Anthem Blue Cross and Blue Shield would like to share some recent enhancements to the online site for our monthly provider publication – Provider News.

Article categories – such as “Administrative,” “Medicaid,” “Products and Programs” and so on – are now appearing directly under the article title on the website and in PDFs.  (This will help differentiate between commercial and government business content.)  Please see the illustration below.

We’ve also enhanced the look and feel of PDFs for individual articles and publications for better readability and printing.  Within PDFs for publications, you’ll find:

 

• A table of contents

• A bold line separating each article

• The URL for each article is included so you can access online if desired

• Attachments will show if appropriate

 

We hope you find these changes helpful, as we continue to work to improve our provider communications vehicle and to make the tool easier to use. 

Some professional (837P/HCFA-1500) claims for services rendered to non-Anthem Blue plan members at retail health locations are being reported with a Place of Service that does not reflect a retail health clinic location. Specifically, for services rendered at a retail health location, some providers are submitting values for Office (11) or Urgent Care Facility (20) instead of the value of Walk-in Retail Health Clinic (17). Reporting Place of Service as 11 or 20 can cause claims to process incorrectly, and thus result in the need for claim adjustments and rework for providers.

 

If your practice is a Walk-in Retail Health Clinic, please remind your coding staff to report the most accurate Place of Service, Walk-in Retail Health Clinic (17), for professional claims when submitting claims for non-Anthem members.

 

 

Patient360 is a real time dashboard you can access through the Availity Portal that gives you a robust picture of your Anthem patient’s health and treatment history and will help you facilitate care coordination.

 

If an Anthem patient has a Care Gap Alert, your medical practice can locate Active Alerts on the Member Summary page of the Patient360 application.

What’s new 

 

Medical providers now have the option available on Patient360 to include feedback for each gap in care that is listed on the patient’s active alerts.

 

However, to be able to access the Care Gap Alert Feedback, you will need to provide an individual national provider identifier (NPI)   number. If you select a NPI from the Express Entry menu, the feedback options will not be available.

 

 

Once you have completed all the required fields, you will land on the Member Summary page of the application. To provide feedback, select the Resolution Health Index (RHI) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry screen. You can choose the feedback menu option that applies to your patient’s care gap.

 

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

 

First, you need to be assigned to the Patient360 Role which your Availity Administrators can locate within the Clinical Roles options.

 

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

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

 

Important reminders

 

• 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 year’s 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 can help 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 applying a modifier appropriately under correct coding guidelines, please follow the normal claims dispute process and include medical records that support the usage of the modifiers when submitting claims for consideration.

 

We will be publishing additional articles on correct coding in upcoming editions of Provider News.

 

 

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 impacts our 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) under the Affordable Care Act (ACA).

 

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 members enrolled in ACA-compliant health insurance plans.  The members’ medical record documentation helps support this data requirement.

 

Analytics are performed internally on claims which do not have the ICD-10 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 assess our risk score values.

 

Anthem network providers – may be PCPs, specialists, facilities, behavioral health, ancillary, and so on – may receive letters from vendors such as Inovalon, Verscend, Ciox, Sharecare, and Episource 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. 

 

We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2020).  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:

 

• Electronic Medical Records (EMR) Interoperability
  

 

Allscripts (Opt in -- signature required to allow for remote review)

NextGen (Opt out -- auto-enrolled)

Athenahealth (Opt out -- auto-enrolled)

MEDENT

 

 

• 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 – Alicia.Estrada@anthem.com.

 

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

 

Code only confirmed cases

According to ICD-10-CM coding guidelines for Chapter One, code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of positive serology or culture for HIV. The provider’s diagnostic statement that the patient is HIV positive or has an HIV-related illness is sufficient.

