In this issue Page. anthem.com. Important phone numbers. December 2017

Transcription

1 December 2017 In this issue Page Announcements Anthem to offer individual health plans in Anthem s 2018 on and off exchange plan guides 3 Coverage and clinical guideline update Coverage guidelines effective March 1, Archived coverage guideline numbers effective September 15, AIM alerts Imaging guidelines expand to include level of care reviews effective March 1, Update to AIM Diagnostic Imaging Clinical Appropriateness Guidelines 10 Business update Provider payments will be made weekly 10 Anthem engages with Alliant Health Solutions 11 New reimbursement policy Scope of license (Professional) 11 Update regarding HCPCS code A0998 Ambulance response and treatment with no transport 11 HEDIS 2017 results are in for our Anthem PPO and Anthem HealthKeepers products 12 Psychiatric care collaboration codes effective 13 Case Management Program 13 ConditionCare Program benefits patients and physicians 14 Integrated Care Model for plans purchased on the Health Insurance Marketplace benefits patients and physicians 15 Coordination of care 15 Important information about utilization management 16 Members rights and responsibilities 18 Misrouted protected health information (PHI) 18 Clinical practice and preventive health guidelines on the Web 18 Frequency editing -- Professional 19 System updates for 2018 Professional 19 anthem.com Important phone numbers 1 of 54 VAPENABSNL (12/17)

2 In this issue, continued Page Health care reform (including health insurance exchange) Refer to anthem.com for information about health care reform and the exchange 19 ebusiness Sign up for electronic funds transfer 20 New provider website Asthma & Me app 20 Introducing our newest addition to Payer Spaces The Education and Reference Center 21 Receive notifications via our Network eupdate 22 FEP update FEP 2018 benefit information available online 22 Changes for Federal Employee Program on Skilled Nursing benefits for Drug/pharmacy update Anthem expands specialty pharmacy level of care drug list 23 Anthem expands specialty pharmacy prior authorization list 23 Anthem expands specialty pharmacy precertification requirements 24 Preventive care expands to include generic low-to-moderate dose statins 24 Anthem addresses opioid misuse to advance patient safety 25 Anthem, Inc. launches new pharmacy benefits manager 26 Pharmacy information available on anthem.com 26 Medicaid information Attention providers seeing Anthem HealthKeepers Plus members: Substance use disorders in pregnancy and neonatal abstinence syndrome 27 Interactive Care Reviewer tool: Register and start using today 29 Peer-to-peer 30 Reimbursement policies 30 MedTox capillary blood lead tests 31 See additional Medicaid articles beginning on PAGE 32 Medicare-Medicaid plan update Include National Provider Identifier on surgical procedure UB-04 bills 48 Critical access hospital reimbursed at Medicare rate 48 Reimbursement policy Portable/Mobile/Handheld Radiology Services under MMP 49 Medicare information Medicare Advantage individual benefits and formularies for Annual visit guidelines for Anthem tiers SNF network 50 Change to the 835 Electronic Remittance Advice (ERA) for all MA members enrolled in D-SNPs 51 See additional Medicare Advantage articles beginning on PAGE 52 Bulletin board Family Medical Care Plan Members New ID cards, ID numbers and prefixes effective January 1 54 December of 54

3 Announcements Anthem to offer individual health plans in 2018 that members can buy on or off the exchange Anthem Blue Cross and Blue Shield has a long history of serving consumers in the Individual market in Virginia, and we remain committed to ensuring all Virginians have an option for health insurance coverage available to them. In today s challenging health care environment, planning and pricing for health benefit plans that comply with the Affordable Care Act (ACA) have become increasingly difficult due to the shrinking Individual market as well as continual changes in federal and state operations, rules and guidance regarding these plans that consumers can purchase on or off the Health Insurance Marketplace (also called the exchange). In August, we made the difficult decision to withdraw from the Individual market in all but a few counties in Virginia due to uncertainties around health care, as the United States Congress continues to grapple with a way forward to provide stabilization to insurance markets. At that time, all other counties in Virginia had at least one health insurer option. Anthem works to fill service area gaps In September, we learned that due to the withdrawal of another insurer, there would be 63 counties and cities in Virginia that would not have access to Individual health plans. We worked closely with state regulators to come up with a solution to address these gaps. As a result, in 2018 Anthem and HealthKeepers, Inc. agreed to provide Individual health plan offerings in 68 cities and counties in Virginia to include both on- and off-exchange health benefit plans that members can purchase. Up to 70,000 Virginians across the state will have access to Individual health insurance coverage in 2018 including many in rural areas, cities and counties. Anthem will remain focused on developments in the Individual marketplace and will continue to advocate for solutions that will stabilize the market and allow us to once again, offer Individual insurance coverage throughout the Commonwealth in the future. List of Virginia cities and counties where Virginia will offer on and off-exchange 2018 individual health insurance products Accomack Galax Powhatan Alleghany Giles Pulaski Anthem s 2018 on and off exchange plan guides For our 2018 exchange plans, you can access information at the following links: Anthem s Off Exchange Health Plan Guide: OFF_HIX_VA_KIT_2018 Anthem s On Exchange Health Plan Guide: ON HIX VA KIT 2018 December of 54

4 Augusta Goochland Radford City Bath Grayson Rappahannock Bland Greensville Richmond County Botetourt Henry Roanoke Bristol City Highland Roanoke City Brunswick King and Queen Rockbridge Buchanan King William Russell Buena Vista City Lancaster Salem City Caroline Lee Scott Carroll Lexington Shenandoah Covington City Madison Smyth Craig Martinsville Southampton Culpeper Middlesex Staunton Dickenson Montgomery Tazewell Emporia City New Kent Washington Essex Northampton Waynesboro Fauquier Northumberland Westmoreland Floyd Norton Winchester City Franklin Orange Wise Franklin City Page Wythe Frederick Patrick December of 54

5 Coverage and clinical guideline update Coverage guidelines effective March 1, 2018 SPECIAL NOTE The services addressed in ALL the coverage guidelines presented in this section (pages 5 through 7) will require authorization for all of our products offered by HealthKeepers, Inc. with the exception of Anthem HealthKeepers Plus (Medicaid). Other exceptions are Medicare Advantage, the Medicare-Medicaid Plan (Dual Integration product), and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). A pre-determination can be requested for our Anthem PPO products. Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will implement the following revised coverage guideline effective March 1, This guideline impacts all our products with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Medicare-Medicaid Plan (Dual Integration product), and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). Furthermore, the guideline was among those recently approved at the quarterly Medical Policy and Technology Assessment Committee meeting held on August 3, This edition of the Network Update includes information on: Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) (CG-DME-31) Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) (CG-DME-31) This clinical UM guideline addresses criteria for powered, motorized wheelchairs, power operated vehicles and power seating systems. CG-DME-31 has been revised to include criteria for groups of power, motorized wheelchairs. Powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs) are considered medically necessary when all of the following are met: A. A written assessment by a physician or other appropriate clinician which demonstrates criteria 1, 2 and 3 below: 1. The individual lacks the functional mobility to safely and efficiently move about to complete mobility-related activities of daily living (MRADLs) (for example, toileting, feeding, dressing, grooming, and bathing in customary locations in the home); and 2. The individual's living environment must support the use of a powered/motorized wheelchair or POV; and December of 54

6 3. The individual has mental and physical capability to consistently operate the powered/motorized wheelchair or POV safely and effectively; and B. Other assistive devices (for example, canes, walkers, manual wheelchairs) are insufficient or unsafe to completely meet functional mobility needs; and C. The individual is unable to operate a manual wheeled mobility device; and D. The individual's medical condition requires a powered/motorized wheelchair or POV device for long-term use of at least 6 months; and E. The powered/motorized wheelchair or POV is ordered by the physician responsible for the individual's care; and F. Use of a powered/motorized wheelchair meets one of the following criteria (1-5) below 1. Use of group 1 or group 2 standard powered/motorized wheelchair without power options if the wheelchair is appropriate for the individuals weight; and 2. Use of a group 2 powered/motorized wheelchair is covered if criteria a or b below are met: a. The individual requires a single power option and meets one of the following: i. Individual requires drive control interface other than a hand or chin-operated standard proportional joystick (for example head control, sip and puff, switch control); or ii. Individual requires power tilt or power recline seating system (see CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories) and the system is being used on the wheelchair; or b. The individual requires multiple power option and meets one of the following: i. Individual requires a power tilt and recline seating system (see CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories) and the system is being used on the wheelchair; or ii. Individual uses a ventilator which is mounted on wheelchair; or 3. Use of a group 3 powered/motorized wheelchair are covered for individuals with mobility limitations due to a neurological condition, myopathy or congenital skeletal deformity and meet one of the following criteria: a. The individual requires no power options and no other powered/motorized wheelchair performance characteristics are needed; or b. The individual requires a single power option and meets one of the following criteria: i. Individual requires a drive-control interface other than a hand or chin-operated standard proportional joystick (for example, head control, sip and puff, switch control); or December of 54

7 ii. The individual requires a power tilt or a power recline seating system (see CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories) and the system is being used on the wheelchair; or c. The individual requires multiple power options and meets one of the following criteria: i. Individual requires a power tilt and recline seating system (see CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories) and system is being used on the wheelchair; or ii. Individual uses a ventilator which is mounted on wheelchair; or 4. Use of a group 4 powered/motorized wheelchair when the following criteria are met: a. Powered/motorized wheelchair is used in the home and routinely for MRADLs outside the home; and b. Individual's medical condition requires a feature(s) not available in a lower level powered/motorized wheelchair to complete MRADLs on a regular basis in customary locations within the home; or 5. Use of a group 5 pediatric powered/motorized wheelchair is covered when the individuals is expected to grow in height and meets one of the following criteria: a. Individual requires a single power option and meets one of the following criteria: i. Individual requires a drive control interface other than a hand or chin-operated standard proportional joystick (for example, head control, sip and puff, switch control); or ii. Individual requires power tilt or power recline seating system (see CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories) and the system is being used on the wheelchair; or b. Individual requires a multiple power option and meets one of the following criteria; and i. Individual requires a power tilt and recline seating system (see CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories) and the system is being used on the wheelchair; or ii. Individual uses a ventilator which is mounted on wheelchair. The HCPCS codes associated with this revised clinical UM guideline are E1230, E1239, K0010, K0011, K0012, K0013, K0014, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, and E2300. This coverage guideline is available for review on our website at December of 54

