures as other Medicare Advantage plans under Anthem.
Is the electronic data interchange (EDI) payer ID for this product the same as others?
Yes, all the claim submission information will be the same (this applies to EDI and paper). Providers must submit this information with the correct ID. Please check the EDI section of the provider website for the correct payer codes to use for your market.
* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.
ABSCRNU-0154-20 510237MUPENMU |