The Department of Health & Human Services (HHS) requires health plans to report whether or not our in-network providers offer telehealth services.

If you provide telehealth services, please tell us by submitting your information to us through Availity.com. Updating your telehealth status will not affect your participation with us. We will add a telehealth indicator to your online provider directory profile, allowing our members to know you offer telehealth services.

If you have questions about submitting your information, please see the instructions below.

If your organization is not currently registered with Availity, you will need to create an account. The person(s) designated as your administrator(s) should go to Availity.com and select Get Started in the upper right corner of the webpage. You may also navigate directly to Availity’s registration website by selecting here.

Begin your application here. To update your application:

1. Log in to Availity Essentials.
2. Select My Providers.
3. Select Provider Data Management.

Please update your telehealth information at the service location.

Beginning with claims processing on or after February 1, 2025, (90-day MAC notice required) HealthKeepers, Inc. is enhancing its claims edits system to ensure claims billed with pharmaceutical drug procedure codes are reported with an FDA-approved indication or an approved off-label indication on the claim.

These enhanced claim edits provide an opportunity for HealthKeepers, Inc. to evaluate submitted claims for drug quality, safety, and effectiveness. The enhancement is to have the claims deny if the diagnosis reported is not one that is an FDA-approved indication or an approved off-label indication for the drug procedure code.

If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual and include medical records that clarify whether the indication was approved through the governing agencies. You will only need to submit the portion(s) of the medical record that is relevant to the drug provided.

If you have any questions about this communication, contact Anthem HealthKeepers Plus Provider Services at 800-901-0020.

Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. will notify you by mail of an upcoming provider contract amendment, which includes a statewide fee schedule update, on November 26, 2024. On that date, log on to Availity Essentials to select the Provider Online Reporting application to securely access and download a digital copy of the amendment documents.

Only authorized users in your practice or facility can view the confidential contract amendments using Provider Online Reporting. Authorization must be obtained through your Availity administrator if you do not currently have access. For easy reference, below is the information needed for getting started with Provider Contract and Fee Schedule Notifications. 

Provider online reporting reference guide: how to get started

Provider Online Reporting is found on Availity.com. This is where you can access the updated fee schedule. Below is a recap of the application and instructions on how to sign up and access notifications. We suggest Google Chrome as your internet browser.

For Availity administrators: how to assign access

If your organization is not currently registered with Availity Essentials, go to Availity.com and select Register to complete the online application.

As an administrator, you must take the following steps to assign access to Provider Online Reporting:

• Assign the user role of Provider Online Reporting to your Availity Essentials access.
• Select Payer Spaces in the top menu bar and choose the payer tile that corresponds to the market.
• First-time users accessing Payer Spaces will be asked to accept a Terms of Use Agreement. The agreement will appear for users once every year.
• On the Applications tab, select Provider Online Reporting.
• Select Organization and then select Submit.
• On the Welcome to Provider Online Reporting page, select Register/Maintain Organization.
• Select Register Tax ID(s) for the applicable program to register the tax IDs.
• A pop-up window will display all tax IDs that must be registered for the program. Mark the box for each tax ID to be registered and select Save.
• Tax ID registration has now been successfully completed. Notice that after the registration has been completed, the status has changed from Register Tax ID(s) to Edit Tax ID(s).

For users: how to navigate to the report

Take the following steps to navigate to the report:

• Log in to Availity.com.
• Select Payer Spaces in the top menu bar.
• Select the payer tile that corresponds to your market.
• Accept the Terms of Use Agreement (once every year).
• On the Applications tab, select Provider Online Reporting.
• Select Organization and then select Submit.
• Select Report Search. Choose the type of report, then launch your program’s reporting application.

The Welcome to Provider Online Reporting webpage will open. This page lists all the organization’s eligible programs. Use the navigation options on the left-hand side of the page to move within the tool.

The Programs page provides a description about the program in which your organization participates and includes any applicable documents related to your program. Select a program using the dropdown menu.

 The Report Search page launches the corresponding reporting application for your program. Select the appropriate program from the dropdown menu. 

Helpful tip

Add Provider Online Reporting to My Favorites for quick access on Availity.com:

• Log on to Availity.com.
• Select Payer Spaces in the top menu bar.
• Select the payer tile that corresponds to your market.
• On the Applications tab, select the heart icon next to Provider Online Reporting. The heart will turn red.
• Provider Online Reporting will now appear at the top under My Favorites.

For assistance:

Visit the Custom Learning Center in Payer Spaces to view Provider Online Reporting user guides.

• If you have questions regarding Availity Essentials, contact Availity Client Services at
  800-282-4548.
• If you have questions about Provider Online Reporting, use the Contact Us section on the application.
• If you have other questions, reference the number on the back of the member ID card for Provider Services.

In July, we announced an enhancement to the 277CA to notify you of submission errors discovered during claims processing.  