8 Archived coverage guideline numbers effective September 15, 2017 The following coverage guideline numbers have been archived. RAD Coronary Artery Imaging: Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA), Coronary Magnetic Resonance Angiography (MRA), and Cardiac Magnetic Resonance Imaging (MRI) [Note: Content of Rad has been transferred to new clinical UM guideline CG-MED-58 (Coronary Artery Imaging: Contrast-Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Cardiac MRI)]. SURG-55 (Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical) [Note: Content of Surg has been transferred to new clinical UM guideline CG-SURG-60 Cervical Total Disc Arthroplasty.] AIM alerts (Information regarding Anthem s implementation of AIM Specialty Health initiatives) Imaging guidelines expand to include level of care reviews effective March 1, 2018 Effective with dates of service on or after March 1, 2018, for members covered by local plans in Virginia, Anthem Blue Cross and Blue Shield (Anthem) will require a medical necessity review of the requested level of care for computed tomography (CT) imaging and magnetic resonance imaging (MRI). A new clinical guideline, Level of Care: Advanced Radiologic Imaging, CG-MED-55, will apply to the review process for dates of service beginning March 1, The review will be administered by AIM Specialty Health (AIM), a separate company. AIM will evaluate the clinical criteria to determine if the imaging service requires a hospital-based outpatient setting, which offers a higher intensity of service resources, or if a free-standing imaging center is a clinically appropriate and available alternative. For additional information, please visit aimproviders.com/radiology/. There may be circumstances where a member's clinical situation requires that he or she receive an MRI or CT scan in a hospital facility. Based on the information you provide, AIM will review both the requested advanced imaging scan for clinical appropriateness and the level of care against health plan clinical criteria. The level of care review does not apply to requests for review of imaging as part of an inpatient stay or when Anthem is the secondary payer. Physicians will continue to request authorization for MRI and CT scans in one of several ways: Access AIM ProviderPortalSM 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. December of 54

9 Access AIM via the Availity Web Portal at availity.com Call the AIM Contact Center toll-free number: ; 7 a.m. to 4 p.m., Monday through Friday. To view the new clinical guideline, Level of Care: Advanced Radiologic Imaging, CG-MED-55, refer to Anthem.com and click on Coverage & Clinical UM Guidelines, and Pre-Cert Requirements. For more information on advanced imaging and site-ofservice requirements, please see the Precertification page of our provider website. What's new, beginning with dates of service on or after March 1, 2018: When providers select a hospital-based outpatient facility as the level of care, a list of alternate free-standing imaging centers will be made available. If providers still select the hospital-based outpatient facility, they will be prompted to indicate the reason that this location is medically necessary. If a request for a hospital-based level of care does not meet medical necessity criteria upon review by a physician, the request will not be approved. We encourage you to discuss the alternate sites with the member. Note to advanced imaging providers: The OptiNet solution, which is accessed through ProviderPortal.com, is a proprietary, multi-faceted program designed to provide health plans with information on outpatient imaging providers. For providers who bill with place of service codes 11, 49, or 81, AIM has prepopulated the "Provider Type" selection with Freestanding Imaging Facility/Physician Groups. For providers who bill with place of service codes 19 or 22, AIM has prepopulated the "Provider Type" selection as Outpatient Hospital Department. Prior to the start date of March 1, 2018, advanced imaging providers should review their OptiNet registration to ensure all information is current, the prepopulated Place of Service code is correct, and the "Provider Type" accurately reflects the site's status as a freestanding imaging center, physician group, or hospital. If the "Provider Type" field is not populated, you may edit the assessment. Once you have selected the applicable "Provider Type," you will need to submit the statement of attestation to ensure that all information submitted is accurate. Provider assessments that are already complete will remain in a Completed status until an update has been applied to the assessment. Please note, the expanded review applies to local fully-insured members in Virginia who have advanced imaging services medically managed by AIM under a full Utilization Management program. Local self-insured [Administrative Services Only (ASO)] benefit plans will be offered the option to add the imaging level of care reviews for their members claims starting in July 1, The imaging level of care guidelines do NOT apply to the following: BlueCard Blue Cross Blue Shield Service Benefit Plan (also known as the Federal Employee Program or FEP) Anthem HealthKeepers Plus (Medicaid) Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) For further questions regarding pre-service clinical review requirements, please contact the provider service number on the back of the member s ID card. If you have additional questions, please contact your Anthem network manager. December of 54

10 Update to AIM Diagnostic Imaging Clinical Appropriateness Guidelines Beginning with dates of service on and after March 9, 2018, the following updates will apply to the AIM Diagnostic Imaging Clinical Appropriateness Guidelines: Criteria for imaging of suspicion for pulmonary embolism The evaluation for pulmonary embolism requires the use of well validated clinical prediction rules. The addition of the use D Dimer to identify patients where imagining for pulmonary embolism is appropriate. For questions related to guideline updates, please contact AIM via at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. Business update Provider payments will be made weekly Starting in 2018, more claim payments and remittance advices issued to Anthem providers will be made on a weekly basis. Additionally, non-federal Employee Program (FEP) payments under $5 will be held for a maximum of 14 days to allow for additional claims to combine to increase the payment amount. This change is being made for efficiency and to ensure consistency between professional and facility claim payments for Anthem PAR/PPO, Anthem HealthKeepers, Federal Employee Program, Anthem Medicare Advantage and Anthem HealthKeepers Plus (Medicaid) members. Please note, this will not affect payments made from our National Accounts system. If you are a provider who receives paper claim checks or Electronic Funds Transfer (EFT) payments from Anthem on a daily basis, you will be able to schedule posting on a weekly cycle after this change. If you have questions, please contact your local Anthem network manager. December of 54

11 Anthem engages with Alliant Health Solutions Effective December 2017, Anthem Blue Cross and Blue Shield (Anthem) has established a contractual relationship with Alliant Health Solutions to assist the organization in validating provider compliance with applicable reimbursement policies and identify instances of incorrect billing for behavioral health services. Alliant, is a behavioral health audit and review company, and will examine Anthem outpatient behavioral health claims data. Utilizing systematic sampling methodology and a broad range of algorithms, the audits and findings will be customized to support Anthem s expectations as outlined in the Anthem Provider Manuals and related policies and procedures. Alliant findings may result in provider audits and record reviews, education and other direct outreach. New reimbursement policy Scope of license (Professional) Beginning March 1, 2018, Anthem Blue Cross and Blue Shield will implement a new policy regarding reimbursement for services or procedures performed outside the scope of a provider s license. If a provider performs a service or procedure that is outside of the provider s scope of license, reimbursement may be denied. Please review the policy in its entirety for more detailed information. Update regarding HCPCS code A0998 Ambulance response and treatment with no transport Beginning with dates of service on and after January 1, 2018, Anthem Blue Cross and Blue Shield (Anthem) will reimburse appropriate and medically necessary care billed under HCPCS code A0998 (Ambulance response and treatment, no transport) by Emergency Medical Service (EMS) providers. The HCPCS code is billed when care is provided in response to an emergency call to a member s home or on a scene, whether or not transportation to the hospital was necessary and occurred. In the past, Anthem reimbursed EMS providers for treatment rendered only when the patient was transported to the hospital emergency room. Anthem will apply medical necessity review to A0998 using coverage guideline CG-ANC-06. Anthem s change in reimbursement policy will apply to Anthem in Virginia s PAR/PPO and Anthem HealthKeepers health plans, and reimbursement will be made in accordance with the member s benefits. As we receive state-bystate approvals from regulators, we will begin reimbursing for A0998 for Medicare and Anthem HealthKeepers Plus (Medicaid) plans. In order to be eligible for this payment, you must provide treatment to your patient per your EMS protocols which are approved by your medical director at the local or state level. Billing of A0998 when treatment is not rendered is not appropriate. For more information, please contact your contract representative. December of 54

12 HEDIS 2017 results are in for our Anthem PPO and Anthem HealthKeepers products Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) data collection project for 2017 impacting members enrolled in our Anthem PPO and Anthem HealthKeepers (excluding Medicaid) products. You play a central role in promoting the health of our members. By documenting services in a consistent manner, it is easy for you to track care that was provided and identify any additional care that is needed to meet the recommended guidelines. Consistent documentation and responding to our medical record requests in a timely manner eliminates follow-up calls to your office and also helps improve HEDIS scores, both by improving care itself and by improving our ability to report validated data regarding the care you provided. The records that you provide to us directly affect the HEDIS results that are listed below. Each year, our goal is to improve our process for requesting and obtaining medical records for our HEDIS project. In order to demonstrate the exceptional care that you have provided to our members and in an effort to improve our scores, you and your office staff can help facilitate HEDIS process improvement by: Responding to our requests for medical records within five days if at all possible Providing the appropriate care within the designated timeframes Accurately coding all claims Documenting all care clearly in the patient s medical record View HEDIS information including 2017 HEDIS results online Further information regarding documentation guidelines and administrative codes can be found on the HEDIS page of our provider portal. You will find reference documents entitled HEDIS 101 for Providers and HEDIS Physician Documentation Guidelines and Administrative Codes. Go to Select Menu and then the provider link. Select Virginia in the drop down menu of states. Once you ve selected the state, you will be navigated to the provider home page. Click the Health & Wellness Tab at the top and then select the Quality Improvement and Standards page to view HEDIS information. Or, if you prefer, click QUALITY to review information including the HEDIS 2017 RESULTS to find a comparison of some of our key measure rates for our Anthem PPO and Anthem HealthKeepers lines of business. IMPORTANT NOTE: Regarding the HEDIS 2017 results, the information presented online pertains only to our Anthem PPO and Anthem HealthKeepers lines of business and does NOT include results for Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Medicare-Medicaid Plan (MMP) under the Commonwealth Coordinated Care Plan, or the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP). HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). December of 54

