Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements starred (*) below.

 

Medical Policies and Clinical Guidelines

• Medical Policy and Clinical Guideline Updates - June 2019*
• New Clinical Guideline: Inpatient Inter-Facility Transfers effective September 1, 2019*

 

Reimbursement Policies

• New Reimbursement Policy: Ambulance Transportation – Professional*
• Reimbursement Policy Update: Frequency Editing – Professional*
• Reimbursement Policy Update: Clinical Validation – Professional [KY only]*

 

Pharmacy Updates

• Anthem expands specialty pharmacy prior authorization list*
• Anthem announces changes in medical non-oncology specialty drug reviews effective June 15, 2019

 

Other Important Updates

• AIM programs may require additional prior authorization documentation
• Medicare and Medicaid News

 

Providers currently submit prior authorization requests to AIM Specialty Health® (AIM) for outpatient diagnostic imaging services, cardiac procedures and sleep studies. As part of our ongoing quality improvement efforts, we want you to know that certain review requests require documentation that supports the clinical appropriateness of the request to be uploaded during the intake process.

 

When requested, providers must submit documentation from the patient’s medical record and/or participate in a prior authorization consultation with an AIM physician reviewer. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. 

 

Continuing our 2019 CRA updates, Anthem Blue Cross and Blue Shield (Anthem) requests your assistance with respect to our Commercial Risk Adjustment (CRA) reporting processes.

 

As a reminder, there are two approaches that we take (Retrospective and Prospective) to improve risk adjustment reporting accuracy.  We are focusing on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), to close the documentation and coding gaps that we are seeing with our members enrolled in our Affordable Care Act (ACA) compliant plans.

 

This month we’d like to focus on the Retrospective approach, and the request to our Providers:

 

As a reminder from our March newsletter, the Retrospective Program focuses on medical chart collection.  We continue to request members’ medical records to obtain undocumented HCC’s.  This particular effort is part of Anthem’s compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership.  The members’ medical record documentation helps support this data requirement.

 

2019 chart collection is about to begin

Retrospective chart collection begins in June and is known as Round 1.  Round 2 follows in November, which is our primary chase and largest volume of requests.  Round 3 is our last chart collection period and begins in January, 2020.

 

Electronic options for chart collections

Submitting medical charts to payers is extremely burdensome and time consuming for your staff.  Utilizing an electronic option can alleviate the constraints on both staff resources and time.

 

1.) Remote/Direct Anthem Access

The most efficient electronic option is to allow the Anthem medical coder team to have direct connection access to your EMR system, so that we may retrieve the records ourselves.  Our team has collaborated with several Providers and Facilities to have direct access to their EMR system so we collect the charts within our own team.  This allows for no vendor interventions and fewer handoffs of the records.  To address compliance concerns, please note that as a health plan, Anthem is a covered entity under the HIPAA Privacy Rule and is bound to protect PHI. 

 

Benefits of providing EMR direct connection access

• Your Medical Records staff resources would be minimally contacted for the charts we are requesting
  • o Depending on your EMR system, requests may also be handled electronically through “push” notifications
• Your Medical Records staff will release only those records we request into the EMR queue for which we have access
• Cost savings from less administrative impact on staff, as well as, no paper copying costs incurred
• Better privacy/security measures for not having to save the medical record to a desktop and then copy/save before transmittal

 

2.) EMR Interoperability -- we have electronic options already in place for the following EMR systems:

• Allscripts (Opt in - signature required -- please work directly with the CRA Representative for your region)
• NextGen (Opt out - auto-enrolled)
• Athenahealth (Opt out - auto-enrolled)
• MEDENT (Opt in - signature required -- please work directly with the CRA Representative for your region)

 

3.) Inovalon virtual visit or onsite -- Inovalon will work directly with your office to utilize electronic connectivity for a virtual visit, or they will have their staff go into the office for medical record retrieval based on a scheduled time that is convenient.

 

4.) Secure FTP -- Set up directly with our vendors as a temporary secure FTP to transfer medical records. 

 

If you are interested in any of these electronic options, or would like to grant our Anthem medical coders with direct access to your EMR, please contact our CRA Representative Natalie.Wilder@anthem.com

 

Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests that will begin soon.

 

Anthem Blue Cross and Blue Shield (Anthem)’s Find A Doctor tool provides Anthem members with the ability to search for in-network providers using the member portal at anthem.com. Find A Doctor currently offers multiple sorting options, such as sorting providers based on distance or name.

 

In May 2019, Anthem added a new sorting option to Find A Doctor. The new sorting option is called “Personalized Match” and is based on algorithms which use a combination of provider location, quality, cost results and member information to intelligently sort and display results for a member’s search. The sorting results take into account member factors such as the member’s medical conditions, and medications as well as provider factors such as areas of specialty, quality and efficiency measures, volumes of patients treated across various disease conditions, and outcome-based quality measures. These member and provider features combine to generate a unique ranking of providers for each member conducting the search. Providers with the highest overall ranking within the search radius are displayed first with other providers displayed in descending order based on overall rank and proximity to the center of the search radius. Members will continue to have the ability to sort from a variety of sorting orders (such as distance), and this enhancement in sorting methodology will have no impact on member benefits.

