We want to express our most sincere thanks for your dedication to serving the patients in your care. Please take a moment to watch this brief thank you message from Anthem Blue Cross and Blue Shield.

 

Like many, Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. are closely monitoring COVID-19 developments and what it means for our customers and our health care provider partners.  Anthem is working to help employers who are facing tough decisions on furloughing or reducing hours of their workforce.  Anthem is doing this by creating health insurance options that provide continued access to care. We continue to seek ways to support our customers by offering affordable alternate products with more flexibility while ensuring members can continue to see their established physicians.

 

Beginning June 1, 2020, Anthem is introducing our Anthem Health Access Plans for certain large group employers currently enrolled in our commercial lines of business only.

 

Anthem Health Access Plans cover the diagnosis and treatment for COVID-19 at 100% in accordance with Anthem guidelines. 

 

These benefit plans cover preventive care, unlimited telemedicine, office visits, prescriptions, and more.  In addition, members enrolled in these plans have digital ID cards and access to Sydney Health and Sydney Care (Anthem’s mobile app that runs on intelligence – as part of our digital strategy). 

 

These plans include some coverage exclusions or limitations. For information about eligibility, available benefits, and a list of exclusions, please visit Availity – our Web-based provider tool at www.availity.com. 

 

We are committed to working with our provider partners to help our members focus on their health and well-being. The new Health Access plans give your patients the needed coverage to manage their everyday health needs.

 

NOTE:  As with all eligibility and benefits inquiries on Availity, providers must have the member ID number (including the three-character prefix) and one or more search options of date of birth, first name and last name.

We are pleased to announce the release of Provider Contract and Fee Schedule Notifications.  Starting in mid-June, when Anthem notifies you of a statewide fee schedule update or provider contract amendment, you can log into Availity.com and download a digital copy of your content.

 

Over the last few months, we have been tirelessly working to streamline our business processes and believe that online Provider Contract and Fee Schedule Notifications will help improve your business interactions with Anthem even more.

 

Based on your feedback, we will no longer send large printed paper mailings or CDs in the mail.  In order to be ready for the digital downloads that start as early as June 15, you should log in to Availity, access the Provider Online Reporting application and register your authorized users. See details below on how to log in and access your reports.

Provider Online Reporting Reference Guide:  How to get started

 

This document will familiarize you with the Provider Online Reporting application found on the Availity Portal.  Using our web-based reporting application, you will be able to access regularly updated reports.

 

• For Availity Administrators – How to assign access

 

• For Users – How to navigate to the reports

 

If your organization is not currently registered for the Availity Portal, go to www.availity.com and select Register to complete the online application.

 

Your Administrator will need to take the following steps to assign access to Provider Online Reporting:

 

1. Assign the user role of Provider Online Reporting to your Availity access.
2. Select Payer Spaces in the navigation bar and then choose the payer tile that corresponds to the market.
3. Accept the User Agreement (once every 365 days).
4. On the Applications tab, select Provider Online Reporting.
5. Choose the organization and select Submit.
6. In the Provider Online Reporting application, register the tax ID by selecting Register/Maintain Organization.
7. Last, register users to the program by selecting Register Users and completing the required fields.

 

Accessing reports:

 

1. After logging in to Availity, select Payer Spaces in the navigation bar and then choose the payer tile that corresponds to the market.
2. Accept the User Agreement (once every 365 days).
3. On the Applications tab, select Provider Online Reporting.
4. Choose the organization and select Submit.
5. Select Report Search, choose the type of report, and then launch your program’s reporting application.

• For further assistance with Availity, please contact Availity Client Services at 1-800-282-4548.

• For other questions, contact your local contract advisor, consultant or Provider Relations representative.

 

507-0620-PN-VA

 

Anthem Blue Cross and Blue Shield is now using the Notification Center on the Availity Portal home page to communicate vital, time sensitive information. A Take Action call out and a red flag in front of the message will make it easy to see that there is something new requiring your attention.

 

The Notification Center is currently being used to notify you if there are payment integrity requests for medical records or recommended training in the Custom Learning Center. Select the Take Action icon to instantly access the custom learning recommended course.

 

For membership where the disputes tool is available, Availity will also post a message in the notification center when a dispute request you have submitted is finalized. Selecting the Take Action icon will allow easy access to your appeals worklist for details.

 

Viewing the Notification Center updates should be included as part of your regular workflow so you are always aware of any outstanding action items and can respond timely.

 

457-0620-PN-VA

The American Medical Association has an alphabetical listing of clinical conditions with which measures and CPT Category II codes are associated. The use of CPT Category II Codes and ICD-10-CM codes can reduce the number of medical records that we request during the HEDIS® medical record review season (January – May each year), thus reducing the administrative burden on physician offices.

 

Below are some commonly used codes for your convenience.

