Updated 2023 provider manual now available

Anthem Blue Cross and Blue Shield (Anthem) reviews and updates our online provider manual annually. The updated manual is effective July 1, 2023, and is available now on our public provider website at anthem.com. Select Providers and choose Policies, Guidelines and Manuals under Provider Resources in the horizontal menu. Select Wisconsin as the state if needed and scroll down to the Provider Manual section. Select Download the Manual. Scroll to the Looking for our Upcoming Provider Manual section and select Preview the upcoming manual to view the manual.

Aside from minor formatting changes, the following sections listed in alphabetical order were updated:

• Updated content:
  • Appointment Access and Geographic Availability:
    • Addition of Routine – Regular Appointments under Behavioral Health
  • Availity Essentials*:
    • Updated section title and expansion of capability information
  • Carelon Medical Benefits Management, Inc.*:
    • Section formerly titled AIM Specialty Health revised to current name
  • Centers of Medical Excellence:
    • Update to statistics, medication-assisted treatment (MAT) added under Substance Use Treatment and Recovery, and Chimeric Antigen Receptor T cell therapies (CAR-T) products changed from five to six
  • Claim Payment Disputes:
    • Includes a list of reasons to submit a claim payment dispute
    • Clarification of a dispute and appeal along with filing timelines previously shared in the April 2023 Provider Newsletter article Update to Claim Payment Dispute process
  • Claim Submission:
    • Includes more information on digital claim submission
  • Clinical Data Sharing:
    • Updated information previously shared in March 2023 Provider Newsletter article New policy for EMR clinical data sharing and ADT notifications
  • Clinical Appeals:
    • Submission can be done through Availity Essentials
    • Submission timeline for returning requested information
    • Information to be submitted with clinical appeals
  • Continuity and Care Coordination:
    • Behavioral Health practitioners added
  • Dispute Resolution, Mediation and Arbitration:
    • Revised language
  • Electronic Data Interchange (EDI):
    • Addition of EDI Response Reports
    • Specific for corrected claims
  • Federal Employees Health Benefits Program:
    • Members admitting to a skilled nursing facility updated to indicate they must be seen by a pulmonologist at least weekly after initial visit (within 12 hours of admission)
  • Fraud, Waste and Abuse Detection:
    • Addition of Pre-payment review under Investigation Process for Special Investigations Unit (SIU)
  • Introduction:
    • Content revised for ease of readability
  • Medical Record Submission:
    • Additional content digital record submission
    • Timeline for submitting requested records
  • Overview of HEDIS^®:
    • Updated information on measures
  • Online Provider Directories and Demographic Data Integrity:
    • Updated information on methods of submitting provider data
  • Quality Improvement Programs:
    • Updates to Program Overview and Goals and Objectives
    • Under Quality and Safety of Clinical Care, Chronic Disease and Prevention removed and MyHealth Coach added
    • Service Quality removed and Patient Safety for Members revised
  • Reimbursement Requirements and Policies:
    • Revision to Blood, Blood Products, and Administration
    • Changes During Admission updated to include Continuous Outpatient Encounter
    • Revision under Lab Charges
    • Revision to Operating Room Time and Procedure Charges section
    • Revision to Respiratory Services section
    • Addition of Services related to non-covered services, supplies, or treatment
  • Utilization Management:
    • Revised content under On-Site/Electronic Medical Record Review (EMR) section
    • Revised content under Retrospective Utilization Management section

The 2022 Wisconsin provider manual will also be available until July 1, 2023.