Status	ICD-10-CM code
Asymptomatic HIV	Assign code Z21 — Asymptomatic human immunodeficiency virus [HIV] infection status when the patient without any documentation of symptoms is listed as being ‘HIV positive’, ‘known HIV’, ‘HIV test positive’ or similar terminology. Assign code B20 — Human immunodeficiency virus [HIV] disease on the claim when the term AIDS is used, when the patient is being treated for HIV-related illness or when the patient is described as having any active HIV-related condition.
Patients with inconclusive HIV serology	Assign code R75 — Inconclusive laboratory evidence of human immunodeficiency virus [HIV] when the patient’s record is documented with inconclusive HIV serology, but there is no definitive diagnosis or manifestations of the illness.
Previously diagnosed HIV-related illness	Code B20 if you document a patient as having had any known prior diagnosis of an HIV-related illness — Z21 is no longer reported. If the patient develops an HIV-related illness, they should be assigned code B20 on every subsequent admission/encounter.
HIV infection in pregnancy, childbirth and the puerperium	Assign code O98.7 — Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium first when a patient presents for treatment of an HIV-related illness during pregnancy, childbirth or the puerperium followed by code B20. Also assign additional code(s) for HIV-related illness(es). Keep in mind that codes from Chapter 16 take priority when sequencing codes on the claim. If a patient with asymptomatic HIV infection status presents for a routine visit during pregnancy, childbirth or the puerperium, the correct code assignment would be O98.7 followed by code Z21.

 

Assign code B20 for all types of HIV infections, which may be described by a variety of terms including:

• AIDS

• Acquired immune deficiency syndrome

• Acquired immunodeficiency syndrome

• AIDS-related complex (ARC)

• AIDS-related conditions

• HIV infection, symptomatic

Testing for HIV:

• Assign code Z11.4 — Encounter for screening for human immunodeficiency virus [HIV] when seeing a patient with no prior diagnosis of HIV infection or positive HIV-status to determine their HIV status.

 

• Code the signs and symptoms when seeing a patient with signs or symptoms for HIV testing. If you provide counseling during the encounter, assign additional code:  Z71.7 — Human immunodeficiency virus [HIV] counseling.

 

• Assign code Z71.7 if a patient’s test results are negative for HIV.

 

• Assign code Z72.8 if a patient is known to be in a high-risk group for HIV infection. Other problems related to lifestyle can be assigned as an additional code.

 

 

Major HIV-related conditions
HIV-related condition	ICD-10-CM code
Pneumonia, unspecified organism	J18.9
Tuberculosis of other sites	A18.89
Sepsis, unspecified organism	A41.9
Candida stomatitis (thrush)	B37.0
Herpes zoster (any site)	B02.9
Encephalopathy, unspecified	G93.40

Other HIV-related conditions
Tinea cruris	B35.6
Anemia, unspecified	D64.9
Underweight	R63.6
Acute lymphadenitis	L04.9
Arthropathy, unspecified	M12.9
Splenomegaly, not elsewhere classified	R16.1
Weakness	R53.1

 

 HIV/AIDS prevention

The CDC works with other federal agencies, state and local health departments, national organizations, and other entities to reduce the spread of HIV in the United States. This work covers several components:

• Behavioral interventions — These interventions ensure people have the information, motivation and skills necessary to reduce the risk of infection.

 

• HIV testing — Testing is critical to prevent the spread of HIV.

 

• Treatment and care — Treatment and care enable individuals with HIV to live longer, healthier lives.

The CDC remains on the forefront of pursuing high-impact prevention. This approach is designed to maximize the impact of prevention efforts for all Americans at risk for HIV infections and the CDC is aligning its efforts with the first National HIV/AIDS Strategy for the United States (NHAS). The Division of HIV/AIDS Prevention has developed a strategic three-year plan for 2017 to 2020 with the goal of one day achieving a future free of HIV.

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.

 

Resources:

 

1. ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2019.

 

http://www.cdc.gov: HIV/AIDS.

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

 

 Benefits update for Special Supplemental Benefits for the Chronically Ill

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 Prior authorization requirements for CardioMEMS

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Beginning January 1, 2020, patients using non-preferred products with a high patient cost share are now contacted about the availability of lower patient cost share preferred alternatives. If the patient is interested in switching, we will call or fax their provider who can determine whether the preferred alternative is clinically appropriate. This is strictly informational and not a substitute for physician‑directed medical evaluations or treatments.

 

A list of the included non-preferred products and corresponding preferred alternatives are listed here. 

