As previously communicated in our March 2019 edition of Provider News, Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. have launched an effort to begin direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs).  This means that NPs and PAs may begin billing their services under their own 10-digit National Provider Identifier (NPI).  This effort will impact all our lines of business: 

 

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

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

 

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

 

• Medicare Advantage health plans.

 

Virginia legislation passed in March 2019 that now requires payers to offer provider contracting opportunities to nurse practitioners who meet Anthem’s terms and conditions effective October 1, 2019. Currently, licensed NPs and PAs can only bill for covered services under the supervision of the employing/supervising participating physician using that physician’s name and NPI number.  Direct contracting means NPs and PAs will be allowed to bill Anthem directly for their services, and the “incident to” guidelines will no longer apply.

 

Benefits of direct contracting for NPs and PAs

 

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

 

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

How Anthem’s contracting process will work

 

Our credentialing and contracting efforts for NPs and PAs are now under way. 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 contains all of the same provisions and obligations as our standard physician agreements.  The allowance schedule will be the same as the current standard physician allowance for our commercial and Medicaid agreements. For Medicare Advantage, we will reimburse NP and PA services at 100 percent of the Anthem Medicare Advantage rate for these provider types.

 

Contracts and network participation for NPs and PAs will not be effective any sooner than September 1, 2019. After September 1, the individual provider’s effective date will be the later of the contract signature date or when credentialing is complete.

 

Credentialing process

 

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

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

 

In addition, we use our email service to communicate new information. If you are not yet signed up to receive our business critical emails, we encourage you to enroll now so you’ll be sure to receive all information we send about billing, upcoming changes, coverage guidelines and other pertinent topics.

 

Reminder notifications sent via email

 

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

 

 

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

 

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

 

• Thursday, October 10, 2019, from 11:30 a.m. to 12:30 p.m. ET

 

Please take time to register today for the webinar using the registration form to the right under the “Article Attachments” section. If you have already registered for the October webinar, please ensure you have received a fax confirmation or a confirmation from an Anthem representative to ensure we’ve received your registration form.  Contact stacey.marsh@anthem.com if you need to confirm your registration.

 

 

 

As a reminder, providers and facilities are required to review all member information received from Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. to help ensure no misrouted PHI is included. Misrouted PHI includes information about members that a provider or facility is not currently treating. PHI can be misrouted to providers and facilities by mail, fax or e-mail. Providers and facilities are required to immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are providers or facilities permitted to misuse or re-disclose misrouted PHI. If providers or facilities cannot destroy or safeguard misrouted PHI, providers and facilities must contact Anthem’s provider services area to report receipt of misrouted PHI.

 

Anthem has been advising via this publication and letters to your offices, of the requirement that your practice provide continuation of care for our members outside of regular business hours.  We have annually conducted after-hours access studies to assess how well practices are meeting this provision, and a high percentage of primary care physicians (PCP) offices do not have the basic messaging for our members for perceived emergency or urgent situations after regular office hours.

 

To be compliant, have your messaging or answering service include appropriate instructions.

 

Emergency situations

 

The compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects caller directly to the physician.  

 

Urgent situations

 

The response for urgent would direct the caller to Urgent Care or ER, to call 911 or directly connect the caller to their physician or the physician on call. 

 

Messaging that only gives callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions is not compliant, as there is no direct connection to their health care practitioner. 

 

Is your practice compliant?

 

Anthem Blue Cross and Blue Shield (Anthem) is working to deliver a new digital ecosystem that better supports our members.  To that end, our new platform is designed to give our members a more personal, simplified experience.  Anthem is driving meaningful change through technology and Artificial Intelligence (AI) powered innovation to deliver an easier to use, more complete Web and mobile health care experience.

 

We’re excited to announce the launch of Sydney – our new mobile app that runs on intelligence – as part of our digital strategy.  Launching September 1, 2019, the new app replaces Anthem Anywhere and provides the same services that members receive from Anthem Anywhere, plus we’ll phase in other features and new capabilities over time. In return, members will get a truly integrated mobile experience with even more personalized information to fit their unique needs. These changes will lead to a more personal experience, better engagement and improved health outcomes.