13 Psychiatric care collaboration codes effective Please be reminded that effective December 1, 2017, Anthem Blue Cross and Blue Shield in Virginia will begin to separately reimburse the new Psychiatric Care Collaborative codes (G0502, G0503 and G0504) for 2017 dates of service. Effective, with dates of service on or after January 2018, please use the new CPT codes 99492, 99493, to report these services. These codes are reportable by primary care for their collaboration with a qualified behavioral health provider, such as a psychiatrist, licensed clinical social worker, etc. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. These codes are intended to represent the care and management for patients with behavioral health conditions that often require extensive discussion, information-sharing, and planning between a primary care physician and a specialist. Case Management Program Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a health care puzzle that for some, are frightening and complex issues to handle. Anthem is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care. Members or caregivers can refer themselves or family members by calling the number located in the grid below. They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals. How do you contact us? Case Management Address Case Management Telephone Case Management Business Hours Number VA.CM@Anthem.com Monday Friday, 8 a.m. 7 p.m. EST (Local/Anthem PAR/PPO and Anthem HealthKeepers only) National VANatlAccts-CM@wellpoint.com Monday Friday, 8 a.m. to 9 p.m. EST, Saturday 9 a.m. to 5:30 p.m. EST Federal Employee Program (FEP) No a.m. to 7 p.m. EST December of 54

14 ConditionCare Program benefits patients and physicians Anthem members have additional resources available to help them better manage chronic conditions. The ConditionCare program helps members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. A team of registered nurses with added support from other health professionals such as dietitians, pharmacists and health educators work with members to help them understand their condition(s), their physician s orders and how to become a better self-manager of their condition. Engagement methods vary by the individual s risk level but can include: Education about their condition through mailings, newsletters, telephonic outreach, and/or online tools and resources Round-the-clock phone access to registered nurses Guidance and support from Nurse Care Managers and other health professionals Physician benefits: Saves time by answering patients general health questions and responding to concerns, freeing up valuable time for the physician and their staff. Supports the doctor-patient relationship by encouraging participants to follow their physician s treatment plan and recommendations. Informs the physician with updates and reports on the patient s progress in the program. Please visit the anthem.com website to find more information about the program such as program guidelines, educational materials and other resources. Go to anthem.com to access our Patient Referral Form, which you can use to refer other patients you feel may benefit from our program. Or, select the following link: If you have any questions or comments about the program, call Our nurses are available Monday through Friday, 8 a.m. to 9 p.m., and Saturday, 9 a.m. to 5:30 p.m. For Federal Employee Program members, call Nurses are available Monday Friday, 9 a.m. to 8 p.m. December of 54

15 Integrated Care Model for plans purchased on the Health Insurance Marketplace benefits patients and physicians An Integrated Care Model affords members with plans purchased on the Health Insurance Marketplace (also called the exchange) the ability to have continuity of care with each care management case. A single primary care nurse provides case and disease assessment and management. This continuity provides opportunity for the member to get assistance working through an acute phase of an illness and then work with their nurse on the necessary behavioral changes needed to improve their health and enhance their well-being. The program is based on nationally recognized clinical guidelines and serves as an excellent adjunct to physician care. The Integrated Care Model helps exchange members better understand and control certain medical conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. Our nurse care managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. Nurse care managers encourage participants to follow their physician s plan of care not to offer separate medical advice. In order to help ensure that our service complements the physician s instructions, we collaborate with the treating physician to understand the member s plan of care and educate the member on options for their treatment plan. Members or caregivers can refer themselves or family members by calling the number located in the grid below. How do you contact Case Management? Virginia Case Management Telephone Number (Local/Anthem PAR/PPO and Anthem HealthKeepers only) Case Management Address VA.CM@Anthem.com Case Management Business Hours Monday through Friday 8 a.m. to 7 p.m. EST. Coordination of care Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Anthem Blue Cross and Blue Shield would like to take this opportunity to stress the importance of communicating with your patients other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners. Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. Anthem urges all network-participating practitioners to obtain the appropriate permission from these patients to coordinate care between Behavioral Health and other health care practitioners at the time treatment begins. December of 54

16 We expect all health care practitioners to: 1. Discuss with the patient the importance of communicating with other treating practitioners. 2. Obtain a signed release from the patient and file a copy in the medical record. 3. Document in the medical record if the patient refuses to sign a release. 4. Document in the medical record if you request a consultation. 5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner. 6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to: - Diagnosis - Treatment plan - Referrals - Psychopharmacological medication (as applicable) In an effort to facilitate coordination of care, Anthem has several tools available on the Provider website including a Coordination of Care template and cover letters for both Behavioral Health and other Health care Practitioners.* In addition, there is a Provider Toolkit on the website with information about Alcohol and Other Drugs which contains brochures, guidelines and patient information.** *Access to the forms and cover letters are available at anthem.com>providers> Provider Home>Answers@Anthem **Access to the Toolkit is available at anthem.com>providers>provider Home> Health and Wellness Important information about utilization management Our utilization management (UM) decisions are based on written criteria, the appropriateness of care and service needed, as well as the member s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. Anthem s coverage guidelines are available on Anthem s website at anthem.com. December of 54

17 You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below. UM criteria are also available on the web. Just select Coverage Guidelines, Clinical UM Guidelines, and Pre-Cert Requirements from the Provider home page at anthem.com. We work with providers to answer questions about the utilization management process and the authorization of care. Here s how the process works: Call us toll free from 8:30 a.m. to- 5 p.m. Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program hours are 8 a.m. 7 p.m. Eastern. If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after midnight will be returned the same business day. Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon. The following phone lines are for physicians and their staffs. Members should call the customer service number on their health plan ID card. To discuss UM Process and Authorizations Behavioral Health: FEP Phone FAX (UM) FAX (ABD) To Discuss Peer-to-Peer UM Prompts 2,5,4,4,1 Behavioral Health: FEP Phone To Request UM Criteria Prompts 2,5,4,4,1 Behavioral. Health: FEP Phone FAX (UM) FAX (ABD) TDD/TTY 711 Or TTY (T) Voice (V) For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them. Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you. December of 54

18 Members rights and responsibilities The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members Rights and Responsibilities statement. It can be found on our website. To access, go to the "Provider" home page at anthem.com. From there, select Provider and Virginia> then Health & Wellness> Quality > Member Rights & Responsibilities. Practitioners may access the FEP member portal at to view the FEPDO Member Rights Statement. Misrouted protected health information (PHI) As a reminder, providers and facilities are required to review all member information received from Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. to help ensure no misrouted PHI is included. Misrouted PHI includes information about members that a provider or facility is not currently treating. PHI can be misrouted to providers and facilities by mail, fax or . Providers and facilities are required to immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are providers or facilities permitted to misuse or re-disclose misrouted PHI. If providers or facilities cannot destroy or safeguard misrouted PHI, providers and facilities must contact Anthem s provider services area to report receipt of misrouted PHI. Clinical practice and preventive health guidelines available on the Web As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines that are available to providers on our website. The guidelines which are used for our quality programs are based on reasonable medical evidence. In addition, the guidelines are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. All guidelines are reviewed annually and updated as needed. The current guidelines are available on our website. To access the guidelines, go to anthem.com. Click Menu at the top of the screen to display options and select Providers. Next, select Virginia from the dropdown listing of states and press Enter. On the Provider home page, select the Health & Wellness tab and then the Practice Guidelines link. December of 54

19 Frequency editing Professional Based on the code description for HCPCS codes A4221 (supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately)) and A4224 (supplies for maintenance of insulin infusion catheter, per week), for claims processed on or after November 18, 2017, we implemented a frequency limit of 1 unit per 7 days for HCPCS codes A4221 and A4224, which we consider to be correct coding. Modifiers will not override the frequency limit edit. System updates for 2018 Professional As a reminder, our claim editing software package will be updated quarterly in February, May, August and November of These updates will: Reflect the addition of new and revised CPT/HCPCS codes and their associated edits Include updates to National Correct Coding Initiative (NCCI) edits Include updates to incidental, mutually exclusive, and unbundled (rebundle) edits Include assistant surgeon eligibility in accordance with the policy Include edits associated with reimbursement policies including, but not limited to, preoperative and post-operative periods assigned by the Centers for Medicare & Medicaid Services (CMS) Health care reform (including health insurance exchange) Refer to anthem.com for information about health care reform and the exchange Visit anthem.com for updates, as we continue to post information on our dedicated web pages regarding health care reform and the health plans HealthKeepers Inc. is offering on and off the exchange. Click either of these Web pages Health Care Reform or Health Insurance Exchange for more information, and refer back to these pages often. December of 54

20 ebusiness Sign up for electronic funds transfer If you still receive reimbursement from Anthem by paper check, it s time to go green. Take advantage of Anthem s electronic solutions by signing up today for payments by electronic funds transfer (EFT). EFT helps you streamline your operations and reduce your administrative costs. Consider these benefits: Reimbursements are deposited to your account faster. EFT payments don t get delayed or lost in the mail. EFT payments are more protected from fraud. Bank fees are lower. You save time by making fewer trips to the bank. Setting up EFT is a fast and reliable method to receive payment. You can sign up using CAQH EFT EnrollHub tool or you can sign up via the Availity Web Portal. Also on Availity, you can access a detailed explanation of payment for each transaction. For more information on EFT and the benefits to your practice, contact your local network manager. New provider website Asthma & Me app Are you looking for innovative ways to engage your patients with asthma? Now you can show them the pathophysiology of asthma. The new Asthma & Me app is a valuable, free, support tool in the care of this pervasive chronic condition. The app uses face detection technology along with augmented reality to simulate a diseased airway. When the camera on a mobile device is aimed at the patient s face, an animation of the lungs is overlaid and a short video illustrating the physiology of an asthma attack is produced and recorded. The video can be used to facilitate discussion with the patient about what occurs during an asthma attack airway inflammation, bronchiole constriction, and mucus production. The video can be saved and shared via social media or . December of 54

