July 1, 2016 C O L O R A D O Drug fee schedule update CMS average sales price (ASP) third quarter fee schedule with an effective date of July 1, 2016 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on August 1, 2016. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/mcrpartbdrugavgsalesprice/. Reminder: Update regarding Specialty Pharmacy program expansion In a previous Provider Communication sent out on March 18, 2016, we shared information about the expansion of the Specialty Pharmacy program to include level of care clinical review for specialty pharmacy infusions and injections beginning with dates of service on and after July 1, 2016. Please note that Specialty Pharmacy level of care clinical reviews will now begin with dates of service on and after July 18, 2016. The new clinical guideline Level of Care: Specialty Pharmaceuticals CG-DRUG-47 is available for review now, and may be helpful as providers consider current processes and the use of alternate level of care providers for specialty pharmacy infusions and injections. As a reminder, once the specialty pharmacy program expansion is implemented, we will review both the drug for clinical appropriateness and the level of care against health plan clinical criteria. The expanded program will continue to be administered by AIM Specialty Health (AIM), a separate company. Additionally, the list of drugs that will be reviewed for level of care (once implemented) is available at www.aimprovider.com/specialtyrx. Reminder: Blue Priority plans expanding to Larimer and Weld counties effective July 1, 2016 As a reminder to our June newsletter, effective July 1, 2016, Anthem Blue Cross and Blue Shield and HMO Colorado Inc. (Anthem) is expanding our existing Blue Priority HMO network to Larimer and Weld counties. Large group business will be available in Larimer and Weld counties starting July 1, and small group business will be available in these counties starting January 1, 2017. The Blue Priority products allow the PCP to manage the whole patient throughout the continuum of care; preventive care through chronic care; and makes referrals as appropriate to other network physicians. HMO This network option: includes a subset of PCPs and Specialists from Anthem s standard HMO network. provides coverage only when using selected PCP groups and selected specialists; (For a complete list of PCPs and Specialists, please reference the Find a Doctor tool, our online provider directory. See navigation instructions below) includes all facilities, ancillary providers, and behavioral health providers in the current HMO network; requires member selection of a PCP; July 2016 Colorado Page 1 of 10
requires referrals for most specialty care; no out-of-network benefits or access to most specialists without a referral The exceptions are emergent and urgent care and specific types of specialty care as required by state law. PPO This three tier PPO option: requires member selection of a PCP; allows access to the broader Anthem PPO network without a referral; provides for the highest level of benefits when using the first tier of providers (Designated Providers); which are those PCPs and specialists in the HMO Blue Priority network; allows access to the second tier of providers (Participating Providers), which includes all other Anthem PPO contracted providers, at a reduced benefit. allows access to non-network providers at a significantly reduced benefit level. Identifying Blue Priority Members Alpha Prefix Product Type Network Name (On Member ID cards) XFA HMO Blue Priority XFD HMO Blue Priority XFI HMO Blue Priority XFH PPO Blue Priority PPO XFM PPO Blue Priority PPO XFS PPO Blue Priority PPO Health Plan ID Cards Samples of our Member Health Plan ID Cards (including Blue Priority HMO and PPO) are available in our Provider Toolkit online. Go to anthem.com, select the Provider link in top center of the page. Select Colorado from drop down list and enter. From the Provider Home tab, select the link titled Provider Communications and Education, then Provider Toolkit, and Membership Health Plan ID Card Samples. Navigation instructions for Anthem s Find a Doctor tool Go to anthem.com, select the Provider link in top center of the page. Select Colorado from drop down list and enter. From the Provider Home tab, select the enter button from the blue box on the left side of page titled Find a Doctor. Important Note: Searching without selecting a plan/network displays information specific to the provider. The most accurate way to search for a provider within a specific member s plan is by the member s alpha prefix search option (first 3 characters in member s ID number). Referrals for Blue Priority HMO members Referrals can be obtained through two options: 1. through our secure portal, providers can submit referral request through Interactive Care Reviewer tool on the Availity Web Portal at availity.com, or 2. through our public website, go to anthem.com, select Provider, then Colorado and enter, from the Provider Home page, select Download Commonly Requested Forms, then the Blue Priority Referral Form link. July 2016 Colorado Page 2 of 10
