At a glance:

• Last month, we published information about the Consolidated Appropriations Act (CAA) data attestation process for Commercial providers here. This article provides additional information for Commercial and Medicare Advantage providers about updating your provider data with us.

• Care providers contracted with us must verify or update their demographic data every 90 days using the Provider Data Management (PDM) capability on Availity Essentials for efficient claims processing and timely reimbursement.

• Updating and attesting data are critical for maintaining accurate service directories for members. Non-compliance with these requirements may result in removal from the online provider directory.

• Availity Essentials not only allows for data attestation but also provides digital applications that enable users to monitor submitted demographic updates in real time, review the history of previously verified data, and manage multiple updates within one spreadsheet via the Upload Roster feature.

What are the requirements for the attestation of demographic data?

We require our contracted care provider partners to attest to their demographic data every 90 days. Maintaining your provider data is critical as it results in improved connection to members seeking care, supports the accuracy of claims processing, and allows for timely reimbursement, while aligning to a bold purpose of improving the health of humanity.

How do I update and attest to my data?

We require the use of the PDM capability available on Availity Essentials to update your provider or facility data. There are two options within Availity Essentials PDM that are available at no cost to care providers:

• Multi-payer platform, which includes Directory Verification and Core PDM: allows care providers to make required updates using Directory Verification and changes using Core PDM
• Roster upload: allows care providers to submit multiple updates within one spreadsheet via the Upload Roster feature (the Upload Roster feature is currently only available and shared with the health plan)

Both the Multi-payer Platform and Roster Upload feature satisfy your 90-day attestation requirement.

To attest to your provider data:

1. Log in to Availity Essentials.
2. Navigate to My Providers > Provider Data Management.
3. Select the action menu next to the business whose information you want to verify.
4. Select Verify Directory Listing.
5. Review each set of data for accuracy.
6. Once complete, select Submit Verified Profile.

Organizations with no changes since their last submission may see a Quick Verify button that allows for directory verification in one click.

Individuals registered for their TIN within the Availity Manage My Organization application on Availity Essentials will receive periodic automated emails and notifications in the Notification Center on Availity reminding them when their attestation is due or overdue.

How do I access Availity Essentials and the PDM application?

To access the PDM application, log on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

Within PDM you also have the ability to:

• Monitor submitted demographic updates in real time with a digital dashboard.
• Review the history of previously verified data.

Why is updating and attesting to my data important?

Our members use Find Care to make informed decisions about their healthcare and find quality doctors and hospitals. Keeping your data up to date ensures members have access to you when they need it the most.

Failure to complete the 90-day attestation requirement puts your organization at risk of being non-compliant with the health plan’s policies and procedures and may result in removal from the online provider directory.

What if I’m not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and secure. There is no cost to register or to use any of the digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one TIN, make sure to register all TINs associated with your account.

If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY (282-4548).

How do I get training on the Availity PDM tool?

You can learn about the Availity PDC tool by attending one of our training opportunities here:

• For more information on Availity PDM, check out the Quick Start Guide here using your Availity Essentials user ID and password.
• For more information about the Roster Upload process:
  • See the Roster Submission Guide on Availity.com > Payer Spaces > Select Payer Tile > Resources > Roster Submission Guide using PDM.
  • Find training specifically for the Standard Template and Rules of Engagement by listening to our recorded webinar here.
  • Take an on-demand class hosted by Availity to learn about Provider Data Management here.

What if I’m a behavioral health care provider?

If you are a behavioral health care provider and assigned to Carelon Behavioral Health, Inc., follow the Carelon Behavioral Health process for attestation. Council for Affordable Quality Healthcare (CAQH) care providers should attest, confirm, or update their data through the CAQH Provider Data Portal. Non-CAQH care providers and facilities should attest, confirm, or update their data directly through the Carelon Behavioral Health Provider Portal.

Contact us

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

We are committed to finding solutions that help our care provider partners offer quality services to our members. For additional support, visit the Contact Us section of our provider website for the appropriate contact.

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised during Quarter 1, 2024. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications, or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit Provider Medical Policies | Anthem.com.

