Updated 2024 Provider Manual now available

Anthem reviews and updates our online Provider Manual annually. The updated manual is effective September 1, 2024 and is available now on our public provider website, anthem.com. Select For 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 (in alphabetical order) were updated.

Appointment access and geographic availability:

• Scheduling of appointments review vendor changed from NATO (North American Testing Organization) to CSS (Center for the Study of Services)
• Addition of routine follow-up visit within 30 days

Audit and review:

• Updates to timeframes in the Procedure section

Availity Essentials:

• Some content moved to Provider and Facility Digital Guidelines section

Carelon Medical Benefits Management, Inc.:

• Updates to OptiNet section

Centers of Medical Excellence:

• Update to statistics and to Maternity Care and Cellular Immunotherapy (Chimeric Antigen Receptor Therapy — “CAR-T”) sections
• Gene Therapy section added

Claim submission:

• Clarification on air ambulance claim submission

Clinical data sharing:

• Updated specific information related Facility to Health Level Seven International (HL7) messaging data for submission for Admission, Discharge and Transfers (ADT)

Clinical appeals:

• Submission can be done through Availity
• Submission timeline for returning requested information
• Information to be submitted with clinical appeals

Dispute resolution, mediation, and arbitration:

• Revised language

Electronic data interchange (EDI):

• Addition of virtual credit card (VCC) information

Federal Employees Health Benefits Program:

• Omnibus Budget Reconciliation Act of 1993 (OBRA ‘93) section added
• FEHBP Member Reconsiderations and Appeals section updated to reflect that providers or facilities may not submit appeals to the Office of Personnel Management without authorization from the member
• FEHBP Inpatient Skilled Nursing Facility Care section content removed with redirection to fepblue.org

Fraud, waste, and abuse detection:

• Updates to the overview and the Investigative Process section
• Removal of Recoupment/Offset/Adjustment for Overpayments section because content is included in the Claims Overpayment section

Medical record submission:

• Information on the clinical documentation lookup tool
• New section — Digital Request for Additional Information (RFAI) section

Medical records standards:

• Removed

Member quality of care and quality of service investigations:

• Updated the overview and the Corrective Action Plan
• Removal of Severity Levels for Quality Assurance and Trend Threshold for Analysis sections

Pharmacy & Prescriber Home Program:

• Updated to include prescribers

Provider enrollment through Availity:

• New — information on the digital provider enrollment application on Availity

Provider and facility digital guidelines:

• Content expanded
• New — information on information Zelis Payment Network (ZPN) electronic payment and remittance combination option for providers

Quality improvement programs:

• Updates to Program Overview and Goals and Objectives
• Under Quality and Safety of Clinical Care, removed Behavioral Health Care Management and Disease Management

Reimbursement requirements and policies:

• New — global services with modifier 26 and TC
• Expansion of Submission of Claim/Encounter Data section
• Revision to Video or Digital Equipment Used in Procedures to remove operating room distinction
• Minor clarifications in Additional Reimbursement Guidelinesfor Disallowed Charges

Utilization Management:

• Revised the Program Overview, Prospective (fka Pre-Service), and Continued Stay Review sections
• Failure to Comply With Utilization Management Program section updated to include a list of approved extenuating circumstances

The updated manual is effective September 1, 2024. Until that date, the 2023 Wisconsin Provider Manual will be available.