As required by the Ethics and Fairness in Carrier Business Practices Act, all health insurance companies licensed to do business in Virginia making material changes to existing agreements or exhibits must do so by way of a formal amendment process.  Through an amendment dated July 15, 2019, Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. notified professional providers about new timely filing requirements effective November 1, 2019.  The July notification indicated that a 90-day timely filing requirement would apply to all professional claims – regardless of date of service – effective November 1, 2019.

Anthem has made the business decision to make the 90-day timely filing requirement effective for professional claims received with a date of service ON or AFTER November 1, 2019.  We will NOT implement the requirement for professional claims with dates of service prior to November 1, 2019. 

Please note that the 90-day timely filing requirement applies to commercial and Medicare Advantage professional claims only.  Claims for members enrolled in Anthem HealthKeepers Plus benefit plans (Medicaid and the Commonwealth Coordinated Care Plus commonly referred to as Anthem CCC Plus) are not impacted.  Additionally, the amendment does NOT apply to facility/hospital contracts.

If you have further questions, please contact your Anthem network manager.

 ABSCARE-0280-19                                                505340VAPENMUB

More exciting new changes are coming to the public provider site at anthem.com. This next wave of updates includes a new, enhanced Coverage Guidelines page. The page will have an improved and straightforward process for viewing guidelines that allows providers to easily scan, sort and filter. In addition, providers will now be able to access “Search” from the Coverage Guidelines Policies landing page. Below is a preview of the streamlined page:

Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Musculoskeletal Program Spine Surgery Clinical Appropriateness Guidelines.

• Conservative management – all sections

• Lumbar Disc Arthroplasty

• Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)

• Lumbar Laminectomy

• Noninvasive Electrical Bone Growth Stimulation

• Bone Graft Substitutes and Bone Morphogenetic Proteins

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access 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 authorization.

• Access AIM via the Availity Web Portal at availity.com.

• Call the AIM Contact Center toll-free number:  866-789-0397, Monday–Friday, 8 a.m. to 5 p.m. ET.

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

Please note, this program does not apply to the Federal Employee Program (FEP) or National Accounts.

Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Sleep Disorder Management Clinical Appropriateness Guidelines.

• Polysomnography and Home Sleep Testing: Established sleep disorder (OSA or other) – follow-up laboratory studies

• Management of OSA using APAP and CPAP Devices

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access 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 authorization.

• Access AIM via the Availity Web Portal at availity.com.

• Call the AIM Contact Center toll-free number: 866-789-0397, Monday–Friday, 8 a.m. to 5 p.m. ET.

Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Radiation Therapy Clinical Appropriateness Guidelines.

• Special Treatment Procedure and Special Physics Consult
  • Removed oral cone endocavitary indication

• Intensity Modulated Radiation Therapy (IMRT), Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiotherapy (SBRT) for bone metastases
  • Broadened description of adjacent normal tissues which may be of concern.

• Single fraction treatment
  • Removed poor performance status criteria

• Central Nervous System cancers
  • Added evidence review

• Spine Lesions; Primary or Metastatic Lesions of the Spine, Metastatic Lesions in the Lung
  • Added note calling out separate criteria for curative intent treatment of extracranial oligometastatic disease.

• SBRT in the treatment of extracranial oligometastatic disease
  • Added new section with discussion and indications

• Prostate cancer – hypofractionation
  • Added fractionation guideline with EBRT/IMRT.

• Prostate cancer – postoperative radiotherapy and SBRT
  • Added indication based on ASTRO/ASCO/AUA recommendation

• Prostate cancer – use of hydrogel spacer
  • Added discussion and medical necessity statement about hydrogel spacers for prostate irradiation

• CPT code changes
  • Added 77316, 77295 and 55874
  • Removed 77427

Effective for dates of service on and after February 9, 2020, the following updates by section will apply to the AIM Advanced Imaging of the Abdomen and Pelvis Clinical Appropriateness Guidelines.

• Foreign body (Pediatric only), Gastrointestinal bleeding, Henoch-Schonlein purpura, Hematoma  or hemorrhage – intracranial or extracranial, Perianal fistula/abscess (fistula in ano), Ascites, Biliary tract dilatation or obstruction , Cholecystitis, Choledocholithiasis, Focal liver lesion, Hepatomegaly, Jaundice, Azotemia, Adrenal mass, indeterminate, Hematuria, Renal mass, Urinary tract calculi, Adrenal hemorrhage, Adrenal mass, Lymphadenopathy, Splenic hematoma, Undescended testicle (cryptorchidism)

• Abdominal and/or pelvic pain
  • Combined pelvic pain with abdominal pain criteria in new “abdominal and/or pelvic pain” indication
  • Required ultrasound or colonoscopy for select adult patients based on clinical scenario
  • Ultrasound-first approach for pediatric abdominal and pelvic pain