 

Beginning September 1, members enrolled in our commercial health benefit plans* (including those plans members purchase on or off the Health Insurance Marketplace) and Medicare health benefit plans will have with Sydney a personalized health assistant that connects questions to answers – and people to the right resources. It's all part of a more seamless digital experience, bringing together fully integrated benefit details, claims information, care finder tools, access to spending accounts and wellbeing programs.  Members can download Sydney at the app stores starting September 1. 

 

As part of our rollout efforts on September 1, Anthem will also launch – using a phased approach – a digital solution called My Family Health Record (MyFHR).  MyFHR offers several benefits for members and providers.  Members will be better able to manage their own health, address care gaps, and have the ability to download electronic medical records (EMR) from one or more providers. With MyFHR, members will also have the ability to share EMR information with family, caregivers, and providers.

 

Watch for information on future enhancements to Sydney and MyFHR in upcoming editions of Provider News. 

 

*Excludes Medicaid health benefit plans.

As part of our recent amendment fee schedule notification in Virginia, we recognize that we made an error to three (3) procedure codes. This edition of Provider News is correcting the procedure codes as follows:

 

Code	Modifier	Corrected rate
80050		$17.36
88305		$42.34
88305	26	$24.13
88305	TC	$18.21
88307		$108.00
88307	26	$35.14
88307	TC	$72.86

 

Please contact your Anthem network manager if you have questions.

Anthem has been advising, via this publication and the Provider Manual, of the requirement that your practice provide the capability for a new patient appointment within a given timeframe. We annually conduct appointment access studies to assess how well practices are meeting this provision and a high percentage of behavioral health (BH) offices do not have timely access for new patients.

 

To be compliant, providers are expected to make best efforts to meet the following access standards:

 

• Initial Routine office visit – A new patient must be seen in the office by a designated BH Practitioner or another equivalent Practitioner in the practice within 10 business days.

Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms, which present no immediate distress and can wait to schedule an appointment without any adverse outcomes. It can be after the Practitioners intake assessment or a direct referral from a treating Practitioner.

 

Is your practice compliant?

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

 

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website at anthem.com/provider/Provider Overviews> scroll down and select ‘Find Resources for Virginia’ > Health and Wellness > Practice Guidelines.

 

Continuing our 2019 reporting CRA updates, Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. request your assistance with respect to our reporting processes.

 

The Centers for Medicare & Medicaid Services (CMS) are conducting a RADV Audit beginning June 2019 through January 2020.  This audit is in accordance with the provisions of the Affordable Care Act (ACA) and its risk adjustment data validation standards.

 

For this audit, CMS will select a statistically valid sample of Anthem’s members enrolled in an ACA-compliant plan. Providers whose patients during the benefit year 2018 were selected for this audit will receive requests and must provide copies of medical record(s)/chart(s). This audit is to verify that diagnosis codes, which have been submitted on claims and reported to CMS, are accurate, properly documented, and coded with accurate levels of specificity.

 

In the event your patients are selected for this RADV audit, please note that Anthem and HealthKeepers, Inc. are working with several vendors to collect the needed medical records and signature attestations (if applicable).  Representatives from Anthem or our vendors may reach out to you to request the required medical records and signature attestations.  We appreciate your assistance and patience during this process.

 

Be advised that Anthem is not requesting copies of “psychotherapy notes” as defined by the Health Insurance Portability and Accountability Act (HIPAA).  Under HIPAA, psychotherapy notes are defined as “notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the individual’s medical record.  However, any data excluded from the definition of psychotherapy notes must be provided where applicable and pursuant to this request.  The following list of items are not included in the definition of “Psychotherapy notes” and therefore, can be included pursuant to HIPAA:

 

• Medication prescription and monitoring
• Counseling session start and stop times
• Modalities and frequencies of treatment furnished
• Results of clinical tests; and
• Summary of the following:

o Diagnosis
o Functional status
o Treatment plan
o Symptoms
o Prognosis; and
o Progress to date

 

If you have any RADV audit questions/concerns, please contact Evelyn.Rey-Hipolito@anthem.com.

 

If you have any questions regarding our reporting process, please contact our CRA network education representative – Alicia.Estrada@anthem.com.

 

Medicare Advantage

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

• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ

• Group Retiree members and National Access Plus

• Bill Medicare Part D for shingles or tetanus vaccination claims

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Medicare Advantage

 

Effective January 1, 2020, IngenioRx will become our new pharmacy benefit manager (PBM) and will start managing prescription coverage for your Medicare Advantage individual and group retiree plan patients. IngenioRx PBM services will include handling your patients’ prescriptions for mail order and specialty pharmacy medications.

