In this issue Page. anthem.com. Important phone numbers. May 2012

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1 May 2012 In this issue Page Announcement Anthem rolls out Quality-In-Sights Program in Virginia 3 Use Provider Online Interactive Tool to view information regarding Anthem Quality-In-Sights 4 Coverage and clinical guideline update New specialty drug precertification requirements for PAR/PPO members 5 New tonsillectomy guidelines for patients under 18 years of age 8 Update on clinical reviews Milliman Care Guidelines update 8 Business update Anthem s ConditionCare Program helps members better manage chronic conditions 9 Reminder: Use participating laboratories for HMO members, including Anthem HealthKeepers Plus members 10 We believe in continuous improvement 12 Clinical practice and preventive health guidelines available on the Web 12 ICD-10 update Proposed new ICD-10 compliance date: October 1, Health care reform updates and notifications Health care reform expands preventive care coverage for women 14 ebusiness Online certificate of coverage booklets coming to Availity for Anthem covered members 17 EDI reports change with migration to HIPAA version Register for the Network Rapid Update 20 anthem.com Important phone numbers 1 of 33 VAPENABSNL (05/12)

2 In this issue, continued Page FEP update Health and FEP wellness programs for members enrolled in the Federal Employee Program 20 Medicare information Home visits address care coordination and hospital re-admissions 22 Medicare covers sexually transmitted infection screening and counseling, obesity counseling 23 CMS clarifies place of service coding instructions 24 Medicare Part D medication management reminders 24 Program helps Medicare Advantage members with Rheumatoid Arthritis who may be missing important medications 25 Referral management 26 Pharmacy update Visit us on the Web for drug-related information 26 Bulletin board 2012 medical office seminars on tap register today 27 Date change for June seminar in central region Medical Office Seminar Schedule Medical Office Seminar Registration Form community involvement and events 32 May of 33

3 Announcement Anthem rolls out Quality-In-Sights Program in Virginia Anthem Blue Cross and Blue Shield is pleased to announce the launch of our Anthem Quality-In-Sights (AQI) program in Virginia. Offered to eligible primary care physicians, AQI is a physician pay-for-performance program that evaluates and financially rewards health care providers when they meet or exceed identified measures related to preventive care, quality of care, appropriate drug utilization, technology adoption and when they have met the objectives in select external physician recognition programs. Quality- In-Sights is a suite of quality recognition and health promotion programs that are designed to help address the most pervasive and costly health concerns. Anthem Quality-In-Sights broadens the relationship that health care providers traditionally have had with insurers by expanding upon the mutually beneficial, patient-focused collaboration that Anthem had initiated years ago with the Performance Extra Program (PEX) in Virginia. We strongly believe that Quality-In-Sights demonstrates our commitment to helping improve access to quality care for our members. More about AQI The clinical measures included in the AQI program are nationally recognized through organizations such as the National Quality Forum (NQF), the National Committee for Quality Assurance (NCQA), Centers for Disease Control and Prevention and the American Academy of Pediatrics. The AQI program replaces the former Performance Extra Program we offered in the past. Physicians practices in the program that meet specific program requirements and measures will be eligible to qualify for incentive compensation, as identified below. The measures for the 2012 program include measures similar to those used for HEDIS reporting, including Breast Cancer and Childhood Well Visits, Asthma, Immunizations, Heart Disease and Diabetes, as well as a new section on medication compliance. In addition to such preventive and clinical quality measures, AQI includes the following quality service, resource and practice management oriented measures: 1. The program includes an External Recognition component as noted below: Participation in Bridges to Excellence (BTE) and/or National Committee for Quality Assurance 2. Resource measures include: An Overall Cost Performance Index Pharmacy measure (generic rate) 3. Clinical Improvement/Patient Centered measure (participation in state and/or national clinical improvement collaborative) 4. Care Systems/technology measures include: Implementation of electronic prescribing; Certification Commission for Health Information Technology (CCHIT) Certified Ambulatory Electronic Health Record; Use of Point of Care or Availity online provider portal(s); and, Certification through the Centers for Medicare & Medicaid (CMS) regarding attainment of Meaningful Use requirements. May of 33

4 Questions Questions regarding the AQI program can be directed to our toll-free, dedicated AQI phone line at or at HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Use Provider Online Interactive Tool to view information regarding Anthem Quality- In-Sights Anthem has created a web-portal to allow practices participating in select provider recognition programs to access, view and print program information including their own practice-specific reports. The Provider Online Interactive Tool or POIT is currently available for practices in the Anthem Quality-In-Sights (AQI) Primary Care and Blue Precision programs. Specific to the AQI program, practices may access and download copies of program documents and measure descriptions and targets. In addition, practices can download the self-report survey form that s necessary to complete and return in order to achieve the maximum points in the AQI program. In Virginia, access to POIT is provided through our online provider tool Point of Care (POC). Only the POC administrator for the practice, or any staff member the administrator designates, can access POIT. There has been confusion for some offices when POC users who are not the designated POC administrators for their practice have tried unsuccessfully to access POIT. Accessing POIT online It is also important to note that the name POIT is not a link or section on Point of Care. Rather, POIT is accessed via the Rewards & Recognition link. To access POIT: POC administrator must first log into Point of Care. From the POC homepage (which states Welcome to Point of Care at the top), refer to the box in the far right column with a blue ribbon and the title Rewards & Recognition. This is the link to access the Provider Online Interactive Tool or POIT. Click on this Rewards & Recognition box, and access the POIT home page. On the POIT home page, refer to the menu items to view program documents and practice reports. We are pleased to provide tools like POIT to allow access and storage of practice-specific information that when available can be viewed and printed by practices at any time. Please note that the AQI program became effective January 1, Therefore, no reports are currently available. Interim reports are tentatively scheduled to be made available in August May of 33