 

Please note, the sorting option “Personalized Match” has been available on Care and Cost Finder since November 12, 2018.

 

Additional information about Personalized Match:

• Provider factors will be updated on a quarterly basis.
• Providers may review a copy of the sorting methodology here.
• If you have general questions about this sorting option in Find A Doctor and the Care and Cost Finder tool, please contact Provider Customer Service.
• If you would like detailed information about quality or cost factors used as part of this unique sorting or you would like to request reconsideration of those factors you may do so by emailing personalizedmatchsorting@anthem.com or by calling 833-292-2601.

 

Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized health care decisions. 

 

As we prepare for potential regulatory proposed standards for electronic attachments, Anthem Blue Cross and Blue Shield (Anthem) will be implementing what is called the X12 275 5010 version of electronic attachments transactions for claims.

 

Standard electronic attachments will bring value to you by eliminating the need for mailing paper records and reduced processing time overall. 

 

Anthem and Availity will be piloting Electronic Data Interchange (EDI) batch electronic attachments with previously selected providers.  Both solicited and unsolicited attachments will be included in our pilots.

 

Solicited Attachment

Provider sends a claim, and the payer determines there is insufficient information to process the claim.  Payer then sends the provider a request for additional information (currently via letter).  Provider can then send the solicited attachment transaction with the documentation requested to process the claim.

 

Unsolicited Attachment

When the provider knows that the payer requires additional information to process the claim, the provider then sends the X12 837 claim with the “Paper Work Included” (PWK) segment tracking number.  Next, the provider sends the X12 275 attachment transaction with the additional information and includes the tracking number that was sent on the claim for matching purposes.

 

What you can do now

We encourage you to start having conversations with your Clearinghouse and/or Electronic Healthcare Records (EHR) vendor to determine their ability to set up the X12 275 attachment transaction capabilities. 

Look for more information about the general availability of this time-saving option later this summer and details on how to work with Anthem and Availity to send your attachments via electronic batch.

 

The Interactive Care Reviewer (ICR), our online authorization tool offers a real time authorization decision for some inpatient and outpatient authorization requests.  Recently we updated the list of services that may result in an immediate authorization decision.

To locate the Immediate Decision list* and review the specific details on those services, go to the Availity Portal and select Payer Spaces then choose the Anthem BCBS logo. Scroll down and select Education and Reference Center | Communication & Education. From the Communication & Education dropdown menu, select Interactive Care Reviewer | ICR Immediate Decision List.

Access ICR from the Availity Portal, select Patient Management | Authorizations & Referrals. To request an authorization you will need to have the Authorization Referral Request Role assigned to you by your Availity administrator.

Attend one of our upcoming webinars and learn about the features that will help you to optimize your ICR experience! Register here.

 

^{*Excludes: some Medicare Advantage, some Medicaid, Federal Employee Program® (FEP), BlueCard® and some National Account members}

^{Requests involving transplant services}

^{Services administered by vendors such as AIM Specialty Health}

^{Services administered by OrthoNet LLC (Indiana ,Kentucky ,Missouri, Ohio, Wisconsin, California, Colorado and Nevada)}

^{For the above requests, follow the same precertification process that you use today.}

 

This quarter, anthem.com will release more exciting enhancements to the public provider site. The next wave of changes includes a new Behavioral Health page that will provide easy and clear access to content and resources, including newsletters, collaboration documents, and other relevant information for providers. The image below illustrates the new Behavioral Health page.

    

We will continue to provide updates as we move forward with migrating content to the new provider pages.

As previously communicated in the April 2019 provider newsletter, AIM Specialty Health® (AIM), a separate company, will begin to perform prior authorization review of rehabilitative (restoring function) and habilitative (enhancing function) services for Anthem Blue Cross and Blue Shield (Anthem) commercial fully insured members beginning July 1, 2019. Currently, OrthoNet LLC is performing medical necessity reviews for physical and occupational therapy services for Anthem. These reviews, in addition to speech therapy service reviews, will transition to AIM.

 

The AIM Rehabilitative Program began April 1, 2019 for Anthem Medicaid members in Indiana and Wisconsin.

 

AIM will manage Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) medical necessity reviews and will require prior authorization for all outpatient facility and office-based rehabilitative and habilitative services following the initial evaluation. AIM will use the following Anthem Clinical UM Guidelines:

• CG-REHAB-04 Physical Therapy
• CG-REHAB-05 Occupational Therapy
• CG-REHAB-06 Speech-Language Pathology Services

 

The clinical criteria used for these reviews can be found on our anthem.com Clinical UM Guidelines page. A complete list of CPT codes requiring prior authorization for the AIM Rehabilitative Program is available on the AIM Rehabilitation microsite. There you can access additional helpful information such as order entry checklists and FAQs.

 

AIM will now begin accepting prior authorization requests on June 24, 2019 for dates of service on and after July 1, 2019.  Ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access 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.
• Access AIM via the Availity Web Portal at availity.com.
• Call the AIM Contact Center toll-free number 800-554-0580, 8:30 a.m.–7:00 p.m. ET.

