December 2015
In this issue
Page
Announcements – ICD-10 update

ICD indicator required on paper claim forms
3
AIM alerts

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
Reminder of the most recent updates to the Cancer Care Quality
Program
4
New program highlights affordable choices for Virginia members 5
Enhancements to AIM Clinical Appropriateness Guidelines for Advanced
Imaging – effective February 22, 2016
7
New precertification requirements for certain radiation therapy services
begins March 1, 2016
9
Coverage and clinical guideline update

REMINDER: Specialty pharmacy site-of-service reviews began
November 1
11
Business update
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1 of 41
New regional vice president and senior clinical officer in
Virginia
13
Updates to Blue Physician Recognition Program
13
Incentive opportunity for physicians treating patients with Anthem plans
purchased on or off the exchange
14
Misrouted protected health information (PHI)
16
HEDIS® 2015 results are in for our PPO and HealthKeepers lines of
business
16
Enhanced Personal Health Care program offers greater value for
members and greater financial opportunity for PCPs
19
Enhanced Personal Health Care: Referral providers benefit by
improving and controlling costs
20
Improving your patients’ health care experience
21
Survey says… Patients see room for improvement with physician
care
21
Respiratory antibiotic use performance
23
We believe in continuous improvement
25
Case Management Program
25
Coordination of care
26
Important information about utilization management
27
Members’ rights and responsibilities
28
anthem.com
Important phone numbers
VAPENABSNL (12/15)
In this issue, continued
Page
Business update, continued


Clinical practice and preventive health guidelines available on the Web
GeoBlue: BlueCard provider outreach
28
28
Behavioral health update

Documentation and reporting guidelines for applied behavior analysis (ABA) and treatments for Autism Spectrum
Disorder
29
Health care reform update (including health insurance exchange)

Refer to anthem.com for information about health care reform and the exchange in 2016
29
eBusiness


Receive e-mail notifications via our Network eUPDATE
Updated contact information for ERA and EFT registration
30
30
Medicaid information

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Attention Medicaid Providers: ICD-10 coding for diabetic complications
Coverage guidelines and Clinical Utilization Management Guidelines update
Update: Home and hydration therapy medical necessity reviews
Update: Scoliosis and spinal deformity medical necessity reviews
Home health and outpatient therapies will require separate authorizations
32
32
32
33
33
Medicare-Medicaid plan update


CDC predicts another moderately severe flu season predominated by influenza A (H3N2)
ICD-10 coding supports MMP providers in reporting more clinical details for diabetic complications
33
34
Medicare information
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Avoid denials of Medicare Advantage diagnostic claims by completing item 20 (CMS-1500) correctly – Individual
membership only
34
Please include modifiers to help ensure accurate payment
35
Oxygen DME precertifications will be reduced in 2016
35
Anthem to review ER level 5 professional claims
35
Register for imaging site scores by March 1, 2016, to avoid unnecessary line-item denials
36
More $0 copay medications available to Medicare Advantage members with chronic conditions
37
Avastin for ophthalmic use – C9257 can be billed in office setting for network providers
37
Enhanced reimbursement available for certain Part B injectable drugs
37
Anthem place of service claims adjudication mirrors CMS guidelines
38
Anthem individual Medicare Advantage plan names changing for 2016
38
Keep up with Medicare Advantage news at Important Medicare Advantage Updates
38
Pharmacy update



CVS/specialty is exclusive in-network specialty pharmacy for Anthem members with medical benefit coverage for
specialty medications
39
Searchable Formulary Tool gives providers easier access to formulary/drug list information
40
Pharmacy information available on anthem.com
41
December 2015
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Announcements – ICD-10 update
ICD indicator required on paper claim forms
With the implementation of ICD-10 on October 1, 2015, it may be appropriate to report either ICD-9 or ICD-10 codes
depending upon the dates of service.
Paper claim forms have an ICD indicator that identifies the ICD code set being reported on the claim.
Anthem Blue Cross and Blue Shield is requiring the ICD indicator field be populated on paper claim forms.
Claims will be rejected if the ICD indicator field is not populated.
This requirement applies to both the UB-04 and CMS-1500 claim forms.


UB-04 form (also known as the CMS-1450 form) – The ICD indicator is Field 66.
(also known as the Diagnosis and Procedure Code Qualifier)
CMS-1500 form version 02/12 – The ICD indicator is Box 21.
(Reminder: We only accept the 02/12 form version)
Providers must enter the qualifier code that denotes the version of the ICD code set being reported on the claim.
Indicator Code
Set
9
ICD-9 diagnosis codes and/or procedure codes
0
ICD-10 diagnosis codes and/or procedure codes
December 2015
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AIM alerts
(Information regarding Anthem’s implementation of AIM Specialty Health ® initiatives)
Reminder of the most recent updates to the Cancer Care Quality Program
Attention Oncologists and Hematologists
As a reminder, Anthem Blue Cross and Blue Shield’s Cancer Care Quality Program ("Program"), a quality initiative, provides
participating physicians with evidence-based cancer treatment information that allows them to compare planned cancer
treatment regimens against evidence-based clinical criteria. The Program also identifies certain evidence-based Cancer
Treatment Pathways ("Pathways"). Participating physicians who are in-network for the member's benefit plan are eligible to
participate in the Program and for enhanced reimbursement if an appropriate treatment regimen is ordered that is on
Pathway. AIM Specialty Health® (AIM), a separate company, administers the Program on behalf of Anthem.
Effective December 1, 2015, Anthem added the following cancer treatment Pathways for the Cancer Care Quality
Program.
New Pathways added to the Program include:

Pathways for gastric and esophageal cancers

Pathways for head and neck cancers
Effective January 1, 2016, the following Pathways are moving from “on” Pathway to “off” Pathway status:


