Providers currently submit pre-service requests to AIM Specialty Health® (AIM) for outpatient diagnostic imaging services, cardiac procedures and sleep studies. As part of our ongoing quality improvement efforts, we want you to know that certain review requests require documentation that supports the clinical appropriateness of the request to be uploaded during the intake process.

When requested, providers must submit documentation from the patient’s medical record and/or participate in a pre-service consultation with an AIM physician reviewer. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. 

To help ensure compliance with the coding and billing of a claim submitted with the diagnosis of sepsis, Anthem Blue Cross and Blue Shield reviews clinical information – including lab results, treatment and medical management – in the medical records submitted.  In order to conduct the review accurately and consistently, our review process for the sepsis diagnosis applies coding and documentation guidelines, in addition to the updated and most recent sepsis 3 clinical criteria, published in the Journal of the American Medical Association (JAMA) February 2016. 

Clinicians and facilities should apply the sepsis 3 criteria when determining at discharge if their patients’ clinical course supports the coding and billing of a diagnosis of sepsis.  The claim may be subject to an adjustment in reimbursement when sepsis is found to be unsupported based on the sepsis 3 definition and criteria.

Beginning with dates of service on or after September 1, 2019, Anthem Blue Cross and Blue Shield’s policy language will be updated to only allow the lower level definitive code drug testing of one to seven drug class(es) (G0480) on the same day as presumptive services. Definitive codes for more than eight drug class(es) will be denied when billed on the same day with presumptive services.  Additionally, the definitive drug testing related coding section was expanded for clarification.

As we prepare for potential regulatory proposed standards for electronic attachments, Anthem Blue Cross and Blue Shield will be implementing what is called the X12 275 5010 version of electronic attachments transactions for claims. Standard electronic attachments will bring value to you by eliminating the need for mailing paper records and reduced processing time overall. 

Anthem and Availity will be piloting Electronic Data Interchange (EDI) batch electronic attachments with previously selected providers.  Both solicited and unsolicited attachments will be included in our pilots.

Solicited attachment

Provider sends a claim, and the payer determines there is insufficient information to process the claim.  Payer then sends the provider a request for additional information (currently via letter).  Provider can then send the solicited attachment transaction with the documentation requested to process the claim.

Unsolicited attachment

When the provider knows that the payer requires additional information to process the claim, the provider then sends the X12 837 claim with the “Paper Work Included” (PWK) segment tracking number.  Next, the provider sends the X12 275 attachment transaction with the additional information and includes the tracking number that was sent on the claim for matching purposes.

What you can do now

We encourage you to start having conversations with your Clearinghouse and/or Electronic Healthcare Records (EHR) vendor to determine their ability to set up the X12 275 attachment transaction capabilities. 

Look for more information about the general availability of this time-saving option later this summer and details on how to work with Anthem and Availity to send your attachments via electronic batch.

This quarter, Anthem will release more exciting enhancements to the public provider site – anthem.com. The next wave of changes includes a new Behavioral Health page that will provide easy and clear access to content and resources, including newsletters, collaboration documents, and other relevant information for providers. The image below illustrates the new Behavioral Health page.

We will continue to provide updates as we move forward with migrating content to the new provider pages.

Our Find A Doctor tool provides members enrolled with Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. the ability to search for in-network providers using the member portal at anthem.com. Find A Doctor currently offers multiple sorting options, such as sorting providers based on distance or name.

In May 2019, Anthem added a new sorting option to Find A Doctor. The new sorting option is called “Personalized Match” and is based on algorithms which use a combination of provider location, quality, cost results and member information to intelligently sort and display results for a member’s search. The sorting results take into account member factors such as the member’s medical conditions, and medications as well as provider factors such as areas of specialty, quality and efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures.

These member and provider features combine to generate a unique ranking of providers for each member conducting the search. Providers with the highest overall ranking within the search radius are displayed first with other providers displayed in descending order based on overall rank and proximity to the center of the search radius. Members will continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology will have no impact on member benefits.