Professional Fee Schedule tool now available on Availity Web Portal This summer we have a new look and sizzling hot features to improve your experience on the Availity Web Portal debuting throughout the summer at Availity.com. This month access the new Professional Fee Schedule tool that s now available: Professional Fee Schedule Retrieve contracted amounts for up to 50 procedure codes at a time with the new Fee Schedule application (includes print functionality). From the Availity Web Portal home page, select Payer Spaces, next choose Anthem BlueCross BlueShield from the list of payer options, select the Applications tab, then from the Fee Schedule box, and then select the Open button. Access your contracted fee schedule, by line of business/network, in three simple steps: 1. Enter your organization information 2. Enter the procedure codes, including modifiers, you d like to view 3. View your results NOTE: this tool is for Professional pricing only, it does not take into account site of service at this time. Make sure your access is in tip top shape for the summer. If you cannot locate this new feature, contact your organization s Availity administrator (formally known as Primary Access Administrator) to request access. Watch for our August newsletter as even more enhancements become available throughout the summer! Have a question about a claim? Check out the Secure Messaging via the Availity Web Portal Secure Messaging is a feature available from the Claim Status Detail page on the Availity Web Portal that allows you to ask a question about a claim. This valuable tool can be used for Local Plan, BlueCard and Federal Employee Plan (FEP ) claim questions. Once you ve submitted a Claim Status Inquiry within Availity, from the Claims Status Detail page you will see a link that state s Do you have a question about this claim? Click on the link to send a Secure Message to Anthem. July 2016 Colorado Page 3 of 10
Once this link is selected, a new window will open and you will choose one of the several questions from a dropdown box and use the freeform text box to add any additional information related to your question and click submit. You will receive an Inquiry Control Number (ICN) which confirms your Secure Message has been sent. Secure Messages are usually responded to within 5 business days. Responses to your Secure Message will be displayed in your Secure Message Inbox. To access your inbox, from the Claims tab (across the top of page), select Claims, then Secure Messaging. Select I Agree to the disclaimer, and then select your Inbox tab. Now Anthem can send you follow-up messages on your claim inquiry. These may share pertinent detail or request additional specific information. You will know if Anthem has sent you a new message because a new column, titled Messages Needing Attention, has been added to your inbox. In this column, if you have a new message, you will see Attention Needed. If you use Secure Messaging, check your inbox periodically for this indicator. It will look like this: Also, when you view your message, look for the option, Download Secure Message, which is located to the right of the message. Use Download Secure Message to save or print the content of the entire message. This eliminates the need for multiple print screens in order to capture the message detail. Don t have access to Secure Messaging yet? The Anthem Services Registration process needs to be completed by your Availity Administrator (previously known as Primary Access Administrator of PAA) in order to use the Secure Messaging tool. Users need to be registered on ProviderAccess, in addition to Availity. When the PAA performs the Anthem Services Registration process on Availity, they will be asked to enter the Users Health Plan User ID ; this is the same as the ProviderAccess User ID. Once the Anthem Services Registration process is completed; when a User conducts a Claims Inquiry transaction, the User will then be able to choose the Secure Provider Messaging link by at the bottom of the Claims Detail page. For more details on completing the Anthem Services Registration process: Go to anthem.com. Select the Provider link (top center of the page), then select Colorado from the drop down list, and click Enter. From the Provider Home page, look for the link titled ProviderAccess Migration to the Availity Web Portal, then select the link titled Anthem Services Registration Instructions. Reminder of the most recent updates to the Cancer Care Quality Program Attention Oncologists, Hematologists and Urologists As a reminder, Anthem s Cancer Care Quality Program ("Program"), a quality initiative, provides participating physicians with evidence-based cancer treatment information that allows them to compare planned cancer treatment regimens against evidence- July 2016 Colorado Page 4 of 10