 

Measure	Description	CPT II Code	Exclusions
Comprehensive Diabetes Care	Whether or not  patient age 18-75 had screening or monitoring for diabetic retinal disease	·  2022F - Dilated retinal eye exam with interpretation by ophthalmologist or optometrist documented and reviewed with evidence of retinopathy ·  2023F - Dilated retinal eye exam with interpretation by ophthalmologist or optometrist documented and reviewed without retinopathy ·  3072F - Low risk for retinopathy (no evidence of retinopathy in the prior year)	·  Documentation of gestational diabetes or steroid-induced diabetes
Comprehensive Diabetes Care	For patient age 18-75, whether or not the most recent A1c level is controlled	·  3044F - Most recent hemoglobin A1c level less than 7.0% ·  3051F - Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0% ·  3052F Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0% ·  3046F Most recent hemoglobin A1c level greater than 9.0%	·  Report one of the four Category II codes listed and use the date of service as the date of the test, not the date of the reporting of the Category II code. ·  Documentation of medical reasons for not pursuing tight control of A1c level (i.e., steroid-induced or gestational diabetes, frailty and/or advanced illness)
Comprehensive Diabetes Care	Whether or not patient age 18-75 received urine protein screening or medical attention for nephropathy	·  3060F - Positive microalbuminuria test documented and reviewed ·  3061F - Negative microalbuminuria test result documented and reviewed ·  3062F - Positive macroalbuminuria test result documented and reviewed ·  3066F - Documentation of treatment for nephropathy	·  Documentation of gestational diabetes or steroid induced diabetes
Controlling High Blood Pressure	During the most recent visit, whether or not a patient age 18 years or older with a diagnosis of hypertension had: ·  a blood pressure reading less than 140 mm Hg systolic and less than 90 mm Hg diastolic OR ·  a blood pressure reading greater than or equal to 140 mm Hg systolic and less than 90 mm Hg diastolic, and prescribed 2 or more anti-hypertensive agents	·  3074F - Most recent systolic blood pressure < 130 mm Hg ·  3075F - Most recent systolic blood pressure 130 to 139 mm Hg ·  3077F - Most recent systolic blood pressure ≥ 140 mm Hg ·  3078F - Most recent diastolic blood pressure < 80 mm Hg ·  3079F - Most recent diastolic blood pressure 80 – 89 mm Hg ·  3080F - Most recent diastolic blood pressure ≥ 90 mm Hg ·  4145F - Two or more anti-hypertensive agents prescribed or currently being taken	·  Report one of the three systolic codes. ·  Report one of the three diastolic codes. ·  Documentation of reason(s) for not prescribing 2 or more anti-hypertensive medications: Medical (i.e., allergy, intolerant, postural hypotension or other reason) Patient (i.e., patient declined, or other patient reason) System (i.e., financial or other system reason)
Timeliness of Prenatal Care	Women who had live births between November 6 of the year prior to the measurement year and November 5 of the measurement year, who were continuously enrolled at least 43 days prior to delivery through 56 days after delivery	·  0500F - Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care. (Report also date of visit and, in a separate field, the date of the last menstrual period – (LMP))   ·  0501F - Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the LMP (Note: If reporting 0501F Prenatal flow sheet, it is not necessary to report 0500F Initial prenatal care visit)
Timeliness of Postpartum Care	Number of women in the denominator who had a postpartum visit on or between 21 days and 56 days after delivery. Denominator: Women who had live births between November 6 of the year prior to the measurement year and November 5 of the measurement year	·  0503F - Postpartum care visit

 

CPT® is a registered trademark of the American Medical Association Copyright 2020 American Medical Association. All rights reserved.

 

460-0620-PN-VA

As a provider, we understand you are committed to providing the best care for our members, including follow up appointments with members after a behavioral health (BH) inpatient stay. Since regular monitoring, follow up appointments and making necessary treatment recommendations or changes are all part of excellent care, we would like to provide an overview of the related HEDIS measure.

 

The Follow-up after Hospitalization for Mental Illness (FUH) HEDIS measure evaluates members (6 years and older) who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.

 

Two areas of importance for this HEDIS measure are:

 

• The percentage of behavioral health inpatient discharges for which the member received follow-up within 7 days after discharge.

 

• The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.

On a regular basis, we continue to monitor if these two consecutive follow-up appointments are being recommended and scheduled during the inpatient stay as part of discharge planning by the eligible behavioral health facilities (such as psychiatric hospitals, freestanding mental health facilities and acute  care hospitals with psychiatric units), as well as practicing behavioral health providers. 

Please consider the following for improving member outcomes for this measure:

 

1. Earliest follow up with a BH provider can help with continuing treatment after leaving the hospital.

 

2. With greater emphasis on care coordination, primary care providers can help facilitate the BH follow up appointments.

 

3. Weekend member discharges have shown to have very inconsistent follow up after discharge. Start discharge planning as soon as possible while members are inpatient so those who are discharged on weekends have scheduled follow up appointments.

