June 2014

In this issue

Page

Announcements 

Company changes alpha prefixes for certain health plans to comply with association requirements 3

Coverage and clinical guideline update 

Coverage and clinical UM guidelines effective September 1, 2014

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Business update 

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New 1500 claim forms should be submitted using appropriate claim software and data element requirements 10 BlueCard® claim adjustments 10 Infusion therapy choice: Lower out-of-pocket expenses and added convenience for members 10 Coding reminder: Reporting screening diagnosis codes 11 Reminder: Use participating laboratories for HMO members – Includes Anthem HealthKeepers Plus members and Anthem HealthKeepers Medicare-Medicaid Plan (MMP) 12 Questions about recovery requests 12 Anthem’s ConditionCare program designed to help members manage chronic conditions 13 We believe in continuous improvement 14 Case Management Program 15 Clinical practice and preventive health guidelines on the Web 15 Coordination of care 16 Important information about Utilization Management 17 Members’ rights and responsibilities 18

Facility footnotes 

Utilization management changes for skilled nursing facilities

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Behavioral health update   

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The final Mental Health Parity Rule released 19 Federal Mental Health Parity 19 Anthem EAP is opening the network to more Virginia providers 22

anthem.com Important phone numbers

VAPENABSNL (06/14)

In this issue, continued

Page

Health care reform update (including Health Insurance Exchange) 

Refer to anthem.com for information about health care reform and the Exchange

22

ICD-10 update 

Statement regarding the delay of the ICD-10 compliance date

23

eBusiness 

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Member eligibility, benefits and claims status functionalities moving exclusively to the Availity Web portal from Point of Care Use Availity for claims inquiries for products that have been purchased on or off the Health Insurance Marketplace Reminder: Out-of-area (BlueCard®) precertification process change effective July 1 Use our online provider directory to search for Anthem-participating health care providers

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FEP update 

Smoking cessation for Anthem HealthKeepers federal employees

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Medicaid information   

AIM Specialty Health outpatient imaging manager Sleep Study Management Program for in-home sleep testing (HST) Topical fluoride varnish 101 update: Bright Smiles for Babies fluoride varnish program

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Medicare information        

House Call Program helps coordinate care for Medicare Advantage members Medicare Advantage members to receive monthly summary statements 2014 Medical chart review program for Medicare Advantage members under way Anthem helps members schedule office visits, preventive screenings HEDIS® measures help promote quality health care Anthem works to prevent opioid overutilization among Medicare Advantage members CPAP/BiPAP devices and related supplies New 2014 Medicare Advantage precertification requirements effective July 1, 2014

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Pharmacy update 

Pharmacy information available on anthem.com

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Bulletin board     

Anthem webinars coming soon – Register today 2014 Medical Office Webinar Schedule and Registration Form Medical office seminars offered statewide 2014 Medical Office Seminar Schedule 2014 Medical Office Seminar Registration Form

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Announcements Company changes alpha prefixes for certain health plans to comply with association requirements

To comply with requirements from the Blue Cross Blue Shield Association, Anthem has begun the process of assigning new alpha prefixes to Virginia members who are enrolled in certain health care plans associated with our individual business. It is important to note that members’ benefits are NOT changing nor have the ID numbers changed. Only the alpha prefix on the member’s ID card contains a different three-letter prefix as follows: 

YTA is changing to YRV

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YTP is changing to YRZ

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YTH is changing to YRX

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YTC is changing to YRW

In April 2014, we began the process of issuing new ID cards, and members can begin using their new cards right away once they receive the new cards. We’ve updated Point of Care – our secure Web-based provider tool – to reflect the new alpha prefixes for the members impacted. As there may be a gap in time before members receive their new ID cards, we suggest that providers refer to Point of Care as the prefix changes in enrollment will display there accurately. While we recommend that providers file claims with the alpha prefix they find on Point of Care, our internal systems will accept either alpha prefix. As a reminder, offices and facilities should request that patients present their most current ID cards at the time of service. When filing claims, please enter the ID numbers exactly as they appear on the card, including the alpha prefix. In addition, when passing along member ID numbers to other providers, such as ordering lab services through LabCorp, medical equipment or home health, be sure to use the members’ current ID cards. This helps avoid reimbursement delays. IMPORTANT NOTE: The alpha prefix change does not impact individual or small group health plans that members purchase “on” or “off” the Health Insurance Marketplace (often referred to as the Exchange). In addition, the change does not apply to our small or large group business.

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Coverage and clinical guideline update Coverage and clinical UM guidelines effective September 1, 2014

Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will implement the following revised coverage guidelines effective September 1, 2014. The guidelines below are among those recently approved by the Medical Policy and Technology Assessment Committee – a group of community providers and Anthem medical professionals. The following coverage guidelines are addressed and available for review on our website at www.anthem.com:

SPECIAL NOTE The services addressed in ALL the coverage guidelines presented in this section (pages 4 through 9) will require authorization for all of our HealthKeepers, Inc. products. A pre-determination can be requested for our PPO products.

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Growth Hormone (DRUG.00009)

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Cardiac Ion Channel Genetic Testing (GENE.00007)

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Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent (GENE.00012) Diagnostic Genetic Testing of a Potentially Affected Individual (Adult or Child) (GENE.00013) Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty (SURG.00001) Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting (SURG.00011) Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions (SURG.00028)

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Endothelial Keratoplasty (SURG.00108)

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Surgical Treatment of Femoroacetabular Impingement Syndrome (SURG.00109)

The following coverage guidelines are also addressed in this edition of the Network Update and will be available for review on our website at www.anthem.com on July 15, 2014: 

Genetic Testing for Hereditary Pancreatitis (GENE.00036)

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Genetic Testing for Macular Degeneration (GENE.00037)

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Genetic Testing for Statin-Induced Myopathy (GENE.00038)

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Cochlear Implants and Auditory Brainstem Implants (Surg.00014)

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Guideline Growth Hormone (DRUG.00009)

Description/Explanation This coverage guideline addresses the use of human growth hormone for the treatment of children, adolescents, and adults with a variety of medical conditions. The medically necessary criteria for the use of growth hormone therapy in children and adolescents with idiopathic growth hormone deficiency were expanded to require signs and symptoms of growth hormone deficiency in addition to a subnormal response of two stimulation tests. A medically necessary indication was also added for children who have had cranial irradiation and have documented evidence of IGF-1 measurement below age-appropriate level with normal thyroid function tests results. HCPCS codes that are currently associated with this revised guideline are J2940, J2941, and Q0515

Guideline Cardiac Ion Channel Genetic Testing (GENE.00007)

Description/Explanation The scope of this coverage guideline was expanded to include genetic testing for all cardiac ion channel mutations, excluding genetic testing for LQTS, to be investigational. This includes but is not limited to: 

Brugada Syndrome (BrS)

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Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)

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Short QT Syndrome (SQTS)

Genetic testing for LQTS remains medically necessary for those that meet the medical necessity criteria. The CPT codes currently associated with this revised coverage guideline are 81280, 81281, 81282, 81404, 81405, 81406, 81407, 81408, and S3861.

Guideline Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent (GENE.00012)

Description/Explanation This revised coverage guideline was expanded to include preconceptional or prenatal genetic testing using panels of genes (with or without next generation sequencing), including but not limited to, whole genome and whole exome sequencing to be investigational unless all components of the panel have been determined to be medically necessary based on the medical necessity criteria. However, individual components of a panel may be considered medically necessary when the criteria are met. At this time, there is no specific CPT code for preconceptional or prenatal testing using panels, whole genome sequencing or whole exome sequencing. CPT code 81479, unlisted molecular pathology procedure, is listed on this revised coverage guideline to represent this test.