 

Non-preferred products	Preferred alternative(s)
Aciphex DR	omeprazole pantoprazole
Actos	pioglitazone HCL
Advair Diskus	fluticasone-salmeterol Wixela Inhub
Aggrenox	aspirin-dipyridamole ER
Ampyra ER	dalfampridine ER
Breo Ellipta	fluticasone-salmeterol Wixela Inhub
Cambia	diclofenac sumatriptan
chlorzoxazone	cyclobenzaprine
Coumadin	warfarin
Crestor	rosuvastatin
Dexilant	omeprazole pantoprazole
Dilantin	phenytoin
Diovan HCT	valsartan/hydrochlorothiazide
Duexis	ibuprofen & famotidine
Dymista	fluticasone & azelastine
Epzicom	abacavir-lamivudine
Evzio	naloxone HCL
Farxiga	Jardiance
Gleevec	imatinib
Glumetza	metformin ER (generic Glucophage XR)
Incruse Ellipta	Spiriva
Invega	paliperidone ER
Invokana	Jardiance
Jublia	ciclopirox
Kerydin	ciclopirox
Kombiglyze	Janumet XR
Lamictal	lamotrigine
Lanoxin	digoxin
Lipitor	atorvastatin
Livalo	atorvastatin lovastatin pravastatin simvastatin
Lovaza	omega-3 acid ethyl esters
Mestinon	pyridostigmine
metformin ER (generic Glumetza)	metformin ER (generic Glucophage XR)
metformin ER OSM (generic Fortamet)	metformin ER (generic Glucophage XR)
Mirapex	pramipexole
Myrbetriq ER	oxybutynin
Nexium	omeprazole pantoprazole
Nilandron	nilutamide
Novolin N	Humulin N
Novolog	Humalog
omeprazole-bicarbonate	omeprazole pantoprazole
Onfi	clobazam
Onglyza	Januvia
Pennsaid	meloxicam
Protonix	omeprazole pantoprazole
Renvela	sevelamer
Requip	ropinirole
Restasis	Xiidra
Soolantra	metronidazole azelaic acid
Symbicort	fluticasone-salmeterol Wixela Inhub
Synthroid	levothyroxine
Tresiba	Basaglar Lantus Toujeo
Trokendi XR	topiramate
Tudorza Pressair	Spiriva
Vasotec	enalapril
Vimovo	naproxen & omeprazole
Wellbutrin XL	bupropion XL
Xalatan	latanoprost
Xenazine	tetrabenazine
Zestoretic	lisinopril/hydrochlorothiazide
Zestril	lisinopril
Zileuton ER	montelukast

 

 

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Anthem Blue Cross and Blue Shield (Anthem) provides benefits for covered services rendered by nurse practitioners (NPs) and physician assistants (PAs) when operating within the scope of their license. Our policy states that these mid-level practitioners are required to file claims using their specific NPI number — not that of the medical physician.

 

We will continue to monitor this area of concern through medical chart review and data analysis. Billing noncompliance can be considered a contract breach.

 

Anthem recognizes the quality of care delivered to our members can be improved by the proper use of NPs and PAs. This notice is in no way intended to discourage their proper use, but rather to clearly define how services should be appropriately billed.

 

Thank you for your continued participation. Should you have any questions, please call the Provider Services number located on the back of the member’s card.

 

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Your patient’s current supplemental benefit for personal home helper has been re-authorized for 2020. For billing in 2020, use the new authorization number. For more information or to view the new authorization number, sign into the Availity Portal or call Provider Services at 1-800-499-9554.

 

Submit claims electronically through Availity

 

Availity is well known as a Web portal and claims clearinghouse, but they are much more. Availity also functions as an electronic data interchange (EDI) gateway for multiple payers and is the single EDI connection for Anthem. It will allow you to submit claims electronically, verify pre-authorization and member information, check claims status, and much more. 

 

To get started, go to https://www11.anthem.com/edi and select your state.

 

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Effective April 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will transition the utilization management of our Outpatient Rehabilitation Program to AIM Specialty Health® (AIM). AIM is a specialty health benefits company. The Outpatient Rehabilitation Program includes physical, occupational and speech therapy services. Anthem has an existing relationship with AIM in the administration of other programs.