5 Coverage and clinical guideline update New specialty drug precertification requirements for PAR/PPO members Effective July 1, 2012, precertification will now be required prior to the provision of certain injectable drugs covered under a member s medical benefit when administered in a facility, physician s office or free-standing infusion center. This change applies to members enrolled in our PAR/PPO plans and will more closely align PAR/PPO review requirements with our HMO injectable drug review requirements. This change does not apply to members covered under the Blue Cross Blue Shield Service Benefit Plan also known as the Federal Employee Program (FEP) or our Medicare Advantage (Anthem Medicare Preferred) plan. FEP and Medicare Advantage information FEP: Medicare Advantage: , option 1 Chemotherapy and non-classified drugs In general, chemotherapy and non-classified drugs will require precertification as will any drug included in an Anthem Coverage or Clinical Utilization Management (UM) Guideline. For the list of Anthem Coverage and/or Clinical UM Drug Guidelines, click on the following link: abel=coverage%20guidelines%20&%20clinical%20um%20guidelines&state=va The list below also represents some commonly administered injectable drugs under the medical benefit. There are less commonly administered drugs that also require precertification prior to their administration. The codes in the following chart are listed for illustrative purposes and other HCPCS and CPT codes applicable to these drugs (such as S-codes, Q-codes or J-codes for different strengths, etc.) will also require review. In order to obtain precertification or to determine if a code requires precertification, providers may consult the Preauthorization Inquiry feature on Point of Care or may contact Medical Management toll free at Please be prepared to provide HCPCS code detail when requesting these reviews. Code J0180 J0256 J0257 J0594 J0894 Description AGALSIDASE BETA ALPHA 1 PROTEINASE INHIBITOR ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), 10MG BUSULFAN INJECTION DECITABINE INJECTION 1 MG May of 33

6 J0897 J1300 J1725 J1750 J1756 J1931 J2170 J2430 J2505 J2507 J2820 J2916 J3487 J3488 J7183 J7185 J7186 J7187 J7189 J7190 J7192 J7193 J7194 J7195 J7198 J7504 J7511 J7599 J7799 J9000 J9001 J9010 J9015 J9017 J9020 J9025 J9027 J9033 J9040 J9041 INJECTION, DENOSUMAB, 1 MG ECULIZUMAB INJECTION INJ, HYDROXYPROGESTERONE CAPROATE, 1 MG INJECTION IRON DEXTRAN INJ IRON SUCROSE 1MG LARONIDASE MECASERMIN INJECTION 1MG PAMIDRONATE DISODIUM /30 MG INJECTION, PEGFILGRASTIM 6MG INJECTION, PEGLOTICASE, 1 MG SARGRAMOSTIM INJECTION INJ,SODIUM FERRIC GLUCONATE INJ,ZOLEDRONIC ACID RECLAST INJECTION VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE FACTOR VIII RECOMB VON WILLEBRAND FACTOR VIII COMPLEX VON WILLEBRAND FACTOR COMPLEX FACTOR VIIA FACTOR VIII (HUMAN) FACTOR VIII RECOMB FACTOR IX NON-RECOMB FACTOR IX COMPLEX FACTOR IX RECOMBINANT ANTI-INHIBITOR COAGULANT COMPLEX LYMPHOCYTE IMMUNE GLOBULIN LYMPHOCYTE IMMUNE GLOBULIN, IMMUNOSUPPRESSIVE DRUG NOC NON-INHALATION DRUG FOR DME DOXORUBIC HCL 10 MG VL CHEMO DOXORUBICIN HYDROCHLORIDE, A ALEMTUZUMAB ALDESLEUKIN/SINGLE USE VIAL ARSENIC TRIOXIDE, 1 MG ASPARAGINASE INJECTION AZACITIDINE INJECTION CLOFARABINE INJECTION INJ, BENDAMUSTINE HCL, 1MG BLEOMYCIN SULFATE INJECTION BORTIZOMIB INJECTION, 0.1MG May of 33