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Guideline Diagnostic Genetic Testing of a Potentially Affected Individual (Adult or Child) (GENE.00013)

Description/Explanation The scope of this revised coverage guideline was expanded to include diagnostic genetic testing using panels of genes (with or without next generation sequencing), including but not limited to, whole genome and whole exome sequencing to be investigational unless all components of the panel have been determined to be medically necessary based on the medical necessity criteria. However, individual components of a panel may be considered medically necessary when the criteria are met. At this time, there is no specific CPT code for diagnostic genetic testing using panels, whole genome sequencing or whole exome sequencing. CPT code 81479, unlisted molecular pathology procedure, is listed on this revised coverage guideline to represent this test.

Guideline Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty (SURG.00001)

Description/Explanation This coverage guideline addresses extracranial carotid, vertebral and intracranial artery stent placement with or without angioplasty. The scope of this revised coverage guideline was expanded to include open approach procedures to be medically necessary when the criteria are met. CPT code 37217, Transcatheter placement of an intravascular stent(s), intrathoracic common carotid artery or innominate artery by retrograde treatment, via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed and radiological supervision and interpretation has been added to the guideline for clinical review.

Guideline Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting (SURG.00011)

Description/Explanation This revised coverage guideline, which addresses the use of soft tissue substitutes in wound healing and surgical procedures, clarifies the name of the standard Alloderm product as “AlloDerm Regenerative Tissue Matrix, also known as AlloDerm ® RTM”. The scope was also expanded to include additional allogeneic, xenographic, synthetic, and composite products as investigational. This includes but is not limited to AlloDerm ® RTM Ready to Use. HCPCS code Q4116, AlloDerm, per sq cm, is associated with this coverage guideline.

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Guideline Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions (SURG.00028)

Description/Explanation The scope of this revised coverage guideline was expanded to include prostatic arterial embolization and prostatic urethral lift. When used for the treatment of benign prostatic hyperplasia, both prostatic arterial embolization and prostatic urethral lift are considered investigational. The CPT code currently associated with this revised coverage guideline is 53899 CPT and HCPCS codes 37243, C9739, and C9740 have been added to the guideline for clinical review.

Guideline Endothelial Keratoplasty (SURG.00108)

Description/Explanation This revised coverage guideline addresses the use of a variety of endothelial keratoplasty (EK) techniques, which are used to treat conditions affecting the cornea. These techniques include Descemet’s membrane endothelial keratoplasty (DMEK), Descemet’s stripping endothelial keratoplasty (DSEK), Descemet’s stripping automated endothelial keratoplasty (DSAEK) and Descemet’s membrane automated endothelial keratoplasty (DMAEK) . Other techniques addressed include Femtosecond Laser-Assisted Corneal Endothelial Keratoplasty (FLEK or FLAK) and Femtosecond and Excimer Lasers-Assisted Endothelial Keratoplasty (FELEK). Descemet’s membrane endothelial keratoplasty (DMEK) and Descemet’s membrane automated endothelial keratoplasty (DMAEK) are medically necessary for the treatment of disorders of the corneal endothelium including but not limited to the following:  



Fuch’s endothelial dystrophy; or Aphakic and pseudophakic bullous keratopathy (corneal edema following cataract extracton); or Failure or rejection of a previous corneal transplant

Descemet’s membrane endothelial keratoplasty (DMEK) and Descemet’s membrane automated endothelial keratoplasty (DMAEK) are investigational when used to treat disease or injury of the corneal stroma (e.g. keratoconus, corneal ulcers caused by infection and traumatic corneal injuries) Femtosecond Laser-Assisted Corneal Endothelial Keratoplasty (FLEK or FLAK) and Femtosecond and Excimer Lasers-Assisted Endothelial Keratoplasty (FELEK) are investigational for all indications. CPT codes currently associated with this revised coverage guideline are 65756 and 65757.

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Guideline Surgical Treatment of Femoroacetabular Impingement Syndrome (SURG.00109)

Description/Explanation Femoroacetabular impingement syndrome (FAIS) is an anatomical abnormality of the hip in which there is abnormal contact between the acetabular rim of the pelvis and the femoral head at extremes of joint flexibility; abnormal contact may result in damage to joint cartilage and later lead to degenerative joint disease. The scope of this coverage guideline was expanded to the use of capsular plication for the treatment of femoroacetabular impingement syndrome (FAIS) as investigational under all circumstances. At this time, there is no specific CPT code for capsular plication. CPT code 27999, unlisted procedure, pelvis or hip joint and 29999, unlisted procedure, arthroscopy are listed on this revised coverage guideline to represent this procedure.

Guideline Genetic Testing for Hereditary Pancreatitis (GENE.00036)

Description/Explanation Hereditary pancreatitis is a subset of chronic pancreatitis. It is an autosomal dominant disease that is characterized by frequent attacks of epigastric pain with nausea and vomiting. Genetic testing for hereditary pancreatitis is considered to be investigational. The CPT codes associated with this new coverage guideline are 81222, 81223, 81224, 81401, 81404 and 81479.

Guideline Genetic Testing for Macular Degeneration (GENE.00037)

Description/Explanation Genetic testing for age related macular degeneration (AMD) is aimed at identifying individuals at risk of developing advanced AMD. Currently available genetic tests for AMD include: 

ARMS2 and CFH genetic mutation testing



Macula Risk®

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RetnaGene ™ AMD

Genetic testing for macular degeneration is considered investigational. The CPT codes associated with this new coverage guideline are 81401, 81405, 81408, 81479, and 81599.

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Guideline Genetic Testing for Statin-Induced Myopathy (GENE.00038)

Description/Explanation This new coverage guideline addresses genetic testing for predicting the risk of myopathy in individuals being treated or considered for treatment with statin therapy. Genetic testing for the presence of variants in the SLCO1B1 gene to identify individuals at increased risk of statin-induced myopathy is considered investigational. The CPT code associated with this new coverage guideline is 81400.

Guideline Cochlear Implants and Auditory Brainstem Implants (Surg.00014)

Description/Explanation The scope of this coverage guideline was expanded to include hybrid cochlear implants. Hybrid cochlear implants are considered investigational for all indications. Currently there is no specific code for a hybrid cochlear implant. CPT code 69949, unlisted procedure, inner ear and HCPCS code L8699, prosthetic implant, not otherwise specified are listed on the coverage guideline to represent this service.

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Business update New 1500 claim forms should be submitted 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.

BlueCard® claim adjustments

Recently, you may have received a remittance that indicates that a BlueCard (out-of-area) claim had been adjusted. However, there were no changes to the reimbursement. This claim was adjusted to reconcile some of our BlueCard program claims internally. There were no processing errors, and there is no action required on your part.

Anthem Blue Cross and Blue Shield 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.

Infusion therapy choice: Lower out-of-pocket expenses and added convenience for members

To promote member satisfaction and to help advance positive health care outcomes, we are working collaboratively with physicians regarding infusion therapy options available to our members. For our members who require infusion therapy services, out-of-pocket expenses, the place of infusion service, safety, time and convenience are contributing factors that can impact health care quality, value and member satisfaction. Here’s how you can help. When possible, please consider and share with members the entire range of potential options available regarding infusion therapy. While the hospital is one option, please include alternative locations – such as office or

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home – when discussing/ordering infusion therapy for members who require these services. In addition, please inform members of any potential self-injection alternatives if appropriate, as members may prefer these convenient and lower-cost options. Referring members who require infusions therapy services to safe, lower-cost settings may result in significant savings in time and out-of-pocket expenses. Members will also appreciate the convenience and the flexibility. Our members count on their physicians to provide comprehensive information so the members can make informed decisions about their health care choices. Members may have questions about alternate settings in which they can receive their intravenous infusions and costs associated with other aspects of their intravenous infusion therapy. To help members maximize their benefits, we may contact members and their physicians in the near future, informing them of opportunities for quality, lower-cost options for intravenous infusion services. As always, you should refer members who require intravenous infusions to the location you deem appropriate. However, we encourage you to discuss with our members the options available to get their intravenous infusions safely and conveniently, at a lower out-of-pocket cost.