Fludarabine+cyclophosphamide+mitoxantrone+rituximab (FCMR) for follicular lymphoma, second and subsequent
lines of therapy
Rituximab for chronic lymphocytic leukemia (CLL), first line therapy
This means that providers will not be eligible for an enhanced reimbursement when these regimens are prescribed. This does
not restrict the use of these regimens for members when clinically appropriate, and claims will be adjudicated in accordance
with the members’ benefit plans.
The Pathways developed for this Program are intended to support quality cancer care. To access the full Pathways
document, go online to Ca nce rCare Qu alit yProgram. com, our dedicated provider website.
Note: Participating physicians who are in-network for the member's benefit plan are eligible to participate in the Program and
for enhanced reimbursement if an appropriate treatment regimen is ordered that is on Pathway.
December 2015
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New program highlights affordable choices for Virginia members
Beginning January 1, 2016, Anthem Blue Cross and Blue Shield in Virginia will launch the Anthem Imaging Shopper, Anthem
Sleep Shopper and Anthem Surgical Shopper programs to help members compare facility costs on computed tomography
(CT) imaging, magnetic resonance imaging (MRI) and in-lab sleep studies. Administered in partnership with AIM Specialty
Health® (AIM), the program will also include many surgical procedures, such as colonoscopy, endoscopy and knee and
shoulder arthroscopy.
The programs are available to all fully insured members and some self-funded (administrative services only or ASO) groups
who have selected the program for their members. The program does not apply to the following plans: The Blue Cross and
Blue Shield Service Benefit Plan (also known as the Federal Employee Program or FEP); plans purchased on or off the
Health Insurance Marketplace (also called the exchange); Anthem HealthKeepers Plus (Medicaid); Medicare Advantage,
Medicare-Medicaid Duals Demonstration or Medicare Supplement plans.
The following programs will be offered, and program highlights are included below:

Anthem Imaging Shopper

Anthem Sleep Shopper (excludes ASO)

Anthem Surgical Shopper
Anthem Imaging Shopper
The Anthem Imaging Shopper program involves proactive outreach to certain Anthem members who are eligible for the
program to provide information about imaging costs to help the members select an imaging provider.
While most members go to locations recommended by their physicians, these members may not realize that their out-ofpocket costs may vary, depending on where they receive imaging service(s). In addition, according to feedback we have
received, most members are open to receiving cost information if it may help them reduce their cost share. As a result, when
we receive precertification requests for certain MRI, magnetic resonance angiography (MRA), CT and/or computed
tomography angiography (CTA) services, we will call the members and give them information so they understand the choices
available to them.
During this outreach, members may have an opportunity to reduce their health care expenses by selecting lower-cost
providers or locations. This is a voluntary program. Members will not be denied access to services if they do not choose
the lower-cost option. Our goal is simply to give our members information to make informed choices about their health plan
benefits.
Note: Our member outreach will exclude pediatric and oncology cases.
Anthem Sleep Shopper
Did you know that a sleep study can cost members as much as $2,500 depending on where they live and where they have
services performed?
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While most members go to the sleep study facility or lab recommended by their physicians, our members may not realize that
their out-of-pocket costs may vary depending on where they receive the service(s). In addition, feedback from our members
indicates that most are open to receiving information that could help them save 10 to 15 percent of their cost share.
Anthem’s Sleep Shopper program includes proactive outreach to members with key information on sleep testing facilities
when an in-lab (PSG), titration, split-night, multiple sleep latency test (MSLT) or maintenance of wakefulness test (MWT) is
requested by their physician. Members may have an opportunity to reduce their health care expenses by selecting a lowercost provider.
This is a voluntary program. Members will not be denied access to services if they do not choose a lower-cost option.
As before, our goal is simply to provide members with information to make informed choices about their health plan benefits.
Note: Our member outreach will exclude pediatric cases.
Anthem Surgical Shopper Program
This new program highlights affordable choices in surgical procedures. Surgical procedures included are:

Colonoscopy- screening, biopsy, and lesion removal

Endoscopy – Upper GI with Biopsy

Arthroscopic ACL Repair

Knee Arthroscopy with Cartilage Repair

Shoulder Arthroscopy

Shoulder Arthroscopy with Rotator Cuff Repair
How the program works:
The ordering or servicing provider may contact AIM when your patient requires one of the above surgical
procedures. Once AIM is notified, aggregate surgical facility cost information will be shared with you and your
eligible patient to help select a lower cost option. The range of approximate cost information is based on Anthem’s
historical claims data for contracted providers for the various services in scope. This data is updated twice per
year.
You may contact AIM in one of two ways:

Online through ProviderPortalSM at www.aimspecialtyhealth.com/goweb

Via telephone at (800) 554-0580 or by using the number displayed on the back of the member ID card
Claims will not be denied for failure to inform AIM of these services. This is a voluntary program. Members will not
be denied access to services if they do not choose a lower-cost option. As always, our goal is simply to provide
members with information to make informed choices about their health plan benefits.
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In addition to the above services listed under the surgical shopper program, members may call (or go online via the “Estimate
Your Cost” tool) to obtain cost information for the following procedures:

Cataract removal

Carpal tunnel repair

CT scans

Ultrasounds

MRI scans

Bariatric surgery

Labor and delivery

Hysterectomy
Registration with Optinet ensures your provider data is accessible for these programs
You must register with Optinet to ensure your provider information is accessible for these shopper programs. Online
registration is available via AIM’s ProviderPortalSM at www.providerportal.com and AIM Specialty Health site via the Availity
Web Portal at www.availity.com.
A checklist and interactive tutorial are available in the AIM portal to assist you in completing your registration. Be sure to
select “Submit” each time you make an update, or the survey will show as incomplete.
For technical assistance in completing your registration, call AIM toll free at 800-252-2021. For general questions about
registration process, please reference the AIM FAQs and other materials available on AIM’s ProviderPortalSM at
www.providerportal.com and AIM Specialty Health site via the Availity Web Portal at www.availity.com.
Should you have any questions about Optinet registration or any of these shopper programs, please contact your Anthem
network manager.
Enhancements to AIM Clinical Appropriateness Guidelines for Advanced Imaging – effective
February 22, 2016
On February 22, 2016, the following changes to the AIM Clinical Appropriateness Guidelines for Radiology, Oncologic
Positron Emission Tomography (PET), and Cardiology will become effective.
A summary of these changes is provided on the next page.
December 2015
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Radiology guidelines

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MRI and CT
o
Expanded list of “red flag” indications for headache evaluation and added a requirement for conservative
therapy in low-risk patients
o
Developed comprehensive new criteria for venous sinus thrombosis based on risk factors
MRI/MRA or CT/CTA
o

CT Neck (soft tissue) and CT Chest
o


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Developed new criteria for headache evaluation for appropriate simultaneous imaging
Added new requirement of short course conservative therapy for low-risk patients with hoarseness
CT Chest
o
Developed new criteria for immunosuppressed patients with persistent pneumonia
o
Aligned pulmonary nodule criteria with the Fleischner Society guidelines
MRI Pelvis
o
Developed new criteria for sports hernia after sufficient initial evaluation and failed conservative management
o
Revised criteria for advanced imaging in low risk prostate cancer and in the surveillance of gynecologic
malignancy
MRI Upper and Lower Extremity
o
Expanded criteria for suspected occult fractures at high-risk sites following non-diagnostic radiographs
Oncologic PET guidelines

Clarified language for surveillance PET imaging

Clarified PET requirement for breast cancer to include invasive disease

Expanded thyroid cancer to include well-differentiated follicular subtype

Replaced “not covered” with “not medically necessary”
December 2015
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Cardiology guidelines

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Revised cardiac imaging criteria for management of patients with Kawasaki disease to align with published
literature.
Clarified appropriate frequency of echocardiography in children with established congenital heart disease. For
younger children with complex congenital heart disease, evaluation based on symptoms is difficult. Therefore, the
guideline has been liberalized to allow more frequent echocardiography in this cohort.
Clarified language to reduce variability of guideline interpretation based on user feedback.
If you have any questions or comments regarding these enhancements to the guidelines, please contact AIM via email at
aim.guidelines@aimspecialtyhealth.com. Click here to access and download a copy of the current guidelines.
New precertification requirements for certain radiation therapy services begins March 1, 2016
On March 1, 2016, Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. are expanding our Radiation
Therapy Program to require precertification of:



Image Guided Radiation Therapy (IGRT).
Fractions (also referred to as units) for breast and bone metastases for covered individuals getting External Beam
Radiation Therapy (EBRT) or Intensity Modulated Radiation Therapy (IMRT).
Special treatment procedure and special physics consult (CPT® codes 77470 and 77370) (e.g., total body
irradiation, hemibody radiation, or endocavitary irradiation and special medical radiation physics consultation).
AIM Specialty Health® (AIM®), a separate company, administers the Radiation Therapy Program on behalf of Anthem and
HealthKeepers, Inc. A complete list of CPT codes requiring precertification is available on the Point of Care preauthorization inquiry via the Availity Web Portal or the actual guidelines for the listing. Effective March 1, 2016, the newly
added CPT codes under the expanded Radiation Therapy Program include:
December 2015
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IGRT
IMRT
EBRT
Special Treatment (e.g.,
total body irradiation,
hemibody radiation, per
oral, or endocavitary
irradiation)
Special medical radiation
physics consultation
CPT Code
G6001
G6002
G6017
77387
77014
G6015 or 77385-6
77427
G6003-6 or 77402
G6007-10 or 77407
G6011-14 or 77412
77427
77470
77370
All Anthem local members who currently require precertification for non-emergency outpatient radiation therapy are included
in this program. For Anthem in Virginia and HealthKeepers, Inc., these precertification requirements do not apply to the
following:

Blue Cross and Blue Shield Service Benefit Plan also known as the Federal Employee Program® (FEP).

Medicare Advantage and Medicare Supplement plans.

Department of Corrections.

National Accounts.

Anthem HealthKeepers Plus/FAMIS plans (Medicaid).

Anthem HealthKeepers Medicare-Medicaid Plan or MMP. [Members are enrolled in both Medicare and Medicaid
under the Commonwealth Coordinated Care Plan, also known as the Duals Demonstration (“Demonstration”)
Program.]

Members with Anthem as secondary coverage.

