On November 12, 2020, Anthem will host our last provider education webinar for the year. Designed for our network-participating providers, the webinar addresses Anthem business updates and billing guidelines that impact your business interactions with us.

 

For your convenience, we offer these informative, hour-long sessions online to eliminate travel time and help minimize disruptions to your office or practice. The date for the fall webinar is scheduled this month:

 

• Thursday, November 12, 2020, from 11 a.m. to noon ET

 

To ensure webinar participation, register by November 5.  Please don’t let the deadline pass you by.  If you’ve not registered for the webinar, it only takes a few minutes to complete the registration form. You can register now for the webinar using the registration form to the right under the “Article Attachments” section. If you have already registered for the November webinar, please ensure you have received an email confirmation from an Anthem representative to note that we’ve received your registration form.  Contact joyce.lindley@anthem.com if you need to confirm your registration.

 

710-1120-PN-VA

U.S. Antibiotic Awareness Week is November 18-24, 2020. This is a one week observance that gives organizations and providers an opportunity to raise awareness on the appropriate use of antibiotics and reduce the threat of antibiotic resistance. The Centers for Disease Control and Prevention (CDC) has over 10 hours of free Continuing Education available for providers at https://www.cdc.gov/antibiotic-use/community/for-hcp/continuing-education.html.

 

The CDC promotes Be Antibiotics Aware, an educational effort to raise awareness encouraging safe antibiotic prescribing practices and use. Be Antibiotics Aware has many resources for health care professionals (in outpatient and inpatient settings) including videos such as The Right Tool  (https://www.youtube.com/watch?v=dETK7Jc-XWA) and Antibiotics Aren’t Always the Answer (https://www.youtube.com/watch?v=byh75p7bf-U) that can be utilized in provider’s waiting rooms. 

 

722-1120-PN-VA

Allowances for dental anesthesia services are reimbursed at a flat rate for the codes/units billed. We do not use a time-based calculation to determine allowances for dental anesthesia services, such as D9222 and D9223.

 

When billing dental anesthesia services, please:

 

1.	Submit the initial 15 minutes of anesthesia services provided using the appropriate Common Dental Terminology (CDT®) code:   D9222 for deep sedation/general anesthesia, initial 15 minutes
2.	Submit subsequent 15-minute increments of anesthesia services provided (after the initial 15 minutes) using the appropriate CDT code:   D9223 for deep sedation/general anesthesia, each subsequent 15-minute increment

 

 Dental anesthesia claim submission tips

 

• D9222 should only be submitted once per claim and for only 1 unit of service.

 

• D9223 should be submitted on a single bill line, please include the number of units of that code within the Units field.

 

• You should not provide anesthesia start to stop time or total number of minutes that anesthesia was provided on your dental anesthesia claim submissions.

 

731-1120-PN-VA

In October, we introduced our new Authorization Rules Lookup tool that you can access through Availity Payer Spaces. The tool replaces the Health Services Review tool that was located on Point of Care. This new self-service application displays prior authorization rules so you can quickly verify if the outpatient services are required for members enrolled in Virginia’s Anthem commercial plans.

 

In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:

 

• Coverage and Clinical Guidelines

 

• Third Party Guidelines, if applicable (such as AIM Specialty Health, IngenioRx)

 

Steps to access the Authorization Lookup application through Availity Payer Spaces

 

Access to the tool does not require an Availity role assignment.

 

1. Select Payer Spaces

 

2. Select the Anthem Blue Cross Blue Shield tile from the Payer Spaces menu

 

3. Select the Applications tab

 

4. Select the Authorization Rules Lookup tile

 

Once you are in the tool you will need to provide the following information to display the service’s prior authorization rules:

 

• Tax ID

 

• National Provider Identifier (NPI)

 

• Member ID and birth date

 

• Member’s Group number or Contract Code

(This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)

 

• CPT/HCPCS code

Give this new tool a try and discover how much this will improve the efficiency of your authorization process.

 

Please note: If a prior authorization is required for outpatient services, you can submit the case through Interactive Care Reviewer Anthem’s online authorization tool which you can also access through the Availity Portal.

 

765-1120-PN-VA

In this 60-minute webinar, you will learn how to use Availity's* Attachment tools to submit and track supporting documentation electronically to Anthem and affiliate payers.

 

We will explore key workflow options to fit your organization’s needs, including how to:

 

• Work a request in the inbox of your Attachments Dashboard.

 

• Enter and submit a Web claim including supporting documentation.

 

• Use EDI batch options to trigger a request in your inbox.

 

• Track attachments you submitted using sent and history lists in your Attachments Dashboard.

 

• Get set up to use these tools.

 

As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.

