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.

• Site of Care medical necessity reviews for long-acting colony-stimulating factors begin June 1, 2021*
• Updates for specialty pharmacy are available – March 2021*
• Some HIV medication combinations may require prior authorization
• Update: Notice of changes to the AIM Small Joint Surgery guideline

Unsolicited medical attachments

To help ensure accuracy and eliminate delays in the adjudication of your claims, the itemized bill must be included with qualifying claim submissions. Including the itemized bill with the high dollar claim just got easier by submitting it as an unsolicited medical attachment (documentation submitted without a formal request from the payer).

Did you know there is an “itemized bill” submission option under Attachments – New!

• Log in to Availity Portal
• Select Claims & Payments | Attachments – New
• Select Send Attachment
• Under the Request for Information, select No, if you are including the supplemental information/attachment for an 837 claim PWK.
  
  
  
• Provide provider, patient and claim information
• Attach Supporting Documentation and Reason

• Send Attachment(s)
  

Solicited medical attachments

Also available to you is the option to submit a claim attachment using Availity Portal for solicited medical attachments (documentation submitted in response to a specific request from payer).

Submit supporting documentation in response to a formal (solicited) request from the payer.

• Log in to Availity Portal
• Select Claims & Payments | Attachments – New
• Select Send Attachment
• Under the Request for Information, select Yes, if you are responding to a request from the health plan or need to submit documentation for a specific claim number
• Add supporting documentation and Reason
• Submit
  

As an added bonus, if you attended a previous webinar there is updated information we want to share with you around submitting an EDI 837 batch, which includes a PWK segment in loops 2300/2400; this detail is the linkage between the electronic claim and your supplemental documentation that can be submitted through the Availity portal.

What does this mean for you?

You may now submit attachments electronically (EDI) using the PWK segment to specify that documents are being submitted in support of the claim and no additional face sheet or coversheet is needed.

Here are the steps:

• Log in to Availity Portal
• Select Claims & Payments I Attachments - New
• From the Inbox tab, select the appropriate claim or open the request in your work queue
• Add files with supporting documentation
• Submit

Get trained

Attend an Availity hosted webinar to learn more about all capabilities. You can register for an upcoming live webinar hosted by Availity here.

or

Log into Availity.com and select Help & Training | Get Trained to open the Availity Learning Center in a new tab (it is your dedicated ALC account).

• Search by keyword (Medattach) to find on-demand and live training options
• Click Enroll to enroll for a course and then go to your Dashboard to access it any time

Get started today with these wide-ranging capability enhancements to transform your business operations to a quick, secure, paperless and simple process to fulfill medical records requests electronically through Availity.

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

Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.

Anthem is committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem has the answers before you ask the questions. With an initial focus on claim-level insights, Anthem has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOP.

Access the Claims Status Listing on Payer Spaces from mediproviders.anthem.com/wi by using the Log In button or through the secure provider portal via Availity.* We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.

Anthem made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem is using digital technology to improve the healthcare experience. If you have questions, please reach out to your Provider Relations representative.

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

We are committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

Effective August 1, 2021, AIM Specialty Health_® (AIM),* a separate company, will expand the AIM Rehabilitative program to perform medical necessity review evaluations for physical, occupational and speech therapy procedures and the requested site of care for Anthem Blue Cross and Blue Shield (Anthem) fully insured members, as further outlined below.

AIM will continue to 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. Prior authorization will now also be required for the requested site of care. AIM will use the following Anthem clinical utilization management (UM) guideline: CG.REHAB.10 Level of care: outpatient physical therapy, occupational therapy, and speech-language pathology services. This clinical guideline can be reviewed online at availity.com by selecting Clinical Resources in the Education and Reference Center under Payer Spaces. Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis, services with diagnosis of autism, or the initial evaluation.

A complete list of CPT^® codes requiring prior authorization for the AIM Rehabilitation program is available on the AIM Rehabilitation microsite. To determine if prior authorization is needed for an Anthem member on or after August 1, 2021, providers can contact Provider Services at 1-855-558-1443 for benefit information. They will be informed whether the AIM Rehabilitation program applies. AIM will also have a file upload from the health plan of the in-scope membership and will not provide prior authorization for members who are out of scope. If providers use the Interactive Care Reviewer (ICR) tool on the Availity Portal* to pre-certify an outpatient rehabilitative or habilitative service, ICR will produce a message referring the provider to AIM. (Note: ICR cannot accept prior authorization requests.)