21 The app is currently available in three languages: English, Spanish, and Tagalog. The language is selected based on the patient s smartphone or tablet settings. A new website to support your diverse patient panel: MyDiversePatients.com The Asthma & Me app can be accessed at MyDiversePatients.com using your smartphone, tablet, or computer. The app supplements the Moving Toward Equity in Asthma Care online provider CME experience, which is available on the site. MyDiversePatients.com features robust resources for providers to help support addressing racial and ethnic disparities in health and health care: CME learning experiences about disparities, potential contributing factors, and opportunities for providers to enhance care. Real-life stories about diverse patients and the unique challenges they face. Tips and techniques for working with diverse patients to promote improvement in health outcomes. The enduring material activity, Moving Toward Equity in Asthma Care, has been reviewed and is acceptable for up to 1 Prescribed credit by the American Academy of Family Physicians. Term of approval begins September 28, Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Introducing our newest addition to Payer Spaces The Education and Reference Center Beginning early 2018, we ll make it even easier for you to access many of the Anthem tools and reference materials you need using the Availity Portal. From the Availity home page menu, select Payer Spaces Applications Education and Reference Center to find important policy information, commonly used forms, as well as presentations and reference guides that can be used to educate provider staff on Anthem s proprietary tools. Can you access the Education and Reference Center without assistance from your Availity Administrator? Yes, you re all set. There s no need to request a role assignment from your Availity Administrator. All users with a log in and password to the Availity Portal will automatically be able to access the Education and Reference Center. That s how easy it is. Additional details If you are having trouble locating the Education and Reference Center, type Education and Reference Center in the Availity Search option located on the top navigation menu. Select the heart next to the application to save it to your Favorites. December of 54

22 Receive notifications via our Network eupdate Our provider newsletter, Network Update, is our primary source for providing important information to health care providers and professionals. Network Update is published bi-monthly and is posted to our website on the Virginia provider section of anthem.com for easy 24/7 access. Note that in addition to this newsletter and our website, we also use our service Network eupdate to communicate new information. If you are not yet signed up to receive Network eupdates, we encourage you to enroll now so you ll be sure to receive all information we will be sending about billing, upcoming changes, coverage guidelines and other pertinent topics. When you sign up, you ll not only receive an reminder for each newsletter posted online, you ll also be notified of other late breaking news and important information you ll need when providing services and filing claims for our members. It s easy to sign up just select Virginia and access the provider home page. There, you ll find a link to register for our Network eupdate. FEP update FEP 2018 benefit information available online To view the 2018 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program (FEP), go to Benefit Plans>Brochure & Forms. Here you will find the Service Benefit Plan Brochure and Benefit Plan Summary information for year For questions please contact FEP Customer Service toll free at Changes for Federal Employee Program on Skilled Nursing benefits for 2018 Anthem Blue Cross and Blue Shield would like to inform you that effective January 1, 2018, the Skilled Nursing Facility (SNF) benefit coverage is changing for members enrolled in the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program (FEP). This change affects the Standard Option PPO members. The Standard Option members will have a limit of 30 days of coverage per year. The benefit is payable when the member signs a case management letter with Anthem FEP case management and the treatment plan for admission to the SNF has been developed and documented prior to the member s admission to the SNF. Members admitted without both the signed case management letter and the documented treatment plan will not have coverage under the Standard Option and thus will be responsible for all charges incurred. Please contact FEP Customer Service toll free at for questions regarding this benefit update. December of 54

23 Drug/pharmacy update Anthem expands specialty pharmacy level of care drug list Effective for dates of service on and after March 1, 2018, the following specialty pharmacy codes from new or current coverage guidelines or clinical UM guidelines will be included in our existing Specialty Pharmacy level of care review process. Anthem in Virginia will manage the level of care pre-service clinical review of these specialty pharmacy drugs. View the Level of Care (Clinical Site of Care) drug list and level of care pre-service clinical review FAQs for more information. Coverage Guideline or Drug Code Clinical Guideline DRUG Cinqair J2786 DRUG Nucala J2182 Anthem expands specialty pharmacy prior authorization list Effective for dates of service on and after March 1, 2018, the following specialty pharmacy codes from new or current coverage guidelines or clinical UM guidelines will be included in our existing pre-service review process. Anthem in Virginia will manage the pre-service clinical review of these specialty pharmacy drugs. The following clinical guidelines or coverage guidelines will be effective March 1, Coverage Guideline or Clinical Guideline Code Drug Comments DRUG J3490, J3590 Besponsa New Drug Policy CG-DRUG-64 J3590 Cyltezo New Drug to Existing Policy CG-DRUG-64 J3590 Mvasi New Drug to Existing Policy December of 54

24 Anthem expands specialty pharmacy precertification requirements Effective for dates of service on and after March 1, 2018, the following clinical UM guideline will be updated to include additional requirements as part of the existing pre-service review process. The clinical guidelines or coverage guidelines below will be effective March 1, Anthem in Virginia will manage the preservice clinical review of the following specialty pharmacy drugs: Coverage Guideline or Treatment Code Clinical Guideline CG-DRUG-09 Immune Globulin (IG) Therapy J1459 J1460 J1556 J1557 J1559 J1560 J1561 J1566 J1568 J1569 J1572 J1575 J1599 J3490 S9338 Preventive care expands to include generic low-to-moderate dose statins Based on the recommendation from the United States Preventive Service Task Force (USPSTF) regarding Statin Use for the Primary Prevention of Cardiovascular Disease in Adults, Anthem Blue Cross and Blue Shield (Anthem) is updating our Affordable Care Act (ACA) preventive care coverage to include generic low-to-moderate dose statins. This coverage is effective December 1, 2017, for all non-grandfathered health plans, and for grandfathered plans that utilize Anthem s ACA preventive care coverage. Providers should continue to verify coverage and benefits for all members. For members with this coverage, low-to-moderate dose statins are covered at 100% with no member cost share. In general, this coverage applies to members between the ages of 40 to 75 years old who have one of the following cardiovascular disease (CVD) risk factors: diabetes, hypertension, dyslipidemia and/or smoking. Members with these risk factors will be proactively identified. In some scenarios, it is possible that a member may not be proactively identified. If a provider feels the member meets the preventive care coverage criteria outlined in the USPSTF statin recommendation, they can call the Express Scripts Prior Authorization Center at and provide qualifying information. December of 54

25 Anthem addresses opioid misuse to advance patient safety Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. are committed to leading the movement to address the national opioid epidemic. In partnership with our provider partners, Anthem and HealthKeepers, Inc. are also focused on prevention, treatment, recovery and deterrence of substance use disorders. In March of 2016, the Centers for Disease Control and Prevention (CDC) released guidelines for prescribing opioid medications. In the fall of 2016, Anthem created clinical edits to put the CDC guidelines into practice. For short-acting opioids, members not currently using opioid analgesics on a regular basis will be limited to a 7 days supply per fill and 14 days supply per 30 days before Anthem requires prior authorization for the drug. For long-acting opioids, Anthem will require prior authorization for the opioids for members who are new starts and are not currently using a long-acting opioid analgesic. Members who are newly prescribed a long-acting opioid and are actively being treated for cancer or those who are terminally ill and undergoing palliative care will be automatically approved. Anthem and HealthKeepers, Inc. are approaching opioid misuse from multiple avenues. We identify members with opioid use patterns of concern and alert their prescriber(s) through our Controlled Substance Utilization Monitoring program. Our Pharmacy Home Program identifies members who meet criteria for possible misuse and requires them to designate one pharmacy for filling their prescriptions. We also expanded access to medications used to treat substance use disorder. Suboxone and similar medications have been made readily available on all Anthem formularies. Prior authorization has been removed on Suboxone, buprenorphine/naloxone sublingual tablets, Bunavail, and Zubsolv. The below recommendations should be considered by all clinicians who prescribe opioids: Register with and utilize prescription drug monitoring program (PDMP). Discuss patients responsibilities for preventing misuse, abuse, storage and disposal of prescription opioids. Consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management. Consider coordination with other treating physicians, including pain specialists when prescribing opioids for management of chronic orofacial pain. Closely evaluate and monitor patients who have a history of alcoholism or other substance use disorder. December of 54

26 Anthem, Inc. launches new pharmacy benefits manager On October 18, 2017, our parent company Anthem, Inc. announced that it is launching IngenioRx, a new pharmacy benefits manager (PBM). IngenioRx will begin offering a full suite of PBM solutions starting in Like you, we believe strongly that every patient should get the best treatment possible. IngenioRx will strengthen Anthem Blue Cross and Blue Shield s value proposition centered on improving health outcomes and helping to lower total health care costs through the power of integration, combining national scale with our local expertise, and developing tools and solutions that paint a real-time picture of total health. We re committed to transitioning our members as seamlessly as possible to our new solution in Until then, nothing is changing for you or for your patients. In addition to the news about launching IngenioRx, we also announced that we re partnering with CVS Health after our current PBM contract expires at the end of IngenioRx will leverage market-leading pricing, our clinical expertise, deep provider relationships and focus on customer centricity with CVS point-of-sale engagement strategies. CVS will also provide prescription fulfillment and claims processing services. This combination will create a truly integrated approach to managing health and driving better outcomes. We are excited about this new direction, and we hope you are too. Please contact our Anthem customer service area for questions. View the Anthem press release for more information. Pharmacy information available on anthem.com For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit anthem.com/pharmacy information. The drug list for our PAR, PPO and Anthem HealthKeepers lines of business is reviewed, and updates are posted to the website quarterly (the first of the month for January, April, July and October). To locate Marketplace Select Formulary (for Affordable Care Act health plans our members purchase on or off the Health Insurance Marketplace or the exchange) and pharmacy information, go to Customer Support, select Virginia, Download Forms and choose Select Drug List. For Statesponsored Business [Anthem HealthKeepers Plus (Medicaid/FAMIS)], visit SSB Pharmacy Information. Website links for the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP) formulary Basic and Standard Options are: Basic Option: Standard Option: This drug list is also reviewed and updated quarterly. FEP Pharmacy Policy updates have been added to the FEP Medical Policy Manual and may be accessed at > Benefit Plans > Brochures and Forms > Medical Policies. December of 54