Coding reminder: Reporting screening diagnosis codes

We value preventive services, and we encourage our members to seek appropriate care. It is very important for providers to use appropriate ICD-9 diagnosis coding guidelines when reporting preventive services, such as preventive “screening” mammograms. When inappropriate ICD-9 diagnosis codes are submitted in the first diagnosis position on the claim form, claims can be processed incorrectly resulting in payments with higher cost shares for members. To help reduce our claim adjustments and your corresponding refunds to members, we are recommending the following approach, which is based on information from the ICD-9-CM Official Guidelines for Coding and Reporting (http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm#guidelines). To help summarize the portion of the guidelines that indicates what may be done when a condition is encountered during a screening, we have included the helpful tip below. When an individual presents to the office solely for the purpose of a screening exam (such as a screening mammogram), without any signs or symptoms of a disease, then a screening diagnosis code may be listed in the first diagnosis position on the claim form. In the event that a “condition” is discovered, during the course of the screening exam, then the code for the condition may then be reported as an additional diagnosis to the screening diagnosis on the claim form.

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Reminder: Use participating laboratories for HMO members Includes Anthem HealthKeepers Plus members and Anthem HealthKeepers Medicare-Medicaid Plan (MMP) members Laboratory Corporation of America (LabCorp) and its subsidiaries Dianon Systems, Inc., Litholink and MedTox are the only participating laboratory providers for ALL HMO outpatient laboratory testing* except for those lab services included on the inoffice laboratory list 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.

Questions about recovery requests Have you received a recovery request letter from Anthem, and you have questions or wish to discuss further? We’re here to help – just call us toll free at 1-800-221-8782 to speak with an Anthem representative.

In some situations, a participating pathologist acts as a subcontractor to perform the professional component of reference laboratory services to hospital inpatients and outpatients and ambulatory surgery center patients. In these situations, providers should file claims to HealthKeepers, Inc. with the professional 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.

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., Litholink and MedTox 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. Note to Pathologists: the place of service billed should represent the location where specimens are collected, such as inpatient, outpatient or ASC. I. Non-Participating HMO Laboratories: We expect Providers to make best efforts to use in-network participating laboratories. In the event that necessary testing cannot be performed by an in-network laboratory, physicians must:

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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.

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Description of the service to be rendered.

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Statement informing member that HealthKeepers is NOT liable for payment. The member is financially liable for the test(s).

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Estimated cost of test(s).

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Date, time and member’s signature.

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 www.labcorp.com under the Find a Lab option. 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 1-800-762-4344. * 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.

Anthem’s ConditionCare program designed to help 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 understand their condition(s), their doctor’s orders and better self-manage their condition. Members are stratified into three different risk levels. Engagement methods vary by risk level but can include: 

Education about health conditions through mailings, telephonic outreach, and/or online tools and resources.

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Round-the-clock phone access to registered nurses.

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Guidance and support from nurse coaches and other health professionals.

Physician benefits: 

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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 physician-patient relationship by encouraging participants to follow their physician’s treatment plan and recommendations. Informs the physician with updates and reports on the patient’s progress in the program.

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 his or her treatment plan. Please visit anthem.com to find more information about the program such as program guidelines, educational materials and other resources. Go to anthem.com and click on “Providers” near the top right side of the Web page. Select Virginia and click Enter. Go to Health and Wellness tab and then click on ConditionCare. Or, if you prefer, use the following link: http://www.anthem.com/wps/portal/ahpprovider?content_path=shared/noapplication/f0/s0/t0/pw_e183013.htm&state=va&root Level=1&label=Condition Care You’ll also find the Patient Referral Form on this page of our website that you can use to refer other patients you feel may benefit from our program. Additional questions If you have any questions or comments about the program, call toll free 877-681-6694. Our nurses are available MondayFriday, 8:30 a.m. to 9 p.m. CST, and Saturday, 9 a.m. to 7:30 p.m. CST.

We believe in continuous improvement

Commitment to our members’ health and their 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 www.anthem.com.

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Case Management Program Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle. Anthem is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care. Members or caregivers can refer themselves or family members by calling the number located in the table below. They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals. How do you contact us?

CM Telephone Number 1-877-332-8193 (Local/Commercial only) Medicare 1-866-797-9884 National 1-877-447-6481 Federal Employee Program 800-711-2225

CM Email Address [email protected] [email protected] [email protected]

CM Business Hours Monday – Friday 8 a.m. – 5 p.m. Monday – Friday 8 a.m. – 5 p.m. EST Monday – Friday 8 a.m. – 5 p.m. Monday – Friday 8 a.m. – 4:30 p.m. EST

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 – all 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. From there, select “Provider” and Virginia, then Health & Wellness> Practice Guidelines. Or, if you prefer, select the following link: http://www.anthem.com/wps/portal/ahpprovider?content_path=provider/va/f2/s2/t0/pw_a035223.htm&state=va&rootLevel=1&l abel=Practice%20Guidelines

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Coordination of care

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Anthem Blue Cross and Blue Shield would like to take this opportunity to stress the importance of communicating with your patients’ other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners. Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. Anthem urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between Behavioral Health and other health care practitioners at the time treatment begins. We expect all health care practitioners to: 1.

Discuss with the patient the importance of communicating with other treating practitioners.

2.

Obtain a signed release from the patient and file a copy in the medical record.

3.

Document in the medical record if the patient refuses to sign a release.

4.

Document in the medical record if you request a consultation.

5.

If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.

6.

Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to: 

Diagnosis

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Treatment plan

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Referrals (specialty care reviews)

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Psychopharmacological medication (as applicable)

In an effort to facilitate coordination of care, Anthem has several tools available on the provider website including a Coordination of Care template and cover letters for both Behavioral Health and other 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>Provider Home>Answers@Anthem **Access to the Toolkit is available at anthem.com>Providers>Provider Home>Health and Wellness

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Important information about Utilization Management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Anthem’s Coverage and Clinical UM Guidelines 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 “Coverage & Clinical UM Guidelines, and Pre-Cert Requirements” from the Provider home page at anthem.com. We work with providers to answer questions about the utilization management process and the authorization of care. Here’s how the process works: 

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Call us toll free from 8 a.m. - 5 p.m. Eastern. Monday through Friday (except on holidays). After business hours, you can leave a confidential voicemail 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 health plan ID card.

To discuss UM Process and Authorizations

1-800-533-1120 Follow the prompts

To Discuss Peer-to-Peer UM Denials with Physicians 1-800-533-1120 Follow the prompts

To Request UM Criteria

1-800-533-1120 Follow the prompts

TTY/TDD

711 or TTY: 800-828-1120(T) Voice: 800-828-1140(V)

Behavioral Health: Behavioral Health: Behavioral Health: 1-800-991-6045 1-800-991-6045 1-800-991-6045 For Medicare: 1-866-797-9884 opt 1 1-866-959-1537 – Fax 1-888-449-4642 – Fax (for providers who previously used 1-800-266-3504 or 1-877-236-5173) Federal Employee Program Members: 1-800-860-2156 Hours: 8 a.m. – 7 p.m. EST

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For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them. Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.

