 Provider News VirginiaSeptember 2021 Anthem Provider News - VirginiaIn the August 2021 edition of Provider News, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. announced that we would be implementing a more streamlined provider payment dispute process for claims for our Commercial lines of business. The process is already in place for claims for members enrolled in our Anthem HealthKeepers Plus (Medicaid) and Medicare Advantage benefit plans.
Originally scheduled for August 17, the implementation date is now scheduled for September 21, 2021. We regret any inconvenience this delay may have caused.
Provider payment dispute process details
For easy reference, we are including information below shared in our August 2021 edition of Provider News.
Unlike claims status inquiries, clinical appeals, or requests for additional information, provider claim payment disputes occur after a claim is finalized, and providers disagree with the claim payments Anthem has issued. Some examples include claim disputes regarding manual processing errors, contract interpretation, reduced payments, code editing issues, other health insurance denials, eligibility issues, timely filing issues,* and so forth.
By aligning the provider claim dispute process across our lines of business, we’re working to have a more cohesive and efficient approach for providers when:
- Filing a claim payment dispute.
- Sending supporting documentation to Anthem.
- Checking the status of a claim payment dispute.
- Viewing the history of a claim payment dispute.
* We will consider reimbursement of a claim that has been denied due to failure to meet timely filing if you can: 1) provide documentation that the claim was submitted within the timely filing requirements; or 2) demonstrate good cause exists.
How the provider claim payment dispute process works
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For Anthem in Virginia, the provider claim payment dispute process consists of two steps:
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STEP 1
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Claim payment reconsideration: As the first step, the reconsideration represents providers’ initial request for an investigation into the outcome of the claim. Most issues are resolved at the claim payment reconsideration step. Providers may submit the claim dispute via customer service (refer to the phone number on the back of the member’s ID card), in writing or via Availity. However, providers are encouraged to submit all reconsiderations via Availity. Providers are only allowed one claim payment reconsideration per claim.
Anthem will make every effort to resolve the claims payment reconsideration within 30 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 30 additional calendar days. We will mail you a written extension letter before the expiration of the initial 30 calendar days.
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STEP 2
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Claim payment appeal: In this second step, providers who disagree with the outcome of the reconsideration may request an additional review as a claim payment appeal. However, we cannot process an appeal without a reconsideration on file. Providers may submit the claim dispute in writing or via Availity, but providers are encouraged to submit all appeals via Availity.
When submitting a claim payment appeal, please include as much information as you can to help us understand why you think the reconsideration determination was in error. If a claim payment appeal requires clinical expertise, it will be reviewed by appropriate Anthem clinical professionals.
Anthem will make every effort to resolve the claim payment appeal within 60 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 60 additional calendar days. We will mail you a written extension letter before the expiration of the initial 60 calendar days.
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Submitting claim payment disputes in writing
When submitting a claim payment dispute in writing, providers must include the Claim Information/ Adjustment Request 151 Form and submit to:
Anthem Blue Cross and Blue Shield
Provider Payment Disputes
P.O. Box 27401
Richmond, VA 23279
Submitting claim payment disputes via Availity
For step-by-step instructions to submit a claim payment dispute through Availity:
- Log into Availity at availity.com.
- Select Help & Training | Find Help.
- Under Contents, select Overpayments and Appeals.
- Select Dispute a Claim.
Through Availity, you can upload supporting documentation and receive immediate acknowledgement of your submission. You do not need to attach a Claim Information/Adjustment Request 151 Form for Commercial claims or a Claim Payment Appeal Form when using Availity.
Anthem’s review and providers’ other options
Anthem will review the claim payment dispute once received and communicate an outcome in writing or through the Availity Portal. Providers can check the status of a claim payment dispute on the Availity portal at any time.
If a provider still disagrees with the reconsideration, the provider can then choose to submit the claim payment appeal. Once the claim payment appeal is submitted, the decision is final. A claim payment dispute may not be submitted again. Providers can contact their state regulatory agency for additional assistance.
Anthem requires providers to use our claims payment reconsideration process if providers feel a claim was not processed correctly.
Once providers complete both the Reconsideration and Appeal processes, providers can contact their Provider Experience Consultant for further assistance. However, providers are required to complete both the Reconsideration and Appeal processes before contacting their Provider Experience Representative for further assistance.