27 Medicaid information (Anthem HealthKeepers Plus offered by HealthKeepers, Inc.) Attention providers seeing Anthem HealthKeepers Plus members: Substance use disorders in pregnancy and neonatal abstinence syndrome Substance use disorders (SUDs) are on the rise and are of particular concern in women of childbearing age who are or may become pregnant. Women who use opioids in the following situations are at risk for delivering babies who are born preterm, have a low birth weight, and/or have neonatal abstinence syndrome (NAS)/neonatal opioid withdrawal syndrome (NOWS): Taking prescribed opioids for pain or addiction treatment Misusing prescribed opioid medications Using opioids illicitly Using opioids in combination with benzodiazepines, selective serotonin reuptake inhibitors (SSRIs) or tobacco Caring for babies born with NAS While traditional care for infants in withdrawal has included tapering doses of opioids, this should not be the first choice. Preliminary studies on preterm infants treated with morphine for pain and studies exposing laboratory animals to morphine, heroin, methadone and buprenorphine reveal some concerning structural brain changes and changes in neurotransmitters. While few follow-up studies exist, those that are available are worrisome for long-term deficits in cognitive function, memory and behavior. Reduction in any exposure to opioids should be the goal for the fetus and newborn. Approaches to reducing the incidence and severity of NAS include: The use of nonpharmacologic techniques to calm and ameliorate symptoms. Adoption of, and strict adherence to, protocols to assess and treat with pharmacologic medications if nonpharmacologic care is not sufficient. Inter-rater reliability testing when using standard assessment tools (such as modified Finnegan). Strict rooming in protocols, rather than placement in neonatal intensive care units, combined with extensive parent education programs improve family involvement and have been shown to reduce lengths of stay and the need for pharmacologic treatment of infants with NAS. When mothers are in stable treatment programs or are stable on safely prescribed medications, breastfeeding has also been shown to reduce the symptoms of NAS. December of 54

28 Caring for women with SUD Pregnancy offers women an opportunity to break patterns of unhealthy behaviors. Providers have a unique opportunity to help break the pattern of opioid misuse and, thus, reduce health consequences for both mother and child. Collaboration with community resources, behavioral health providers, addiction treatment centers and OB providers is imperative to designing programs that engage families at risk for SUDs. Women of childbearing age who are not pregnant and who do not wish to become pregnant should receive family planning counseling. Women who are already pregnant benefit from parenting education as early as possible in their pregnancies so they can be prepared to understand and care for their babies who might experience symptoms of NAS and who often require prolonged hospitalizations after birth. As these infants may remain symptomatic for several months after hospital discharge, they are at higher risk for abuse and maltreatment; therefore, close follow up with ongoing support is imperative. Guidelines and programs which have been shown to improve the care of women at risk of SUDs in pregnancy and their infants include the following: Center for Addiction in Pregnancy: > Clinical Services > Addiction and Substance Abuse > Center for Addiction and Pregnancy (CAP) Fir Square Combined Care Unit: > Our Services > Pregnancy & Prenatal Care > Pregnancy, Drugs & Alcohol Improving Outcomes for Infants and Families Affected by NAS A Universal Training Program: > Quality & Education > NAS Universal Training Program Protecting Our Infants Act: Final Strategy: > Topics > Specific Populations > Age- and Gender-Based Populations > Pregnant Women and Infants > Protecting Our Infants Act: Final Strategy Public Health Strategies to prevent Neonatal Abstinence Syndrome: Ko JY, Wolicki S, Barfield WD, et al. CDC Grand Rounds: Public Health Strategies to Prevent Neonatal Abstinence Syndrome, MMWR Morb Mortal Wkly Rep : doi: Rooming In to Treat Neonatal Abstinence Syndrome: Improved Family Centered Care at Lower Cost: Volpe Holmes, A, et al. Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost, Pediatrics 137 (2016): 6. doi: /peds Sheway: A Community Program for Women and Children: Snuggle ME webinar series: > Programs > Snuggle ME Webinar Series Support We are here to support you, our pregnant members and their little ones on the way. If you would like more information about our OB Case Management Program or if you have a member who needs behavioral health case management, contact Provider Services at December of 54

29 Interactive Care Reviewer tool: Register and start using today Beginning September 16, 2017, HealthKeepers, Inc. allows practices to initiate online preauthorization requests for Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members more efficiently and conveniently with our Interactive Care Reviewer (ICR) tool available through the Availity Portal. The ICR offers a streamlined process to request inpatient and outpatient procedures through the Availity Portal. How do I gain access to the ICR? You can access our ICR tool via the Availity Portal. If your organization has not yet registered for Availity, go to and select Register in the upper right-hand corner of the page. If your organization already has access to Availity, your Availity administrator can grant you access to authorization and referral request for submission capability and authorization and referral inquiry for inquiry capability. You can then find our tool under Patient Registration Authorizations & Referrals. From this area, you can select the authorizations or authorization/referral inquiry option as appropriate. Who can I contact with questions? For questions regarding our ICR tool, please contact your local Network Relations representative. For questions on accessing our tool via Availity, call Availity Client Services at AVAILITY. Availity Client Services is available Monday through Friday from 8 a.m. to 7 p.m. (excluding holidays) to answer your registration questions. What benefits/efficiencies does the ICR provide? You are automatically routed to our ICR. Once the ICR is available, when you go to Authorizations in the Availity Portal, you are automatically routed to the ICR in order to begin your prior authorization request. You can determine if prior authorization is needed. For most requests, when you enter patient, service and provider details, you will receive a message indicating whether or not review is required. You will have inquiry capability. Ordering and servicing physicians and facilities can locate information on preauthorization requests for those they are affiliated with; this includes requests previously submitted via phone, fax, ICR or another online tool. The ICR is easy to use. You can submit outpatient and inpatient requests for services online using the same, easyto-use functionality. The ICR reduces the need to fax. The ICR allows text detail as well as images to be submitted along with the request. Therefore, you can submit requests online and reduce the need to fax medical records. There is no additional cost to you. The ICR is a no-cost solution that s easy to learn and even easier to use. You can access the ICR tool almost anywhere. You can submit your requests from any computer with internet access. (Note: We recommend you use Internet Explorer 11, Chrome, Firefox or Safari for optimal viewing.) December of 54

30 You receive a comprehensive view of all your preauthorization requests. You have a complete view of all the utilization management requests you submitted online, including the status of your requests and specific views that provide case updates and a copy of associated letters. Peer-to-peer HealthKeepers, Inc. encourages Anthem HealthKeepers Plus providers to speak with one of our medical directors in a peerto-peer conversation if he or she believes an adverse decision has been rendered on insufficient information. Currently, Anthem HealthKeepers Plus medical directors conduct these peer-to-peer discussions with all physicians whether they have or have not directly participated in the member s care. Beginning November 1, 2017, Anthem HealthKeepers Plus medical directors conduct peer-to-peers only with the member s attending physician. Reimbursement policies The following section addresses two reimbursement policy updates: 1. Multiple Radiology Payment Reduction 2. Portable/Mobile/Handheld Radiology Services Policy Update: Multiple Radiology Payment Reduction (Policy , effective 03/15/2018) HealthKeepers, Inc., for our Anthem HealthKeepers Plus members, allows reimbursement for multiple diagnostic imaging procedures. Multiple diagnostic imaging procedures will be subject to a Multiple Procedure Payment Reduction when services are performed by the same provider with the same National Provider Identifier (NPI) on the same date of service during the same patient encounter. The global, professional component and technical component of diagnostic imaging procedures will reimburse at 100% of the contracted/negotiated rate for each Professional Component and Technical Component service with the highest payment. Reimbursement of subsequent services is based on: 95% for the professional component of subsequent services furnished by the same provider to the same patient in the same session on the same day. 50% for the technical component of subsequent services furnished by the same provider to the same patient in the same session on the same day. December of 54

31 A reduced allowance for the second and subsequent procedures will not apply when multiple imaging procedures are billed appended with Modifier 59. For additional information, please refer to the Multiple Radiology Payment Reduction reimbursement policy at Policy Update: Portable/Mobile/Handheld Radiology Services (Policy , effective 03/15/2018) Anthem HealthKeepers Plus providers will be reimbursed for portable/mobile radiology services when furnished in a residence used at the patient s home and if ordered by a physician and performed by qualified portable radiology suppliers. Portable/mobile radiology studies should not be performed for routine purposes or for reasons of convenience. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate for the radiological service and transportation and setup components with the use of applicable modifiers. Note: Portable radiology suppliers must be licensed or registered to perform services as required by applicable state laws. Transportation and setup HealthKeepers, Inc. allows reimbursement for transportation and setup of portable radiology equipment when transported to the Anthem HealthKeepers Plus member s residence. Transportation costs are payable when the portable X-ray equipment used was actually transported to the location where the X-ray was taken. Reimbursement for the setup cost of portable radiology equipment is separately reimbursable. Handheld radiology The use of handheld radiology instruments is allowed. Reimbursement will be part of the physician s professional service, and no additional charge will be paid. The technical components for handheld radiology are not separately reimbursable. For additional information, refer to the Portable/Mobile/Handheld Radiology Services Reimbursement Policy at MedTox capillary blood lead tests A reminder for providers seeing Anthem HealthKeepers Plus members: A blood lead test result equal to or greater than five micrograms per one deciliter obtained by capillary specimen (finger stick) must be confirmed using a venous blood sample. This is in accordance with Early and Periodic Screening, Diagnosis and Treatment periodicity schedules and guidelines using blood level determinations as part of scheduled periodic health screenings appropriate to age and risk. December of 54