based clinical criteria. The Program also identifies certain evidence-based Cancer Treatment Pathways. Participating physicians who are in-network for the member's benefit plan are eligible to participate in the Program and for enhanced reimbursement if an appropriate treatment regimen is ordered that is on a designated Cancer Treatment Pathway. The Program is administered by AIM Specialty Health (AIM), a separate company. Effective August 1, 2016, Anthem will make the following changes to the Cancer Treatment Pathways for the Cancer Care Quality Program: New Cancer Treatment Pathways added to the Program include: Classical Hodgkin Lymphoma Mantle Cell Lymphoma Colorectal Cancer FOLFOXIRI plus bevacizumab will be added to 1 st or 2 nd line therapy Trifluridine/tipiracil will be added to 3 rd line therapy Cancer Treatment Pathways removed* from the Program include: Colorectal Cancer Regorafenib will be removed from 3 rd line therapy This means that providers will not be eligible for an enhanced reimbursement when these regimens are prescribed. This does not restrict the use of these regimens for members when clinically appropriate, and claims will be adjudicated in accordance with the members benefit plans. The Cancer Treatment Pathways developed for this Program are intended to support quality cancer care. To access the full Cancer Treatment Pathways document, go online to CancerCareQualityProgram.com, our dedicated provider website. Note: Participating physicians who are in-network for the member's benefit plan are eligible to participate in the Program and for enhanced reimbursement if a designated Cancer Treatment Pathway is ordered that is included in the Program. Commercial HEDIS 2016: Provider incentive winners announced! We have completed the HEDIS data collection for 2016 and want to thank all of our provider offices and their staff who assisted us. Your collaboration in this process allows us to achieve the best HEDIS results possible. This is the 5 th year for our incentive program to acknowledge some of our providers who either responded in a timely manner or went above and beyond to help make our HEDIS data collection successful. Any practices that responded within 5 business days of our initial request or who went out of their way by taking additional steps to help us with data collection were entered in a drawing to receive a gift. In the event an office was not able to accept a tangible gift, a special written recognition was given. We are pleased to announce that our Colorado incentive winners are as follows: For Submission Timeliness For Going Above and Beyond Paladina Health LLC Pueblo Pam at Sands and Associates Fort Collins Rocky Mountain Cancer Centers Longmont Rachel at UC Health/Longmont Clinic Longmont Littleton Pediatric Medical Clinic - Littleton Helen at CO Springs Family Practice CO Springs July 2016 Colorado Page 5 of 10
Green Valley Ranch Medical Center Denver Emily at University of CO Health (Metro) - Aurora Bariatric & Lifestyle Medicine Fort Collins Thanks again to all of our provider offices and their staff for assisting us in collecting HEDIS data. Our HEDIS results reflect the care you provide to our members. An overview of our HEDIS rates will be published in the 4 th quarter provider newsletter. More information on HEDIS is available online at anthem.com. Click on the Provider link at the top of the landing page (under the Other Anthem Websites section). Select Colorado and click enter. Click on the Health and Wellness tab (on the blue toolbar), and select the Quality Improvement and Standards link, then scroll down to HEDIS Information. We look forward to working with you next HEDIS season! HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Update to Claims Processing Edits and Professional Reimbursement Policies Update to Claims Processing Edits and Reimbursement Policies On August 1, 2016, we will be updating Anthem s secure Provider Portal, ProviderAccess, with the following new and/or revised reimbursement policies. The updates below identify if the article pertains to professional or facility provider billing. After Hours, Emergency, and Miscellaneous E/M Services and Place of Service Professional We have updated our policies dated May 23, 2016 to reflect that after hours Current Procedural Terminology (CPT ) codes 99050 and 99051 may be eligible for separate reimbursement when reported with an urgent care place of service (place of service code 20 ) in addition to an office place of service (place of service code 11 ). Claims Editing Overview Professional Beginning with claims processed on or after May 23, 2016, we have relaxed our gender edits for those procedure codes and diagnosis codes that are assigned to a patient of the opposite sex, therefore, we have removed references to the gender to procedure and gender to diagnosis edits from our policy. Durable Medical Equipment and Modifier Rules Professional We corrected information in our Durable Medical Equipment and Modifier Rules policies dated July 1, 2016. Modifier NR was identified as a DME rental modifier in error; however, modifier NR is a DME purchase modifier and is included in any DME purchase modifier edits that were effective for dates of service on or after July 1, 2016. In addition, we are updating language under our Purchase and Rent to Purchase (P/RTP) section of our Durable Medical Equipment policy to clarify information regarding our 10 month rental limit guidelines. Injection and Infusion Professional In our policy dated August 1, 2016, have added CPT codes 99601 and 99602 (home infusion/specialty drug administration) to document our current edit that supplies are not eligible for separate reimbursement when reported with these home infusion services. The revisions do not change the policy position or criteria. July 2016 Colorado Page 6 of 10
