Anthem Blue Cross and Blue Shield (Anthem) reviews and updates our online provider manual annually.  The updated manual is effective July 1, 2022 and is available now on our public provider website at anthem.com . Select Providers and choose Policies, Guidelines and Manuals under Provider Resources in the horizontal menu.  Select Wisconsin as the state if needed and scroll down to the Provider Manual section.  Select Download the Manual.  Scroll to the Looking for our Upcoming Provider Manual section and select Preview the upcoming manual to view the manual. 

 

There were changes to the following sections listed in alphabetical order:

Updated content

• AIM Specialty Health_® (AIM)
  • Updated Contact Center telephone number
• Appointment Access and Geographic Availability
  • Behavioral Health Appointment Access for Urgent Care changed to within 24 hours
  • Geographic availability data source changed from GeoAccess^® software to Quest Analytics Suite^TM software
• Availity Portal
  • Updated application capability information
• Centers of Medical Excellence
  • Update to statistics and Cellular Immunotherapy (Chimeric Antigen Receptor Therapy -“CAR-T”) section
• Claim Payment Disputes
  • Disputes of Prepayment Itemized Bill Review Findings added under non-clinical claim payment disputes.
• Clinical Appeals
  • Providers submitting an appeal on behalf of the member may be required to submit a member authorization form added
• Continuity of Care/Transition of Care Program
  • Added information related to the Federal Consolidations Appropriations Act (CAA)
• Directory of Services
  • Updated Provider Experience contacts
• Dispute Resolution and Arbitration
  • Revised language
  • Consolidation and Interest sections added
• Fraud, Waste and Abuse Detection
  • Additional information for Special Investigations Unit (SIU)
• Insurance Requirements
  • Content reduced to one paragraph
• Overview of HEDIS
  • Updated information on data collection
• Quality Improvement Programs
  • Updates to Program Goals and Objectives
• Reimbursement Requirements and Policies
  • Supplies related to the use of robotic technology included in operating room charge not eligible for separate reimbursement
  • Routine supplies section shortened
  • Hospital/Technical Anesthesia Component added under Time Calculation
• Utilization Management
  • Discharge Planning added under UM Definitions.
  • Virtual review added to On-Site Review section.
  • Submit authorization requests digitally via Availity added.
• Wisconsin Autism Mandate
  • Removed Sensory integration therapy under services not covered
  • Updated links to statutes and regulations

 

The 2021 Wisconsin Provider Manual will also be available until July 1, 2022.

 

2114-0522-PN-WI

The total economic cost of alcohol use disorder has been estimated to be $249 billion according to the Centers for Disease Control and Prevention (CDC)¹, $27 billion of which has been accounted for healthcare costs². The CDC projects the economic impact to society is about $807 per person, per year.³

 

Alcohol use disorder also impacts the economy through work force disruptions caused by tardiness, absenteeism, employee turnover and conflict in the workplace. It causes a reduction in potential employees, customer and taxpayer bases.⁴

 

According to the CDC, alcohol use was directly tied to 95,000 deaths annually between 2011 and 2015. This was more than all illicit substances combined. The CDC estimates that alcohol-attributed disease resulted in almost 685,000 years of potential life lost for the same period.

 

This chart shows the years of potential life lost (YPLL) related directly or indirectly to alcohol use disorder:

Cause	YPLL
Total YPLL	>2.7 million
100% alcohol attributed disease	684,750
Suicide	334,058
Motor vehicle crashes	323,610
Liver disease	202,391
Heart disease	118,021
Cancer	88,729

 

If you need assistance connecting your patients to opioid, substance use or alcohol use disorder treatment, contact your Anthem Blue Cross and Blue Shield (Anthem) health plan.