• Lower extremity edema
  • Added requirement to exclude DVT prior to abdominopelvic imaging

• Splenic mass, benign, Splenic mass, indeterminate, Splenomegaly
  • Added new indications for diagnosis, management, and surveillance of splenic incidentalomas following the ACR White Paper (previously reviewed against “tumor, not otherwise specified”)

• Pancreatic mass
  • Separated criteria for solid and cystic pancreatic masses
  • Defined follow up intervals for cystic pancreatic masses

• Diffuse liver disease
  • Added criteria for MR elastography

• Inflammatory bowel disease
  • Limited requirement for upper endoscopy to patients with relevant symptoms
  • New requirement for fecal calprotectin or CRP to differentiate IBS from IBD

• Enteritis or colitis, not otherwise specified
  • Incorporated Intussusception (pediatric only), and Ischemic bowel

• Prostate cancer
  • Moved this indication to Oncologic Imaging Guideline

• CPT codes
  • Added MR elastography CPT code 76391

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access 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 authorization.

• Access AIM via the Availity Web Portal at availity.com.

• Call the AIM Contact Center toll-free number:  866-789-0397, Monday - Friday, 8 a.m. to 5 p.m. ET.

For questions related to guidelines, please contact AIM via email at: aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming AIM guidelines.

As the physician of a member who has coverage under Affordable Care Act (ACA) compliant plans, you play a vital role in accurately documenting the health of the member to ensure compliance with ACA program reporting requirements. When Anthem members visit your practice, we encourage you to document ALL of the members’ health conditions, especially chronic diseases.  Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.

Please ensure that all codes captured in your EMR system are also included on the claim(s), and are not being truncated by your claims software management system.  For example, some EMR systems may capture up to 12 diagnosis codes, but the claims system may only have the ability of capturing four.  If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.

Reminder about ICD-10 coding

As you may be aware, the ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits.  Additionally, Anthem uses ICD-10 codes submitted on claims to monitor health care trends and costs, disease management, and clinical effectiveness of management of medical conditions.  The Centers for Medicare & Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a member’s health.

Using specific ICD diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.

• Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.

• Include any secondary diagnosis codes that are actively being managed.

• Include all chronic historical codes, as they must be documented each year pursuant to the ACA.  (e.g., an amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).

If you are interested in having a coding training session conducted by an Anthem coding auditor, please contact our Commercial Risk Adjustment Representative who supports Virginia:

• Alicia.Estrada@anthem.com

Category:  Medicaid

In 2019, we began direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs) in Virginia. Once contracted and credentialed, Anthem HealthKeepers Plus NPs and PAs can begin billing services under their own 10-digit NPI.

Virginia legislation passed in March 2019 requires payers to offer provider contracting opportunities to nurse practitioners who meet HealthKeepers, Inc.’s terms and conditions effective October 1, 2019. Currently, licensed NPs and PAs can only bill for covered services under the supervision of the participating physician using that physician’s name and NPI. With this change, NPs and PAs must bill HealthKeepers, Inc. directly and the “incident to” guidelines will no longer apply. CMS defines “incident to” services as services billed by physicians and nonphysician practitioners that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home. Note that the new participation agreement will not apply to certified nurse midwives as they are contracted under a separate participation agreement.

How the contracting process will work

Credentialing and contracting of NPs and PAs is now underway. Our network managers have begun reaching out to network-participating providers who we know currently employ NPs and PAs. Please note that the new participation agreement will not apply to certified nurse midwives or clinical nurse specialists, as they are contracted under a separate agreement.

Other than the provider type description, the participation agreement will contain the same provisions and obligations as our standard physician agreements.

Credentialing process

NPs and PAs are required to be credentialed through HealthKeepers, Inc. Therefore, NPs and PAs must complete the online application process through the Council for Affordable Quality Healthcare, Inc. (CAQH).

To join CAQH ProView®:

1. Go to https://proview.caqh.org/pr.
2. Select register now on the bottom right and follow the instructions.

If you already participate with CAQH and have completed your online application, ensure you authorized HealthKeepers, Inc. access to your credentialing information.

Note: If you have selected Global Authorization, HealthKeepers, Inc. will already have access to your data. To authorize HealthKeepers, Inc.:

1. Go to https://proview.caqh.org/pr and enter your username and password.
2. Select the cog wheel in the upper right and then select Authorize.
3. Scroll down, locate Anthem and check the box beside Anthem.
4. Select Save to submit your changes.

For questions about CAQH ProView, call the CAQH help desk at 1-888-599-1771 or email providerhelp@proview.CAQH.org.

