 Provider News VirginiaSeptember 2022 Anthem Provider News - VirginiaThis communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).
We are carefully monitoring the recent outbreak of monkeypox infections in the U.S. and are working to support our members and our network care providers with information to help you respond appropriately in the context of your patient population.
The best source of up-to-date information is at the Centers for Disease Control and Prevention which has a dedicated monkeypox page for healthcare professionals.
In addition to resources for care providers, the CDC has developed educational materials for the public, available for free download online.
FAQ
Who can become infected?
With this recent outbreak, monkeypox has spread through close, intimate contact with someone who has monkeypox. Many cases initially occurred in men who have sex with men. However, anyone can get monkeypox.
How dangerous is the disease?
Monkeypox virus belongs to poxvirus family and infection is rarely fatal. Patients whose immune system is compromised are most at risk for severe disease, along with children younger than 8 years old, pregnant and breastfeeding people, and people with a history of atopic dermatitis or other active skin conditions.
What are monkeypox symptoms?
Patients often have a characteristic rash (well-circumscribed, firm, or hard macules evolving to vesicles or pustules) on a single site on the body. Patients may also present with a fever and muscle aches. The rash may start in the genital and perianal areas. The lesions are painful when they initially emerge, but can become itchy as they heal, and then go away after two to four weeks. Symptoms can be similar or occur at the same time as sexually transmitted infections.
How does monkeypox spread?
Monkeypox does not spread easily between people without close contact. Person-to-person transmission is possible by skin-to-skin contact with body fluids or monkeypox sores, or respiratory droplets during prolonged face-to-face contact, and less likely through contaminated items such as bedding, clothing, or towels. Patients are contagious until the scabs heal and are replaced by new skin.
Is there a monkeypox vaccine?
Yes, although at the time of this writing, availability is limited. Smallpox and monkeypox vaccines are effective at protecting people against monkeypox when given before exposure to monkeypox, and vaccination after a monkeypox exposure may help prevent the disease or make it less severe. You can access the CDC’s vaccination updates online.
How can monkeypox be treated?
There are no treatments specifically for monkeypox virus infections. However, antiviral drugs and vaccines developed to protect against smallpox may be used to prevent and treat monkeypox virus infections.
Do I need to report a case of suspected monkeypox?
Yes. Contact your state health department if you have a patient with monkeypox. They can help with testing and exposure precautions.
What are the behavioral health impacts of monkeypox?
Studies reporting psychiatric symptoms have indicated that the presence of anxiety, depression, or low mood is common among hospitalized patients with monkeypox infection. Care providers can help by listening with compassion, understanding underlying behavioral health concerns that may be heightened during isolation, and refer patients to the appropriate level of support following a monkeypox diagnosis.
Register today for the “Exploring the Intersection of Race and Disability” forum hosted by Anthem Blue Cross and Blue Shield (Anthem) and Motivo* for Anthem providers on September 21, 2022.
Anthem is committed to making healthcare simpler and reducing health disparities. We believe that continuing the discussion we started at our June 2022 event to deepen the conversation about the disability experience for people of is critically important. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve.
Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem about the intersection of disability and race. This forum will explore ways we can:
- Advance equity in healthcare
- Demonstrate cultural humility
- Address and deconstruct bias
- Have difficult and productive conversations
- Learn about valuable resources
- Increase the diversity of the healthcare profession.
Forum date and time
Wednesday, September 21, 2022
4 p.m. to 5:30 p.m. ET
Please REGISTER for this event today.
The Health Resources & Services Administration (HRSA) Women’s Preventive Services Guidelines recommend women receive at least one preventive care visit per year.
While many members may receive a standalone preventive care visit, well-women visits may also include prepregnancy, prenatal, postpartum, and interpregnancy visits. For members receiving prepregnancy, prenatal, postpartum, and/or interpregnancy care that is billed using a global maternity code (for example, CPT® 59400, 59510, 59610, 59618) or antepartum/postpartum codes (for example, CPT 59425, 59426, 59430), it is appropriate to submit a claim for a wellness visit (for example, CPT 99385, 99386, 99387, 99395, 99396, 99397) when recommended preventive care has been rendered for a member who has not received a wellness visit in the last year. This will help ensure recognition that recommended preventive services have been provided for our members.
Please note, wellness evaluation and management (E/M) codes should not be billed on the same day as global maternity or antepartum/postpartum codes. Providers should continue to verify eligibility and benefits for all members prior to rendering services.