 

4. In addition, other social determinants of health pertinent to the member such as housing, food, living in a rural area, transportation, job schedule, family and social support, child care, etc., can impact follow-up opportunities. Please address these needs and issues; refer to resources that can help support the member.

 

5. Social workers at the facilities can contact Anthem member services to learn if additional sources of assistance are available through Anthem such as case management and other referrals.

 

6. Telehealth services have been identified as part of follow up for this HEDIS measure available in certain parts of the country. Telehealth follow up may not be the best choice for everyone; however, not having a BH follow up for several weeks can be detrimental to the member can be a reason for relapse.

 

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

440-0620-PN-VA

Anthem is committed to collaborating with the provider community and offering flexible options to meet the needs of both the retrospective program and the prospective 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.

 

Retrospective Chart Requests

 

We appreciate that care providers across the country on the front line are committed to providing care during these challenging times, and as such, that care results in a visit where we may need the medical chart.  Medical chart collection must be done to obtain undocumented HCC’s on your patients in order to be compliant with the provisions of the Affordable Care Act, (ACA), that require our company to collect and report diagnosis code data for ACA membership.  This process will begin in June. In order to make these chart requests the most efficient for your office, we have electronic options available:

 

EMR Interoperability o   Allscripts (Opt in – signature required) o   NextGen o   Athenahealth o   MEDENT

Remote/Direct Anthem access

Vendor virtual or onsite visit (if the offices are opened back up from COVID-19 closures)

Secure FTP

 

The goal of these electronic options is to both improve the medical record data extraction and the experience for Anthem’s providers.  If you are interested in this type of set up or any other remote access options, please contact the Commercial Risk Adjustment Network Education Representative listed below.

 

Prospective Patient Outreach

(Incentive opportunity for properly completed health assessments:
Physicians are eligible to receive $100 for electronic submissions or $50 for paper in addition to the office visit reimbursement.)

 

We encourage members to form a relationship with their Primary Care Physician to complete a clinical assessment to ensure you have a clearer picture of your patients’ health.  Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions.  Previous Anthem news updates have given telehealth reimbursement guidance to follow when submitting the claim.

 

As a reminder, the May Provider News mentioned incentives for prospective program participation ($100 or $50).  We would be happy to meet and review incentive opportunities along with other flexible options for program participation and chart collection.  Please contact the Commercial Risk Adjustment network education representative listed below to set up a meeting.

 

Alicia.Estrada@anthem.com  

 

Thank you for your continued efforts with the CRA Program.

454-0620-PN-VA

Billing for Anthem HealthKeepers Plus member treatment can be complex, particularly when determining whether modifiers are required for proper payment. HealthKeepers, Inc.’s reimbursement policies and correct coding guidelines explain the appropriate use of coding modifiers. We would like to highlight the appropriate use of some commonly used modifiers.

 

Things to remember

 

• Review the CPT^® Surgical Package Definition found in the current year’s CPT Professional Edition. Use modifiers such as 25 and 59 only when the services are not included in the surgical package.

 

• Review the current CPT Professional Edition Appendix A — Modifiers for the appropriate use of modifiers 25, 57 and 59.

 

• When an evaluation and management (E&M) code is reported on the same date of service as a procedure, the use of the modifier 25 should be limited to situations where the E&M service is “above and beyond” or “separate and significant” from any procedures performed the same day.

 

• When appropriate, assign anatomical modifiers (Level II HCPCS modifiers) to identify different areas of the body that were treated. Proper application of the anatomical modifiers helps ensure the highest level of specificity on the claim and show that different anatomic sites received treatment.

 

• Use modifier 59 to indicate that a procedure or service was distinct or independent of other non-E&M services performed on the same date of service. The modifier 59 represents services not normally performed together, but which may be reported together under the circumstances.

 

If you feel that you have received a denial after appropriately applying a modifier under correct coding guidelines, please follow the normal claims dispute process and include medical records that support the use of the modifier(s) when submitting claims for consideration.

 

HealthKeepers, Inc. will publish additional articles on correct coding in provider communications.

 

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-0229-20

All associates who make utilization management (UM) decisions regarding members enrolled in Anthem HealthKeepers Plus are required to adhere to the following principles:

 

• UM decision making is based only on appropriateness of care and service and existence of coverage.

 

• We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support, or tend to support, denials of benefits.

 

• Financial incentives for UM decision makers do not encourage decisions that result in underutilization or create barriers to care and service.

 

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-0238-20

What are social determinants of health (SDOH)?

The World Health Organization (WHO) defines SDOH as “conditions in which people are born, grow, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequalities.” Capturing SDOH is becoming a necessary element of documentation.

Official coding guidelines for SDOH — new update

 

For 2019, the ICD-10-CM Official Guidelines for Coding and Reporting has been updated to allow reporting SDOH using the documentation of clinicians other than the patient’s provider. Most of the patient-specific SDOH information is captured by ancillary staff supporting the physicians.