Unicare and HealthLink.
Determine if precertification is needed for an Anthem or HealthKeepers, Inc. member by clicking the “Coverage & Clinical UM
Guidelines, and Pre-Cert Requirements” link on anthem.com or by calling the precertification phone number printed on the
member’s ID card.
December 2015
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Starting February 22, 2016, ordering physicians may submit a precertification request for these additional requirements to
AIM through the AIM ProviderPortalSM (available 24/7 to process orders in real-time), through the Availity Web Portal or by
calling the AIM call center toll free at 1-866-789-0158 (weekdays, 8 a.m. to 5 p.m. ET).
Note: Retrospective requests received more than two business days after the date of service will not be accepted by AIM for
precertification review. Any post-service clinical review will be handled by anthem or HealthKeepkers according to the terms
of the applicable health benefit plan and/or provider agreement.
Radiation therapy performed as part of an inpatient admission will continue to be reviewed through Anthem’s inpatient
precertification process. Members currently undergoing treatment on March 1, 2016, will not be impacted by the new
enhancements to this program. However, members starting treatment on or after March 1, 2016 must follow the enhanced
Radiation Therapy Program precertification requirements noted above.
Thank you for your collaboration and ongoing support of the Radiation Therapy Program. If you have further questions,
please contact your local network manager or call the provider customer service area at the phone number on the member’s
ID card.
Coverage and clinical guideline update
REMINDER: Specialty pharmacy site-of-service reviews began November 1
In our August 2015 edition and October 2015 edition of the Network Update, Anthem Blue Cross and Blue Shield and
affiliate HealthKeepers, Inc. shared information about a new requirement that the setting for specialty pharmacy infusions will
be reviewed for appropriate clinical setting beginning November 1, 2015. In this December edition, we are sharing details
about this change again as a reminder and for easy reference.
Anthem and HealthKeepers, Inc. recognize that most patients prefer to receive their infusions in their physician’s office,
infusion center or at home through home infusion therapy. This is more convenient for the member, results in lower member
financial responsibility and, in many cases, is a clinically appropriate setting. 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.
However, there may be other circumstances where a patient’s medical situation requires that he or she receive infusions in a
hospital facility. Therefore, beginning November 1, the setting for specialty pharmacy infusions will be reviewed for
appropriate clinical setting. Anthem and HealthKeepers, Inc. will review the drug appropriateness for clinical indications and
the site of service using a new clinical guideline CG-DRUG-47. During the review process, the nurse reviewer will provide
other options if a setting is considered not medically necessary. More information follows below about CG-DRUG-47.
December 2015
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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. We encourage you to
discuss with our members the options available to get their intravenous infusions safely and conveniently, at a lower, out-ofpocket cost.
Level of Care: Specialty Pharmaceuticals (CG-DRUG-47)
This new clinical UM guideline provides clinical criteria for use of outpatient infusion therapy service in the hospital outpatient
department or hospital outpatient clinical level of care for intravenous (IV) infusion therapy.
An outpatient infusion therapy service in the hospital outpatient department or hospital outpatient clinic level of care for the
use of an infused pharmacologic or biologic agent is considered medically necessary when all of the following are present:
1.
The inherent complexity or risk of the infusion required by an individual is such that it can be performed safely and
effectively only by or under the general supervision of skilled nursing personnel; AND
2.
The individual's medical status or therapy is such that it requires enhanced monitoring beyond that which would
routinely be needed for infusion therapy; AND
3.
The potential changes in the individual’s clinical condition are such that immediate access to specific services of a
medical center/hospital setting, having emergency resuscitation equipment and personnel, and inpatient admission
or intensive care is necessary, for example, the individual is at significant risk of sudden life-threatening changes in
medical status based on clinical conditions including but not limited to:
a.
b.
c.
Concerns regarding fluid overload status, or
History of anaphylaxis to prior infusion therapy with a related pharmacologic or biologic agent, or
Acute mental status changes.
All other uses of outpatient infusion therapy services in the hospital outpatient department or hospital outpatient clinic level
of care for the infusion of pharmacologic and biologic agents are considered not medically necessary.
The services addressed in this coverage guideline will require authorization for all of our products offered by HealthKeepers,
Inc. with the exception of Anthem HealthKeepers Plus (Medicaid). Other exceptions are Medicare Advantage, the MedicareMedicaid Plan (Dual Integration product) and the Blue Cross Blue Shield Service Benefit Plan (also known as the Federal
Employee Program or FEP) which will not be reviewed at this time with this guideline. A pre-determination can be requested
for our Anthem PPO products.
December 2015
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Business update
New regional vice president and senior clinical officer in Virginia
Recently, Anthem Blue Cross and Blue Shield announced that Maureen Dempsey, M.D., joined Anthem in Virginia as
regional vice president and senior clinical officer. Dr. Dempsey, a board-certified pediatrician, succeeds Karen Remley,
M.D., who accepted the position of chief executive officer with the prestigious American Academy of Pediatrics.
In her position as Anthem in Virginia's senior clinical officer, Dr. Dempsey will be responsible for clinical program oversight,
medical management and quality of care initiatives. She will also have a leadership role working with our internal provider
solutions team to expand and create effective provider collaboration activities such as our Enhanced Personal Health Care
program.
Most recently, Dr. Dempsey was the regional medical director for Humana's Mid-Atlantic region. She has also worked at the
Virginia Department of Health (VDH) where she served as chief deputy commissioner for Public Health. During her last year
at VDH, she was the acting commissioner of health. Dr. Dempsey has also served as a physician surveyor for the National
Committee on Quality Assurance, and she was the executive director of Health and Dental Care for Kids in St. Louis.
With her vast experience and background, Dr. Dempsey is uniquely positioned to engage our provider partners, as we work
collaboratively to help ensure Anthem members continue to have access to affordable and quality health care.
Updates to Blue Physician Recognition Program
Anthem Blue Cross and Blue Shield (Anthem) is committed to providing members with the tools they need to effectively
partner with their physicians and make more informed health care choices. As part of that effort, Anthem is pleased to
participate in the Blue Cross and Blue Shield Association’s consumer engagement initiative.
The Blue Physician Recognition (BPR) Program is designed to reinforce Blue Plans’ commitment to quality by providing more
meaningful and consistent information on physician quality improvement and recognition on the Blue National Doctor &
Hospital Finder site and on Anthem’s online provider directories. A BPR indicator is used to identify physicians, groups
and/or practices who have demonstrated their commitment to delivering quality and patient-centered care by participating in
local, national, and/or regional quality improvement programs as determined by the local Blue Plan.
Anthem recognizes primary care physicians practicing in the specialties of Family Practice, Internal Medicine and General
Practice with a BPR designation if they have achieved recognition from either the National Committee for Quality Assurance
(NCQA) or Bridges to Excellence (BTE) based on their successful completion of a care recognition program. Information
regarding these recognition programs can be found at http://www.ncqa.org or http://www.hci3.org.
December 2015
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At a minimum, we will update these recognitions annually to reflect the current status as identified by the Blue Cross and
Blue Shield Association’s Quality Recognition Extract.
If you have questions regarding the update, please contact your Anthem network contracting representative.
Incentive opportunity for physicians treating patients with Anthem plans purchased on or off the
exchange
In 2014, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. announced that we would engage Inovalon
– an independent company that provides secure, clinical documentation services – to conduct outreach efforts for our health
care exchange business. Anthem and HealthKeepers, Inc. are working with Inovalon to help ensure that our members, who
have purchased health care plans on and off the exchange, get their diagnoses confirmed, corrected, and updated every
year, as well as have potential preventive care gaps addressed. To accomplish this goal, Anthem network providers – usually
primary care physicians – may receive letters from Inovalon, asking you to perform patient outreach and assessments,
followed by submission of a SOAP Note (also called Encounter Facilitation Form). SOAP Note stands for Subjective,
Objective, Assessment, and Plan which is the standardized document format of a medical record.
If you receive a request from Inovalon, we understand that completing these SOAP Note requests may take time. We would
like to offer contracted exchange providers the opportunity to increase your reimbursement. As a reminder, you are eligible
to receive $100 in addition to your office visit fee for each properly submitted electronic SOAP Note submitted through
Inovalon's ePASS tool.
You may also elect to submit your patient assessment data for the members we request using the paper SOAP Note option
via Inovalon's secure fax line at 1-866-682-6680. For each paper SOAP Note properly submitted for patient assessments
performed, you are eligible to receive $50 in addition to your office visit fee.
Submitting a SOAP Note
Paper: You have the option to fax in a completed paper SOAP Note to Inovalon at 1-866-682-6680. To ensure that the paper
SOAP Note is fully processed, all required fields must be completed and signed by the member's physician.
Electronically: You may use ePASS (Electronic Patient Assessment Solution Suite), an electronic tool that retrieves
information about your Anthem patients, including potential preventive care gaps, and drops this data into the SOAP Note to
document your patients’ conditions. The ePASS® tool may be used for members Inovalon identifies, and the members have
purchased individual and small group health plans on and off the exchange. To utilize ePASS®, please sign up online at the
following Web address: https://ePASS.inovalon.com
Overview of the ePASS® tool
If you receive a request from Inovalon to complete a SOAP note and you're interested in an overview of the ePASS®
tool, please see below for various webinar dates. We encourage you to register in advance by sending an email to
ePASSProviderRelations@Inovalon.com with your name, organization, contact information and date of the webinar you’d
like.
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This webinar provides a practical overview of how ePASS can be used to access a supplemental clinical profile and complete
a compliant electronic encounter SOAP Note for patients Inovalon identifies on Anthem’s behalf. The webinar typically lasts
30 minutes with time for questions.
Tips for joining an ePASS® tool overview webinar:

First: Join by calling the toll-free number and enter the access code.

Second: click on WebEx Link and enter meeting code.
Webinar Date
Time
December 02, 2015
3:00 - 3:30 p.m. EST
December 09, 2015
3:00 - 3:30 p.m. EST
December 16, 2015
3:00 - 3:30 p.m. EST
January 06, 2016
3:00 - 3:30 p.m. EST
January 13, 2016
3:00 - 3:30 p.m. EST
January 20, 2016
3:00 - 3:30 p.m. EST
January 27, 2016
3:00 - 3:30 p.m. EST
The following dial-in information and WebEx link/entry code are the same for all webinar dates.

Phone Number/Access Code: 1-888-850-4523. Enter Access Code: 10860

WebEx Link/Meeting Code: Visit:https://inovalon.webex.com. Enter: 745 497 369
For more information on the outreach process or the ePASS tool, please click HERE. Or, go to anthem.com>Providers
(select Virginia)>Health Insurance Exchange> “Anthem engages Inovalon to conduct outreach efforts for our ACA individual
and small group on and off exchange business – FAQs.” You may also contact Inovalon toll free at 1-877-448-8125.
December 2015
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Misrouted protected health information (PHI)
As a reminder, providers and facilities are required to review all member information received from Anthem Blue Cross and
Blue Shield and our affiliate HealthKeepers, Inc. to help ensure no misrouted PHI is included. Misrouted PHI includes
information about members that a provider or facility is not currently treating. PHI can be misrouted to providers and facilities
by mail, fax or e-mail. Providers and facilities are required to immediately destroy any misrouted PHI or safeguard the PHI for
as long as it is retained. In no event are providers or facilities permitted to misuse or re-disclose misrouted PHI. If providers
or facilities cannot destroy or safeguard misrouted PHI, providers and facilities must contact Anthem’s provider services area
to report receipt of misrouted PHI.
HEDIS® 2015 results are in for our PPO and HealthKeepers lines of business
Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) data collection project
for 2015 impacting our PPO and HealthKeepers (non-Medicaid) lines of business. You play a central role in promoting the
health of our members. By documenting services in a consistent manner, it is easy for you to track care that was provided
and identify any additional care that is needed to meet the recommended guidelines. Consistent documentation and
responding to our medical record requests in a timely manner eliminates follow-up calls to your office and also helps improve
HEDIS scores, both by improving care itself and by improving our ability to report validated data regarding the care you
provided.
Further information regarding documentation guidelines can be found on the HEDIS page of our provider portal. The
provider portal can be accessed at www.anthem.com and clicking on “Provider,” followed by “Virginia” then “Health and
Wellness,” and “Quality Improvement and Standards.” You will find reference documents entitled “HEDIS 101 for Providers”
and the “HEDIS Physician Documentation Guideline” under the HEDIS information section on the Quality Improvement and
Standards webpage.
The table below shows some of our key measure rates across East Region. The rates in bold in the HEDIS 2015 column
reflect an increase from 2014 rates.