Benefits of direct contracting for NPs and PAs

This direct contracting and credentialing approach will allow us to include NPs and PAs in our provider directories as independent providers. Our members can easily search our provider finder tool for participating NPs and PAs.

In addition, direct contracting with NPs and PAs will allow for simplified handling of Medicare crossover claims. Medicare crossover claims for services provided by NPs and PAs to members holding a secondary group coverage policy will process under the participating NP or PA record — without rebilling by the group under the supervising physician’s NPI.

Looking ahead

Going forward, we will keep you informed of details and the date contracted NPs and PAs can begin billing directly for their services.

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.

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

• Review additional information about the 2019 Enhanced Personal Health Care Program releases myFHR

 503661MUPENMUB

• Visit us on the Web for additional information about the new Reimbursement Policy: Update Drug Screen Testing

501120MUPENMUB

• Visit us online for additional information about the rehabilitative services prior authorization review update

504173MUPENMUB

• Check out additional information about the billing Medicare Part D for shingles or  tetanus vaccination claims

53569WPPENMUB

The Blue Cross and Blue Shield Association issued a mandate requiring a change in the way we process Host and Home plan HEDIS® STARS Care Gaps, risk adjustment (RADV) and medical records requests. The goal of this mandate is to improve health outcomes and care management for Medicare Advantage out-of-area members.

More information about this mandate will be published in the December 2019 edition of Provider News.

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

504427MUPENMUB

The Centers for Medicare & Medicaid Services (CMS) define an expedited/urgent request as:

“An expedited/urgent request for a determination is a request in which waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in seriously jeopardy.”

Contracted providers should submit requests in accordance with CMS guidelines to allow for organization determinations within the standard turnaround time, unless the member urgently needs care based on the CMS definition of an expedited/urgent request.

504409MUPENMUB

Category:  Medicare

As required by the Ethics and Fairness in Carrier Business Practices Act, all health insurance companies licensed to do business in Virginia making material changes to existing agreements or exhibits must do so by way of a formal amendment process.  Through an amendment dated July 15, 2019, Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. notified professional providers about new timely filing requirements effective November 1, 2019.  The July notification indicated that a 90-day timely filing requirement would apply to all professional claims – regardless of date of service – effective November 1, 2019.

Anthem has made the business decision to make the 90-day timely filing requirement effective for professional claims received with a date of service ON or AFTER November 1, 2019.  We will NOT implement the requirement for professional claims with dates of service prior to November 1, 2019. 

Please note that the 90-day timely filing requirement applies to commercial and Medicare Advantage professional claims only.  Claims for members enrolled in Anthem HealthKeepers Plus benefit plans (Medicaid and the Commonwealth Coordinated Care Plus commonly referred to as Anthem CCC Plus) are not impacted.  Additionally, the amendment does NOT apply to facility/hospital contracts.

If you have further questions, please contact your Anthem network manager.

 ABSCARE-0280-19                                              505340VAPENMUB

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 some topics we’re addressing in this edition:

Electronic visit verification

New Reimbursement Policy: Update Drug Screen Testing

Category:  Medicaid

You may be surprised to learn that suicide is currently the 10th leading cause of death in the United States. In 2017 alone, there were an estimated 1.4 million suicide attempts by Americans. As staggering as these numbers are, we’d like to focus on what can be done to mitigate these statistics. The front lines in the battle against suicide are prevention and intervention. According to the CDC, suicide prevention should incorporate reducing factors that increase risk and increasing factors that help with resilience and/or coping.

Please read through the information below, which can be used to both prevent and intervene when it comes to suicide and your Anthem HealthKeepers Plus patients.

Suicide statistics

While the following statistics may be hard to read, awareness plays a big role in solving this issue:

• Nearly 45,000 lives were lost to suicide in 2016.
• Suicide rates went up more than 30% in half of U.S. states since 1999.
• There was a significant rise in suicide rate among youth ages 10 to 14.
• Suicide is the second leading cause of death for people 10 to 34 years of age.
• Men are more likely to use more lethal methods, such as firearms or suffocation, while women are more likely to attempt suicide by poisoning or prescription overdose.
• American Indian/Alaska Native youth and middle-aged persons have the highest rate of suicide.

Risk factors

Understanding who is at risk is vital to suicide prevention/intervention. The following traits are risk indicators:

• Depression, other mental disorders or substance use disorder
• Chronic pain
• A prior suicide attempt
• Family history of a mental disorder, substance use or suicide
• Family violence, including physical or sexual abuse
• Having guns or other firearms in the home
• Having recently been released from prison or jail
• Being exposed to others' suicidal behavior, such as that of family members, peers or celebrities

Warning signs

• Talking about wanting to die or to kill oneself.
• Looking for a way to kill oneself, such as searching online or buying a gun.
• Talking about feeling hopeless or having no reason to live.
• Talking about feeling trapped or in unbearable pain.
• Talking about being a burden to others.
• Increasing the use of alcohol or drugs.
• Acting anxious or agitated; behaving recklessly.
• Sleeping too little or too much.
• Withdrawing or feeling isolated.
• Showing rage or talking about seeking revenge.
• Displaying extreme mood swings.