Please note, the sorting option “Personalized Match” has been available on Care and Cost Finder since November 12, 2018.   

Additional information about Personalized Match

• Provider factors will be updated on a quarterly basis.

• Providers may review a copy online of the sorting methodology.

• If you have general questions about this sorting option in Find A Doctor and the Care and Cost Finder tool, please contact Provider Customer Service.

• If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors, you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.

Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions. 

Continuing our 2019 Commercial Risk Adjustment (CRA) reporting updates, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. request your assistance with respect to our CRA reporting processes.

As a reminder, there are two approaches that we take (Retrospective and Prospective) to improve risk adjustment reporting accuracy.  We are focusing on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), to close the documentation and coding gaps that we are seeing with our members enrolled in our Affordable Care Act (ACA) compliant plans.

This month, we’d like to focus on the Retrospective approach and the request to providers:

As a reminder from our March newsletter, the Retrospective program focuses on medical chart collection.  We continue to request members’ medical records to obtain undocumented HCC’s.  This particular effort is part of Anthem’s compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership.  The members’ medical record documentation helps support this data requirement.

2019 chart collection is about to begin

Retrospective chart collection begins in June and is known as Round 1.  Round 2 follows in November, which is our primary chase and largest volume of requests.  Round 3 is our last chart collection period and begins in January 2020.

Electronic options for chart collections

Submitting medical charts to payers is extremely burdensome and time consuming for your staff.  Utilizing an electronic option can alleviate the constraints on both staff resources and time.

1.) Remote/direct Anthem access

The most efficient electronic option is to allow the Anthem medical coder team to have direct connection access to your electronic medical record (EMR) system, so that we may retrieve the records ourselves.  Our team has collaborated with several providers and facilities to have direct access to their EMR system so we collect the charts within our own team.  This allows for no vendor interventions and fewer handoffs of the records. 

To address compliance concerns, please note that as a health plan, Anthem is a covered entity under the Health Insurance Portability and Accountability Act’s (HIPAA) Privacy Rule and by law must safeguard protected health information (PHI). 

Benefits of providing EMR direct connection access

• Your Medical Records staff resources would be minimally contacted for the charts we are requesting. (Depending on your EMR system, requests may also be handled electronically through “push” notifications).

• Your Medical Records staff will release only those records we request into the EMR queue for which we have access.

• Cost savings from less administrative impact on staff, as well as, no paper copying costs incurred.

• Better privacy/security measures for not having to save the medical record to a desktop and then copy/save before transmittal.

 2.) EMR Interoperability -- We have electronic options already in place for the following EMR systems:

• Allscripts (Opt in - signature required -- please work directly with the CRA Representative for your region).

• NextGen (Opt out - auto-enrolled).

• Athenahealth (Opt out - auto-enrolled).

• MEDENT (Opt in - signature required -- please work directly with the CRA Representative for your region).

 4. ) Secure FTP -- Set up directly with our vendors as a temporary secure FTP to transfer medical records.

If you are interested in any of these electronic options, or would like to grant our Anthem medical coders with direct access to your EMR, please contact our CRA Representative Alicia Estrada via email at:

• Alicia.Estrada@anthem.com

Thank you for your continued efforts with our CRA Program and expediting these medical chart collection requests that will begin soon.

Category:  Medicare


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

• Medicare risk adjustment provider training

• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ

• Group Retiree members and National Access Plus

• Prior authorization requirements for DME repair and portable oxygen  

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• Submitting corrected claims                                                            76313MUPENMUB

• 2019 Utilization Management Affirmative Statement                      70907MUPENMUB

Category:  Medicare


Anthem Blue Cross and Blue Shield (Anthem) has identified an increased trend in billing emergency department level 5 evaluation and management (E&M) codes. To ensure documentation meets or exceeds the components necessary to support its billing, beginning September 1, 2019, Anthem will initiate post-pay reviews for emergency department professional claims billed with level 5 99285 or G0384. Emergency department professional claims with the highest potential for up-coding will be selected.

