As we announced in the October 2021 edition of Provider News, Anthem Blue Cross and Blue Shield (Anthem) is working to comply with the requirements of the Consolidated Appropriations Act, or CAA.

Improving the accuracy of provider directory information

As part of the CAA, soon providers will be asked to verify their online provider directory information on a regular basis to help ensure Anthem members can locate the most current information for in-network providers and facilities. It is important that you keep your information up to date. Here’s what you can do now:

• Review your online provider directory information on a regular basis to ensure it is correct. You can check your directory listing on Anthem’s Find Care Consumers, members, brokers, and providers use the Find Care tool to identify in-network physicians and other healthcare providers supporting member health plans. To ensure we have your most current and accurate information, please take a moment to access Find Care. Go to Anthem.com, select Providers, then under Provider Overview, choose Find Care.

• Submit updates and corrections to your directory information by using 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.

Consolidated Appropriations Act implementation

The Consolidated Appropriations Act does not preempt state law requirements. This means that the CAA applies in addition to any state law requirements of providers to update their provider directory information.

On August 20, 2021, the Tri-Agencies (Departments of Labor, Health and Human Services and the Treasury) announced that regulations to implement the provider directory requirements would be issued on or after January 1, 2022. Health plans are expected to implement the provider directory requirements based on a good faith, reasonable interpretation of the requirements by January 1, 2022, with a primary focus on ensuring that members who rely on provider directory information that inaccurately depicts a provider’s network status are only liable for in-network cost sharing amounts. Anthem is moving forward with compliance of this good faith, reasonable interpretation of the requirements while awaiting additional regulatory guidance.

Watch for upcoming editions of Provider News in 2022 for updates on our ongoing efforts to comply with the CAA requirements.

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Anthem Blue Cross and Blue Shield (Anthem) has expanded our high performance network to Calumet, Outagamie and Winnebago counties, allowing employers there to offer their employees Blue High Performance Network^SM (BlueHPN^SM) plans for the 2022 benefit year. BlueHPN_® plans offer access to a select set of providers with a record of delivering high quality, efficient care.

In Wisconsin, the BlueHPN network is called Blue Connection, and includes providers in Calumet, Kenosha, Milwaukee, Outagamie, Ozaukee, Racine, Washington, Waukesha and Winnebago counties. Anthem is offering large and small group employers in Wisconsin employee benefit plans with access to the HPN. These plans offer an Exclusive Provider Organization (EPO) benefit design and are supported by the BlueHPN, Blue Connection network.

Beginning January 1, 2022, you may see patients accessing a BlueHPN network this network through either a national, or local employer plan. Under EPO benefit plans, out of network benefits are limited to emergency or urgent care. Members must select a primary care provider, but PCP referrals are not required for specialty care.

If you are not sure whether your practice is part of Blue Connection, ask your office manager or business office, or contact your Anthem network representative. Blue Connection participation will be displayed in provider profiles in our provider directory January 1, 2022.

Below is a sample ID card for a member from Wisconsin enrolled in the national employer BlueHPN plan. Note the new “Blue High Performance Network” and “Blue Connection” network names and “BlueHPN” indicator in the suitcase icon.

You may see Wisconsin member ID prefixes H8W and H9W for these plans.

If you are interested in learning more, please see the BlueHPN FAQ, BlueHPN Introduction WI and BlueHPN Quick Reference Guide WI that are available under Forms and Guides on anthem.com.  Select Providers, Forms and Guides under Provider Resources.

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As a reminder, we will continue to upgrade our claim editing software for professional services monthly throughout 2022, with most updates occurring quarterly. These upgrades may apply to same provider, provider group (tax identification number). They may also apply across providers and across claim types (professional and facility) and include, but are not limited to:

• Addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits such as:
  • ICD-10 laterality and Excludes1 notes
  • Add-on procedures (indicated by + sign)
  • Code book parenthetical statements and other directives about appropriate code use (e.g. “separate procedure”, “do not report”, “list separately in addition to”, etc.)
• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to incidental, mutually exclusive, and unbundled (rebundle) edits
• Updates to assistant and co-surgeon eligibility in accordance with the policy
• Updates to edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