As a reminder, when billing medical drug codes to Anthem Blue Cross and Blue Shield, include these three components:
- National Drug Code (NDC)
- Quantity
- Unit of measure
To prevent possible denial of the of the billed code, please ensure all three components are included in the claim.
Keeping your provider directory information current is key for members and your healthcare partners to engage with you seamlessly. Please review your information regularly and let us know if any of your information we show in our online directory has changed.
To update your information, use our online Provider Maintenance Form. Online update options include:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).
Effective July 1, 2022, Anthem recognizes and accepts qualifying claims for acute Hospital in Home (HiH) services through the newly established revenue code 0161. We encourage hospitals or other entities that meet the HiH requirements to reach out to their Anthem contractor to get an appropriate participation agreement in place, which will ensure more streamlined processing of HiH claims.
The new code enables hospitals to distinguish acute inpatient care in the home for qualifying patients. The code will follow the same guidelines and policies associated with any services performed in an inpatient setting, including but not limited to utilization management. Facilities must comply with all requests from Anthem for any information and data related to the HiH services and be an approved, active participant of the CMS Acute Hospital Care at Home Program for Medicare products. All services are subject to the Covered Individual Health Benefit Plan coverage and, if a covered benefit, the benefit will follow the inpatient hospital benefits that apply to services that are performed in a traditional hospital setting, which includes, but is not limited to, any applicable deductibles, copays, and coinsurance.
The following Anthem benefit plans are in scope for participation in HiH:
- Anthem Commercial
- Medicare Advantage (Individual and Group)
- Medicare Advantage Special Needs plans, including Dual-Eligible Special Needs (D-SNP)
The following Anthem plans are out of scope for participation in HiH:
- Federal Employee Program (FEP)
- Medicaid
Note:
- Be advised that while you may submit an electronic transaction to verify a Blue Plan member’s benefits and eligibility, Anthem suggests that you call the member’s Blue Plan to definitively determine whether the member has HiH benefits, since the electronic eligibility inquiry may not yield an answer specific to HiH eligibility. We suggest calling because if the member does not have this as a covered benefit, HiH services would then be the member’s financial responsibility.
- Covered individuals must express preference for and consent to treatment in the home setting for the HiH program and must be 18 years of age or older. This consent must be documented through a signed consent form. (Sample form available upon request.)
- Covered individuals may be admitted to the program from the emergency department (for a patient that needs the inpatient level of care) or transferred from the inpatient hospital setting.
- Facility shall not bill Anthem or the covered individual for any items or services provided by the facility in the home setting that typically would not be billed during an inpatient hospitalization.
- Notify Anthem immediately through the utilization management nurse assigned to the HiH case when:
- An applicable member is admitted to the HiH program
- A member in the program is transferred back to hospital inpatient care or has any other status change in their care plan
- As with other claims, participating facilities and/or providers may not bill the member for any denied HiH-related charges. Providers who disagree with the claim denial may request a review of the denial using the reconsideration and appeal process outlined in your Anthem Agreement and/or as outlined in the applicable Anthem provider manual.
- We will continue to update billing guidance as these programs evolve.
Three things to do when you do not find your claim in Claim Status
We appreciate the positive feedback you have shared about the new Claim Status Send Attachment feature. This enhancement to the attachment process enables you to submit an attachment directly to your claim at https://www.availity.com* by simply selecting the new Send Attachment button. We want to keep that positive momentum by answering your questions about those times when you are not able to find your claim in the Claim Status application using Availity Essentials. Here are a few suggestions:
- Double check your search information. Is the member information entered correctly? Many times, it is as simple as double checking the basic information needed to search for the claim.
- Do you have a claim number? If we have requested additional information to process your claim, the claim number will be included in the letter to you. Use this claim number to search for your claim.
- If you have located your claim, but the Send Attachment feature is not displayed, we have a solution for you:
- From the Claims & Payment tab, select Attachments – New. This will take you to your Attachments Dashboard.
- From the Attachments Dashboard, select Send Attachment.
- From the dropdown, select Medical Attachment.
- Complete the form and use the Add Attachment button to upload your files.
- Select Send Attachments, and your documents will be attached to your claim.
Claims attachment learning opportunities
In collaboration with Availity Essentials, we have made it easy for you to learn when it is convenient for you. Through this on-demand webinar, learn how to submit claim attachments through Claim Status. Access the course. If live webinars fit into your schedule, go to sign up today.