32 Update to coverage guideline for cervical cancer screening and human papillomavirus testing (CG- MED-53) Effective January 1, 2018, in relation to Anthem HealthKeepers Plus members, coverage guideline CG-MED-53 that applies to cervical cancer screening and human papillomavirus (HPV) testing will be updated. Important items to note: Cervical cancer screening with cytology, with or without HPV testing, for women under 21 years of age is considered not medically necessary with the exception of women who are chronically immunosuppressed (i.e., organ transplant recipients or seropositive for HIV). Cervical cancer screening with HPV testing, alone or in combination with cytology, for women younger than 30 years of age is considered not medically necessary with the exception of women who are chronically immunosuppressed. Cervical cancer screening with cytology, with or without HPV testing, is considered medically necessary for women under 30 years of age who are chronically immunosuppressed. There is no change to the medical necessity criteria for cervical cancer screening with cytology and without HPV testing for women ages years of age. If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at HealthKeepers, Inc. to conduct post-service reviews of certain modifiers and services Beginning in the fourth quarter of 2017, HealthKeepers, Inc., on behalf of Anthem HealthKeepers Plus members, will conduct post-service reviews of professional claims billed with the following modifiers: 25, 62, 80, 81, 82, AS and 91. Additionally, HealthKeepers, Inc. will conduct post-service reviews of Evaluation and Management services billed during a global surgery period. As part of the review, HealthKeepers, Inc. may contact providers to request additional documentation related to the services. If billing discrepancies are identified, HealthKeepers, Inc. will provide a written report of the findings to providers and initiate recoupments as appropriate. Findings may assist your office with quality improvement efforts. For more information about post-service reviews, contact Provider Services at December of 54

33 New review process for not otherwise classified drug codes Effective February 1, 2018, HealthKeepers, Inc. is implementing a new review process for not otherwise classified (NOC) drug codes. Our Reimbursement Policy for Unlisted or Miscellaneous Codes requires NOC drug codes be submitted with the correct national drug code (NDC). As a large number of NOC drug claims do not contain the NDC, we will review claims for Anthem HealthKeepers Plus members to ensure the presence of a NDC, and claims without an NDC will be denied. The scope of review will include both professional and facility claims for Medicaid members. The NOC drug codes listed below will suspend and be routed for review. Note, to ensure billed drugs are a benefit and covered per our medical policies or state policies, HealthKeepers, Inc. may request that you submit medical records. NOC drug codes and descriptions as of May 4, 2017: A9150 Nonprescription drug A9152 Single vitamin/mineral/trace element oral, per dose, not otherwise specified (NOS) A9153 Multiple vitamins (with or without minerals and trace elements) oral, per dose, NOS C9399 Unclassified drug or biological J1566 Immune globulin injection intravenous, lyophilized, NOS (500 mg) J1599 Immune globulin injection intravenous, nonlyophilized, NOS (500 mg) J3490 Unclassified drug J3590 Unclassified biological J7199 Hemophilia clotting factor NOC J7599 Immunosuppressive drug NOC J7699 NOC drugs inhalation solution administered through durable medical equipment (DME) J7799 NOC drugs drugs (other than inhalation drugs) administered through DME J7999 Compounded drug NOC J8498 Antiemetic drug rectal/suppository, NOC J8499 Prescription drug oral, nonchemotherapeutic, NOS J8597 Antiemetic drug oral, NOS J8999 Prescription drug oral, chemotherapeutic, NOS J9999 Antineoplastic drugs NOC S5000 Prescription drug generic S5001 Prescription drug brand name Unlisted vaccine/toxoid Need assistance? If you have questions about this communication or need assistance with any other item, call Provider Services at December of 54

34 Update to provider payment frequency Starting in 2018, more claim payments and remittance advice issued by HealthKeepers, Inc. for Anthem HealthKeepers Plus members will be made on a weekly basis to providers. Additionally, non-federal Employee Program (FEP) payments under $5 will be held for a maximum of 14 days to allow for additional claims to combine to increase the payment amount. This change is being made for efficiency and to ensure consistency between professional and facility claim payments for commercial, FEP, Medicare and Medicaid members. Please note, this will not affect payments made from our national account system. If you are a provider who receives paper claim checks or electronic fund transfer payments from HealthKeepers, Inc. on a daily basis, you will be able to schedule posting on a weekly cycle after this change. Need assistance? If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at New case management program to identify PTSD in parents of infants in the NICU We are launching a new case management (CM) program for screening of post-traumatic stress disorder (PTSD) in parents of infants hospitalized in the neonatal intensive care unit (NICU). This CM program will support Anthem HealthKeepers Plus mothers and families at risk for PTSD due to the stressful experience of having a baby in NICU. What is the purpose of this program? The NICU PTSD program seeks to improve outcomes for families of babies who are in the NICU by screening and facilitating referral to treatment for PTSD in parents. How will it work? Case managers will reach out by phone to parents of babies who have been in the NICU for 30 days or more. They will screen and facilitate referral to treatment for PTSD. What is PTSD? PTSD is an anxiety disorder that may develop after exposure to a terrifying event or ordeal. However, people who have seen another person experience a life-threatening event can also suffer from PTSD. PTSD is diagnosed when the stress symptoms persist for more than a month. December of 54

35 Symptoms of PTSD include intrusive memories (like flashbacks and upsetting dreams), attempts to avoid thinking or talking about the event and hyperarousal, such as irritability or anger. Onset of symptoms of PTSD may be delayed for even a year after the initiating event. Why screen for PTSD in parents of long-term NICU patients? One in 10 infants in the U.S. are admitted to a NICU. Incidence of parental NICU-related PTSD varies from 20 to 41%. PTSD is treatable if identified. Lack of treatment can affect the health of the parent and the child. Children cared for by mothers with PTSD are at significantly higher risk for psychological aggression, child abuse and neglect. Parental-PTSD can have long-term adverse impacts on children, such as lower cognitive performance and conduct disorders. If you would like more information on the new case management program for PTSD in the NICU, please call Provider Services at Amendment to the Virginia HMO Medicaid Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement Effective December 1, 2017, the following changes will be made to your Virginia HMO Medicaid Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement. These changes are required by the Department of Medical Assistance Services in support of the new Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) program Federal Managed Care. Consistent with Federal managed care regulations at 42 C.F.R (u), the Provider shall maintain books, records, documents, and other evidence of administrative, medical, and accounting procedures and practices for ten (10) years following the final date of the term of the Agreement. In following with 12VAC , for Members who are children under age 21 and enrolled in the tech program, the Provider shall retain records for the greater period of a minimum of ten (10) years or at least six (6) years after the minor has reached 21 years of age. Copies on microfilm or other appropriate media of the documents contemplated herein may be substituted for the originals provided that the microfilming or other duplicating procedures are reliable and are supported by an effective retrieval system which meets legal requirements to support litigation, and to be admissible into evidence in any court of law. In addition, Provider agrees to comply with all record retention requirements and, December of 54

36 where applicable, the special reporting requirements on sterilizations and hysterectomies stipulated in HMO's Government Contract. 5.7 This provision intentionally left blank. These changes are made in accordance with Paragraph 7.1, Regulatory Amendment of your Virginia HMO Medicaid Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement: Notwithstanding the amendment provision in the agreement, this attachment shall be automatically modified to conform to required changes to regulatory requirements related to Medicaid programs without the necessity of executing written amendments. Amendment to the Virginia HMO Medicaid Participation Attachment to the Anthem Blue Cross and Blue Shield Facility Agreement for Dialysis, Home Health, Hospice and Skilled Nursing Facilities Effective December 1, 2017, the following changes will be made to your Virginia HMO Medicaid Participation Attachment to the Anthem Blue Cross and Blue Shield Facility Agreement. These changes are required by the Department of Medical Assistance Services in support of the new Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) program Consistent with Federal managed care regulations at 42 C.F.R (u), the Provider shall maintain books, records, documents, and other evidence of administrative, medical, and accounting procedures and practices for ten (10) years following the final date of the term of the Agreement. In following with 12VAC , for Members who are children under age 21 and enrolled in the tech program, the Provider shall retain records for the greater period of a minimum of ten (10) years or at least six (6) years after the minor has reached 21 years of age. Copies on microfilm or other appropriate media of the documents contemplated herein may be substituted for the originals provided that the microfilming or other duplicating procedures are reliable and are supported by an effective retrieval system which meets legal requirements to support litigation, and to be admissible into evidence in any court of law. In addition, Provider agrees to comply with all record retention requirements and, where applicable, the special reporting requirements on sterilizations and hysterectomies stipulated in HMO's Government Contract. These changes are made in accordance with Paragraph 4.2, Regulatory Amendment of your Virginia HMO Medicaid Participation Attachment to the Anthem Blue Cross and Blue Shield Facility Agreement: Notwithstanding the amendment provision in the agreement, this attachment shall be automatically modified to conform to required changes to regulatory requirements related to Medicaid programs without the necessity of executing written amendments. December of 54