 

 Do SDOH affect everyone?

 

The SDOH codes are very powerful tools in capturing the complexity of patient populations and allowing application of more accurate care. These conditions affect patient care. This publicly reported data will also improve capture of conditions that impact readmission reduction and mortality metrics.

 

SDOH diagnosis codes are one of the few tools that are shared collectively to measure and evaluate SDOH on a national scale.

 

How can providers address SDOH issues for the members?

 

• Using the CMS Screening Tool, which can be found at:
• https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf

 

• Submitting ICD-10-CM codes from Chapter 21 (Z00 to Z99) to identify issues that may impact member health via claims

 

Coding SDOH

 

SDOH codes are represented in ICD-10-CM code categories Z55 to Z65 — persons with potential health hazards related to socioeconomic and psychosocial circumstances. Codes in the Z55 to Z65 groupings include the following:

 

Code grouping	Examples
Z55 — Problems related to education and literacy	Illiteracy/low level of literacy, schooling unavailable
Z56 — Problems related to employment and unemployment	Unemployment, change of job, threat of job loss, military deployment status, sexual harassment on the job
Z57 — Occupational exposure to risk factors	Occupational exposure to noise, radiation, dust, tobacco, toxic agents in agriculture, extreme temperature
Z59 — Problems related to housing and economic circumstances	Homelessness, inadequate housing, discord with neighbors, extreme poverty, low income
Z60 — Problems related to social environment	Adjustment to lifestyle transition, problems living alone, acculturation difficulty, social exclusion and rejection
Z62 — Problems related to upbringing	Inadequate parental supervisions and control, parental overprotection, institutional upbringing
Z63 — Other problems related to primary support group, including family circumstances	Problems with spousal or other relationship, absence of a family member, alcoholism or drug addiction in family
Z64 — Problems related to certain psychosocial circumstances	Problems with unwanted pregnancy, problems related to multiparity, discord with counselors
Z65 — Problems related to other psychosocial circumstances	Conviction, imprisonment, victim of crime or terrorism

 

SDOH diagnosis code reference

 

Z55 problems related to education and literacy:

• Z55.0 — Illiteracy and low-level literacy
• Z55.1 — Schooling unavailable and unattainable
• Z55.2 — Failed school examinations
• Z55.3 — Underachievement in school
• Z55.4 — Educational maladjustment and discord with teachers and classmates
• Z55.8 — Other problems related to education and literacy
• Z55.9 — Problems related to education and literacy, unspecified

 

Problems related to employment and unemployment:

• Z56.0 — Unemployment, unspecified
• Z56.1 — Change of job
• Z56.2 — Threat of job loss
• Z56.3 — Stressful work schedule
• Z56.4 — Discord with boss and workmates
• Z56.5 — Uncongenial work
• Z56.6 — Other physical and mental strain related to work
• Z56.8 — Other problems related to employment:
• Z56.81 — Sexual harassment on the job
• Z56.82 — Military deployment status
• Z56.89 — Other problems related to employment
• Z56.9 — Unspecified problems related to employment

 

Occupational exposure to risk factors:

• Z57.0 — Occupational exposure to noise
• Z57.1 — Occupational exposure to radiation
• Z57.2 — Occupational exposure to dust
• Z57.3 — Occupational exposure to other air contaminants:
• Z57.31 — Occupational exposure to environmental tobacco smoke
• Z57.39 — Occupational exposure to other air contaminants
• Z57.4 — Occupational exposure to toxic agents in agriculture
• Z57.5 — Occupational exposure to toxic agents in other industries
• Z57.6 — Occupational exposure to extreme temperature
• Z57.7 — Occupational exposure to vibration
• Z57.8 — Occupational exposure to other risk factors
• Z57.9 — Occupational exposure to unspecified risk factor

 

Problems related to housing and economic circumstances:

• Z59.0 — Homelessness
• Z59.1 — Inadequate housing
• Z59.2 — Discord with neighbors, lodgers and landlord
• Z59.3 — Problems related to living in residential institution
• Z59.4 — Lack of adequate food and safe drinking water
• Z59.5 — Extreme poverty
• Z59.6 — Low income
• Z59.7 — Insufficient social insurance and welfare support
• Z59.8 — Other problems related to housing and economic circumstances
• Z59.9 — Problem related to housing and economic circumstances, unspecific

 

 Problems related to social environment:

• Z60.0 — Problems of adjustment to life-cycle transitions
• Z60.2 — Problems related to living alone
• Z60.3 — Acculturation difficulty
• Z60.4 — Social exclusion and rejection
• Z60.5 — Target of (perceived) adverse discrimination and persecution
• Z60.8 — Other problems related to social environment
• Z60.9 — Problem related to social environment, unspecified