7 J9043 J9045 J9050 J9060 J9065 J9098 J9100 J9120 J9130 J9150 J9151 J9160 J9165 J9178 J9181 J9185 J9200 J9201 J9206 J9207 J9208 J9211 J9212 J9216 J9219 J9230 J9261 J9264 J9265 J9266 J9268 J9270 J9280 J9293 J9300 J9302 J9305 J9307 J9315 J9320 INJECTION, CABAZITAXEL, 1 MG CARBOPLATIN INJECTION CARMUS BISCHL NITRO INJ CISPLATIN 10 MG INJECITON INJ CLADRIBINE PER 1 MG CYTARABINE LIPOSOME 10MG CYTARABINE HCL 100 MG INJ DACTINOMYCIN ACTINOMYCIN D DACARBAZINE 10 MG INJ DAUNORUBICIN DAUNORUBICIN CITRATE LIPOSOM DENILEUKIN DIFTITOX DIETHYLSTILBESTROL INJECTION INJ EPIRUBIN HCL 2MG ETOPOSIDE 10 MG INJ FLUDARABINE PHOSPHATE INJ FLOXURIDINE INJECTION GEMCITABINE HCL IRINOTECAN INJECTION IXABEPILONE INJECTION IFOSFOMIDE INJECTION IDARUBICIN HCL INJECITON INTERFERON ALFACON-1 INTERFERON GAMMA-1B LEUPROLIDE ACETATE IMPLANT, MECHLORETHAMINE HCL INJ NELARABINE INJECTION 50MG PACLITAXEL INJECTION PACLITAXEL INJECTION PEGASPARGASE/SINGL DOSE VIAL PENTOSTATIN INJECTION PLICAMYCIN (MITHRAMYCIN) INJ MITOMYCIN 5 MG INJ MITOXANTRONE HYDROCHL / 5 MG GEMTUZUMAB OZOGAMICIN, 5 MG INJ OFATUMUMAB, 10 MG PEMETREXED INJECTION -10MG INJ PRALATREXATE, 1 MG INJ ROMIDEPSIN, 1 MG STREPTOZOCIN INJECTION May of 33

8 J9328 TEMOZOLOMIDE INJ, 1MG J9330 TEMSIROLIMUS INJECTION J9340 THIOTEPA INJECTION J9351 INJ TOPOTECAN, 0.1 MG J9357 VALRUBICIN,INTRAVESICAL, 200 J9360 VINBLASTINE SULFATE INJ J9390 VINORELBINE TARTRATE/10 MG J9395 FULVESTRANT INJECTION, 25MG J9600 PORFIMER SODIUM J9999 CHEMOTHERAPY DRUG Q2041 INJ, VON WILLEBRAND FACTOR COMPLEX New tonsillectomy guidelines for patients under 18 years of age In our continuing effort to promote clinical quality through adherence to evidence-based clinical practice guidelines, Anthem is implementing a new clinical guideline: Tonsillectomy for Children (CG-SURG-30). The Academy of Otolaryngology Head and Neck Surgery Clinical Practice Guideline entitled Tonsillectomy in Children advocates conservative treatment and sets criteria for appropriate surgical tonsillectomy recommendations. The primary purpose of the guideline is to provide clinicians with evidence-based guidance in identifying children who are the best candidates for tonsillectomy. The procedure codes associated with this guideline are 42820, 42821, and Effective August 1, 2012, a health services review/pre-certification will be required in advance for members under the age of 18 in Anthem s PAR and PPO Virginia plans as well as our HMO (including Medicaid and FAMIS). The guideline is available for review at To review the new guideline, simply enter CG-SURG-30 or tonsillectomy in the Search Anthem field at the top of the Virginia provider home page at anthem.com. Update on clinical reviews Milliman Care Guidelines update Effective May 21, 2012, Anthem will transition to the most recent edition (16th) of the Milliman Care Guidelines. This may change some of the clinical information requested during the review process or adjustments to a length of stay. Our staff is happy to assist you in providing the information needed to complete a review of your request. In the case of an adverse decision, we can provide you with the area(s) of criteria that were not met. However, due to licensing restrictions, Anthem is unable to offer complete Milliman documentation. You must obtain complete documentation directly from Milliman. May of 33

9 Business update Anthem s ConditionCare Program helps members better manage chronic conditions Anthem members have additional resources available to help them better manage chronic conditions. The ConditionCare program is designed to help participants improve their health and enhance their well-being. The program is based on nationally recognized clinical guidelines and serves as an excellent adjunct to physician care. The ConditionCare program helps members better understand and control certain medical conditions like diabetes, chronic obstructive pulmonary disease (COPD), heart failure, asthma and coronary artery disease. A team of nurses with added support from other health professionals such as dietitians, pharmacists and health educators work with members to help them understand their condition(s), their doctor s orders and how to become a better self-manager of their condition. The program offers: Education about their condition through mailings, telephonic outreach, and online tools and resources. Round-the-clock phone access to registered nurses. Guidance and support from Nurse Coaches and other health professionals. Physician benefits: Saves time for the physician and staff by answering patient questions and responding to concerns, freeing up valuable time for the physician and their staff. Supports the doctor-patient relationship by encouraging participants to follow their doctor s treatment plan and recommendations. Informs the physician with updates and reports on the patient s progress in the program. Nurse coaches Nurse coaches encourage participants to follow their physician s plan of care not to offer separate medical advice. In order to help ensure that our service complements the physician s instructions, we collaborate with the treating physician to understand the member s plan of care and educate the member on options for their treatment plan. Providers are given a quarterly report for patients who are currently enrolled in the program including sharing the member s current educational goals. Additional information Please visit the Healthy Returns website to find more information about the program such as program guidelines, educational materials and other resources. Go to and click on Physicians and then Care Management. Also May of 33