Webinars available
To learn more about the claim dispute tool, register for a live webinar:
- Log in to Availity and select Help & Training | Get Trained.
- Select Sessions and go to Your Calendar to locate a webinar.
- Select View Course and then select Enroll.
- The Availity Learning Center will email you with instructions to attend.
As always, providers can refer to the Provider Manual in their provider contracts, as the manual includes additional information about inquiries, the provider claim dispute process, reconsiderations and appeals. As a reminder, the above notice does not impact the Federal Employee Program.
The above notice applies to our Commercial lines of business. However, the notice does NOT impact the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP®).
Adults 40 to 75 years of age with diabetes, who do or do not have clinical atherosclerotic cardiovascular disease (ASCVD), should be started on a statin for primary and secondary prevention of ASCVD regardless of lipid status.1
Studies show that statin use reduces comorbidities and mortality from heart disease and non-adherence to statins may increase cardiovascular events and even death.2
Clinicians play a powerful role in ensuring their patients are adherent to their statin therapies. In fact, 90% of patients can be successfully adherent to statin therapy with a personalized approach.
CALL TO ACTION: We created this video to offer clinicians best practices in helping their patients remain adherent to their statin therapies.
The following seven strategies can help increase adherence to statin therapy in your patients:
- Initiate statin therapy for patients with diabetes or clinical ASCVD as appropriate
- For patients with diabetes without ASCVD, use MODERATE INTENSITY statin for primary prevention.2
- For patients with diabetes and ASCVD, use HIGH INTENSITY statin for secondary prevention.1
- Low Intensity statins are not recommended unless unable to tolerate moderate or high intensity.4
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Medications
One of the following medications must have been dispensed to satisfy the SUPD measure.
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Drug Category
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Medications
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Statin medication
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- Lovastatin
- Fluvastatin
- Pravastatin
- Simvastatin
- Rosuvastatin
- Atorvastatin
- Pitavastatin
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Statin combination products
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- Atorvastatin / amlodipine
- Atorvastatin / ezetimibe
- Lovastatin / niacin
- Simvastatin / ezetimibe
- Simvastatin / niacin
- Simvastatin / sitagliptin
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Timeframe
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Standard exclusion(s)
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Any time during the measurement year
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- End-stage renal disease
- Hospice
- Rhabdomyolysis or myopathy
- Pregnancy, lactation, or fertility
- Liver disease
- Pre-diabetes
- Polycystic ovary syndrome (PCOS)
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- If a statin is not suitable for a patient, document exclusion criteria with the appropriate ICD-10 code
- Educate patients about the long-term cardiovascular benefits of statin therapy and potential side effects
- Try a lower dose, different statin, or consider intermittent statin therapy if there were previous statin-associated side effects
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Intensity and dose of statin therapy
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High Intensity
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Moderate Intensity
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Low Intensity
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Daily dose lowers LDL-C on average by ≈ ≥50%
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Daily dose lowers LDL-C on average by ≈ 30% to <50%
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Daily dose lowers LDL-C on average by <30%
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Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg
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- Atorvastatin 10-20 mg
- Rosuvastatin 5-10 mg
- Simvastatin 20-40 mg
- Pravastatin 40-80 mg
- Lovastatin 40 mg
- Fluvastatin XL 80 mg
- Fluvastatin 40 mg bid
- Pitavastatin 2-4 mg
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- Simvastatin 10 mg
- Pravastatin 10-20 mg
- Lovastatin 20 mg
- Fluvastatin 20-40 mg
- Pitavastatin 1 mg
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- Inform patients that a significant number of generic statin medications are available for $0 for a 90-day supply on most plans
- Encourage patients to use their plan ID card to fill statin medications
- Watch this video to learn best practices on helping improve statin therapy adherence and your organization’s overall quality and STARS performance.
Did you know the cost Impact of medication non-adherence is $528 billion from non-optimized medication therapy?1 That’s equivalent to 16% of U.S. total health expenditures and contributes to 275,689 deaths per year.2
As a healthcare provider, you can motivate your patients to adhere to their medication regimens, which can contribute to improved outcomes and increased STARS performance. We developed this video to offer best practices in boosting medication adherence among your patient population.