Notes/updates

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• LAB.00039 - Combined Pathogen Identification and Drug Resistance Testing; Previously Titled: Pooled Antibiotic Sensitivity Testing:
• Revised title
• Revised Position Statement to address “combined pathogen identification and drug resistance” testing
• OR-PR.00008 - Osseointegrated Limb Prostheses:
• Outlines the Medically Necessary and Not Medically Necessary criteria for the use of osseointegrated (bone-anchored) prosthetic devices for improving the mobility and function of people who have had limb loss.
• SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures:
• Revised Medically Necessary criteria for basivertebral nerve ablation (BVNA)
• SURG.00162 - Implantable Shock Absorber for Treatment of Knee Osteoarthritis:
• Use of an implantable shock absorber device for treatment of osteoarthritis of the knee is considered Investigational & Not Medically Necessary.
• CG-DME-53 - Biomechanical Footwear Therapy:
• Biomechanical footwear therapy is considered Not Medically Necessary for all indications.
• CG-LAB-32 - Cancer Antigen 125 Testing:
• Outlines the Medically Necessary and Not Medically Necessary criteria for the tumor marker cancer antigen 125 (CA-125) testing.
• CG-MED-94 - Vestibular Function Testing:
• Revised Medically Necessary and Not Medically Necessary statements to include vestibular-evoked myogenic potential tests
• CG-MED-96 - Prefabricated External Infant Ear Molding Systems:
• Outlines the Medically Necessary, Reconstructive and Cosmetic & Not Medically Necessary criteria for the use of prefabricated external infant ear molding systems to treat external ear malformations and deformations.

Medical Policies

On February 15, 2024, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to HealthKeepers, Inc. These Medical Policies take effect September 15, 2024.

Clinical UM Guidelines

On February 15, 2024, the MPTAC approved the following Clinical UM Guidelines applicable to HealthKeepers, Inc. These guidelines were adopted by the medical operations committee for Anthem HealthKeepers Plus members on March 28, 2024. These guidelines take effect September 15, 2024.

The following services will be added to precertification for the effective dates listed below.

Precertification responsibility

The ordering or rendering provider of service is responsible for completing the prior authorization process.

HMO plans: Services that require precertification will be denied if rendered without the appropriate prior authorization for in-network providers. HMO members may not have benefits for non-emergency services rendered outside of the network and are subject to review and may be denied.

PPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement.

EPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement. No out of network benefit is available with the exception of ER/Urgent Care and authorized services.

To request precertification with the Virginia Plan

Access Availity (Availity.com).

For maternity, medical, surgical precertification, call the number listed on the back of the member’s ID card.

For mental health and substance abuse precertification, call 800-755-0851. Professionals are available 24 hours a day, seven days a week.

Effective December 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage 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 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(s):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider. Choose the Select a State ribbon and then find on the Resources tab. Contracted providers can also access Availity.com. 

The Federal Employee Program^® (FEP) offers a quality reimbursement program for providers. Coding for CPT^® II category codes for A1c results, blood pressure readings, and the first prenatal visit are reimbursed at $10 per code.

The program has been a success in improving HEDIS^® scores and data collection. The FEP Quality Reimbursement Program for PPO providers was revised as noted below effective May 12, 2023.

Revisions to CPT II category II code requirements for $10 reimbursement:

• Only professional HCFA billing providers
• Only these six places of service codes are applicable:
  • 2 — telehealth not home
  • 10 — telehealth home
  • 11 — office
  • 12 — home
  • 17 — walk-in clinic
  • 20 — urgent care
• Only a specific diagnosis code that coordinates with the applicable CPT II code

Submitting the claim

Submit the CPT II code in field 24 of the HCFA 1500 with a charge of $10.

Use the applicable CPT II code, place of service code, and diagnosis code according to the information below.

Blood pressure — systolic and diastolic readings

Reimbursable DX codes: I10, I11.9, I12.9, I13.10, I15, I15.1, I15.8, I15.9, I16.0, I16.1, I16.9

Hemoglobin A1c

Reimbursable DX codes: E10.8, E10.9, E11.8, E11.9

First prenatal visit

The first prenatal visit date of service must be on the claim (field 24A HCFA 1500) with the appropriate code.

Reimbursable DX codes: Maternity-related diagnosis code

For additional information about the FEP Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com.

Anthem is excited to announce the development of the Blue National Physician Performance Dataset. This initiative is a collaborative approach between Blue Cross Blue Shield Association, Blue Health Intelligence (BHI), and Motive Medical Intelligence (MMI) to develop a consistent national approach to evaluating physicians at the National Provider Identifier (NPI) level that incorporates measures of quality of care, appropriateness of care, and cost/efficiency of care.

