In this issue Page. June Health Care Reform (including Health Insurance Exchange) Updates and notifications 2. Administrative Update

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1 June 2014 In this issue Page Health Care Reform (including Health Insurance Exchange) Updates and notifications 2 Administrative Update Claims The WellPoint Cancer Care Quality Program 3 Quality and cost program to expand 4 Sleep treatment with PAP equipment 4 Reminder: Protect members PHI 5 New alpha prefixes 5 New Blue 7 SM plans 6 KY: Fee schedule notification 6 Use the Provider Maintenance Form to update your information 6 Customized claim edits 6 New 1500 claim form 7 ebusiness FEP MyAnthem SM and the Availity Web Portal 7 AIM program will be expanded to the Federal Employee Program 8 MO: Smoking cessation program 8 Health Care Management Important change: Use ICR for precert status requests 9 Precertification Department is changing IVR prompts 11 Medical policy: Code C1300 will require precert 11 New MA precertification requirements 12 Medicare WI: MA carrier priced code updates 12 House call program 12 MA members receive monthly summary statements medical chart review program 13 Helping members schedule office visits, screenings 13 HEDIS measures help promote quality 13 Preventing opioid overutilization 14 Updated self-service telephone options 14 CENL 0614 IN, KY, MO, OH, WI 1 of 23

2 IN, OH: Bone density screening 15 OH: Care coordination for skilled nursing 15 Pharmacy Quality Pharmacy information available at anthem.com 15 ConditionCare helps members better manage their conditions 15 We believe in continuous quality improvement 16 Case management program 16 Clinical practice and preventive health guidelines 17 Coordination of care 17 Important information about UM 18 Members rights and responsibilities 19 Reimbursement Facility reimbursement: Implant Policy 20 IN: Facility reimbursement policy notification 20 Notice of revised professional reimbursement policies 21 IN, OH, WI: Material change to contract 22 View Anthem reimbursement policies 22 Specialty Services: Behavioral Health Final mental health parity rule released 23 Health Care Reform (including Health Insurance Exchange) Updates and Notifications Please be sure to check the Health Care Reform Updates and Notifications and Health Insurance Exchange sections of our website regularly for the new updates on health care reform and Health Insurance Exchanges. Health Care Reform Click here to find new information, including notification of new online processes for ERA only registration, or visit anthem.com>providers (select state)>health Care Reform Updates and Notifications. Health Insurance Exchange Please check this section often for updates on the networks that support Health Exchange products, how the Health Exchange work, who is affected, Plan names, how to identify members covered by a Health Exchange plan and much more. For example, see Verify member grace period status electronically using Availity or EDI.at anthem.com>providers (select state)>health Insurance Exchange. Sign up to receive immediate notification of new information. June of 23

3 Note that in addition to this newsletter and our website, we also use our service, Network eupdate to communicate new information. If you are not yet signed up to receive Network eupdates, we encourage you to enroll now so you ll be sure to receive all information we ll be sending about Exchanges. To sign up, visit anthem.com > Providers (enter state) Network eupdate. Administrative Update The WellPoint Cancer Care Quality Program Go online to learn more The WellPoint Cancer Care Quality Program ( Program ), a quality initiative, provides participating physicians with evidencebased cancer treatment information that allows them to compare planned cancer treatment regimens against evidence-based clinical criteria. The Program also identifies certain evidence-based WellPoint Cancer Treatment Pathways ( Pathways ). Participating physicians that are in-network for the member s benefit plan are eligible to participate in the Program and for enhanced reimbursement if an appropriate treatment regimen is ordered that is on Pathway. A Program website, cancercarequalityprogram.com, helps support Anthem network hematology and oncology practices as they get ready to participate. Since its launch, the Cancer Care Quality Program website has drawn more than 1,000 visitors, and more than half have returned to the site multiple times to view content and download materials designed to help educate practices about the Program. Practices are finding information on WellPoint s Cancer Treatment Pathways of strong interest. Available are: A comprehensive list of current Pathways that can allow physicians and other clinicians to better understand our Pathways and how they were developed. Pathways worksheets for each cancer type managed under the Program. These worksheets are an ideal way for practice staff to gather the information they need to submit cancer regimens for review. Many other resources and tools, tips and timelines. Online process simplifies practice workflow The Program will be administered by AIM Specialty Health (AIM), a separate company. Participating practices are likely to find entering their information via the AIM Provider PortalSM both quick and convenient. In testing, users have provided positive feedback on this online process, with most saying they will be able to submit orders in fifteen minutes or less. Additionally, participating providers in need of support may call the AIM Call Center at AIM will begin taking orders for the Program on June 23, 2014 for treatment that begins on or after July 1, Helpful links Register for access to the AIM Provider Portal. View the Cancer Care Quality Program website. Get more information on WellPoint Cancer Treatment Pathways. Access program FAQs, including information on enhanced reimbursement. June of 23