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As a reminder, Anthem Blue Cross and Blue Shield (Anthem) will continue to upgrade our claim editing software for outpatient facility services monthly throughout 2022, with most updates occurring quarterly. These upgrades will include, but are not limited to:

• Addition of new and revised codes (for example CPT, HCPCS, ICD-10, modifiers, and revenue codes) and their associated edits

• Updates related to the appropriate use of various code combinations, which can include, but are not limited to:

• Procedure code to revenue code
• HCPCS to revenue code
• Type of bill to procedure code
• Type of bill to HCPCS code
• Procedure code to modifier
• HCPCS to modifier

• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC)

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Talking to a teenager about Chlamydia can be difficult. But, if untreated, the typical teenager could develop Pelvic Inflammatory Disease (PID) or worse, infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. For a free Chlamydia How-To Implementation Guide for Healthcare Providers, visit the National Chlamydia Coalition website at http://chlamydiacoalition.org.

One of the largest growing populations for Chlamydia is teens and young adults aged 15 to 24. Through annual screening – a simple urine test in your office or in an off-site lab – teens and young adults can maintain good health.

Chlamydia Screening in Women (CHL): HEDIS_® recommends annual screenings for teens starting at age 16 and for women up to age- 24. Sexually active teens and women as well as those who meet any of the following criteria should be tested each calendar year:

• Made comments or talked to you about sexual relations   
• Taken a pregnancy test
• Been prescribed birth control (even if used for acne treatment)   
• Received Gynecological services
• A history of sexually transmitted diseases
• A history of sexual assault or abuse

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The annual behavioral health access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded during the first through third quarters of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine follow-ups.

The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Anthem’s demographic database, i.e. incorrect or non-working phone numbers; practitioner moved, retired, or deceased; the practice has resigned their Anthem contract, accepts private pay only, or is no longer in practice; as well as, staff refusing to participate in the survey. We ask that you update office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Anthem’s contract.

The primary appointment type not meeting compliance is consistently obtaining the initial routine appointment. This is the initial conversation with a professional after the intake assessment for a new patient for a non-urgent condition. Please refer to compliant timeframe and explanation below.

To be compliant, per the Provider Manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:

• Non-life-threatening emergency – The patient must meet with their BH practitioner, another practitioner in the practice or a covering practitioner within 6 hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate.
  • Explanation - These calls concern members in acute distress whose ability to conduct themselves for their own safety, or the safety of others, may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. The situation has the potential to escalate into an emergency without clinical intervention.
• Urgent – The patient must meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 48 hours.
  
  • Explanation - These calls are non-emergent with significant psychological distress when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
• Initial routine office visit – A new patient must meet with a designated BH practitioner or another equivalent practitioner in the practice within 10 business days. It can be after the intake assessment or a direct referral from a treating practitioner.
  • Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms which presents no immediate distress, and can wait to schedule an appointment without any adverse outcomes.
• Routine office visit – The patient must meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 30 calendar days.
  • Explanation - These calls concern existing members to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
• BH follow-up appointment after discharge – The patient must meet with their practitioner or another practitioner in the practice within 7 calendar days.
  • Explanation – These calls concern members being released from inpatient psychiatric hospital care requesting a follow-up appointment to evaluate what has taken place since release, including med management.

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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, and/or
• calls being auto forwarded with no identification, no voicemail or messaging

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 and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.

What does this mean for our members and your patients? The annual member experience survey of Anthem enrollees indicated 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 three 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.

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.  

Urgent situations

Compliant responses for urgent needs after hours:

• Live person, via a service or hospital, advises practitioner or on call practitioner is available and connects.
• Live person or recording directs caller/patient to Urgent Care, ER or call 911.

Non-compliant responses for urgent needs after hours:

• No provision for after-hours 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. (Not a direct connection to their practitioner.)

Is your practice compliant?

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Anthem Blue Cross and Blue Shield (Anthem) utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. Our medical policies are available on Anthem’s website at anthem.com.

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below.  UM criteria are also available on the web. Just go to anthem.com, and select Providers > Provider Resources > Policies, Guidelines and Manuals > Select Indiana > View Medical Policies and Clinical UM Guidelines.

