In 2019, Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. will launch an effort that will allow us to begin direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs), so they may begin billing their services under their own 10-digit National Provider Identifier (NPI).  This effort will impact all our lines of business:

• Anthem’s PAR/PPO health plans including the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP).

• Anthem HealthKeepers commercial plans including health plans purchased on or off the Health Insurance Marketplace (also known as the exchange).

• Anthem HealthKeepers Plus [Medicaid/FAMIS and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) plans].

• Medicare Advantage health plans.

As you may know, Virginia legislation went into effect on July 1, 2018, allowing nurse practitioners who meet certain work history requirements to begin practicing independently.  Licensed NPs and PAs currently can only bill for covered services under the supervision of the employing/supervising participating physician using that physician’s name and NPI number.  Direct contracting means NPs and PAs will be allowed to bill Anthem directly and the “incident to” guidelines will no longer apply.

How Anthem’s contracting process will work

We expect to begin the contracting effort sometime in the second quarter of 2019 by reaching out to network-participating providers we know currently employ NPs and PAs. Please note that the new participation agreement WILL NOT apply to certified nurse midwives, clinical nurse specialists, or psychiatric/mental health nurse practitioners, as they are contracted under a separate agreement.

Other than the provider type description, the participation agreement will contain all of the same provisions and obligations as our standard physician agreements.  The allowance schedule will be the same as the current standard physician allowance for our commercial and Medicaid agreements.  For Medicare Advantage, we will reimburse NP and PA services at 100 percent of the Medicare rate for these provider types.

Credentialing process

NPs and PAs will be required to be credentialed through Anthem in Virginia.  Therefore, NPs and PAs must complete the online application process through CAQH.  [To contact CAQH, dial 888-599-1771 (Monday -Thursday 7 a.m. – 9 p.m. ET; Friday 7 a.m. - 7 p.m. ET), or visit the CAQH website at http://www.caqh.org/ucd_physician_register.php.]

Benefits of direct contracting for NPs and PAs

This direct contracting and credentialing approach with NPs and PAs will allow us to include these providers on our provider directories as independent providers, and our members – your patients – can easily search our provider finder tool for NPs and PAs who participate with members’ health plans.

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

Looking ahead

Going forward, we’ll keep you informed of details and the date contracted NPs and PAs can begin billing directly for their services.  Watch for upcoming editions of our provider newsletter for further details.

Our provider newsletter, Network Update, is our primary source for providing important information to health care providers and professionals. Network Update is published monthly and is posted to our website on the Virginia provider section of anthem.com for easy 24/7 access.

Note that in addition to this newsletter and our website, we also use our email service – Network eUPDATE – to communicate new information. If you are not yet signed up to receive Network eUPDATEs, we encourage you to enroll now so you’ll be sure to receive all information we will be sending about billing, upcoming changes, coverage guidelines and other pertinent topics.

Reminder notifications sent via email

When you sign up, you’ll not only receive an email reminder for each newsletter posted online, you’ll  also be notified of other late breaking news and important information you’ll need when providing services and filing claims for our members. It’s easy to sign up – just select Virginia and access the provider home page.  There, you’ll find a link to register for our Network eUPDATE. 

On April 10, 2019, Anthem will offer a provider education webinar. Designed for our network-participating providers, the webinars address Anthem business updates and billing guidelines that impact your business interactions with us.

For your convenience, we offer these informative, hourly sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the first scheduled webinar for 2019 is:

• Wednesday, April 10, 2019, from 10 a.m. to 11 a.m. 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 April webinar, please check that you have received a fax confirmation or a confirmation from an Anthem representative to ensure we’ve received your registration form.  Please contact stacey.marsh@anthem.com if you need to confirm your registration.

Anthem Blue Cross and Blue Shield has designated Availity to operate and serve as your electronic data interchange (EDI) entry point or also called the EDI Gateway.  The EDI Gateway is a no-cost option for our providers who choose to submit their own EDI claims to Anthem.  If you prefer to use a clearinghouse or billing company, please work with them directly to ensure connectivity.

