 Provider News WisconsinJanuary 2019 Anthem Wisconsin Provider NewsletterAnthem Blue Cross and Blue Shield (Anthem) is committed to investing in primary care, rewarding coordinated, patient-centered care, and promoting proactive chronic care management. In recognition of the time-intensive nature of this work, Anthem will reimburse chronic care management and advance care planning services for Commercial health plans effective for claims processed on or after February 23, 2019.
Chronic care management (CCM) is care rendered by a physician or non‐physician health care provider and their clinical staff, once per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Only one practitioner can bill a CCM service per service period (month). Three CCM codes are included in this payment policy change: 99490, 99487and 99489.
Advance care planning (ACP) is a face-to-face service between a physician or other qualified health care professional and a patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document in which a patient appoints an agent and/or records the wishes of a patient pertaining to their medical treatment at a future time if they cannot decide for themselves at that time. No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary. Two ACP codes are included in the payment policy change: 99497 and 99498
Anthem requires patient consent prior to CCM or ACP service(s) being provided. Please refer to the current Claims Requiring Additional Documentation policy for more information. For more information, review our Bundled Services and Supplies policy dated February 23, 2019 by visiting the reimbursement policy page for your state, Indiana, Kentucky, Missouri, Ohio, Wisconsin, found on anthem.com. We will begin requesting medical records in February via a phone call to your office followed by a fax.
The fax will contain 1) a cover letter with contact information your office can use to contact us if there are any questions; 2) a member list, which includes the member and HEDIS measure(s) the member was selected for; and 3) an instruction sheet listing the details for each HEDIS measure. As a reminder, under HIPAA, releasing PHI for HEDIS data collection is permitted and does not require patient consent or authorization. HEDIS and release of information is permitted under HIPAA since the disclosure is part of quality assessment and improvement activities [45 CFR 164.506(c) (4)]. For more information, visit www.hhs.gov/ocr/privacy.
HEDIS review is time sensitive, so please submit the requested medical records within five business days.
To return the medical record documentation back to us in the recommended 5-day turnaround time, simply choose one of these options:
- Upload to our secure portal. This is quick and easy. Logon to www.submitrecords.com, enter the password included with your HEDIS Member List and select the files to be uploaded. Once uploaded you will receive a confirmation number to retain for your records.
OR
- Send a secure fax to 1-888-251-2985
OR
- Mail to us via the US Postal Service to:
Anthem, Inc., 66 E. Wadsworth Park Drive, Suite 110H, Draper, UT 84020
Please contact your Provider Network Representative to let them know if you have a specific person in your organization that we should contact for HEDIS medical records.
Thank you in advance for your support of HEDIS.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). In early 2018, Anthem Blue Cross and Blue Shield (Anthem) became one of the first major insurers to reimburse EMS providers for appropriate and medically necessary care billed under HCPCS code A0998 (Ambulance response and treatment, no transport). The code, which has been active since January 2018 for most standard Anthem benefit plans, allows EMS providers to receive reimbursement for treatment rendered in response to an emergency call to a member’s home or scene, when transportation to the hospital emergency room (ER) was not provided. Previously, Anthem reimbursed EMS providers for treatment rendered only when a patient was transported to the ER.
Important reminders:
- The code is currently active and available for EMS use.
- If an EMS provider responds to an emergency call and provides appropriate treatment at-home or on-site without transporting to the ER, code A0998 can be used.
- The EMS provider must render treatment to the patient per EMS protocols which are approved by the medical director at the local or state level.
- Billing of A0998 when treatment is not rendered is not appropriate.
- Anthem will apply medical necessity review to A0998 using clinical guideline CG-ANC-06.
- HCPCS code A0998 applies to all of Anthem’s commercial health plans, and reimbursement will be made in accordance with the member’s benefits.
Questions?
- For contract questions, please reach out to your contract representative.
- For questions about using code A0998, please reach out to Jay Moore, Senior Clinical Director for Anthem, Inc.
Anthem Blue Cross and Blue Shield (Anthem) is committed to offering efficient and streamlined solutions for submitting prior authorizations (PAs). This helps reduce the administrative burden while improving the member experience for their patients.