 

This relationship with AIM will enable Anthem to expand and optimize this program, further ensuring that care aligns with established evidence-based medicine. AIM will follow the clinical hierarchy established by Anthem for medical necessity determination. Anthem makes coverage determinations based on guidance from CMS, including national coverage determinations, local coverage determinations, other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.

 

AIM will continue to use criteria documented in Anthem clinical guidelines CG.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://medicalpolicies.amerigroup.com/am_search.html.

 

Detailed prior authorization requirements are available online https://www.availity.com by accessing the Precertification Lookup Tool under Payer Spaces. Contracted and noncontracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.

 

Prior authorization review requirements

 

For services to be rendered for dates of service from October 1, 2019, through March 31, 2020, no prior authorization is required for outpatient rehabilitation services. For these service dates, in addition to all other rights Anthem has under our provider contract and law, Anthem and AIM will continue to monitor claims history and utilization trends and will validate provider and member information.

 

AIM will facilitate training sessions to provide an overview of the program and demonstrate the AIM ProviderPortalSM. Please access the AIM Rehabilitation Provider Portal to register for an upcoming session.

 

For services that are scheduled on or after April 1, 2020, providers must contact AIM to obtain prior authorization. Beginning March 19, 2020, providers will be able to contact AIM for prior authorization of services to take place on or after April 1, 2020. Providers are strongly encouraged to verify that they have obtained prior authorization before scheduling and performing services.

 

How to place a review request

 

You may place a prior authorization request online via the AIM ProviderPortal. This service is available 24/7 to process requests in real time using clinical criteria. Go to www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday through Friday 7 a.m. to 7 p.m. Central time.

 

For more information

 

For resources to help your practice get started with the Outpatient Rehabilitation Program, go to www.aimproviders.com/rehabilitation. For portal login Issues, call 1-800-252-2021.

 

The AIM website provides access to useful information and tools, such as order entry checklists, clinical guidelines and a FAQ.

 

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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 are topics we’re addressing in this edition:

 

Electronic visit verification claims receiving denial code Z79

 

Revision to evaluation and management services — over-coded services postponed

 

Update: electronic visit verification transition period extended

 

HealthKeepers, Inc. is committed to providing the educational and training resources our Anthem HealthKeepers Plus health care professionals need.

 

Approximately 2.5 million Americans visit outpatient clinical settings for low back pain each year. Approximately 75% of adults will experience low back pain at some time in their lives. In any three-month period, approximately 25% of Americans will experience at least one day of back pain.

 

Evidence shows that unnecessary or routine imaging (X-ray, MRI, CT scans) for low back pain is not associated with improved outcomes. It also exposes patients to unnecessary harms such as radiation and further unnecessary treatment. For the majority of individuals who experience severe low back pain, pain improves within the first two weeks of onset.

 

Avoiding imaging for patients when there is no indication of an underlying condition can prevent unnecessary harm and unintended consequences to patients and can reduce health care costs.

 

Joint guidelines from the American College of Physicians (ACP) and the American Pain Society state that clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain and should reserve imaging for patients with severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical examination.

 

Potential red flags to consider earlier imaging are easily remembered by an acronym: TUNA FISH.

 

T     Trauma or tuberculosis

U     Unexplained loss of weight

N     Neurological deficits, bowel and bladder incontinence

A     Age < 20 and ≥ 55

 

F     Fever

I      Intravenous drug use

S     Steroid use or immunosuppressed

H    History of cancer

 

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.

 

 REFERENCES:

¹ Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians Ann Intern Med. 2017; 166(7):514-530

 

² Use of Imaging Studies for Low Back Pain (LBP) HEDIS Measures and Technical Resources. https://www.ncqa.org/hedis

 

 

Effective February 1, 2020, HealthKeepers, Inc. requires prior authorization (PA) for certain physical therapy services for Anthem HealthKeepers Plus members.

 

We recommend that providers visit https://mediproviders.anthem.com/va/pages/pluto.aspx to review the list of services and service categories that currently require PA. Should providers need clarification regarding whether a specific code or service requires PA, they should call the Utilization Management contact numbers below.

 

The list of services requiring PA will be updated as needed.

