In this issue Page

Transcription

In this issue Page

April 2013
In this issue
Page
Health Care Reform
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A closer look at health insurance exchanges
Site launched to educate on health care reform
Breast pumps covered under preventive care benefits
Updates and notifications
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Account Update
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Western Dairy Transport
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Administrative Update
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Redesigned member EOB is easier to read
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Preventable adverse events, hospital acquired conditions audits 5
National consumer cost tool expansion
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Louisville, KY PO boxes no longer in use
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Update your Provider Maintenance form
6
Claim Filing
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Customized claim edit
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The ICD-10 Updates webpage is a resource for information
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Reminder: Where to file lab, DME and specialty RX Blue claims 9
eBusiness
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Introducing ICR, our new self-service provider web tool
Expanded member search on AIM Specialty Health℠
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Health Care Management
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Medical policy update
Clinical guideline updates
These specialty pharmacy drugs will require precert
Anthem’s peer-to-peer process
Milliman Care Guidelines (MCG™) update
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Medicare
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Corrected claim guidelines
CMS issues additional NPI requirements for some providers
Annual member surveys
Preventive health calls
MA precert requirements updated for 2013
MA members receive personalized checklists
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CENL 0413
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OH: Rheumatoid arthritis claims
Pilot program facilitates delivery of health reminders
Supporting the Million Hearts program
Making progress to improve member safety
Improving drug utilization controls for opioids
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Pharmacy
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More pharmacy information
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Better health for members who need care the most
Clinical practice & preventive health guidelines
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Quality
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Reimbursement
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Facility reimbursement policy: Emergency Department services 24
Professional reimbursement policies
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−3D rendering of imaging studies
−Screening services with E/M services
−Modifier 22
−Sleep study and bundled services
−Urgent care (coding and bundled supplies)
−View professional reimbursement policies on anthem.com
Health Care Reform
Updates and Notifications
A Closer Look at Health Insurance Exchanges
The Affordable Care Act (ACA) calls for the creation of state public health insurance exchanges by 2014, with the first open
enrollment date set for October 1, 2013. These insurance marketplaces are designed to help qualified individuals and small
businesses shop for health insurance plans, options, and benefits. Similar to the way travel and shopping websites allow
consumers to compare a service or product before purchasing, an exchange will present consumers with many choices
related to their health insurance coverage, all in one online marketplace.
There is still much to be determined about how insurance exchanges will be structured. For example, some exchanges will
use a state-run model, while others will use a state-federal partnership model or a federal model. The following FAQs help
answer questions about health insurance exchanges and their current development. We will continue to update providers
about exchanges and their impact on our day-to-day business with providers as we receive additional guidance from the
United States Department of Health and Human Services (HHS) and as exchange marketplaces develop. To learn more
about health insurance exchanges, including details around the Individual Mandate and cost sharing subsidies, see our
expanded FAQ.
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Frequently Asked Questions – Exchanges
Q: What are health insurance exchanges?
A: Exchanges are a new marketplace where qualified individuals and small businesses can buy qualified health plans
(QHPs).
Q: What is the purpose of health insurance exchanges?
A: The primary purpose of health insurance exchanges is to create a more organized and easy-to-compare market for health
insurance by offering a choice of plans, establishing common rules about the plans and price of health insurance, and
providing information to help consumers better understand the options available to them.
Q: When must health insurance exchanges be established?
A: Exchanges must be operational by January 1, 2014, with open enrollment beginning on October 1, 2013.
Q: Who will operate health insurance exchanges?
A: Each state will be responsible for creating and running its own exchange. However, if a state chooses not to create one,
HHS will run the exchange.
Q: Will health insurance exchanges replace buying private health insurance in the traditional market?
A: No. The health insurance exchanges are simply a new place to shop and buy health insurance plans.
Q: How will health insurance exchanges be set up?
A: States can choose to set up exchanges in one of three ways:
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State-run facilitator model – any health insurance company that meets the minimum state and federal requirements
can be in this exchange.
State-run active purchaser model – the state solicits bids from health insurance companies and negotiates the
prices as well as the benefits that will be offered on the exchange.
Federally-run model –HHS will run the exchanges in states that choose not to create one.
Q: When will health insurance exchanges start enrolling individuals and small group employers in plans?
A: It is planned that exchanges will start open enrollment on October 1, 2013 with coverage effective dates beginning
January 1, 2014.
Q: What benefits will be included in the health plans on exchanges?
A: All plans offered on the health insurance exchange must be considered a Qualified Health Plan (QHP) and include
“essential health benefits” (EHBs) as defined by the ACA (or health care reform law). We anticipate additional guidance on
EHBs to be released by HHS soon. Plans must include items and services from at least 10 of the following categories of
care:
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Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
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Q: Will the plans offer different levels of coverage to choose from?
A: Yes. Exchange plans will be offered in a tiered format. The tiers are named after metals, and are based on
actuarial value:
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Bronze – 60% coverage
Silver – 70% coverage
Gold – 80% coverage
Platinum – 90% coverage
Each level may have several plans to choose from and will include essential health benefits. Bronze plans will
have the lowest monthly premium, but member cost share will be more when health care services are rendered.
Platinum plans will have the highest monthly premium, but member cost share will be less when services are
rendered.
Disclaimer- This content is provided solely for informational purposes: it is not intended as and does not constitute legal
advice. The information contained herein should not be relied upon or used as a substitute for consultation with legal,
accounting, tax and/or other professional advisors.
Site launched to educate on Health Care Reform
Anthem recently launched an educational site about health care reform for members and consumers. The site is featured on
anthem.com in a new area specifically for health care reform information.
Health Care Reform 4 You provides simple, straight-forward information to help your patients understand how the health
care reform law affects them. There are easy-to-use tools, such as a timeline of what to expect, and descriptions of important
health care reform laws. Members can get a big picture view of health care reform or learn greater detail about changes to