We work with providers to answer questions about the utilization management process and the authorization of care. Here’s how the process works:

• Call us toll free from 8:30 a.m. to 5 p.m., Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8 a.m. to 7 p.m. ET.
• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after 12 midnight will be returned the same business day.
• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

The following phone lines are for physicians and their staffs. Members should call the customer service number on their health plan ID card.

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.

Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.

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Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.

Anthem Blue Cross and Blue Shield (Anthem) is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

How do you contact us?

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The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield (Anthem) has adopted a member rights and responsibilities statement.

To read the member rights and responsibilities statement, visit the Policies, Guidelines and Manuals page of our provider website. Scroll down the page and select “Read about member rights.” Under the FAQ question titled “Laws and Rights that Protect You” you can find information about Anthem member rights and responsibilities.

Practitioners may access the FEP member portal at fepblue.org/memberrights to view the FEPDO Member Rights Statement.

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Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral.  Anthem Blue Cross and Blue Shield (Anthem) would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner.  Anthem urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other health care practitioners at the time treatment begins.

We expect all health care practitioners to:

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:

• Diagnosis
• Treatment plan
• Referrals
• Psychopharmacological medication (as applicable)

In an effort to facilitate coordination of care, Anthem has several tools available on our anthem.com Provider website for behavioral health and other medical practitioners including:

• Coordination of Care Form
• Coordination of Care Letter Template – Behavioral Health
• Coordination of Care Letter Template – Medical

The following behavioral health forms, brochures, and screening tools for substance abuse and attention-deficit/hyperactivity disorder (ADHD) are also available on our anthem.com Provider website:

• Alcohol Use Assessment Brochure
• Antidepressant Medication Management
• Edinburgh Postnatal Depression Scale
• Opioid Use Assessment Brochure
• Substance Brief Intervention/Referral Tool (SBIRT)
• Vanderbilt ADHD Diagnostic Parent Rating Scale

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As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. 

All guidelines are reviewed annually and updated as needed. The current guidelines are available on our website at anthem.com > Provider > Select Policies, Guidelines & Manuals under Provider Resources> scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.

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

• Durable medical equipment prior authorization requirement changes effective December 1, 2021
  
  
• Updates to AIM Specialty Health musculoskeletal interventional pain management clinical appropriateness guideline
  
  
• Medical drug benefit clinical criteria updates
  
  
• Updates to AIM Specialty Health Cardiology Clinical Appropriateness Guidelines

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

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

To view a guideline, visit https://www.anthem.com/provider/policies/clinical-guidelines/search.

Notes/updates:

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

• *CG-SURG-112 — Carpal Tunnel Decompression Surgery
  • Outlines the Medically Necessary and Not Medically Necessary criteria for carpal tunnel decompression surgery
• *CG-SURG-113 — Tonsillectomy with or without Adenoidectomy for Adults
  • Outlines the Medically Necessary and Not Medically Necessary criteria
• *DME.00043 — Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
  • The use of a neuromuscular electrical training device is considered Investigational & Not Medically Necessary for the treatment of obstructive sleep apnea or snoring
• *GENE.00058 — TruGraf Blood Gene Expression Test for Transplant Monitoring
  • TruGraf blood gene expression test is considered Investigational & Not Medically Necessary for monitoring immunosuppression in transplant recipients and for all other indications
• *LAB.00040 — Serum Biomarker Tests for Risk of Preeclampsia
  • Serum biomarker tests to diagnosis, screen for, or assess risk of preeclampsia are considered Investigational & Not Medically Necessary
• *LAB.00042 — Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy
  • Molecular signature testing to predict response to Tumor Necrosis Factor inhibitor (TNFi) therapy is considered Investigational & Not Medically Necessary for all uses, including but not limited to guiding treatment for rheumatoid arthritis
• *OR-PR.00007 — Microprocessor Controlled Knee-Ankle-Foot Orthosis
  • Outlines the Medically Necessary and Not Medically Necessary criteria for the use of a microprocessor controlled knee-ankle-foot orthosis
• *SURG.00032 — Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
  • Added Medically Necessary statement for transcatheter closure of left atrial appendage (LAA) for individuals with non-valvular atrial fibrillation for the prevention of stroke when criteria are met
  • Revised Investigational & Not Medically Necessary statement for transcatheter closure of left atrial appendage when the criteria are not met
• *SURG.00077 — Uterine Fibroid Ablation: Laparoscopic, Percutaneous, or Transcervical Image Guided Techniques
  • Added Medically Necessary statement on use of laparoscopic or transcervical radiofrequency ablation
  • Added Not Medically Necessary statement on use of laparoscopic or transcervical radiofrequency ablation when criteria in Medically Necessary statement are not met
  • Removed laparoscopic radiofrequency ablation from Investigational & Not Medically Necessary statement
  • Removed Investigational & Not Medically Necessary statement on radiofrequency ablation using a transcervical approach