Anthem’s Proactive PA process approves select drugs in real time, using an automated prior authorization (PA) process. Proactive PA uses integrated medical and pharmacy data to seamlessly approve medication prior authorization requests where diagnoses are required. Anthem’s prior authorization process helps to ensure clinically appropriate use of medications.
Providers can take advantage of the electronic prior authorization (ePA) submission process by logging in at covermymeds.com. Creating an account is FREE, and many prior authorizations are approved in real time. Read more about the ePA submission process in the article published in December 2018. To access this article, select your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin
Additionally, providers may be able to access real-time, patient-specific prescription drug benefits information through their electronic medical record (EMR) system. To learn more about this feature, refer to the article published in October 2018. To access this article, select your state: Indiana, Kentucky, Missouri, Ohio, Wisconsin
Anthem Blue Cross and Blue Shield (Anthem) continually monitors and updates the list of drugs not approved by the Food and Drug Administration (FDA), which are considered non-covered under prescription drug benefits. When drugs are added to this list, Anthem notifies impacted members that the drug is not FDA approved and will no longer be covered.
Effective December 1, 2018, these drugs were added to our list of drugs not approved by the FDA. For new members just beginning an Anthem plan or not yet having used one of these non-FDA-approved drugs, coverage for these drugs ended December 1, 2018.
Existing members who had been identified as already using at least one of the drugs added to the list received a letter to let them know their drug(s) will no longer be covered after December 31, 2018. However, if the patient had a prior authorization for a drug on this list, coverage for that drug continued until the prior authorization expired on December 31, 2018.
On November 1, 2017, the Centers for Medicare & Medicaid Services (CMS) issued its 2018 Outpatient Prospective Payment System “OPPS” Final Rule, CMS CY2018 OPPS Final Rule, which finalized the Medicare Part B payment for certain drugs acquired through the 340B Program.
As appropriate, the 340B Program requires drug manufacturers to provide outpatient drugs to eligible health care organizations and covered entities at significantly discounted prices.
As described in the Final Rule, CMS established two new modifiers to identify 340B drugs – the “JG” and “TB” modifiers. Beginning January 1, 2018, affected entities were required to report these modifiers on outpatient claims for certain separately payable drugs or biologicals that are acquired through the 340B program and administered or dispensed to patients.
Beginning April 1, 2019, for our Commercial lines of business, Anthem Blue Cross and Blue Shield will require that all facilities eligible for the 340B Program bill these modifiers on all outpatient claims impacted by these modifiers.
These facilities are excluded from this billing requirement:
- Sole community hospitals (“SCHs”)
- Children’s hospital
- PPO-exempt cancer hospitals
- Critical access hospitals (“CAHs”)
- Drugs administered/dispensed in non-excepted hospital off-campus outpatient departments (“HOPDs”)
Visit anthem.com/pharmacyinformation for more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs.
The commercial drug list is posted to the web site quarterly (the first of the month for January, April, July and October).
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. AllianceRX Walgreens Prime is the specialty pharmacy program for the FEP. You can view the 2018 Specialty Drug List or call us at 888-346-3731 for more information.
Anthem Blue Cross and Blue Shield (Anthem) recently introduced a redesigned monthly Explanation of Benefits (EOB) to Medicare Advantage members.
The new EOB includes:
- Personalized tips to help members save on health care expenses.
- A preventive care checklist — to point out opportunities for screenings or other care.
- Alerts when a claim needs immediate attention.
If you or your members have any questions about how to read the new EOB, please call the number on the back of the member ID card.
Effective March 1, 2019, Anthem Blue Cross and Blue Shield (Anthem) will transition its Outpatient Rehabilitation Utilization Management (UM) program to AIM Specialty Health ® (AIM), a specialty health benefits company. The Outpatient Rehabilitation UM program includes physical, occupational and speech therapy services.
Anthem has an existing relationship with AIM in the administration of other programs and is excited to expand this relationship to include outpatient rehabilitation services. AIM works with leading insurers to improve health care quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe and affordable.
This transition enables Anthem to expand and optimize this program, further ensuring that care aligns with established evidence-based medicine. AIM will continue to use criteria documented in Anthem Clinical UM Guidelines GC.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at availity.com by selecting Clinical Resources in the Education and Reference Center under Payer Spaces.