Anthem will request documentation for identified claims. Professional reviews will evaluate the appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and Anthem guidelines. Reimbursement should be based on the emergency department E&M code the submitted documentation supports.

Please note, these coding reviews are not related to any prior notification reviews which examine the appropriate use of emergency departments for non-emergencies, nor do they include the examination of emergent versus non-emergent reasons patients utilize emergency room services.

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Category:  Medicare


You want what’s best for your patients’ health. When a patient doesn't follow your prescribed treatment plan, it can be a challenge. Approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed.¹  What can be done differently?

The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg, that is, the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline — the giant, often invisible, patient self-talk that may not get discussed aloud — can create a misalignment between patient and provider.

We’ve created an online learning experience to teach the skills and techniques that can help you navigate these uncharted patient waters. After completing the learning experience, you’ll know how to see the barriers, use each appointment as an opportunity to build trust and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence — and you’ll earn continuing medical education credit along the way.

Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

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¹  Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm.

Visit us online for additional information about the 2019 Utilization Management Affirmative Statement.

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, HealthKeepers, Inc. has adopted a Members’ Rights and Responsibilities Statement, which is located in the Anthem HealthKeepers Plus provider manual.

If you need a physical copy of the statement, call us at 1-800-901-0020.

Anthem HealthKeepers Plus utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://mediproviders.anthem.com/va/Pages/medical.aspx.

You can request a free copy of our UM criteria from our Medical Management department. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below. To access UM criteria online, go to https://mediproviders.anthem.com/va/Pages/medical.aspx.

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title and organization name when initiating or returning calls regarding UM issues.

You can submit precertification requests by:

• Calling us at 1-800-901-0020.
• Faxing to 1-800-964-3627.
• Visiting https://www.availity.com.

Have questions about utilization decisions or the UM process?

Call our Clinical team at 1-800-901-0020 Monday through Friday from 8:30 a.m. to 5:30 p.m. Eastern time.

Managing illness can be a daunting task for our Anthem HealthKeepers Plus members. It is not always easy to understand test results or know how to obtain essential resources for treatment or who to contact with questions and concerns.

HealthKeepers, Inc. is available to offer assistance in these difficult moments with our Complex Case Management program. Our care managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members, families, primary care physicians and caregivers. The Complex Case Management process utilizes the experience and expertise of the Case Coordination team to educate and empower our members by increasing self-management skills. The Complex Case Management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the Member Services number located on the back of their ID card. They will be transferred to a team member based on the immediate need. Physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about health care decisions and goals.

HealthKeepers, Inc. has identified an increased trend in billing emergency department level 5 evaluation and management (E&M) codes for Anthem HealthKeepers Plus members. To ensure documentation meets or exceeds the components necessary to support its billing, beginning September 1, 2019, HealthKeepers, Inc. will initiate post-pay reviews for emergency department professional claims billed with level 5 99285 or G0384. Emergency department professional claims with the highest potential for up-coding will be selected.

HealthKeepers, Inc. will request documentation for identified claims. Professional reviews will evaluate the appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and guidelines from HealthKeepers, Inc.. Reimbursement should be based on the emergency department E&M code the submitted documentation supports.

Please note that this communication relates to Anthem HealthKeepers Plus members.

You want what’s best for your patients’ health. When a patient doesn't follow your prescribed treatment plan, it can be a challenge. Approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed.¹   What can be done differently?

The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg, that is, the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline — the giant, often invisible, patient self-talk that may not get discussed aloud — can create a misalignment between patient and provider.

We’ve created an online learning experience to teach the skills and techniques that can help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence — and you’ll earn continuing medical education credit along the way.

Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

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

¹  Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm.