 

Register for an upcoming webinar session

 

1. In the Availity Portal, select Help & Training > Get Trained.

 

2. The Availity Learning Center opens in a new browser tab.

 

3. Search for and enroll in a session using one of these options:

 

• In the Catalog, search by webinar title or keyword.
  • To find this specific live session quickly, use keyword medattach.

 

• Select the Sessions tab to scroll the live session calendar.

 

4. After you enroll, you’ll receive emails with instructions to join the session.

 

Webinar dates

 

DATE	DAY	TIME
November 4, 2020	Wednesday	Noon to 1 p.m. ET
November 17, 2020	Tuesday	2 p.m. to 3 p.m. ET
December 4, 2020	Friday	3 p.m. to 4 p.m. ET
December 15, 2020	Tuesday	3 p.m. to 4 p.m. ET

 

762-1120-PN-VA

We are targeting November 30, 2020, to retire Virginia’s Point of Care secure provider portal. The Availity Portal will become your exclusive, secure multi-payer portal to access many of Anthem’s online tools and resources. At this time, you will no longer be able to access the Payer Spaces link on Availity that redirects you to Point of Care.

 

Authorization requests and inquiries have been the only remaining transactions available on Point of Care. On October 17, 2020, we introduced Interactive Care Reviewer (ICR) our medical and behavioral health online authorization tool for our members enrolled in Anthem’s Commercial lines of business (this includes Commercial plans offered by our affiliate, HealthKeepers, Inc.); and on August 15, 2020, for members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® or FEP).

 

Interactive Care Reviewer is accessed through the Availity Portal.  You can now check the status and update all authorizations that were previously submitted for these patients through Point of Care using the ICR tool.

 

Take these steps to have access to ICR:

 

Ask your Availity administrator to grant you the required ICR role assignment now so you can begin using the tool immediately.

 

• Do you create and submit prior authorization requests?

Authorization and Referral Request role assignment

 

• Do you check the status of the case or results of the authorization request?

Authorization and Referral Inquiry role assignment

 

Follow these steps to navigate to ICR through Availity to request and check the status of prior authorizations

 

1. Select Patient Registration from Availity’s home page

 

2. Select Authorizations & Referrals

 

3. Select Authorizations (for requests) | Select Auth/Referral Inquiry (for inquiries)

 

Are you new to ICR or need a refresher?

 

We offer training every month to familiarize new users with ICR features and navigation of the tool.  Register Here to attend the webinar taking place on November 11.

 

Additional ICR resources are available through the Custom Learning Center

 

Follow the steps outlined below to access self-paced videos located on the Custom Learning Center. From Availity’s home page, select Payer Spaces | Anthem tile | Applications | Custom Learning Center

 

1. Select Catalog from the menu located on the upper left corner of the Custom Learning Center screen.

 

2. Use the catalog filter and select Interactive Care Reviewer-Online Authorizations or Authorizations from the Category

 

3. Click Apply then enroll for the courses (videos) you want to view.

Illustrated reference guides that you can print are located on Custom Learning Center Resources. Select Resources from the menu located on the upper left corner of the screen.  Use the catalog filter and select Authorizations or Interactive Care Reviewer-Online Authorizations from the Category menu. Select Download to view and/or print the reference guide.

 

764-1120-PN-VA

 

You recently received an amendment to your Professional Provider contract, effective October 1, 2020, that included an update to Vaccine Administration, AMA CPT procedure codes 90460-90461, 90471-90474. We have made a business decision to delay implementation of this change until January 1, 2021.

The rate(s) previously in effect prior to October 1, 2020, for these services will remain in effect until January 1, 2021. Please note that all other changes in the amendment went into effect on October 1, 2020. This update is applicable to all of the Commercial networks offered by Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc.  

 

742-1120-PN-VA

 

The purpose of this article is to provide additional information regarding submission of the Clinical Laboratory Improvement Amendments (CLIA) number on claims for laboratory services that include QW or 90 modifiers. As a reminder, claims filed without the CLIA number are considered incomplete and will reject. 

 

Both paper and electronic claim formats accommodate the CLIA number. 

 

• On the CMS-1500 form, Box 23 (Prior Authorization) is reserved for the CLIA number.

 

• On the 837P, REF segments are available: REF (X4) in loops 2300 and 2400, and REF (F4) in loop 2400. 

 

Note: The CLIA number for the Referring Clinical Laboratory should be included in REF (F4). 

