Embed Size (px)
Citation preview
July 2020 Anthem Provider News - Virginia Page 1 of 39
Virginia Provider NewsJuly 2020 Anthem Provider News - Virginia
Products & Programs:
Behavioral Health:
Pharmacy:
Administrative:
Guideline Updates:
Coverage and Clinical Guidelines:
Medicaid:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anthem Commercial Risk Adjustment (CRA) reporting update;2020 program year progression: What’s in it for you and yourpatients
3
2020 is the last year for Virginia Behavioral Health Pay forPerformance program
4
Anthem prior authorization updates for specialty pharmacy areavailable
5
Updated coverage for HIV PrEP medications 7
Clinical nurse specialist contracting 8
Welcome to the Custom Learning Center in Availity 9
Targeting August to launch Interactive Care Reviewer, Anthem’sonline prior authorization tool for Federal Employee Program
11
Register for Anthem’s fall webinar scheduled for November 12 13
UPDATE: Notice of changes to the AIM MusculoskeletalProgram prior authorization requirements and settingdeterminations
14
New MCG 24th edition guidelines 16
Coverage guidelines effective October 1, 2020 16
Medical drug benefit Clinical Criteria updates 18
July 2020 Anthem Provider News - Virginia Page 2 of 39
Medicare:
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO productsunderwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. InMissouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company(HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten byHMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada:Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. In New Hampshire:Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten byMatthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as AnthemBlue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east ofState Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), which underwrites or administers the PPO and indemnity policiesand underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation(Compcare) underwrites or administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers WellPriority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of AnthemInsurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation. Use of the Anthem websites constitutes your agreement with our Terms of Use.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Coding spotlight: Provider guide to coding for cardiovascularconditions
18
Quarterly pharmacy formulary change notice 25
UPDATE: Previous changes in DME incontinence quantitylimits
26
Keep up with Medicaid news 27
Prior authorization codes moving from AIM Specialty Health toAnthem Blue Cross and Blue Shield
27
Medical drug benefit Clinical Criteria updates 29
In-Office Assessment Program 30
Henry County and Henry County Public Schools offer MedicareAdvantage option
32
2020 Special Needs Plans 33
Keep up with Medicare news 38
July 2020 Anthem Provider News - Virginia Page 3 of 39
Anthem Commercial Risk Adjustment (CRA) reporting update;2020 program year progression: What’s in it for you and yourpatientsPublished: Jul 1, 2020 - Products & Programs
As a provider, you are committed to providing the best care for our members which nowinvolves telehealth visits. Telehealth visits are an acceptable format for seeing your patientsand assessing if they have risk adjustable conditions. As we reported in the May and June editions of Provider News, we are completing ourprospective and retrospective reviews for 2020 for Anthem’s Commercial Risk Adjustment(CRA) program. The retrospective program focuses on medical chart collection. Theprospective program focuses on member health assessments for patients withundocumented Hierarchical Condition Categories (HCC’s), in order to help close patients’gaps in care. What’s in it for you First, monthly you will receive a list of your patients who are Anthem members enrolled inAffordable Care Act (ACA) compliant coverage. We encourage you to reach out to thesepatients who may have gaps in care to come in for office visits earlier. Second, we’ve heard resoundingly from providers that participation in these programs helpsthem better evaluate their patients and, as a result, perform more strongly in populationhealth management and gain sharing programs. Many providers cite that they now askdifferent questions today that allow them to better manage treatment options for theirpatients end to end. Finally, when you see Anthem ACA members and submit health assessments, we payincentives of $100 for each properly completed electronic submission and $50 for apaper submission. For additional details on how to earn these incentives and the optionsavailable, please contact the CRA Network Education Representative listed below. What’s in it for your patients
July 2020 Anthem Provider News - Virginia Page 4 of 39
Anthem is completing monthly postcard campaigns to members with ACA compliantcoverage when we suspect a high-risk condition with messaging to encourage members tocall their Primary Care Provider (PCP) and schedule an annual checkup. The goal is to getthe members to have a visit with their PCPs, so the PCPs have an overall picture of theirpatients’ health and schedule any screenings that may be needed. Telehealth visits havebecome very flexible formats for patients and doctors to meet, so we encourage telehealthvisits to be scheduled if that is what the patient is most comfortable with at this time.We will continue these monthly postcard mailings throughout the remainder of 2020 toencourage the members to schedule an annual checkup, which supplements any patientoutreach you may be doing. If you have any questions regarding our reporting processes, please contact the CRANetwork Education Representative via email at [email protected]. We applaud your continued commitment to delivering quality care to our members. 527-0720-PN-VA
URL: https://providernews.anthem.com/virginia/article/anthem-commercial-risk-adjustment-cra-reporting-update-2020-program-year-progression-whats-in-it-for-you-and-your-patients-2
2020 is the last year for Virginia Behavioral Health Pay forPerformance programPublished: Jul 1, 2020 - Products & Programs / Behavioral Health
Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. are offering outpatientnetwork providers an opportunity to participate in the 2020 Virginia Behavioral Health Pay forPerformance (VBH-P4P) program. This program provides Behavioral Health providers anopportunity to earn incentive payment for performing at or above target on a set of qualitycare measures. Year 2020 will be the last year we will be offering our current Virginia BehavioralHealth Pay for Performance program to outpatient network providers. We are makingchanges for 2021 and will be presenting new and exciting opportunities for thecoming year.
July 2020 Anthem Provider News - Virginia Page 5 of 39
Beginning in 2021, providers who have participated in the previous Virginia program will beinvited to participate in the BH Provider Collaboration Value-Based Payment program.Lauren Sims, BHH PC Program Director, presented at the May 13, 2020, Virginia BHProvider P4P bi-annual meeting. If you have any questions, please contact her [email protected]. Additional overview training will be offered the beginning offourth quarter. Communications will be sent directly to providers interested in participating inthe BH Provider Collaboration program. The remainder of 2020 will continue as previous years with the VBH-P4P program incentivessent to providers in June, and the last bi-annual meeting held in October. For specificsrelated to the current VBH-P4P program, please contact [email protected]. 508-0720-PN-VA
URL: https://providernews.anthem.com/virginia/article/2020-is-the-last-year-for-virginia-behavioral-health-pay-for-performance-program
Anthem prior authorization updates for specialty pharmacy areavailablePublished: Jul 1, 2020 - Products & Programs / Pharmacy
Prior authorization updates Effective for dates of service on and after October 1, 2020, the following specialty pharmacycodes from current or new clinical criteria documents will be included in our priorauthorization review process. The Health Plan requires that claims for injection services performed in the office settingmust include the applicable HCPCS J-code, Q-code, or S-code, with the correspondingNational Drug Code (NDC), for the injected substance. This requirement is consistent withthe Centers for Medicare & Medicaid Services (CMS) guidelines. A covered drug will not beeligible for reimbursement when the NDC is not reported on the same claim.