In an effort to help your patients maintain healthy blood sugar levels throughout pregnancy, reduce the probability that babies will be born weighing greater than 4,500 grams and, thereby, reduce the potential for Cesarean section, HealthKeepers, Inc. offers the Diabetes in Pregnancy program to support you and your patients. Eligible Anthem HealthKeepers Plus members in need of additional support may be enrolled in case management or care coordination and referred to a registered dietitian/nutritionist or certified diabetes educator.

The program includes providing meal planning assistance, physical activity interventions, weight gain interventions and monitoring blood sugars patterns. Pregnant members with diabetes are identified as early as possible and are targeted for outreach to engage in case management.

Diabetes in pregnancy

The common types of diabetes seen during pregnancy are type 1, type 2 and gestational diabetes, which is defined as diabetes first diagnosed in the second or third trimester of pregnancy that is clearly neither pre‑existing type 1 or type 2 diabetes. According to the Centers for Disease Control and Prevention, pre‑existing diabetes occurs in 1% to 2% of all pregnancies and gestational diabetes in 6% to 9% of pregnancies.¹

While pregnancy complicated with diabetes is a low percentage of all pregnancies, the risk of Cesarean sections are much higher in this population than for women with uncomplicated pregnancies. Sixty-four percent of women with pre-existing diabetes and 46% of women with gestational diabetes will have a Cesarean section compared to 32% of women who do not have diabetes during pregnancy.²

Whether diagnosed with type 1 or type 2 diabetes or diagnosed with gestational diabetes, blood sugar control is essential for the health and well-being of mother and infant. All types of diabetes put the baby at risk for macrosomia, making a Cesarean section delivery more likely.³  Research indicates that early lifestyle interventions, such as meal planning and physical activity, can help women reach healthy blood sugar targets more quickly and help them stay in target longer, thus reducing the risk of macrosomia in the infant.⁴

According to the American College of Obstetricians and Gynecologists (ACOG), Cesarean sections should be limited to babies of at least 4,500 grams in mothers with diabetes.⁵ 

For more information

If you have a patient who would benefit from speaking with a registered dietitian/nutritionist, certified diabetes educator or an obstetric case manager, please call Provider Services and ask for a case management referral for the member.

If you would like more information on the Diabetes in Pregnancy program, please contact

Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

¹Retrieved from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/ diabetes-during-pregnancy.htm.

² Agency for Healthcare Research and Quality Statistical Brief #102. Retrieved from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb102.jsp.

³The New England Journal of Medicine, May 8, 2008 vol. 358 no. 19. Hyperglycemia and Adverse Pregnancy Outcomes, The HAPO Study Cooperative Research Group. Retrieved from: https://www.nejm.org/doi/full/10.1056/NEJMoa0707943.

⁴ Effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-analysis of individual participant data from randomized trials. BMJ 2017;358:j3119 doi: 10.1136/bmj.j3119 (Published 19 July 2017).

⁵ACOG Obstetrics Care Consensus No.1, March 2014 (reaffirmed 2016), Safe Prevention of Primary Cesarean Delivery. Retrieved from: https://www.acog.org/Clinical-Guidance-and-Publications/ Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery.

Policy update

Professional anesthesia services

(Policy 06-019, effective 09/01/2019)

HealthKeepers, Inc. allows reimbursement of anesthesia services rendered by professional providers for covered Anthem HealthKeepers Plus members. Reimbursement is based upon:

• The reimbursement formula for the allowance and time increments in accordance with Department of Medical Assistance Services’ guidelines.

• Proper use of applicable modifiers.

Providers must report anesthesia services in minutes. Anesthesia claims submitted with an indicator other than minutes may be rejected or denied. Start and stop times must be documented in the member’s medical record. Anesthesia time starts with the preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal and continuous attendance. The reimbursement formula for anesthesia allowance is based on state guidelines.

Effective September 1, 2019, HealthKeepers, Inc. reimburses neuraxial epidural anesthesia services provided in conjunction with labor and delivery at a flat rate regardless of time involved.

Please refer to the Professional Anesthesia Services reimbursement policy for additional details at https://mediproviders.anthem.com/va.