health insurance benefits, such as pre-existing condition changes and the expansion of preventive care benefits. Health
Care Reform 4 You offers even more personalized information to viewers when they answer a few simple questions.
We understand that providers often encounter questions from our members about health care reform. We hope that you find
this to be a valuable resource that can be shared with your patients to obtain information about how health care reform
impacts them.
Breast pumps covered under preventive care benefits
The preventive care provision of the Affordable Care Act (ACA) states that health plans must cover one breast pump per
pregnancy with no cost sharing for female members. This benefit applies to nongrandfathered plans with renewals starting on
or after August 1, 2012. For more information on this benefit, please see our FAQ online, under the Health Care Reform
Updates and Notifications section at anthem.com>Providers (enter state
Updates and notifications
Please go to anthem.com to learn about the many ways health care reform may impact you. New articles are added regularly.
To view all, see updates, or visit anthem.com>Providers (enter state)>Health Care Reform Updates and Notifications.
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Account Update
Company
Western Dairy
Transport
Effective Date
5/1/2013
Alpha Prefix
DVY
Precert Number
866-643-7087
Customer Service Number
855-634-3386
Administrative Update
Redesigned explanation of benefits (EOB) easier to read
Many Anthem members living in IN, KY, MO, OH and WI are receiving a new explanation of benefits (EOB) that is easier to
read and understand. Anthem began sending the redesigned EOB to members, effective March 15. Members now can
compare the information included in the EOB with the information in providers’ bills, to make sure that Anthem paid the right
amount for the right service. It also shows members what they owe the provider.
The new EOB gives members a complete picture of the services rendered, how they were paid for and how those payments
work with their health plan, what was covered, what was paid and what’s owed.
Our goal for our improved EOB includes helping members understand their health care benefits and responsibilities for out of
pocket costs. Go here to view it.
Preventable adverse events and hospital acquired conditions audits
Beginning March 1, 2013, Anthem has contracted with EquiClaim, Inc and Healthcare Recoveries to perform reviews of
Preventable Adverse Events (PAE) and Hospital Acquired Conditions (HAC). The vendors will be reviewing medical records
and identifying the charges and/or days which are the direct result of a PAE/HAC, in accordance to the provider contract
language.
National Consumer Cost Tool expansion
The Blue Cross and Blue Shield Association (BC/BS) is working with Blue plans to implement member out of pocket cost
transparency as part of its National Consumer Cost Tool (NCCT) strategy. This expansion supports member-level cost
transparency similar to the online Estimate Your Cost tool that is already available to Anthem members today. It is intended
to promote a consistent national approach to cost transparency for all Blue members. The National Consumer Cost Tool
expansion planned for this year will also enable Anthem members to obtain cost transparency information for additional
services not previously available through NCCT. These will include outpatient procedures and common in-office visits, tests,
and procedures.
Kentucky PO boxes no longer in use
The Louisville, Kentucky mailing addresses for paper claims and claims-related correspondence transitioned to Atlanta,
Georgia in October 2010. Since then, Anthem has been forwarding the mail received in the PO Boxes in Kentucky to the
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appropriate PO Boxes in Atlanta. However, the forwarding order is ending very soon. Effective April 1, 2013, any mail sent
to the Kentucky PO Boxes will be returned to the sender.
If you have not already done so, please download the updated form for Provider Adjustment Requests and delete the
old one showing a Louisville, Kentucky PO Box.
Provider Adjustment Instruction Sheet and forms can be found at www.anthem.com>Providers (enter
state)>Answers@Anthem.
For more information, see our Network eUPDATE at anthem.com>Providers (enter state) Network eUPDATE, Mail Sent to
Kentucky PO Boxes Will Be Returned.
Update your Provider Maintenance form
We are continually updating our provider directories to help ensure that your current practice information is available to our
members. When a provider recently joins or leaves your practice, or you have a change in your address, phone number, etc.,
please let us know by completing the Anthem Provider Maintenance Form at anthem.com. Thank you for your help and
continued efforts to keep our records up to date.
Claim Filing
Customized claim edits
The following Anthem customized claim edits will be implemented around June 14, 2013 and apply to the following products:
Blue Access®, Blue Access Choice, Blue Preferred®, Blue Preferred Primary, Blue Preferred Primary Plus, Blue Preferred
Plus, Blue Priority SM , Blue Priority Plus, Blue Traditional®, Hospital Surgical (PPO) Blue Traditional®.
Revised Edit #720- Positive Pressure Airway Pressure Devices Supplies or Initiation and Management of Continuous
Positive Airway Pressure Ventilation (CPAP) with Actigraphy Testing, Sleep Studies, Multiple Sleep Latency and
Polysomnography.
Rationale: The revision to this edit was the addition of 2 new sleep study codes for 2013 — 95782 and 95783 (which are
sleep studies for individuals younger than 6 years of age). Anthem and the National Correct Coding Initiative Edits Version19.0) does not reimburse separately for supplies and testing components (such as: electrocardiograms, pulse oximetry and
etc) when billed along with actigraphy testing, sleep studies, multiple sleep latency tests and polysomnographies.
New Edit #771- Electronic Analysis of Programmable, Implanted Pump for intrathecal or Epidural Drug Infusion {includes
Evaluation of Reservoir Status, Alarm Status, Drug Prescription Status}; with or without or Programming or not Programming
of Pump with Refilling and Maintenance of Implantable Pump or Reservoir for Drug Delivery, Spinal {Intrathecal, Epidural} or
Brain {Intraventricular}, includes Electronic Analysis of Pump.
Rationale: Codes 95990 and 95991 bundle to 62367, 62368, 62369 or 62370, following the American Medical Association,
Current Procedure Terminology Manual for 2013 (page 334) and the National Correct Coding Initiative Edits (Version 19.0)
which lists 95990 and 95991 as component codes to codes 62369 and 62370. Therefore, if 95990 or 95991 is submitted with
62367, 62368, 62369 or 62370—only 62367, 62368, 62369 or 62370 reimburse.
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New Edit #773- Special Dosimetry (e.g., TLD, Microdosimetry)(Specify) only when Prescribed by the Treating Physician with
Intensity Modulated Treatment Delivery, Single of Multiple Fields/Arcs, Via Narrow Spatially and Temporally Modulated
Beams, Binary, Dynamic MLC, per Treatment Session.
Rationale: Code 77331 is incidental with 77418, following National Correct Coding Initiative Edits (Version 19.0).
Therefore, if 7731 is submitted with 77418—only 77418 reimburse.
New Edit #774-Anesthesia for Patient of Extreme Age, Younger than 1 Year or Older than 70, Anesthesia Complicated by
Utilization of total Body Hypothermia or by Utilization of Controlled Hypotension or Anesthesia Complicated by Emergency
Conditions with Daily Hospital Management of Epidural or Subarachnoid Continuous Drug Administration.
Rationale: Codes 99100, 99116, 99135 or 99140 are redundant/mutually exclusive to 01996, following the American
Society of Anesthesiologists, Relative Value Guide, 2010 (page 28) which states that “qualifying circumstances codes
(99100 through 99140) should not be reported with 01996”. Therefore, if 99100, 99116, 99135 or 99140 is submitted with
01996—only 01996 reimburses.
New Edit #775-Vaginal Delivery Only or Vaginal Delivery Only After Previous Cesarean Delivery with Routine Obstetric Care
Including Antepartum, Vaginal Delivery or Vaginal Delivery After a Previous Cesarean Delivery and Postpartum Care.
Rationale: Codes 59409 is incidental to 59400 and 59612 is incidental to 59610, but code 59409-59 does not bundle with
59400 and code 59612-59 does not bundle with 59610. Based on the American College of Obstetrician and Gynecologist
recommendation certain coding guidelines have been established for billing for multiple births and this edit is following those
guidelines. Therefore, if 59409 is submitted with 59400—only 59400 reimburses but if 59409-59 is submitted with 59400—
