The new name will reflect the company's exciting strategy for the future.

 

We are very excited to share the news that our parent company, Anthem, Inc., has filed a preliminary proxy statement to change its name. The new name, pending shareholder approval, will be Elevance Health.

 

Please know that if the name change is approved by shareholder vote, the following will not change:

• Your contract, reimbursement, or level of support
• Your patients’ plan or coverage

 

We will continue to do business as Anthem Blue Cross and Blue Shield.

 

Why the change?

The upcoming name change reflects the company’s strategy to elevate the importance of whole health and to advance health beyond healthcare for our customers, their families, and our communities.

 

Our path forward is clear

We are thrilled to share our journey with you as our parent company continues its evolution from a traditional health benefits organization to a health company that looks beyond the traditional scope of physical health and how to best support it.

 

For more information, please read the press release.

 

Thank you for being our trusted health partner.

Bryony Winn

President, Anthem Health Solutions

Anthem, Inc.

 

1811-0422-PN-CNT

Anthem Blue Cross and Blue Shield (Anthem) appreciates your commitment to delivering quality care to our members and improving the overall health of our communities. To help ensure accurate claims processing, providers should report evaluation and management (E/M) services in accordance with the American Medical Association CPT^® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. We have created a summary of the CMS guidance that may assist you with the documentation requirements necessary to support the level of service submitted on claims. 

 

Effective January 1, 2021, documentation guidelines for office and other outpatient visits are based on two components:

• Medical decision making (MDM)
• Total time

 

Total time is the complete time spent on the date of the encounter and may now include the time spent before, during, and after the visit, as well as the time spent documenting the visit. Previous components of history and physical exams are no longer used to determine the level of service; however, a medically appropriate history and exam are required.

 

The 2021 guidance for time allows providers to receive credit with appropriate supporting documentation for the following elements:

• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other healthcare professionals (when not separately reported)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• Care coordination (not separately reported)

 

The intent of the revised documentation criteria is not to eliminate the need for providers to support medical appropriateness, but to provide them with the ability to account for additional time elements that were previously excluded.

 

CMS guidelines state the provider must help ensure that medical record documentation supports the level of service reported to a payer. Providers should not use the volume of documentation to determine which specific level of service to bill. The total time spent on the date of the encounter will determine the specific level of service billing. Services must meet specific medical necessity requirements in the statute, regulations, and American Medical Association and CMS manuals, and specific medical necessity criteria defined by national coverage determinations and local coverage determinations. For every service billed, providers should indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.

 

Clear and concise documentation is imperative to providing quality care. It is the provider’s responsibility to help ensure the documentation furnished reflects services provided to receive accurate and timely reimbursement.

 

References:

American Medical Association CPT® 2021 Professional Edition

CMA Evaluation and Management Services Guide Booklet, MLN06764

Documentation Guidelines for Evaluation and Management

 

1162-0422-PN-IN.MO.OH.WI

The Centers for Disease Control and Prevention (CDC) public sector vaccine ordering data shows a 14% drop in 2020 and 2021 compared to 2019, and measles vaccine is down by more than 20%. Children need to get caught up now, so they are protected as they get back to regular schedules, play times and prepare for summer camps. Healthcare providers can identify families whose children have missed doses and contact them to schedule appointments.¹

 

Well-child visits

A well-child visit is an opportunity for parents to get regular updates about their child’s growth and development. For adolescents, it can be lifesaving, particularly when you discuss HPV, which isn’t always easy. The CDC has developed several resources for providers about how to recommend the HPV vaccine and how to talk to parents about the HPV vaccine. Get these resources from cdc.gov.

 

Adults need preventive care, too

Getting good medical care that finds problems early and treats them effectively is an essential part of staying healthy. That’s why it is important for your adult patients to get those annual check-ups. It’s an opportunity for you to provide essential health services such as blood pressure, cholesterol and diabetes screenings. It is the perfect time to talk to your patients about their physical activity, their diet, and their overall wellbeing. Scheduling annual visits with your adult patients can lead to better health outcomes.