4 Quality and cost program to expand for plans managed by Indiana and Ohio Anthem previously has implemented an integrated management program to help members compare facility costs on imaging and sleep services. The program is administered in partnership with AIM. On September 1, 2014, this program will expand for some of your patients to include surgical procedures. Please check the back of members health plan identification (ID) cards to determine if they are included in the program (new additions may occur every few months). Note: The program expansion applies to fully insured members covered by Anthem plans in Indiana and Ohio. Surgical procedures included in the expansion are: Colonoscopy- screening, biopsy, and lesion removal Endoscopy Upper GI with Biopsy Arthroscopic ACL Repair Knee Arthroscopy with Cartilage Repair Shoulder Arthroscopy Shoulder Arthroscopy with Rotator Cuff Repair Program components: Provider notification You may contact AIM when your patient requires one of the surgical procedures listed above. Both ordering and servicing providers may contact AIM. Provider/patient transparency Once AIM is notified, surgical facility cost information will be shared with you and your patient to help select a lower-cost option. This enhancement is available for fully-insured members. Cost information is based on Anthem s historical paid claims data for the various services in scope. This data is updated twice per year. You may contact AIM in one of two ways: Online through ProviderPortalSM at Via telephone at (800) or by using the number displayed on the back of the member ID card Claims will not be denied for failure to inform AIM. Members will not be denied access to services if they do not choose a lower-cost option. Our goal is simply to provide members with information to make informed choices about their health care. Note: FEP members are not included in this program. If you have any questions about this information, please contact your local Network Relations consultant. Sleep treatment with PAP equipment There is growing industry concern regarding patient compliance with PAP treatments used to treat obstructive sleep apnea (OSA). Poor compliance can lead to serious health issues and result in wasted dollars spent on equipment and supplies. June of 23

5 For this reason, Anthem is introducing an enhancement to our sleep testing and treatment program, administered by AIM, which will allow us to support your efforts to encourage patient compliance. AIM Sleep Disorder Management Diagnostic and Treatment Guidelines provide that ongoing treatment is indicated only for patients who demonstrate compliance with therapy. In order to satisfy the medical necessity of ongoing treatment, demonstration of compliance is required every 90 days for the first year of therapy and annually thereafter. Beginning August 1, patient attestation of sleep therapy compliance will no longer be required to support a preauthorization request. Instead, AIM will be requiring DME device data to confirm compliance with therapy. In order to facilitate the submission by your practice of DME device data, AIM has implemented a direct link with the following manufacturers that will automatically provide device usage information to AIM about a particular patient when you make a request for ongoing therapy. Philips Fisher and Paykel Healthcare ResMed To take advantage of the convenience of these arrangements, you should register each patient in the appropriate DME manufacturers web-based software, per the training materials provided to you by each manufacturer. We also recommend that you perform periodic downloads of member device usage data before contacting AIM for review requests so that you can determine if the criteria for ongoing treatment are met. For patients with devices manufactured by other companies, you will need to manually enter compliance data from their devices into the AIM system. We are pleased that this enhancement to our sleep management program will: Help you more easily identify patients who may need help using their PAP equipment Promote more accurate clinical appropriateness determinations from actual compliance data Save you time by streamlining the approval process Note: FEP members are not included in this program. For more information, please contact your local Network Relations consultant. Reminder: Protect members PHI When submitting records and/or correspondence for a member, please make sure that you are attaching only records/correspondence for the Patient noted on the first Page. New alpha prefixes Anthem recently assigned some new prefixes for some members covered by our Individual plans. Please note that a member s ID card may show an old alpha prefix but for those who have been converted to a new prefix, when the provider checks eligibility and benefits on the Availity Web Portal, the new prefix automatically populates June of 23