Please note, inclusion of NDC code on your claim will help expedite claim processing ofdrugs billed with a Not Otherwise Classified (NOC) code.
July 2020 Anthem Provider News - Virginia Page 6 of 39
Access the Clinical Criteria information.
For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., priorauthorization clinical review of these specialty pharmacy drugs will be managed by Anthem.Drugs used for the treatment of Oncology will still require pre-service clinical review by AIMSpecialty Health (AIM), a separate company. This applies to members with Preferred Provider Organization (PPO), HealthKeepers(HMO), POS AdvantageOne, Act Wise (CDH plans).
Clinical Criteria HCPCS or CPTCode(s)
Drug
ING-CC-0038 J3110 BonsityING-CC-0162 J3490
J3590Tepezza
ING-CC-0163 J3490C9399
Durysta
Step therapy updates Effective for dates of service on and after October 1, 2020, the following specialty pharmacycodes from current or new clinical criteria documents will be included in our existingspecialty pharmacy medical step therapy review process. Access the Clinical Criteria information with step therapy(ies). For Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc., prior authorizationclinical review of these specialty pharmacy drugs will be managed by Anthem. Drugs usedfor the treatment of Oncology will still require pre-service clinical review by AIM SpecialtyHealth (AIM), a separate company. This applies to members with Preferred Provider Organization (PPO), HealthKeepers(HMO), POS AdvantageOne, Act Wise (CDH plans).
®
®
July 2020 Anthem Provider News - Virginia Page 7 of 39
Clinical Criteria Status Drug(s) HCPCSCodes
ING-CC-0072 Preferred Avastin J9035, C9257ING-CC-0072 Preferred Mvasi Q5107ING-CC-0072 Preferred Zirabev Q5118ING-CC-0072 Preferred Eylea J0178ING-CC-0072 Non-preferred Lucentis J2778ING-CC-0072 Non-preferred Macugen J2503ING-CC-0072 Non-preferred Beovu J0179
CORRECTION: June 2020 step therapy update on clinical criteria ING-CC-0003: Panzyga has been non-preferred for ING-CC 0003 since 2018. In the June 2020 Provider News edition, we published information regarding Panzyga to beeffective September 1, 2020. This was published in error. 540-0720-PN-VA
URL: https://providernews.anthem.com/virginia/article/anthem-prior-authorization-updates-for-specialty-pharmacy-are-available-5
Updated coverage for HIV PrEP medicationsPublished: Jul 1, 2020 - Products & Programs / Pharmacy
Beginning July 1, 2020, most of Anthem Blue Cross and Blue Shield’s Affordable Care Actcompliant, non-grandfathered health plans will cover pre-exposure prophylaxis (PrEP)medication at 100% with no member cost share, when used for prevention of HIV anddispensed at an in-network pharmacy with a prescription.
July 2020 Anthem Provider News - Virginia Page 8 of 39
Since medications used for PrEP can also be used to treat HIV, Anthem will review medicaland pharmacy claims data to determine if a member has been diagnosed and prescribedtreatment for HIV or prescribed PrEP for preventive purposes. When prescribed forprevention of HIV, this drug is covered with no member cost share. When prescribed fortreatment of HIV, member cost shares apply based on the member’s benefit plan. Coverageincludes Truvada (200-300 mg), and its generic components, Emtriva 200mg and tenofovir300mg. When medically necessary, a prior authorization process is available for Descovy tobe covered with no member cost share when used for prevention of HIV. Providers can contact the provider service number on the back of the member ID card todetermine if a member’s plan includes this benefit. 515-0720-PN-VA
URL: https://providernews.anthem.com/virginia/article/updated-coverage-for-hiv-prep-medications-2
Clinical nurse specialist contractingPublished: Jul 1, 2020 - Administrative
Pursuant to Virginia House Bill No.1057 (HB No. 1057 Health Insurance, Clinical NurseSpecialists), effective July 1, 2020, a clinical nurse specialist (CNS) may contract and bepaid directly for covered health care services provided to Anthem members. Currently,Anthem contracts directly with clinical nurse specialists who provide behavioral healthservices. Effective July 1, 2020, clinical nurse specialists can contract with Anthem to receive directpayment for services rendered for any covered medical service, not just behavioral health,within their scope of license. Digital Onboarding through Availity is not yet available forclinical nurse specialists outside of behavioral health. As such, please contact yourAnthem network manager directly for further details. Watch for upcoming editions of Provider News for more information. 550-0720-PN-VA
URL: https://providernews.anthem.com/virginia/article/clinical-nurse-specialist-contracting
July 2020 Anthem Provider News - Virginia Page 9 of 39
Welcome to the Custom Learning Center in AvailityPublished: Jul 1, 2020 - Administrative
The Custom Learning Center in the Availity portal offers an array of learning opportunitieswhere you can access required training, recommended/elective trainings and view additionallearning resources. Access to the Custom Learning Center is via Payer Spaces in theAvaility Portal.
Highlights of the Custom Learning Center
All the learning is in one place
You can filter topics of interest
View all your completed training
Course resources may include links to a job aid
Your required courses are easily accessible and the available content is specific to yourregion. You may track your accomplishments, and view or download your training history viathe Custom Learning Center Dashboard. Select Access Your Custom Learning Center from the Applications tab in Payer Spaces.
July 2020 Anthem Provider News - Virginia Page 10 of 39
Examples of trainings offered in the Custom Learning Center:
Authorizations
Coding and Documentation
Claims and Payments
Recommended administrative support courses
In addition, illustrated reference guides are located on Custom Learning Center -Resources. Select Resources from the menu located on the upper left corner of thescreen. Usually, you may download or print reference guide materials. Current Reference Guide topics include:
Interactive Care Reviewer – Request Appeals Reference Guide
Interactive Care Reviewer – Inquiries Reference Guide
Patient 360 Navigation
Remittance Inquiry Tips
July 2020 Anthem Provider News - Virginia Page 11 of 39
Be sure to visit the Custom Learning Center in the Availity Portaloften. New content is regularly added to the site.