Effective January 1, 2025, Anthem may incorporate the Blue National Physician Performance Dataset in various ways, including but not limited to:

• Providing special opportunities to participate in product offerings.
• When members contact Anthem with requests for referral options.
• Developing provider designations in provider directory (FindCare) tools.
• Enhancing existing tools in FindCare and Cost Finder, such as Personalized Match, that assist members with identifying or sorting providers.

For more information on how physicians are evaluated within each of the three categories (quality, appropriateness, and cost), you can view the Blue National Physician Performance Dataset Evaluation Method.

If you have any questions about the Methodology or your score, contact your local provider relationship management representative

We are writing to inform you about an important change in our billing policy regarding S5102, Adult day health care. S5102 is a per diem code. Care providers may bill only one unit per day per member. Effective from November 1, 2024, HealthKeepers, Inc. will begin denying claims for S5102 when the units billed do not exactly match the date span. Previously we announced an earlier date.

For example, if a care provider bills for a date of service (DOS) covering May 22 through May 26, equating to five days, then the care provider must bill exactly five units. Any claims not billed with the precise unit amount for the date span billed will be denied. The Explanation of Benefits (EOB) will note this as a Q64 denial — Service dates do not match units billed. Additionally, this billing discrepancy will trigger a Claim Adjustment Reason Code (CARC) 16 — Claim/service lacks information or has submission/billing error(s).

We encourage all care providers to review their billing practices for S5102 to ensure that unit billing corresponds exactly with the dates of service. This change is crucial in preventing claim denials. You are valued for the care you provide for our members, and we want to support you in getting your claims paid correctly.

If you have any questions about this communication, contact Provider Services at 800-901-0020, your regional provider relationship management representative, or the team at valtsspr@anthem.com.

The specialty pharmacy updates for Anthem are listed below.

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc. 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, 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.

The inclusion of a 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 (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.

Prior authorization updates

Effective for dates of service on or after December 1, 2024, 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.

* Oncology use is managed by Carelon Medical Benefits Management.

Site of care updates

Update: In the May 2024 edition of Provider News, we announced the site of care review requirements for the following drugs would be effective August 1, 2024. Please be advised that the following drugs were not implemented to have SOC requirements added.

Access our Clinical Criteria to view the complete information for these site-of-care updates.

Step therapy updates

Effective for dates of service on or after December 1, 2024, 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.

Access our Clinical Criteria to view the complete information for these step therapy updates.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Effective for dates of service on or after December 1, 2024, the specialty Medicare Part B drugs listed 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.

Effective for dates of service on or after December 1, 2024, the specialty Medicare Part B drugs listed 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.

Want to reduce administrative burden and help your patients save on prescription costs?

With real-time prescription benefit (RTPB), care providers can access patient-specific drug benefit information within the e-prescribing process. This functionality allows care providers to proactively identify barriers to cost and improve medication adherence.

"Prescription pickup rates have increased 3.2% and saved patients on average $40 per prescription with using real-time prescription benefit.” — Surescripts.²

When using real-time prescription benefit during e-prescribing, care providers can see patient-specific benefit information including:

• Formulary status of selected medication.
• Patient cost share of medication at a retail and mail order pharmacy.
• Up to five formulary drug alternatives.
• Coverage alerts, including prior authorization and step therapy.

Benefits you and your patients will experience when using RTPB:

• Clearer, faster information
• Opportunity to lower cost barriers
• Decreased administrative burden
• Reduced time to therapy
• Enhanced patient experience

How real-time prescription benefit works:

1. Prescriber enters prescription information through e-prescribing.
2. The e-prescribing system triggers a data call to the pharmacy benefit manager (PBM).
3. The PBM receives the real-time prescription benefit request.
4. The PBM delivers cost, formulary, and utilization information for the selected pharmacy back to the prescriber’s electronic health record (EHR).
5. Prescriber and patient make a choice together.

Help your patients save money on their prescriptions with EHR access to patient-specific drug coverage and out of pocket costs. Find out if your EHR vendor provides real-time prescription benefits information. There’s no charge for the service; however, you will need the latest version of your EHR.

Visit the Drug Lists page on our website at anthem.com/ms/pharmacyinformation/home.html for more information about:

• Copayment/coinsurance requirements and their applicable drug classes.
• Drug lists and changes.
• Prior authorization criteria.
• Procedures for generic substitution.
• Therapeutic interchange.
• Step therapy or other management methods subject to prescribing decisions.
• Any other requirements, restrictions, or limitations that apply to using certain drugs.

The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.

To locate the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.

Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at fepblue.org > Pharmacy Benefits.

Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access.

Through our efforts, we are committed to reducing administrative burden because we value you, our care provider partner.