6 New Blue 7 SM plans On July 1, 2014, Anthem will add new health plans in Indiana, Kentucky, Missouri, Ohio and Wisconsin that include more cost share options for members. Benefits include a limited number of office visit copayments plus remaining covered services subject to deductibles and coinsurance. Beginning with the fourth office visit charge, deductible and coinsurance applies. Copayments, deductibles and coinsurance also apply to inpatient and outpatient services. The formulary is limited. Members covered by these Plans have more financial responsibility for the health care services they receive. As always, it is very important that providers verify member eligibility, benefits or account information via Availity or by calling the number listed on the back of the member s identification card. KY: Fee schedule notification Physicians were mailed a notification that PPO, HMO and POS fee schedules will be updated for services provided on or after August 16, A sample list of the top high volume codes was enclosed. As a reminder, J codes are reimbursed at Average Sales Price (ASP) + 6% and are updated quarterly. If you have additional questions on specific codes or need further information, please contact your Network Relations Consultant at Use the Provider Maintenance Form to update your information We continually update our provider directories to help ensure that your current practice information is available to our members. At least 30 days prior to making any changes to your practice updating address and/or phone number, adding or deleting a physician from your practice, etc. -- please notify us 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. Claims Customized claim edits The following revised Anthem customized claim edit will be implemented around September 15, These changes in the claim edits will apply to the following products: Blue Access, Blue Access Choice, Blue Preferred, Blue Preferred Primary, Blue Preferred Primary Plus, Blue Preferred Plus, Blue PrioritySM, Blue Priority Plus, Blue Traditional, Anthem Essential and Hospital Surgical (PPO) Blue Traditional. Revised Edit # bundles with Rationale: Per CPT code descriptions, the hemophilus influenza b vaccine (Hib) is already a component of Therefore, if is submitted in conjunction with only reimburses. Revised Edit # bundles with Rationale: These services represent a clinically unlikely scenario as it would not be likely that two separate surgical approaches to treat the same clinical condition would occur on the same date of service. Therefore, if is submitted in conjunction with only reimburses. New Edit # bundles with Rationale: An arthrotomy and joint exploration of the same site is considered a component of an excision or curettage of a bone cyst or benign tumor. This edit is consistent with CMS guidelines found in the National Correct Coding Policy Manual June of 23

7 for Part B Medicare Carriers, Chapter 1, which states, Exposure and exploration of the surgical field is integral to an operative procedure and is not separately reportable. Therefore, if is submitted in conjunction with only reimburses. 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). New 1500 claim forms Please submit using appropriate claim software and data element requirements In June 2013, the National Uniform Claim Committee (NUCC) announced the approval of an updated 1500 Claim Form (version 02/12) that accommodates reporting needs for ICD-10 and aligns with requirements in the Accredited Standards Committee X12 (ASC X12) Health Care Claim: Professional (837P) Version 5010 Technical Report Type 3. On April 1, 2014, the Protecting Access to Medicare Act of 2014 was signed into law, and this bill includes a provision that effectively delays the implementation of ICD-10 diagnosis and inpatient procedure codes for at least one year. Anthem continues to accept claims submitted using the updated 1500 Claim Form (version 02/12). Providers should take special care to ensure billing areas utilize claim software that supports the corresponding 1500 Claim Form version submitted to Anthem. For example, if you are submitting paper claims on version 02/12 of the 1500 Claim Form, please be sure that your office is using claim software that supports the 02/12 version of the 1500 Claim Form. Claims submitted with mismatched form types and data elements will be rejected. Additionally, please check the alignment of data elements on your paper claims to ensure they are properly aligned in their designated field(s). Please follow the guidelines set forth by the NUCC for completing the new 1500 Claim Form, or your claim may be rejected. For more information about the revised 1500 Claim Form, please visit the National Uniform Claim Committee website, which provides helpful resources such as a list of changes between the 08/05 and 02/12 claim versions and the 1500 Instruction Manual. ebusiness MyAnthem and the Availity Web Portal: Access both with one log-in Effective June 21, 2014, users will access MyAnthem SM exclusively via the Availity Web Portal. MyAnthem functionality, including view of online remittances, professional fee schedule and other valuable information, will continue to be available on MyAnthem, but you will access it with one log-in to Availity. How can you prepare for this change? If you are your organization's Availity Primary Access Administrator (PAA), continue to use Account Administration to register new users and assign required Availity functionality. Make sure that you have entered each MyAnthem Health Plan ID into Anthem Services Registration on Availity. June of 23