10 on our website is the Patient Referral Form that you can use to refer other patients you feel may benefit from our program. You can find the form by clicking on the patient referral tab. If you have any questions or comments about the program, call Our nurses are available Monday-Friday, 8:30 a.m. to 9 p.m. CST, and Saturday, 9 a.m. to 7:30 p.m. CST. For members enrolled in Anthem HealthKeepers Plus (Medicaid), please call Reminder: Use participating laboratories for HMO members, including Anthem HealthKeepers Plus members Laboratory Corporation of America (LabCorp) and its subsidiaries Dianon Systems, Inc. and Home Health Laboratory of America are the only participating laboratory providers for ALL HMO outpatient laboratory testing* except for those lab services included on the in-office laboratory list in your Provider Agreement. If you have questions about LabCorp services or need to set up a LabCorp account, obtain supplies, or discuss LabCorp testing options, please call LabCorp at Additional reminders and details about how to appropriately bill for lab tests are provided below. Further information can also be found in your provider agreement. A. Direct billing policy: Reference laboratory services must be billed to Anthem s affiliated HMO HealthKeepers, Inc. by the provider of service. This means that lab tests performed in a physician s office should continue to be billed to HealthKeepers by the physician. However, lab tests performed by an outside laboratory must be billed directly to HealthKeepers by that laboratory, regardless if they are participating or non- participating. In some situations, a participating pathologist acts as a subcontractor to perform the professional component of reference laboratory services. In these situations, providers should file claims to HealthKeepers with the component of the laboratory service they performed, using the appropriate HCPCS or CPT modifier (when applicable). By following this billing guideline, providers are helping to adhere to the terms and conditions of their provider agreements and helping to reduce the administrative costs of reprocessed claims. B. Venipuncture: HealthKeepers will continue to reimburse physicians for one venipuncture per member per day (CPT code and 36416) as specified in the Provider Agreement. If two venipuncture services are reported by the same provider for the same day, the second code will be denied as not eligible for separate reimbursement. C. Professional payment for HMO inpatient/outpatient/ambulatory surgery center (ASC) procedures: Participating HMO pathologists will be reimbursed the professional component (Modifier 26) of laboratory/pathology tests provided as part of an inpatient/outpatient/asc procedure. D. Appropriate use of modifier 26: Modifier 26 is reimbursable only when billed for select pathology and laboratory CPT codes that require a separately identifiable professional interpretation beyond the technical component. The list of pathology and laboratory codes for which modifier 26 may be reimbursed may change from time to time and is based on the CMS National Physician Fee Schedule Relative Value File. May of 33

11 E. No reimbursement for other hospital inpatient/outpatient /ASC lab tests, including the technical component of this defined in C above: Physicians who provide clinical lab, pathology, radiology or other diagnostic testing services to hospital inpatients or outpatients shall only be reimbursed for the professional component fee allowance (when the code has a separate professional component RVU assigned based on CMS guidelines). There will be no reimbursement to the physician for the technical only component or the complete service. Such reimbursement has been included in the payment to the hospital. F. HMO in-office laboratory list: Anthem s affiliated HMO, HealthKeepers, Inc., contracts with Laboratory Corporation of America (LabCorp) and its subsidiary Dianon Systems, Inc. and Home Health Laboratory of America to provide HMO outpatient laboratory services. Providers must use these designated labs for HMO members. However, those tests included on the in-office laboratory list may be performed in a physician s office. See your Provider Agreement for a complete list of in-office lab tests that will be reimbursed. If applicable, both the technical and professional components will be reimbursed. G. Place of service: Providers should only bill place of service 81 (independent laboratory) if they are recognized by Anthem as an independent laboratory provider and have executed an Independent Laboratory Agreement. Providers who are interested in participating in Anthem s independent laboratory network should contact Ashley Milam at Note to Pathologists: the place of service billed should represent the location where specimens are collected, such as inpatient, outpatient or ASC. H. HMO Prefixes: HMO members can be identified by the following three-alpha prefixes: YTD, YTE, YTF, YTH, YTI, YTJ, YTS or YTT. I. Non-Participating HMO Laboratories: Certain non-participating HMO laboratory providers such as Athena Diagnostics, Genomic Health, GenPath/BioReference Laboratories, Greensboro Pathology, Medical Diagnostic Laboratories (MDL), Myriad Genetics, NTD Laboratories, Prometheus, Solstas Lab Partners, and Quest Diagnostics may be directly marketing their tests to physicians. To order an out-of- network lab test, physicians must: Obtain prior authorization from HealthKeepers for out-of-network services Should prior authorization be denied, physicians have the option to obtain a signed waiver from the member BEFORE services are rendered. By signing the waiver, members indicate that they accept the specified terms and agree to be held financially responsible, as members are aware that the test will be performed by a non-participating laboratory. The waiver must include: Date of service. Description of the service to be rendered. Statement informing member that HealthKeepers is NOT liable for payment. The member is financially liable for the test(s). Estimated cost of test(s). Date, time and member s signature. LabCorp may refer certain highly specialized or patented testing out to other laboratories, such as Atherotech or LipoScience. In these cases, order the testing through LabCorp which will allow the services to be provided in network. J. LabCorp Patient Service Centers: LabCorp has many conveniently located patient service centers to assist in the collection of members lab specimens. Members can now locate and schedule an appointment for their next visit to a LabCorp Patient Service Center via the LabCorp website at under the Find a Lab option. May of 33