 

The following examples illustrate how the CLIA number as well as procedure code modifiers QW and 90 should be filed:

 

Claim Format	Location(s) Reserved for Procedure Modifier and CLIA#
Modifier QW – diagnostic lab service is a CLIA waived test
CLIA Waived Tests: Simple laboratory examinations and procedures that have an insignificant risk of an erroneous result
CMS-1500	Procedure modifier ‘QW’: Box 24d	CLIA#: Box 23 Prior Authorization
837P	Procedure modifier ‘QW’: Loop 2400 SV101-3 (1st position)	CLIA#: Loop 2300 or 2400 REF X4
Modifier 90 – Reference (Outside) Laboratory
Referring laboratory – refers a specimen to another laboratory for testing Reference laboratory – receives a specimen from another laboratory and performs one or more tests on that specimen
CMS-1500	Procedure modifier ‘90’: Box 24d	CLIA#: Box 23 Prior Authorization
837P	Procedure modifier ‘90’: Loop 2400 SV101-3 – SV101-6	CLIA#: Loop 2300 or 2400 REF X4	CLIA# - Referring Facility Identification: Loop 2400 REF F4

Additional information regarding CLIA is available on the Centers for Medicare & Medicaid Services (CMS) website:  https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/

 

If you have additional questions, please call the telephone number on the back of the member’s identification card.

 

733-1120-PN-VA

The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory testing in the United States through the Clinical Laboratory Improvement Amendments (CLIA). The objective of the CLIA program is to ensure quality laboratory testing.

 

Starting October 1, 2020, Anthem implemented a new CLIA edit.  Providers must submit a valid CLIA Certificate Identification number (#) for clinical laboratory services subject to the CLIA 1988 federal statute and regulations. 

 

This edit began returning as a warning only on October 1, 2020. Below is the edit that will return on your electronic claim report.

 

Edit 60119 - Clinical Laboratory Improvement Amendment (CLIA) Number is required for the technical component of this laboratory test.

 

On December 3, 2020, the edit will change from a warning to a rejection. Anthem will require that a valid CLIA Certificate Identification number is included on each claim billed for laboratory services subject to CLIA legislation.

 

Please contact your clearinghouse or software vendor to ensure the necessary changes are complete by December 3, 2020, to avoid electronic claim rejections.

 

How to apply for a CLIA Certificate:

https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/How_to_Apply_for_a_CLIA_Certificate_International_Laboratories

 

For detailed information on the tests subject to CLIA, please refer to the CMS link below:

https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/                   

 

760-1120-PN-VA  

Introducing the Anthem Provider Digital Engagement Supplement to the provider manual

 

Using our secure provider portal or electronic data interchange (EDI) submissions (via Availity), administrative tasks can be reduced by more than 50% when filing claims with or without attachments, checking statuses, verifying eligibility and benefits, and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website or the secure provider portal via Availity.

 

Get payments faster

 

By eliminating paper checks, Electronic Funds Transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and you can receive payments faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance, which meets all mandates of the Health Insurance Portability and Accountability Act (HIPAA) – eliminating the need for paper remittances.

 

Member IDs go digital

 

Anthem members are transitioning to digital member identification cards making it easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

 

Anthem makes going digital easy with the Provider Digital Engagement Supplement

 

From our digital member identification cards to EDI transactions, application programming interfaces (APIs) to Direct Data Entry, we cover it all in our Digital Provider Engagement Supplement to the provider manual available online and on our secure provider portal through Availity. The Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits.

 

The Provider Digital Engagement Supplement to the provider manual is another example of how Anthem is using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Provider Engagement Supplement and go digital with Anthem.

 

774-1120-PN-VA

Anthem is committed to creating innovative tools that help simplify health care. In pursuit of that commitment, we recently enhanced our digital tool that enables members to share their personal health data with physicians and hospitals. This tool – referred to as My Health Records*-- merges patient health records from providers who may have cared for an individual member and stores the data in one secure place that is accessible to the member via the Sydney Health mobile app and anthem.com. My Health Records provides a new way for members to access their personal health information from multiple providers’ databases then view, download and share their health data and medical records with physicians via their smartphones or computers.

 

My Health Records allows members to share important health information with physicians, such as:

 

• Lab results and historical insights with visualizations

 

• Medications, Conditions, Immunizations, Vaccinations

 

• Health records

 

• Health records of dependents (14 years and under)

 

• Easy access to provider information

 

• Personalized health data tracking over time

 

• Integration for member authorization to more health record data

 

The enhanced digital tool gives physicians and hospitals a holistic view of a member’s up-to-date health data. This complete health data in one trusted place enables providers and members to feel more confident in making important life decisions easily and quickly.

 

*This tool is now available to Anthem members in our Medicare, Individual, Small Group and Fully Insured Large Group business segments and will be available to members in our Large Group Administrative Services Only (ASO) and Anthem National Account business segments in early 2021.