How to help someone at risk

• Ask the question, “Are you thinking of killing yourself?”
• Keep them safe from harming or endangering themselves.
• Be there and promote a connectedness.
• Help them connect to resources.
• Follow up with your patient after determining they are at risk.

New evidence-based practice for health care providers

• Health care providers can help prevent suicide when they understand the risk factors and use evidence-based treatments and therapies.
• The Joint Commission recommends screening all patients in all medical settings for suicide risk using validated, population and setting-specific tools.
• It is no longer acceptable to contract for safety with patients; you need to remove or ensure safe storage of potentially lethal items.
• Familiarize yourself with the social media outlets in order to identify suicidal content and get help for the person posting the message. Websites such as Instagram, Facebook, Snapchat, Tumblr, Twitter and YouTube have built in safety tools.

Be familiar with the resources

• National Suicide Prevention Lifeline 1-800-273-TALK (8255) — this is a free, 24-hour hotline available to anyone in suicidal crisis or emotional distress. Callers are routed to the closest crisis center within Lifeline’s network of more than 160 centers.

• Suicide Prevention Resource Center (SPRC) — SPRC provides technical assistance, training and materials to assist states, tribes, campuses, organizations, professionals and stakeholders develop suicide prevention programs, interventions and policies. SPRC also acts as Secretariat to the National Action Alliance for Suicide Prevention.

• National Action Alliance for Suicide Prevention — this is a public/private partnership that advances the National Strategy for Suicide Prevention through the work of nearly 200 organizations.

• Behavioral Health Treatment Services Locator — this tool is a directory of mental health and substance use treatment facilities in the United States and U.S. territories.

• Garrett Lee Smith Suicide Prevention Program — the purpose of this program is to support states and tribes with implementing youth suicide prevention and early intervention strategies in schools, educational institutions, juvenile justice systems, substance use programs, mental health programs, foster care systems, and other child- and youth-serving organizations.

• Tribal Technical Assistance Center (TTAC) — The TTAC provides culturally relevant, evidence-based, holistic technical assistance to support native communities who seek to address mental and substance use disorders and suicide.

Additional resources:

• National Action Alliance for Suicide Prevention: www.actionallianceforsuicideprevention.org
• National Indian Child Welfare Association: www.nicwa.org/YouthSuicidePreventionToolkit
• Indian Health Services Resources: www.ihs.gov/behavioral/index.cfm?module=BH&option=Suicide
• Veterans Crisis Line: www.veteranscrisisline.net

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. American Foundation for Suicide Prevention (2019). Suicide Statistics. AFSP. Retrieved from: https://afsp.org/about-suicide/suicide-statistics.
2. Centers for Disease Control and Prevention (2018). Suicide: Prevention strategies. CDC. Retrieved from https://www.cdc.gov/violenceprevention/suicide/prevention.html.
3. National Institute of Mental Health (2017, May). Mental health information. NIH. Retrieved from https://www.nimh.nih.gov/health/index.shtml.
4. Substance Abuse and Mental Health Services Administration (n.d). SAMHSA. Retrieved from www.samhsa.gov.
5. Suicide Prevention Lifeline. National Suicide Prevention Lifeline. Retrieved from https://suicidepreventionlifeline.org.

Category:  Medicaid

Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. The online process is faster and easier to complete, and the response is automatic, which helps Anthem HealthKeepers Plus members get their medications sooner. You can complete this process through your current electronic health record/electronic medical record (EHR/EMR) system or via the following ePA sites:

• Surescripts®: https://providerportal.surescripts.net/providerportal

• CoverMyMeds®: https://www.covermymeds.com/main

Creating an account is free and takes just a few minutes. If you are experiencing any issues or have a question about how the systems operate:

• For questions or issues with accessing the Surescripts portal, call 1-866-797-3239.

• For questions or issues with accessing the CoverMyMeds portal, call 1-866-452-5017.

For questions regarding pharmacy benefits, please contact Provider Services at 1-800-901-0020.

Category:  Medicaid

On June 20, 2019, the Pharmacy and Therapeutic (P&T) Committee approved Clinical Criteria applicable to the HealthKeepers, Inc. medical drug benefit for Anthem HealthKeepers Plus members. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria are publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting July 2019. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.