Use the six SIMPLE strategies below to help improve medication adherence among your patient population.
S - Simplify the regimen
- Limit the # of doses and frequency
- Encourage adherence aids such as a pill box
- Utilize generic prescriptions if clinically appropriate
- Implement real-time pharmacy benefit to understand patient cost-share at the point of care
I - Impart knowledge
- Assess patient’s knowledge of medication regimen
- Provide clear medication instructions (written and verbal)
- Patient-provider shared decision-making
M - Modify patient beliefs and behavior
- Ask open ended questions about impact of not taking medications
- Empower patients to self-manage their condition
P - Provide communication and trust
- Provide emotional support
- Allow adequate time for the patient to ask questions
L - Leave the bias
- Understand patient’s health literacy and how it affects outcomes
- Develop a patient-centered communication styles
E - Evaluate Adherence
- Utilize motivational interviewing to confirm adherence
- Review pharmacy refill records, Rx bottles, lab testing
- Identify barriers to adherence
- Determine interventions and follow-up
- When appropriate, prescribe 90-day fills for chronic conditions
Watch this video to learn more best practices on helping improve medication adherence and your organization’s overall quality and STARS performance.
A mother has a sick child and like all good mothers, wants comfort and care for the child. And a prescription for antibiotics. BMJ Journals published a study that rated how many patients with upper respiratory infections (URI) prior to consultation with their physician expected a prescription for antibiotics:1
Evidence-based data does not support the use of antibiotics in the treatment of the common cold because they do not improve symptoms or shorten the course of the illness.2 Instead of putting away the prescription pad, use this one.
Offered by the Centers for Disease Control and Prevention’s (CDC) Be Antibiotics Aware campaign, the “Relief for common symptoms of colds and cough” prescription pad provides an alternative to unnecessary antibiotics. Get the prescription pad through the CDC website.
Measure up: HEDIS® guidelines for URI/Pharyngitis
URI measures the percentage of episodes for members 3 months of age and older with a URI diagnosis that did not result in an antibiotic dispensing event.
Appropriate Testing for Pharyngitis (CWP) evaluates members 3 years of age and older where the member was diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.
Records and Billing Codes
URI: In the patient’s medical records, document results of all strep tests or refusal for testing. If antibiotics are prescribed for another condition, take care to associate the antibiotic with the appropriate diagnosis.
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Description
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CPT/HCPCS/ICD-10
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Pharyngitis
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ICD10CM: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91
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URI
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ICD10CM: J00, J06.0, J06.9
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Online assessments
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CPT: 98970, 98971, 98972, 99421, 99422, 99423, 99457
HCPCS: G0071, G2010, G2012, G2061, G2062, G2063
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Telephone visits
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CPT: 98966, 98967, 98968, 99441, 99422, 99423
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CWI: In the patient’s medical records, document results of all strep tests or refusal for testing. If antibiotics are prescribed for another condition, take care to associate the antibiotic with the appropriate diagnosis.
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Description
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CPT/HCPCS/ICD-10
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Pharyngitis
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ICD10CM: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91
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Group A streptococcal tests
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CPT: 87070, 87071, 87081, 87430, 87650-87652, 87880
LOINC: 11268-0, 17656-0, 17898-8, 18481-2, 31971-5, 49610-9, 5036-9, 60489-2, 626-2, 6557-3, 6558-1, 6559-9, 68954-7, 78012-2
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Online assessments
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CPT: 98970, 98971, 98972, 99421, 99422, 99423, 99457
HCPCS: G0071, G2010, G2012, G2061, G2062, G2063
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Telephone visits
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CPT: 98966, 98967, 98968, 99441, 99422, 99423
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Overview
Join us in a Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving STARs ratings.
Program objectives
- Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas.
- Apply the knowledge you gain from the webinars to improve your organization’s quality and STARs ratings.
Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.
REGISTER HERE for our upcoming clinical quality webinars.
Effective November 1, 2021, EnrollSafe will replace CAQH Enrollhub as the electronic funds transfer (EFT) enrollment portal for Anthem providers. As of November 1, 2021, CAQH Enrollhub will no longer offer EFT enrollment to new users.
When you sign up for EFT through EnrollSafe, the new enrollment portal, you’ll receive your payments up to seven days sooner than through the paper check method. Not only is receiving your payment more convenient, so is signing up for EFT. What’s more, it’s easier to reconcile your direct deposits.