 

Problems related to upbringing:

• Z62.0 — Inadequate parental supervision and control
• Z62.1 — Parental overprotection
• Z62.2 — Upbringing away from parents:
• Z62.21 — Child in welfare custody
• Z62.22 — Institutional upbringing
• Z62.29 — Other upbringing away from parents
• Z62.3 — Hostility towards and scapegoating of child
• Z62.6 — Inappropriate (excessive) parental pressure
• Z62.8 — Other specified problems related to upbringing:
• Z62.81 — Personal history of abuse in childhood:
• Z62.810 — Personal history of physical and sexual abuse in childhood
• Z62.811 — Personal history of psychological abuse in childhood
• Z62.812 — Personal history of neglect in childhood
• Z62.813 — Personal history of forced labor or sexual exploitation in childhood
• Z62.819 — Personal history of unspecified abuse in childhood
• Parent-child conflict:
• Z62.820 — Parent-biological child conflict
• Z62.821 — Parent-adopted child conflict
• Z62.822 — Parent-foster child conflict
• Other specified problems related to upbringing:
• Z62.890 — Parent-child estrangement NEC
• Z62.891 — Sibling rivalry
• Z62.898 — Other specified problems related to upbringing
• Z62.9 — Problem related to upbringing, unspecified

 

Other problems related to primary support group, including family circumstances:

• Z63.0 — Problems in relationship with spouse or partner
• Z63.1 — Problems in relationship with in-laws
• Z63.3 — Absence of family member:
• Z63.31 — Due to military deployment
• Z63.32 — Other absence of family member
• Z63.4 — Disappearance and death of family member
• Z63.5 — Disruption of family by separation and divorce
• Z63.6 — Dependent relative needing care at home
• Z63.7 — Other stressful life events affecting family and household:
• Z63.71 — Stress on family due to return of family member from military deployment
• Z63.72 — Alcoholism and drug addiction in family
• Z63.79 — Other stressful life events affecting family and household
• Z63.8 — Other specified problems related to primary support group
• Z63.9 — Problem related to primary support group, unspecified

 

Problems related to certain psychosocial circumstances:

• Z64.0 — Problems related to unwanted pregnancy
• Z64.1 — Problems related to multiparity
• Z64.4 — Discord with counselors

Problems related to other psychosocial circumstances:

• Z65.0 — Conviction in civil and criminal proceedings without imprisonment
• Z65.1 — Imprisonment and other incarceration
• Z65.2 — Problems related to release from prison
• Z65.3 — Problems related to other legal circumstances
• Z65.4 — Victim of crime and terrorism
• Z65.5 — Exposure to disaster, war and other hostilities
• Z65.8 — Other specified problems related to psychosocial circumstances
• Z65.9 — Problem related to unspecified psychosocial circumstances.

 

Resources

World Health Organization, About social determinants of health, found online at: https://www.who.int/social_determinants/sdh_definition/en.

 

ICD-10-CM Expert for Physicians, the complete official code set, Optum360, LLC. 2020.

 

AVA-NU-0240-20

We understand providers are committed to providing our members enrolled in Anthem HealthKeepers Plus with quality care, including follow-up appointments after a behavioral health (BH) inpatient stay. Since regular monitoring, follow-up appointments and making necessary treatment recommendations or changes are all part of quality care, we would like to provide an overview of the related HEDIS^® measure.

 

The Follow-up after Hospitalization for Mental Illness (FUH) HEDIS measure evaluates members 6 years and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.

 

Two areas of importance for this HEDIS measure are:

 

• The percentage of BH inpatient discharges for which the member received follow-up within seven days after discharge.

 

• The percentage of BH inpatient discharges for which the member received follow-up within 30 days after discharge.

 

On a regular basis, we continue to monitor if these two consecutive follow-up appointments are recommended and scheduled during the inpatient stay as part of discharge planning by the eligible BH facilities (such as psychiatric hospitals, freestanding mental health facilities and acute care hospitals with psychiatric units), as well as by practicing BH providers. 

 

Please consider the following for improving member outcomes for this measure:

 

• Earliest follow-up with a BH provider can help with continuing treatment after leaving the hospital.

 

• With greater emphasis on care coordination, PCPs can help facilitate the BH follow-up appointments.

 

• Weekend discharges have shown to have very inconsistent follow-up appointments after discharge. Start discharge planning as soon as possible during inpatient stay so those who are discharged on weekends have already scheduled follow-up appointments.

 

• In addition, facilitate discussion of other social determinants of health (such as housing, food, living in a rural area, transportation, job schedules, family and social support, child care, etc.) which can influence follow-up opportunities. Please address these needs and issues during the behavior health inpatient stay.

 

• Social workers at the facilities can contact Member Services for HealthKeepers, Inc. to learn if additional sources of assistance are available through case management or other referrals.