Yellow boxes indicate rates that are above the national average.

Bold indicates improvement in rate over the previous year.

Comprehensive Diabetes Care - Poor HbA1c Control (>9): Lower rate is good
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Anthem HealthKeepers/POS Measures
HEDIS 2015 Rate (Percent)
Adult BMI Assessment
Childhood Immunization Status - DTAP
84.58
89.43
Childhood Immunization Status - MMR
Childhood Immunization Status - HIB
Childhood Immunization Status - VZV
Childhood Immunization Status - PCV
Childhood Immunization Status – HEP A
Childhood Immunization Status - ROTAVIRUS
Childhood Immunization Status – TDAP/TD
Immunizations for Adolescents – MENINGITIS
Weight Assessment/Counseling–Nutritional Counseling - TOTAL
Weight Assessment and Counseling – Physical Activity- TOTAL
Appropriate Treatment Children w/ URI
Spirometry Testing for COPD
Well-Child Visits in the first 15 Months of Life (6+ visits)
Persistence of Beta-Blocker Treatment after AMI
Comprehensive Diabetes Care – Eye Exams
Comprehensive Diabetes Care – Nephropathy
93.37
97.54
94.35
92.14
85.26
90.17
89.43
64.80
60.58
55.72
81.16
37.90
84.36
85.22
60.58
86.13
Antidepressant Medication Mgmt – Acute
FU Care Children’s ADHD Medication – Initiation
*lower rate is better
60.79
37.42
December 2015
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PPO Measures
HEDIS 2015 Rate (Percent)
Adult BMI Assessment
Childhood Immunization Status – DTAP
Childhood Immunization Status – IPV
Childhood Immunization Status – MMR
Childhood Immunization Status – HIB
Childhood Immunization Status – HEP B
Childhood Immunization Status – VZV
Childhood Immunization Status – PCV
Childhood Immunization Status – ROTAVIRUS
Childhood Immunization Status – TDAP/TD
Colorectal Cancer Screening
Immunizations for Adolescents – MENINGITIS
Immunizations for Adolescents – TDAP/TD
Weight Assessment and Counseling – BMI TOTAL
Weight Assessment and Counseling – Nutrition Counseling
TOTAL
Weight Assessment and Counseling – Physical Activity TOTAL
81.10
84.18
90.27
87.83
90.27
86.62
89.05
84.43
84.67
81.33
69.47
63.88
81.33
51.82
56.45
Antibiotic Treatment Adults w/ Acute Bronchitis
19.14
Appropriate Testing for Children w/ Pharyngitis
Appropriate Treatment Children w/ URI
Well-Child Visits in the first 15 Months of Life (6+ visits)
82.61
79.83
80.39
Effectiveness of Care - Cardiovascular
Persistence of Beta-Blocker Treatment after AMI
80.87
Effectiveness of Care - Diabetes
Comprehensive Diabetes Care – Blood Pressure Control <140/90
65.69
Effectiveness of Care – Behavioral Health
Antidepressant Medication Mgmt – Acute
63.69
Antidepressant Medication Mgmt – Continuation
47.53
FU Care Children’s ADHD Medication – Initiation
34.89
FU Care Children’s ADHD Medication - Continuation
*lower rate is better
39.50
52.31
In Virginia, many scores for the HealthKeepers/Point of Service line of business improved and exceeded the national
average, especially those in Weight Access/Counsel Physical Activity Total, Medication Management for people with asthma
with the largest rate increases noted in Weight Access/Counseling Physical Activity. In the PPO line of business, there were
December 2015
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also many improved scores that exceeded the national average, especially those in Weight Access/Counseling total BMI 7-14
year, Weight Access/Counseling BMI 12-17 years and with the largest rate increases noted in Weight Access/Counseling in
BMI and Weight Access/Counseling Physical Activity 12-17 years.
Although many rates were above the national average, this year the PPO plan had the greatest number of decrease in rates.
There are opportunities for improvement for the measures with the most significant decreases in rates including: Follow-Up
Care Children ADHD Med Initiation, Follow Up Care Med Continuation, Persistence of Beta Blocker Treatment after AMI,
Well-Child visits in the first 15 months of Life (6+ visits), and Child Immunization Status DTap.
Each year, our goal is to improve our process for requesting and obtaining medical records for our HEDIS project. In order to
demonstrate the exceptional care that you have provided to our members and in an effort to improve our scores, you and
your office staff can help facilitate commercial HEDIS process improvement by:

Responding to our requests for medical records within five days if at all possible