 

763-1120-PN-VA

Please note, this communication applies to Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

HealthKeepers, Inc. appreciates the recent improvements seen in early elective delivery (EED) rates across the country. These improvements have been brought about through the collaborative efforts of state Medicaid agencies, the March of Dimes, CMS, the Joint Commission, the American College of Obstetricians and Gynecologists (ACOG), and many others. The implementation of hospital hard stop policies describing the review of clinical indications and scheduling approval for EED has also increased awareness of the harm that can be caused by non-medically necessary EED and encouraged discussion on the topic between patients, their care providers and hospitals. Voluntary efforts combined with payment reform have been found to further decrease EED rates while increasing gestational age and birth weight for the covered population.¹

 

Early elective delivery is defined as a delivery by induction of labor without medical necessity followed by vaginal or caesarean section delivery or a delivery by caesarean section before 39 weeks gestation without medical necessity. Vaginal or caesarean delivery following non-induced labor is not considered an early elective delivery regardless of gestational weeks.

 

What does this mean for providers?

 

To improve birth outcomes for our members and further reduce EED, HealthKeepers, Inc. requires a Z3A code indicating gestational age, the appropriate code to indicate the outcome of delivery and supporting medical necessity diagnosis codes on all professional delivery claims for all EED. HealthKeepers, Inc. will apply Milliman Care Guidelines, which defines medically necessary criteria for EED.

 

All professional delivery claims (59400, 59409, 59410, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622) with dates of service [date], or after, will require a Z3A code indicating gestational age at the time of delivery. If the code is not present on the claim, the claim will deny with the explanation code e02: Delivery diagnoses incomplete without report of pregnancy weeks of gestation. You may resubmit the claim with the appropriate Z3A code.

 

• Professional delivery claims with dates of service [date], or after, with gestational age dates of 37 and 38 weeks will require a supporting medically necessary diagnosis code for the early delivery.

 

• If a professional delivery claim is submitted without evidence of medical necessity for the early delivery, the claim will deny with code k34: Delivery is not medically indicated. You may resubmit the claim with the appropriate supporting diagnosis code or appeal with medical records.

 

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. Thank you for being a valued partner. We appreciate your commitment to the health of our members.

 

¹ Dahlen, Heather M., J. Mac Mccullough, Angela R. Fertig, Bryan E. Dowd, and William J. Riley. Texas Medicaid Payment Reform: Fewer Early Elective Deliveries and Increased Gestational Age And Birthweight. Health Affairs 36.3 (2017): 460-67. Print.

 

AVA-NU-0301-20

Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

 

Make sure members have their contact information up to date so they’re the first to know when it’s time to renew.

 

Medicaid renewals may be on hold, but you can help members stay informed. Remind them to keep their contact information, including their mailing address, up to date with the state so they don’t miss any important notices about renewing their benefits.

           

Update contact info here (https://commonhelp.virginia.gov).

                       

Help our community stay healthy and insured

 

Many people have recently been laid off or had their hours reduced at work. To help them through this difficult time, they can search for assistance with food, housing, paying utility bills and more using our Community Resource Link (https://anthemhkp.auntbertha.com). If they lost their health insurance, Medicaid may be an option. Direct members to www.chooseanthemhealth.com/medicaid.

 

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-0284-20

Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

 

Effective December 1, 2020, prior authorization (PA) requirements will change for HCPCS code 55899. This will be reviewed using MED.00132: Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures. This code will require PA by HealthKeepers, Inc. for Anthem HealthKeepers Plus members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

 

• 55899 — Unlisted procedure, male genital system

 

To request PA, you may use one of the following methods:

 

• Web: https://www.availity.com

 

• Fax: 1-800-964-3627

 

• Phone: 1-800-901-0020

 

Not all PA requirements are listed here. PA requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com by visiting https://mediproviders.anthem.com/va > Login. Contracted and noncontracted providers who are unable to access Availity* may call Provider Services at 1-800 901-0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687 for PA requirements.

 

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

 

AVA-NU-0286-20

Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

 

On February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for HealthKeepers, Inc. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting June 2020. Visit Clinical Criteria to search for specific policies.

           

If you have questions or would like additional information, use this email.

 

AVA-NU-0287-20

Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

 

Need for coding compliance

 

Coding compliance refers to the process of ensuring that the coding of diagnosis, procedures and data complies with all coding rules, laws and guidelines.

 

All provider offices and health care facilities should have a compliance plan. Internal controls in the reimbursement, coding, and payment areas of claims and billing operations are often the source of fraud and abuse, and have been the focus of government regulations.

 

Compliance plan benefits:

 

• More accurate payment of claims

 

• Fewer billing mistakes

 

• Improved documentation and more accurate coding

 

• Less chance of violating state and federal requirements including self-referral and anti-kickback statutes.

 

Compliance programs can show the provider practice is making an effort to submit claims appropriately and send a signal to employees that compliance is a priority.

 

Medical records documentation

 

All medical records entries should be complete and legible, and should include the legible identity of the provider and date of service.