8 If you are your organization's Site Administrator for MyAnthem, continue to use Manage My Users to register new users and assign required Anthem-specific functionality. Note that effective June 21, passwords will no longer be generated, even though users will still need be registered for MyAnthem. Note: We strongly recommend that the Availity PAA also serves as a Site Administrator on MyAnthem. If you are a user today who regularly uses tools on both MyAnthem and Availity, once the above steps are completed, you can go to Availity and see My Payer Portals on the left navigation bar. From there, you can choose Anthem Provider Portal to be navigated into MyAnthem without entering an additional log-in or password. If you go to My Payer Portal, then Anthem Provider Portal today, once you click on the message that you understand you are navigating away from Availity, you will see a message that your access is properly set up and you are all ready for the June 21, 2014 changes. What preparations have begun? As of May 17, 2014, under Anthem Services Registration, Availity PAAs can now see an option to add users to the Provider Portal. If the Availity PAA has registered a user for secure messaging or AIM Specialty Health, the user was automatically granted access to Provider Portal and no further action by the PAA is required. Also, all users with Claims Management or Claims Inquiry access now are automatically able to use secure messaging. Therefore, secure messaging no longer requires a separate registration. What's next? MyAnthem users should work with their Site Administrators to make sure all their MyAnthem accounts have the same log-in. On Availity, only a single MyAnthem ID can be connected through Anthem Services Registration for each user. As a reminder, do you have all of your tax IDs registered on the Availity Web Portal? If not, use Availity's Change Request Form -- Organization Maintenance to add any additional tax IDs. For questions regarding these changes contact a local econsultant at central.eprovider.rep@anthem.com. Availity, an independent company, provides claims management services for Anthem Blue Cross and Blue Shield. FEP AIM program will be expanded to the Federal Employee Program Anthem is dedicated to meeting the evolving needs of our members. With consumers looking for tools to guide better health care decision making, we are pleased to announce that our Imaging Management Solution program has been expanded and will include the Federal Employee Program later this year, in August of Look for additional information and details about the program in the August issue of this newsletter. MO: Smoking cessation program for Blue Preferred Plus POS federal employees In an effort to help reduce future health risks, the Blue Preferred Plus POS Federal Employees Health Benefits Program would like to introduce the Tobacco Cessation benefits that are offered to their members. The benefits provide coverage with no out-of-pocket expense and they include: June of 23

9 individual, group, and telephone counseling coverage for physician prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence You can help guide members to the Living Free Fitness and Health information online at anthem.com>federal Employee Programs>Value Programs>Special Offers. Members can also obtain information through their online registered account at anthem.com. If you have any questions, please contact customer service at Health Care Management Important change: Use ICR for precert status updates Note: The following information does not impact submissions of precertification requests. Effective September 5, 2014, the Anthem Precertification Department will stop providing courtesy notification of status of a case by phone for the Precertification Department numbers listed below. Provider Services and Provider Relations also will not have access to this information. Instead, providers will be directed to utilize our Interactive Care Reviewer (ICR) tool via the Availity Web Portal. You will continue to receive notifications of our determinations consistent with how you have received these notifications in the past. Precertification Department numbers:* , , , , , , , , , If you have not yet discovered the ease of making status inquiries using our ICR, now is a great time to begin viewing the status of any precertification previously submitted via phone, fax, ICR, or other online tool, i.e. ereview, for any member covered by Anthem Blue Cross and Blue Shield, Anthem Blue Cross (California) or Blue Cross and Blue Shield of Georgia. You can access the inquiry functionality under Auths and Referrals on the left navigation bar on You will then be navigated to the ICR tool and once you click I agree to the ICR disclaimer, you will be able to choose which option you want to search by. It is important to note that as our ICR tool evolves, additional courtesy UM status inquiries may shift to online access only. Be on the lookout for upcoming notifications. For example, we will communicate a date soon that the following National toll free numbers will be added to the list of courtesy UM status inquiries that are available exclusively online via ICR. The numbers will include: , , , , , , & Note: This change does not apply to FEP. See the screen shots below for additional detail: June of 23