As of November 1, 2024, the 277CA will include additional corrective action types for your review. As communicated in July, these errors will still be sent through physical mailing.

With these added error types, there is no reduction to the services we already provide.

Through our efforts, we are committed to reducing administrative burden, improving communication, and ensuring timely payments because we value you, our care provider partners.

Find Care, the doctor finder and transparency tool in the Anthem online directory, provides Anthem members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options such as sorting providers based on distance, alphabetical order, and provider name.

In our November 2022 newsletter, we provided an update regarding Personalized Match, an additional Find Care sorting option for Commercial members. We informed you that this provider sorting option was based on provider efficiency and quality outcomes described in a methodology document linked in the newsletter article, in addition to member search radius.

We want to inform you that, beginning in December 2024 or later, we will be enhancing Personalized Match. This will expand upon the existing program. Newer components of the provider personalization metrics will contain up to 10 times as many features as compared to existing metrics such as gaps in care and additional types of service cost and utilization. Personalized Match will continue to display providers with the highest overall ranking within the member’s search radius, first. Members will continue to have the ability to sort based on distance, alphabetical order, and provider name.

Helpful resources on Availity

You may review a copy of the Personalized Match methodology that has been posted on Availity, our secure web-based provider tool, using the following navigation:

• Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.

If you have general questions regarding these upcoming changes, please submit an inquiry via the web at Availity.com. If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.com.

Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.

We are excited to announce the release of an Applied Behavior Analysis (ABA) Provider Resource Guide designed to assist with proper billing and documentation practices. This essential guide simplifies the complexities of ABA coding and requirements, ensuring that you can navigate these processes with ease.

Refer to attached ABA Provider Resource Guide.

Summary:

• Long-acting injectable (LAI) antipsychotics enhance adherence, reduce relapses, and improve outcomes in schizophrenia.
• They are recommended for chronic nonadherence, first-episode psychosis, and early-stage schizophrenia patients.
• They stabilize drug levels, reduce daily medication stigma, and allow better monitoring by healthcare providers.

The American Psychiatric Association’s practice guideline for treatment of patients with schizophrenia recommends the use of LAI antipsychotics in patients who prefer long-acting injectables or have a history of poor or uncertain adherence.⁴ LAI antipsychotics are commonly used in patients with chronic nonadherence or multiple relapses; however, experts suggest that patients with first-episode psychosis or early-stage schizophrenia may benefit most.^1,2

Early use of LAI antipsychotics may help increase treatment response, prevent relapse, and reduce structural neurologic changes in early disease. Patients at high risk for poor adherence or relapse should also be considered for LAI antipsychotics. When used in combination with cognitive and behavioral techniques that help patients understand their illness and need for treatment, LAI antipsychotics may help some patients break a cycle of multiple hospitalizations resulting from unstable illness.

Clinical benefits of LAI use include:

• Improved medication adherence: The biggest advantage of long-acting injectable antipsychotics is that they significantly improve medication adherence because they largely eliminate the need for daily pill taking.
• Stable drug levels: Long-acting injectables provide steady and controlled release of the medication, helping maintain consistent blood levels of the drug and may lead to better therapeutic consistency and fewer side effects.
• Monitoring: The use of long-acting injectables allows healthcare providers to better monitor treatment adherence, which can be vital in managing conditions like schizophrenia or bipolar disorder.
• Fewer relapses: Several studies have shown that using LAI antipsychotics can help patients avoid psychiatric hospitalizations and reduce the frequency of relapses.
• Less daily impact: A regular injection may be less disruptive or stigmatizing than taking daily oral medications, particularly if the injections can be administered at a general healthcare provider, rather than a psychiatric facility.
• No first-pass metabolism: Unlike oral medications, LAI antipsychotics bypass the gastrointestinal tract and first-pass metabolism in the liver so they can often be given in lower doses with similar therapeutic efficacy.

Typically, patients are transitioned to the LAI formulation of the same oral antipsychotic they responded to. However, it is important to consider other factors in the selection such as patient comorbidities and potential side effects. Like oral medications, second-generation LAI antipsychotics are favored because of their more favorable side effect profile.

See this table adapted from Guide to Long-Acting Medications.

LAI best practices:

1. Focus on member preference for treatment, empowering the member to take ownership and understanding of their treatment plan.
2. During administration use the proper injection technique and systematically rotate the injection site.
3. Discuss potential side effects and educate members on what to do in an emergency, such as if they are having suicidal thoughts.
4. Ensure maintained appointment availability in practice for patients and schedule follow-up appointments and subsequent injections before the patient leaves the current appointment.
5. Outreach patients who cancel appointments and reschedule as soon as possible to maintain medication adherence and continuity of care.
6. Obtain baseline diabetes initial screening, test again three to four months later, then order annually.
7. Order a yearly diabetes screening test for all patients on antipsychotic medication.
8. Include a family member or caregiver in discussions regarding treatment when able.