Medical Policies

On August 12, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect December 8, 2021.

Clinical UM Guidelines

On August 12, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for members on September 23, 2021. These guidelines take effect December 8, 2021.

AWI-NU-0329-21

Summary of update

Effective December 1, 2021, prior authorization (PA) requirements will change for 0018U and 0245U. The medical codes listed below will require PA by Anthem Blue Cross and Blue Shield for BadgerCare Plus 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 PA rules and must be considered first when determining coverage.

Please note: Noncompliance with new requirements may result in denied claims.

What medical codes will now require PA?

PA requirements will be added to the following:

• 0018U — Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy
• 0245U — Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of four mRNA markers using next-generation sequencing, fine needle aspirate, report includes associated risk of malignancy expressed as a percentage

How do I request a PA?

To request a PA, you may use one of the following methods:

• Through the Availity Portal:* Once logged in to Availity at com, select Patient Registration > Authorizations & Referrals > Choose either Authorizations or Auth/Referral Inquiry, as appropriate.
• By fax: 800-964-3627
• By phone: 855-558-1443

Are all PA requirements listed in this update?

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://providers.anthem.com/wi. You must log in to see detailed PA requirements. Contracted and noncontracted providers who are unable to access Availity may call Provider Services at 855 558-1443 for assistance with PA requirements.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your assigned Provider Experience associate or call Provider Services at 855-558-1443.

AWI-NU-0317-21

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

Effective for dates of service on and after March 13, 2022, the following updates will apply to the listed AIM Specialty Health_® (AIM)* Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates by guideline:

• Imaging of the Brain:

• Acoustic neuroma — removed indication for CT brain and replaced with CT temporal bone
• Meningioma — new guideline establishing follow-up intervals
• Pituitary adenoma — removed allowance for CT following nondiagnostic MRI in macroadenoma
• Tumor, not otherwise specified — added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

• Imaging of the Head and Neck:
• Parathyroid adenoma — specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
• Temporomandibular joint dysfunction — specified duration of required conservative management
• Imaging of the Heart:
  • Coronary CT angiography — removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
• Imaging of the Chest:
• Pneumonia — removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
• Pulmonary nodule — aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT
• Imaging of the Abdomen and Pelvis:
• Uterine leiomyomata — new requirement for ultrasound prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
• Intussusception — removed as a standalone indication
• Jaundice — added requirement for ultrasound prior to advanced imaging in pediatric patients
• Sacroiliitis — defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
• Azotemia — removed as a standalone indication
• Hematuria — modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline
• Oncologic Imaging:
• National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin and Non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers.
• Cancer screening — new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
• Breast cancer — clinical scenario clarifications for diagnostic breast MRI and PET/CT

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM via:

• AIM’s ProviderPortal_SM directly at providerportal.com.
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• The Availity* Portal at availity.com.
• Phone at 800-714-0040, Monday through Friday from 7 a.m. to 7 p.m. CT.

If you have questions related to guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines online.

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Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override.

For additional information, please review the Drug Screen Testing reimbursement policy at https://providers.anthem.com/wi.

AWI-NU-0318-21

We have enhanced your ability to search, review, and download a copy of the remittance advice on Availity* when there is not an associated payment. For remit advice with payment, you can continue to search with the Check/EFT number.

Below are images reflecting the scenarios that have been enhanced:

Paper remittance

Electronic remittance advice (ERA/835)

What has changed?

1. Non-payment number display in the Check Number and Check/EFT Number fields:
   • Old — There were two sets of numbers for the same remittance advice. The paper remittance displayed 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displayed 27 bytes (9999999999 — [year] #############).
   • Enhancement — The updated numbering sequence for the paper remittance and corresponding 835 (ERA) now contain the same 10-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.