 

¹Center for Disease Control and Prevention, 2019 https://www.cdc.gov/alcohol/features/excessive-drinking.html

²National Institute on Drug Use, 2018 https://archives.drugabuse.gov/trends-statistics/costs-substance-abuse

³Center for Disease Control and Prevention, 2019

⁴National Institute on Drug Use, 2018

 

2186-0522-PN-CNT

Many resources are available for health professionals to support hypertension prevention and management and educate others. To support that effort, the Centers for Disease Control and Prevention (CDC)’s Division for Heart Disease and Stroke Prevention has put together these sets of educational materials for health professionals and patients:

• Hypertension Communications Kit: Health professionals can share these social media messages, graphics, and resources to educate their audiences about hypertension.
• Hypertension Patient Education Handouts: These fact sheets and handouts can help patients understand how hypertension affects their health and how to make healthy lifestyle changes.
• Hypertension Tools and Training: These materials can help health professionals develop and support programs for preventing and managing hypertension.

 

Visit the Million Hearts^® website for more resources designed for health professionals. Million Hearts^® is a national initiative co-led by CDC and the Centers for Medicare & Medicaid Services (CMS). Million Hearts^® aims to prevent 1 million heart attacks and strokes within five years.

 

Measure Up: Controlling High Blood Pressure (CBP) HEDIS^® measure

The HEDIS measure Controlling High Blood Pressure (CBP) assesses adults ages 18–85 with a diagnosis of hypertension and whose blood pressure was properly controlled based on the following criteria:

• Adults 18–59 years of age whose blood pressure was <140/90 mm Hg
• Adults 60–85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg
• Adults 60–85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg

 

Patient claims should include one systolic reading and one diastolic reading:

CPT II Code	Most recent systolic blood pressure
3074F	<130 mm Hg
3075F	130-139 mm Hg
3077F	≥ 140 mm Hg
CPT II Code	Most recent diastolic blood pressure
3078F	<80 mm Hg
3079F	80-89 mm Hg
3080F	≥ 90 mm Hg

 

When charting your patient’s blood pressure readings, in addition to the systolic and diastolic readings, and dates, if the patient has an elevated blood pressure, but does not have hypertension, note the reason for follow-up.

 

Additional tips for talking to patients:

• Continue to educate patients about the risks of hypertension
• Encourage weight loss, regular exercise and diet
• Advise patients who are smoking to quit
• Talk about chronic stress and ways to cope with it in a healthy way

 

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)

 

Resource: Centers for Disease Control and Prevention. https://www.cdc.gov/bloodpressure/educational_materials.htm

 

2185-0522-PN-CNT

The annual PCP 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 appointment timeframes for our members with an urgent condition or for routine.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Anthem Blue Cross and Blue Shield (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 your 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.

 

Another item captured in the survey is open panel status for new patients.  At the office level, we are capturing more closed panel data than is reflected in the provider directory for members. Please keep Anthem abreast of the open/close panel status of your practice. 

 

What does this mean for our members?  If the directory indicates “open” and the practitioner is not available for new patients, the member is making multiple calls to select a primary care physician. Their experience is reflected in the annual CAHPS® member survey of Anthem enrollees, which indicated “not open to new patients” as the number one reason throughout Anthem plan’s for not getting a personal doctor.

 

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

• Urgent – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within twenty-four (24) hours. 
  Explanation – These callers are experiencing a non-emergent condition or injury with acute symptoms that require immediate attention (without prior authorization).

• Routine – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within 10 business days. 
  Explanation – A regular routine appointment is a non-symptom related visit for existing patients, such as a check-up, including physicals and chronic monitoring.

• Routine follow-up – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within 30 calendar days. 
  Explanation – This is for an evaluation of progress or services, including, but not limited to, medication management. This includes new or existing patients.

Note to staff: It is imperative that your office updates any changes to your practice using the online Provider Maintenance Form on Anthem.com.

 

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Submitting your updates in a timely manner helps to ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information in our online provider directory has changed.

 

If updates are needed, you can use 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.

 

The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. We appreciate your help in keeping our online provider directories current.

 

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Change Healthcare will transition out of the post-payment hospital bill audit (HBA) program by the end of 2022. Effective immediately, Anthem Blue Cross and Blue Shield (Anthem)’s complex and clinical audit (CCA) team will conduct the HBA program. For a short period of time, Change Healthcare may continue to contact you to finalize any work that is in process, or already scheduled.