12 If you have questions about these guidelines or coordinating lab services for your patients, please contact your Anthem network manager. If you have questions about LabCorp services, or need to set up a LabCorp account, obtain supplies, or discuss LabCorp testing options, please call LabCorp at * Anthem s PAR and PPO products have several in-network laboratory choices. Please refer to the provider directory at anthem.com for a complete listing. We believe in continuous improvement Commitment to our members health and satisfaction with the care and services they receive is the basis for the Anthem Blue Cross and Blue Shield Quality Improvement Program. Annually, Anthem prepares a quality program description that outlines the plan s clinical quality and service initiatives. We strive to support the patient-physician relationship, which ultimately drives all quality improvement. The goal is to maintain a well-integrated system that continuously identifies and acts upon opportunities for improved quality. An annual evaluation is also developed highlighting the outcomes of these initiatives. To see a summary of Anthem s quality program and most current outcomes, visit us at Clinical practice and preventive health guidelines available on the Web As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health, and preventive health guidelines, 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 the "Provider" home page at anthem.com> select Virginia> Health & Wellness> Practice Guidelines. May of 33

13 ICD-10 update Proposed new ICD-10 compliance date: October 1, 2014 On April 17, 2012, the Department of Health and Human Services (HHS) published a proposed rule that would delay the compliance date for ICD-10 from October 1, 2013, to October 1, There is a 30-day public comment period in effect, ending May 17, At that time, HHS will issue a final rule. However, we fully expect this new compliance date to be the final rule. How does the new compliance date affect Anthem Blue Cross and Blue Shield s implementation plan? We built our ICD-10 plans to provide us with flexibility. We continue to work towards implementing ICD-10 and are committed to being fully compliant and capable of accepting and processing ICD-10 diagnosis and procedure codes on the compliance date. My organization decided not to change our plan timeline. If I m ready to submit ICD-10 codes by October 1, 2013, will Anthem accept ICD-10 codes on my claims? No. We are aligning with the guidance HHS provided, so we will NOT accept ICD-10 codes prior to the compliance date of October 1, When will Anthem begin testing? Currently, we are designing our testing plans and anticipate external partner testing to begin on January 1, We will release more information as it becomes available through the Network Update provider newsletter. Now that we know the new compliance date, we have more time. Should we delay starting our ICD-10 implementation plan for our organization? If your organization has not begun planning to transition to ICD-10, it s not too early to begin preparations even though there is a delay with the compliance date. To assist providers with the transition from ICD-9 to ICD-10, CMS has published implementation handbooks. The handbooks suggest that planning begin at least 24 months prior to the compliance date. You can begin by assessing the current state of your organization and to determine what will be needed for the transition. To access the implementation handbooks and more provider resources, access the CMS ICD-10 website at this link: We will keep you informed on our implementation plans. If you have any other questions about ICD-10, please us at: ICD10-Inquiry@anthem.com Link to HHS s announcement on the new compliance date: May of 33

14 Additional resources on ICD-10: Blue Cross and Blue Shield Association (BCBSA) American Health Information Management Association (AHIMA) Healthcare Information and Management Systems (HIMSS) American Academy of Professional Coders (AAPC) Health care reform updates and notifications Health care reform expands preventive care coverage for women On August 1, 2011, HHS released new guidelines outlining required preventive care services for women. The new guidelines require non-grandfathered health plans to cover these services without cost sharing for policies beginning on or after August 1, The chart below shares details of how each service will impact current benefits for Anthem Blue Cross and Blue Shield policies. It is important to remember that not all plans are subject to the new guidelines, and policies under the new guidelines have varied effective dates. Providers should continue to verify eligibility and benefits when determining copayments or coinsurance due by members for services rendered. Preventive Service Guideline Well Woman Visits Screening for Gestational Diabetes Description of Requirement Current Benefits Future Benefit Under HCR (effective on or after August 1, 2012) Well woman preventive care visit to be covered annually at 100% for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care. Screening for gestational diabetes to be covered at 100% under preventive benefits. We currently cover preventive visits. We currently cover gestational diabetes screenings as a diagnostic service under maternity benefits. No additional services will be added. We will cover gestational diabetes screening for women at 100% under preventive benefits. May of 33