10 Don t forget you can submit both inpatient and outpatient precertifications online 1. And, as a reminder, if an intermittent outage occurs within the system, you will receive a message to try again later. If your organization is NOT currently registered for Availity: The designated Administrator for your organization should go to Click on "Get Started" under Register Now for the Availity Web Portal, then complete the online registration wizard. The administrator will receive an from Availity with a temporary password and next steps. Not sure if your organization is registered? Call Availity Client Services for registration status of your Tax ID. If your organization is registered for Availity and just needs access to inquiry: 1 Note: ICR submissions are not currently available for Medicare Advantage, Medicaid, FEP, BlueCard and some 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. June of 23

11 Your Primary Access Administrator can grant you access to Authorization and Referral Inquiry. Once you have access to Auths and Referrals on the Availity Web Portal, click on Auth/Referral Inquiry from the left navigation bar and you can start using our tool right away. If your organization is registered for Availity and just needs access to submit a precertification request: Your Primary Access Administrator can grant you access to Authorization and Referral Request. Once you have access to Auths and Referrals on the Availity Web Portal, click on Authorizations from left navigation bar and you can start using our tool right away. Need Training? To learn more about how you can streamline the precertification process by taking advantage of our ICR s many features, register today by clicking here or go to For questions regarding our ICR, please contact your local Network Management consultant. For questions on accessing our tool, call Availity Client Services at 800-AVAILITY ( ) or questions to support@availity.com. Availity Client Services is available Monday-Friday, 8 a.m. to 7 p.m. ET (excluding holidays) to answer your registration questions. 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 Availity, an independent company, provides claims management services for Anthem Blue Cross and Blue Shield Precertification Department is changing IVR prompts Effective September 5, 2014, some of the Precertification Department IVR prompts will change. Callers seeking membership, benefits, or claims information will be directed to customer service. Other callers will be asked to select Behavioral Health or Hospital/Medical Precertification. This is a change from the current system which gives callers five options (For Membership, press 1; Benefits 2, Eligibility 3, Claims 4, Precertification 5.) Medical policy: Code C1300 will require precert The following change applies to these Anthem plans: Blue Priority SM, Blue Preferred Primary, Blue Priority Plus, Blue Preferred Primary Plus, Blue Access, Blue Access Choice, Blue Preferred Plus, Lumenos health plans, Anthem (Bronze/Silver/Gold/Platinum) Direct Access, Anthem Catastrophic/Core/Essential/Preferred) Direct Access, and in some cases Blue Traditional. An additional code, C1300, will require precertification according to current medical policy. The change applies to MED Hyperbaric Oxygen Therapy (Systemic/tropical) and is effective September 3, Note: The change does not apply to some National Accounts, Medicare Advantage (MA), or Federal Employee Plan (FEP). To view medical policies online, go to (select state)>medical Policies and Clinical UM Guidelines. June of 23

12 New MA precertification requirements effective July 1, 2014 There are new 2014 precert requirements for Anthem Medicare Advantage (MA) plans that Anthem made available March 28, 2014 on the Provider Forms section of the Anthem MA public provider portal. These new requirements will go into effect on July 1, The main changes effective in July include the requirement for providers to precert select procedures for Knee Arthroscopy, Pain Management, Cardiac Catheterization, and Pacemakers (with defibrillators). Some of these services were listed as required since January 1, 2014 but are called out here as reinforcement. Please visit the Provider Forms section of the Anthem MA public provider portal ( to see the new precert list that is effective July 1, 2014 as well as the precertification requirements that were effective January 1, 2014 through June 30, To obtain precert or to verify member eligibility, benefits or account information, please call the telephone number listed on the back of the member s identification card. Y0071_14_19693_I_002 Medicare WI: MA carrier priced code updates Effective June 15, 2014, Anthem will update reimbursement rates on the Wisconsin Medicare Advantage Fee Schedule for a small number of Carrier Priced Codes. Per CMS, Carriers establish RVUs and payment amounts for these services. Fee schedules are available for review on our secure MyAnthem Provider TM Portal. Please contact your Network Relations Consultant with any additional questions. Y0071_14_20050_1 05/27/2014 House call program The House Call Program gives our MA members the opportunity to receive non-invasive health services and a health evaluation in the comfort of their own home. Both members and providers benefit from the additional care coordination the program provides: The visiting licensed and credentialed clinician is able to collect information that helps Anthem identify patients who may benefit from case management programs. Our members physicians can use the evaluation forms to match health care needs with the appropriate level of care. Anthem is able to meet its Centers for Medicare & Medicaid Services (CMS) annual obligation for reporting all required diagnoses to CMS for each member for the purpose of risk adjustment. During the visit, the clinician uses a health evaluation form to document all medical conditions that exist on the date of the visit. We will make copies of the completed forms available to the members physicians to include in their records. We will also provide copies of the forms to members at their request. In addition, based on the outcome of the health evaluation, Anthem may conduct post-visit outreach with a member s physician and may make a case management referral. June of 23