 

Transferring prescriptions

 

We will automatically transfer prescriptions to IngenioRx Home Delivery Pharmacy for patients currently using Express Scripts Mail Order Pharmacy. Members will receive instructions for initializing IngenioRx Home Delivery Pharmacy later this year. For patients receiving specialty drugs from Accredo, we will automatically transfer prescriptions to IngenioRx Specialty Pharmacy. Most patients will be able to fill their prescriptions at their same retail pharmacy outlet. If your patient’s pharmacy will not be available, we will notify your patient by letter and include a list of three alternative pharmacies near his or her home.

 

Prescriptions for controlled substances currently being filled at Express Scripts Mail Order Pharmacy or Accredo cannot be transferred to another pharmacy under federal law. Patients currently receiving these medications will need a new prescription sent to IngenioRx Home Delivery Pharmacy or IngenioRx Specialty Pharmacy.

 

For providers	Then
Who use ePrescribing	There are no changes — Simply select IngenioRx.
Who do not use ePrescribing	You should send your mail order and specialty prescriptions to IngenioRx. IngenioRx will begin accepting prescriptions January 1, 2020. Please consider the days’ supply of the prescription when making these requests.   IngenioRx Mail Order Pharmacy new prescriptions: o   Phone: 1-833-203-1742 o   Fax: 1-800-378-0323   IngenioRx Specialty Pharmacy: o   Prescriber phone: 1-833-262-1726 o   Prescriber fax: 1-833-263-2871

 

You can confirm whether your patient has transitioned to IngenioRx through the Availity Portal.

Your patient’s PBM information can be located in the Patient Information section of their patient profile as part of the eligibility and benefits inquiry.

 

If you have immediate questions, you can contact the Provider Service phone number on the back of your patient’s ID card or call the number you normally use for questions.

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Medicare Advantage

Beginning December 1, 2019, prior authorization (PA) requirements will change some codes covered by Anthem Blue Cross and Blue Shield (Anthem) for Medicare Advantage members. Federal and state law, state contract language and CMS guidelines (including definitions and specific contract provisions and exclusions) take precedence over these rules and must be considered first when determining coverage. Anthem will deny claims that are noncompliant with the new rules.

 

PA requirements will be added to the following:

 

• T1019 — Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)

 

• C9740 — Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants

 

• E0953 — Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware

 

• E1031 — Rollabout chair, any and all types with castors 5 inches or greater

 

• E1090 — High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests

 

• E1130 — Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests

 

• E1140 — Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests

 

• E1260 — Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest

 

• E1285 — Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest

 

• E1290 — Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest

 

• E2207 — Wheelchair accessory, crutch and cane holder

 

• E2378 — Power wheelchair component, actuator, replacement only

 

• K0039 — Leg strap, H style

Not all PA requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com. Contracted and noncontracted providers who are unable to access the Availity Portal may call the number on the back of your patient’s Anthem ID card for PA requirements.

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Medicare Advantage

Effective November 1, 2019, customizations will be implemented for Chemotherapy and Inpatient & Surgical Care (W0162) for adult patients. The customizations provide specific criteria and guidance on the following:

 

• Clinical indications for admission; examples will also be added for:

          o Aggressive hydration needs that cannot be managed in an infusion center

          o Prolonged marrow suppression.

 

• Regimens that cannot be managed outpatient; examples will also be added.

 

Providers can view a summary of the 23rd edition of the MCG Care Guidelines customizations online by selecting Customizations to MCG Care Guidelines 23rd Edition.

502203MUPENMUB

 

Medicare Advantage

On March 29, 2019, April 12, 2019 and May 1, 2019, the Pharmacy and Therapeutic (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 website (www.anthem.com/medicareprovider), and the effective dates will be reflected in the Clinical Criteria Q2 update. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

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Medicare Advantage

As we prepare for the potential regulatory-proposed standards for electronic attachments, Anthem Blue Cross and Blue Shield (Anthem) will be implementing X12 275 electronic attachment transactions (version 5010) for claims.

 

Standard electronic attachments will bring value to you by eliminating the need for mailing paper records and reducing processing time overall. 