15 HPV Testing Counseling for Sexually Transmitted Infections Counseling and Screening for HIV Contraceptives and Counseling (females only) High-risk human papillomavirus DNA testing in women with normal cytology results will be covered at 100% under preventive benefits. Counseling on sexually transmitted infections (STIs) for all sexually active women will be covered at 100% under preventive benefits. Counseling and screening for human immune-deficiency virus infection for all sexually active women at 100% under preventive benefits. All Food & Drug Administration (FDA) approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity will be covered at 100% under preventive care. We currently cover cervical cancer screenings (pap smears) for sexually active women. We currently cover counseling for STIs. We currently cover counseling and screening for HIV. We currently cover women s preventive visits and counseling under preventive benefits. We will cover HPV testing for all women. No additional services will be added. No additional services will be added. We will add coverage for medical contraceptives/sterilizations (office or facility based medical and surgical services) to the preventive benefit for females. There will be no age or frequency limits. We will add coverage for pharmacy prescription contraceptives for females to the preventive benefit. This coverage will be available through retail pharmacies or mail order. We will cover generic oral contraceptives (birth control bills) at 100%, and those brands which do not have a generic equivalent. Multisource brands with a generic equivalent will continue to require a patient cost share. Over-the-counter contraceptives will not be covered. Since we currently cover preventive visits and counseling under the preventive benefit, no additional benefits will be May of 33

16 Breastfeeding Support, Supplies, and Counseling Screening and Counseling for Interpersonal and Domestic Violence Comprehensive lactation support and counseling by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment covered at 100% under preventive benefits. Screening and counseling for interpersonal and domestic violence covered at 100% under preventive benefits. We currently cover lactation classes, preventive visits and counseling services under the preventive benefit. We currently cover preventive visits and preventive counseling services under preventive benefits. added related to these services. We will add coverage for breast pumps (rental and purchase) and breast pump supplies to the preventive benefit. These services will be covered as medical (not pharmacy) benefits. Breast pumps must be purchased/ rented from an in-network medical provider to get 100% coverage. Breast pumps obtained from other sources will be covered, but may result in a member cost share. One breast pump will be covered per pregnancy, although exceptions may be approved through the appeal/authorization process. No additional services will be added. Visit us on the Web at anthem.com for updates regarding health care reform. Once on anthem.com, select providers and then Virginia. Select the Health Care Reform Updates and Notifications link under Communications and Updates or click HERE. May of 33

17 ebusiness Online certificate of coverage booklets coming to Availity for Anthem covered members Providers will soon be able to view a copy of an Anthem member s certificate of coverage booklet online on availity.com. The certificate booklet contains details about a member s benefits including covered services, exclusions and so forth. Availity is a multi-payer portal that gives providers access to multiple payers information with one sign-on. In addition, Availity offers a variety of online functions to help providers reduce administrative costs by eliminating paperwork and phone calls. The certificate booklet, when available, will be accessed from the eligibility and benefits screen for an Anthem local covered member. The certificate booklet may help to answer benefit questions that may not be available from the HIPAA standard eligibility and benefits results provided, thus allowing you to spend less time on the phone and more time assisting and taking care of your patients. As a reminder, display of a member s certificate of coverage is not a guarantee of payment. Please check the provider home page on our website at anthem.com for continued updates on additional features coming to Availity. To register for access to Availity, go to availity.com, contact your local provider representative or call Availity Client Services at 800-AVAILITY ( ). Availity Enhancements Anthem recently made two enhancements on Availity to help Virginia providers. Availity is now able to display facility claims details for those claims that contain a large number of lines. All line-level detail is now displayed for finalized claims with more than 99 lines. In addition, Availity now shows the line-level detail on claims that have been processed and finalized but not yet remitted. Availity, an independent company, provides claims management services for Anthem Blue Cross and Blue Shield. EDI reports change with migration to HIPAA version 5010 Once migrated to HIPAA version 5010, you will experience important changes with electronic data interchange (EDI) reports. Reports are vital, providing an audit trail for your practice while acknowledging the acceptance or rejection of electronic transmissions submitted to us. Understanding and monitoring reports also allow you to correct and resubmit rejected claims often without missing a remittance cycle. May of 33