2. Searching for non-payment remittance:
   • Old — When using Remit Inquiry to locate paper remittance, the search field required a date range and tax ID to locate a specific remittance due to same number scenario (10 bytes (9999999999) being used for every non-payment remittance.
   • Enhancement — Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers provides a faster and simplified process to find the specific remittance.

The way your organization receives remittances and payments has not changed; we have simply enhanced the numbering for the non-pay remittances. These changes do not impact previously issued non-payment remittance advice.

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

AWI-NU-0307-21

The following HEDIS_® measures assess the percentage of emergency department (ED) visits for which the member received a follow-up appointment within seven days and 30 days of being seen in the ED for mental illness or for alcohol and other drug abuse and dependence.

Follow-Up After ED Visit for Mental Illness (FUM)

Evaluates the percentage of ED visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit with any practitioner for mental illness. Two rates are reported. The percentage of ED visits for which the member received:

1. Follow-up within seven days of the ED visit (8 total days).
2. Follow-up within 30 days of the ED visit (31 total days).

Timely follow-up care for people with mental illness can lead to fewer repeat visits to the ED and improved physical and mental health function.

Follow-Up After ED Visit for Alcohol and Other Drug Abuse or Dependence (FUA)

Evaluates the percentage of ED visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow-up visit with any practitioner for AOD. Two rates are reported. The percentage of ED visits for which the member received:

1. Follow-up within seven days of the ED visit (8 total days).
2. Follow-up within 30 days of the ED visit (31 total days).

According to studies, follow-up care for individuals with AOD who were seen in the ED is associated with reduced substance use, repeat ED visits, and hospital admissions.

Members earn rewards for screenings through the Healthy Rewards Program

Through Healthy Rewards, members receive incentives for completing their follow-up appointments. They can redeem their reward dollars for retail gift cards.

Helpful tips:

• Maintain appointment availability for patients with recent ED visits.
• Assist in scheduling in-person or telehealth follow-up appointments as soon as possible after the ED visit.
• Use appropriate documentation and correct coding. Use the same diagnosis for mental illness or substance use for follow-up visits (a non-mental health/non-substance diagnosis code will not fulfill the measure).
• Reference the Plan’s Quality Measures Desktop Reference for Medicaid Providers and the HEDIS Benchmarks and Coding Guidelines for Quality that is provided for coding information.
• Educate patients on the importance of compliance with their discharge plan and their follow-up appointments.
• Reach out to patients who cancel their appointments and assist with rescheduling as soon as possible.
• Facilitate referrals to behavioral healthcare specialists when appropriate.

HEDIS_® is a registered trademark of the National Committee for Quality Assurance (NCQA).

AWI-NU-0319-21

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

• Updates to AIM Specialty Health musculoskeletal interventional pain management clinical appropriateness guideline
  
  
• Medical drug benefit clinical criteria updates
  
  
• Protocol for providers serving members with hearing aid coverage administered by Hearing Care Solutions
  
  
• New York City Medicare Advantage announcement
  
  
• Medical policies and clinical utilization management guidelines update
  
  
• Updates to AIM Specialty Health Cardiology Clinical Appropriateness Guidelines 
  (WI only)

An overview of notable 2022 benefit changes and service area updates are now available at this link.

Please continue to check https://www.anthem.com/medicareprovider for the latest Medicare Advantage information.

ABSCRNU-0283-21

Beginning January 1, 2022, Medicare Advantage Organizations (MAOs) and Medicare-Medicaid Plans (MMPs) are responsible for adjudicating claims for COVID-19 vaccines and their administration and for COVID-19 monoclonal antibodies and their administration.