Members’ rights and responsibilities The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement. It can be found on our website. To access, go to the "Provider" home page at www.anthem.com. From there, select “Provider” and Virginia> then Health & Wellness> Quality > Member Rights & Responsibilities.

Facility footnotes Utilization management changes for skilled nursing facilities

Utilization management decisions are performed using objective criteria that are based on reasonable medical evidence. Criteria is reviewed at least annually and updated if necessary. The member’s individual needs and the availability of services within the local delivery system are assessed at the time of determination of medical necessity. Many post-acute inpatient facilities have been accustomed to providing an admission review and then a clinical review every seven days. This process will change effective July 1, 2014, to a frequency based on the current status of the member and will be more frequent than every seven days. Please note that this notification impacts our commercial lines of business.

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Behavioral health update The final Mental Health Parity Rule released

The federal government released the final Mental Health Parity Rule on November 13, 2013. This replaces the temporary rule from February 2010. As a result, Anthem Blue Cross and Blue Shield will apply this final rule to our new or renewing benefit plans, effective on or after July 1, 2014. The intent of the rule is to ensure that patient access to mental health or substance abuse services is the same access to medical services. Note: The Affordable Care Act (ACA) or health care reform law expanded the mental health parity rule to affect small group and individual plans. Grandfathered small groups are still exempt from the law and benefit plans (small group or individual) purchased under Medicare. For more on the rule, please click here.

Federal Mental Health Parity

Effective July 1, 2014, Anthem is making changes to our coverage and billing guidelines to be in compliance with the Federal Mental Health Parity Laws. What is the Federal Parity Law? Millions of Americans with mental health or substance abuse disorders do not have adequate insurance protection against the costs of treatment for mental and substance abuse disorders. The Mental Health Parity and Addiction Equity Act (MHPAEA) makes it easier for those Americans to get the care they need by prohibiting certain discriminatory practices that limit insurance coverage for behavioral health treatment and services. How the Mental Health Parity and Addiction Equity Act Works The Mental Health Parity and Addiction Equity Act (MHPAEA) requires many insurance plans that cover mental health or substance abuse disorders to offer coverage for those services that are no more restrictive than the coverage for medical/surgical conditions. This requirement applies to: 

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Copays, coinsurance, and out-of-pocket maximums

Limitations on services utilization, such as limits on the number of inpatient days or outpatient visits that are covered

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

The use of care management tools

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Coverage for out-of-network providers

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Criteria for medical necessity determinations

CHANGES IN COVERAGE AND BILLING GUIDELINES EFFECTIVE JULY 1, 2014 New residential treatment benefits Effective July 1, 2014, Anthem will cover residential treatment for substance abuse and mental health covered services. An agreement or an amendment to your current agreement is required to participate in this network. A residential treatment facility (RTF) is an inpatient psychiatric or substance abuse facility that provides psychiatric, substance abuse and other therapeutic and clinically informed services to individuals whose immediate treatment needs require a structured 24-hour residential setting that provides all required services (including schooling) on site. Services provided include, but are not limited to, multi-disciplinary evaluation, medication management, individual, family and group therapy, parent guidance, substance abuse education/counseling (when indicated) and other support services including on site education (where appropriate), designed to assist the person to achieve success in a less restrictive setting. RTF programs must be under the direction of a board-eligible or certified child psychiatrist or general psychiatrist with experience in the treatment of children (if the RTF provides services to children and adolescents). RTF programs must be accredited by the Joint Commission on Accreditation of Healthcare Organizations, (JCAHO) the Commission on Accreditation of Rehabilitation Facilities (CARF) or the Council on Accreditation (COA) must accredit the program as a residential treatment facility. Hospital licensure is required if the treatment is hospital based. Residential Treatment Psychiatric Patient is a Covered Individual who is admitted to a residential treatment program and during such admission receives psychiatric Covered Services (including eating disorders, but not including Covered Services for substance abuse). Residential Treatment Substance Abuse Patient is a Covered Individual who is admitted to a residential treatment program and during such admission receives substance abuse Covered Services. SPECIAL NOTE: For members enrolled in the Blue Cross Blue Shield Service Benefit Plan (also known as the Federal Employee Plan or FEP), services performed or billed by Residential Treatment Centers are not a covered benefit in 2014. NEW PARTIAL DAY AND INTENSIVE OUTPATIENT BILLING GUIDELINES Effective July 1, 2014, partial day and intensive outpatient covered services must be billed on a UB claim form as an outpatient service using bill type 131 and the revenue codes specific to the services as listed below. This service cannot be billed as an inpatient service for any services with an admit date on or after July 1, 2014. Any claims submitted for admit dates of July 1 and after that are not submitted as an outpatient claim will be returned to the provider. For admit dates prior to July 1, bill the claim as you currently do. For Example: if the patient’s treatment begins on June 15 and ends on July 1, submit this claim using the criteria that is in effect on June 15. If the patient is admitted in to the program on July 1 or after, then the claim must be billed as an

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outpatient claim using bill type 131 and the revenue codes listed below for the service. Revenue Code 183 (furlough Days) will no longer be accepted for this type of service. In addition, intensive outpatient mental health services will now be a covered benefit for our members. Please contact your provider representative for information to participate in this network. A Partial Day Program is a licensed or approved day or evening treatment program that includes the major diagnostic, medical, psychiatric and psychosocial rehabilitation treatment modalities designed for psychiatric or substance abuse patients who require coordinated, intensive, comprehensive and multi-disciplinary treatment with such program lasting a minimum of six or more continuous hours per day. The term "Partial Day Program" shall also refer to intensive outpatient programs for treatment of alcohol or drug dependence which provides treatment over a period of three or more continuous hours per day. Partial Day Psychiatric Patient is a Covered Individual who is admitted to a Partial Day Program and during such admission receives psychiatric Covered Services (not including Covered Services for substance abuse), remains in the Partial Day Program a minimum of six (6) hours per day, but does not remain in the Partial Day Program overnight. Effective July 1, 2014, all Partial Day Psychiatric Patient Covered Services must be billed as an outpatient service using bill type 131 and revenue code 912 for each unit of care. Partial Day Substance Abuse Patient is a Covered Individual who is admitted to a Partial Day Program and during such admission receives substance abuse Covered Services, remains in the Partial Day Program a minimum of six (6) hours per day, but does not remain in the Partial Day Program overnight. Effective July 1, 2014, all Partial Day Substance Abuse Covered Services must be billed as an outpatient service using bill type 131 and revenue code 913 for each unit of care. Intensive Outpatient refers to a Covered Individual who is admitted to a Partial Day Program and during such admission receives substance abuse or mental health services, remains in the Partial Day Program a minimum of three (3) hours per day, but less than six (6) hours per day, and does not remain in the Partial Day Program overnight. Effective July 1, 2014, all Intensive Outpatient Covered Services must be billed as an outpatient service using bill type 131 and revenue code 905 (substance abuse) or 906 (Mental Health). SPECIAL NOTE: FEP does not require precertification for Intensive Outpatient or Partial Day Programs but must be medically necessary for 2014. NEW METHODONE TREATMENT BENEFITS Effective July 1, 2014, Anthem will cover methadone treatment for our members. An agreement or an amendment to your current facility agreement is required to participate in the network. Methadone treatment is a comprehensive treatment program that involves the long-term prescribing of methadone as an alternative to the opioid on which the member was dependent. Central to methadone treatment is the provision of counseling, case management and other medical and psychosocial services. Programs must have a dispensing unit, counseling offices, examining rooms and an administrative area. In addition to dispensing medication, programs must also provide counseling and other medical services. The federal agency responsible for oversight of methadone treatment is the Center for Substance Abuse Treatment (CSAT), an agency of the Substance Abuse and Mental Health Services Administration (SAMHSA) which is part of the U.S. Department of Health and Human Services. Clinics must be certified by SAMHSA.