Summary of update
Effective October 1, 2022, Anthem Blue Cross and Blue Shield (Anthem) and AIM Specialty Health®* (AIM), a separate specialty benefits management company, will launch a new Back Pain Management Program for fully insured members, as further outlined below.
Who is AIM?
Anthem has an existing relationship with AIM in the administration of other programs. Anthem is excited to expand this relationship to include additional services. AIM works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.
What is the Back Pain Management Program?
In pursuit of the commitment to improve healthcare quality and costs, we have created a new voluntary Back Pain Management Program to help educate and support members navigate through their back pain journey to reduce risk of chronicity, minimize recurrences, and minimize complications.
The program will be utilizing predictive analytic models to identify members who are experiencing back pain or are at risk for complications related to back pain conditions. This early identification allows our program to target members who could experience an increase in back pain without the right education and support.
Our member engagement process includes:
- Predictive models for members likely to be referred for back surgery based on several risk factors.
- Risk stratification to ensure the appropriate level of support is provided.
- Targeted outreach to members through our digital engagement platform, email, and calls.
- Customized education and support of provider treatments based on member’s specific needs.
- Education and support of services such as behavioral health as appropriate.
Who is included in this new program?
All fully insured members currently participating in AIM and Anthem programs are included.
The following groups are excluded: Self-funded (ASO) groups, Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program® (FEP).
The AIM Back Pain Program microsite helps you learn more and access helpful information and tools such as program information and FAQs.
We value your participation in our network and look forward to working with you to help improve the health of our members.
The AIM Rehabilitation Program effectivie date is still delayed. A prior authorization will not be required for therapy services at this time.
Previously, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. shared with you our plans to transition medical necessity review of physical, occupational, and speech therapy services to AIM Specialty Health®* (AIM), a separate company, effective September 1, 2022. We recently informed you that we were experiencing a technical issue related to Anthem’s Commercial members in Virginia.
The program will continue to be postponed while we will focus on resolving our technical issues. We will share the new effective date in advance in a future communication.
At Anthem, we value your business and understand the seriousness of this delay. Please know that we regret any inconvenience or disruption this situation may have caused you and your staff.
Blue Cross and Blue Shield Service Benefit Plan, also known as the Federal Employee Program (FEP), is now requiring new information on claims that are required by the Omnibus Budget Reconciliation Act of 1993 (OBRA 93) law to be priced at the Medicare allowance. Members who are over 64 years old and do not have Medicare Part B coverage fall under the OBRA 93 law for Medicare pricing. In order for us to obtain the Medicare pricing, the CMS 1500 claim must have a rendering provider ID submitted on the claim. Claims submitted without the rendering provider ID will deny for the following message on the remittance and require the provider to resubmit with this required field.
Remit message:
339 NEED PROVIDER NAME & NPI IN ORDER TO DETERMINE MEDICARE FEE SCHEDULE
This claim submission requirement applies to federal employee member claims only. A federal member can be identified with an R followed by 8 digits (for example, Rxxxxxxxx).
If you have any questions, please contact FEP Customer Service at 800-552-6989.
Specialty pharmacy updates for of Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Our Medical Specialty Drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health (AIM®*), a separate company.
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.
This applies to members with Preferred Provider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDH plans).
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code. 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, 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.
Prior authorization updates
Effective for dates of service on and after December 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT® code(s)
|
|
ING-CC-0217
|
Amvuttra™ (vutrisiran)
|
J3490, J3590
|
|
ING-CC-0218
|
Xipere® (triamcinolone acetonide injectable suspension)
|
J3299
|
Note: Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Quantity limit updates
Effective for dates of service on and after December 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT® code(s)
|
|
ING-CC-0217
|
Amvuttra (vutrisiran)
|
J3490, J3590
|
|
ING-CC-0218
|
Xipere (triamcinolone acetonide injectable suspension)
|
J3299
|
Note: Oncology use is managed by AIM.
Effective for dates of service on and after December 1, 2022, the following current Clinical Criteria were revised, and might result in services that were previously covered but may now be found to be not medically necessary.
For Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc., prior authorization of these specialty pharmacy drugs will be managed by Anthem. Drugs used for the treatment of oncology will still require prior authorization by AIM Specialty Health® (AIM*), a separate company. This applies to members with Preferred Provider Organization (PPO), Anthem HealthKeepers (HMO), POS AdvantageOne, and Act Wise (CDH plans).