 

Measure Up

 

Adults’ Access to Preventive/ Ambulatory Health Services (AAP) HEDIS® measure includes members 20 years of age and older who have completed an ambulatory or preventive care visit during the measurement year.

 

Coding AAP

Ambulatory visit	CPT: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99483 HCPCS: G0402, G0438, G0439, G0463, T1015 ICD-10-CM: Z00.00, Z00.121, Z00.129, Z00.3, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9, Z76.1, Z76.2
Other ambulatory visits	CPT: 92002, 92004, 92012, 92014, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 HCPCS: S0620, S0621 UBREV: 0524, 0525
Telephone visits	CPT: 98966, 98967, 98968, 99441, 99442, 99443
Online assessments	CPT: 98969, 98970, 98971, 98972, 98972, 99421, 99422, 99423, 99444, 99457, 99458 HCPCS: G0071, G2010, G2012, G2061, G2062, G2063

 

Child and Adolescent Well Care Visits (WCV) measures the percentage of members 3 to 21 years of age who had a least one comprehensive well-care visit with a PCP or an OB/GYN during the measurement year.

 

Coding WCV

This is an abbreviated list of codes associated with the WCV measure.

Well-care	CPT: 99381-99385, 99391-99395, 99461
Encounter for routine child health check with abnormal findings	ICD-10: Z00.121
Encounter for routine child health check without abnormal findings	ICD-10: Z00.129
Encounter for examination for period of rapid growth in childhood	ICD-10: Z00.2

 

Healthcare Effectiveness Data and Information Set (HEDIS_®) is a registered trademark of NCQA.

 

¹cdc.gov. https://www.cdc.gov/vaccines/partners/childhood/downloads/childVax-infographic.pdf

 

1489-0422-PN-CNT

 

The annual after-hours access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate phone messaging for our members with perceived emergency or urgent situations after regular office hours. Unfortunately, most of the Anthem Blue Cross and Blue Shield (Anthem) plans assessed fell short of the expectation of having a live person or a directive in place after hours.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to an inability to reach the provider and/or the lack of after-hours messaging altogether. They include:

• inaccurate provider information in Anthem’s demographic database to allow assessment of the after-hours messaging
• no voicemail or messaging at all
• voicemail not reflecting the practitioner’s name
• calls being auto forwarded with no identification, no voicemail or messaging

 

Update your office information

To help both your patients’ and Anthem’s ability to reach your practice, we ask that you update your office information using the online Provider Maintenance Form. Also, review your after-hours messaging regarding connectivity for patients’ urgent accessibility.

 

What this means for our members and your patients

The annual member experience survey of Anthem enrollees indicated that of those needing advice, a sizable number sometimes, or never, reached the provider’s office for urgent instructions. To improve upon these instances of failing to meet our member’s needs, implement these steps:

1. Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
2. Be sure to turn on the messaging mechanism when you leave the office.
3. Be sure you are using the acceptable messaging for compliance with your contract.
4. A live person or recording must express if there are prior arrangements with patients for after hour needs, to be compliant.

 

Be compliant

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:

• Emergency situations: Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects the caller directly to the practitioner.
• Emergent / Urgent situations: Compliant responses for urgent needs after hours:
  • Live person, via a service, advises their practitioner or on call practitioner is available and connects.
  • Live person or recording directs or directly connects caller/patient to Urgent Care, 24-hour crisis services, 911 or ER.
  • Mechanism connects the caller to their practitioner or the practitioner on call. (Must directly connect)

 

Non-compliant responses for urgent needs after hours include:

• No provisions for after hour accessibility.
• Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. These scenarios are non-compliant because there is no direct connection to their practitioner. This prompt can be used in addition to, but not in place of instructions.

 

Is your practice compliant?