 

Each encounter in the medical record must include the patient’s full name and date of birth. Documentation integrity is at risk when there is wrong information on the wrong patient health record because it can affect clinical decision-making and patient safety.

Providers’ signatures and credentials are of the utmost importance in all documentation efforts. The signature is an attestation from the treating and documenting provider that certifies the written document as reflecting the provider’s intentions regarding the services performed during the encounter, and the reason(s).

 

Specific information is required to describe the patient encounter each time he or she presents for medical services.

 

Each encounter generally will need to contain the following:

 

• The chief complaint

 

• The history of present illness

 

• The physical examination

 

• Assessment and care plan

 

Common coding and billing risk areas

 

The following billing risks are commonly subject to Office of Inspector General (OIG) investigations and audits:

 

• Billing for items or services not rendered or not provided as claimed

 

• Double billing, resulting in duplicate payment

 

• Submitting claims for equipment, medical supplies, and services that are not reasonable and necessary

 

• Billing for non-covered services

 

• Knowingly misusing provider identification numbers, which results in improper billing

 

• Unbundling

 

• Failure to properly use modifiers

 

• Upcoding the level of service.

 

Evaluation and Management (E&M) claims are typically denied for two reasons:

 

• Incorrect coding, such as the code not matching the documentation, and insufficient documentation, which can include a lack of a provider signature or no record of the extent and amount of time spent in counseling.

 

• Coordination of care when it is used to qualify for a particular level of E&M service.

 

There are several strategies on how to prevent E&M claims being denied:

 

• In addition to the individual requirements for billing a selected E&M code, providers should also consider whether the service is reasonable and necessary (for example, a level 5 office visit for a patient with a common cold and no comorbidities will not be reasonable and necessary).

 

• Remember the following when selecting codes for E&M services:

 

Patient type (new or established)

Setting/place of service

The level of service provided based on the extent of the history, the extent of the examination, and the complexity of the medical decision making (for example, the number and type of the key components performed).

 

Best practices to avoid common documentation mistakes

 

Providers need to formulate a complete and accurate description of the patient’s condition with a detailed plan of care for each encounter. Listing problems without a corresponding plan of care does not confirm physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (for example, diabetes management (DM), chronic kidney disease (CKD), congestive heart failure (CHF): Continue current treatment plan) equally diminishes the complexity and effort put forth by the physician.

 

The care plan needs to be documented clearly. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another provider is primarily managing the problem. For example, one provider can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD).

 

Pathology service, laboratory testing, radiology and medicine-based diagnostic testing contributes to diagnosing or managing patient problems.

 

Documentation tips:

 

• Specify tests ordered and document rationale in the medical record

 

• Document test review by including a description in the note (for example, elevated glucose levels)

 

• Indicate when images, tracings, or specimens are personally reviewed; be sure to include a comment on the findings

 

• Summarize any discussions of unexpected or contradictory test results with the provider performing the procedure or diagnostic study.

 

Patient risk in E&M is categorized as minimal, low, moderate or high based on the presenting problem, diagnostic procedures ordered and management options selected. Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered less risky than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis. 

 

To determine the right complexity of the patient’s problems, providers should:

 

• Document the status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; do not assume that the auditor or coder can infer this from the documentation details.

 

• Document all diagnostic or therapeutic procedures considered.

 

• Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.

 

Frequent auditing is key to medical coding compliance

 

To ensure your organization’s E&M services are coded appropriately, it is important to periodically review your charts to check for insufficient documentation, miscoding, upcoding and downcoding. Conducting audits of your medical coding process and procedures can help give you an understanding of recurring risk areas and key improvement opportunities. Using these insights, you can then incorporate best practices and address any bad habits, lessening the chances of negative consequences.

 

Resources

 

1. CPT^® Professional Edition, 2020. AMA
2. Compliance Guidance. Office of Inspector General. https://oig.hhs.gov/compliance/compliance-guidance/index.asp
3. Risk Adjustment Documentation & Coding, 2^nd edition. American Medical Association

 

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-0289-20

Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

This is a notification regarding inhaled nitric oxide.

 

The purpose of this notification is to inform participating hospitals that the use of inhaled nitric oxide (iNO) during an inpatient stay will be reviewed for medical necessity using our Clinical Utilization Management (UM) Guideline for Inhaled Nitric Oxide, CG-MED-69. iNO is a covered service for eligible members when the use of iNO meets medical necessity criteria. To view the Clinical UM Guideline for INO, visit our https://mediproviders.anthem.com/va.

 

This also requires that the facility notify us of the use of iNO during the course of an inpatient review, and it must be reviewed and approved at some point prior to discharge to avoid exclusion of charges for iNO from the claim payment. If we are not alerted to the use of iNO and, therefore, medical necessity cannot be determined, and charges for iNO are included in the claim submission, the charges for iNO will not be considered in calculation of reimbursement for the stay.