 

• Telehealth services may be considered as part of follow-up for this HEDIS measure if permitted in your state for BH follow-up and must be based on your clinical evaluation since this may not be the best choice of follow up for everyone.

 

However, it is also extremely important to note that telehealth services are subject to state and federal policies, coding and other requirements.

Please follow required guidelines and policies related to telehealth services specific to this measure.

 

• Our goal is continuity of care and treatment within seven days of inpatient BH discharge, followed by another visit within 30 days.

 

Please note this bulletin is for informational purposes only, as a resource for BH HEDIS follow up guidelines.

 

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.

 

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

AVA-NU-0242-20

Managing illness can be a daunting task for Medallion and FAMIS members enrolled in Anthem HealthKeepers Plus. It is not always easy to understand test results, to know how to obtain essential resources for treatment, or to know whom 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, PCPs and caregivers. The Complex Case Management process uses 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. In addition, 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.

 

If you have questions or would like additional information, you can contact us by phone at 1-800-901-0020. Case Management business hours are Monday through Friday, 8 a.m. to 6 p.m. ET.

 

AVA-NU-0243-20

Utilization management (UM) decisions for members enrolled in Anthem HealthKeepers Plus 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. To access UM criteria online, go to: 

https://mediproviders.anthem.com/va/Pages/medical.aspx 

Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below.

 

We are staffed with clinical professionals who coordinate our members’ care. Staff are available during business hours, Monday through Friday, 8:30 a.m. to 5 p.m. ET 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 Provider Services at 1-800-901-0020 or calling Anthem CCC Plus Provider Services at 1-855-323-4687.

 

• Faxing to 1-800-964-3627.

 

• Visiting https://www.availity.com.*

 

* Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

AVA-NU-0244-20

The delivery of reliable health care requires cooperation between Anthem HealthKeepers Plus 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 provider manual.

 

If you need a physical copy of the statement, call us at 1-800-901-0020 or Anthem CCC Plus Provider Services at 1-855-323-4687.

 

AVA-NU-0245-20

HealthKeepers, Inc. is the brand Virginians have trusted for more than 20 years.

 

Open enrollment for Central Virginia is April 19 to June 31, 2020. Your Medicaid patients receive all the same Medallion or FAMIS benefits, like doctor visits, prescriptions and our 24/7 NurseLine at no cost.

 

Anthem HealthKeepers Plus members also receive:

 

• No-cost GED testing.

• Rides to grocery stores and farmers’ markets.

• Weight Watchers^®* membership.

• Boys & Girls Club of America^®* memberships (where available).

 

Now including dental benefits for adults ages 21 to 64 — one cleaning, one exam and one bitewing X-ray per year.

 

Assist your patients in switching enrollment to the state’s largest Medicaid plan now

 

For more information, your patients can visit https://coverva.org, download the Virginia Medallion mobile app or call the Managed Care Helpline at 1-800-643-2273 (TTY 711) to switch to the Anthem HealthKeepers Plus plan.

 

* Weight Watchers® is an independent company providing weight management on behalf of HealthKeepers, Inc. Boys & Girls Club of America® is an independent company providing after-school programs for young people on behalf of HealthKeepers, Inc.

 

AVA-NU-0249-20

 

Effective for dates of service on and after August 16, 2020, the following updates for Anthem HealthKeepers Plus providers will apply to the AIM Specialty Health_®* (AIM) Sleep Disorder Management Clinical Appropriateness Guideline.

 

Sleep Disorder Management Clinical Appropriateness Guideline updates by section:

 

Bi-Level Positive Airway Pressure (BPAP) Devices: Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and alignment with Medicare requirements for use of BPAP

Multiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing: Style change for clarity Code changes: none

 

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

 

• Accessing 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 PA.

 

• Accessing AIM via the Availity Portal.*

 

• Calling the AIM Contact Center at 1-800-714-0040 from 7 a.m. to 7 p.m. ET.

 

What if I need assistance?

 

If you have questions related to AIM guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of HealthKeepers, Inc. Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.
AVA-NU-0251-20

 

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

 

MCG care guidelines – 24^th edition, Virginia

Billing for patient treatment can be complex, particularly when determining whether modifiers are required for proper payment. Anthem Blue Cross and Blue Shield (Anthem) reimbursement policies and correct coding guidelines explain the appropriate use of coding modifiers. We would like to highlight the appropriate use of some commonly used modifiers.

 

Things to remember

 

• Review the CPT^® Surgical Package Definition found in the current year’s CPT Professional Edition. Use modifiers such as 25 and 59 only when the services are not included in the surgical package.

 

• Review the current CPT Professional Edition Appendix A — Modifiers for the appropriate use of modifiers 25, 57 and 59.

 

• When an evaluation and management (E&M) code is reported on the same date of service as a procedure, the use of the modifier 25 should be limited to situations where the E&M service is “above and beyond” or “separate and significant” from any procedures performed the same day.