18 As you transition to HIPAA 5010, work with your clearinghouse to review and obtain training on new EDI reports. Understanding changes to your EDI reporting process will optimize effectiveness in detecting and resolving submission issues. Below is an overview of each report that will be delivered once you have migrated to Version For information about each report, its format and delivery schedule, visit our website at Go to 5010 Companion guide >EDI User guide. If you have questions on any of these reports, call EDI Solutions at Report name Anthem contact Description Anthem contact Access Anthem EDI Solutions Interchange Acknowledgement TA1 X12 Alert Failed Inbound Transactions Generated when the electronic file structure and/or data contained within the file is invalid or corrupted. With invalid or corrupted information Anthem is unable to open, identify or read the electronic file submission. Errors identified will cause the entire file to reject. Delivery Schedule Daily: Report generates only when a file error is detected. Call EDI specialist at EDI User Guide Acknowledgement and Reports 999 Interchange Acknowledgement 277CA Claims Acknowledgement Report confirms acceptance and/or Acknowledgement rejection of claim files. Anthem validates to ensure the file is addressed appropriately and its contents are valid based on HIPAA file structure and submission requirements. Errors identified on this HIPAA report cause the entire file to reject. Delivery Schedule Daily: Report generates acknowledgement of the rejection of a file submission. X12 HIPAA Health Care Claim Acknowledgement is the business level acknowledgement for health care claims-837. Report returns a reply of Accepted or Not accepted status based on the electronic claim Technical Report 3 and front end edits. For claims Not Accepted, the 277CA will detail additional actions required of the submitter in order to correct and resubmit. Errors identified at this Call EDI specialist at Call EDI specialist at EDI User Guide Acknowledgement and Reports EDI User Guide Acknowledgement and Reports May of 33

19 Adjudicated Claims Response File X12 Level 3 Anthem Business level will cause individual claims to reject. Delivery Schedule Report generates acknowledging the acceptance or non-acceptance of a claim. Proprietary report that provides the status Response File Proprietary report that provides the status Response File Proprietary report that provides the status Response File Proprietary report that provides the status Response File of each claim received by our claims processing system. Errors detected will cause individual claims to reject. This report is the providers record of timely filing. Call EDI specialist at Claim status/error resolution: Call Anthem Group Business: Richmond area or EDI User Guide Acknowledgement and Reports Delivery Schedule Daily: Report generates displaying all claims processed at this level. Claims are acknowledged with an acceptance or rejection. of each claim received by our claims processing system. Errors detected will cause individual claims to reject. This report is the providers record of timely filing. Alert Messages Important electronic messages such as system modifications, submission tips and other Anthem communications. Call EDI specialist at EDI User Guide Acknowledgement and Reports Delivery Schedule As needed. It is imperative that providers review Alert messages; they often require important action from the provider. May of 33

20 Register for the Network Rapid Update We continue our registration efforts to enroll providers and their staff to receive our Network Rapid Update our streamlined communications tool. Get important need-to-know provider updates delivered conveniently to your electronic inbox. We will only use the Network Rapid Update as the need arises to communicate urgent, critical or time-sensitive information that impacts you and how you do business with us. If you d like to receive the Network Rapid Update, you need to provide us with an address where we can send these critical alerts. Only those providers who sign up will receive the Network Rapid Update via . To register your address with us, select the Network Rapid Update link on the Virginia provider home page of anthem.com or click HERE. You may receive Web security alert/information questions. Simply answer yes to the security questions and complete the short registration form. FEP update Health and wellness programs for members enrolled in the Federal Employee Program Members enrolled in the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program or FEP, have access to a variety of health and wellness programs and services at no extra charge. Blue Health Connection is a series of programs and resources that help our members become more aware of health issues and advance better health. We at Anthem Blue Cross and Blue Shield encourage you to recommend these no-cost programs to your FEP patients to supplement and support your plan of care. FEP will also include the message below on your remittances to promote the Health and Wellness of our members. The Federal Employee Program offers free services to our members to help you stay connected to their health. Ask your patient to register and take advantage of the wellness tools offered at MyBlue contains a health assessment tool. Once a member completes the assessment, they will get personalized feedback that identifies potential health risks. They will also receive suggestions for action and talking points to share with you during their next appointment. May of 33

21 FEP Health and Wellness Programs and Additional Information PATIENT HELP FEP PROGRAM DESCRIPTION CONTACT Health Savings When patients complete their Blue Health Blue Health Assessment, they receive: Assessment a $35 health debit card to use for qualified medical expenses, an optional $15 credit opportunity when participating in online health programs that can help patients reach their health goals. Improve Heart Health WalkingWorks (for adults) Healthier Pregnancies Special Help for Complex/Chronic Health Issues When the Doctor is not available Future Moms Case Management Blue Health Connection Encourages patients to add activity to their daily routine Free pedometer to track steps Online tracking tool to manage progress All FEP members are encouraged to enroll Proven program helps identify highrisk pregnancies. Helpful support for all expectant parents with educational materials and 24/7 access to a registered nurse experienced in obstetrical care. Enrollment during first trimester is recommended. Special assistance at no charge for those with complex or chronic health issues. URAC-accredited program may include alternative insurance benefits through the flexible benefit option. A team of specially trained health care professionals works with the patient and his or her physicians and providers to promote high quality, cost effective outcomes. Free nurse triage and health information available 24 hours a day, 7 days a week, 365 days a year. Telephone assistance anytime from registered nurses to discuss health problems and assess symptoms or or May of 33