 

When iNO is used, providers are required to submit an itemized list of charges with the claim for the inpatient stay.

 

Impact on the diagnosis-related group (DRG) payment

 

The charges for iNO that are determined to be not medically necessary will not be considered and could impact the DRG outlier payment, as the stay may not reach outlier status as soon as it would with inclusion of these charges. If the case reaches the outlier threshold, we will adjudicate the claim consistent with the financial terms of the contract for outliers, without inclusion of charges for iNO that are not medically necessary or the use of which was not disclosed.

 

Providers should direct questions regarding this guideline or in relation to the Utilization Management review process to the health plan numbers listed below:

 

• 1‑800‑901‑0020

Providers should fax new prior authorization requests for physical health inpatient services to 1-800-964-3627.

 

Fax submissions of clinical documentation as requested by the Inpatient Utilization Management department supporting medical necessity reviews for inpatient concurrent reviews to 1-866-920-4095.

 

AVA-NU-0290-20

Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

 

A key goal of the provider transparency initiatives of HealthKeepers, Inc. is to improve quality while managing health care costs. One of the ways this is accomplished is through our value-based programs (for example, the Provider Quality Incentive Program, the Provider Quality Incentive Program Essentials, Risk and Shared Savings, etc.), known as the Programs. 

 

Value-Based Program Providers (also known as Payment Innovation Providers) in our various value-based programs receive quality, utilization and/or cost data, reports and information about other health care providers (Referral Providers). The Value-Based Program Providers can use that information in selecting Referral Providers for 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 the provider getting more referrals from Value-Based Program Providers. If Referral Providers are lower quality and/or higher cost, the converse should be true.

 

Providing this type of data, including comparative cost information, to Value-Based Program 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.

 

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

 

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-0295-20

Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

 

Effective for dates of service on and after January 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation or renewal, in addition to the current medical necessity review of all drugs noted below.

 

The Clinical Criteria below will be updated to include the requirement of a preferred agent effective January 1, 2021.

 

Clinical Criteria	Preferred drug	Nonpreferred drug
ING-CC-0166	Herzuma (Q5113), Kanjinti (Q5117), Ogivri (Q5114), Ontruzant (Q5112), Trazimera (Q5116)	Herceptin (J9355)

 

Clinical Criteria is publicly available on our provider website at https://mediproviders.anthem.com/va.

 

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-0299-20

Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

 

Effective for dates of service on and after January 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria will be included in our medical step therapy precertification review process. Step therapy review will apply on precertification initiation or renewal in addition to the current medical necessity review of all drugs noted below.

 

The clinical criteria below will be updated to include the requirement of a preferred agent effective January 1, 2021.

Clinical Criteria	Preferred drug	Nonpreferred drug
ING-CC-0107	Mvasi (Q5107), Zirabev (Q5118)	Avastin (J9035)

 

The Clinical Criteria is publicly available on https://mediproviders.anthem.com/va.

 

What if I need assistance?

 

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

AVA-NU-0300-20

The Aspire Health* telehealth program provides an additional layer of telephonic support to Anthem HealthKeepers Plus members facing a serious illness. The program is focused on helping ensure patients understand their diagnosis, facilitating conversations with patients and their families around the patient's goals of care, and helping ensure patients receive care aligned with their goals and values.

 

The program begins with an initial 30- to 60-minute telephonic assessment by a specially trained Aspire social worker with the conversation focused on building rapport and completing a comprehensive assessment, including understanding the patient's perception of his or her illness and current treatment plan. Follow-up calls occur every 2 to 4 weeks, typically lasting 15 to 45 minutes, with the exact frequency based on a patient's individual need. Aspire's social worker is supported by Aspire's full interdisciplinary team of board-certified palliative care physicians, nurses and chaplains who provide additional telephonic support to patients and their families as needed. 

 

Patients enrolled in the telehealth program have access to Aspire's 24/7 on-call support. The average patient is enrolled in the program 6 to 8 months, with key outcomes being the ability for patients to teach-back their current medical situation, articulate their health and quality-of-life goals, and establish a future care plan through either the completion of advance care planning documents and/or a transition to hospice when appropriate.

 

More information is available at www.aspirehealthcare.com or by calling the 24/7 Patient & Referral Hotline at 1-844-232-0500.

 

* Aspire Health is an independent company providing telephonic palliative care services on behalf of HealthKeepers, Inc.

 

AVA-NU-0280-20

Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

 

Introducing the HealthKeepers, Inc. Provider Digital Engagement Supplement to the provider manual

 

Using our secure provider portal or EDI submissions (via Availity*), administrative tasks can be reduced by more than 50% when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website or the secure provider portal via Availity.