13 The House Call Program is a voluntary program offered at no out-of-pocket cost to our MA members. Providers may request a copy of member evaluations by ing housecallprogram-external@wellpoint.com or calling Cheryl Young at or Lisa Ware at MA members receive monthly summary statements Anthem MA members began receiving a new monthly Explanation of Benefits (EOB) in May 2014.The monthly EOB, called the Monthly Report, is a summary of claims processed in the previous month for medical and supplemental services. MA members also will continue to receive per claim MA EOBs. This new monthly report is required by CMS. We bring this new EOB to your attention in case members bring their Monthly Report with them to upcoming office visits medical chart review program Each year, Anthem requests your assistance in our retrospective medical chart review program. This program, which includes a request for our MA members medical charts for 2013 dates of service, is a vital part of Anthem s compliance with CMS guidance that requires MA health plans to collect and report to CMS all member diagnosis data. CMS requires that this data be supported by the member s medical record documentation. To assist with our medical chart review program, Anthem will collaborate with Verisk Health (Verisk), formerly known as MediConnect Global, Inc. (MediConnect). Verisk Health is a leading records retrieval and electronic document management company that specializes in medical records retrieval, coding and delivery via the internet. Verisk s web based workflows will help reduce time and improve efficiency and costs associated with record retrieval, coding and document management. Anthem will be working with Verisk in retrieving and reviewing our MA member medical records. As in previous years, the request for medical records began in the spring of 2014 and will continue throughout the year. Physicians for our MA members play a critical role in the success of this program and our compliance with CMS requirements. By maintaining quality coding and documentation practices and by cooperating with our medical chart requests, you will be instrumental in helping Anthem meet its CMS obligations and will help ensure risk adjustment payment integrity and accuracy. Helping members schedule office visits, screenings Anthem analyzes claim records to identify MA members who may be missing important preventive screenings or other services to manage chronic conditions. We call members to tell them about these services and to offer help scheduling an appointment. If the member would like help scheduling an office visit or screening, we will place a call to the member s physician or screening facility to schedule an appointment while we re on the phone with the member. We continue to make these reminder calls to help ensure our MA members receive the key services recommended by CMS. HEDIS measures help promote quality health care MA health plan ratings are in place to improve an individual s health care experience, improve the overall health of individuals and promote cost-efficient, quality health care. Health Effectiveness Data Information Set (HEDIS) measures associated with these health plan ratings include, but are not limited to: June of 23

14 Colorectal Cancer Screening Breast Cancer Screening Comprehensive Diabetes Care Controlling Blood Pressure Helping ensure that our members receive these important screenings and preventive services will help members better manage chronic conditions and also presents a good opportunity to discuss the importance of early detection. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Preventing opioid overutilization Anthem continues to mail and/or call providers upon identification of MA members with suspected patterns of opioid overutilization due to multiple prescribers and multiple pharmacies. During the phone call, our pharmacists attempt to facilitate a conversation with providers about the appropriate use, medical necessity and safety of the high opioid dosage for their patient. Our goal is to work with providers to prevent overutilization and to determine the appropriate amount of opioids for our members. For more information, please reference: (1) GAO , GAOInstancesofQuestionableAccesstoPrescriptionDrugs.pdf (2) CMS Supplemental Guidance, Coverage/PrescriptionDrugCovContra/Downloads/HPMSSupplementalGuidanceRelated-toImprovingDURcontrols.pdf Y0071_14_19540_I 03/17/2014 Updated self-service telephone options Updated self-service telephony options were added for healthcare providers treating Anthem members covered by Individual and Employer Group Retiree MA PPO and HMO plans, including Anthem Medicare Preferred (PPO), Blue Medicare Access (Regional PPO), Anthem Senior Advantage (HMO) and Anthem MediBlue (HMO). When you call the customer service number on the back of the member s ID card, your call is routed through the Medicare Voice Self Service (VSS) Interactive Voice Response (IVR) system. The IVR system is available 24 hours a day, seven days a week. IVR provides telephone access to real-time eligibility, benefits and claims information for one or multiple MA members in a single call. This ensures quick access to most self-service options as well as provides the necessary information for your call to route to the appropriate agent should you need to speak to someone. To gain access to the self-service menu options or to route to an agent for assistance, you must provide a valid National Provider Identification (NPI) number or Tax Identification Number (TIN). June of 23