For questions regarding the Availity Portal, please contact AvailityClient Services at 1-800-282-4548. 526-0720-PN-VA
Article Attachments
URL: https://providernews.anthem.com/virginia/article/welcome-to-the-custom-learning-center-in-availity-4
Targeting August to launch Interactive Care Reviewer, Anthem’sonline prior authorization tool for Federal Employee ProgramPublished: Jul 1, 2020 - Administrative
We are targeting August 15, 2020, to introduce Interactive Care Reviewer (ICR) – AnthemBlue Cross and Blue Shield’s online authorization tool for members enrolled in the BlueCross and Blue Shield Service Benefit Plan (commonly referred to as the Federal EmployeeProgram® or FEP). You will access ICR through the Availity Portal. At this time, ICR willbecome your exclusive online tool for all new FEP medical and behavioral health inpatientand outpatient authorization requests and inquiries. You may already be using ICR for your patients enrolled in Medicare Advantage and AnthemHealthKeepers Plus (Medicaid). Additionally, we plan to introduce ICR for our membersenrolled in Anthem’s Commercial lines of business. (This includes Commercial plans offeredby our affiliate, HealthKeepers, Inc.) The ability to request and check case status of yourmedical and behavioral health authorizations using one online application should furtherstreamline your authorization workflow process. In the coming months, please continue to check Point of Care and Availity News andAnnouncements for new updates we may post regarding this transition to ICR. Are you new to ICR? Get a head start now and ask your Availity administrator to grant you the required ICR roleassignment.
July 2020 Anthem Provider News - Virginia Page 12 of 39
Do you create and submit prior authorization requests?Authorization and Referral Request role assignment Do you check the status of the case or results of the authorization request?Authorization and Referral Inquiry role assignment Beginning on August 15, follow these steps to navigate to ICR through Availity: Select Patient Registration from Availity’s home page Select Authorizations & Referrals Select Authorizations (for requests) | Select Auth/Referral Inquiry (for inquiries) ICR training is offered monthly Register for one of our free webinars created to familiarize new users with ICR features andnavigation. Can’t make it to the webinar? Follow the steps outlined below to access self-paced videos located on the Custom LearningCenter. From Availity’s home page, select Payer Spaces | Anthem tile | Applications |Your Custom Learning Center
Select Catalog from the menu located on the upper left corner of the Custom LearningCenter screen
Use the catalog filter and select Interactive Care Reviewer-Online Authorizations orAuthorizations from the Category menu
Click Apply then enroll for the courses (videos) you want to view.
July 2020 Anthem Provider News - Virginia Page 13 of 39
Illustrated reference guides that you can print are located on Custom Learning CenterResources. Select Resources from the menu located on the upper left corner of thescreen. Use the catalog filter and select Authorizations or Interactive Care Reviewer-Online Authorizations from the Category menu. Select Download to view and/or print thereference guide.
551-0720 -PN-VA
URL: https://providernews.anthem.com/virginia/article/targeting-july-18-to-launch-interactive-care-reviewer-anthems-online-prior-authorization-tool-for-federal-employee-program-and-anthems-commercial-membership
Register for Anthem’s fall webinar scheduled for November 12Published: Jul 1, 2020 - Administrative
On November 12, 2020, Anthem will offer a provider education webinar. Designed for ournetwork-participating providers, the webinar addresses Anthem business updates and billingguidelines that impact your business interactions with us. For your convenience, we offer these informative, hour-long sessions online to eliminatetravel time and help minimize disruptions to your office or practice. The date for the fallwebinar is:
Thursday, November 12, 2020, from 11 a.m. to noon ET
Please take time to register today for the webinar using the registration form to the rightunder the “Article Attachments” section. If you have already registered for the Novemberwebinar, please ensure you have received a fax confirmation or a confirmation from anAnthem representative to ensure we’ve received your registration form. [email protected] if you need to confirm your registration.
July 2020 Anthem Provider News - Virginia Page 14 of 39
523-0720-PN-VA
Article Attachments
Anthem Webinarand RegistrationForm 2020.pdfapplication/pdf - 312.49
KB
URL: https://providernews.anthem.com/virginia/article/register-for-anthems-fall-webinar-scheduled-for-november-12
UPDATE: Notice of changes to the AIM Musculoskeletal Programprior authorization requirements and setting determinationsPublished: Jul 1, 2020 - Guideline Updates
As you know, AIM Specialty Health (AIM) administers the musculoskeletal program, whichincludes the medical necessity review of certain surgeries of the spine and joints andinterventional pain treatment. For certain surgeries, the review also includes a considerationof the level of care for Commercial fully insured Anthem members and some administrativeservices only (ASO) groups. According to the clinical criteria for level of care, which is based on clinical evidence asoutlined in the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures, itis generally appropriate to perform joint codes (CPT codes 27130, 29871, 29892) and 4spine codes (CPT codes 22633, 22634, 63265 and 63267) in a hospital outpatient setting. To avoid additional clinical review for these procedures, providers requesting priorauthorization should either choose “hospital observation” admission as the site of service orHospital Outpatient Department (HOPD). If the provider determines that an inpatient stay isnecessary due to post-operative care requirements, they can initiate a concurrent reviewrequest for inpatient admission with the health plan by contacting the number on the back ofthe member ID card.Total hip arthroplasty (CPT code 27130) is currently reviewed for medical necessity and levelof care. Effective October 1, 2020, four spine codes (CPT codes 22633, 22634,63265 and 63267) and two joint codes (29871 and 29892) will be incorporated into theAIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. We willreview requests for inpatient admission and will require the provider to substantiate themedical necessity of the inpatient setting with proper medical documentation thatdemonstrates one of the following:
®
July 2020 Anthem Provider News - Virginia Page 15 of 39
Current postoperative care requirements are of such an intensity and/or duration thatthey cannot be met in an observation or outpatient surgical setting.
Anticipated postoperative care requirements cannot be met, even initially, in anobservational surgical setting due to the complexity, duration, or extent of the plannedprocedure and/or substantial preoperative patient risk.
Peer-to-peer conversations are available to a provider at any time to discuss the applicableclinical criteria and to provide information about the circumstances of a specific member. Providers should continue to submit pre-service review requests to AIM using one of thefollowing ways:
Access AIM ProviderPortal directly at providerportal.com. Online access is available24/7 to process orders in real-time, and is the fastest and most convenient way to requestauthorization.
Access AIM via the Availity Portal at availity.com.
Call the AIM toll-free number at 866-789-0397, Monday through Friday, 8 a.m. to 5 p.m.ET.