 

Get payments faster

 

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and will deliver payments to you faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the Availity Provider Portal or the EDI 835 remittance, which meets all mandates of the Health Insurance Portability and Accountability Act (HIPAA) — eliminating the need for paper remittances.

 

Member ID cards go digital

 

Members who are transitioning to digital member ID cards, will find it is easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

HealthKeepers, Inc. makes going digital easy with the Provider Digital Engagement Supplement

 

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available by going to https://mediproviders.anthem.com/va/pages/manuals-directories-training.aspx > Manuals, Directories, Training & Resources > Anthem HealthKeepers Plus Manuals, Directories, Training & Resources > Provider Digital Engagement, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid, including medical, dental and vision benefits.

 

The Provider Digital Engagement Supplement to the provider manual is another example of how HealthKeepers, Inc. is using digital technology to improve the health care experience. We are asking providers to go digital with HealthKeepers, Inc. no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now by going to https://mediproviders.anthem.com/va/pages/manuals-directories-training.aspx > Manuals, Directories, Training & Resources > Anthem HealthKeepers Plus Manuals, Directories, Training & Resources > Provider Digital Engagement, and go digital with HealthKeepers, Inc.

 

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.

 

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

 

AVA-NU-0302-20

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:

 

New specialty pharmacy medical step therapy requirements

 AVA-NU-0291-20

On January 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) implemented a preferred edit on Medicare Part B eligible continuous glucose monitors (CGMs). The preferred CGM is Freestyle Libre.

 

Preferred CGM edits do not apply to the following plans/plan types:

 

• Employer Group Waiver Plans (EGWP) Medicare Advantage Part D (MAPD) through Anthem

 

• Employer Group Waiver Plans (EGWP) Medicare Advantage (MA only) through Anthem

 

• Individual Medicare Advantage Plans (MA only) through Anthem

 

Delivery channels

 

Only members enrolled in a plan using preferred CGM edits will need to obtain their CGM systems from a retail or mail order pharmacy. Members on a plan without preferred CGM edits will be able to obtain their CGM systems through durable medical equipment (DME) providers in addition to retail and mail order pharmacies. Please check member and plan benefits to confirm the available delivery channels for accessing CGM products.

 

ABSCARE-0664-20                   512818MUPENMUB

You now have a new option to have questions answered quickly and easily. With Anthem Blue Cross and Blue Shield (Anthem) and AMH Health, LLC Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity.* Provider Chat offers:

 

• Faster access to Provider Services for all questions.

 

• Real-time answers to your questions about prior authorization and appeals status, claims, benefits, eligibility, and more.

 

• An easy to use platform that makes it simple to receive help.

 

• The same high level of safety and security you have come to expect with Anthem and AMH Health.

 

Chat is one example of how Anthem and AMH Health are using digital technology to improve the health care experience, with the goal of saving valuable time. To get started, access the service through Payer Services on Availity.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield and AMH Health, LLC.

 

ABSCARE-0683-20                   513641MUPENMUB

On February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting June 2020. Visit Clinical Criteria to search for specific policies.

           

If you have questions or would like additional information, use this email.

 

ABSCRNU-0173-20                   512909MUPENMUB

Anthem Blue Cross and Blue Shield (Anthem) reviews the activities of the FDA’s approval of drugs and biologics on a regular basis to understand the potential effects for both our providers and members.

 

The FDA approves new drugs/biologics using various pathways of approval. Recent studies on the effectiveness of drugs/biologics going through these different FDA pathways illustrates the importance of clinicians being aware of the clinical data behind a drug or biologic approval in making informed decisions.

 

Here is a list of the approval pathways the FDA uses for drugs/biologics:

 

• Standard Review: The Standard Review process follows well-established paths to make sure drugs/biologics are safe and effective when they reach the public. From concept to approval and beyond, FDA performs these steps: reviews research data and information about drugs and biologics before they become available to the public, watches for problems once drugs and biologics are available to the public, monitors drug/biologic information and advertising, and protects drug/biologic quality. Learn more about the Standard Review process.

 

• Fast Track: Fast Track is a process designed to facilitate the development and expedite the review of drugs/biologics to treat serious conditions and fill an unmet medical need. Learn more about the Fast Track process.

 

• Priority Review: A Priority Review designation means FDA’s goal is to take action on an application within six months. Learn more about the Priority Review process.

 

• Breakthrough Therapy: A process designed to expedite the development and review of drugs/biologics that may demonstrate substantial improvement over available therapy. Learn more about the Breakthrough Therapy process.

 

• Orphan Review: Orphan Review is the evaluation and development of drugs/biologics that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. Learn more about the Orphan Review process.