EnrollSafe is safe, secure and available 24-hours a day.
Beginning November 1, 2021, log onto the EnrollSafe enrollment hub at https://enrollsafe.payeehub.org to enroll in EFT. You’ll be directed through the EnrollSafe secure portal to the enrollment page, where you’ll provide the required information to receive direct payment deposits.
Already enrolled in EFT through CAQH Enrollhub?
If you’re already enrolled in EFT through CAQH Enrollhub, no action is needed unless making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, after October 31, 2021, use EnrollSafe to update your account.
Electronic remittance advice (ERA) makes reconciling your EFT payment easy and paper-free.
Now that you are enrolled in EFT, using the digital ERA is the very best way to reconcile your deposits – securely and safely. You’ll be issued a trace number with your EFT deposit that matches up with your ERA on Availity.
ERAs can be retrieved directly from Availity. Log onto Availity and select Claims and Payments > Send and Receive EDI Files > Received Files folder. When using a clearinghouse or billing service, they will supply the 835 ERA for you. You also have the option to view or download a copy of the Remittance Advice under Payer Spaces > Remittance Inquiry tool.
Instead of faxing multiple pages of medical records for HEDIS® studies, use Anthem Blue Cross and Blue Shield’s Remote Electronic Medical Record (EMR) Access Service we offer to providers – allowing us to access your EMR system directly to pull the documentation we need. Our Remote EMR Access Service helps reduce the time and costs associated with medical record retrieval while improving efficiency and lessening the impact on your office staff.
We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on Health Insurance Portability and Accountability Act (HIPAA) requirements, EMR systems, and HEDIS® measure updates. We complete medical record retrieval based on minimum necessary guidelines:
- We only access medical records of members pulled into the HEDIS® sample using specific demographic data.
- We only retrieve the medical records that have evidence related to the HEDIS® measures.
- We only view face sheets when there are demographic discrepancies.
- We exclude data related to hospice, long-term care, inpatient, and palliative care.
Let us help you. Getting started with Remote EMR Access is just one click away.
Download and complete this registration form and email it to us at Centralized_EMR_Team@anthem.com.
To learn more about our Remote EMR Access Service, view the frequently asked questions below.
How does Anthem retrieve medical records?
We access your EMR using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally, on our secure network drives.
Is printing necessary?
Yes. The National Committee for Quality Assurance (NCQA) audit requires print-to-file access.
Is this process secure?
Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives.
Why does Anthem need full access to the entire medical record?
There are several reasons we need to look at the entire medical record of a member:
- HEDIS® measures can include up to a 10-year look back at a member’s information.
- Medical record data for HEDIS® compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
- Compliant data may be documented or housed in a non-standard format, such as an in-office lab slip scanned into miscellaneous documents.
What information is needed to submit to use Anthem's Remote EMR Access Service?
Complete the registration form that requests the following information:
- Practice/facility demographic information (for example address, National Provider ID, taxpayer identification numbers, etc.)
- EMR system information (for example type of EMR system, required access forms, access type – web-based or VPN-to-VPN connection, special requirements needed for access, etc.)
- List of current providers/locations or a website for accessing this list. Also, if applicable, a list of providers affiliated with the group that are not in the EMR System.
In the July 2021 edition of Provider News, Anthem Blue Cross and Blue Shield (Anthem) announced that the Blue Cross and Blue Shield Service Benefit Plan (also called Federal Employee Program or FEP) will transition all reviews of diagnostic imaging services to AIM Specialty Health® (AIM) beginning October 1. 2021. In this September edition, we are sharing that the effective date of this transition has changed to November 1, 2021. These services will require prior authorization to determine medical necessity prior to rendering the service for Anthem federal employee members.
Your practice can benefit from participation in several ways, including:
- Improving the clinical appropriateness of imaging services through the application of evidence-based guidelines in an efficient and effective review process. Anthem Federal Employee Program (FEP) will be utilizing the FEP Medical Policy to review for medical necessity. In the absence of a controlling FEP Medical Policy, medical necessity determinations will be made using Anthem’s Coverage Guidelines, and/or AIM Clinical Guidelines.