 

Anthem and Availity will pilot electronic data interchange batch electronic attachments with previously selected providers. Both solicited and unsolicited attachments will be included in our pilots.

 

Attachment types

 

• Solicited attachments: The provider sends a claim and the payer determines there is not enough information to process the claim. The payer will then send the provider a request for additional information (currently done via letter). The provider can then send the solicited attachment transaction, with the documentation requested, to process the claim.

 

• Unsolicited attachment: When the provider knows that the payer requires additional information to process the claim, the provider will then send the X12 837 claim with the Paper Work Included segment tracking number. Then, the provider will send the X12 275 attachment transaction with the additional information and include the tracking number that was sent on the claim for matching.

What you can do

 

As we prepare for this change, you can help now by having conversations with your clearinghouse and/or electronic healthcare records vendor to determine their ability to set up the X12 275 attachment transaction capabilities.

 

In addition, you should be on the lookout for additional information and details about working with Anthem and Availity to send attachments via electronic batch.

 

501704MUPENMUB

 

Effective since May 1, 2019, certain service requests for Anthem HealthKeepers Plus members require medical necessity review for level of care. This includes requests for certain procedures currently reimbursed in the inpatient setting (for example, services corresponding to codes found on the CMS Inpatient Only [IPO] List).

 

Certain services that have historically been authorized in the acute inpatient setting may be clinically appropriate for an alternate level of care. For example, while codes for services are listed on the CMS IPO List (a list developed for use in Medicare and not Medicaid managed care), the corresponding services may be appropriate for an alternate level of care. When a request is submitted for a service that may be appropriate for a level of care other than acute inpatient, we review the procedure for medical necessity and apply medical necessity criteria to determine if inpatient level of care is medically necessary.

 

To review for appropriate level of care, we use the applicable MCG Care Guidelines, which may include customizations specifically for Anthem HealthKeepers Plus members, applicable Clinical Utilization Management (UM) Guidelines or AIM Specialty Health® (AIM) guidelines. If medically necessary criteria for the procedure are met, the procedure will be approved. If inpatient level of care is requested but medical necessity criteria for acute inpatient care is not met, the request for inpatient level of care will be denied. A modified approval or denial letter will be issued accordingly.

 

Services requiring prior authorization

 

The list of services requiring prior authorization (PA) will be updated as needed. Regardless of whether PA is required, all services must be medically necessary to be covered. To avoid a claim denial based upon medical necessity, we encourage you to review the corresponding medical necessity criteria prior to rendering nonemergent services (even if PA is not required).

 

Please review the Clinical UM Guidelines and Coverage Guidelines on the provider page as well as the AIM guidelines. The specific MCG Care Guidelines used to make a determination can be provided upon request.

 

Providers are responsible for verifying eligibility and benefits for members before providing services. Excluding emergencies, failure to obtain PA for the services and level of care requiring PA may result in a denial of reimbursement.

 

Requesting PA via Interactive Care Reviewer

 

We are pleased to offer Interactive Care Reviewer (ICR), a UM website that allows you to submit PA requests. ICR is accessible via the Availity Portal at no cost to providers. ICR will accept:

 

• Inpatient requests.

• Outpatient requests.

• Medical and surgical requests.

 

Availity is an independent company that administers a secure provider portal on our behalf. We encourage you to use ICR to submit new PA requests and check the status of already submitted PA requests. If you have questions about ICR or the Availity Portal, contact your network representative.

 

Requesting PA via phone

 

To request PA via phone, report a medical inpatient admission or ask questions regarding PA, contact the UM department at 1-800-901-0020.

 

Requesting PA via fax

 

To request PA via fax for:

 

• Inpatient or outpatient services, call 1-800-964-3627.

• Medical pharmacy (for drugs typically administered by a health care professional), call 1-844-512-7022.

• Pharmacy (for drugs typically self-administered), call 1-844-512-7020.

 

What if I need assistance?

 

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.

On March 29, 2019, April 12, 2019, and May 1, 2019, the Pharmacy and Therapeutic (P&T) Committee approved changes to Clinical Criteria applicable to the Anthem HealthKeepers Plus 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 our provider website (https://mediproviders.anthem.com/va), and the effective dates will be reflected in the Clinical Criteria Q2 web posting. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutic (P&T) Committee approved changes to 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 is publicly available on the provider website (https://mediproviders.anthem.com/va), and the effective dates will be reflected in the Clinical Criteria Q1 web posting. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

The upgrade to the 23rd edition of the MCG Care Guidelines for HealthKeepers, Inc. has changed from May 24, 2019, to September 5, 2019. In addition, HealthKeepers, Inc. has customized some of the MCG Criteria for members enrolled in Anthem HealthKeepers Plus.