For questions, please contact the provider number on the back of the member ID card. 553-0720-PN-VA
URL: https://providernews.anthem.com/virginia/article/update-notice-of-changes-to-the-aim-musculoskeletal-program-prior-authorization-requirements-and-setting-determinations-3
SM
July 2020 Anthem Provider News - Virginia Page 16 of 39
New MCG 24th edition guidelinesPublished: Jul 1, 2020 - Guideline Updates
Effective July 1, 2020, we will begin using the new acute viral illness guidelines that havebeen added to the 24 edition of MCG. Based on the presenting symptoms or requiredinterventions driving the need for treatment or hospitalization, these guidelines are not asubstantive or material change to existing MCG guidelines we use now, such as systemic orinfectious condition, pulmonary disease, or adult or pediatric pneumonia guidelines. Inpatient & Surgical Care (ISC)
Viral Illness, Acute – Inpatient Adult (M-280)
Viral Illness, Acute – Inpatient Pediatric (P-280)
Viral Illness, Acute – Observation Care (OC-064)
Recovery Facility Care (RFC)
Viral Illness, Acute – Recovery Facility Care (M-5280)
For questions, please contact the provider service number on the back of the member's IDcard. 521-0720-PN-VA
URL: https://providernews.anthem.com/virginia/article/new-mcg-24th-edition-guidelines-2
Coverage guidelines effective October 1, 2020Published: Jul 1, 2020 - Guideline Updates / Coverage and Clinical Guidelines
th
July 2020 Anthem Provider News - Virginia Page 17 of 39
Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., willimplement the following new and revised coverage guidelines effective October 1, 2020. These guidelines impact all our products – with the exception of Anthem HealthKeepers Plus(Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCCPlus) plan, and the Blue Cross and Blue Shield Service Benefit Plan (also called the FederalEmployee Program or FEP). Furthermore, the guidelines were among those recentlyapproved at the Medical Policy and Technology Assessment Committee meeting held onMay 14, 2020. The services addressed in these coverage guidelines in this section and in the attachmentunder "Article Attachments" on the right will require authorization for all of ourHealthKeepers, Inc. products with the exception of Anthem HealthKeepers Plus (Medicaid),Medicare Advantage, and the Anthem CCC Plus plan. Please note that FEP is excludedfrom these requirements as well. A pre-determination can be requested for our PPOproducts.
If applicable, services related to specialty pharmacy drugs (non-cancer related) require amedical necessity review, which includes site of care criteria, as outlined in the applicablecoverage or clinical UM guideline.
Guidelines addressed in this edition of Provider News are:
Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of theExtremities in the Home Setting (CG-DME-46)
Analysis of RAS Status (CG-GENE-02)
Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatmentof Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation) (CG-MED-64)
Therapeutic Apheresis (CG-MED-68)
July 2020 Anthem Provider News - Virginia Page 18 of 39
546-0720-PN-VA
Article Attachments
Coverage guidelineseffective October 1,2020.pdfapplication/pdf - 141.88
KB
URL: https://providernews.anthem.com/virginia/article/coverage-guidelines-effective-october-1-2020
Medical drug benefit Clinical Criteria updatesPublished: Jul 1, 2020 - State & Federal / Medicaid
On November 15, 2019, and February 21, 2020, the Pharmacy and Therapeutics (P&T)Committee approved Clinical Criteria applicable to the Anthem HealthKeepers Plus medicaldrug benefit for HealthKeepers, Inc. These policies were developed, revised or reviewed tosupport clinical coding edits. The Clinical Criteria is publicly available on the provider websites, and the effective dates willbe reflected in the Clinical Criteria Web Posting February 2020. Visit Clinical Criteria tosearch for specific policies. If you have questions or would like additional information, use this email. AVA-NU-0247-20
URL: https://providernews.anthem.com/virginia/article/medical-drug-benefit-clinical-criteria-updates-29
Coding spotlight: Provider guide to coding for cardiovascularconditionsPublished: Jul 1, 2020 - State & Federal / Medicaid
In this Anthem HealthKeepers Plus coding spotlight, we will focus on several cardiovascularconditions; codes from Chapter 9 of the ICD-10-CM are listed in the table below.
July 2020 Anthem Provider News - Virginia Page 19 of 39
Diseases of the circulatory system Categorycodes
Acute rheumatic fever I00-I02Chronic rheumatic heart diseases I05-I09Hypertensive diseases I10-I16Ischemic heart diseases I20-I25Pulmonary heart disease and diseases of pulmonary circulation I26-I28Other forms of heart disease I30-I52Cerebrovascular diseases I60-I69Diseases of arteries, arterioles and capillaries I70-I79Diseases of veins, lymphatic vessels and lymph nodes, notelsewhere classified
I80-I89
Other and unspecified disorders of the circulatory system I95-I99 Hypertension ICD-10-CM classifies hypertension by type as essential or primary (categories I10 to I13)and secondary (category I15). Categories I10 to I13 classify primary hypertension according to a hierarchy of the diseasefrom its vascular origin (I10) to the involvement of the heart (I11), chronic kidney disease(I12), or heart and chronic kidney disease combined (I13).
Elevated blood pressure versus hypertension A diagnosis of elevated blood pressure reading, without a diagnosis of hypertension,is assigned code R03.0. This code is never assigned on the basis of a blood pressurereading documented in the medical record; the physician must have specifically documenteda diagnosis of elevated blood pressure. The postoperative hypertension is classified as a complication of surgery, and code I97.3,postprocedural hypertension, is assigned. When the surgical patient has pre-existinghypertension, only codes from categories I10 to I13 are assigned.Hypertensive heart disease
1
July 2020 Anthem Provider News - Virginia Page 20 of 39
ICD-10-CM presumes a causal relationship between hypertension and heart involvementand classifies hypertension and heart conditions to category I11 — hypertensive heartdisease — because the two conditions are linked by the term with in the alphabetic index ofthe ICD-10-CM. These conditions should be coded as related even in the absence ofprovider documentation linking them. First, code I11.0, hypertensive heart disease withheart failure as instructed by the note at category I50, heart failure. If the providerspecifically documents different causes for the hypertension and the heart condition, thenthe heart condition (I50.-, II51.4-I51.9) and hypertension are coded separately. Other heart conditions that have an assumed causal connection to hypertensive heartdisease Code DescriptionI51.4 Myocarditis, unspecifiedI51.5 Myocardial degenerationI51.7 CardiomegalyI51.81 Takotsubo syndromeI51.89 Other ill-defined heart diseasesI51.9 Heart disease, unspecified
Hypertension, secondary Two codes are required: one to identify the underlying etiology and one from category I15 toidentify the hypertension. For example:
Hypertension due to systemic lupus erythematosus, M32.10 + I15.8.