 

Anthem continues to work with Cotiviti as a post-payment DRG validation audit partner. Effective immediately, the Anthem CCA team is assuming a larger role in conducting post-payment DRG validation audits and DRG readmission audits. In addition to receiving requests from Anthem’s CCA team, network-participating providers may continue to receive letters from Cotiviti requesting access to medical records for the purpose of conducting these audits. We will do our best to avoid duplicate medical record requests from Anthem and Cotiviti. 

 

Thank you for your continued efforts to expedite medical record requests. 

 

This notification applies to all lines of business and all markets. If you have questions about this notification, please contact Provider Services.

 

2120-0522-PN-ALLCSBD

We’ve heard it all our lives: 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 their outcomes as well. The COVID-19 pandemic has reignited public attention about the serious public health risks and consequences of disparities, and the critical need for health equity.

 

Health equity means everyone has the opportunity to reach their highest level of health, and barriers to doing so must be removed. Health disparities are health differences that are closely linked with social, economic, and/or environmental disadvantage.¹ Achieving health equity requires focus on the elimination of barriers and disparities associated with factors such as race, ethnicity, gender, gender identity, religion, socioeconomic status, disability, and even where you live.² As a result, it is imperative to offer access to care that is tailored to the unique needs of patients, and Anthem Blue Cross and Blue Shield (Anthem) is committed to supporting our providers in this effort. 

 

MyDiversePatients.com is where you can find resources, information, and techniques to help provide individualized care every patient deserves, regardless of their diverse backgrounds. There you can also find opportunities for free Continuing Medical Education (CME) credit for learning experiences on topics related to cultural competency and disparities. Mydiversepatients.com is free and accessible from any device (desktop computer, laptop, phone, or tablet) with no account or log in required. Scan the QR code below for direct access to mydiversepatients.com.

Stronger Together is a website where you can find free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created in collaboration with national organizations and are available for you to share with your patients and communities. Scan the QR code below for direct access to Stronger Together.

While there is no single, easy answer to address health care disparities, the vision of MyDiversePatients.com and Stronger Together is a start to reversing health care inequity one person at a time.

 

¹Office of Disease Prevention and Health Promotion. (2022, Feb 6). Healthy People - Disparities. Retrieved from https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities

²Think Anthem.com. (2022, Feb 7). Why We Need Health Equity. Retrieved from https://www.thinkanthem.com/health-equity/what-are-health-disparities/

 

1805-0522-PN-CNT

 

Effective March 1, 2022, the following Part B medications from the current Clinical Utilization Management (UM) Guidelines will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below.

 

Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

 

Clinical UM Guidelines	Preferred drug(s)	Nonpreferred drug(s)
ING-CC-0062	Inflectra Remicade, Infliximab (unbranded)	Avsola Renflexis

 

ABSCARE-1286-22

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

 

Diabetes measures

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

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

 

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

 

Race/ethnicity stratification

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

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

 

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

dedicated to the advancing health equity in data and quality measurement.

 

New measures

Antibiotic Utilization for Respiratory Conditions (AXR): The percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event

 

This measure was added given antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse. Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic use. Given this new measure, the Antibiotic Utilization measure has been retired.

 

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

 

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

 

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

 

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

 

Measure changes

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

 

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

 

Source: NCQA.org

 

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

 

ABSCRNU-0325-22

 

Anthem Blue Cross and Blue Shield has partnered with Everlywell* to provide at-home lab tests for a subset of our eligible patients. We mail at-home test kits directly to patients’ homes with instructions on how to complete and return the kits. Clinical Laboratory Improvement Amendments-certified labs process the tests, and an independent physician reviews the results.

 

We provide PCPs a list of their patients who receive test kit(s) and send individual results to the patient and their doctor. You can help your patients navigate needed testing by encouraging them to complete kits mailed to them. A physician’s recommendation is a significant factor in patient screenings.