 

Customizations to the 23rd edition of the MCG Care Guidelines:

 

Effective September 5, 2019, the following customizations will be implemented:

 

• Left Atrial Appendage Closure, Percutaneous (W0157) — customized to refer to SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention

 

• Spine, Scoliosis, Posterior Instrumentation, Pediatric (W0156) — customized to refer to Musculoskeletal Program Clinical Appropriateness Guidelines, Level of Care Guidelines and Preoperative Admission Guidelines

 

Effective November 1, 2019, customizations will be implemented for Chemotherapy and Inpatient & Surgical Care (W0162) for adult patients. The customizations provide specific criteria, guidance and/or examples for the following:

 

• Clinical indications for admission:

          o Aggressive hydration needs that cannot be managed in an infusion center

          o Prolonged marrow suppression

 

• Regimens that cannot be managed outpatient

 

Providers can view a summary of the 23rd edition of the MCG Care Guidelines customizations online by selecting Customizations to MCG Care Guidelines 23rd Edition (Publish date November 1, 2019).

 

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.

In December 2018, providers were notified of a new clinical guideline for wound care in the home setting. In order to assist you in receiving authorization for Anthem HealthKeepers Plus members as quickly as possible, we have developed a fax sheet for wound care requests. This information is required in order to determine wound healing strategies over time. We suggest using this format instead of sending multi-page faxes for review. This will enable our review team to accurately and quickly review the plan of care so that you receive authorization as soon as possible.

 

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.

 

In an ongoing effort to ensure accurate claims processing and payment, HealthKeepers, Inc. is taking additional steps to verify the accuracy of payments made to Anthem HealthKeepers Plus providers. Beginning on October 27, 2019, HealthKeepers, Inc. will assess selected claims for evaluation and management (E&M) services using an automated analytic solution to ensure payments are aligned with national industry coding standards.

                                                                                                                          

Providers should report E&M services in accordance with the American Medical Association CPT manual and CMS guidelines for billing E&M service codes (Documentation Guidelines for Evaluation and Management).

 

The level of service for E&M service codes is based primarily on the documented key factors, medical history, examination and medical decision-making. Counseling, coordination of care, the nature of the presenting problem and face-to-face interaction are considered contributing factors. The appropriate E&M level code should reflect and not exceed what is needed to manage the member’s condition(s).

 

Claims will be selected from providers who, based on a risk adjusted analysis, code a higher level E&M services compared to their peers with similar risk-adjusted members. Individual claims will be identified as over-coded based on a claim specific risk adjusted analysis. If a claim is determined to be over-coded, it will be reimbursed at the fee schedule rate for the appropriate level of E&M for the condition(s) identified. Providers whose coding patterns improve are eligible to be removed from the program.

 

If providers have medical record documentation to support reimbursement for the originally submitted E&M service, those medical records should be submitted for consideration.

 

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.

Effective December 1, 2019, prior authorization (PA) requirements are changing for the codes listed below. The listed codes will require PA by HealthKeepers, Inc. for Anthem HealthKeepers Plus members and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC 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 are being added to the following:

 

• Lower extremity prosthesis — shank foot system with vertical loading pylon (L5987)

• Gait trainer, pediatric size — anterior support, includes all accessories and components (E8002)

• Wheelchair, pediatric size — tilt-in-space, folding, adjustable, without seating system (E1234)

• Wheelchair, pediatric size — tilt-in-space, rigid, adjustable, without seating system (E1233)

• Transport chair, pediatric size (E1037)

• Multi-positional patient transfer system with integrated seat, operated by care giver (E1035)

• Wheelchair accessory — ventilator tray, gimbaled (E1030)

• Water circulating heat pad with pump (E0217)

 
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 (for Anthem HealthKeepers Plus members), 1-855-323-4687 (for Anthem CCC Plus members)

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-800-901-0020 (for Anthem HealthKeepers Plus members) or 1-855-323-4687 (for Anthem CCC Plus members) for PA requirements.