Quality impact — Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA) HEDIS^® measure:

• SAA measure description: the percentage of members 18 years of age and older during the measurement year with schizophrenia or schizoaffective disorder who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period.
• Inclusion criteria:
  • Members with either one acute inpatient encounter or two outpatient encounters with a diagnosis of either schizophrenia or schizoaffective disorder with at least two antipsychotic medication dispensing events
  • Members aged 18 and older covered under Commercial, Medicaid, or Medicare lines of business
• Exclusion criteria:
  • Members with dementia
  • Members over the age of 80 diagnosed with frailty
  • Members using hospice services at any time during the year
• A member passes the measure when their proportion of days covered (PDC) for their antipsychotic medications is at least 80% of their treatment period.

The Affordable Care Act (ACA) requires many health plans to cover recommended preventive care services without member cost sharing when the services are rendered by an in-network provider and/or facility. Screening colonoscopies (even when polyps are removed) are included as a covered preventive care service. Since colonoscopies are rendered for both screening and diagnostic purposes, it is important for providers to use appropriate coding guidelines when reporting colonoscopies. When inappropriate CPT^® and ICD-10-CM codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.

The following services are covered with no member cost share:

• The colonoscopy screening procedure
• Anesthesia charges when anesthesia is billed with the appropriate screening CPT code (even when polyps are removed)
• Other associated facility charges when the colonoscopy is billed with an appropriate screening diagnosis code
• When polyps are removed during a screening colonoscopy — the removal, examination, and analysis of the polyps

When a screening colonoscopy starts out as screening but turns into a diagnostic procedure due to polyps being removed, Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. follow CPT guidelines for the Commercial benefit plans — not Medicare guidelines. The CPT 2018 Professional Edition manual shares the following information regarding the billing of anesthesia for any screening colonoscopy: “Report 00812 to describe anesthesia for any screening colonoscopy regardless of ultimate findings.”

We are committed to helping our members more easily access the care they need.

To align with Department of Medical Assistance Services requirements, we are updating our claims processing system. All telehealth claims billed with a date of service on or after November 1, 2024, must use place of service codes (POS) 02 or 10 only.

This update will retroactively allow POS code 02 back to May 13, 2024. Claims using POS 02 may continue to be denied until November 1, 2024, but will be reprocessed after this update is complete.

State guidance on telehealth services can be found here.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.

As respiratory syncytial virus (RSV) season approaches, we would like to remind providers about available RSV immunizations to help prevent severe RSV related disease in infants. According to a report from the CDC (March 2024), infant preventive antibodies showed 90% effectiveness against the need for hospitalization for RSV in babies. Two immunizations are available to prevent RSV lower respiratory tract infections in infants:

• Pfizer's Abrysvo, a maternal vaccine given during pregnancy
• Nirsevimab (Beyfortus), a monoclonal antibody administered to the baby

The maternal vaccine, Abrysvo, is recommended for those who are 32 to 36 weeks pregnant during RSV season, which generally falls between October and March. The vaccine can provide protection for infants up to six months if the mother receives it at least two weeks prior to delivery.

Nirsevimab (Beyfortus) provides up to five months of protection against RSV and is approved for infants under 8 months during their first RSV season, and certain children between 8 and 19 months at increased risk of severe RSV disease. In some cases where a mother received an RSV vaccine, Nirsevimab can still be considered for the child if there is a substantial risk for severe RSV disease or if the maternal immune response to the vaccination is inadequate.

Nirsevimab is covered under the Vaccines for Children Program. Additional information about RSV prevention and Nirsevimab (Beyfortus) can be found at cdc.gov/rsv.

We look forward to sharing resources and working with you to achieve improved outcomes for children in our communities.

Please open this flier to learn more about opportunities to enhance your skill set in caring for patients with intellectual and developmental disabilities. Upon completion of this course, you will earn CME credits.

As a contracted provider for a special needs plan (SNP) from Anthem, you are required to participate in an annual Model of Care training for providers, per CMS regulations. This training includes a detailed overview of Anthem special needs plans and program information, highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Please remember this training is specific to our plans and delivery of care for members, ensuring their specific care needs are met. Your participation is critical for improved quality and health outcomes.

Training for the SNP product is self-paced and available at Availity.com. The training must be completed by December 31, 2024.

How to access the Custom Learning Center:

1. Log in to the Availity website at Availity.com.
2. At the top of the Availity website, select Payer Spaces and select the appropriate payer.
3. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
4. In the Custom Learning Center, select Required Training.
5. Select Special Needs Plan and Model of Care Overview.
6. Select Enroll.
7. Select Start.
8. Once the course is completed, select Begin Attestation and complete.

Not registered for Availity Essentials?