Hypertensive crisis A code from category I16, hypertensive crisis, is assigned for any documentedhypertensive urgency (I16.0), hypertensive emergency (I16.1), or unspecifiedhypertensive crisis (I16.9). Report two codes, at a minimum, for hypertensive crisis. Thecrisis code is reported in addition to the underlying hypertension code (I10-I15). Pulmonary hypertension
1
1
July 2020 Anthem Provider News - Virginia Page 21 of 39
Pulmonary hypertension is classified to category I27, other pulmonary heart diseases.For secondary pulmonary hypertension (I27.1, I27.2-), any associated conditions or adverseeffect of drugs or toxins should be coded. Ischemic heart disease Category I25, chronic ischemic heart disease, includes coronary atherosclerosis, oldmyocardial infarction, coronary artery dissection, chronic coronary insufficiency, myocardialischemia, and aneurysm of the heart. ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris.The subcategories for these codes are I25.11, atherosclerotic heart disease with anginapectoris and I25.7, atherosclerosis of coronary artery bypass graft(s) and coronaryartery of transplanted heart with angina pectoris. When using one of these combination codes, it is not necessary to use an additional codefor angina pectoris. A causal relationship can be assumed in a patient with bothatherosclerosis and angina pectoris, unless the documentation indicates that anginais due to a condition other than atherosclerosis. Heart failure Systolic heart failure is coded as I50.2 and diastolic heart failure is coded as I50.3-;combined systolic and diastolic heart failure is assigned code I50.4. Fifth characters furtherspecify whether the heart failure is unspecified, acute, chronic or acute on chronic. Other classifications of heart failure include:
Right heart failure, unspecified (I50.810)
Acute right heart failure (I50.811)
Chronic right heart failure (I50.812)
2
2
July 2020 Anthem Provider News - Virginia Page 22 of 39
Acute on chronic right heart failure (I50.813)
Right heart failure due to left heart failure (I50.814)
Biventricular heart failure (I50.82)
High output heart failure (I50.83)
End-stage heart failure (I50.84)
Other heart failure (I50.89)
Unspecified (I50.9)
For a diagnosis of left ventricular, biventricular and end-stage heart failure, two codes arerequired to completely describe the condition: one to report the left, biventricular or end-stage heart failure, and one to identify the type of heart failure. Cardiomyopathy Cardiomyopathy is coded as I42- with the third character describing:
I42.0 Dilated cardiomyopathy, which includes congestive cardiomyopathy
I42.1 Obstructive hypertrophic cardiomyopathy, including idiopathic hypertrophicsubaortic stenosis
July 2020 Anthem Provider News - Virginia Page 23 of 39
I42.2 Other hypertrophic cardiomyopathy, including nonobstructive hypertrophiccardiomyopathy
I42.3 Endomyocardial (eosinophilic) disease, including endomyocardial (tropical)fibrosis and Loffler’s endocarditis
I42.4 Endocardial fibroelastosis, including congenital cardiomyopathy andelastomyofibrosis
I42.5 Other restrictive cardiomyopathy, including constrictive cardiomyopathy nototherwise specified
I42.6 Alcoholic cardiomyopathy due to alcohol consumption: a code for alcoholism(F10.-) is also assigned if present
I42.7 Cardiomyopathy due to drug and external agent: code first the poisoning due todrug or toxin; if applicable (T36-T65 with fifth or sixth character 1-4 or 6); if the condition iscaused by an adverse effect, use an additional code, if applicable, to identify the drug(T35-T50 with fifth or sixth character)
I42.8 Other cardiomyopathies
I42.9 Unspecified
July 2020 Anthem Provider News - Virginia Page 24 of 39
Two codes may be required for cardiomyopathy due to other underlying conditions; forexample, cardiomyopathy due to amyloidosis is coded E85.4, organ-limited amyloidosis, andI43, cardiomyopathy in diseases classified elsewhere. The underlying disease, amyloidosis,is sequenced first. Status Z codes ICD-10-CM provides several Z codes to indicate that the patient has a health status relatedto the circulatory system, such as the following:
Z94.1 Heart transplant status
Z95.0 Presence of cardiac pacemaker
Z95.1 Presence of aortocoronary bypass graft
Z95.810 Presence of automatic (implantable) cardiac defibrillator
Z95.811 Presence of heart assist device
Z95.828 Presence of other vascular implants and grafts
These codes are assigned only as additional codes and are reportable only when the statusaffects the patient’s care for a given episode. Resources ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2020.
ICD-10-CM/PCS Coding. Theory and practice. 2019/2020 Edition. Elsevier
2
1
2
July 2020 Anthem Provider News - Virginia Page 25 of 39
AVA-NU-0250-20
URL: https://providernews.anthem.com/virginia/article/coding-spotlight-provider-guide-to-coding-for-cardiovascular-conditions-1
Quarterly pharmacy formulary change noticePublished: Jul 1, 2020 - State & Federal / Medicaid
The formulary changes listed in the table below apply to all Anthem HealthKeepers Plusmembers (FAMIS and Medallion) and Anthem HealthKeepers Plus, CommonwealthCoordinated Care Plus (Anthem CCC Plus) members. These changes were reviewed andapproved at the fourth quarter 2019 pharmacy and therapeutics committee meeting. Effective May 1, 2020, formulary changes, non-formulary changes and prior authorization(PA) requirements will apply.
Effective for all members on May 1, 2020
Therapeutic class Medication Formularystatus change
Potentialalternatives(preferredproducts)
PEDIATRIC MULTIPLEVITAMINS
(BRAND)POLY-VI-SOL
DROPSPOLY-VI-SOL WITH
IRON DROPS
PREFERRED N/A
ADDITIONAL UM EDITS, EFFECTIVE NO LATER THAN AUGUST 1, 2020,CAN BE FOUND ON THE EXTENDED VERSION ON OUR PROVIDER PAGE
What action do I need to take? Please review these changes and work with your Anthem HealthKeepers Plus patientsand/or Anthem CCC Plus patients to transition them to formulary alternatives. If youdetermine formulary alternatives are not clinically appropriate for specific patients, you willneed to obtain PA to continue coverage beyond the applicable effective date.
July 2020 Anthem Provider News - Virginia Page 26 of 39
What if I need assistance? We recognize the unique aspects of patient cases. If your patients cannot be converted to aformulary alternative, call our Pharmacy department at 1-800-901-0020 (AnthemHealthKeepers Plus members) or 1-855-323-4687 (Anthem CCC Plus members) and followthe voice prompts for pharmacy PA. You can find the Preferred Drug List (formulary) on ourprovider website at https://mediproviders.anthem.com/va > Pharmacy > MedicaidCommon Core Formulary > Common Core Preferred Drug List. If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. AVA-NU-0253-20
URL: https://providernews.anthem.com/virginia/article/quarterly-pharmacy-formulary-change-notice-4
UPDATE: Previous changes in DME incontinence quantity limitsPublished: Jul 1, 2020 - State & Federal / Medicaid
In March 2020, HealthKeepers, Inc. informed Anthem HealthKeepers Plus providers that theplan was aligning incontinence benefit limits with those of the Department of MedicalAssistance Services (DMAS). This policy only affected members 21 and over. However,these limits did not go into effect on May 1, 2020, as scheduled.