both services reimburse separately. The same is true when code 59612 is submitted with 59610—only 59610 reimburses,
but if 59612-59 is submitted with 59610—both services reimburse separately.
Some additional Anthem customized claim edits will be implemented around July 15, 2013.
Revised Edit #305- Screening Papanicolaou (Pap Smear) with Evaluation and Management Services.
Rationale: Code Q0091 is incidental to all problem oriented and preventive evaluation and management services. Anthem
considers screening services to be a part of performing an evaluation and management service and does not separately
reimburse for the obtaining of a screening pap smear. Therefore, if Q0091 is submitted with any evaluation and management
service---only the evaluation and management service reimburses.
Revised Edit #321- Cervical or Vaginal Screening with Evaluation and Management Services.
Rationale: Code G0101 is incidental to all problem oriented and preventive evaluation and management services. Anthem
considers screening services to be a component of an evaluation and management service and does not separately
reimburse for the performance of a cervical or vaginal screening service. Therefore, if G0101 is submitted with any
evaluation and management service---only the evaluation and management service reimburses.
New Edit #770-Drug Screen, other than Chromatographic, any Number of Drug Classes by CLIA Waived Test or Moderate
Complexity Test, Patient Encounter with Drug Screen, Qualitative Multiple Drug Classes by High Complexity Test Method
(e.g., Immunoassay, enzyme assay), per Patient Encounter.
Rationale: Code G0434 is incidental to G0431, following the National Correct Coding Initiative Edits (Version 19.0).
Therefore, if G0434 is submitted with G0431—only G0431 reimburses.
New Edit #776- Intravenous, Subcutaneous Infusions, Injections, Intravenous Push or Intra-Arterial Injection or Infusions for
Therapy, Prophylaxis or Diagnosis (Specify Substance or Drug) with Nuclear Medicine Diagnostic or Therapy Services.
Rationale: Codes 96365, 96369, 96372, 96373, 96374 or 96379 are incidental to 78012-78018, 78070-78099, 78102-78199,
78201-78299, 78300-78399, 78414-78494, 78499, 78579-78599, 78600-78699, 78700-78725, 78740-78799, 78800-78999,
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79005-79999. Based on the National Correct Coding Initiative Manual, 2013, Chapter 9 (CPT codes 70000-79999) under
Section E-Nuclear Medicine #1 (page 12): “ The injection of radiopharmaceutical is an integral component of nuclear
medicine procedure. CPT codes for vascular access (e.g., CPT codes 36000) and injection of the radiopharmaceutical (e.g.,
CPT codes 96300-96376) are not separately reportable.” Therefore, if 96365, 96369, 96372, 96373, 96374 or 96379 is
submitted with 78012-78018, 78070-78099, 78102-78199, 78201-78299, 78300-78399, 78414-78494, 78499, 78579-78599,
78600-78699, 78700-78725, 78740-78799, 78800-78999, 79005-79999—only 78012-78018, 78070-78099, 78102-78199,
78201-78299, 78300-78399, 78414-78494, 78499, 78579-78599, 78600-78699, 78700-78725, 78740-78799, 78800-78999,
79005-79999 reimburses.
New Edit #777- Prostate Cancer Screening, Digital Rectal Examination with All Problem Oriented and Preventive Evaluation
and Management Services.
Rationale: Code G0102 is incidental to all problem oriented and preventive evaluation and management services. Anthem
considers a prostate cancer screening services to be a part of performing an evaluation and management service and does
not separately reimburse for this screening. Therefore, if G0102 is submitted with any evaluation and management service--only the evaluation and management service reimburses.
New Edit #778- Irrigation of Implanted Venous Access Device for Drug Delivery Systems with Problem Oriented,
Consultation, Emergency Department and Home Services Evaluation and Management Services.
Rationale: Code 96523 is redundant/mutually exclusive to 99201-99205, 99211-99215, 99241-99245, 99281-99285 and
99341-99350. Based on the American Medical Association, Current Procedural Terminology Manual, 2013 (page 549) and
the National Correct Coding Initiative Edits (Version 19.0) code 96523 bundles with these services. Therefore, if 96523 is
submitted with 99201-99205, 99211099215, 99241-99245, 99281-99285 and 99341-99350—only 99201-99205,
99211099215, 99241-99245, 99281-99285 and 99341-99350 reimburse.
Find additional detail about specific Claim Edits online at anthem.com>Provider (enter state)>Anthem Customized Claim
Edit.
CPT® is a registered trademark of the American Medical Association (AMA).
The ICD-10 Updates webpage is a resource for information
Follow these steps for insight into ICD-10 reimbursement impacts
We continue to make progress in our ICD-10 implementation and related strategies. The ICD-10 Updates webpage on our
provider website contains key decisions we’ve made that will be important for you to understand as we continue to do
business together once the industry transitions to ICD-10. Two of these decisions are highlighted below.
Pre-authorizations
We will begin accepting and processing pre-authorization requests containing ICD-10 codes on June 1, 2014. Note that this
is only for services scheduled on or after October 1, 2014. ICD-9 codes must be used to pre-authorize services scheduled
through September 30, 2014.
ICD-10 claim processing for HIPAA standard transactions
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Dual processing: We will not use any crosswalks for claims processing. We will operate on a dual-processing
environment, which means that our systems will be able to process both ICD-10 and ICD-9 codes. Claims submitted
will be processed in their native code.
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No mixed claims: Consistent with CMS guidelines, we will not accept “mixed” claims (claims filed with ICD-9 and
ICD-10 codes on the same claim).
ICD-10 codes: We will not accept ICD-10 codes for dates of service or dates of discharge prior to October 1, 2014.
ICD-9 codes: HIPAA does not allow the use of ICD-9 codes for claims with dates of service or dates of discharge
after October 1, 2014.
Resubmitting claims: When resubmitting claims, providers should utilize the code set valid for the dates of service
or dates of discharge. With the ability to dual-process, we will leverage that functionality as appropriate to the
mandate.
Visit the ICD-10 Updates webpage on our provider website often to stay up-to-date with the most current information on our
transition to the new code set.
Reminder: Where to file lab, DME and specialty pharmacy Blue claims
Effective October 14, 2012, Anthem implemented claim filing requirements, based on ancillary provider type. The
requirements reflect a Blue Cross and Blue Shield Association (BC/BS) mandate and apply to the following ancillary provider
types: Independent Clinical Laboratory, Durable/Home Medical Equipment and Supplies and Specialty Pharmacy.
As previously communicated in our newsletters, Network eUPDATE and online FAQs, the claim filing requirements include:
Independent Clinical Laboratory (Lab) --The claim must be filed to the BC/BS Plan where the specimen was drawn.
Durable/Home Medical Equipment and Supplies (D/HME) --The claim must be filed to the BC/BS Plan where the
equipment was delivered to or rented/purchased at a retail store.
Specialty Pharmacy --The claim must be filed to the BC/BS Plan where the ordering/referring physician is located.
If you are one of these ancillary provider types, please follow the ancillary claim requirements listed in the chart starting on
the next page. This will avoid your claims rejecting because Anthem is not the correct Plan to process.
Note: Other ancillary provider types, including Home Infusion Therapy providers, are not subject to this requirement. The
mandate applies to all lines of Anthem business except FEP, also known as Federal Employee Health Benefits (FEHB)
Program.
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Provider Type
How to file (required fields)
Where to file
Independent Clinical
Laboratory
Referring Provider:
File the claim to the Plan in Blood is drawn* in lab or
whose service area the
office setting located in
specimen was drawn.*
Plan X service area. Blood
analysis is done in Plan Y
Where the specimen was service area.
drawn will be determined
by the address associated File to: Plan X service
with the referring/ordering area.
provider’s NPI.
*Claims for the analysis of
a lab must be filed to the
Plan in whose service area
the specimen was drawn.
Durable/Home Medical
Equipment and Supplies
(D/HME) delivered to
patient.
Patient’s Address:
Field 5 on CMS 1500
Health Insurance Claim
Form or
Loop 2010CA on the 837
Professional Electronic
Submission.