Qualitative Drug Screen Testing Professional We have made language revisions to our policy dated August 1, 2016; however, the revisions do not change the policy position or criteria. Reimbursement Policies and Clear Claim Connection are available on our secure provider portal, ProviderAccess Please review the full policy for any changes referenced above for further information. All professional Reimbursement Policies are located on our secure provider portal, ProviderAccess. Please go to anthem.com, and select the Provider link in the top center of the page. Select Colorado from the drop down list, and enter. From the Provider Home page, go to the ProviderAccess Login tout (blue box on the left side of the page), and select Medical from the drop down list and click on the login button. Once logged into ProviderAccess, from the Overview tab, under the Policies and Procedures section, select the link titled View Professional Reimb & Admin Policies. From the Anthem s Professional Reimbursement and Administrative Policies overview page, select Continue. Select link titled Anthem s Professional Reimbursement & Administrative Policies By Type, then select the Reimbursement link, and next the Policy you would like to view. Clear Claim Connection TM is our web-based editing tool from McKesson and includes an interface that will allow you to view the clinical rationale for ClaimsXten edits when you enter claim scenarios. If you have not used Clear Claim Connection previously, we would like to take this opportunity to encourage you to access this user-friendly tool to explore the ClaimsXten edits. Follow the directions listed above to log into ProviderAccess. Once logged in, from the Claims tab, select the Clear Claim Connection link. CPT is a registered trademark of the American Medical Association ClaimsXten is a registered trademark of McKesson Information Solutions LLC Medicare Advantage Updates Reach a nurse directly for prior authorizations that require clinical reviews, services that require Anthem authorization Effective July 15, providers can speak to a nurse directly to request a prior authorization requiring clinical review for an individual Medicare Advantage members. Just call the number of the back of member ID card for prior authorization of services authorized by Anthem. The nurse may be able to make the clinical review immediately if the necessary clinical information is available. We hope this increased access to clinicians will streamline the prior authorization process for you and for our members. Please use the phone numbers on the back of the member ID card and fax numbers published on our provider portal to reach us. Some fax numbers may be updated at a later date. 59277MUPENMUB 03/17/2016 Additional AIM OptiNet imaging services registration webinars available The implementation of the AIM OptiNet imaging services initiative has been delayed until January 1, 2017. We encourage all providers to take the OptiNet survey early. All participating providers who provide imaging services should complete registration for AIM s online registration tool, OptiNet. OptiNet will collect modality-specific data from providers who render X-ray, ultrasound (abdominal/retroperitoneum, gynecological and obstetrical services only at this time), Magnetic Resonance (MR), Computed Tomography (CT), nuclear medicine (NUC), positron emission tomography (PET) and echocardiograph imaging services in areas such as: facility qualifications, technician and physician qualifications, accreditation, equipment and technical registration. July 2016 Colorado Page 7 of 10
These data will be used to calculate site scores for providers who render imaging services to our individual Medicare Advantage members. All participating providers who provide imaging services, including x-rays and ultrasounds as noted above, should complete the registration. This includes providers who have delegated risk arrangements and who may see Anthem members outside of those risk arrangements. Providers who score less than 76 or who did not complete the survey by January 1, 2017 will receive a line-item denial for the technical component of the outpatient diagnostic imaging service only. Providers who have not registered, and therefore have no score, also will be subject to line-item denials for claims submitted for dates of service on or after January 1, 2017. All facility diagnostic imaging services are excluded from line item denials at this time. OptiNet scores are used for all radiology services for facility and non-facility based providers during the AIM provider selection process. Please remember, even if you have registered your radiology equipment for commercial business, you must also register for the Medicare Advantage individual line of business. AIM can help you transfer your commercial registration information to the Medicare Advantage registration site. How to register Registration is available online via the AIM ProviderPortalSM (registration required). To access: 1. Go to www.aimspecialtyhealth.com/goweb 2. Select Anthem MA from the drop down menu 3. Log in to ProviderPortal 4. Select Access My OptiNet Registration from the ProviderPortal home page to begin your registration For additional assistance you may also call AIM toll free at 800-714-0040, Monday through Friday, 