 

• Accelerated Approval: These regulations allowed drugs/biologics for serious conditions that filled an unmet medical need to be approved based on a surrogate endpoint. Learn more about the Accelerated Approval process.

 

New molecular entities approvals — January to August 2020

 

Certain drugs/biologics are classified as new molecular entities (NMEs) for purposes of FDA review. Many of these products contain active ingredients that have not been approved by FDA previously, either as a single ingredient drug or as part of a combination product; these products frequently provide important new therapies for patients.

 

Anthem reviews the FDA-approved NMEs on a regular basis. To facilitate the decision-making process, we are providing a list of NMEs approved from January to August 2020, along with the FDA approval pathway utilized.

 

Generic name	Trade name	Standard Review	Fast Track	Priority Review	Break-through Therapy	Orphan Review	Accelerated Approval	Approval date	Indication
Abametapir	Xeglyze	X						July 24, 2020	Head lice
Amisulpride	Barhemys	X						February 26, 2020	Postoperative nausea and vomiting
Avapritinib	Ayvakit		X	X	X	X		January 9, 2020	PDGFRa exon 18 mutant gastrointestinal stromal tumor
Belantamab mafodotin	Blenrep			X	X	X	X	August 5, 2020	Multiple myeloma
Bempedoic acid	Nexletol	X						February 21, 2020	Dyslipidemia
Brexucabtagene autoleucel	Tecartus			X	X	X	X	July 24, 2020	Mantle cell lymphoma
Capmatinib	Tabrecta			X	X	X	X	May 6, 2020	Non-small cell lung cancer (NSCLC)
Decitabine/ cedazuridine	Inqovi			X		X		July 7, 2020	Myelodysplastic syndromes
Eptinezumab-jjmr	Vyepti	X						February 21, 2020	Migraine prevention
Fostemsavir	Rukobia		X	X	X			July 2, 20202	HIV treatment
Inebilizumab	Uplizna	X			X	X		June 11, 2020	Neuromyelitis optica spectrum disorder
Isatuximab	Sarclisa	X				X		March 2, 2020	Multiple myeloma
Lurbinectedin	Zepzelca			X		X	X	June 15, 2020	NSCLC
Nifurtimox	Lampit			X		X	X	August 6, 2020	Chagas disease
Oliceridine	Olinvyk	X	X					August 7, 2020	Moderate to severe acute pain
Opicapone	Ongentys	X						April 24, 2020	Parkinson’s disease
Osilodrostat	Isturisa	X				X		March 6, 2020	Cushing’s disease
Ozanimod	Zeposia	X						March 25, 2020	Multiple sclerosis
Peanut (Arachis hypogaea) allergen powder-dnfp	Palforzia	X	X		X			January 31, 2020	Peanut allergy
Pemigatinib	Pemazyre			X	X	X	X	April 17, 2020	Cholangiocarcinoma
Remimazolam	Byfavo	X						April 2, 20202	Sedation for procedures
Rimegepant	Nurtec ODT			X				February 27, 2020	Migraine treatment
Risdiplam	Evrysdi		X	X	X	X		August 7, 2020	Spinal muscular atrophy
Ripretinib	Qinlock		X	X	X	X		May 15, 2020	Gastrointestinal stromal tumor
Sacituzumab-hziy	Trodelvy		X	X	X	X	X	April 22, 2020	Triple negative breast cancer
Selpercatinib	Retevmo			X	X	X	X	May 8, 2020	NSCLC and thyroid cancers
Selumetinib	Koselugo		X	X	X	X		April 10, 2020	Neurofibromatosis type 1
Tafasitamab	Monjuvi	X	X		X	X	X	July 31, 2020	Large B-cell lymphoma
Tazemetostat	Tazverik			X		X	X	January 23, 2020	Epithelioid sarcoma
Teprotumumab-trbw	Tepezza		X	X	X	X		January 21, 2020	Thyroid eye disease
Triheptanoin	Dojolvi	X	X			X		June 30, 2020	Long-chain fatty acid oxidation disorders
Tucatinib	Tukysa		X	X	X	X		April 17, 2020	Breast cancer
Viltolarsen	Viltepso		X	X		X	X	August 12, 2020	Duchenne muscular dystrophy

Source: www.fda.gov

 

ABSCRNU-0178-20                   513586MUPENMUB

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

 

Prior authorization for selected codes

 ABSCRNU-0172-20                  512805MUPENMUB

 

AIM Musculoskeletal program expansion update

ABSCRNU-0174-20                   513024MUPENMUB

 

AIM rehabilitation prior authorizations suspended for Group Retiree Solutions members until December 31, 2020

ABSCRNU-0175-20                   513168MUPENMUB

 

Transition to AIM Rehabilitative Service Clinical Appropriateness Guidelines

ABSCRNU-0177-20                   513917MUPENMUB