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These services will also be covered and reimbursed directly to professional providers who use CMS-1500 forms for billing purposes. If your practice/facility offers any of the new services listed above, and you would like to participate in the network or need additional information about professional reimbursement and billing, please contact your provider network manager or consultant.

Anthem EAP is opening the network to more Virginia providers

SPECIAL NOTE: Methadone Treatment is a medical benefit in FEP for 2014. Anthem’s Employee Assistance Program (EAP) is now accepting applications to join the EAP from all participating Virginia behavioral health providers. Go to Anthem EAP > Providers > scroll to Panel Consideration and follow the instructions to request an application.

Health care reform (including Health Insurance Exchange) Refer to anthem.com for information about health care reform and the Exchange

We continue to post information on our dedicated Web pages regarding health care reform and the health plans HealthKeepers, Inc. is offering on and off the Exchange. Click either of these Web pages Health Care Reform or Health Insurance Exchange for more information, and refer back to these pages often. We’d like to draw your attention to recent postings regarding new online processes for electronic remittance advices and management of paper remittances. A second posting includes additional information regarding grace periods for our members who have purchased health plans on or off the Exchange. New Online Processes for ERA Only Registration and Provider Management of Paper Remittance Vouchers – May 2014 Verify Member Grace Period Status Electronically Using Point of Care, Availity and EDI – May 2014

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ICD-10 update Statement regarding the delay of the ICD-10 compliance date

On April 1, 2014, the Protecting Access to Medicare Act of 2014 was signed into law. The bill includes a provision that effectively delays the implementation of ICD-10 diagnosis and inpatient procedure codes for at least one year. Anthem is committed to meeting the requirements of all mandates, including the implementation of the ICD-10 code set. We are currently assessing the impact of this change. Our plans will continue to be updated as we receive more information about the ultimate ICD-10 implementation date. Anthem is able to accept the revised CMS-1500 claim form (incorporating changes that will accommodate ICD-10) that became effective on April 1, 2014. No ICD-10 codes should be submitted on claims, however until the mandated compliance date. Note that the new version of the form is not required, and Anthem will be able to accept and process claims submitted using either version of the form. Anthem will continue to work to help ensure that our systems, supporting business processes, policies and procedures successfully meet the implementation standards and deadlines without interruption to day-to-day business practices. We will be capable of accepting and processing ICD-10 diagnosis and inpatient procedure codes on the mandated compliance date.

eBusiness Member eligibility, benefits and claims status functionalities moving exclusively to the Availity Web portal from Point of Care

In our April 2014 edition of the Network Update, we shared with you our plans to begin transitioning certain functionality from Point of Care to Availity. Anthem Blue Cross and Blue Shield is working with Availity to offer a multi-payer portal solution that gives you secure, single sign-on access to multiple payers' information. You can access eligibility, benefits, claims status, claim submission, patient care summary, care reminders, member certificate booklets on Availity – all free of charge. Availity also offers access to ask a question about a claim via Secure Messaging and link to Point of Care for online remittances and medical management. Due to Availity's ease of use, broad functionality and breadth of services, Anthem will transition some of our electronic tools to exclusive access via Availity by December 12, 2014. After this time, these functions will no longer be available on Point of Care.

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

Eligibility

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Benefits

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Claim Status Inquiry

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151 Form

How to get started To register for access to Availity, go to www.availity.com/providers/registration-details/. It's that simple.

IMPORTANT: Please ensure that all Availity users in your practice or facility have their own INDIVIDUAL User ID and password for Availity. Logins CANNOT be shared. If your organization has multiple tax identification numbers (TINs), please ensure that individuals are registered to every TIN to which they will require access. Click here and we'll walk you through setting up a new user. Here’s how you can help make it even easier for users to navigate between Availity and Point of Care By entering each user’s Point of Care user ID in to Anthem Services Registration on Availity’s Web Portal and checking the box next to the access called Blue Cross Blue Shield Provider Portal, each user will be able to go to My Payer Portal/Anthem Provider Portal on Availity and navigate to their Point of Care account without entering another log in and password. Free Training Once you log into the secure portal, you'll have access to many resources to help jumpstart your learning, including free live training, frequently asked questions, and comprehensive help topics. To view the current training webinar schedule, click Free Training at the top of any page in the Availity portal or click www.rsvpbook.com/availitytraining to find a current schedule of FREE Availity workshops and webinars. Client service representatives are also available Monday through Friday to answer your questions toll free at 800AVAILITY(800-282-4548). SPECIAL NOTE: Electronic transactions submitted via our Enterprise EDI Gateway are unaffected; you may continue to submit all X12 transactions through your current EDI transmission channels.

Use Availity for claims inquiries for products that have been purchased on or off the Health Insurance Marketplace

If you would like to submit an electronic inquiry about a claim for one of our new products that our members have purchased on or off the Health Insurance Marketplace (commonly referred to as the Exchange), you will need to use Availity – our

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secure Web-based provider tool. You can submit an inquiry for any Anthem claim using Availity. However, claim inquiries for our new Exchange products must be done on Availity. All you need to do is: 

View the claim in Availity

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From the claim status page, click a link to create a Secure Message



Enter information as appropriate and complete your Secure Message

For easy reference, a grid that has the prefixes for the new Exchange products is available online at anthem.com using the following link: http://www.anthem.com/provider/va/f1/s0/t0/pw_e211680.pdf?refer=ahpprovider&state=va

Reminder: Out-of-area (BlueCard®) precertification process change effective July 1 As we shared with you in the April 2014 edition of the Network Update, the Blue Cross and Blue Shield Association (BCBSA) is implementing some new requirements beginning July 1. For your easy reference, we are once again including the notification here. Effective July 1, 2014, PAR/Host Plans must require all participating providers to: 

Obtain Pre-Service Review for inpatient facility services unless otherwise specified in the Member and/or account contract. -

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Providers must notify the Control/Home Plan within 48 hours when a change to the original Pre-Service Review occurs unless otherwise specified in the Member and/or account contract. Information on how to access and obtain precertification is below.

Obtain Pre-Service Review for emergency and/or urgent admission within 72 hours unless otherwise specified in the Member and/or account contract. Hold Members harmless when Pre-Service Review is required and not received for inpatient facility services, unless responsibility for Pre-Service Review is otherwise specified in the Member and/or account contract.

You may now obtain precertification for out-of-state members through the Availity® Web Portal for admissions, elective procedures and request approval for out-of-network services to be covered. Below is how to access this portal. New Electronic Provider Access (EPA) feature available Anthem Blue Cross and Blue Shield (Anthem) now offers the ability to issue precertification for out-of-state members through the Availity® Web Portal. This new functionality routes providers to the Home Plan of an out-of-state member and from there, providers can access the Home Plan’s electronic precertification capabilities, if available. [Note: In accordance with a Blue Cross Blue Shield Association (BCBSA) mandate, Blue Cross Blue Shield plans have until mid2014 to fully comply if they offer an electronic precertification tool.]