 

1311-0422-PN-CNT

 

The National Committee for Quality Assurance (NCQA) has changed, revised, and retired HEDIS for measurement year 2022. Below is a summary of some of the key changes to be aware of:

 

Diabetes measures

NCQA has separated the Comprehensive Diabetes indicators into stand-alone measures:

• Hemoglobin A1c Control for Patients with Diabetes (HBD) (HbA1c Control <8 and Poor Control HbA1c)
• Eye Exam Performed for Patients with Diabetes (EED)
• Blood Pressure for Patients with Diabetes (BPD)
• Kidney Health Evaluation for Patients with Diabetes (KED)

 

The process measure Comprehensive Diabetes HbA1c testing was retired as the goal is to move towards more outcome measures.

 

Race/ethnicity stratification

To address health care disparities, the first step is reporting and measuring performance.  Given this, NCQA has added race and ethnicity stratifications to the following HEDIS measures:

• Colorectal Cancer Screening (COL)
• Controlling High Blood Pressure (CBP)
• Hemoglobin A1c Control for patients with Diabetes (HBD)
• Prenatal and Post-Partum Care (PPC)
• Child and Adolescent Well Care Visits (WCV)

 

NCQA plans to expand the race and ethnicity stratifications to additional HEDIS measures over several years to help reduce disparities in care among patient populations. This effort builds on NCQA’s existing work dedicated to the advancing health equity in data and quality measurement.

 

New measures

 

Antibiotic Utilization for Respiratory Conditions (AXR). Measures the percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event. This measure was added given antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse.

 

Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic.  Given this new measure, the Antibiotic Utilization measure has been retired.

 

Deprescribing of Benzodiazepines in Older Adults (DBO). The percentage of Medicare members 65 years of age and older who were dispensed benzodiazepines and achieved a 20 percent decrease or greater in benzodiazepine dose during the measurement year. 

 

Guidelines recommend that benzodiazepines be avoided in older adults, and deprescribing benzodiazepines slowly and safely, rather than stopping use immediately. There is an opportunity to promote harm reduction by assessing progress in appropriately reducing benzodiazepine use in the older adult population.

 

Advanced Care Planning (ACP). Measures the percentage of adults 65 to 80 years of age, with advanced illness, an indication of frailty or who are receiving palliative care, and adults 81 years of age and older, who had advance care planning during the measurement year. 

 

Advance care planning is associated with improved quality of life, this measure will allow an understanding if it is provided to those who are most likely to benefit from it. Given this new measure, the Care for Older Adults measure has been retired.

 

Measure changes

 

Use of Imaging Studies for Low Back Pain (LBP). This measure was expanded to the Medicare line of business and the upper age limit for this measure was expanded to age 75. Additional exclusions to the measure were also added.

 

A complete summary of 2022 HEDIS changes and more information, can be found at NCQA HEDIS 2022.

 

Source: NCQA.org

 

1232-0422-PN-CNT

 

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. We are asking that you take a few  minutes to review your online provider directory information to help ensure Anthem Blue Cross and Blue Shield (Anthem) members can locate your most current information.

 

If changes are needed, please take the time to update your information by submitting updates and corrections to us on 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.

 

1572-0422-PN-CNT

 

This is a reminder that effective January 1, 2022, CVS Specialty Pharmacy and IngenioRx Specialty Pharmacy no longer dispense the brand name drug Botox^®. However, Botox is still be available to Anthem Blue Cross and Blue Shield (Anthem) members through other vendors.

 

Please note:

• This is not a change in member benefits. This is a change in the Botox vendor only.
• If the member is not using IngenioRx Specialty Pharmacy or CVS Specialty Pharmacy to obtain Botox, no action is needed.
• This change does not affect any other specialty pharmacy coverage.

 

Medical specialty pharmacy benefits

Our members who obtained Botox through CVS Specialty Pharmacy using their medical specialty pharmacy benefits must move this prescription, as of January 1, 2022. Here are the options:

• Providers can purchase Botox for their patients, then supply it to Anthem members. Providers would then bill Anthem for the drug and administration of the drug. This will require a new prior authorization to notify Anthem of this change.
• If the Anthem member’s pharmacy benefit manager is IngenioRx, providers can transition the Botox prescription to receive the drug from any in-network pharmacy using their pharmacy benefits. Transferring the coverage will require a new prescription and new prior authorization.