Detailed prior authorization requirements are available online by accessing the Precertification Lookup Tool at availity.com under Payer Spaces. Contracted and non-contracted providers can call Provider Services at 1-855-558-1443 for prior authorization requirements or additional questions.
You can also authorize these services online through the Interactive Care Reviewer on the Availity Portal. Log on to Availity, select Authorizations and Referrals under the Patient Registration menu and choose Authorizations.
Pre-service review requirements
Providers should contact Anthem to obtain prior authorization for all outpatient rehabilitation services that are scheduled to be rendered through February 28, 2019. Any authorizations Anthem makes prior to the transition date of March 1, 2019, will be honored, and claims will process accordingly.
Providers should contact AIM to obtain prior authorization for all services scheduled on or after March 1, 2019. Beginning February 11, 2019, providers will be able to contact AIM for prior authorization on services scheduled to take place on or after March 1, 2019. Providers are strongly encouraged to verify prior authorization has been obtained before scheduling and performing services.
How to place a review request
Providers can submit prior authorization requests to AIM in one of the following ways:
- Access AIM ProviderPortalSM directly at providerportal.com. You will first need to register for this portal at aimspecialtyhealth.com/goweb.html. Online access is available 24/7 to process orders in real time and is the fastest and most convenient way to request authorization. Registration opens February 11, 2019.
- Access AIM via the Availity Portal at availity.com. For any questions, call the AIM Contact Center toll-free number at 1-800-554-0580 Monday through Friday from 7 a.m. to 7 p.m. Central time.
For more information
For resources to help get started with the Outpatient Rehabilitation UM program, go to aimprovider.com/rehabilitation. The AIM provider website provides access to useful information and tools, such as order entry checklists, Clinical UM Guidelines and an FAQ.
We value your participation in our network and look forward to working with you to help improve the health of our members.
If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-855-558-1443.
While there’s no single, easy answer to the issue of health care disparities, the vision of My Diverse Patients is to harness the power of data and identify ways to bridge gaps often experienced by diverse populations.
We’ve heard it all our lives: in order to be fair, you should treat everybody the same. But the challenge is that everybody is not the same — and these differences can lead to critical disparities not only in how patients access health care, but in their outcomes as well.
The reality is that the burden of illness, premature death and disability disproportionately affects certain populations.1 My Diverse Patients features robust educational resources to help support you in addressing these disparities, such as:
- Continuing medical education about disparities, potential contributing factors and opportunities for you to enhance care.
- Real life stories about diverse patients and the unique challenges they face.
- Tips and techniques for working with diverse patients to promote improvement in health outcomes.
Accelerate your journey to becoming your patients’ trusted health care partner by visiting mydiversepatients.com today. You may also access the site with the QR code provided.
1 Centers for Disease Control and Prevention. (2013, Nov 22). CDC Health Disparities and Inequalities Report — United States, 2013. Morbidity and Mortality Weekly Report. Vol 62 (Suppl 3); p3. The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed 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. For markets with carved-out pharmacy services, the applicable listings below are informational only.
Please share this notice with other members of your practice and office staff.
To search for specific policies or guidelines, visit Anthem Wisconsin Medicaid webpage.
Medical Policies
On September 13, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem).
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Publish date
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Medical Policy number
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Medical Policy title
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New or revised
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10/17/2018
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MED.00125
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Biofeedback and Neurofeedback
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New
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10/17/2018
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SURG.00103
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Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
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Revised
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Clinical UM Guidelines
On September 13, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on September 27, 2018.
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Publish date
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Clinical UM Guideline number
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Clinical UM Guideline title
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New or Revised
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10/17/2018
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CG-DME-46
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Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Lower Limbs
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New
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10/17/2018
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CG-SURG-90
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Mohs Micrographic Surgery
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New
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9/20/2018
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CG-DRUG-94
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Rituximab (Rituxan®) for Non-Oncologic Indications
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Revised
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10/17/2018
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CG-DRUG-107
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Pharmacotherapy for Hereditary Angioedema
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Revised
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9/20/2018
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CG-SURG-40
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Cataract Removal Surgery for Adults
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Revised
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