ABSCRNU-0286-21

Effective for dates of service on and after March 13, 2022, the following updates will apply to the listed AIM Specialty Health_® (AIM)* Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates by guideline:

• Imaging of the Brain:

• Acoustic neuroma — removed indication for CT brain and replaced with CT temporal bone
• Meningioma — new guideline establishing follow-up intervals
• Pituitary adenoma — removed allowance for CT following nondiagnostic MRI in macroadenoma
• Tumor, not otherwise specified — added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

• Imaging of the Head and Neck:
• Parathyroid adenoma — specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
• Temporomandibular joint dysfunction — specified duration of required conservative management
• Imaging of the Heart:
  • Coronary CT angiography — removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
• Imaging of the Chest:
• Pneumonia — removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
• Pulmonary nodule — aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT
• Imaging of the Abdomen and Pelvis:
• Uterine leiomyomata — new requirement for ultrasound prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
• Intussusception — removed as a standalone indication
• Jaundice — added requirement for ultrasound prior to advanced imaging in pediatric patients
• Sacroiliitis — defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
• Azotemia — removed as a standalone indication
• Hematuria — modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline
• Oncologic Imaging:
• National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin and Non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers.
• Cancer screening — new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
• Breast cancer — clinical scenario clarifications for diagnostic breast MRI and PET/CT

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM via:

• AIM’s ProviderPortal_SM directly at providerportal.com.
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• The Availity* Portal at availity.com.
• Phone at 800-714-0040, Monday through Friday from 7 a.m. to 7 p.m. CT.

If you have questions related to guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines online.

ABSCRNU-0281-21

Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override.

For additional information, please review the Drug Screen Testing reimbursement policy at https://www.anthem.com/medicareprovider.

ABSCRNU-0270-21

We have enhanced your ability to search, review, and download a copy of the remittance advice on Availity* when there is not an associated payment. For remit advice with payment, you can continue to search with the Check/EFT number.

Below are images reflecting the scenarios that have been enhanced:

Paper remittance

Electronic remittance advice (ERA/835)

What has changed?

1. Non-payment number display in the Check Number and Check/EFT Number fields:
   • Old — There were two sets of numbers for the same remittance advice. The paper remittance displayed 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displayed 27 bytes (9999999999 — [year] #############).
   • Enhancement — The updated numbering sequence for the paper remittance and corresponding 835 (ERA) now contain the same 10-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.

2. Searching for non-payment remittance:
   • Old — When using Remit Inquiry to locate paper remittance, the search field required a date range and tax ID to locate a specific remittance due to same number scenario (10 bytes (9999999999) being used for every non-payment remittance.
   • Enhancement — Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers provides a faster and simplified process to find the specific remittance.

The way your organization receives remittances and payments has not changed; we have simply enhanced the numbering for the non-pay remittances. These changes do not impact previously issued non-payment remittance advice.

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

ABSCRNU-0260-21

We are pleased to announce a new no-cost care management program available for your Medicare Advantage covered patients with chronic kidney disease (CKD) or end-stage kidney disease (ESKD). This high-touch program, delivered by Somatus*, is designed to support and enhance your existing patient care by providing hands-on, one-on-one care management to eligible patients with kidney disease.

Somatus is the leading and largest provider of kidney care management services in the country. Through an innovative care-delivery model, Somatus surrounds patients with access to the full suite of support services and education needed to delay kidney disease progression and retain quality of life.

Somatus’ care management services are personalized to each participating member and may include:

• A full care team comprised of a nurse, community health worker, pharmacist, dietitian, and social worker.
• Ongoing in-home physical assessments, environmental assessments, face-to-face education, and health coaching to identify problems early and avoid potential hospitalizations and complications.
• Comprehensive 1:1 care management of the patient’s kidney disease and co-morbidities, delivered in person (at home, clinic, or hospital) or via telephone.
• Clinical and logistical assistance to help patients transfer safely from hospital to home, if needed.
• Meal planning, appointment scheduling, transportation coordination, connection to local resources and community-based organizations, and more.

Anthem Blue Cross and Blue Shield will identify Medicare Advantage patients in your practice that qualify for and would benefit from Somatus’ kidney-care services, and we look forward to working with you to ensure these patients enroll and take part in this no-cost opportunity. A member of the Somatus team will be in touch to discuss your eligible patients and how you can help encourage their participation.

For more information about Somatus, visit www.somatus.com or, contact the Somatus Care Team at:

• Phone: 855-851-8354, Monday through Friday, 9 a.m. to 9 p.m. ET
• Email: care@somatus.com

* Somatus is an independent company providing care management services on behalf of Anthem Blue Cross and Blue Shield.

ABSCRNU-0285-21