 

For questions regarding a member’s medical specialty pharmacy benefits, call Provider Services using the information on the back of the member’s ID card.

 

Pharmacy benefits manager benefits

 

Effective January 1, 2022, members who obtained Botox through IngenioRx Specialty Pharmacy using their pharmacy benefits must move this prescription from IngenioRx Specialty Pharmacy to another in-network specialty pharmacy that dispenses Botox. If there are refills still available on the current prescription, members can transfer it to the new pharmacy. If not, members will need a new prescription.

 

For questions regarding a member’s pharmacy benefits, call Pharmacy Member Services using the information on the back of the member’s ID card.

 

1485-0422-PN-CNT

 

The new name will reflect the company's exciting strategy for the future.

 

We are very excited to share the news that our parent company, Anthem, Inc., has filed a preliminary proxy statement to change its name. The new name, pending shareholder approval, will be Elevance Health.

 

Please know that if the name change is approved by shareholder vote, the following will not change:

• Your contract, reimbursement, or level of support
• Your patients’ plan or coverage

We will continue to do business as Anthem Blue Cross and Blue Shield.

 

Why the change?

The upcoming name change reflects the company’s strategy to elevate the importance of whole health and to advance health beyond healthcare for our customers, their families, and our communities.

 

Our path forward is clear

We are thrilled to share our journey with you as our parent company continues its evolution from a traditional health benefits organization to a health company that looks beyond the traditional scope of physical health and how to best support it.

 

For more information, please read the press release.

 

Thank you for being our trusted health partner.

Bryony Winn

President, Anthem Health Solutions

Anthem, Inc.

 

AWIPEC-1723-22

As a contracted provider for a Special Needs Plan (SNP) from Anthem Blue Cross and Blue Shield (Anthem), you are required to participate in an annual training on Anthem’s Model of Care. This training includes a detailed overview of SNPs and program information highlighting cost sharing, data sharing, participation in the Interdisciplinary Care Team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination.

 

Training for Anthem’s SNP product is self-paced and available on the Availity* Portal at Availity.com.

 

How to access the Custom Learning Center on the Availity Portal:

• Log in to Availity at Availity.com.
• At the top, select Payer Spaces and select the appropriate payer.
• On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
• In the Custom Learning Center, select Required Training.
• Select Special Needs Plan and Model of Care Overview.
• Select Enroll.
• Select Start.
• Once the course is completed, select Begin Attestation and complete.

 

Not registered for the Availity Portal?

Have your organization’s designated administrator register your organization for Availity.

• Visit Availity.com to register.
• Select Register.
• Select your organization type.
• In the Registration wizard, follow the prompts to complete the registration for your organization.

 

Complete registration instructions are available on the Availity website.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0307-22

This communication applies to the Commercial and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem).

 

Anthem appreciates your commitment to delivering quality care to our members and improving the overall health of our communities. To help ensure accurate claims processing, providers should report evaluation and management (E/M) services in accordance with the American Medical Association CPT® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. We have created a summary of the CMS guidance that may assist you with the documentation requirements necessary to support the level of service submitted on claims. 

 

Effective January 1, 2021, documentation guidelines for office and other outpatient visits are based on two components:

• Medical decision making (MDM)
• Total time

 

Total time is the complete time spent on the date of the encounter and may now include the time spent before, during, and after the visit, as well as the time spent documenting the visit. Previous components of history and physical exams  are no longer used to determine the level of service; however, a medically appropriate history and exam are required.

 

The 2021 guidance for time allows providers to receive credit with appropriate supporting documentation for the following elements:

• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other healthcare professionals (when not separately reported)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• Care coordination (not separately reported)

 

The intent of the revised documentation criteria is not to eliminate the need for providers to support medical appropriateness, but to provide them with the ability to account for additional time elements that were previously excluded.