 

• When appropriate, assign anatomical modifiers (Level II HCPCS modifiers) to identify different areas of the body that were treated. Proper application of the anatomical modifiers helps ensure the highest level of specificity on the claim and show that different anatomic sites received treatment.

 

• Use modifier 59 to indicate that a procedure or service was distinct or independent of other non-E&M services performed on the same date of service. The modifier 59 represents services not normally performed together, but which may be reported together under the circumstances.

 

If you feel that you have received a denial after appropriately applying a modifier under correct coding guidelines, please follow the normal claims dispute process and include medical records that support the use of the modifier(s) when submitting claims for consideration.

 

Anthem will publish additional articles on correct coding in provider communications.

 

ABSCRNU-0127-20      509409MUPENMUB

Risk adjustment is the process by which the Centers for Medicare & Medicaid Services (CMS) reimburses Medicare Advantage plans, based on the health status of their members. Risk adjustment was implemented to pay Medicare Advantage plans more accurately for the predicted health cost expenditures of members by adjusting payments based on demographics (age and gender) as well as health status.

 

In 2020, Anthem Blue Cross and Blue Shield (Anthem) will work with Optum,* who is working with Ciox Health,* to request medical records with dates of service for the target year 2019 through present day.

 

Jaime Marcotte, Medicare Retrospective Risk Program Lead, is managing this project. If you have any questions regarding this program, please contact Jaime at jaime.marcotte@anthem.com or 1-843-666-1970.

 

Additional information, including an FAQ, will be available on the provider website at Important Medicare Advantage Updates.

 

* Optum and Ciox Health are independent companies providing medical record review services on behalf of Anthem Blue Cross and Blue Shield.
ABSCRNU-0140-20              509218MUPENMUB

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

 

Medicare Risk Adjustment and Documentation Guidance (General)

 

When: Offered the first Wednesday of each month from 1 to 2 p.m. ET

 

Learning objective: This onboarding training will provide an overview of Medicare Risk Adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) Model, with guidance on medical record documentation and coding.

 

Credits: This live activity, Medicare Risk Adjustment and Documentation Guidance, from January 8, 2020, to December 2, 2020, has been reviewed and is acceptable for up to one prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at https://bit.ly/2z4A81e.

*Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (Condition specific)

 

Series: Offered on the third Wednesday of every other month at 12 to 1 p.m. ET

 

Learning objective: This is a collaborative learning event with Enhanced Personal Health Care (EPHC) to provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.

 

Credits: This live series activity, Medicare Risk Adjustment Documentation and Coding Guidance, from January 15, 2020, to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

 

• Red Flag HCCs, part one: Training will cover HCCs most commonly reported in error as identified by CMS (chronic kidney disease stage 5, ischemic or unspecified stroke, cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina and other acute ischemic heart disease, end-stage liver disease) {Recording will play upon registration.}
• https://bit.ly/3ae9znc

• Red Flag HCCs, part two: Training will cover HCCs most commonly reported in error as identified by CMS (atherosclerosis of the extremities with ulceration or gangrene, myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcohol psychosis, lung and other severe cancers, diabetes with ophthalmologic or unspecified manifestation) {Recording will play upon registration.}
• https://bit.ly/3abKg52

• Neoplasms (recording link will be available later 2020.)

 

• Acute, Chronic and Status Conditions (July 15, 2020)
• https://bit.ly/2ygZfNR

• Diabetes Mellitus and Other Metabolic Disorders (September 16, 2020)
• https://bit.ly/2XQ9hjZ

• TBD - This Medicare Risk Adjustment webinar will cover the critical topics and updates that surface during the year (November 18, 2020)
• https://bit.ly/2xxjhUj

 

ABSCRNU-0141-20              509514MUPENMUB

Diabetes is a complex chronic illness requiring ongoing patient monitoring. The National Committee for Quality Assurance (NCQA) includes diabetes in its HEDIS^® measures on which providers are rating annually.

 

Since diabetes HbA1c testing is a key measure to assess for future medical conditions related to complications of undiagnosed diabetes, NCQA requires that health plans review claims for diabetes in patient health records.  The findings contribute to health plan Star Ratings for commercial and Medicare plans and the Quality Rating System measurement for marketplace plans. A systematic sample of patient records is pulled annually as part of the HEDIS medical record review to assess for documentation.

 

Which HEDIS measures are diabetes measures?

 

The diabetes measures focus on members 18 to 75 years of age with diabetes (type 1 and type 2) who had each of the following assessments:

 

• Hemoglobin A1c (HbA1c) testing

 

• HbA1c poor control (> 9%)

 

• HbA1c control (< 8%)

 

• Dilated retinal exam

 

• Medical attention for nephropathy

 

The American College of Physicians’ guidelines for people with type 2 diabetes recommend the desired A1c blood sugar control levels remain between 7% to 8%.¹

 

In order to meet the HEDIS measure HbA1c control < 8, providers must document the date the test was performed and the corresponding result. For this reason, report one of the four Category II codes and use the date of service as the date of the test, not the date of the reporting of the Category II code.