 

Providers are responsible for verifying eligibility and benefits for Anthem HealthKeepers Plus members before providing services. Except for an emergency, failure to obtain PA may result in denial of reimbursement.

 

Requesting PA

 

To request PA, report a medical admission or ask questions regarding PA, contact the Utilization Management department:

 

• Phone: 1-800-901-0020

 

• Fax: 1-800-964-3627

Regardless of PA requirement, all services must be medically necessary to be covered. To access our medical necessity criteria, visit https://www11.anthem.com/search.html.

 

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.

HealthKeepers, Inc. has developed a Social Determinants of Health (SDOH) initiative to proactively outreach members enrolled in Anthem HealthKeepers Plus who need support for social, economic or environmental circumstances. Our goal is to identify members with social needs and link them with available resources. With your help, we can work together to address these important issues.

 

What are Social Determinants of Health?

 

Social Determinants of Health are conditions that affect a wide range of health, functioning, and quality of life outcomes and risks.Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, healthy foods, employment, and more.

 

More information:

 

• “Resources that enhance quality of life can have a significant influence on population health outcomes.” Office of Disease Prevention and Health Promotion

 

• “There has been increased recognition that improving health and achieving health equity will require broader approaches that address social, economic, and environmental factors that influence health.” Kaiser Family Foundation

 

How can providers partner with HealthKeepers, Inc. to address SDOH issues for Anthem HealthKeepers Plus members?

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

 

• Use our Community Resource Link to assist members in finding resources: https://mss.anthem.com/va/support/community-resources.html.

 

• We are asking all providers to submit ICD-10-CM codes from Chapter 21 (Z00 to Z99) to identify issues that may impact member health via claims. Codes specifically related to SDOH issues are located on the SDOH Diagnosis Code Reference Sheet (Z Codes).

 

SDOH-related benefits HealthKeepers, Inc. offers for Anthem HealthKeepers Plus members:

 

Value-added benefit	CCC Plus	Medallion
Air Purifier	✓	✓
Grocery Store Transportation	✓	✓
Healthy Rewards	✓	✓
Meal Program	✓	✓
Smartphone	✓	✓
Sports Physicals		✓
Stroller, Diapers and Books for Babies		✓
Boys & Girls Club Membership		✓
GED Program		✓

For a complete listing of these and other benefits, visit https://mss.anthem.com/va/virginia-home.html.

 

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.

 

References

 

• Kaiser Family Foundation (2018). Beyond health care: the role of social determinants in promoting health and health equality. Retrieved from https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity

 

• Office of Disease Prevention and Health Promotion, Social Determinants of Health, Retrieved from: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

 

• Centers for Medicare & Medicaid Services: The Accountable Health Communities Health-Related Social Needs Screening Tool. Retrieved from: https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf

 

HealthKeepers, Inc. provides benefits for covered Anthem HealthKeepers Plus services rendered by nurse practitioners (NPs) and physician assistants (PAs) when operating within the scope of their license. Our policy states that these mid-level practitioners are required to file claims using their specific NPI number — not that of the medical physician.

 

We will continue to monitor this area of concern through medical chart review and data analysis. Billing noncompliance can be considered a contract breach.

 

HealthKeepers, Inc. recognizes the quality of care delivered to our members can be improved by the proper use of NPs and PAs. This notice is in no way intended to discourage their proper use, but rather to clearly define how services should be appropriately billed.

 

Thank you for your continued participation. 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.

HealthKeepers, Inc. offers additional health care benefits to our Anthem HealthKeepers Plus members who are also eligible for Medicare coverage. These members may now default enroll into our Anthem MediBlue Dual Advantage (HMO D-SNP) Plan, a special Medicare Advantage plan for people with both Medicare and full Medicaid benefits.

 

The Anthem MediBlue Dual Advantage (HMO D-SNP) Plan is a dual-eligible special needs plan available only to people that have both Medicaid and Medicare. Besides covering medical services, the plan includes Medicare prescription drug coverage, so members do not need to select a separate drug plan to get their prescriptions. We help coordinate all parts of member health coverage and services — Medicare, Medicaid and prescription drugs.