 

CMS guidelines state the provider must help ensure that medical record documentation supports the level of service reported to a payer. Providers should not use the volume of documentation to determine which specific level of service to bill. The total time spent on the date of the encounter will determine the specific level of service billing. Services must meet specific medical necessity requirements in the statute, regulations, and American Medical Association and CMS manuals, and specific medical necessity criteria defined by national coverage determinations and local coverage determinations. For every service billed, providers should indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.

 

Clear and concise documentation is imperative to providing quality care. It is the provider’s responsibility to help ensure the documentation furnished reflects services provided to receive accurate and timely reimbursement.

 

References:

American Medical Association CPT® 2021 Professional Edition

CMA Evaluation and Management Services Guide Booklet, MLN06764

Documentation Guidelines for Evaluation and Management

 

ABSCRNU-0318-22

On November 19, 2021, December 13, 2021, and January 10, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised, or reviewed to support clinical coding edits.

 

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

 

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

Please share this notice with other members of your practice and office staff.

 

Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

 

Effective date	Document number	Clinical Criteria Title	New or revised
04/08/2022	*ING-CC-0205	Fyarro (sirolimus albumin bound)	New
04/08/2022	*ING-CC-0206	Besremi (ropeginterferon alfa-2b-njft)	New
04/08/2022	*ING-CC-0207	Vyvgart (efgartigimod alfa-fcab)	New
04/08/2022	*ING-CC-0208	Adbry (tralokinumab)	New
04/08/2022	*ING-CC-0209	Leqvio (inclisiran)	New
04/08/2022	ING-CC-0124	Keytruda (pembrolizumab)	Revised
04/08/2022	ING-CC-0079	Strensiq (Asfotase Alfa)	Revised
04/08/2022	ING-CC-0015	Infertility and HCG Agents	Revised
04/08/2022	ING-CC-0102	Gonadotropin releasing hormone (GNRH)  Analogs for Oncologic Indications	Revised
04/08/2022	ING-CC-0168	Tecartus (brexucabtagene autoleucel)	Revised
04/08/2022	ING-CC-0029	Dupixent (dupilumab)	Revised
04/08/2022	*ING-CC-0004	Repository Corticotropin Injection	Revised
04/08/2022	ING-CC-0072	Selective Vascular Endothelial Growth Factor (VEGF) Antagonists	Revised

 

ABSCRNU-0315-22

As a provider, every patient encounter is an opportunity to demonstrate how well you can listen and understand their needs and concerns. Likewise, to ensure your patients can implement your plan of care, you want to be sure that your patients are truly listening and understanding the advice you are giving.

 

Strategies to improve your communication to patients

One way to figure out if your communication with a patient is effective is by asking them to repeat back the plan of care you discuss with them. You will be able to identify gaps in their understanding and clarify by asking a patient to repeat the next steps back to you.

 

If you have just shared information with your patient, ask them to repeat back what you told them.  For example, you could say, “I just shared a lot of information with you about the new medication I think you should try. Can you please repeat it back to me so we can make sure you remember all of the important points?”. 

 

How does your patient know you are listening to them?

To make sure your patient knows you are listening, repeat back to them what you have heard. A quick summary helps assure you heard correctly. For example, you might say, “I want to make sure that I understand all of the important information you just shared. Let me repeat back what I heard so you can verify I didn’t miss anything.” This will help your patients know you are understanding their needs.

 

ABSCRNU-0312-22

 

Policy G-13001, effective 07/01/22

 

Effective July 1, 2022, when a member is readmitted within 30 days as part of a planned readmission and placed on a leave of absence, the admissions are considered to be one admission, and only one diagnosis-related group (DRG) will be reimbursed.

 

For additional information, please review the Inpatient Readmission reimbursement policy at https://www.anthem.com/medicareprovider.

 

ABSCRNU-0301-21

We want to provide you with an update regarding the offering for City of New York retirees – the NYC Medicare Advantage Plus plan, an alliance between Empire BlueCross BlueShield and EmblemHealth.