Types of Service include
but are not limited to: Blood

or urine specimens
Types of Service include,
but are not limited to:
Hospital beds, oxygen
tanks, crutches, etc.
Field 17B on CMS 1500
Form or
Loop 2310A (claim level)
on the 837 Professional
Electronic
Ordering Provider:
Form or
Loop 2420E (line level) on
the 837 Professional
Electronic Submission.
Place of Service:
Field 24B on the CMS
1500 Health Insurance
Claim Form or
Loop 2300, CLM05-1 on
Electronic Submissions.
April 2013
Example
File the claim to the Plan in Wheelchair is
rented/purchased from an
equipment was delivered. ancillary supplier located in
Plan X service area and
delivered to an address in
Plan Y service area.
File to: Plan Y service
area.
Oxygen is rented from an
ancillary supplier located in
Plan X service area and is
delivered to the patient’s
address in Plan Y service
area.
area.
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Provider Type
How to file (required fields)
Durable/Home Medical
Equipment and Supplies
(D/HME)
rented/purchased at a
retail location.
Ordering Provider:
Types of Service include,
but are not limited to:
Hospital beds, oxygen
tanks, crutches, etc.

Where to file
Example
File the claim to the Plan in Crutches are purchased at
a retail store located in
Plan Y service area.
equipment was
rented/purchased in a
retail store.
Form or
area.
Loop 2420E (line level) on
Place of Service:

Field 24B on the CMS
1500 Health Insurance
Claim Form or
Loop 2300, CLM05-1 on
Electronic Submissions.
Service Facility Location
Information:

Field 32 on CMS 1500
Health Insurance Form or
Loop 2310C (claim level)
Specialty Pharmacy
Referring Provider:
Types of Service:

Non-routine, biological
therapeutics ordered by a
healthcare professional as
a covered medical benefit.
Form or
Loop 2310A (claim level)
File the claim to the Plan in Patient is seen by a
physician in Plan X service
area who orders a specialty
ordering/referring
pharmacy injectable for this
physician is located.
patient. Patient will receive
the injections in Plan Y
The ordering/referring
service area where the
physician location is
determined by the address member lives for 6 months
of the year.
associated with the
provider NPI.
File to: Plan X service
area.
For more information, please see the June 2012 issue of Network Update at anthem.com>Providers (select state)>Network
Update. You also can refer to Ancillary Claim Filing Requirements FAQ at anthem.com>Providers (select
state)>Answers@Anthem.
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eBusiness
Introducing ICR (Interactive Care Reviewer), our new self-service provider web tool
Anthem launches a new secure, online provider utilization management tool – register today!
With ICR, your practice can now initiate precertification requests online more efficiently and conveniently. Our new tool offers
a streamlined precertification process, using cutting-edge IBM Watson™ technology. Access our ICR via Availity® to request
outpatient procedures* for many members covered by Anthem plans.
Here are just a few benefits and efficiencies your office may experience:
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Reduces the need to fax – Submit online precertification requests without the need to fax medical records. ICR
allows both text detail and photo and image attachments to be submitted along with the request.
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No additional cost -- You get access to a no-cost solution that’s easy to learn and even easier to use.
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Gives you access almost anywhere -- Submit your requests from any computer with internet access. For optimal
viewing, you must have a browser that supports 128-bit encryption, including Internet Explorer 8, Chrome, Firefox or
Safari.
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Consolidates UM requests – You have a complete view of your UM requests submitted online, along with status of
your requests.
How does a provider gain access to our Interactive Care Reviewer (ICR)?
Access our ICR tool via Availity. If your organization has not yet registered for Availity, go to www.availity.com and click on
Register Now. If your organization already has access to Availity, your Primary Access Administrator can grant you access to
Authorizations and you can start using our tool right away.
How can providers learn more about our Interactive Care Reviewer (ICR) tool?
Anthem will offer informational webinars to help you learn more about the features and benefits of our new tool and how to
navigate within it. To Register and to review the dates and times available, please click here.
What’s next?
Future planned enhancements to our tool will allow you to precertify inpatient medical stays and expand the use to include
additional Anthem membership.
Who can providers contact with questions?
For questions regarding our ICR, please contact your local Network Management consultant. For questions on accessing our
tool via Availity, call Availity Client Services at 800-AVAILITY (800-282-4548) or email questions to [email protected].
Availity Client Services is available Monday-Friday, 8 a.m. to 7 p.m. ET (excluding holidays) to answer your registration
questions.
*Note: ICR is not currently available for Medicare Advantage, Medicaid, FEP, BlueCard®, and National Account members;
requests involving Behavioral Health or transplant services; or services administered by AIM Specialty Health SM. For these
requests, follow the same precertification process that you use today.
IBM, the IBM logo, ibm.com, and Watson are trademarks of International Business Machines Corp., registered in many jurisdictions worldwide. Other
product and service names might be trademarks of IBM or other companies. A current list of IBM trademarks is available on the Web at “Copyright and
trademark information” at www.ibm.com/legal/copytrade.shtml
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Availity, an independent company, provides claims management services for Anthem Blue Cross and Blue Shield.
Expanded member search on AIM Specialty Health (AIM)
You now can initiate precertification requests on AIM’s secure portal for any Anthem member whose coverage includes an
AIM program. For more information, see our Network eUPDATE at anthem.com>Providers (enter state)>Network eUPDATE.
Health Care Management
Medical Policy update
The following Anthem medical polices were reviewed on February 14, 2013 for Indiana, Kentucky, Missouri, Ohio and
Wisconsin. These policies will be implemented on July 15, 2013:
DRUG.00054
Ocriplasmin (Jetrea ®) Intravitreal Injection Treatment
This is a new medical policy which outlines the medically necessary, and investigational and not medically necessary criteria
for an intravitreal ocriplasmin injection.
SURG.00136
Intraocular Telescope
This is a new medical policy which addresses the medically necessary, and investigational and not medically necessary
criteria for implantation of an intraocular telescope.
BEH.00002
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Neuropsychiatric
Disorders
This medical policy was revised to clarify the medically necessary indications and the list of contraindications was revised to
include specific neurological indications that do not meet the medically necessary criteria for transcranial magnetic
stimulation.
MED.00100
Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
This medical policy was reformatted with no substantive change to criteria. Also, the coding was revised to include HCPCS
C-codes, C1778 and C1816, for electrodes and the device.
Clinical guideline updates
CG-DRUG-09, Intravenous Immune Globulin Therapy (IVIG), has required clinical review for many years. There were
some diagnoses that processed without requiring review. These diagnoses included: 079.83, 279.00279.09,279.12,279.2,287.30-287.39,287.5,333.91,357.0,358.00-358.01,358.1,446.1,694.4, 694.5,694.60694.61,757.39,775.2,776.1,V21.30-V21.35,279.3,996.80-996.89. Effective July 1, 2013, all diagnoses that may not have
been previously reviewed will require precertification.
CG-MED-43 Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT). This is a new UM
guideline that addresses multiple sleep latency testing (MSLT) and maintenance of wakefulness testing (MWT). Anthem has
moved criteria and other language addressing MSLT and MWT from MED.00002 to this new clinical UM guideline. There is
no change to criteria.
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The following guidelines are effective July 4, 2013:
CG-DME-31: Wheeled Mobility Devices: Wheelchairs–Powered, Motorized, With or Without Power Seating Systems
and Power Operated Vehicles (POVs). This guideline addresses criteria for wheelchairs–powered, motorized, power
operated vehicles. Anthem added medically necessary and not medically necessary clinical indications for power seating
systems and added not medically necessary indications for wheelchair options/accessories which address seat lift
mechanisms.
CG-DME-34: Wheeled Mobility Devices: Wheelchair Accessories. This guideline addresses criteria related to accessories
and options for manual or powered wheelchairs. Note: The following revisions to the current clinical UM guideline apply to
select National Accounts:

Clarified medically necessary statement for options or accessories used for covered wheeled mobility devices

Added medically necessary criteria for custom fabricated back cushion or seat cushion

Clarified medically necessary criteria for tilt-in-space option

Clarified medically necessary criteria for skin protection seat cushion

Clarified not medically necessary statement for wheelchair options/accessories to only address manual seat lift
mechanisms

Removed powered seat lift mechanisms criteria from not medically necessary statement and moved to CG-DME-31
These specialty pharmacy drugs will require precert
On July 1, 2013, the following specialty drugs will be placed on precertification for group members in the following Anthem
local plans: Blue Priority SM , Blue Preferred® Primary, Blue Priority Plus, Blue Preferred Primary Plus, Blue Access®, Blue
Access Choice, Blue Preferred Plus and Lumenos® health plans. Note: In most cases, the changes do not apply to Blue
Traditional®, National Accounts, Medicare Advantage (MA), or Federal Employee Plan (FEP).