Access the Clinical Criteria document information.
|
ING-CC-0041
|
Complement Inhibitors
|
|
ING-CC-0061
|
Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
|
|
ING-CC-0150
|
Kymriah (tisagenlecleucel)
|
Effective with dates of service on and after October 1, 2022, and in accordance with the IngenioRx* Pharmacy and Therapeutics (P&T) process, Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. will update its drug lists that support Commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | September 1, 2022 Reimbursement policy update - Modifiers 25 and 57: Evaluation and Management with Global ProceduresPolicy Update
Modifiers 25 and 57: Evaluation and Management with Global Procedures
(Policy G- 06003)
Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for HealthKeepers, Inc. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.
For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy at https://providers.anthem.com/va.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | September 1, 2022 Enhancing claims attachment processes through digital applicationsPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Submitting attachments electronically is the most efficient way for you to receive your claim payments faster. That’s why we’ve made submitting digital claims attachments easier, more intuitive and streamlined. You can now submit your claims attachments through the Claims Status Inquiry application on Availity.com.* Submitting attachments electronically is the most efficient way for you to receive your claim payments faster.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time: no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and too much personal health information sharing.
If your workflow for attachments is through electronic data interchange (EDI) submissions or directly through the Availity application, we have a solution for that.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are three options for submitting attachments:
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Three options for submitting attachments
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Instructions
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Through the attachments dashboard inbox:
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From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox.
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Through the 275 attachment:
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Important: You must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.
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Through the Availity.com application:
|
From Availity.com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. Find your claim, and use the Send Attachments button.
|
If you submit your claim through the Availity application:
- Simply submit your attachment with your claim.
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. Find your claim, and use the Send Attachments button.
For more information and educational webinars
In collaboration with Availity, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up today.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | September 1, 2022 New specialty pharmacy medical step therapy requirementsPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Effective for dates of service on and after October 1, 2022, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon precertification initiation or renewal in addition to the current medical necessity review of all drugs noted in the chart.
The Clinical Criteria are publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.
|
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS codes
|
|
ING-CC-0166
|
Preferred
|
Kanjinti
|
Q5117
|
|
ING-CC-0166
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Non-preferred
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Herceptin
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J9355
|
|
ING-CC-0166
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Non-preferred
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Herzuma
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Q5113
|
|
ING-CC-0166
|
Non-preferred
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Ogivri
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Q5114
|
|
ING-CC-0166
|
Non-preferred
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Ontruzant
|
Q5112
|
|
ING-CC-0166
|
Non-preferred
|
Trazimera
|
Q5116
|
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | September 1, 2022 Provider Services Solution enrollment for MCO-only providersPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
In April 2022, the Virginia Department of Medical Assistance Services (DMAS) launched a new website to manage provider enrollment — the Provider Services Solution (PRSS). Medicaid providers will use the PRSS website, located on the Medicaid enterprise system (MES) website, to complete enrollment and maintenance processes. This platform will be more efficient and make it easier for you to access the information you need as a Medicaid provider. All Medicaid managed care network providers must enroll through PRSS to satisfy and comply with federal requirements in the 21st Century Cures Act. Those network providers who are currently enrolled as FFS in Medicaid do not have to re-enroll in PRSS.
This communication only applies to providers that have not already enrolled with DMAS or Behavioral Health providers not already enrolled with Magellan BHSA
As an Anthem HealthKeepers Plus participating provider, you will need to initiate enrollment through the new PRSS enrollment wizard. Go to Enroll as a new provider, or check your enrollment status. Only one enrollment application is necessary in PRSS, even if you participate with more than one Managed Care Organization (MCO). The application process allows for selection of one or more MCO plans. Once approved, providers will need to create a PRSS website online account to revalidate their enrollment, make changes to personal or business information, and check member eligibility. You may be asked to provide evidence of your submission. You can find helpful training resources on the MES website.