37 Coverage Guidelines and Clinical Utilization Management Guidelines update Coverage Guidelines update On August 3, 2017, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Coverage Guidelines applicable to Anthem HealthKeepers Plus members. These guidelines were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the below listing. The Coverage Guidelines were made publicly available on our provider website on the effective date listed below. Visit to search for specific guidelines. Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Note: CG-DRUG-29 Hyaluronan Injections in the Knee will be implemented as investigational and not medically necessary on December 1, RAD will be archived effective September 15, CG-MED-58 will be effective September 15, Effective date Coverage Coverage Guideline title New or Guideline number revised 8/17/2017 DRUG Guselkumab (Tremfya ) New 9/27/2017 LAB Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis 8/17/2017 DRUG Abatacept (Orencia ) Revised 8/17/2017 DRUG Pharmacotherapy for Hereditary Angioedema Revised 8/17/2017 DRUG Pembrolizumab (Keytruda ) Revised 8/17/2017 DRUG Daratumumab (DARZALEX ) Revised 8/17/2017 DRUG Cerliponase Alfa (Brineura ) Revised 8/17/2017 DRUG Avelumab (Bavencio ) Revised 8/17/2017 GENE Gene Expression Profiling for Managing Breast Revised Cancer Treatment 8/17/2017 MED Implantable Ambulatory Event Monitors and Mobile Revised Cardiac Telemetry 8/17/2017 MED Cognitive Rehabilitation Revised 8/17/2017 RAD Coronary Artery Imaging: Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA), Fractional Flow Reserve derived from Computed Tomography (FFRCT), Coronary Magnetic Resonance Angiography (MRA), and Cardiac Magnetic Resonance Imaging (MRI) New Revised December of 54

38 Effective date Coverage Guideline number Coverage Guideline title New or revised 8/17/2017 RAD Multiparametric Magnetic Resonance Fusion Imaging Revised Targeted Prostate Biopsy 8/17/2017 SURG Cervical Total Disc Arthroplasty Revised 8/17/2017 SURG Transcatheter Heart Valve Procedures Revised Clinical Utilization Management Guidelines update On August 3, 2017, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines applicable to Anthem HealthKeepers Plus members. These clinical guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the following listing. This list represents the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division on August 24, On August 3, 2017, the clinical guidelines were made publicly available on our Coverage Guidelines and Clinical UM Guidelines subsidiary website. Visit to search for specific guidelines Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Effective date Clinical UM Guideline number Clinical UM Guideline title 9/27/2017 CG-ADMIN-02 Clinically Equivalent Cost Effective Services Targeted Immune Modulators 9/27/2017 CG-MED-57 Cardiac Stress Testing with Electrocardiogram (ECG) New New or revised 8/17/2017 CG-ANC-06 Ambulance Services: Ground; Non-Emergent Revised 8/17/2017 CG-SURG-27 Sex Reassignment Surgery Revised New December of 54

39 Quality Management Program Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is committed to excellence in the quality of service and care our members receive, as well as to the satisfaction of our network providers. To that end, Anthem s Quality Management (QM) Program is essential to ensuring our members medical and service needs are met and the quality of care and services are continuously improved. The QM Program addresses issues related to quality management and quality performance measures for both state and national compliance. Aspects and certain outcomes of the health care management services, such as disease management, case management and utilization management, are also presented and analyzed to evaluate effectiveness of the health plan s clinical aspects of care. We are always looking for ways to refine our comprehensive QM Program that includes: Adhering to federal, state and National Committee for Quality Assurance (NCQA) standards. Objectively monitoring and evaluating the care and services provided to members. Planning studies across the continuum of care to ensure ongoing, proactive evaluation and refinement of the program. Reflecting the demographic and epidemiological needs of the population served. Encouraging both members and providers to weigh in with recommendations for improvement. Identifying areas where we can promote and improve patient safety. Measuring our progress to meet annual goals. Throughout the year, we evaluate data trends related to how our members receive health care and preventive care services and compare our findings to national practice guidelines. Our network physicians and office staff are the key to helping us collect this information and improve our quality performance. Therefore, we would like to share our annual summary goals, processes and outcomes related to clinical performance and service satisfaction. Clinical performance and service satisfaction are based upon results from HEDIS and CAHPS. About HEDIS and CAHPS HEDIS was developed to measure important dimensions of care and service performance. HEDIS measures evaluate a broad range of important health issues including immunizations, preventive care and screening, comprehensive diabetes care, asthma medication use, controlling hypertension, and access to care. CAHPS surveys evaluate member satisfaction related to care and services received over the past six months. Plan members are randomly sampled and asked to answer questions about their doctors and the health plan. December of 54

40 HEDIS and CAHPS results help us identify areas of strength as well as areas where we need to focus our improvement efforts. We use the results to measure our performance against our goals and to determine the effectiveness of plans we implemented to improve our results QM accomplishments Achieved NCQA Accreditation Commendable status - Approved behavioral health (BH), utilization management (UM), clinical management (CM) and QM program descriptions - Approved BH, UM, CM, and QM program evaluations Completion of Anthem s first Multicultural Healthcare (MHC) QM Program Evaluation Investigated, trended and took necessary action on potential QOC concerns with 96.67% of these concerns being closed within the required timeframe of 90 days Completed the CAHPS Survey with rating of the health plan, rating of personal doctor, and rating of healthcare exceeding the 75th national percentile for both surveys Successful DMAS Health Services Advisory Group (HSAG) audit with 100% on the HEDIS2017 Medical Record Review Validation (MRRV) audit The QM Member Outreach team has conducted 168 Clinic Day Events as of second quarter that resulted in an overall show rate of 76% with more than 3,900 care gaps closed Evaluated cultural and linguistic needs of membership Implemented and conducted three Health Education Advisory Committee (HEAC) meetings as on second quarter (also referred to as Member Focus Group meetings) resulting in actionable requests from members, which were researched and resolved QM direction for 2018 Improve NCQA accreditation status from commendable to excellent Improve CAHPS composite rating of health plan to 75th percentile Enhanced member engagement/incentive platforms Improved provider collaboration strategies, gaps in care reporting and data acquisition Enhanced member data collection CAHPS improvement strategies December of 54

41 Multichannel outreach methods Develop a more unified and collaborative approach between CM and UM to help meet member needs and avoid potentially fragmented care Clinical practice and preventive health guidelines distribution Clinical Practice Guidelines (CPG) are evidence-based guidelines known to be effective in improving health outcomes. Guideline effectiveness is determined through scientific evidence, professional standards or expert opinion. We provide clinical care and preventive health guidelines to our network physicians that are based on current research and national standards. All guidelines are reviewed annually and updated as needed. To access the guidelines, go to the Provider home page at From there, select Provider and Virginia, then Health & Wellness Practice Guidelines. The following guidelines are available on our website: ADHD Asthma Bipolar disorder management adolescents Bipolar disorder management adults Chronic kidney disease Chronic obstructive pulmonary disease Congestive heart failure Coronary artery disease Diabetes mellitus HIV/AIDS management Hypertension adult Hypertension childhood and adolescent Major depression management Obesity management children and adolescents Preventive health recommendations adult Schizophrenia management We suggest providers refer to the American Academy of Pediatrics recommendations for preventive pediatric health care for children up to age 21. Additionally, immunization schedules can be found on the Centers for Disease Control and Prevention website. If you have questions about the guidelines or would like a paper copy, call Member Services at Clinical practice guidelines performance We are grateful to the providers who participated in the medical record review project that monitors providers clinical practice guidelines compliance in ADHD; depression; asthma; Early and Periodic Screening, Diagnosis and Treatment (EPSDT); obesity; antepartum/postpartum; and diabetes medical records. Outlined below are our recommendations regarding a few of these compliance areas. December of 54

42 ADHD As you work to improve ADHD documentation, we request the use of an ADHD rating scale when seeing a new member on ADHD medications even if the member was referred by another provider. Two ADHD rating scales we recommend are listed below: Vanderbilt Assessment Scale Conners Test Diabetes There was demonstrated improvement in the diabetes guideline; however, providers still need to improve their overall compliance with this clinical practice guideline. Providers can improve by receiving lab results, documenting medical histories and physicals, and educating patients about the risks and next steps to controlling their diabetes. For more information and tools to better educate patients, please visit the American Diabetes Association website. Asthma Providers improved documentation for asthma guidelines, but areas that still need improvement include patient education about risk factor assessment, asthma action plan and appropriate asthma medication. Providers can improve by providing enhanced follow-up care. For an example of an asthma action plan, please visit the Centers for Disease Control website. Medical record chart abstraction As part of our activities for 2018, we will be asking providers to participate in the medical record chart abstraction process. If you are chosen to participate, you will receive a list of randomly selected patient medical records for Anthem members in which we will conduct a required onsite chart abstraction. You will be contacted to set up an appointment for the chart abstraction. We greatly appreciate your participation and cooperation. Case Management Program Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a health care puzzle that for some, are frightening and complex issues to handle. Anthem is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals who are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness and learn about care choices in order to access quality, efficient health care. Members or caregivers can refer themselves or family members by calling the number located in the grid below. They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals. December of 54

43 How do you contact us? CM telephone Number CM business hours Ext Monday to Friday, 8:30 a.m. to 5:00 p.m. Eastern time Case management access In addition to disease management programs, we offer a complex case management program for high-risk members. Using claim and utilization data, we can identify diseases for which members are most at risk and to which they are most susceptible. Our case managers use evidence-based guidelines to coordinate care for members and their families with physicians and other health care providers. They work with everyone involved in the members care to help implement a case management plan based on the members individual needs. We provide education and support to our members and their families to help improve the members health and quality of life. To refer a high-risk member to this program, please call us at , Ext Pharmacy management information Up-to-date pharmacy information is available on the Pharmacy section of our website > > Pharmacy. You can access our formulary, the Prior Authorization Form and Preferred Drug List. If you have questions about the formulary or would like a paper copy, call the Pharmacy department at Pharmacy technicians are available Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 10 a.m. to 2 p.m. Eastern time. Important information about utilization management Our UM decisions are based on the appropriateness of care and service needed, as well as the member s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care, nor do we make decisions about hiring, promoting or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. Anthem s medical policies are available on Anthem s website at You can also request a free copy of our UM criteria from our Medical Management department, and providers may discuss a UM denial decision with a physician reviewer by calling us toll-free at the numbers listed below. UM criteria are also available to search on the web at We work with providers to answer questions about the UM process and the authorization of care. Here s how the process works: Call us toll free from 8:30 a.m. to 5 p.m. Monday through Friday (except on holidays) Eastern time. December of 54