Brentuximab Vedotin (Adcetris) (You were previously notified in the February 2012 issue of Network Update that a
new Medical Policy, DRUG.00047, for brentuximab vedotin (Adcetris) would be implemented May 1, 2012 for all
lines of business in IN, KY, OH, MO, WI)
Corticotrophin injection (HP Acthar Gel) (CG DRUG-24)
Eribulin (Halaven) (You were previously notified in the February 2012 issue of Network Update that a new Medical
Policy, DRUG.00048, for eribulin (Halaven) would be implemented May 1, 2012 for all lines of business in IN, KY,
OH, MO, WI)
Denosumab (Prolia & XGEVA)
Sipuleucel-T (Provenge) (AMP MED.00106)
Belatacept (Nulojix) (You were previously notified in the June 2012 issue of Network Update that a new Medical
Policy, DRUG.00049, for belatacept (Nulojix) would be implemented October 1, 2012 for all lines of business in IN,
KY, OH, MO, WI)
Eculizumab (Soliris) (You were previously notified in the October 2012 issue of Network Update that a new Medical
Policy, DRUG.00050, for eculizumab (Soliris) would be implemented January 15th, 2013 for all lines of business in
IN, KY< OH, MO, WI)
Cabazotaxel (Jevtana)
Topotecan (Hycamtin)
The preferred way to obtain precertification for specialty pharmacy drugs is online, through Availity’s link out to AIM. To
submit your precert request, you may also use the Specialty Pharmacy Clinical Data Submission tools; they serve as guides
to make sure that you have submitted all necessary information for Anthem to complete the review. (Note: Tools are not
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available for all specialty pharmacy data submissions.) You can find the tools at anthem.com>Providers (enter state)>
Precertification>Clinical Data Submission Tools> Specialty Pharmacy Clinical Data Submission Tools.
Anthem’s peer-to-peer process
Anthem uses a medical peer-to-peer review process by which our internal staff physicians re-examine cases when an
adverse clinical determination is made regarding health care services for members. This process allows attending, treating
or ordering physicians to request a peer-to-peer review to offer additional information and further discuss their cases with our
peer clinical reviewers who made the initial adverse determination.
It is important to note that a peer-to-peer review is NOT an appeal nor does it take the place of an appeal. In addition, a
peer-to-peer review is not required prior to requesting an appeal. The adverse clinical determination letter may indicate a
time frame for you to initiate a peer-to-peer request to encourage early resolution of your concerns. We will accept your
request to initiate a peer-to-peer review until such time as the appeal process has been exhausted.
As a reminder, the following guidelines address peer-to-peer reviews through Anthem. The guidelines apply to all our lines of
business (PAR, PPO and HMO), including the Blue Cross Blue Shield Service Benefit Plan (also known as the Federal
Employee Program or FEP), our Medicaid plans and Medicare Advantage.
Peer-to-peer guidelines
Initiating a peer-to-peer request
You can initiate a peer-to-peer request IF you are the attending, treating or ordering physician who provides the care for
which any adverse clinical determination is made. In compliance with nationally recognized guidelines from the National
Committee for Quality Assurance (NCQA) and URAC, you or your designee may request the peer-to-peer review. Others
such as hospital representatives, employers and vendors are not permitted to do so.
Availability of clinical peer reviewers
Our peer clinical reviewers are available for pre-service or continued stay/services reviews and for post-service clinical claim
reviews. If the clinical reviewer who made the initial adverse determination is unavailable, another peer clinical reviewer is
assigned to the case.
Our commitment to contacting physicians
Peer clinical reviewers make a minimum of two best effort attempts to contact the attending, treating or ordering physician in
response to a peer-to-peer request. We will work to accommodate the attending/treating/ordering physician’s schedule
within normal business hours for that physician’s time zone.
Milliman Care Guidelines (MCG) update
Milliman Care Guidelines (MCG) update
In December 2012, Milliman Care Guidelines became part of the Hearst Corporation which recently adopted a new name,
MCG, for this publication. The legally registered name is now MCG Health, LLC. As a result, when the 17 th edition is
released, it will reflect “MCG” as the name in place of Milliman Care Guidelines.
Anthem’s Care Management department (inclusive of both Utilization Management and Case Management) will
upgrade to the 17th edition of MCG, effective May 6, 2013. However, there are several guidelines that are either new or
the LOS has decreased. For those changes, the implementation will be July 4, 2013; see below for changes.
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See the next section for a summary of some of the changes included in the MCG 17th edition. Note: ICD-10 Procedure and
Diagnosis codes will be included in the 17 th Edition, along with ICD-9 Procedure and Diagnosis codes. In addition, Anthem
Care Management will begin accepting authorization requests containing ICD-10 codes on June 1, 2014 for Dates of
Service/Dates of Discharge/Dates of Admission occurring on or after the CMS ICD-10 compliance date of Oct 1 , 2014.
Changes to MCG 17 th edition
See below for changes made in the 17 th edition.
Two new inpatient & surgical care optimal recovery guidelines (ORG) were added, which Anthem will implement on July 4,
2013:


Cardiovascular Surgery: Percutaneous Revascularization, Lower Extremity: Code S-1310 Adult, GLOS Ambulatory
or 1 day post-operative
General Surgery: Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy; Code S-516; GLOS 1 day
post-operative. (Note: The Clinical Indications for Procedure in the Milliman guideline for Gastric Restrictive
Procedure, Sleeve Gastrectomy, by Laparoscopy will be customized to see SURG.00024 Surgery for Clinically
Severe Obesity.)
Goal Length of Stay (GLOS) changed for four Optimal Recovery Guidelines (outlined in the table below). These updates were
based on review of the medical literature, and supplemented in some cases by review of statistical data. Anthem’s GLOS
guidelines will reflect these changes.
Guideline
ORG Code
16 th Edition GLOS
17 th Edition GLOS
17 th Edition GLOS
Implementation
Date
Knee Arthrotomy
S-710
A or 1 day
A or 2 days
May 6, 2013
Myocardial Infarction
M-230
2 or 3 days
2 days
July 4, 2013
Partial Laryngectomy
S-790
4 days
3 days
July 4, 2013
Shoulder Arthroplasty
S-634
A or 2 days
A or 1 day
July 4, 2013
Split guidelines
The Pediatrics Meningitis Optimal Recovery Guideline (P-220) was split into two guidelines. Anthem’s GLOS will reflect this
change.
Guideline
Meningitis, Bacterial
Old Title
ORG Code
GLOS
Implementation
Date
Meningitis
P-220
4 days
July 4, 2013
Meningitis, Suspected or Meningitis
Viral
P-219
A or 2 days
July 4, 2013
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The following has been revised:
Guideline
Orthopedics, ORG Code W0072,
Lumbar Fusion or Lumbar Artificial
Intervertebral Disk
Original language (deleted text Implementation Date
crossed out)
Revision fusion surgery for adjacent July 4, 2013
segment disease as indicated by
ALL of the following:

Radiographic evidence of
adjacent segment disease
(e.g., neural compression)

Persistent disabling
symptoms (low back pain,
radiculopathy)

Failure of 3 months of
nonopertive therapy
In addition, Anthem annually reviews changes to MCG, and then maps MCG customizations to related existing Medical
Policy. The customizations may be one of four types:




Customizations to MCG Care Guidelines clinical indications based on integration with Anthem’s medical policy and
clinical UM guidelines.
Customizations to MCG Care Guidelines clinical indications with changes to the original MCG criteria which includes
adding or revising appropriateness criteria.
Customizations to MCG Care Guidelines goal length of stay with changes to the original MCG.
Other customizations to MCG Care Guidelines may include adding reference(s), adding a Related Guidelines
section with anthem’s related medical policy or clinical UM guidelines or other changes to MCG Care Guidelines,
e.g., revision to Alternatives for Procedure.
Customized Guidelines are available on request.
A summary document with customizations to MCG Care Guidelines is located online, to view it, go to anthem.com>Providers
(enter state)> Medical Policy and Clinical UM Guidelines.
Medicare
Corrected claims guidelines
When submitting a corrected claim to a claim that has already processed, a Provider Adjustment Request (PAR) form must be completed.
All fields on the form should be filled out completely and the form should indicate what is being corrected on the claim. A copy of the
corrected claim must be attached to the form. The corrected claim copy should mirror the entire claim, not just the line or fields that are
being corrected. The corrected claim that is attached to the PAR form will be the source of truth. We require the entire claim to be
attached to reduce the risk of errors and multiple adjustments. All replacement claims, late charges, and any other changes/additions
/deletions require a PAR form. The PAR forms are available on our website at www.anthem.com/Medicare. You may also submit
corrected claims electronically, and please remember to submit all lines on the claims, including corrections.
Anthem Blue Cross is the trade name of Blue Cross of California: Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem
Insurance Companies, Inc. The Blue Cross names and symbols are registered marks of the Blue Cross Association.
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CMS issues additional NPI requirements for certain providers
In August 2012, the Centers for Medicare & Medicaid Services (CMS) announced additional requirements relating to the use
of the 10-position, all numeric National Provider Identifier (NPI). The new regulation requires that an “organization covered
entity” (such as a facility or group practice) must require any provider the entity employs or contracts with to obtain a NPI
number and use it when writing prescriptions.
Covered NPI-eligible providers who do not already have their NPI numbers and are prescribers must obtain a NPI
number from the National Plan and Provider Enumeration System (NPPES) and begin to use the NPI number by May
6, 2013.
According to the CMS rule, if a provider writes a prescription while acting within his or her business relationship with the
organization, the provider must disclose the NPI number upon request to entities (such as pharmacies) that need the
identifier for a standard transaction. Often, pharmacies encounter situations where the NPI number of a prescribing health
care provider is omitted either because the prescriber does not have a NPI number or chooses not to disclose it. (This
situation is particularly problematic for Medicare Part D drug claims.) With the new NPI requirements, prescribers must
provide NPI numbers as requested so they can be identified appropriately in standard electronic transactions as required by
the Health Insurance Portability and Accountability Act (HIPAA).
Minimal impact to most providers
CMS expects the rule to have minimal impact on health care providers, as there are relatively few providers who do not
already have NPI numbers. For those health care providers who currently do not have NPI numbers and need one as a
condition of this rule, they can obtain a NPI number quickly and free of charge from NPPES.
Additional information
For additional information or to register for a NPI number, please access the Internet for the following Web resources:
National Plan and Provider Enumeration System NPI registry website
https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do
CMS Fact Sheet: “HHS adopts a HIPAA standard for a unique health plan identifier and an addition to the National Provider
Identifier requirements”: http://www.himss.org/content/files/CMS%20Fact%20Sheet%20HPID-OEID-NPI%208-2412%20final.pdf
The final rule, CMS-0040-F, may be viewed at www.ofr.gov/inspection.aspx.
A news release on the final rule may be viewed at http://www.hhs.gov/news and
http://www.cms.gov/apps/media/press_releases.asp.
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Annual member surveys
As we reminded readers in previous issues of Network Update, CMS surveys Medicare Advantage (MA) health plan members
to assess the quality of care provided by their physician as well as member satisfaction with MA health plans. Health plan
members are chosen at random and may receive the HOS (Health Outcome Survey) and/or the CAHPS (Consumer
Assessment of Healthcare Providers & Systems) survey.
The surveys will be distributed until July.
The survey also asks MA members if their doctor has spoken to them about increasing physical activity and other health
concerns relevant to seniors.
Please consider the following actions that can help boost member survey ratings.





At least annually assess your MA patients for bladder incontinence, fall risk, and level of physical activity
Offer the flu vaccine on an annual basis
Ask your patients if they have any questions for you
Ask your patients to repeat back instructions that you have given them to ensure they understand correctly
Give printed educational material and pertinent web sites to your patients; here are some helpful links:

American College of Physicians: Health Tips including Urinary incontinence. Health tips are a tear off,
prescription type pad to share information with your patients. HEALTH TiPS - American College of
Physicians Foundation

National Institute on Aging: Age Pages including Urinary Incontinence, Fall Prevention and Exercise. The
Age Pages are pamphlets that can be given to your patients or left in your waiting room. Healthy Aging.
Age Pages
Preventive health calls
When our MA Clinical Quality Care team calls members to remind them to complete important preventive care and
screenings, they’ll also take the opportunity to speak with our MA members about any concerns they may have about urinary
incontinence and the risk of falling. During those conversations, we’ll encourage those members to speak with their
physicians about these issues.
We encourage you to also check in with your senior patients about these issues to help ensure they are receiving needed
care. The following information may be useful in starting these conversations:
Fall Risk
Ask your patients if they have fallen or nearly fallen in the past 12 months. If so, ascertain the reason for falling or nearly
falling and ask if they currently experience or have experienced any of the following (especially in the past 12 months):






Trouble with balance
Joint pain
Joint stiffness
Muscle weakness
Trouble with balance
Trouble with vision
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Ask the member if there are loose rugs or other possible hazards in the house that can be fixed. You also may want to review
the following risks with your patients:




Falls can lead to fractures
Fractures are a common cause of admission to nursing homes
As many as one in four adults who lived independently before their hip fracture remains in a nursing home for at
least a year after their injury
One out of five hip fracture patients dies within a year of their injury
Urinary Incontinence
Ask if the member has accidentally leaked urine in the past six months. If so, ascertain how much of a problem, if any, the
urine leakage is for the member and discuss the following interventions to help prevent urine leakage:





Drink less alcohol and caffeine
Drink less fluid in the evening
Learn how to do pelvic exercises
Do not smoke
Maintain a healthy weight
Review treatment options for urine leakage, including:




Bladder training
Pelvic exercises
Medication
Surgery
MA precert requirements updated for 2013
Please see Medicare Advantage 2013 Precertification Requirements for a list of MA precertification requirements.
Network physicians are required to obtain precertification for MA members for the covered services listed. For the member to
receive maximum benefits, the health plan must authorize or precertify these covered services prior to being rendered.
Please note:
A list of the 2013 prior authorization requirements is posted on the MA provider portals. Please reference the document,
Medicare Advantage 2013 Precertification Requirements, for the list of precertification requirements. The most current
list of Precertification Requirements can be found at www.anthem.com/medicareprovider