 

The NYC Medicare Advantage Plus plan is not being implemented on April 1, 2022. All retirees will remain in their current plans until further notice.

 

What does this mean?

City of New York retirees will remain in their current plan until further notice and will not transition to the NYC Medicare Advantage Plus plan on April 1, 2022. At this time, City of New York retirees do not need to opt out of the NYC Medicare Advantage Plus plan in order to remain in senior care or their current plan.

 

Where should I submit claims?

Please continue to follow your current processes for claims submission for the City of New York retirees under your care. Those processes will not change on April 1, 2022, as City of New York retirees will remain in their current plan.

 

When will City of New York retirees transition to the NYC Medicare Advantage Plus plan?

A new effective date has not yet been determined. Detailed information will be made available regarding the new effective date once it has been established.

 

Thank you for your continued care for City of New York retirees.

 

ABSCRNU-0324-22

Please continue to read news and updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

 

• Medical policies and clinical utilization management guidelines update
  
  
• AIM Specialty Health Outpatient Rehabilitative and Habilitative Services Clinical Appropriateness Guidelines updates
  
  
• Anthem expands specialty pharmacy precertification list

 

The new name will reflect the company's exciting strategy for the future.

 

We are very excited to share the news that our parent company, Anthem, Inc., has filed a preliminary proxy statement to change its name. The new name, pending shareholder approval, will be Elevance Health.

 

Please know that if the name change is approved by shareholder vote, the following will not change:

• Your contract, reimbursement, or level of support
• Your patients’ plan or coverage

We will continue to do business as Anthem Blue Cross and Blue Shield.

 

Why the change?

The upcoming name change reflects the company’s strategy to elevate the importance of whole health and to advance health beyond healthcare for our customers, their families, and our communities.

 

Our path forward is clear

We are thrilled to share our journey with you as our parent company continues its evolution from a traditional health benefits organization to a health company that looks beyond the traditional scope of physical health and how to best support it.

 

For more information, please read the press release.

 

Thank you for being our trusted health partner.

Bryony Winn

President, Anthem Health Solutions

Anthem, Inc.

 

ABSCARE-1421-22

Anthem Blue Cross and Blue Shield appreciates your commitment to delivering quality care to our members and improving the overall health of our communities. To help ensure accurate claims processing, providers should report evaluation and management (E/M) services in accordance with the American Medical Association CPT_® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. We have created a summary of the CMS guidance that may assist you with the documentation requirements necessary to support the level of service submitted on claims. 

 

Effective January 1, 2021, documentation guidelines for office and other outpatient visits are based on two components:

• Medical decision making (MDM)
• Total time

 

Total time is the complete time spent on the date of the encounter and may now include the time spent before, during, and after the visit, as well as the time spent documenting the visit. Previous components of history and physical exams are no longer used to determine the level of service; however, a medically appropriate history and exam are required.

 

The 2021 guidance for time allows providers to receive credit with appropriate supporting documentation for the following elements:

• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other healthcare professionals (when not separately reported)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• Care coordination (not separately reported)

 

The intent of the revised documentation criteria is not to eliminate the need for providers to support medical appropriateness, but to provide them with the ability to account for additional time elements that were previously excluded.

 

CMS guidelines state the provider must help ensure that medical record documentation supports the level of service reported to a payer. Providers should not use the volume of documentation to determine which specific level of service to bill. The total time spent on the date of the encounter will determine the specific level of service billing. Services must meet specific medical necessity requirements in the statute, regulations, and American Medical Association and CMS manuals, and specific medical necessity criteria defined by national coverage determinations and local coverage determinations. For every service billed, providers should indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.

 

Clear and concise documentation is imperative to providing quality care. It is the provider’s responsibility to help ensure the documentation furnished reflects services provided to receive accurate and timely reimbursement.

 

AWI-NU-0363-22

On November 19, 2021, December 13, 2021, and January 10, 2022, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. These policies were developed, revised, or reviewed to support clinical coding edits.

 

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

 

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

Please share this notice with other members of your practice and office staff.