Beginning June 1, 2022, in-state providers will begin enrolling in a phased in approach by region following the below:
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Launch date
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Region of Virginia
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|
June 1, 2022
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Priority hospitals, nursing facilities, residential treatment facilities, and pharmacies within Virginia
|
|
July 1, 2022
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Far Southwest
|
|
August 1, 2022
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Charlottesville — Western
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|
August 1, 2022
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Roanoke-Alleghany
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|
September 1, 2022
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Tidewater
|
|
September 1, 2022
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Charlottesville- Western
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|
October 1, 2022
|
Northern Virginia
|
|
October 1, 2022
|
Tidewater
|
|
October 1, 2022
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Charlottesville - Western
|
|
November 1, 2022
|
Northern Virginia
|
|
November 1, 2022
|
Tidewater
|
|
December 1, 2022
|
Northern Virginia
|
|
January 1, 2023
|
Central
|
|
January 1, 2023
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Northern Virginia
|
|
February 1, 2023
|
Central
|
|
February 1, 2023
|
Northern Virginia
|
|
March 1, 2023
|
Central
|
Questions?
Contact PRSS Provider Enrollment Helpline at 804-270-5105 or 888-829-5373 and Provider Enrollment email address at vamedicaidproviderenrollment@gainwelltechnologies.com. If you have questions related to non-enrollment, please work with your health plan.
Provider Education and training courses
Managed care network providers can get ready to use the new PRSS website by using training resources on the MES website. DMAS offers a variety of live and pre-recorded training opportunities to help prepare providers to receive the maximum benefits from the PRSS website. Please encourage your staff to register for virtual instructor-led courses to make sure your organization is ready to use the new website. Please visit the MES website for a comprehensive listing of current courses.
Training schedule and registration
You must register to participate in live webinars. Webinar participants must use a computer with internet access and a telephone line to dial in. Registered participants will have the chance to engage with the trainer and ask specific questions.
As you review training options, please be sure to register for the following three courses:
- PRSS-111 Provider Enrollment Application: This training course explains the provider enrollment process, identifies the different enrollment types, and offers guidance on the documentation that providers need to prepare before enrolling. The training also includes an overview of what the provider enrollment application looks like and how to submit a provider enrollment application.
- PRSS-118 Introduction to Provider and MCO Portal Delegate Management: The goal of this virtual training is to offer instructions on this important process for providers, authorized administrators of providers, and delegates of providers. In PRSS, a provider’s primary account holder and/or delegate administrators must register their delegates and assign them permission to access the provider website to complete enrollments and other tasks.
- PRSS-120- Introduction to the Provider Website: The goal of this virtual training is to introduce the provider website registration process and the functions, features, and basic navigation within the provider website.
There is also an optional working session available (PRSS-111-WS Working Session: Provider Enrollment Support) that provides real-time support from our trainer as you work through one or more provider enrollment applications.
To register for any training, please visit the MES Provider Training Registration page to choose a date and time that works best for you.
Registration is now open. Courses began on May 31, 2022, and spaces are filling quickly. Register early. Please help us spread the word about this upcoming training opportunity. If you have questions related to training, please contact DMAS VA at MESregistrations@briljent.com.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | September 1, 2022 Help your pregnant patients quit smokingPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Smoking is well-known to have negative health effects. Not only is it detrimental to the health of our members, but smoking also increases the risk of health issues in developing babies, including increasing the risk of preterm birth, low birth weight, miscarriage, fetal tissue damage in the lungs and brain, sudden infant death syndrome (SIDS), birth defects, and asthma or allergies in infants.1 Quitting smoking during and after pregnancy can help ensure the health of the infant, as well as promote the health of our members.2 As nicotine is highly addictive, it is important that mothers receive the support they need to quit smoking during pregnancy.
Available resources for members
There are a variety of resources available to connect individuals to counseling services. Providers can offer a direct referral to the National Tobacco Quit Line (800-QUIT NOW), which provides ongoing counseling and support covered by their MCO. If this service is not the right fit for your patient, there are other telephone based quit-smoking programs:
- American Heart Association:
- American Lung Association:
- American Cancer Society:
Covered services
|
Nicotine replacement therapy
|
Other medications
|
|
Preferred
|
Non-Prescription
|
Prescription
|
|
Nicotine Lozenge
|
Nicotine Patch
|
Nicotine Gum
|
n/a
|
n/a
|
Chantix®/Chantix® DS PK
|
Bupropion SR
|
|
Non-preferred (requires PA)
|
Nicorette® Lozenges
|
NicoDerm CQ Patch
|
Nicorette® Gum
|
Nicotrol Inhaler
|
Nicotrol Nasal Spray
|
Zyban®
|
Figure 1. Covered Smoking Cessation Treatments
Note: Length of authorizations are six months. Routine PDL.