Precertification includes a review of both the service and the setting.
Please notify us within one business day of any planned or unplanned admission or transfer, including to or from a
skilled nursing facility, long term acute care hospital or acute rehabilitation center
There is a new 2013 precertification requirement for sleep studies and related supplies for all MA plans except plans
in ME, NH, NY and CT.
−If the required precertification is not obtained prior to the service, the claim may be administratively
denied, or a retrospective review for medical necessity will be conducted when the claim is submitted.
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MA members receive personalized checklist
We recently mailed a personalized healthy checklist to our MA members. The checklist is specific to each member’s health
status. The checklist reminds members to ask you about preventive care and screenings they may need. Members may bring
the checklist to their next office visit. We encourage you to review the checklist with them to help ensure they understand and
receive any preventive care or screenings they may need.
OH: Accurate rheumatoid arthritis claims connect to quality care
Anthem may contact you to request claims correction if ambiguity is discovered regarding a claim submission of Rheumatoid
Arthritis for our MA members. A letter will be sent to providers, detailing the claim in question, with specific instructions for
compliance. This will greatly assist our efforts to support the quality and excellence of care you provide to our MA members.
Pilot program facilitates delivery of health reminders to members
Like you, we’re always looking for new ways to help MA members help themselves to improved health. In 2013, we hope to
expand a program that makes it possible for physicians to reach hundreds of their MA patients directly with important
preventive health care reminders with just a few minutes of their time.
In 2012, we worked with Heritage Provider Network in southern California to test the following concept: Will patients respond
to a prerecorded phone message from their own physician asking them to complete cancer screenings and other important
preventive measures?
Fifteen physicians with Heritage Provider Network recorded a short message encouraging their patients to complete key
services which the member may have missed as suggested by our medical and pharmacy claims.
At the end of the call, members had the opportunity to schedule an appointment with their doctor to complete the missing
services. The prerecorded message from the Heritage Provider Network doctors suggested a greater percentage of patients
listened to the message as compared to a standard interactive voice response call.
In 2013, we plan to expand this program to more provider groups and to experiment with different kinds of messages, such
as those encouraging members to talk with their doctor about fall risk and urinary incontinence.
Supporting the Million Hearts campaign
CMS supports the Million Hearts campaign, a national initiative to prevent one million heart attacks and strokes over five
years. CMS has asked all Medicare Advantage Organizations to focus their Chronic Care Improvement Program (CCIP) on
meeting these goals. The campaign brings together communities, health systems, non-profit organizations, federal agencies
and private sector partners throughout the United States to fight heart disease and stroke.
Our CCIP focuses on diabetes, the chronic condition of highest prevalence among our MA members. Throughout the year,
we’ll be in touch with MA members who appear to be non-compliant on key diabetes self-management measures, including:




annual screenings for LDL
A1C testing
kidney disease monitoring
dilated retinal eye exam
April 2013
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
medication adherence for diabetics with high cholesterol and hypertension
We will call and send health notes to members who appear to be non-compliant with these measures to help them schedule
appointments and address other barriers to care. We also will encourage aspirin therapy, blood pressure control and help
ensure members have and can implement their physician guided Plan of Care. In some cases, members will be offered home
testing kits to support LDL and A1c screening.
In addition, Anthem has a comprehensive program to support selection of ACE-inhibitor and ARB medications in the
management of hypertension among our members with diabetes. The American Diabetes Association recommends
pharmacologic treatment with either an ACE inhibitor or ARB in members with diabetes and hypertension. As part of our
program, pharmacists review our members’ medication histories and may fax educational alerts to providers when potential
gaps in care are identified. We encourage all providers to take action on these alerts as appropriate. Pharmacists are also
available to consult with members on their hypertension management and medication use.
Making progress to improve member safety
Our plan is required to monitor prescriptions activity for high-risk medications as defined by The Centers for Medicare and
Medicaid Services (CMS). The goal is to improve patient safety.
Anthem is now regularly updating a database of all our members who are at least 65 years old and take medications that may
be inappropriate for older patients. We use this database to generate a list of claims for patients who are taking medications
on the CMS list.
If one of your patients fills a prescription for a medication on this list for the first time this year, we will send you a fax. We
want to help avoid second fills on prescriptions for these high-risk medications.
If you receive a fax from us, please review it and help us support safe medication choices. Alternatives to these high-risk
medications are listed on www.anthem.com/maprovidertoolkit
If you have questions about this program, please contact Jennifer Horn at [email protected]
Y0071_13_16630_I 1/18/2013
35280MUPENMUB
Improving drug utilization review controls for opioids
In the previous issue, we informed you that CMS expects Part D plans to have more effective programs to address
overutilization of medications to protect beneficiaries and to reduce fraud, waste and abuse in the Part D program. CMS
expects plans to improve retrospective Drug Utilization Review programs and case management as related to opioid
medication overutilization.
To support the case management efforts, CMS expects plans to send written inquiries to providers about the appropriate use,
medical necessity and safety of the high opioid dosage for their patient. Beginning in March 2013, Anthem will begin to mail
and/or call providers upon identification of members with suspected patterns of opioid overutilization due to multiple
prescribers and multiple pharmacies.
Some physicians in Ohio and Wisconsin may be familiar with this type of notification, as Anthem has been targeting opioid
overuse in these two states for several years.
Our goal is to work with providers to prevent overutilization among our members.
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For more information, please reference:
GAO-11-699, http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/GAOInstancesofQuestionableAccesstoPrescriptionDrugs.pdf
CMS Supplemental Guidance, http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/HPMSSupplementalGuidanceRelated-toImprovingDURcontrols.pdf
Y0071_13_16970_I 03/28/2012
Pharmacy
More pharmacy information
Visit http://www.anthem.com/pharmacyinformation for more information on copayment/coinsurance requirements and their
applicable drug classes, Drug Lists and 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.
Quality
Better health for members who need care the most
Our Case Management program helps members who are at risk for greater illness and cost, and would benefit from outreach
and support. Our goal is to offer information and guidance to optimize members’ health, from the very sick to those returning
to full health.
We offer Case Management to members who are currently going through major medical care. We also reach out to members
who are likely to need a lot of health care services in the near future. Our goals are:


To help you by supporting your plan of care for members.
To help members have better health, which could lower their cost of care.
Who qualifies for the program?
Case Management uses more than 500 health markers to find members who may be at highest risk for serious conditions.
We also reach out to members who currently have serious health problems. These are members who are going through major
procedures and treatments and may need extra help and follow-up care.
Some typical conditions for which members often need significant care:

Multiple sclerosis

Severe heart problems

Major stomach diseases

Severe neurological issues

Any major hospitalization from a diagnosis or injury
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How the program works
We call members who qualify for the program and tell them how we can help. When they join the program, our nurse coaches
work closely with them to support your treatment plan. The nurses answer questions about diagnosis and drugs, and set
goals for better health. Members who have recently left the hospital get support on discharge planning, home health care,
follow-up appointments and community resources. We focus mainly on spotting and resolving gaps in care. Our outreach for
enrollment includes live and automated telephone calls and letters to members. More than 86% of members were “satisfied”
or “very satisfied” with Case Management and 93% of members thought our program was “extremely valuable” or “very
valuable.”*
*2012 Member Satisfaction Survey
35654MUPENMUB 02/13
Clinical practice & preventive health guidelines
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, which are available to providers on our
website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and 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>Providers (enter state)> Health & Wellness> Practice Guidelines.
Reimbursement
Facility reimbursement policy
Facility emergency department reimbursement policy
The following policy is effective on July 1, 2013:
The Emergency Department (ED) is a hospital-owned location or department for the provision of unscheduled episodic
services to patients who present for immediate medical attention. Services rendered to a patient in the ED usually do not
exceed 24 hours.
Emergency Department level of service is determined by the intervention(s) that are performed in relationship to the intensity
of medical care required by the presenting symptoms and resulting diagnosis of the patient:
Straight Forward Complexity (99281/G0380) : The presented problem(s) are self-limited or minor conditions with no
medications or home treatment required, signs and symptoms of wound infection explained, return to ED if problems develop.
Low Complexity (99282/G0381) : The presented problem(s) are of low to moderate severity. Over the counter (OTC)
medications or treatment, simple dressing changes; patient demonstrates understanding quickly and easily.
Moderate Complexity (99283/G0382): The presented problem(s) are of moderate severity. Head injury instructions, crutch
training, bending, lifting, weight-bearing limitations, prescription medication with review of side effects and potential adverse
reactions; patient may have questions, but otherwise demonstrates adequate understanding of instructions either verbally or
by demonstration.
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Moderate-High Complexity (99284/G0383): The presented problem(s) are of high severity, and require urgent evaluation
by the physician but do not pose an immediate significant threat to life or physiologic function. Head injury instructions,
crutch training, bending, lifting, weight-bearing limitations, prescription medication with review of side effects and potential
adverse reactions; patient may have questions, but otherwise demonstrates adequate understanding of instructions either
verbally or by demonstration.
High Complexity (99285/G0384): The presented problem(s) are of high severity and pose an immediate significant threat to
life or physiologic function. Multiple prescription medications and/or home therapies with review of side effects and potential
adverse reactions; diabetic, seizure or asthma teaching in compromised or non-compliant patients; patient/caregiver may
demonstrate difficulty understanding instructions and may require additional directions to support compliance with prescribed
treatment.
Policy
The payment, if any, for Emergency Department (ED) Services is specified in the Plan Compensation Schedule or Contract.
The Health Plan requires that the patient’s medical record documentation for diagnosis and treatment in the ED must indicate
the presenting symptoms, diagnoses and treatment plan and requires a written order by the physician clearly documented in
the medical record.
A Current Procedural Terminology (CPT) ® Code or a Healthcare Common Procedure Coding System (HCPCS) ® Code for
Evaluation and Management (E&M) must be billed for the complexity of service that occurred during the patient encounter at
the ED. The Health Plan defines the complexity level of service for the E&M codes as described in the table in Exhibit A,
attached.
The table in Exhibit A provides criteria that The Health Plan will use to determine the level of reimbursement as applicable for
ED services. Exhibit A lists the E&M codes and defines the levels. Each level provides procedure and clinical examples that
align with the complexity level to assist the facility in understanding the meaning of the descriptors used to define the level of
E&M service. The procedure and clinical examples in Exhibit A are not an all-inclusive list. The highest level E&M code for
which a claim clinically qualifies will be used to determine the level of reimbursement, as applicable for ED services.
For more information, please refer to our Emergency Department facility reimbursement policy by going to the secure Anthem
provider portal, MyAnthem℠, at www.anthem.com, select Providers, select state, hit enter, go to left side of the screen and
select Login for MyAnthem, enter login and password, select the Administrative Support tab, select the link labeled
Procedures for Facility Reimbursement.
Professional reimbursement policies
Anthem is implementing five new professional reimbursement policies for Indiana, Kentucky, Missouri, Ohio and Wisconsin.
Please see below for more detail. In addition, all professional reimbursement policies can be accessed online at our secure
provider portal, MyAnthem. Please see the article on page 27, View Anthem Professional Reimbursement policies at
MyAnthem for Providers, for more information on accessing this site. If you have other questions, please contact your local
Network Relations consultant.
3D rendering of imaging studies
In the February 2013 issue of Network Update, providers were notified that, effective May 20, 2013, 3D rendering of imaging
studies - CPT codes 76376 and 76377 -- is not eligible for separate reimbursement.
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Anthem Blue Cross and Blue Shield in Indiana, Kentucky, Missouri, Ohio, and Wisconsin (referred to herein as the Health
Plan) has developed a reimbursement policy titled 3D Rendering of Imaging Studies, effective May 20, 2013, to outline its
position on 3D rendering of imaging studies for CPT codes 76376 and 76377. Please review the full policy for further
information at www.anthem.com. In addition, we have updated our Bundled Services policy to include this information,
effective May 20, 2013.
Screening services with E/M services
Anthem in Indiana, Kentucky, Missouri, Ohio and Wisconsin (referred to herein as the Health Plan), has adopted a new policy
that describes its claims processing guidelines when screening services are reported with a preventive/annual examination
and/or a problem-oriented examination. Effective for claims with dates of service July 14, 2013, the Health Plan considers
screening services to be ineligible for separate reimbursement when reported on the same date of service as preventive
medicine services and annual GYN examinations; screening services will be considered a component of the preventive
medicine services or annual GYN examinations. When reported with problem oriented E/M services, the screening service
should be considered when determining the appropriate level of E/M services reported. Please reference customized edits
305, 321, and 777 for additional information concerning these screening services. For additional reference regarding this
policy, please see the article, Customized claim edits, on page 6 of this newsletter issue. Also view the full text of the policy
at www.anthem.com.
Modifier 22
Anthem in Indiana, Kentucky, Missouri, Ohio, and Wisconsin (referred to herein as the Health Plan) has posted a new
reimbursement policy titled Modifier 22 (Increased Procedural Services). This policy outlines the Health Plan’s current
position today when modifier 22 is appended to a Current Procedural Terminology (CPT®) or Healthcare Common Procedure
Coding System (HCPCS Level II) code.
Modifier 22 is described by CPT as identifying an increased procedural service. Appendix A of the 2012 CPT Manual states
that “When the work required to provide a service is substantially greater than typically required, it may be identified by
adding modifier 22 to the usual procedure code.”
The Health Plan’s reimbursement for a procedure takes into account the average work effort required to perform the
procedure. There may be times when a procedure requires less effort than typically warranted and at other times a procedure
may require some additional effort. View the full text of the policy at www.anthem.com.
Sleep study and bundled services
Effective July 20, 2013, Anthem has updated its Sleep Study and Bundled Services professional reimbursement policy to
include two additional Bundled Services and Supplies codes for Polysomnography and Other Sleep Studies/Tests:


95782 describes a technologist attended polysomnography, younger than 6 years, sleep staging with 4 or more
additional parameters of sleep
95783 describes a technologist attended polysomnography, younger than 6 years, sleep staging with 4 or more
additional parameters of sleep, with initiation of continuous positive airway pressure therapy (CPAP) or bi-level
ventilation positive airway pressure (BiPAP)
In addition, updates were made to clarify codes listed in the Description section of the policy:


Technologist Current Procedural Terminology (CPT ® ) code 95807 replaced 95800-95801 and;
Unattended/home sleep CPT codes 95800 and 95801 replaced 95807.
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View the full text of the policy at www.anthem.com.
Urgent care (coding and bundled supplies)
Anthem (referred to herein as the Health Plan) defines “urgent care” as a service or treatment for a non life-threatening
unexpected illness or injury that requires immediate medical attention to minimize pain and/or the severity of symptoms,
and/or to reduce the risk of complications.
The Health Plan has posted a new reimbursement policy referencing the Health Plan’s current position regarding “urgent
care” services. Standard CPT coding guidelines and all of the reimbursement policies that apply to services rendered in a
physician’s office also apply to services performed in an urgent care center.
View the full text of the policy at www.anthem.com.
View Anthem Professional Reimbursement policies at MyAnthem for Providers
Below are instructions for accessing Anthem Professional Reimbursement policies at www.anthem.com:
Non-Registered MyAnthem:
If you do not have a MyAnthem user ID and Password, sign onto www.anthem.com, select provider, select your state from
the dropdown box, press the enter key. In the left corner of the Provider Home Page is an option to register. Complete the
registration form and your ID and Password will be mailed to you within two weeks. If you are unable to complete the
registration online because the provider's tax ID is already registered, you will need to send your request to
[email protected].
Registered MyAnthem:
If you are a registered MyAnthem user, sign onto www.anthem.com, select provider, select state, hit enter, go to left side of
the screen and select Login for MyAnthem, enter login and password, select the Administrative Support tab, select the link
labeled Procedures for Professional Reimbursement.
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