 

The Anthem MediBlue Dual Advantage (HMO D-SNP) Plan offers additional benefits that traditional Medicare does not cover, including:

 

• Over $300 each quarter to spend on over-the-counter drugs.

 

• Extra preventive dental coverage that includes two exams, two cleansings and one X-ray every year.

 

• Extra comprehensive dental allowance of $625 each quarter.

 

• Extra vision coverage, including one eye exam and up to $300 for glasses or contacts.

 

• One routine hearing exam and $3,000 a year for hearing aids.

 

• A $0 copay for a SilverSneakers® gym membership.

 

There is no additional cost and no copayment for these additional benefits. We think the Anthem MediBlue Dual Advantage (HMO D-SNP) Plan is a great opportunity for our Anthem HealthKeepers Plus members eligible for Medicare.

 

As a convenience to our members, we automatically enroll our Anthem HealthKeepers Plus members in our Anthem MediBlue Dual Advantage (HMO D-SNP) Plan beginning on the first day of the month in which they begin to receive Medicare coverage. Members are allowed to opt out by writing to us and/or calling us directly.

What does this mean for our providers?

 

The Anthem MediBlue Dual Advantage (HMO D-SNP) Plan will be primary payer for all Medicare-covered services received by these members. HealthKeepers, Inc. will be the secondary payer for any Medicare-covered, non-Part D costs not covered by the Anthem MediBlue Dual Advantage (HMO D-SNP) Plan. To keep things simple for you, we will coordinate payment for these services. You only need to submit one claim, and we will handle the rest. For Medicaid benefits, you will continue to bill HealthKeepers, Inc. as you do today.

 

These dually enrolled members will have separate ID cards for each plan and should show both when receiving services.

 

We look forward to jointly serving the Medicaid and Medicare population with you. If you have any questions regarding billing and eligibility, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. You can also find additional information on the provider website at https://mediproviders.anthem.com/va.

HealthKeepers, Inc. is pleased to offer several educational events for Anthem HealthKeepers Plus providers in 2020.

 

Educational events will launch as live webinars that offer continuing medical education/continuing education units and the opportunity to connect with the Anthem HealthKeepers Plus staff.

 

Do not miss these learning events coming your way in 2020. The first topic in our lineup of training webinars is social determinants of health (SDOH). Join us to learn how conditions and places where members live, learn, work and play affect a wide range of health risks and outcomes. Understand how you can collaborate with HealthKeepers, Inc. to improve member care and access resources to help meet the social needs of our members. Additional educational topics for 2020 include:

 

• ICD-10 diagnostic coding

• Common coding and claims issues

• Focus on quality care

This information pertains to Anthem HealthKeepers Plus providers.

 

Overuse of antibiotics is directly linked to the prevalence of antibiotic resistance. Promoting judicious use of antibiotics is important for reducing the emergence of harmful bacteria that is unresponsive to treatment. The following HEDIS® measures assess appropriate antibiotic dispensing for pharyngitis, upper respiratory infection and bronchitis/bronchiolitis. Changes for HEDIS 2020 include expanded age range and additional stratifications.

 

Appropriate Testing for Pharyngitis (CWP)

 

Pediatric Clinical Practice Guidelines recommend only children with lab‑confirmed group A strep or other bacteria-related ailments be treated with appropriate antibiotics. This measure reports the percentage of episodes for members 3 years of age and older where the member was diagnosed with pharyngitis, prescribed an antibiotic at an outpatient visit and received a group A strep test. A higher rate indicates better performance (in other words, appropriate testing).

 

Appropriate Treatment for Upper Respiratory Infection (URI)

 

This measure calculates the percentage of episodes for members 3 months of age and older with a diagnosis of upper respiratory infection that did not result in an antibiotic dispensing event. Reducing unnecessary use of antibiotics is the goal of this measure. It is reported as an inverted rate. A higher rate indicates appropriate upper respiratory infection treatment (in other words, the proportion of episodes that did not result in an antibiotic dispensing event).

 

Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)

 

There is considerable evidence that prescribing antibiotics for uncomplicated acute bronchitis is not indicated unless it is associated with a comorbid diagnosis. This measure assesses the percentage of episodes for members ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event. It is reported as an inverted rate. A higher rate indicates appropriate acute bronchitis/bronchiolitis treatment (in other words, the proportion of episodes that did not result in an antibiotic dispensing event).