 

To report most recent hemoglobin A1c level greater than or equal to 8% and less than 9%, use 3052F. To report most recent A1c level less than or equal to 9%, use codes 3044F, 3051F and 3052F:²

 

1. If the most recent hemoglobin A1c (HbA1c) level is less than 7%, use 3044F.

 

2. If the most recent hemoglobin A1c (HbA1c) level is greater than or equal to 7% and less than 8%, use 3051F.

 

3. If the most recent hemoglobin A1c (HbA1c) level is greater than or equal to 8% and less than or equal to 9%, use 3052F.

 

Continued management and diverse pathways to care are essential in controlling blood glucose and reducing the risk of complications. While it is extremely beneficial for the patient to have continuous management, it also benefits our providers. As HEDIS rates increase, there is potential for the provider to earn maximum or additional revenue through Pay for Quality, Value-Based Services and other pay-for-performance models.³

 

Racial and ethnic disparities with diabetes

 

It is also important for providers to be aware of critical diabetes disparities that exist for diverse populations.

Compared to non-Hispanic whites:⁴

• African Americans, Hispanics, and American Indian/Alaska Natives have higher mortality rates from diabetes.

 

• African Americans and Hispanics have higher rates of complications from uncontrolled diabetes, including lower limb amputation and end-stage renal disease.

 

• More than half of Asian Americans and nearly half of Hispanic Americans with diabetes are undiagnosed.⁵

 

• Asian Americans are at risk for type 2 diabetes at a lower body mass index (BMI); therefore, diabetes screening at a BMI of 23 is recommended.⁶

 

Sources include:

 

• Diabetes prevalence:
  • 2015 State Diagnosed Diabetes Prevalence, https://www.cdc.gov/diabetes/data.
  • 2012 State Undiagnosed Diabetes Prevalence, Dall et al., “The Economic Burden of Elevated Blood Glucose Levels in 2012”, Diabetes Care, December 2014, vol. 37.

• Diabetes incidence:
  • 2015 State Diabetes Incidence Rates, https://www.cdc.gov/diabetes/data.

• Cost:
  • American Diabetes Association, “Economic Costs of Diabetes in the U.S. in 2017”, Diabetes Care, May 2018.

• Research expenditures:
  • 2017 National Institute of Diabetes and Digestive and Kidney Diseases funding, https://projectreporter.nih.gov.
  • 2017 CDC diabetes funding, https://www.cdc.gov/fundingprofiles.

 

¹ https://www.medicalnewstoday.com/articles/321123#An-A1C-of-7-to-8-percent-is-recommended

² https://www.ama-assn.org/system/files/2020-01/cpt-cat2-codes-alpha-listing-clinical-topics.pdf

³ https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.html

⁴ Office of Minority Health. Minority Population Profiles:  https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlID=26

⁵ U.S. Department of Health and Human Services, National Institutes of Health. (2015, September 8), More than half of Asian Americans with diabetes are undiagnosed. Retrieved from https://www.nih.gov/news-events/news-releases/more-half-asian-americans-diabetes-are-undiagnosed.

⁶ ADA; NCAPIP; AANHPI DC; Joslin Diabetes Center Asian American Diabetes Initiative. (2015, September). Screen at 23. Retrieved from http://screenat23.org/wp-content/uploads/2015/10/Screenat23package-1.pdf.

  

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
ABSCRNU-0145-20              509427MUPENMU

Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Specialty Health_®* (AIM) Sleep Disorder Management Clinical Appropriateness Guideline.

 

Sleep Disorder Management Clinical Appropriateness Guideline updates by section:

 

• Bi-Level Positive Airway Pressure (BPAP) Devices: 
  • Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and alignment with Medicare requirements for use of BPAP

 

• Multiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing:
  • Style change for clarity
  • Code changes: none 

 

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

 

• Accessing AIM’s ProviderPortal_SM directly at com. Online access is available 24/7 to process orders in real time, and is the fastest and most convenient way to request PA.

 

• Accessing AIM via the Availity Portal.*

 

• Calling the AIM Contact Center at 1-800-714-0040 from 7 a.m. to 7 p.m. ET.

 

What if I need assistance?

 

If you have questions related to guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines.

 

* AIM Specialty Health is an independent company providing some utilization review 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.
ABSCRNU-0146-20                             509517MUPENMU

 

Please continue to check Important Medicare Advantage Updates for the latest Medicare Advantage information, including:

Acquisition of Beacon Health Options
BSCRNU-0134-20      509210MUPENMUB

 

MCG care guidelines — 24th edition 
ABSCRNU-0136-20      508666MUPENMUB