15 IN, OH: Bone mineral density screening at no out-of-pocket cost to members com Osteoporosis is a condition that causes brittle and weak bones and may affect the Medicare population. Anthem has initiated optional in-home Bone Mineral Density (BMD) screenings for female MA members in Ohio HMO and LPPO plans and Indiana LPPO plans. Members who have had a fracture in the last six months are contacted and offered an in-home BMD screening for no fee. The results of the screening are faxed to the member s Primary Care Provider (PCP) on file in an effort to coordinate care. Y0017_14_19788_I 04/22/2014 OH: Care coordination available for MA members Anthem is teaming with our vendors to provide individualized high-risk patient management services for our MA members. An interdisciplinary team of case managers, social workers, nurse practitioners and physicians will work with the member and family to ensure the member has a safe discharge and understands what he or she should do to prevent an unnecessary readmission to the hospital. The patient also may receive ongoing care management. Members will be strongly advised to continue follow-up with their PCP. Anthem has engaged these vendors to ease the transition from hospital to skilled nursing facility (SNF) or home for both the member and the member s physician. Y0071_14_19775_I 04/22/2014 Pharmacy Pharmacy information available at anthem.com For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit The drug list is reviewed and updates are posted to the web site quarterly. Quality ConditionCare helps members better manage their 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, 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. Members are stratified into three different risk levels. June of 23

16 Engagement methods vary by risk level but can include: Education about their condition through mailings, telephonic outreach, and/or online tools and resources. Round-the-clock phone access to registered nurses. Guidance and support from Nurse Coaches and other health professionals. Physician benefits: Save time for the physician and staff by answering patient questions and responding to concerns, freeing up valuable time for the physician and their staff. Support the doctor-patient relationship by encouraging participants to follow their doctor s treatment plan and recommendations. Inform the physician with updates and reports on the patient s progress in the program. 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 treatment plan options. To find more information about the program, including program guidelines, educational materials and other resources, go to (select state)> Health and Wellness>ConditionCare. Also on our website is the Patient Referral Form, which you can use to refer patients to the program. If you have any questions or comments about the program, call Our nurses are available Monday-Friday, 9:30 am - 10 pm EST, and Saturday, 10 am 8:30 pm ET/ 8:30 am - 9 pm CST, and Saturday, 9 am 7:30 pm CST. We believe in continuous quality improvement Commitment to our members health and their satisfaction with the care and services they receive is the basis for the Anthem 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 Case management program Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources are frightening and complex issues for some to handle. Anthem is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes the care coordination team s experience and expertise whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care. June of 23

17 Members or caregivers can refer themselves or family members by calling the number located in the grid below. They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us by telephone or electronic means. No issue is too big or too small. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals. How do you contact us? Telephone Number Address Business Hours General centregcmref@anthem.com Monday - Friday :30 am 5 pm EST Medicare National (IN) FEP CM-concierge@wellpoint.com INDYNatlAccts-CM@wellpoint.com n/a Monday - Friday 8 am 5 pm EST Monday - Friday 8 am 5 pm EST Monday Friday 8 am 4:30 pm EST 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 (enter state)> Health & Wellness> Practice Guidelines. Coordination of care Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Anthem would like to take this opportunity to stress the importance of communicating with your patient s other health care practitioners. This includes PCPs and medical specialists, as well as behavioral health practitioners. Coordination of care is especially important for members with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. Anthem urges all of its practitioners to obtain the appropriate permission from these members to coordinate care between behavioral health and other health care practitioners at the time treatment begins. We expect all health care practitioners to: 1. Discuss with the patient the importance of communicating with other treating practitioners. 2. Obtain a signed release from the patient and file a copy in the medical record. 3. Document in the medical record if the patient refuses to sign a release. 4. Document in the medical record if you request a consultation. 5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner. June of 23