There are several approaches to helping your pregnant patients quit smoking. The first intervention recommended is to start with smoking cessation counseling, either individual or group. In accordance with the U.S. Preventive Services Task Force, these services are fully covered for Medallion 4.0 and CCC Plus members. Depending on the patient’s needs, they may be eligible for different levels of services. We offer individual counseling visits, 3 to 10 minutes (99406), individual counseling visits > 10 minutes (99707), and unclassified group patient education (S9446). We cover six units per calendar year with no preauthorization.
For some high-risk patients, smoking cessation counseling is not enough, and it may be beneficial to pursue pharmacotherapy as an adjunct to counseling. Groups that may benefit from this service include pregnant women who would not otherwise be able to quit smoking without intervention, heavy smokers (> 10 cigarettes/day), individuals smoking later in pregnancy, and those who have been unsuccessful in their previous attempts to quit.3 The second line of intervention, tobacco dependence treatment (for example, tobacco/smoking cessation) is covered at no cost to members. We provide coverage for smoking cessation in accordance with the SUPPORT Act requirements.
Pharmacotherapy
There are several principles for prescribing drugs during pregnancy. Firstly, to minimize fetal exposure, providers should prescribe the lowest dose necessary to achieve success. Despite concerns about underdosing due to the changes in pharmacokinetics during pregnancy, it is still best practice to start with the lowest dose. Secondly, to avoid embryogenesis, it is recommended that therapy is delayed until the second trimester as the fetus is most sensitive to teratogens before the second trimester. Both nicotine replacement therapy (NRT) and bupropion are sufficient treatment options for the general population, however the safety and efficacy of these drugs have not been directly compared in randomized trials with pregnant persons.3 Please note that the optimal treatment is not known.
While many providers are reluctant to use NRT with pregnant patients, this may be a healthier alternative to smoking during pregnancy. Although the efficacy of NRT and fetal impact of treatment in pregnancy is not well established, the treatment does not appear to be harmful and may be associated with lower rates of premature birth. There is no strong evidence that pregnant smokers being treated with NRT are at a higher risk of adverse perinatal events than pregnant patients who smoke and are not using NRT. Even if NRT cannot eliminate all risk associated with smoking during pregnancy, engaging in maternal smoking cessation reduces the risk of fetal exposure in-utero to toxins that may contribute to poor pregnancy outcomes.3
Another treatment option is bupropion. Bupropion typically is used as an adjunct to counseling or for individuals with contraindications to NRT, patients who do not want to use NRT, or patients who have been unsuccessful with combined counseling and NRT. Bupropion should not be prescribed or taken while using NRT. Patients should be aware the bupropion crosses the placenta, but it should be noted that the data available on fetal impact is limited, inconsistent, and there are possibly confounding factors such as antidepressant use. No clear association with congenital malformations has been established, however a preventive option to consider is delaying the initiation of medication until after the first trimester ultrasound (11-14 weeks). The risk of miscarriage and birth defects after first trimester exposure to Bupropion were consistent with the general population rate. While there have been some cases of fetal heart defects in pregnant patients taking bupropion, the data is insufficient to evaluate the true risk. Patients also may consider waiting until the second trimester (18-20 weeks), once a more detailed anatomical ultrasound assessment can be conducted.3
Provider recommendations
It is important that the available data is discussed with patients to give them an opportunity to consider their options and what is best for their health and the health of their baby. Appropriate interventions are based on the patient’s situation and willingness to quit. We encourage providers to use the five major steps to intervention, the five As — ask, advise, assess, assist, and arrange, which have been adapted for use in smoking cessation during pregnancy.
The five As approach for delivering tobacco treatment interventions in maternal care settings
Step 1: ask
Ask the patient about their smoking status. Regardless of smoking status, providers should consider assessing exposure to secondhand smoke.
Action: Given high nondisclosure rates, identification of the pregnant smoker can be difficult. Specific strategies to identify women who smoke include:
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1.
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Use multiple choice questions when assessing whether a patient smokes. The following multiple-choice question is recommended in either oral or written form.
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Which of the following describes you best?
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2.
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Focus particular attention on women who report that they stopped smoking after conception. About half of nondisclosers in one series reported quitting after conception.
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Step 2: advise
Advise the patient with clear, strong advice for quitting smoking with personalized messages about the impact of smoking and quitting on mother and fetus.
Action:
- Discuss the risks of smoking during pregnancy: low birth weight, placental abruption, placenta previa, premature delivery, stillbirth, and preterm premature rupture of membranes.