Have your organization’s designated administrator register your organization for the Availity website:

1. Visit Availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

Refer to these PDF documents for complete registration instructions.

In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care, effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here.

Site of Care Guidelines:

• Site of Care for Advanced Imaging
• Rehabilitative Site of Care
• Surgical Site of Care

Please share this notice with other members of your practice and office staff.

In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here:

• Site of Care Guidelines:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

Please share this notice with other members of your practice and office staff.

Effective on November 17, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.

You may access and download a copy of the current and upcoming guidelines here:

• Musculoskeletal:
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

The above guideline updates have a publish date of November 17, 2024.

Please share this notice with other members of your practice and office staff.

Effective on November 30, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines updates will be adopted for HealthKeepers, Inc. This article is to communicate the plan adoption of these Clinical Appropriateness Guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.

You may access and download a copy of the current and upcoming guidelines here.

• Genetic Testing:
  • Cell-free DNA Testing for the Management of Cancer
  • Prenatal Testing using cell-free DNA
  • Somatic Tumor Testing
• Musculoskeletal:
  • Joint Surgery
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

The above guideline updates have a publish date of November 17, 2024.

Please share this notice with other members of your practice and office staff.

At a glance:

• High Performing Providers will also be known as Anthem Diamond Providers.
• Providers receiving a designation based on the Blue National Physician Performance Dataset will also be known as Anthem Diamond Providers (National).

High Performing Provider program

Over the last several months, we have communicated with our providers about our High Performing Provider program. PCPs and specialists meeting certain criteria are designated High Performing Providers. High Performing Providers may also be referred to as Anthem Diamond Providers.

As a reminder, the following specialties may be designated High Performing Providers (aka Anthem Diamond Providers) from this program:

• PCP: family practice, general practice, geriatric medicine, internal medicine, pediatric medicine, and nurse practitioners
• Specialists: cardiology, endocrinology, nephrology, neurology, neurosurgery, obstetrics gynecology, orthopedic surgery, psychiatry, pulmonology, and rheumatology

If you have any questions about this program, contact Provider Services or your local provider relationship management representative.

Blue National Physician Performance Dataset

This is an Anthem designation program for providers in networks supporting Anthem national accounts and certain out-of-area providers.

As we previously communicated to you, effective January 1, 2025, Anthem may incorporate insights from the Blue National Physician Performance Dataset (Dataset) in various initiatives. For Anthem national accounts and certain out-of-area providers, Anthem will use data made available in the Dataset to assess individual physician’s performance at the NPI level. The individual physician’s performance is assessed across the three domains — cost of care/efficiency, quality of care, and appropriateness of care — for the following 16 primary care and specialty areas: cardiothoracic surgery, cardiovascular disease, endocrinology, neurology, ob/gyn, ophthalmology, orthopedics, pediatrics, primary care, pulmonology, surgery, urology, gastroenterology, otolaryngology, oncology, and radiation oncology.

The providers who qualify for the designation from this Dataset program will also be referred to as Anthem Diamond Providers (National).

If you have any questions regarding this, contact your local provider relationship management representative.

At a glance:

• Care providers must prepare for HEDIS^® medical record reviews starting January 2025.
• Care providers will submit records through Remote Electronic Medical Record (EMR) Access Service, website upload, fax, secure file transfer protocol (SFTP), mail, or on-site.

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

Background

Each year, we perform a review of a sample of our members’ medical records as part of the HEDIS quality study. HEDIS is part of a nationally recognized quality improvement initiative and is used by the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and several states to monitor the performance of managed care organizations.

We will begin requesting medical records in January 2025. No special authorization is needed for you to share member medical record information with us since quality assessment and improvement activities are routine parts of healthcare operations.

Ways to submit your records in our preferred order:

• Remote EMR Access Service: We offer the Remote EMR Access Service to care providers to submit member medical record information to us. If you are interested in more information, contact us at Centralized_EMR_Team@anthem.com.
• Upload: Medical records can be uploaded to our secure website using the instructions in the request document.
• Fax: Medical records can be faxed to us using the instructions in the request document.
• SFTP: Medical records can be uploaded via a secure website.
• U. S. Postal Service: Medical records can be mailed to us using the instructions in the request document.
• On-site: Medical records can be pulled by a representative at your local office where medical records are located.

HEDIS review is time sensitive, so submit the requested medical records within the timeframe indicated in the initial HEDIS request document.

We appreciate the care you provide our members. Your assistance is crucial to ensuring our data is statistically valid, auditable, and accurately reflects quality performance.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

The Consumer Assessment of Healthcare Providers and Systems^® (CAHPS) is an annual standardized survey conducted anonymously by a third-party vendor (Center for the Study of Services) to assess a random sample of consumers' experiences with their health plan, their personal provider, and healthcare services.

Refer to attachment to view full details.