On June 1, 2020, HealthKeepers, Inc. removed all benefit/quantity limits for incontinencesupplies for all Medallion and Anthem HealthKeepers Plus, Commonwealth CoordinatedCare Plus (Anthem CCC Plus) members of all ages (see DMAS Appendix B for impactedcodes). HealthKeepers, Inc. will reimburse DME providers for all quantities prescribed by themember’s physician and for services documented on a Certificate of Medical Necessity.HealthKeepers, Inc. will perform periodic reviews of all incontinence services to ensure thatmembers are receiving the appropriate amount of supplies.
July 2020 Anthem Provider News - Virginia Page 27 of 39
Reminder: Medicaid does not reimburse for incontinent briefs or incontinent underpads for children under the age of 3 years. If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. AVA-NU-0256-20
URL: https://providernews.anthem.com/virginia/article/update-previous-changes-in-dme-incontinence-quantity-limits
Keep up with Medicaid newsPublished: Jul 1, 2020 - State & Federal / Medicaid
Please continue to check our website https://mediproviders.anthem.com for the latestMedicaid information for members enrolled in HealthKeepers, Inc.’s Anthem HealthKeepersPlus and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) benefit plans. Hereare the topics we’re addressing in this edition: Updates to AIM Specialty Health advanced imaging Clinical Appropriateness Guidelines AVA-NU-0252-20
Modifier use remindersAVA-NU-0229-20
Coverage Guidelines for Virginia and Clinical Utilization Management Guidelines update AVA-NU-0248-20
New behavioral health discharge call-in lineAVA-NU-0246-20
URL: https://providernews.anthem.com/virginia/article/keep-up-with-medicaid-news-34
Prior authorization codes moving from AIM Specialty Health toAnthem Blue Cross and Blue ShieldPublished: Jul 1, 2020 - State & Federal / Medicare
July 2020 Anthem Provider News - Virginia Page 28 of 39
AIM Specialty Health (AIM)* currently performs utilization management review for bi-levelpositive airway pressure (BiPAP) equipment and all associated supplies. Beginning July 1,2020, the following codes will require prior authorization with Anthem Blue Cross and BlueShield (Anthem) rather than with AIM. Line of business: Individual Medicare Advantage, Group Retiree Solutions, andMedicare-Medicaid Plans E0470 Respiratory assist device, bi-level pressure capability, without
back-up rate feature, used with noninvasive interface, such as anasal or facial mask (intermittent assist device with continuouspositive airway pressure device)
E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, such as a nasalor facial mask (intermittent assist device with continuous positiveairway pressure device)
AIM will continue to manage the supply codes for automatic positive airway pressure (APAP)and continuous positive airway pressure (CPAP) requests. Anthem will continue to follow the COVID-19 Public Health Emergency orders from CMSuntil the waivers no longer apply. If the Public Health Emergency Orders are no longer inplace beginning July 1, 2020, the following codes will require prior authorization with Anthemrather than with AIM when used in combination with the BiPAP codes above. Precertification requests Submit precertification requests via:
Fax – 1-866-959-1537
Telephone – Dial the customer service number on the back of the member’s card;identify yourself as a provider and follow the prompts to reach the correct precertificationteam. There are multiple prompts. Select the prompt that fits the description for theauthorization you plan to request.
®
July 2020 Anthem Provider News - Virginia Page 29 of 39
Web – Use the Availity Web Tool by following this link:https://apps.availity.com/availity/web/public.elegant.login
A4604 Tubing with heating elementA7046 Water chamber for humidifier, replacement, eachA7027 Combination Oral/Nasal Mask used with positive airway pressure
device, eachA7030 Full Face Mask used with positive airway pressure device, eachA7031 Face Mask Cushion, Replacement for Full Face MaskA7034 Nasal Interface (mask or cannula type), used with positive airway
pressure device, with/without head strapA7035 HeadgearA7036 ChinstrapA7037 TubingA7039 Filter, non-disposableA7044 Oral Interface for Positive Airway Pressure TherapyA7045 Replacement Exhalation Port for PAP TherapyA7028 Oral Cushion, Replacement for Combination Oral/Nasal Mask,
eachA7029 Nasal Pillows, Replacement for Combination Oral/Nasal Mask,
pairA7032 Replacement Cushion for Nasal Application DeviceA7033 Replacement Pillows for Nasal Application Device, pairA7038 Filter, disposable
* AIM Specialty Health is an independent company providing utilization managementservices on behalf of Anthem Blue Cross and Blue Shield. ABSCARE-0535-20 510502MUPENMUB
URL: https://providernews.anthem.com/virginia/article/prior-authorization-codes-moving-from-aim-specialty-health-to-anthem-blue-cross-and-blue-shield-3
Medical drug benefit Clinical Criteria updatesPublished: Jul 1, 2020 - State & Federal / Medicare
®
July 2020 Anthem Provider News - Virginia Page 30 of 39
On November 15, 2019, and February 21, 2020, the Pharmacy and Therapeutics (P&T)Committee approved Clinical Criteria applicable to the medical drug benefit for AnthemBlue Cross and Blue Shield (Anthem). These policies were developed, revised or reviewedto support clinical coding edits. The Clinical Criteria is publicly available on the Anthem provider website, and the effectivedates will be reflected in the Clinical Criteria Web Posting February 2020. Visit ClinicalCriteria to search for specific policies. For questions or additional information, use this email. ABSCRNU-0144-20 509512MUPENMUB
URL: https://providernews.anthem.com/virginia/article/medical-drug-benefit-clinical-criteria-updates-30
In-Office Assessment ProgramPublished: Jul 1, 2020 - State & Federal / Medicare
Anthem Blue Cross and Blue Shield (Anthem) is proud to offer the 2020 Optum* In-OfficeAssessment (IOA) Program, formerly known as the Healthcare Quality Patient AssessmentForm/Patient Assessment Form (HQPAF/PAF) program. The name change reflectssignificant advancements in technology over the past few years, evolving from a paper form-based program to a program that securely exchanges clinical information digitally throughmultiple digital modalities. If you are interested in learning about the electronic modalities available, please contact yourOptum representative or the Optum Provider Support Center at 1-877-751-9207 from 8 a.m.to 7 p.m. Eastern time, Monday through Friday. The IOA Program is designed to help participating providers ensure chronic conditions areaddressed and documented to the highest level of specificity at least once per calendar yearfor all of our participating Medicare Advantage plan members. The IOA Program is designedto help overall patient quality of care (preventive medicine screening, chronic illnessmanagement and trifurcation of prescriptions for monitoring of high-risk medications andmedication adherence) and care for older adults when generated for a Special Needs Plan(SNP) member.