 

Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

 

Effective date	Document number	Clinical Criteria title	New or revised
05/08/2022	*ING-CC-0205	Fyarro (sirolimus albumin bound)	New
05/08/2022	*ING-CC-0206	Besremi (ropeginterferon alfa-2b-njft)	New
05/08/2022	*ING-CC-0207	Vyvgart (efgartigimod alfa-fcab)	New
05/08/2022	*ING-CC-0208	Adbry (tralokinumab)	New
05/08/2022	*ING-CC-0209	Leqvio (inclisiran)	New
05/08/2022	ING-CC-0124	Keytruda (pembrolizumab)	Revised
05/08/2022	ING-CC-0079	Strensiq (Asfotase Alfa)	Revised
05/08/2022	ING-CC-0102	Gonadotropin releasing hormone (GNRH)  Analogs for Oncologic Indications	Revised
05/08/2022	ING-CC-0168	Tecartus (brexucabtagene autoleucel)	Revised
05/08/2022	ING-CC-0029	Dupixent (dupilumab)	Revised
05/08/2022	*ING-CC-0004	Repository Corticotropin Injection	Revised
05/08/2022	ING-CC-0072	Selective Vascular Endothelial Growth Factor (VEGF) Antagonists	Revised

 

AWI-NU-0357-22

The Disease Management/Population Health program is designed to support providers in caring for patients with chronic healthcare needs. Anthem Blue Cross and Blue Shield (Anthem) provides members enrolled in the Disease Management/ Population Health program with continuous education on self-management, assistance in connecting to community resources, and coordination of care by a team of highly qualified professionals whose goal is to create a system of seamless healthcare interventions and communications.

 

Who is eligible?

Disease Management/Population Health program case managers provide support to members with:

• Asthma
• Bipolar disorder
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure
• Coronary artery disease
• Diabetes
• HIV/AIDS
• Hypertension
• Major depressive disorder — adults
• Major depressive disorder — children and adolescents
• Schizophrenia
• Substance use disorder

 

The Disease Management/Population Health program includes and addresses the following for each condition:

• Condition monitoring (including self-monitoring and medical testing)
• Adherence to treatment plans (including medication adherence, as appropriate)
• Medical and behavioral health co-morbidities and other health conditions (e.g. cognitive deficits, physical limitations)
• Health behaviors
• Psychosocial issues including depression and substance use screening
• Providing information about the patient’s condition to caregivers who have the patient’s consent
• Encouraging patients to communicate with their practitioners about their health conditions and treatment
• Additional resources external to the organization, as appropriate

 

Our case managers use member-centric motivational interviewing to identify and address health risks, such as tobacco use and obesity, to improve condition-specific outcomes. Interventions are rooted in evidence-based Clinical Practice Guidelines from recognized sources. We implement continuous improvement strategies to increase evaluation, management, and health outcomes.

 

For more information on our program and how to refer an Anthem member, please visit https://providers.anthem.com/wisconsin-provider/patient-care/health-education/disease-management.

 

Your input and partnership are valued. Once your patient is enrolled in the Disease Management/Population Health program, you will be notified by the clinical associate assigned.

 

We look forward to working with you.

 

AWI-NU-0348-22

Policy G-13001, effective 07/01/22

 

Effective July 1, 2022, when a member is readmitted within seven days as part of a planned readmission and/or placed on a leave of absence, the admissions are considered to be one admission, and only one diagnosis-related group (DRG) will be reimbursed.

 

For additional information, please review the Inpatient Readmission reimbursement policy at

https://providers.anthem.com/wi.

 

AWI-NU-0345-21

Please continue to check Provider Communications & Updates on the provider website for the latest BadgerCare Plus information, including:

 

• Medical policies and clinical utilization management guidelines update
  
  
• Phone number change for AIM in Wisconsin
  
  
• Medical drug benefit clinical criteria updates
  
  
• Specialty pharmacy site of care program retraction
  
  
• Prior authorization updates for medications billed under the medical benefit