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To access this functionality via the Availity Web Portal, users must have access to “Authorization and Referral Request” and select Authorizations under Auths and Referrals on the Availity left navigation menu. For precertification of services, users then choose Anthem as the payer, choose their organization if applicable, and then enter the prefix of the member along with the expected date (s) of service. If the prefix is for an out-of-state member, users will be prompted to add their Tax ID and National Provider Identifier (NPI) number. At that point, users will then be routed to the electronic precertification tool for the member’s Home Plan, if available. If the Home Plan does not have electronic capabilities, then traditional phone or fax methods of precertification need to be utilized. Point of Care users If you are using our other Web-based provider tool – Point of Care – and you are a provider in Virginia requesting precertification of services for an out-of-state member, the following message will display on Point of Care: “This authorization is not available from the Virginia Plan. To complete the authorization at the member’s Home Plan, please use Availity.com. To continue with your request here, please provide the following additional data so Anthem can submit the authorization request to the member Blue Cross Blue Shield Home Plan. Please be patient while we process this request.” Additional information If you have questions, please contact your local network manager, or contact Availity at 800-AVAILITY (800-282-4548) or e-mail questions to [email protected]. Availity Client Services is available Monday-Friday, 8 a.m. to 7 p.m. ET (excluding holidays). Availity, an independent company, provides claims management services for Anthem Blue Cross and Blue Shield.

Use our online provider directory to search for Anthem-participating health care providers

Visit the Virginia provider section of our website at www.anthem.com to view online provider directories that give you up-to-date information based on specific networks – including providers who participate in our networks or those whose network status may have changed. We routinely update our website as information becomes available to help ensure our online provider directory contains accurate and current information regarding the network participation status of primary care physicians (PCPs), specialists, hospitals and other health care providers. As before, printed copies of provider directories are only available upon request – simply dial toll free 800-533-1120 and select option 2, option 4 and then option 1 to speak with an Anthem representative.

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FEP update Smoking cessation for Anthem HealthKeepers federal employees

In an effort to help reduce future health risks, we would like to introduce the tobacco cessation benefits that are available to members enrolled in the Anthem HealthKeepers Federal Employees Health Benefits Program. The benefits provide coverage with no out-of-pocket expense and include: 

Tobacco cessation programs

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Physician prescribed over-the-counter (OTC) and FDA-approved drugs for the treatment of tobacco use

Providers 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 providers have any questions, they can contact our customer service area at 855-580-1200.

Medicaid information AIM Specialty Health outpatient imaging manager

Effective July 1, 2014, AIM Specialty Health (AIM) will provide outpatient imaging services for our members enrolled in the Anthem Medicare Preferred Plan and/or Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan (Anthem HealthKeepers MMP). We will continue to process claims as in the past. In addition, there will be NO changes to: 

Clinical and coverage guidelines

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Network of providers offering radiology services to our members

Health service reviews (prior authorizations) are currently required for the following services: 

Computer tomography (CT/CTA) scans

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Nuclear cardiology

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

Magnetic resonance (MRI/MRA)

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Positron emission tomography (PET) scans

Health service reviews (prior authorizations) will be required, effective July 1, 2014, for the following service: 

Echocardiogram (ECHO)

Remember: 

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The ordering provider is responsible for obtaining a health services review (prior authorization). To obtain this authorization: -

Online: go to www.aimspecialtyhealth.com/goweb

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By phone, call AIM at 1-800-714-0040 Monday through Friday, 8 a.m.– 5 p.m. Eastern time

Fax requests will no longer be accepted for high tech radiology. Providers rendering the above services should verify that the necessary health services review was obtained in advance. Failure to do so may result in denied claims. Imaging and procedures performed as part of inpatient or urgent/emergent care do not require authorization.

We appreciate your support and look forward to your assistance in assuring our Anthem Medicare Preferred and HealthKeepers MMP members receive diagnostic imaging services in a clinically appropriate fashion. Additional Anthem Medicare information is located on our www.anthem.com website HERE, while additional Anthem HealthKeepers MMP information can be found online at https://mediproviders.anthem.com/va/pages/home.aspx. Adherence to the new procedures is required to ensure appropriate payment of claims. Should you have questions, please contact Anthem Medicare Preferred Provider Services toll free at 1-866-805-4589 or Anthem HealthKeepers MMP Customer Care at 1-855-817-5788.

Sleep Study Management Program for in-home sleep testing (HST)

We’re including in this edition of the Network Update information regarding our new sleep study management program for in home sleep testing (HST) as it relates to our Medicaid plans and Medicaid-Medicare plan (MMP). Effective May 15, 2014, HST became available for members enrolled in: 

Anthem HealthKeepers Plus, including Medicaid and FAMIS

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

Anthem HealthKeepers Medicare-Medicaid plan (MMP), a Commonwealth Coordinated Care plan (Anthem HealthKeepers MMP).

Members who are suspected of having non-complicated Obstructive Sleep Apnea will have the ability to test at home using the AccuSom wireless HST device provided by vendor NovaSom. How NovaSom works We selected NovaSom Inc. as our exclusive vendor of home sleep tests and services. NovaSom provides telephonic clinical support, allowing for self-administered sleep studies in your patient’s home. This allows for enhanced comfort and test results more reflective of typical sleeping behaviors. All data is wirelessly transmitted from the AccuSom™ sleep testing device to the NovaSom secure portal during the test process. Data are reviewed by sleep technicians to assure quality, and daily clinical telephonic support is provided to coach the patient throughout the testing process. Once the study is complete, a board-certified sleep physician interprets the study and provides a report with treatment recommendations. The goal is to provide reports within 48 hours of study completion to ordering physicians. Treatment Many members who completed HST and were found to have Obstructive Sleep Apnea may not require Continuous Positive Airway Pressure (CPAP) titration. Members may benefit from Auto-titrating Positive Airway Pressure (APAP) therapy, allowing patients to continue their treatment at home without traditional CPAP titration. Pre-authorization for CPAP/APAP will be required through the code: E0601. Pre-authorization for participation We will require pre-authorizations for all sleep studies as well as verification of clinical appropriateness for using a lab versus home setting. Pre-authorization for all sleep tests are required for the following codes:         

95782 95783 95800 95801 95806 95807 95808 95810 95811

Once a home sleep test is pre-certified, we will contact NovaSom to set up the home testing and send out the needed equipment to our member. To submit pre-authorization or fax requests, please refer to the following table:

Anthem HealthKeepers Plus Anthem HealthKeepers MMP

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Pre-authorization Requests Dial 1-800-454-3730 Dial 1-855-817-5788

Fax Requests Dial 1-800-964-3627 Dial 1-800-964-3627

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Questions For any questions regarding the procedure for home testing, call the NovaSom’s inside sales department at 1-877-753-3776.

Topical fluoride varnish 101 update: Bright Smiles for Babies fluoride varnish program

The Virginia Department of Health’s Bright Smiles for Babies (BSB) fluoride varnish program trains medical providers to do oral screenings and fluoride varnish applications for children who are at high risk for developing early childhood caries. The procedure takes less than two minutes and can be performed by physicians, nurses, physician assistants and nurse practitioners. Medicaid, including all Managed Care Organizations in Virginia, reimburses medical providers for six applications between the ages of 6 months and the third birthday at $20.79 per application. The BSB training components include oral risk assessment and screening, fluoride varnish application, parent counseling and local dental referrals. The training can be held in your office at your convenience, and consists of a two-hour power point with a hands-on demonstration. You receive a “start-up” kit and other resources you need to implement the program. There is no charge for the training. If you are interested in more information or to schedule a training session, please contact: Susan Pharr, RDH, MPH Early Child Oral Health Coordinator Dental Health Program Virginia Department of Health [email protected] 804-864-7782

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Medicare information House Call Program helps coordinate care for Medicare Advantage members

The House Call Program gives our Medicare Advantage 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: 

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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 meet our 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. The House Call Program is a voluntary program that we offer at no out-of-pocket cost to our Medicare Advantage members. Providers may request a copy of member evaluations by e-mailing [email protected] or calling Cheryl Young at 513-770-7088 or Lisa Ware at 513-770- 7515.