July 2020 Anthem Provider News - Virginia Page 31 of 39
Success stories Below are some achievements Optum has accomplished with provider groups through theIOA Program:
As a result of incorporating technology and/or different types of resources offeredunder the IOA Program, numerous provider offices demonstrated an increase inproductivity, documentation and coding accuracy.
Providers have taken advantage of the IOA Program resources to help alleviate someof the burden for their staff and office resources.
COVID-19 update Anthem knows this is a difficult time for everyone. We will continue to adapt and evolve ourpractices to fully address the changing dynamics of these unprecedented events. Anthem isfollowing the CDC guidelines on social distancing; thus, all nonessential IOA Programpersonnel are to work telephonically/electronically with the provider groups until furthernotice. Dates and tips to remember:
Anthem strongly encourages participating providers to review their patient populationas soon as possible. This will help get patients scheduled for an appointment if they havenot already scheduled an in-office visit. This will also help the provider manage chronicconditions, which impact the health status of the patient.
At the conclusion of each office visit with a patient, providers participating in the IOAProgram are asked to complete and return an In-Office Assessment The form should becompleted based on information regarding the patient’s health collected during the officevisit. Participating providers may continue to use the 2020 version of the In-OfficeAssessment form for encounters that take place on or before December 31, 2020.
July 2020 Anthem Provider News - Virginia Page 32 of 39
Anthem will accept the 2020 version of the form for 2020 encounters until midnightJanuary 31, 2021.
Participating providers are required to submit an Account Setup Form, W9 andcompleted direct deposit enrollment by March 31, 2021. Participating providers should call1-877-751-9207 if they have any questions regarding this requirement. Participatingproviders who fail to comply with this requirement will result in forfeiture of the providerpayment for submitted 2020 In-Office Assessment forms if applicable.
If you have any questions regarding the IOA Program, please call Optum at 1-877-751-9207,Monday through Friday from 9:30 a.m. to 7:30 p.m. Eastern time. * Optum is an independent company providing medical chart review services on behalf ofAnthem Blue Cross and Blue Shield.
ABSCRNU-0150-20 509687MUPENMU
URL: https://providernews.anthem.com/virginia/article/in-office-assessment-program-4
Henry County and Henry County Public Schools offer MedicareAdvantage optionPublished: Jul 1, 2020 - State & Federal / Medicare
Effective July 1, 2020, Henry County and Henry County Public Schools will offer an AnthemMedicare Preferred (PPO) Medicare Advantage Plan with Part D (MAPD). Retirees withMedicare Parts A and B are eligible to enroll in the MAPD plan. The plan includes theNational Access Plus benefit, which allows retirees to receive services from any provider, aslong as the provider is eligible to receive payments from Medicare. The MAPD plan offersthe same hospital and medical benefits that original Medicare covers and also coversadditional benefits that original Medicare does not, such as an annual routine physical exam,hearing, LiveHealth Online* tool and SilverSneakers .*
®
July 2020 Anthem Provider News - Virginia Page 33 of 39
The prefix on Henry County and Henry County Public Schools member ID cards will be VAY.The cards will also show the Henry County and Henry County Public Schools name andNational Access Plus icon. Providers may submit claims electronically using the electronic payer ID for the Anthem BlueCross and Blue Shield (Anthem) plan in their state or submit a UB-04 or CMS-1500 form tothe Anthem plan in their state. Do not file claims with original Medicare. Contracted and non-contracted providers may call the provider services number on the back of the member IDcard for benefit eligibility, prior authorization requirements and any questions about HenryCounty and Henry County Public Schools member benefits or coverage. Detailed prior authorization requirements also are available to contracted providers byaccessing the Availity Portal* at https://www.availity.com. * LiveHealth Online is the trade name of Health Management Corporation, an independentcompany, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield.Availity, LLC is an independent company providing administrative support services on behalfof Anthem Blue Cross and Blue Shield. Tivity Health, Inc. is an independent companyproviding the SilverSneakers fitness program on behalf of Anthem Blue Cross and BlueShield. ABSCRNU-0153-20 509934VAPENABS
URL: https://providernews.anthem.com/virginia/article/henry-county-and-henry-county-public-schools-offer-medicare-advantage-option
2020 Special Needs PlansPublished: Jul 1, 2020 - State & Federal / Medicare
Introduction Anthem Blue Cross and Blue Shield (Anthem) is offering Dual Special Needs Plans (D-SNPs) to people eligible for both Medicare and Medicaid benefits or who are qualifiedMedicare Advantage beneficiaries. D-SNPs provide enhanced benefits to people eligible forboth Medicare and Medicaid. These include supplemental benefits such as hearing, dental,vision and transportation to medical appointments. Some D-SNP plans include a card orcatalog for purchasing over-the-counter items. D-SNPs do not charge premiums.
July 2020 Anthem Provider News - Virginia Page 34 of 39
D-SNP members under Anthem benefit from a model of care that is used to assess needsand coordinate care. Within 90 days of enrollment and annually thereafter, each memberreceives a comprehensive health risk assessment (HRA) that covers physical, behavioraland functional needs, and a comprehensive medication review. The HRA is used to create amember Care Plan. Members with multiple or complex conditions are assigned a health plancase manager. D-SNP HRAs, Care Plans and case managers support members and their providers byhelping to identify and escalate potential problems for early intervention, ensuringappropriate and timely follow-up appointments, and providing navigation and coordination ofservices across Medicare and Medicaid programs. Provider training required Providers contracted for D-SNP plans are required to complete an annual training to stay up-to-date with plan benefits and requirements, including details on coordination of care andmodel of care elements. Every provider contracted for D-SNP is required to complete anattestation, which states they have completed their annual training. These attestations arelocated at the end of the self-paced training document. To take the self-paced training, go to the Model of Care Provider Training link on the AvailityPortal.*
How to access the Custom Learning Center on the Availity Portal
1. Log in to the Availity Portal.
1. At the top of Availity Portal, select Payer Spaces and select the appropriate payer.
2. On the Payer Spaces landing page, select Access Your Custom Learning Centerfrom Applications.
3. In the Custom Learning Center, select Required Training.
4. Select Special Needs Plan and Model of Care Overview.
5. Select Enroll.6. Select Start.7. Once the course is completed, select Attestation and complete.
July 2020 Anthem Provider News - Virginia Page 35 of 39
Not registered for Availity? Have your organization’s designated administrator register your organization for Availity.