AIM will be accepting authorizations on July 19, 2021, for services performed on or after August 1, 2021.

How to place a review request

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 Portal at availity.com.
• Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. ET.

Initiating a request on AIM’s ProviderPortal for PT/OT/ST and entering all the requested clinical questions will allow you to receive an immediate determination. If the request is approved, you will receive the order ID, the number of visits and valid time frame. The AIM Rehabilitation Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.

AIM Rehabilitation training webinars

Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortal_. Go to the AIM Rehabilitation microsite to register for an upcoming webinar. If you have previously registered for other services managed by AIM, there is no need to register again.

We value your participation in our network and look forward to working with you to help improve the health of our members.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

Why are these changes necessary?

Changes are meant to simplify code selection criteria, make coding more clinically relevant and to reduce documentation overload for office-based evaluation and management (E/M) services, while continuing to differentiate payment based on complexity of care.

Key elements of major revisions for 2021:

• Physicians may choose their documentation based on medical decision making (MDM) or total time (including non-face-to-face services).
• History and exam are still important parts of the notes and may contribute to both time and MDM, but they will no longer be scored for determining the level of the E/M visit.
• MDM criteria has moved away from simply adding up tasks to instead focusing on tasks that affect the management of a patient’s condition.
• Code 99201 was deleted.
• Codes 99202 to 99215 were revised.

Changes to time documentation

Time will now be defined as the total time spent by the provider (both face-to-face and time spent on non-face-to-face activities related to this patient’s visit performed on the same day as the visit). This may include the services listed below but should not include time spent on separately billable services (such as X-ray interpretation). Effective January 1, 2021:

• The total time spent must be documented clearly by the provider for the E/M level to be determined by time and does not include ancillary staff time.
• Time will no longer need to be dominated by counseling.
• All time used for leveling the E/M must be on the same day as the face-to-face visit.

Services included in total time:

• Preparing for the visit (for example, reviewing test results)
• Obtaining and/or reviewing separately obtained history
• Performing a medically necessary examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering tests, medications, prescriptions or procedures after the visit
• Referring and communicating with other health care professionals (when not reported separately)
• Documenting clinical information in the patient’s medical record
• Independently interpreting results (not separately reportable) and communicating results to the patient/family/caregiver
• Care coordination (not separately reportable)

Prolonged office services

2021 changes include addition of a new add-on code (currently labeled 99417) for prolonged office visits when time is used for code level selection, including face-to-face and non-face-to-face provider time of at least 15 additional minutes on the same date of service for level five office visits (99205, 99215).

Medical decision making (MDM)

Using the new MDM table, medical decision making for office/outpatient visits will be based on meeting (or exceeding) two out of three categories:

Number and complexity of problems addressed at the encounter:

• Straightforward: One self-limited or minor problem
• Low: Two or more self-limited or minor problems; one stable chronic illness, one acute, uncomplicated illness or injury
• Moderate: One or more chronic illnesses with exacerbation, progression or side effects of treatments; two or more stable chronic illnesses; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; one acute complicated injury
• High: One or more chronic illnesses with severe exacerbation, progression or side effects of treatment; one acute or chronic illness or injury that poses a threat to life or bodily function.

Amount and/or complexity of data to be reviewed and analyzed

The 2021 guidelines list three categories for data:

1. Tests, documents or independent historians.
2. Independent interpretation of tests
3. Discussion of management or test interpretation.