 

Need training?

Anthem invites you to take advantage of an informational webinar that will introduce you to the Rehabilitative Program and the robust capabilities of the AIM ProviderPortalSM.  Visit the AIM Rehab microsite to register for an upcoming training session.

 

Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

 

• Medicare risk adjustment provider training
  
  

• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ
  
  
• Group Retiree members and National Access Plus
  
  
• Prior authorization requirements for DME repair and portable oxygen  
  
  
• Submitting corrected claims
  
  
• 2019 Utilization Management Affirmative Statement concerning utilization management decisions

 

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This article applies to Medicare Advantage members

 

Anthem Blue Cross and Blue Shield (Anthem) has identified an increased trend in billing emergency department level 5 evaluation and management (E&M) codes. To ensure documentation meets or exceeds the components necessary to support its billing, beginning September 1, 2019, Anthem will initiate post-pay reviews for emergency department professional claims billed with level 5 99285 or G0384. Emergency department professional claims with the highest potential for up-coding will be selected.

 

Anthem will request documentation for identified claims. Professional reviews will evaluate the appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and Anthem guidelines. Reimbursement should be based on the emergency department E&M code the submitted documentation supports.

 

Please note, these coding reviews are not related to any prior notification reviews which examine the appropriate use of emergency departments for non-emergencies, nor do they include the examination of emergent versus non-emergent reasons patients utilize emergency room services.

 

^{ABSCRNU-0020-19}

You want what’s best for your patients’ health. When a patient doesn't follow your prescribed treatment plan, it can be a challenge. Approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed¹. What can be done differently?

 

The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg, that is, the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline — the giant, often invisible, patient self-talk that may not get discussed aloud — can create a misalignment between patient and provider.

 

We’ve created an online learning experience to teach the skills and techniques that can help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence — and you’ll earn continuing medical education credit along the way.

 

Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

 

^{1 Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm.}

 

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

 

• Prior authorization requirements for drug codes
• 2019 Utilization Management Affirmative Statement concerning utilization management decisions

 

Anthem Blue Cross and Blue Shield (Anthem) has identified an increased trend in billing emergency department level 5 evaluation and management (E&M) codes. To ensure documentation meets or exceeds the components necessary to support its billing, beginning September 1, 2019, Anthem will initiate post-pay reviews for emergency department professional claims billed with level 5 99285 or G0384. Emergency department professional claims with the highest potential for up-coding will be selected.

 

Anthem will request documentation for identified claims. Professional reviews will evaluate the appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and Anthem guidelines. Reimbursement should be based on the emergency department E&M code the submitted documentation supports.

 

Please note, these coding reviews are not related to any prior notification reviews which examine the appropriate use of emergency departments for non-emergencies, nor do they include the examination of emergent versus non-emergent reasons patients utilize emergency room services.

 

^{AWI-NU-0109-19}

You want what’s best for your patients’ health. When a patient doesn't follow your prescribed treatment plan, it can be a challenge. Approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed¹. What can be done differently?

 

The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg, that is, the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline — the giant, often invisible, patient self-talk that may not get discussed aloud — can create a misalignment between patient and provider.

 

We’ve created an online learning experience to teach the skills and techniques that can help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence — and you’ll earn continuing medical education credit along the way.

 

Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

 

^{1 Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm.}

 

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Managing illness can be a daunting task for our members. It is not always easy to understand test results or know how to obtain essential resources for treatment or who to contact with questions and concerns.

 

Anthem Blue Cross and Blue Shield is available to offer assistance in these difficult moments with our Complex Case Management program. Our care managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members, families, primary care physicians and caregivers. The Complex Case Management process utilizes the experience and expertise of the Case Coordination team to educate and empower our members by increasing self-management skills. The Complex Case Management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient health care.

 

Members or caregivers can refer themselves or family members by calling the Member Services number located on the back of their ID card. They will be transferred to a team member based on the immediate need. Physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about health care decisions and goals.

 

You can contact us by phone at 1-855-558-1443. Case Management business hours are Monday through Friday from 8 a.m. to 5 p.m. Central time.

 

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Our 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 underutilization. Our medical policies are available on our provider website at https://mediproviders.anthem.com/wi/Pages/manuals-directories-training.aspx.

 

You can request a free copy of our UM criteria from our Medical Management department. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below. To access UM criteria online, go to https://mediproviders.anthem.com/wi/Pages/manuals-directories-training.aspx.

 

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title and organization name when initiating or returning calls regarding UM issues.

 

You can submit precertification requests by:

• Calling us at 1-855-558-1443.
• Faxing to 1-800-964-3627.

 

Have questions about utilization decisions or the UM process?

Call our Clinical team at 1-855-558-1443 Monday through Friday from 8 a.m. to 5 p.m. Central time.

 

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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 has adopted a Members’ Rights and Responsibilities Statement, which is located in the provider manual.

 

If you need a physical copy of the statement, call us at 1-855-558-1443.

 

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