44 If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after midnight will be returned the same business day. Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon. The following phone lines are for physicians and their staffs. Members should call the customer service number on their health plan ID card. To discuss UM process and authorizations To discuss Peer-to-Peer UM denials To request UM criteria TTY/TDD Ext Behavioral Health: Ext Ext Behavioral Health: Ext Ext Behavioral Health: Ext TTY: Voice: For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them. Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you. Affirmative statement about incentives HealthKeepers, Inc., as a corporation and as individuals who are involved in utilization management decisions, is governed by the following statements: Utilization management decision-making is based only on appropriateness of care/service and existence of coverage. HealthKeepers, Inc. does not specifically reward practitioners or other individuals for issuing a denial of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support or tend to support denials of benefits. Financial incentives for utilization management decision-makers do not encourage decisions that result in underutilization or create barriers to care and service. December of 54

45 Performance measures DMAS sets performance targets for a predefined set of measures, and HealthKeepers, Inc. must report on these targets and measures on an annual basis. DMAS uses this information to compare the performance of all contracted Medicaid plans in Virginia. HEDIS and administrative measures are also used to compare how well a health plan performs in areas related to quality of care, access to care and member satisfaction. HealthKeepers, Inc. uses the results to identify areas of strength and areas for improvement. We compare the results against our goals and measure the effectiveness of actions we have implemented to improve our outcomes. Some of the performance measures we focus on are related to health issues, such as immunizations, blood pressure, pregnancy, diabetes and well-child visits. With the help of our provider network, we saw improvements in some of our scores, but we still have work to do. We are constantly seeking opportunities for improvement. Current interventions include: Provider and member outreach and education efforts specifically to members who are due or past due for preventive care services. Community events and Anthem Clinic Days as a way to encourage members to see their provider for care. Consultation services with our QM staff to identify ways to help practices improve their performance. Annual coverage renewal It is important that members renew their health care coverage every 12 months and that their local social services agency has their most updated contact information. The state will send out letters informing members their coverage is about to end, and they need to renew. Members will also receive a prepopulated renewal form for them to correct any errors and/or complete any missing information. They will need to sign the form and return it by mail using the provided envelope. If a member has recently moved or has renewal questions, they can call Cover Virginia at or go online to Member rights and responsibilities We want to keep you informed about our members defined rights and responsibilities; therefore, they can be found on our website at > Handbooks and More > Medicaid Handbook English. To receive a copy in the mail, call Member Services at Our Member Services representatives serve as advocates for our members. To reach Member Services, please call , TTY 711. Member satisfaction We measure member satisfaction through an annual CAHPS survey. Analysis of the survey results helps us to identify areas where we do not meet member expectations. The analysis is grouped into five areas: Getting care quickly December of 54

46 Shared decision-making How well doctors communicate Getting needed care Customer service For the adult member satisfaction survey conducted in 2017, results showed that key drivers for overall satisfaction were: Health care overall Customer service treating members with courtesy/respect Easy-to-get care/treatment/tests necessary Easy to get urgent care appointments Listening carefully to members For the child member satisfaction survey conducted in 2017, results showed that key drivers for overall satisfaction were: Customer service treating members with courtesy/respect Easy-to-get care/treatment/tests necessary Easy to get urgent care appointments Listening carefully to members Provider satisfaction Every year, we conduct a provider satisfaction survey. Analysis of the survey responses helps us identify aspects of performance that do not meet provider expectations and initiate an action plan to improve performance. A positive working relationship with our contracted providers is important to the delivery of health care to our members. The objective of the survey is to measure overall provider satisfaction with and loyalty to HealthKeepers, Inc. as well as identify areas of strength and opportunities for improvement. The survey also assesses provider satisfaction in the following categories: Customer service at the Call Center Local health plan Provider Services Communication and technology Claims processing and provider reimbursement Network UM QM Pharmacy and drug benefits Disease Management Centralized Care Unit Continuity and coordination of care December of 54

47 2016 Survey results The overall results from the CY2016 Provider Satisfaction Survey are as follows: Key measures (average scores) Virginia Medicaid Overall satisfaction 67% Provider enrollment process 70% Provider complaint systems 54% ICD-10 made easy On October 1, 2015, the U.S. Department of Health and Human Services (HHS) mandated that health care providers, health plans and health care clearinghouses transition to ICD-10. Effective October 1, 2015, HealthKeepers, Inc. began accepting and processing ICD-10 diagnosis and inpatient procedure codes for claims with dates of service and discharge on/after the compliance date of October 1, Our systems, supporting business processes and policies and procedures are now compliant with ICD-10. The ICD-10 updates webpage contains reference materials and other information for your use including: Coding guidelines for preauthorization. Claims submission reference chart. Reference chart for claims billing by service type. Information on billing claims with span dates. Link to electronic data interchange edits for ICD-10. Guidance on paper claims containing ICD-10 codes. Our response to the CMS/American Medical Association announcement on ICD-10 in July Frequently asked questions. Updated coverage guidelines and clinical utilization management guidelines. Website ( December of 54

48 Medicare-Medicaid Plan update This section of the newsletter addresses information about the Anthem HealthKeepers Medicare-Medicaid Plan or MMP. Members are enrolled in both Medicare and Medicaid under the Commonwealth Coordinated Care Plan, also known as the Duals Demonstration ( Demonstration ) Program. Include National Provider Identifier on surgical procedure UB-04 bills In October 2017, HealthKeepers, Inc. will edit for operating provider National Provider Identifier (NPI) when a surgical procedure code is billed for claims for members enrolled in the Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan, having an individual Medicare Advantage or MMP plan. A surgical procedure code is a code within the range of but excluding 10035, 10036, , , 15792, 15793, 20527, , 20555, 20612, 20615, , 36406, 36410, 36415, 36416, 44705, 47531, 47532, 50430, 50431, 59425, 59426, 59430, , , , 69209, When a surgical procedure code is billed, the operating provider s NPI must be included in box 77 on the facility UB-04 CMS Claim Form for outpatient services. If a surgical procedure code is billed without an operating provider NPI, the claim will be denied for missing NPI MUPENMUB Critical access hospitals reimbursed at Medicare rate Effective May 26, 2017, for providers who treat members enrolled in the Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan, HealthKeepers, Inc. began using a rate database sourced from CMS-published Medicare hospital cost reports of critical access hospital (CAH) inpatient, swing-bed and outpatient rates to price claims from noncontracted CAHs for individual Medicare Advantage and MMP members. Consequently, HealthKeepers, Inc. usually will not need a Medicare administrative contractor (MAC) rate letter to process claims from noncontracted CAHs for individual Medicare Advantage and MMP members. However, HealthKeepers, Inc. will require a MAC rate letter in the situations noted below. We look forward to handling your claims in a more timely manner with this process change. HealthKeepers, Inc. still will require a MAC rate letter or additional information from CAHs in the following situations: Noncontracted CAHs must submit a MAC rate letter for claims for Medicare Advantage group-sponsored members. Contracted CAHs compensated using Medicare rates must continue to submit MAC rate letters to their HealthKeepers, Inc. network managers as required by contract. December of 54

49 All CAHs should update HealthKeepers, Inc. regarding a change in status in Method (from I to II or II to I). Note that Method II reimbursement applies to contracted CAHs only if specified in contract MUPENMUB Reimbursement policy Portable/Mobile/Handheld Radiology Services under MMP Policy Update: Portable/Mobile/Handheld Radiology Services (Policy , effective 03/15/2018) For members enrolled in Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan, HealthKeepers, Inc. allows reimbursement for portable/mobile radiology services when furnished in a residence used at the patient s home and if ordered by a physician and performed by qualified portable radiology suppliers. Portable/mobile radiology studies should not be performed for reasons of convenience. HealthKeepers, Inc. allows preventive screenings performed by portable/mobile radiology studies for routine purposes. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate for the radiological service and transportation and setup components with the use of applicable modifiers. Note: Portable radiology suppliers must be licensed or registered to perform services as required by applicable state laws. Transportation and setup HealthKeepers, Inc. allows reimbursement for transportation and setup of portable radiology equipment when transported to the member s residence. Transportation costs are payable when the portable X-ray equipment used was actually transported to the location where the X-ray was taken. Handheld radiology The use of handheld radiology instruments is allowed. Reimbursement will be part of the physician s professional service, and no additional charge will be paid. The technical components for handheld radiology are not separately reimbursable. For additional information, refer to the Portable/Mobile/Handheld Radiology Services Reimbursement Policy at VAPENABC December of 54

50 Medicare information (Anthem s Medicare Advantage and Medicare Supplement plans) Medicare Advantage individual benefits and formularies for 2018 Summary of benefits, evidence of coverage and formularies for 2018 individual Medicare Advantage plans will be available at anthem.com/medicareprovider. An overview of notable 2018 benefit changes also will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider. Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information. Annual visit guidelines for 2018 Anthem Medicare Advantage plans will continue to offer coverage for routine physicals in 2018 for individual and group-sponsored Medicare Advantage members. A routine physical exam will help aid in appropriately diagnosing, monitoring, assessing, evaluating and/or treating conditions that may not otherwise be captured, closing gaps in care and creating a comprehensive care plan to manage possible chronic conditions. Please see Important Medicare Advantage Updates at anthem.com/medicareprovider for claims submission and other information. Anthem tiers SNF network It is important to know when a member is discharged to a Skilled Nursing Facility (SNF) setting to coordinate patient care. To help ensure optimal quality with reduced readmissions to acute care facilities, Anthem is implementing tiering for our Skilled Nursing Facility provider network based on a preferred designation for qualified providers within Anthem s Medicare Advantage network. Additional information will be available at Important Medicare Advantage Updates at anthem.com/medicareprovider. December of 54