As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway. 

Do you already have an Availity User ID and Login? You can use the same login for your Anthem EDI transactions.  

• Log in to the Availity Portal and select Help & Training | Get Trained. In the Availity Learning Center, search the Catalog by key word “SONG” for live and on-demand resources created especially for you.

If you wish to become a direct a trading partner with Availity, the setup is easy.

• Use the Availity Welcome Application to begin the process of connecting to the Availity EDI Gateway for your Anthem EDI transmissions.

Need Assistance?

The Availity Quick Start Guide  will assist you with any EDI connection questions you may have.

835 Electronic Remittance Advice (ERA)

Please use Availity to register and manage account changes for ERA.

If you were previously registered to receive ERA, you must register using Availity to manage account changes.

Log into the Availity Portal and select My Providers | Enrollments Center | ERA Enrollment to enroll for 835 ERA delivery.

Electronic Funds Transfer (EFT)

To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.

If you have any questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 8 a.m. to 7:30 p.m. Eastern Time.

Have you been using the medical attachment tool on the Availity Portal to submit solicited medical records in support of a claim? You will now find these changes that were recently introduced:

• Select the “Attachment – New” option to submit medical records when Anthem has requested additional information to process a claim
• To send a solicited attachment, now find the “Send Attachment” link on the top, right side of the page
• Expanded file size – each attachment can be up to 40 MB with a total of 80 MB as the file size limit
• Ability to submit an itemized bill

If you have not tried the Medical Attachment tool to submit electronic documentation in support of a claim, now is the time to give it a try! This tool makes the process of submitting requested medical records simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Anthem) medical record attachments through the Availity Portal.

The existing Medical Attachment tool will not be removed from the Availity Portal immediately, but users are encouraged to connect to the ‘Attachment – New’ option for greater capabilities.

How to Access solicited Medical Attachments for Your Office

• Availity Administrator, complete these steps:

From My Account Dashboard, select Enrollments Center>Medical Attachments Setup, follow the prompts and complete the following sections:

1. Select Application>choose Medical Attachments Registration
2. Provider Management>Select Organization from the drop-down. Add NPIs and/or Tax IDs (Multiples can be added separated by spaces or semi-colons)
3. Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name

Using Medical Attachments

Availity User, complete these steps:

1. Log in to www.availity.com
2. Select Claims and Payments > Attachments-New >Send Attachment Tab
3. Complete all required fields of the form
4. Attach supporting documentation
5. Submit

Need Training?

To access additional training for this Availity feature:

1. Log in to the Availity Portal at www.availity.com
2. At the top of any Availity portal page, click Help and Training > Get Trained (Make sure you do not have a pop-up blocker turned on or the next page may not open.)
3. In the new window a list of available topics will open. Locate and click Medical Attachments
4. Under the Recordings section, click View Recording

One of the measures we report on is the Controlling High Blood Pressure (CBP) measure. This measure focuses on the percentage of members who are 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement year (2018).

What’s new for 2019?

• The Controlling High Blood Pressure (CBP) measure is no longer strictly a hybrid measure, which means that we review both medical records and claims. We can now use claims data to confirm both the diagnosis of hypertension as well as the blood pressure reading (CPT II codes).
• If you submit a claim using CPT II codes to document the blood pressure reading, we can now use that information, eliminating the need to request the medical record from you.
• Compliant BP is defined as <140/90 mm Hg for all members.
• Blood pressure readings taken from remote monitoring devices that are electronically submitted directly to the Provider can be utilized for the measure.

What do we need from you?

We need the last two office visit notes from 2018 with the blood pressure documented. Also, if the member was diagnosed with end stage renal disease, renal dialysis, renal transplant or pregnancy in 2018 please send that documentation as well.

Common chart deficiencies:

• Recheck elevated blood pressures readings and document all BP readings in the medical record.