 

Helpful tips:

 

• When patients present with symptoms of pharyngitis, ensure proper testing (for strep) is performed to avoid the unnecessary prescribing of antibiotics. Record the results of the strep test.

 

• If prescribing an antibiotic to members with acute bronchitis, be sure to use the diagnosis code for the bacterial infection and/or comorbid condition.

 

• Educate members on the difference between bacterial and viral infections. Refer to the illness as a common cold, sore throat or chest cold. Parents and caregivers tend to associate these labels with a less frequent need for antibiotics.

 

• Write a prescription for symptom relief, such as rest, fluids, cool mist vaporizers and over‑the‑counter medicine.

 

• If a patient insists on an antibiotic, consider using delayed prescribing. Refer to the CDC handout for patients titled What is Delayed Prescribing? available at the link below.

 

Resources:

 

• CDC’s Be Antibiotics Aware campaign: https://www.cdc.gov/antibiotic-use/index.html

 

• CDC handouts for patients: https://www.cdc.gov/antibiotic-use/community/materials-references/index.html

 

 

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

 

Please note that HealthKeepers, Inc. will continue to waive the need for Targeted Case Management (TCM) registrations for Anthem HealthKeepers Plus members. The TCM registration requirement is waived through December 31, 2019, and will continue for approximately six months.

 

We will provide another communication when we finalize the reinstatement date.

 

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. 

A change to CPT® codes for psychological and neuropsychological test administration and evaluation services for Anthem HealthKeepers Plus members was effective January 1, 2019.* The new codes do not crosswalk on a one-to-one basis with the deleted codes.

 

These coding changes separate test administration from test evaluation, psychological testing evaluation from neuropsychological testing evaluation and define the testing performed by a professional or technician. The information below clarifies coding for these services.

 

Please note: Prior authorization (PA) requirements have not changed. Please check the Precertification Look Up Tool for PA requirements for each code.

Neurobehavioral status exams

Neurobehavioral status exams are clinical interview examinations performed by a psychologist or neuropsychologist to assess thinking, reasoning and judgment.

Providers should continue to use CPT code 96116 when billing for the first hour.

Test administration and scoring by a psychologist or neuropsychologist

Two or more tests using any method should now be billed using CPT code 96136 for the first 30 minutes and 96137 for each additional 30 minutes.

Test administration and scoring by a technician

Two or more tests using any method should now be billed using CPT code 96138 for the first 30 minutes and 96139 for each additional 30 minutes.

 

Testing evaluation services 

Testing evaluation services include the selection of the appropriate tests to be administered; integration of patient data; interpretation of standardized test results and clinical data; clinical decision-making; treatment planning; and reporting and interactive feedback to the patient, family members, or caregivers (when performed). There are distinct testing evaluation service codes for psychological testing and for neuropsychological testing.

Providers should now use CPT code 96130 to bill for the first hour of psychological testing evaluation services and 96131 for each additional hour.

Neuropsychological evaluation services should now be billed using CPT code 96132 for the first hour and 96133 for each additional hour.

Single automated test administration

 

Single automated test administration should be reported with newly created code 96146 for a single automated psychological or neuropsychological instrument that is administered via electronic platform and formulates an automated result. Psychologists should not use this code if two or more electronic tests are administered and/or if administration is performed by the professional or technician. Instead, the psychologist should use the appropriate codes listed above for test administration and scoring. A single automated test as the only service is not considered appropriate for the many elements seen with test evaluation.

Screening and risk assessment (repetitive assessment after screening)

Screening and risk assessment (repetitive assessment after screening) includes brief emotional/behavioral assessment (for example, a depression inventory or ADHD scale) with scoring and documentation, per standardized instrument. This should be billed using CPT code 96127 separately from testing. Brief emotional/behavioral assessments should not be billed as psychological or neuropsychological testing.

 

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.

 

 

* American Psychological Association website: 2019 Psychological and Neuropsychological Testing Billing and Coding Guide: https://www.apa.org