22 Online information about conditions, medical treatment, diagnostic tests and general health: Ask Our Nurse: R.N. responses to s within 24 hours. Online Symptom Adviser recommends the appropriate action. Clinical Reference System (CRS) describes thousands of medical conditions, procedures and medications. Audio Health Library covers hundreds of health topics. Condition Center: detailed information on heart disease, heart failure, diabetes and asthma. Health Tracker: store and track family health information and print out to bring to appointments. Medicare information Home visits address care coordination and hospital re-admissions Anthem Blue Cross and Blue Shield is expanding the role of home visits among Medicare Advantage members. These home visits are intended to help ensure that Medicare Advantage members who are particularly frail, who have complex care management needs or who have just returned home from the hospital understand and receive the care and medications they need. Preventing hospital re-admissions If a recently hospitalized Medicare Advantage member appears to be at risk for a hospital readmission and agrees to Anthem s request to send a nurse to their home, a home visit will be coordinated by the home health vendor and the Anthem case manager. These home visits will be completed by an RN or Nurse Practitioner employed by an experienced home visit vendor to help identify gaps in care and to help prevent unnecessary hospital readmissions. Information obtained in these visits will be shared with the primary care physician and the Anthem case manager. May of 33

23 Care coordination We also will schedule home visits for members who are particularly frail or need more intense care coordination. Anthem will send the results of the home visit to the member s primary care physician. Members may receive multiple home visits as needed and Anthem nurses and social workers will call these members to check on their condition between visits. A physician s order is needed to initiate these home visits. For more information, please contact Melissa Trownsell at (317) or Melissa.Trownsell@wellpoint.com. House call health evaluation for risk adjustment data collection Anthem also will continue to complete risk adjustment health evaluations that take place in the Medicare Advantage member s home. The house call program s health evaluation assesses our Medicare Advantage member s medical conditions and health status annually. Throughout 2012, we will contact all Virginia Medicare Advantage Local Preferred Provider Organization members to offer them an in-home health evaluation. All diagnosis data collected during the health evaluation will be reported to the Centers for Medicare and Medicaid Services (CMS) as part of Anthem s CMS-required risk adjustment data submissions. To encourage collaboration and communication between Anthem, the primary care physician (PCP) and the member, a copy of the health evaluation will be provided to the member s PCP. In addition, where appropriate, the member s PCP will be contacted to discuss appropriate clinical follow-up care. We will be working with an experienced vendor who will send credentialed providers to conduct a comprehensive health evaluation and document health conditions and clinical diagnosis data. We look forward to working with you on these important initiatives for your Medicare Advantage patients. If you have any questions, please call the Customer Service number on the back of the member s ID card. Medicare covers sexually transmitted infection screening and counseling, obesity counseling The Centers for Medicare & Medicaid Services (CMS) announced that Medicare will pay for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs (ICD-10) and will also cover Intensive Behavioral Therapy for Obesity. The new services will be added to other covered preventive services at no additional cost to beneficiaries.* Effective for claims with dates of service on and after November 8, 2011, CMS will cover screening for chlamydia, gonorrhea, syphilis and hepatitis B with the appropriate FDA-approved lab tests used consistent with FDA-approved labeling and in compliance with Clinical Laboratory Improvement Amendments regulations when ordered by a primary care provider and performed by an eligible Medicare provider for these services. For CMS s claim coding directions for this preventive service, please see May of 33

24 Also effective for claims with dates of service November 29, 2011, and later, Medicare beneficiaries with obesity (BMI of more than 30 kg/m 2 ), who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner in a primary care setting are eligible for: One face-to-face visit every week for the first month One face-to-face visit every other week for months 2-6 One face-to-face visit every month for months 7-12 For CMS s claim coding directions for this preventive service, please see *The no cost share for members applies to (Brand s) contracting providers. Out of Network cost sharing may apply to members who have out of network services. CMS clarifies place of service coding instructions The Centers for Medicare & Medicaid Services recently released MLN Matters article MM7631 to clarify place of service (POS) coding instructions. For details on the billing guidelines and a complete list of the POS codes paid at facility and nonfacility rates, see MLN article MM7631 located at: Medicare Part D medication management reminders The Centers for Medicare and Medicaid Services (CMS) developed performance and quality measures to help Medicare beneficiaries make informed decisions regarding health and prescription drug plans. As part of this effort, CMS currently calculates and publicizes seven patient safety measures: High Risk Medication (HRM), Diabetes Treatment (DT), Drug-Drug Interaction (DDI), Diabetes Medication Dosage (DMD) and Adherence (ADH) for three therapeutic areas. This year we will introduce new initiatives for Drug-Drug Interaction and Diabetes Dosing measures. We will continue our previous initiatives for the High Risk Medication, Diabetes Treatment and Adherence measures. The DDI rate analyzes the percentage of Medicare Part D beneficiaries who received a prescription for a target medication during the measurement period and who were dispensed a prescription for a contraindicated medication with or subsequent to the initial prescription. If you have patients who are identified via their pharmacy claims data to have a potential drug-drug interaction, you may receive the following Pharmacy Personal Care Note reminder from us: We recently suggested this member talk to you about his/her prescriptions for [drug 1] and [drug 2], which can have serious side effects if taken together. May of 33