Medicare Advantage members to receive monthly summary statements

Anthem Medicare Advantage members began receiving a new monthly Explanation of Benefits (EOB) in May 2014.The monthly EOB called the “Monthly Report” is a summary of medical and supplemental services claims processed in the previous month. Medicare Advantage members also will continue to receive “per claim” Medicare Advantage EOBs. This new monthly report is required by the Centers for Medicare & Medicaid Services. We bring this new EOB to your attention in case members bring their Monthly Report with them to upcoming office visits.

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2014 Medical chart review program for Medicare Advantage members under way

Each year, Anthem requests your assistance in our retrospective medical chart review program. This program, which includes a request for our Medicare Advantage members’ medical charts for 2013 dates of service, is a vital part of Anthem’s compliance with CMS guidance that requires Medicare Advantage 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 be collaborating 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 Medicare Advantage member medical records. As in previous years, the request for medical records began in the spring of 2014 and will continue throughout the year. As the physician for our Medicare Advantage members, you 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.

Anthem helps members schedule office visits, preventive screenings

Anthem analyzes claim records to identify Medicare Advantage 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 Medicare Advantage members receive the key services recommended by the Centers for Medicare & Medicaid Services.

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HEDIS® measures help promote quality health care

Medicare Advantage health plan ratings are in place to improve an individual’s health care experience, improve the overall health of individuals and to 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: 

Colorectal Cancer Screening

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Breast Cancer Screening

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Comprehensive Diabetes Care

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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).

Anthem works to prevent opioid overutilization among Medicare Advantage members

Anthem continues to mail and/or call providers upon identification of Medicare Advantage 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-11-699, http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/GAOInstancesofQuestionableAccesstoPrescriptionDrugs.pdf

2)

CMS Supplemental Guidance, http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/HPMSSupplementalGuidanceRelated-toImprovingDURcontrols.pdf

Y0071_14_19540_I 03/17/2014

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CPAP/BiPAP devices and related supplies

The Continuous Positive Airway Pressure Device (CPAP) and Bi-level Positive Airway Pressure Device (BiPAP) are covered pieces of durable medical equipment (DME) for Anthem Medicare Advantage members when medically necessary. In order to ensure that your claims are not unnecessarily delayed or denied, we strongly encourage you to obtain prior authorization from Anthem. For a more detailed list of the criteria used to determine coverage of CPAP/BiPAP devices, CLICK HERE.

New 2014 Medicare Advantage precertification requirements effective July 1, 2014

There are new 2014 precertification requirements for Anthem Blue Cross and Blue Shield (Anthem) Medicare Advantage plans that Anthem made available March 28, 2014. Please see the Provider Forms section of the Anthem Medicare Advantage public provider portal. These new precertification requirements will go into effect on July 1, 2014. The main changes effective in July are the requirement for providers to pre-certify select procedures for: 

Knee Arthroscopy

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Pain Management

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Cardiac Catheterization

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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 Medicare Advantage public provider portal (www.anthem.com/medicareprovider) to see the new precertification list that is effective July 1, 2014, as well as the precertification requirements that were effective January 1, 2014, through June 30, 2014. To obtain precertification or to verify member eligibility, benefits or account information, please call the telephone number listed on the back of the member’s identification card.

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Pharmacy update Pharmacy information available on anthem.com

For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit http://www.anthem.com/pharmacyinformation . The drug list is reviewed and updates are posted to the website quarterly. For state-sponsored business (Medicaid), visit SSB Pharmacy Information.

Bulletin board Anthem webinars coming soon – Register today

Only two more webinars remain for the year. Don’t miss an opportunity to attend one of these online sessions. For your convenience, we offer these informative, hourly sessions online to eliminate travel time and help minimize disruptions to your office or practice. Please take time now to register today for a webinar that’s convenient for you.

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2014 Medical Office Webinar Schedule and REGISTRATION FORM Due to subject matter content, these webinars will be made available ONLY to “professional providers,” defined as Anthem networkparticipating providers and their staffs who submit claims using the 837P or CMS-1500 claim format, and who have the following medical credentials: MD, DO, DC, DPM, LCSW, LCP, LPC, LFMT, CNS, CNM, plus DDS, DMD & OD (non-routine medical services only).

W EBINAR ATTENDEES MUST HAVE I NTERNET AND SIMULTANEOUS TELEPHONE ACCESS . T HE BELOW INFORMATION IS REQUIRED IN ORDER TO RECEIVE OUR W EBINAR CONNECTIVITY INFORMATION : Provider Request for Anthem WEBINAR Invitation Provider/Practice Name: __________________________________________________________________________ Medical Specialty: ____________________________________

Your Provider Type(s) (circle):

MD, DO, DC, DPM, LCSW, LCP, LPC, LFMT, CNS, CNM, DDS, OD, or OTHER: _______________________ Primary location + City/State: _____________________________________________________________________ NPI #: ____________________________________ Tax ID #: ___________________________________________ *Attendee Name: _______________________________________________________________________________ *E-mail Address: _______________________________________________________________________________ Phone #: ___________________________________________ Fax #: _____________________________________ *IMPORTANT NOTE: If multiple attendees will be viewing the webinar and listening together as a group via a single computer and phone line, we only need one e-mail address. However, if multiple attendees will each be viewing and listening from their own work stations, we must have SEPARATE registration forms with each individual’s e-mail address. Please mark which 2014 WEBINAR(s) you wish to attend:  Wednesday, August 20

(10:30 a.m. to 11:30 a.m.) – 3Q14 Anthem updates

 Wednesday, November 19

(10:30 a.m. to 11:30 a.m.) – 4Q14 Anthem updates PLEASE COMPLETE THIS FORM AND FAX TO 804-354-2979

Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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Medical office seminars offered statewide

In 2014, we continue to offer in-person seminars on a limited basis in the eastern, northern and western regions of Virginia. Four quarterly webinars are also being offered in 2014, and network-participating providers as described below across the state can register for any of these webinars. As always, these provider training opportunities are available only to Anthem-contracting “professional providers” and their staffs. These informative sessions are offered free of charge as a benefit of network participation. “Professional providers,” defined as those who submit claims using the 837P (electronic) or CMS-1500 (paper) claims format, include the following practitioners and their office staffs: MDs, DOs, DPMs, DCs, LCPs, LPCs, LCSWs, LMFTs, CNSs, CNMs, plus DDSs and DMDs (who render nonroutine medical or dental services to Anthem members), and optometrists (ODs) and opticians (who render non-routine medical vision services to Anthem members). Due to the wide range of medical specialties represented, we cannot target information specific to each, so we will take a more global approach in the covered material to afford useful information for all. Additionally, practitioners with other than the credentials shown above should contact their local Anthem network manager to learn of training opportunities that may be available for their respective specialties. Please make plans now to attend this seminar and/or one or more of our remaining webinars that can be conveniently accessed from anywhere in the Anthem (Virginia) service area via your office computer and telephone (see seminar and webinar listings and registration form in this edition of the Network Update). 2014 Eastern region medical office seminar offered at new location In addition to this year’s quarterly webinar schedule, a medical office seminar for the eastern region of Virginia will be offered at the following new location to accommodate the higher attendance we experienced last year. Date/Time:

Thursday, September 11, 2014 1 p.m. – 4 p.m.

Location/Address:

Meyera E. Oberndorf Central Library 4100 Virginia Beach Boulevard Virginia Beach, VA 23452

For the complete schedule of medical office seminars, please see page 40 in this edition of the Network Update. Seminar Topics The following topics may be included in this three-hour seminar. Additional topics of local interest not listed here may also be included. 

Claims filing for professional providers with emphasis on the 837P professional electronic claim transactions, and other e-transactions.