1. Visit https://www.availity.com to register.
2. Select Register.3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for yourorganization.
Q&A What does it mean to be dual-eligible? What is a D-SNP?The term dual eligible refers to people with Medicare coverage who also qualify for sometype of state Medicaid benefit — meaning that these members are eligible for both Medicaid and Medicare. Theseindividuals may have higher incidence of chronic conditions, cognitive impairments andfunctional limitations. D-SNPs are special Medicare Advantage plans that enroll only dual-eligible people, providing them with more intensive coordination of care and services thanthose offered by traditional Medicare and Medicare Advantage plans. What is a D-SNP model of care?CMS requires Dual Special Needs Plans (D-SNPs) to have a model of care that describeshow the D-SNP will administer key components of care management programs, includingassessments and training. The model of care describes the unique needs of the populationbeing served and how Anthem will meet these needs. Each D-SNP model of care isevaluated and scored by the NCQA and approved by CMS. How does the model of care help physicians?The three major components of the model of care, 1) the HRA, 2) Care Plan and 3) casemanager, support providers in serving D-SNP members. Each member receives acomprehensive HRA that covers physical, behavioral and functional needs, and acomprehensive medication review. Health plan staff use the HRA information to create aCare Plan. Members with multiple or complex conditions may be assigned to a casemanager.
July 2020 Anthem Provider News - Virginia Page 36 of 39
These key model of care components identify and escalate potential problems for earlyintervention, ensure appropriate and timely follow-up, and help coordinate services acrossMedicare and Medicaid programs. Through the provider website, providers have access toreview the Care Plan, the results of the HRA and other information to help manage care. How are transitions of care managed?Anthem case managers are involved in transitions of care (for example, discharge fromhospital to home for those at high risk of readmission). Such transitions may trigger areassessment and updates to the member’s Care Plan as needed. Following a discharge,case managers help ensure that D-SNP members see their PCP within a week and workthrough barriers that members experience in adhering to post-discharge medicationregimens. Who makes up the Interdisciplinary Care Team (ICT)?Members of the ICT include any of the following: nurses, physicians, social workers,pharmacists, the member and/or the member’s caregiver, behavioral health specialists, orother participants as determined by the member, the member’s caregiver, or a relative of themember. Providers who care for Anthem members are considered participants in the ICT and may becontacted by a case manager to discuss the member’s needs. The case manager maypresent recommendations concerning care coordination or other needs. The goal of the ICTis to assist providers in managing and coordinating patient care. Do I have to become a Medicaid provider?You are not required to become a Medicaid provider, but we recommend that you do. Even ifyou are only providing services covered by Medicare Part A or Part B to D-SNP members,we recommend that you attain a Medicaid ID because the state Medicaid agency mayrequire this for the Medicare cost share. Do I need a separate agreement or contract to see D-SNP members under Anthem?No, if you see Medicare Advantage HMO members under Anthem, you are consideredcontractually eligible to see D-SNP members under Anthem. How do I file claims for D-SNP members?Claims for services to D-SNP members are filed the same way claims are filed for MedicareAdvantage members under Anthem who are not part of D-SNP. Providers should ensure thatthe claim has the correct member ID (including the prefix).
July 2020 Anthem Provider News - Virginia Page 37 of 39
How is the D-SNP member’s cost sharing handled?D-SNP benefits are administered similarly to Medicare fee-for-service benefits. Uponreceiving an explanation of payment (EOP) from Anthem, you should bill the state Medicaidagency or the applicable Medicaid MCO contracted with the state for processing of anyMedicare cost sharing applied. Medicare cost sharing is paid according to each state’s Medicaid reimbursement logic. Somestates do not reimburse for Medicare cost sharing if the payment has already met orexceeded Medicaid reimbursement methodology. Do I have to file claims twice for D-SNP members?Yes, when you treat D-SNP members under Anthem, you will file the initial claim withAnthem and then bill the state Medicaid agency or the applicable Medicaid MCO contractedwith the state for Medicare cost sharing processing. Please use the same electronic claimsubmission or address you currently use for Anthem claims filing. Do D-SNP members have access to the same prescription drug formulary as otherMedicare Advantage members under Anthem?Yes, D-SNP members have coverage for the same prescription drugs listed on the MedicareAdvantage prescription drug formulary for Anthem. Please note that in California the tier placement may vary. Be sure to review the plan’sspecific formulary for details on California D-SNPs as the formulary depends on the market. What are D-SNP benefits for Anthem?The D-SNP for Anthem members covers all Medicare Part A and Part B services andincludes full Part D prescription coverage. Anthem also covers a range of preventiveservices with no cost sharing for the member. In addition, the D-SNP includes coverage forsupplemental benefits that may include routine dental, vision and nonemergency medicaltransportation. A summary of the D-SNP benefits is posted on the provider website forAnthem members. Any Medicaid benefits available to the member will be processed under their Medicaidcoverage directly with the state or the Medicaid organization in which the member isenrolled. Does the D-SNP use the same procedure codes and EDI payer codes?Yes, the D-SNP uses the same procedure and payer codes and electronic filing proceduresas other Medicare Advantage plans under Anthem.
July 2020 Anthem Provider News - Virginia Page 38 of 39
Is the electronic data interchange (EDI) payer ID for this product the same as others?Yes, all the claim submission information will be the same (this applies to EDI and paper).Providers must submit this information with the correct ID. Please check the EDI section ofthe provider website for the correct payer codes to use for your market. * Availity, LLC is an independent company providing administrative support services onbehalf of Anthem Blue Cross and Blue Shield. ABSCRNU-0154-20 510237MUPENMU
URL: https://providernews.anthem.com/virginia/article/2020-special-needs-plans-4
Keep up with Medicare newsPublished: Jul 1, 2020 - State & Federal / Medicare
Please continue to check Important Medicare Advantage Updates for the latest MedicareAdvantage information, including: Modifier use reminders ABSCRNU-0127-20 509409MUPENMUB
2020 affirmative statement concerning utilization management decisionsABSCRNU-0138-20 509491MUPENMUB
New behavioral health discharge call-in lineABSCRNU-0142-20 509390MUPENMUB
Medical Policies and Clinical Utilization Management Guidelines update ABSCRNU-0143-20 509763MUPENMUB
Updates to AIM Specialty Health advanced imaging Clinical Appropriateness Guidelines ABSCRNU-0148-20 509893MUPENMUB
Transition to AIM Rehabilitative Services Clinical Appropriateness Guidelines ABSCRNU-0152-20 509884MUPENMUB
July 2020 Anthem Provider News - Virginia Page 39 of 39
URL: https://providernews.anthem.com/virginia/article/keep-up-with-medicare-news-144