For more information on HEDIS, visit the Anthem Provider Portal online at Anthem.com. Click on Providers > Click Polices and Guidelines > Select State>Scroll down and click View Med Policies and UM Guideline >Click Health & Wellness > Scroll down to Quality Improvement and Standards> and then scroll down on the page to HEDIS Information.

Thank you for your continued cooperation and support of HEDIS.

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

This March, anthem.com will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms, as seen below.

This first version of the new Provider Forms will keep growing and evolving in the coming months.

We will continue to keep you informed of upcoming changes to the public provider site, as we progress toward streamlining our Web platform and other business processes.

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

Each year, Anthem requests your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), in order to document and close the coding gaps. 

The CRA Program is specific to our Affordable Care Act (ACA) members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).

With our Retrospective Program, we focus on medical chart collection.  We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS).  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.

Analytics are performed internally on claims which do not have the ICD10 code for which we suspect a chronic condition.  These medical records will be requested, reviewed, and any additional codes abstracted can be submitted to CMS to increase our risk score values.

Anthem network providers -- may be PCPs, specialists, facilities, behavioral health, ancillary, etc. -- may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review.  These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf.  The vendors’ Web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management. 

We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2019, at the latest).  While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.

Electronic options that may make medical chart collection easier for providers:

• EMR Interoperability

• Remote/Direct Anthem access
• Vendor virtual or onsite visit
• Secure FTP

The goal of these electronic options is to both improve the medical record data extraction and the experience for Anthem’s network-participating hospitals, clinics and physician offices.  If you are interested in this type of set up or any other remote access options, please contact our Commercial Risk Adjustment Network Education Representative for Virginia via her email:  Alicia.Estrada@anthem.com 

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

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways this is done is by giving certain providers (“Payment Innovation Providers”) in Anthem’s various Payment Innovation Programs (such as Enhanced Personal Health Care, Bundled Payments, Medical Home programs, etc.) (the “Programs”) quality, utilization and/or cost information about the health care providers (“Referral Providers”) to whom the Payment Innovation Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in their getting more referrals from Payment Innovation Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

Providing this type of data, including comparative cost information, to Payment Innovation Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Payment Innovation Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers -- including any opportunities for improvement. For questions or support, please refer to your local market representative or care consultant.

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

If you have questions or feedback, please use this email link.

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

Group retiree membership and National Access Plus PPO

2019 risk adjustment provider training  

New provider learning opportunity: Put the AIM ProviderPortal to work for you  

New provider service phone number beginning January 1, 2019

75743MUPENMUB 01/24/2019

In 2019, Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will begin direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs), so they may begin billing their services under their own 10-digit National Provider Identifier (NPI).  This effort will begin during the second quarter of 2019 and impact all our lines of business, including Medicare Advantage. To learn more, please see Important Medicare Advantage Updates at anthem.com/medicareprovider.

 75743MUPENMUB 01/24/2019

The following revised clinical criteria will be effective May 1, 2019. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.

75743MUPENMUB 01/24/2019

Anthem updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433. The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:

• Group code patient responsibility (PR) will be assigned.

• Claim adjustment reason codes (CARCs) will include the following:

• Remittance advice remark codes (RARCs) will include the following:

Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.

75743MUPENMUB 01/24/2019

In 2019, Anthem is offering Dual Eligible Special Needs Plans (D-SNPs) to people who are eligible for both Medicare and Medicaid benefits or who are qualified Medicare beneficiaries (QMBs).  D-SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These plans are $0 premium plans.  Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments.  Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.  

Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in Q1 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.

Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.

For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.

75743MUPENMUB 01/24/2019

Click here for additional information about Update: Evaluation and management with Modifier 25.

Click here for additional information about the Modifier 25 Reimbursement Policy Update

Click here for additional information about Direct contracting for nurse practitioners and physician assistants in 2019

Click here for additional information about the Coding Spotlight: Cancer