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



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Use of e-tools found on our open Web portal at anthem.com, as well as our secure portal, “Point of Care”, plus information regarding Availity. New product and/or benefit changes for our PAR, PPO, HMO, Medicaid HMO and Medicare Advantage plans, as well as HIX and Duals. Any known updates for state (Commonwealth of Virginia), local (The Local Choice), and federal (Blue Cross and Blue Shield Service Benefit Plan or FEP®) government programs.



The BlueCard® Program (out-of-area program) from the national Blue Cross and Blue Shield Association.

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Medical Management; Utilization Management; Pharmacy Management.



And/or other topics of timely importance.

Certificate of Completion Those who complete an in-person seminar will receive an Anthem “Certificate of Completion” for submission to various professional organizations for possible continuing education credit. Regarding CEUs for CPCs, Anthem has recently learned that the American Academy of Professional Coders (AAPC) has decided to invoke much stricter approval requirements for health insurance payers this year that include charging payers a fee for each CEU credit hour. Since those participants who attend our Anthem seminars may have credentials from multiple professional organizations other than the AAPC, it would be unfair for Anthem to pay the AAPC and no others. Please note that our previously approved 2014 webinar CEUs will remain valid. However, Anthem will not offer AAPC CEU approval for this year's seminars or for any of our provider seminars or webinars going forward. We are extremely disappointed, but thank you for your understanding and continued support in attending our free educational programs as a benefit of your Anthem network participation.

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Registration/cancellation Reservations are required as seminar seating is limited. We will contact you if this session has already reached capacity or is being cancelled due to low registration. Please include your e-mail address, business telephone and fax numbers. Submit your completed registration form by FAX or mail (not both) as follows: 





For EASTERN Region Seminar ONLY FAX:

757-326-5141 or

MAIL:

Anthem Blue Cross and Blue Shield Attn: EASTERN Medical Office Seminars Mail Drop VAV101-A000 277 Bendix Road, Suite 100 Virginia Beach, VA 23452

For NORTHERN and WESTERN Region Seminars ONLY FAX:

703-227-5355 (Northern) 540-853-3065 (Western) or

MAIL:

Anthem Blue Cross and Blue Shield Attn: NORTHERN and WESTERN Medical Office Seminars Mail Drop VACH01-A000 3800 Concorde Parkway, Suite 2000 Chantilly, VA 20151

For WEBINAR REGISTRATION ONLY (Regardless of your location) FAX: 804-354-2979

NOTE: If you must cancel after registering, please give us the courtesy of a call with at least 24 hours’ notice, or as soon as possible: 

for WEBINARS, call 804-354-2334



for EASTERN seminars, call 757-326-5152



for NORTHERN and WESTERN seminars, call 703-227-5315

For your comfort and convenience We highly recommend attendees bring a sweater or jacket for personal comfort. Please note that some meeting locations prohibit food and beverages in their conference rooms. Beverages/snacks will be provided at seminars with the exception noted in our schedule, or you may “brown bag” your meal if the meeting location permits.

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2014 Medical Office Seminar Schedule REGION

DATE and TIME

WESTERN

June 19 10 a.m. to 1 p.m.

EASTERN

September 11 1 p. m. to 4 p.m.

WESTERN

September 17 10 a.m. to 1 p.m.

WESTERN

September 25 10 a.m. to 1 p.m.

NORTHERN

October 23 10 a.m. to 1 p.m.

LOCATION Clinch Valley Medical Center Conference Room 6801 Governor George C. Peery Hwy RICHLANDS, VA Meyera E. Oberndorf Central Library 4100 Virginia Beach Boulevard VIRGINIA BEACH, VA IMPORTANT NOTE: No food or beverages will be allowed at this seminar location.

Wythe County Community Hospital Room TBD 600 West Ridge Road WYTHEVILLE, VA Bristol Regional Medical Center Rooms: Willow Room/Walnut Room/Spruce Room 1 Medical Park Boulevard BRISTOL, TN Prince William County Hospital Room – TBD 8700 Sudley Road MANASSAS, VA

NOTE: TBD = To be designated. ADDITIONAL TIPS: • We highly recommend attendees bring a sweater or jacket for personal comfort. • Please note that some meeting locations prohibit food and beverages in their conference rooms. Beverages/snacks will be provided at seminars with the exception noted above or you may “brown bag” your meal if the meeting location permits. • Please ensure you submit your registration to the correct fax number that corresponds with your region.

Anthem Health Pl ans of Virgi nia, Inc. trades as Anthem Blue Cross and Blue Shield i n Virgi nia, and its servi ce area is all of Vi rginia except for the City of Fai rfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross and Blue Shi eld Associ ation. ® ANTHEM is a registered t rademark of Anthem Insurance Compani es, Inc. The Blue Cross and Blue Shiel d names and symbols are registered marks of the Blue Cross and Blue Shield Associ ation.

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2014 Medical Office Seminar REGISTRATION FORM Complete this entire form; then FAX as follows: EASTERN R EGION - (757) 326-5141 NORTHERN REGION - (703) 227-5355 W ESTERN REGION - (540) 853-3065 IMPORTANT! Please read and complete the information below. Remember that faxes often lose quality in transit so please print legibly. 

These FREE seminars are for network-participating physicians (MDs, DOs and DPMs), as well as Behavioral Health providers (MDs, PhDs, LPCs, LCPs, LCSWs, LMFTs, and CNSs), doctors of chiropractic (DCs), certified nurse midwives (CNMs), dental/oral surgery providers of medical (non-routine) services, and optometrists (ODs) and opticians for medical (non-routine) services rendered to Anthem members, and their office personnel.



Each 2014 Medical Office Seminar will contain current updates on a variety of topics as described online at www.anthem.com under Provider Seminars or in the seminar article featured in each issue of the bi-monthly provider newsletter, Network Update.

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An Anthem “Certificate of Completion” will be given to attendees at the conclusion of each seminar for submission to various professional organizations for possible CEU credit.



For seating purposes, reservations are required; seating is on a first-come, first-served basis. If you register and then need to cancel, please give us 24 hours or as much notice as possible by calling as follows: for Peninsula and Tidewater, call (757) 326-5152; for Northern and Western, call (703) 227-5315.



For personal comfort, we highly recommend attendees bring a sweater or jacket. Please note that some meeting locations prohibit food and beverages in their conference rooms. Beverages/snacks will be provided at seminars with the exception of those sessions indicated. You may also “brown bag” your meal unless otherwise noted. If a hospital is providing lunch, this will be specified on the schedule.

Seminar Date/Time _______________________________ and Location ______________________________________ Attendee #1 _____________________________________ Attendee #2 _______________________________________ Provider Name ___________________________________Provider Specialty__________________________________ NPI # (individual) _______________________________ or NPI # (group) ____________________________________ Provider Address with City /State /Zip __________________________________________________________________ Phone Number ___________________________________ Fax Number ____________________________________ E-mail Address ____________________________________________________________________________________ Provider Website (if applicable) _______________________________________________________________________ CONFIRMATION of your registration, or notification that your seminar selection is full or has been cancelled, will be sent to you via E-MAIL or FAX; therefore, it is critical that you include your e-mail address, phone, and fax numbers when completing this form. THANK YOU. Anthem Health Pl ans of Virgi nia, Inc. trades as Anthem Blue Cross and Blue Shield i n Virgi nia, and its servi ce area is all of Vi rginia except for the City of Fai rfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross and Blue Shi eld Associ ation. ® ANTHEM is a registered t rademark of Anthem Insurance Compani es, Inc. The Blue Cross and Blue Shiel d names and symbols are registered marks of the Blue Cross and Blue Shield Associ ation.

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