- If the patient has had a history of a complicated pregnancy, discuss how smoking may have contributed to this complication.
- Discuss risks of secondary smoke, particularly for patients with children at home, SIDS, upper respiratory infections, otitis media asthma, and pneumonia.
- Recommend that the patient quit as soon as possible for maximal benefit; however, quitting at any time during pregnancy has some benefit.
Step 3: assess
Assess the willingness of the patient to make a quit attempt within the next month.
Action: Ask, Quitting smoking is one of the most important things you can do for your health and the health of your baby. If we help you, are you willing to try?
Step 4: assist
Assist smoker in quitting.
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ACTION
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1.
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Provide pregnancy-specific, self-help smoking cessation materials; multi-lingual educational packets are available on the web at http://www.modimes.org.
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2.
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Encourage the use of problem-solving methods and skills for cessation:
Review withdrawal symptoms.
Identify high-risk situations where they are more likely to relapse and set up strategies for avoiding them.
Strongly consider referral to a social worker who can help patient gain access to services available to minimize stressors at home.
Consider referral to coping and stress management program.
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3.
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Encourage patient to seek family and social support:
Identify nonsmoking individuals, particularly successful quitters who can be supportive.
Offer referral to smoking partner for smoking cessation.
Patient should inform family that they intend to quit smoking during the pregnancy and ask for their support (for example, not smoking in the same room).
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4.
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Consider pharmacotherapy for patients who smoke 10 cigarettes or more and are unable to quit. Use lowest dose necessary:
a. Bupropion
b. NRT
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Step 5: arrange
Arrange frequent follow up about smoking status throughout pregnancy and encourage cessation for continuing smokers.
Action:
- Place a label on each chart that identifies the patient as a smoker.
- Ask about smoking at each visit.
- If the patient is still smoking, encourage cessation and consider adjunct pharmacotherapy as outlined.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | September 1, 2022 Clinical Laboratory Improvement AmendmentsPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Effective October 1, 2022, claims submitted with incorrect Clinical Laboratory Improvement Amendments (CLIA) information in accordance with the Centers for Medicare & Medicaid Services (CMS) policy will result in a claim rejection.
CMS considers a claim with missing or invalid CLIA information as an unclean claim, and the claim will be rejected by HealthKeepers, Inc. on the front end. Rejected claims will require claim resubmission to HealthKeepers, Inc. for the claim to be considered for reimbursement. Rejected claims do not have appeal rights nor are they counted toward any timely filing requirements.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | September 1, 2022 Alcohol use disorders linked to chronic diseasesPlease note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
A number of chronic diseases, including heart disease, cancer, and type 2 diabetes, are linked to alcohol use disorders (AUD).
Heart disease1
Low alcohol consumption is associated with a reduced risk for cardiovascular disease (CVD), but higher amounts and binge drinking lead to a higher risk of CVD. Binge drinking and chronic heavy alcohol consumption is associated with a higher risk of hypertension. Alcohol leads to buildup of plaque in the arteries, disruptions in arterial function, oxidative stress throughout the body, and imbalances in hormones that control blood pressure regulation.
Heavy alcohol use is also associated with increased risk for coronary heart disease, stroke, peripheral arterial disease, and cardiomyopathy. It is suspected that the increase in blood pressure from heavy alcohol use plays a part in these increased risks. Alcohol also appears to contribute to arthrosclerosis and chronic inflammation, which follow the pathophysiologic process behind most CVD.
See Piano, 2017 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513687/) for a more thorough examination of the increased risk of CVD from excess alcohol use; mechanisms of action; biomarkers; and considerations of genetic, socioeconomic, and racial factors.
Cancer
An estimated 3.5% of cancer deaths in the United States are alcohol-related. Alcohol is a known human carcinogen.2 When consumed, ethanol breaks down into acetaldehyde, which is carcinogenic.
Alcohol consumption is linked to seven types of cancers.3 It raises the risk for cancer of the mouth, larynx, throat, and esophagus. Drinking and smoking together significantly increases this risk. Alcohol helps the harmful chemicals in tobacco to better infiltrate the cells and cause disease. Alcohol can also limit the cells’ ability to repair DNA damage from the chemicals in tobacco.