6:00am 6:00pm MT. Learn more: Attend a webinar Anthem continues to offer webinars to help providers complete their OptiNet surveys. These surveys collect information about the imaging capabilities of all Anthem Medicare Advantage contracted providers who provide the technical component of a number of outpatient diagnostic imaging services for our individual Medicare Advantage members. Learn how to: Access the OptiNet Assessment Copy previously completed OptiNet Assessments to your Anthem Medicare Advantage account Complete a new AIM OptiNet registration Interpret and improve your site score Choose one of the sessions below to register for the webinar. July 12, 2016, 11-12 pm MT July 28, 2016, 3-4 pm MT August 8, 2016, 3:30-4:30 pm MT August 25, 2016, 12-1 pm MT September 16, 2016, 11-12 pm MT September 26, 2016, 3-4 pm MT July 2016 Colorado Page 8 of 10
October 12, 2016, 12-1 pm MT October 28, 2016, 2:30-3:30 pm MT November 9, 2016, 11-12 pm MT December 17, 2016, 3-4 pm MT Part D drugs must be prescribed for FDA-supported indications, Medicare compendiums Anthem is responsible for ensuring that the Medicare Part D drugs that it covers are prescribed for medically accepted indications. Part D drugs must be prescribed for an indication supported by FDA-approved labeling and/or supported by at least one Medicare-approved compendium. If not, then by definition the drug is not considered a Part D drug. Please see Chapter six of the Medicare Prescription Drug Benefit Manual (https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovcontra/downloads/part-d-benefits- Manual-Chapter-6.pdf) for additional information. 59806WPPENMUB 04/27/2016 Ensure the accuracy of your information in the provider directory CMS requires that Anthem ensures that the information in our provider directories is accurate. Anthem conducts quarterly verifications of provider demographic and participation information. You may receive a fax, email or letter requesting that this information be confirmed. We appreciate your continued cooperation with this initiative. Upon receipt of your verification form, please validate your demographic information for the specific location identified, indicate if changes are required and fax back a revised form to the number indicated in your communication. If we need to verify information for your other locations or plans, we will contact you separately. For reference, Anthem will ask you to submit any changes to the information listed below. Upon receipt, Anthem will include those changes in the provider directory within 30 days. Provider Name Provider Specialty Street Address Phone Number Accepting New Patients NPI Fax Number Email Claim adjustments may change member cost share Anthem reminds providers to please check the explanation of payments on claims. There are situations in which a claim may be adjusted and this may change a member cost-share. If you receive a claim adjustment from Anthem, please ensure the member cost-share is still accurate. Member cost-share information is located on the front right-side of the member ID card. Please note that all cost shares are not listed. If you have any questions about a member s cost share, please call the number on the back of the member ID card. Anthem offers Medicare Advantage member incentive for annual routine physical Anthem is launching a wellness campaign for individual D-SNP and HMO members in Colorado. As part of this campaign, we will contact members by letter and encourage them to see their provider for a routine physical by December 31, 2016, to earn a $50 incentive. To receive the reward, members will be required to obtain provider signature attesting to the annual physical. As a result of this campaign, you may experience more than the usual number of appointment requests from your MA patients. We hope you will complete their visits by December 31, 2016. Thank you for supporting this program and our members. July 2016 Colorado Page 9 of 10
Keep up with Medicare news Please continue to check Important Medicare Advantage Updates at www.anthem.com/medicareprovider for the latest Medicare Advantage information, including: June reimbursement policy provider bulletin Medicare Advantage reimbursement policies 2016 Diabetic Supply Coverage for Individual Medicare Advantage Members Providers Must Enroll with Medicare to be able to Prescribe Part D Beginning Feb. 1, 2016 Contact Medicare Part B Specialty Pharmacy before Injections, Infusion Drug Prior Authorization Expire 60509WPPENMUB 06/09/2016 Health Care Reform Updates (including Health Insurance Marketplace / Affordable Care Act) We invite you to go to anthem.com to learn about the many ways health care reform and health insurance marketplace / affordable care act information may impact you. New information is added regularly. To view the latest articles on health care reform and/or health insurance marketplace / affordable care act, and all achieved articles, go to anthem.com; select the Provider link in the top center of the page. Select Colorado from the drop down list, and click Enter. From the Provider Home page, select the link titled Health Care Reform Updates and Notifications or Health Insurance Exchange Marketplace / Affordable Care Act information. July 2016 Colorado Page 10 of 10