18 6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to: Diagnosis Treatment plan Referrals Psychopharmacological medication (as applicable) In an effort to facilitate coordination of care, Anthem has several tools available online at (select state), including a Coordination of Care template and cover letters for both behavioral health and other healthcare practitioners.* In addition, there is a Provider Toolkit on the website with information about Alcohol and Other Drugs which contains brochures, guidelines and patient information.** *Access to the forms and cover letters are available at anthem.com>providers (enter state)>answers@anthem **Access to the Toolkit is available at anthem.com>providers (enter state)>health and Wellness Important information about UM Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member s coverage according to the member s health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Anthem s medical policies are available on Anthem s website at anthem.com. You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us toll-free at the numbers listed below. UM criteria are also available on our website. Just select Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements from the Provider home page at We work with providers to answer questions about the utilization management process and the authorization of care. Here s how the process works: Call us toll free from 8:30 am 6 pm EST, Monday and Friday; 8:30 am 5 pm EST, Tuesday, Wednesday and Thursday. Closed holidays, except Martin Luther King Day, when hours are 8:30 am 6 pm, EST. After business hours, you can leave a confidential voic message. Please leave your contact information so one of our associates can return your call the next business day. Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon. The following phone lines are for physicians and their staffs. Members should call the customer service number on their member ID card. June of 23

19 To discuss UM Process and Authorizations OH IN, KY MO WI For claims or benefits information, call number on back of member s ID card To discuss Peer-to-Peer UM Denials w/physicians Additional Options for precert, pharmacy or radiology or number on back of member s ID card National: or number on back of member s ID card National: or number on back of member s card CDHP/Lumenos: National: or number on back of member s ID card Local WI Nasco: National: To request UM Criteria TTY/TDD 711 or TTY: (V/T) Voice: (V/T) 711 or IN: (V/T) KY: (T/ASCII) (V) 711 or TTY/ASCII: Voice: or TTY: (T) Voice: (V) For FEP: For Medicare: opt 1; Fax; Fax (for providers who previously used or ) For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them. Our UM associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific UM requirements, operational review procedures, and discuss UM decisions with you. Members rights and responsibilities The delivery of quality health care requires cooperation between members, their providers and their health care benefit plans. One of the first steps is for members and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem has adopted June of 23

20 a Members Rights and Responsibilities statement which can be found on our Web site. To access, go to (enter state)>health & Wellness>Quality>Member Rights & Responsibilities. Reimbursement Facility reimbursement: Implant Policy Anthem Blue Cross and Blue Shield in Indiana, Kentucky, Missouri, Ohio, and Wisconsin (individually referred to herein as the Health Plan) reviews its facility reimbursement policies regularly to determine if any changes or revisions are required. The Health Plan will implement a new Implant Policy, effective September 5, The Policy is intended to outline Anthem s definition of implants and to describe Anthem s reimbursement policy regarding implants that are deemed contaminated and/or considered waste and/or were not implanted in the Covered Individual. Implants are objects or materials which are implanted, such as a piece of tissue, a tooth, a pellet of medicine, a medical device, a tube, a graft, or an insert, placed into a surgically or naturally formed cavity of the human body to continuously assist, restore or replace the function of an organ system or structure of the human body throughout its useful life. Implants include but are not limited to: stents, artificial joints, shunts, pins, plates, screws, anchors and radioactive seeds, in addition to non-soluble, or solid plastic materials used to augment tissues or to fill in areas traumatically or surgically removed. Instruments that are designed to be removed or discarded during the same operative session during which they are placed in the body are not implants. In addition to meeting the above criteria, implants must also remain in the Covered Individual s body upon discharge from the inpatient stay or outpatient procedure. Staples, sutures, clips, as well as temporary drains, tubes, and similar temporary medical devices shall not be considered implants. A Facility shall not bill Anthem for implants that are deemed contaminated and/or considered waste and/or were not implanted in the Covered Individual. Additionally, Anthem will not reimburse Facility for implants that are deemed contaminated and/or considered waste and/or were not implanted in the Covered Individual. IN: Facility reimbursement policy notification Anthem Blue Cross and Blue Shield in Indiana (referred to herein as the Health Plan) will adopt the following facility reimbursement policy, effective August 1, The Health Plan considers 3D rendering of imaging studies to be included in the reimbursement for the imaging study performed. The Health Plan considers 3D rendering of imaging studies to be a technology and technique improvement, enabling computer generated real-time interaction with the image volume dataset. Therefore, separate visual enhancements reported with CPT codes and are not eligible for separate or additional reimbursement even when billed with modifier -59. Coding D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation Requiring image post-processing on an independent workstation June of 23