Regular, heavy alcohol use damages the liver and causes inflammation and scarring. This increases the risk of liver cancer. In addition, alcohol can raise estrogen levels, which is associated with a higher risk of breast cancer. Moderate drinkers have up to a one and a half times increased risk of ectal cancer. While the risk is increased for men and women, the evidence of this link is stronger in men.
Type 2 diabetes
Chronic use of alcohol is considered to be a potential risk factor for the development of type 2 diabetes mellitus (T2D).4 Like heart disease, low alcohol consumption decreases the risk of T2D, but chronic heavy alcohol use increases the risk. Alcohol disrupts glucose homeostasis in the body and is associated with insulin resistance.
In addition, alcohol affects excess caloric intake, pancreatitis, and impaired liver function. This affects blood glucose levels and causes hypoglycemia. Alcohol alters the brain’s ability to produce hunger hormones and increases food-seeking behaviors. Dysregulation of these hormones (specifically ghrelin and leptin) plays a part in T2D.
Heavy alcohol use can worsen symptoms in patients with T2D and cause hyper- and hypoglycemia.5 Alcohol-induced hypoglycemia can lead to serious neurological complications in T2D patients, which may or may not be reversible. It can also cause life-threatening ketoacidosis and worsen diabetic neuropathy and retinopathy. Alcohol has serious interactions with some T2D medications including Chlorpropamide, Metformin, and Troglitazone.
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
State & Federal | HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid products | September 1, 2022 Keep up with Medicaid news: September 2022Please continue to check our website https://providers.anthem.com/virginia-provider/home 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:
On December 1, 2022, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements will change for the following code. 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. Non-compliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following code:
L6715 — Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement
Not all PA requirements are listed here. Detailed PA requirements are available to providers on the provider website at https://www.anthem.com/provider/news/archives/?cnslocale=en_US_co&category=medicareadvantage or by accessing Availity* at https://availity.com.
Providers may also call Provider Services for assistance with PA requirements by referencing the number on the back of the patient’s member ID card.
Policy Update
Modifiers 25 and 57: Evaluation and Management with Global Procedures
(Policy G-06003)
The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for Anthem Blue Cross and Blue Shield. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.
For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy at https://www.anthem.com/medicareprovider.
Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.
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.
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HCPCS or CPT® codes
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Medicare Part B drugs
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J0172
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Aduhelm (aducanumab-avwa)
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AIM Specialty Health®* (AIM) created new contact center phone numbers for Medicare providers to call for prior authorization requests. The new phone number for the Virginia market is 888-240-5058.
Note: The old number is not available for requests after August 15, 2022, so please use this new number to submit new prior authorization AIM requests.
As always, the best way to reach AIM is to use the ProviderPortal.SM It is:
- Self-service.
- Available 24/7.
- Customizable with physician information.
- Easy to use and allows real-time determinations.
The ProviderPortal is a fast and efficient way to start a case. It also allows your team to:
- Check order status and view order history.
- Print/save PDF of order summary.
- Use multiple staff members to enter/view the practice’s orders.
- Increase payment certainty.
- Reference desk training and tutorials, including clinical criteria and CPT® lists.
If not already registered, your first step is to register your practice in the ProviderPortal at www.providerportal.com.
Submitting attachments electronically is the most efficient way for you to receive your claim payments faster. That’s why we’ve made submitting digital claims attachments easier, more intuitive and streamlined. You can now submit your claims attachments through the Claims Status Inquiry application on Availity.com.* Submitting attachments electronically is the most efficient way for you to receive your claim payments faster.
Submitting attachments electronically:
- Reduces costs associated with manual submission.
- Reduces errors associated with matching the claim when attachments are submitted manually.
- Reduces delays in payments.
- Saves time: no need to copy, fax, or mail.
- Reduces the exchange of unnecessary member information and too much personal health information sharing.
If your workflow for attachments is through electronic data interchange (EDI) submissions or directly through the Availity application, we have a solution for that.
Didn’t submit your attachment with your claim? No problem!
If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are three options for submitting attachments:
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Three options for submitting attachments
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Instructions
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Through the attachments dashboard inbox:
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From Availity.com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox.
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Through the 275 attachment:
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Important: You must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.
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Through the Availity.com application:
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From Availity.com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. Find your claim, and use the Send Attachments button.
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If you submit your claim through the Availity application:
- Simply submit your attachment with your claim.
- If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:
- From Availity.com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. Find your claim, and use the Send Attachments button.
For more information and educational webinars
In collaboration with Availity, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up today.
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