• Straightforward: Minimal or none
• Low (one category required):
  • Two tests/documents or independent historian
• Moderate (one category required):
  • Three tests, documents and/or independent historian
  • Independent interpretation of a test
  • Discussion of management or test interpretation
• High (two categories required):
  • Three items between documents and independent historian
  • Independent interpretation of a test
  • Discussion of management or test interpretation

Risk of complications and/or morbidity or mortality of patient management

For the purposes of MDM, level of risk is based upon the consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization:

• Minimal: Rest, gargle, elastic bandages, superficial dressings
• Low: OTC drugs, physical therapy, minor surgery with no identified risk factors, IV fluids without additives
• Moderate: Management of a prescription drug, minor surgery with identified risk factors, decision regarding major surgery without identified risk factors, diagnosis or treatment
• High: Need to discuss higher risk problems that could happen for which physician or other qualified health care professional will watch or monitor.

Tips to prepare your practice for E/M office visit changes:

• Identify project lead
• Schedule team preparation time
• Update practice protocols
• Consider coding support
• Review business liability coverage
• Guard against fraud/abuse
• Update compliance plan
• Check with your electronic health record (EHR)vendor
• Assess financial impact
• Understand medical liability coverage

Resources:

1. CPT^® Professional Edition, 2021. AMA
2. AMA Elements of Medical Decision Making. https://www.ama-assn.org/system/files/2019-06/cpt-revised- mdm-grid.pdf
3. AMA Press Release 2021 CPT code set. https://www.ama-assn.org/press-center/press-releases/ama-releases- 2021-cpt-code-set
4. Major E/M Changes Coming Are you prepared? https://www.aapc.com/evaluation-management/em- codes-changes-2021.aspx

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

• DME checklist of information needed from providers
  
  
• MCG Care Guidelines 24th edition customization

Anthem Blue Cross and Blue Shield will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.

We encourage providers who offer telehealth services to use the online Provider Maintenance Form to notify us, and we will add a telehealth indicator to your online provider directory profile.

Visit anthem.com to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.

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The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note that several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

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

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

Notes/updates:

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

• *GENE.00055 – Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
  • Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications
• *LAB.00037 – Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
  • Serological testing for biomarkers of irritable bowel syndrome (for example, CdtB and
  • anti-vinculin), using tests such as, IBSDetex, ibs-smart or IBSchek, is considered investigational and not medically necessary for screening, diagnosis or management of irritable bowel syndrome, and for all other indications
• *DME.00011 – Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
  • Revised scope to only include non-implantable devices and moved content addressing implantable devices to SURG.00158
  • Added “non-implantable” to bullet point on percutaneous neuromodulation therapy
  • Added percutaneous electrical nerve field stimulation (PENFS) as investigational and not medically necessary for all indications
• *SURG.00062 – Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
  • Expanded scope to include percutaneous testicular vein embolization for varicocele and added embolization of the testicular (spermatic) veins as investigational and not medically necessary as a treatment of testicular varicocele
• *CG-LAB-15 – Red Blood Cell Folic Acid Testing
  • RBC folic acid testing is considered not medically necessary in all cases
• *CG-LAB-16 – Serum Amylase Testing
  • Serum amylase testing is considered not medically necessary for acute and chronic pancreatitis and all other conditions
• *CG-GENE-04 – Molecular Marker Evaluation of Thyroid Nodules
  • Added the Afirma Xpression Atlas as not medically necessary
• 00158 – Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
  • A new Medical Policy was created from content contained in DME.00011.
  • There are no changes to the policy content.
  • Publish date is December 16, 2020.
• CG-GENE-21 – Cell-Free Fetal DNA-Based Prenatal Testing
  • A new Clinical Guideline was created from content contained in GENE.00026.
  • There are no changes to the guideline content.
  • Publish date is December 16, 2020.

Medical Policies

On November 5, 2020, 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 March 8, 2021.

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

Clinical UM Guidelines

On November 5, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on November 19, 2020. These guidelines take effect March 8, 2021.

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

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

Through predictive analytics, healthcare teams can now receive real-time solutions to claim denials.

Anthem is committed to providing digital first solutions. Healthcare teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem has the answers before you ask the questions. With an initial focus on claim-level insights, Anthem has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to payment. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOP.

Access the Claims Status Listing on Payer Spaces from https://mediproviders.anthem.com/wi by using the Log In button or through the secure provider portal via Availity.* We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.

Anthem made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online — all in one place.

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem is using digital technology to improve the healthcare experience. If you have questions, please reach out to your Provider Relations representative.

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

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