- Maximizing a health plan’s network value through a wide range of solutions including provider assessment tools, cost and quality transparency and reporting.
- Engaging consumers in understanding the range of choices they have in selecting imaging providers and increasing their ability to make informed decisions.
For services that are scheduled to begin on or after November 1, 2021, all providers must contact AIM to obtain pre-service review for the following non-emergency modalities:
- Nuclear imaging, including myocardial perfusion imaging, cardiac blood pool imaging, infarct imaging and Positron Emission Tomography (PET) myocardial imaging
- Computed Tomography (CT), including CT angiography, derived fractional flow reserve, structural CT and quantitative evaluation of coronary calcification
- Magnetic Resonance Imaging (MRI)
- Magnetic Resonance Angiography (MRA)
- Magnetic Resonance Spectroscopy (MRS)
- Stress Echocardiography (SE)
- Resting Echocardiography (TTE)
- Transesophageal Echocardiography (TEE)
How to submit a request for review
In the July 2021 edition of Provider News, we also announced that providers could begin submitting requests for review on September 20, 2021. This date has now changed. Starting October 18, 2021, providers can begin submitting requests for review with dates of service on or after November 1, 2021, or can verify order numbers using one of the following methods as a registered AIM portal provider:
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How to register online:
The AIM ProviderPortalSM is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. To register, go to https://aimspecialtyhealth.com/providerportal/.
Registration opens October 18, 2021.
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How to register by phone:
Call AIM Specialty Health toll-free at 866-789-0397, Monday through Friday between 7 a.m. to 7 p.m. CT.
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For more information about the Radiology Program and to help your practice get started, go to: http://www.aimprovider.com/radiology.This website can also help you learn more about provider access to useful information and tools such as order entry checklists and clinical guidelines.
Anthem’s Federal Employee Program values your participation in our network, as well as the services you provide. We look forward to working with you to help improve the health of our members.
Prior authorization updates
Effective for dates of service on and after December 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
The Health Plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code (NDC), for the injected substance. This requirement is consistent with CMS guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.
Please note, inclusion of National Drug Code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Access the Clinical Criteria information.
For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.
This would apply to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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**ING-CC-0201
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J9999
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Rybrevant
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* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
Quantity limit updates
Effective for dates of service on and after December 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
The Health Plan requires that claims for injection services performed in the office setting must include the applicable HCPCS J-code, Q-code, or S-code, with the corresponding National Drug Code (NDC), for the injected substance. This requirement is consistent with CMS guidelines. A covered drug will not be eligible for reimbursement when the NDC is not reported on the same claim.
Please note, inclusion of National Drug Code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified code.
Access the Clinical Criteria information.
For Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc., prior authorization clinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of Oncology will still require pre-service clinical review by AIM Specialty Health® (AIM), a separate company.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
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Clinical Criteria
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HCPCS or CPT Code(s)
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Drug
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*ING-CC-0050
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J3490, J3590
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Skyrizi
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*ING-CC-0075
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Q5123
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Riabni
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* Non-oncology use is managed by the medical specialty drug review team.
** Oncology use is managed by AIM.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | September 1, 2021 Keep up with Medicaid news - September 2021Please continue to check our website https://providers.anthem.com/virginia-provider/communications for the latest Medicaid information for members enrolled in HealthKeepers, Inc.’s Anthem HealthKeepers Plus and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) benefit plans. Here are the topics we’re addressing in this edition:
Effective November 30, 2021, Anthem Blue Cross and Blue Shield claims for members who leave against medical advice and are admitted to another acute care facility on the same day are considered transfers and will follow the criteria detailed in the policy.
On November 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) prior authorization (PA) requirements will change for L8702 covered by Anthem. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.
PA requirements will be added for the following code:
- L8702 — Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://www.anthem.com/provider/news/archives/?cnslocale=en_US_co&category=medicareadvantage > Login or by accessing Availity.* Once logged in to Availity (http://availity.com), select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at the number on the back of your patients’ Anthem ID card for assistance with PA requirements.
The best way to ensure you're submitting everything needed for a prior authorization is to use the prior authorization/precertification form at https://www.anthem.com/medicareprovider > Providers > Provider Resources > Forms and Guides. By filling out the form completely and with as much information as possible, you can be sure we have the information to process your request timely.
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