 

A patient may receive up to two at-home test kits:

• Fecal immunochemical test for colorectal cancer screening
• Hemoglobin A1c test to measure average glucose levels over the past two to three months for those with diabetes

 

How the program works:

• Test kit(s) are automatically mailed to eligible patients, and patient lists are sent to physicians.
• Patients collect samples at home, using instructions provided.
• Patients mail samples to Everlywell in the provided, postage-paid envelope.
• Individual test results are sent to patients and their primary care physician, providing evidence of preventive screening completion.

 

If you have questions about the at-home testing program, contact your local representative. For additional information about Everlywell, visit everlywell.com.

 

* Everlywell is an independent company providing at-home lab testing services on behalf of Anthem Blue Cross and Blue Shield.

 

ABSCRNU-0320-22

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

 

• Anthem expands specialty pharmacy precertification list-March 2022 update
  
  
• Anthem expands specialty pharmacy precertification list-April 2022 update
  
  
• New specialty pharmacy medical step therapy requirements-May 2022 update

 

High-prevalence demographics

The lifetime prevalence of AUD in the U.S. population is approximately 29.1%. However, only 19.8% of people with AUD receive treatment. Prevalence of AUD is high in white and Indigenous people, younger men (age < 65), unmarried people, and those with low incomes.¹

 

22.8 million people over the age of 12 reported having a substance use disorder (SUD) in 2019; AUD accounted for 63% of this population. An additional 12% presented with AUD and another SUD (excluding nicotine) according to the National Survey on Drug Use and Health (NSDUH).²

 

AUD and COVID-19

Evidence suggests that alcohol consumption increased during the COVID-19 pandemic. One study found that 60% of respondents reported increased alcohol-intake.³ In 2020, alcohol sales increased by 262% online and 21% in stores, which participants reported was due to increased stress, alcohol availability, and lockdown boredom.⁴ This increase was most substantial between March to April 2020. The study suggests those most affected by COVID-19 (job loss, friend loss, family loss, and isolation) may be more at risk of AUD.3

 

AUD co-occurring with mental health conditions

People with a variety of mental health conditions are at increased risk of developing an AUD or have an existing co-occurring AUD.⁵ While the rates are higher for co-occurring disorders with mental health conditions, there is also a higher risk of greater severity and a worse prognosis for both the mental condition and AUD. 

 

Trauma, including adverse childhood events (ACEs) and post-traumatic stress disorder (PTSD), are often precursors for AUD.⁶ Traumatic brain injuries (TBI) are also associated with AUD. Alcohol intoxication is one of the strongest predictors of a TBI. In addition, people with a TBI are more likely to abuse alcohol.⁷

 

In most co-occurring disorders, the mental health condition preceded the AUD. This indicates that people diagnosed with a mental health condition should be screened for AUD. Preventive work should begin at the onset of symptoms of a mental health condition.⁵

 

What if I need assistance?

If you have difficulty connecting patients with AUD to treatment, please contact Anthem Blue Cross and Blue Shield Medicaid. If you have questions about this communication or need assistance with any other item, call Provider Services at 855-558-1443.

 

1 Recovery Research Institute, 2019 https://www.recoveryanswers.org/addiction-101/epidemiology

2 Substance Abuse and Mental Health Services Administration, 2020 Results from the 2019 National Survey on Drug Use and Health

3 Pollard, Tucker, and Green (2020) https://doi.org/10.1001/jamanetworkopen.2020.22942

4 The Neilsen Company (2020) https://www.nielsen.com/us/en/insights/article/2020/rebalancing-the-covid-19-effect-on-alcohol-sales

5 Glantz et al., (2020) https://doi.org/10.1016/j.addbeh.2019.106128

6 Brady and Back (2012) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860395

7 Weil, Corrigan, and Karelina (2018) https://pubmed.ncbi.nlm.nih.gov/31198656

 

AKY-NU-0390-22

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

 

• AIM Specialty Health Outpatient Rehabilitative and Habilitative Services Clinical Appropriateness Guidelines updates
  
  
• Prior authorization requirement change for HCPCS code K1022
  
  
• New specialty pharmacy medical step therapy requirements-March 2022