Providing the appropriate care within the designated timeframes

Accurately coding all claims

Documenting all care clearly in the patient’s medical record
Again, we thank you and your staff for demonstrating teamwork as we work together to improve the health of our members
and your patients. We look forward to working with you again next HEDIS season.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Enhanced Personal Health Care program offers greater value for members and greater financial
opportunity for PCPs
Anthem Blue Cross and Blue Shield has a long history of offering payment innovation programs to primary care providers
(PCPs) and some specialist providers in our networks. Because the health care industry continues to evolve to a more
patient-centered approach to care delivery, we are focusing our efforts on our Enhanced Personal Health Care (EPHC)
program which offers greater value for our members and greater financial opportunity for PCPs.
Enhanced Personal Health Care is the name we give to arrangements between our health plan and
participating providers when the arrangements include three things:
1.
Value-based payment that rewards high quality and efficiency
2.
Exchange of clinical data, and
3.
A mutual commitment to ensuring our members receive patient-centered care.
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Enhanced Personal Health Care arrangements are flexible enough to accommodate organizations of all sizes, and run the
gamut from agreements with solo primary care physicians to accountable care agreements with large integrated systems.
The goal is to have a more effective outreach and care coordination to help close gaps in care for Anthem members who are
high risk and/or have chronic health conditions.
For large national employer customers, we offer a national network of providers who work under value-based payments. That
national network includes Enhanced Personal Health Care within our affiliated health plans’ geographic coverage area, but
also includes similar programs hosted by other members of the Blue Cross and Blue Shield Association. This network of
patient-centered, value-based payment programs is called Blue Distinction Total Care.
Providers who participate in Enhanced Personal Health Care arrangements are part of Blue Distinction Total Care by
default. Employers and their employees, your patients, may refer to the program by either name. Our “Find a Doctor”
tool may identify you as a participant in Enhanced Personal Health Care or Blue Distinction Total
Care.
As our fellow Blue Cross and Blue Shield plans grow their own value-based programs, we will increasingly share information
between plans, and gain the ability to share more information with participating providers even if the patient is covered by
another Blue Cross Blue Shield Association member plan. The design of other plans’ value-based payment programs will
not necessarily mirror Enhanced Personal Health Care in every respect or in every case, but BCBS Association member
plans share the aim of rewarding high-quality evidence-based efficient care with primary care at the heart of a patientcentered delivery system.
Enhanced Personal Health Care: Referral providers benefit by improving quality and controlling
costs
A key goal of the Enhanced Personal Health Care Program is to improve quality while controlling health care costs. One of
the ways this is done is by giving primary care physicians (PCPs) in the Program quality and cost information about the
health care providers to which the PCPs refer their attributed members (the referral providers). If a referral provider is higher
quality and/or lower cost, this component of the Program should result in their getting more referrals from PCPs. The
converse should be true if referral providers are lower quality and/or higher cost. We will share data on which we relied in
making these evaluations upon request, and will discuss it with referral providers including any opportunities for
improvement. Any such requests should be directed to your Anthem network manager.
December 2015
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Improving your patients’ health care experience
Anthem is committed to working with our network physicians to make our members’ health care experience a positive one.
Towards this end we wanted to share with you a document we discovered that was developed by the California Quality
Cooperative. This resource outlines some helpful tips you can use to improve your relationship with your patients and provide
better care at the same time.
Simply log onto our website at www.anthem.com and follow this path: Providers>Select State>Enter>Health &
Wellness>Guide to Improving the Patient Experience.
"This information is provided by the California Quality Collaborative. A health care improvement organization dedicated to
advancing the quality and efficiency of outpatient care in California."
Survey says… Patients see room for improvement with physician care
Every year, Anthem Virginia sends out the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey to
our HealthKeepers (HMO)/Point of Service (POS) members. The survey provides Anthem members an opportunity to share
their perceptions of the quality of care and services provided by our HMO/POS network physicians. The CAHPS survey is
used by all HMO/POS plans that undergo accreditation review by the National Committee for Quality Assurance (NCQA).
The following tables compare our results from 2014 with those in 2015. Each column contains the score achieved for each
measure along with the box color coded to reflect the NCQA Quality Compass National Percentile achieved by Anthem
Virginia. These Quality Compass percentiles are derived from the scores of all other HMO plans across the country that
perform the CAHPS survey. Our goal is to achieve the 75th Percentile.
When you’re reviewing these results, we encourage you to focus on and address those performance areas of your own
practice that may have room for improvement. Addressing those areas will help our members, your patients, have a positive
experience that meets their medical needs and their satisfaction with the quality of services provided.
December 2015
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2015 Anthem Virginia HealthKeepers/POS
CAHPS® Adult Member Satisfaction Survey Results
and NCQA Quality Compass Percentile Achieved
NCQA Quality Compass Percentile Legend 5
10th
25th
50th
75th
90th
Trend 2014
vs. 2015
Survey Question
2014
2015
Rating of Physician 1
Rating of Personal Doctor
Rating of Specialist Seen Most Often
Rating of All Health Care Provided in Past 12 Months
83%
83%


80%
85%
80%
79%
Got appointment for urgent care as soon as needed
88%
91%

Got appointment for check-up or routine care as soon as needed
89%
82%

How often personal doctor explained things understandably to you
96%
97%

How often personal doctor listened carefully to you
93%
95%

How often personal doctor showed respect for what you had to say
94%
95%

How often personal doctor spent enough time with you
90%
93%

DNA
89%
--
DNA
68%
--
DNA
67%
--
74%
81%

73%
76%

Getting Care Quickly

2
Got help or advice needed when calling doctor after regular office hours
Doctor’s Communication with Patients
2
Shared Decision Making
Doctor discussed reasons to take a medicine?
3
Doctor discussed reasons not to take a medicine?
Doctor asked what you thought was best for you?
3
4
Continuity of Care and Health Promotion
How often did your personal doctor seem informed about care you received from
other health providers? 2
Did you and your doctor discuss ways to prevent illness?
4
1 = Percent responding 8, 9 or 10 (0-10, where 0 is the worst and 10 is the best).
2 = Percent responding “Usually” or “Always.”
3 =% responding “A lot” or “Some”
4 = % responding "Yes"
5 = Percentile Definition – A score equal to or greater than 75 percent of all those attained on a survey question is said to be
in the 75th percentile.
DNA = Data Not Available
December 2015
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NA = Number of survey respondents too low to be valid.
Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is a registered trademark of the Agency for
Healthcare Research and Quality (AHRQ).
*The source of data contained in this report is Quality Compass ® 2015 and is used with the permission of the National
Committee for Quality Assurance (NCQA). Any analysis, interpretation or conclusion based on these data is solely that of the
authors, and NCQA specifically disclaims responsibility for any such analysis, interpretation or conclusion. Quality Compass
is a registered trademark of NCQA.
Respiratory antibiotic use performance
Improving antibiotic use improves patient outcomes and saves money. The National Committee for Quality Assurance
(NCQA) has identified three Healthcare Effectiveness Data and Information Set (HEDIS) measures around antibiotic use:



Children (2 to 18 years) who present with Pharyngitis who are first given a group A streptococcus (strep) test and
then appropriately receive an antibiotic.
Children (3 months to 18 years) with a diagnosis of Upper Respiratory Infection who are not given an antibiotic
prescription.
Adults with a diagnosis of Acute Bronchitis who are not given an antibiotic prescription.
The ratings for each of these metrics are determined by claims data only. Furthermore, it only takes one time of an antibiotic
being inappropriately prescribed (and filled) in the one year measurement period to lower the scores.
Local performance for appropriate testing and antibiotic prescribing – Anthem and our affiliate HealthKeepers, Inc.
Based on claims data for our Anthem PPO and HealthKeepers lines of business in Virginia, the reported HEDIS rates were
as follows:
Appropriate testing for
Pharyngitis in Children
Appropriate treatment for
Children with Upper Respiratory
Infection
Appropriate treatment for Adults
with Acute Bronchitis
December 2015
Measurement
Period
Rate Guide
HealthKeepers
Rates
PPO Rates
7/1/2013 to
6/30/2014
7/1/2013 to
6/30/2014
Higher is better.
90.65%
82.61%
Reported as an
inverted rate.
Higher is better.
Reported as an
inverted rate.
Higher is better.
81.16%
79.83%
16.3%
19.14%
1/1/2013 to
6/30/2014
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Things that might help you
In an effort to help slow the emergence of antibiotic resistant bacteria and prevent the spread of antibiotic resistant
infections, please commit to:

Avoid prescribing antibiotics inappropriately: Recent studies have shown that displaying poster-sized
commitment letters in exam rooms to avoid inappropriate antibiotic prescribing was a simple, low-cost, and effective
method for improvement.1 Write a prescription for symptom relief instead of an antibiotic and educate patients on
comfort measures that may work without antibiotics.

Communicate with patients: Parents indicate that they would be satisfied with their medical visit even if
antibiotics are not prescribed, provided that the physician explains the reasons for the decision.2 Discuss realistic
expectations for recovery time, explain that antibiotics do not significantly reduce the duration of symptoms, and that
unnecessary use of antibiotics may cause adverse effects that lead to antibiotic resistance.

Test for bacterial infections: If a child presents with a sore throat, do a strep test and prescribe accordingly.
Don’t send a script home with the patient “just in case,” but rather offer to call it in if the test comes back positive.

Code claims correctly and accurately: If your patient has comorbidities, bacterial infections, or competing
diagnoses, the standard codes for adults with acute bronchitis (AAB) and upper respiratory infection (URI) may not
be applicable. Ensure proper documentation is in the medical record and use correct diagnosis and procedure
codes on claim/encounter.
Here are some resources that might help you and your patients:
Anthem one-minute video: www.anthem.com/cold
Choosing Wisely—www.choosingwisely.org: 5 Patient Questions to ask Before Taking Antibiotics and Antibiotics:
When you Need them and When you Don't in English and Antibiotics: When you Need them and When you Don't
in Spanish
AWARE program materials-- Physician-Patient Resources in English and Spanish
CDC “Get Smart about Antibiotics”-- Patient and Provider Materials and References including Clinical Guidelines




SOURCES
1 Meeker,
Daniella, et al. “Nudging Guidelines – Concordant Antibiotic Prescribing: A Randomized Clinical Trial.” JAMA Internal Medicine. 2014; 174
(3): p 425-431.
2 Barden,
LS, et al. “Current Attitudes regarding use of Antimicrobial Agents: Results from Physicians’ and Parents’ Focus Group Discussions.” Clinical
Pediatrics (Phila). Nov 1998; 37(11): p 665-671.
December 2015
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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.
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 grid 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.
Contacting us
CM Telephone Number
1-877-332-8193
(Local/Commercial only)
National
1-877-447-6481
Federal Employee Program
800-711-2225
December 2015
CM Email Address
VA.CM@Anthem.com
VANatlAccts-CM@wellpoint.com
CM Business Hours
Monday – Friday, 8 a.m. to 9 p.m. EST
Saturday, 9 a.m. to 5:30 p.m.
Monday – Friday, 8 a.m. to 5 p.m.
No email
Monday – Friday, 8 a.m. to 7 p.m. EST
25 of 41
Coordination of care
Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment
and referral. Anthem would like to take this opportunity to stress the importance of communicating with your patient’s other
health care practitioners. This includes 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:
o
Diagnosis
o
Treatment plan
o
Referrals
o
Psychopharmacological medication (as applicable)
In an effort to facilitate coordination of care, Anthem in Virginia has several tools available on the provider website including
a coordination of care template and cover letters for both behavioral health and other health care 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
December 2015
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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 under-utilization. Anthem’s coverage 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 the web. 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:



Call us toll free from 8:30 a.m. - 5 p.m. Monday through Friday (except on holidays). More hours may be available
in your area. Federal Employee Program hours are 8 a.m. – 7 p.m. Eastern.
If you call after normal business hours, you can leave a private message with your contact information. Our staff
will return your call on the next business day. Calls received after midnight will be returned the same 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
Behavioral Health:
1-800-991-6045
Federal Employee
Program
Phone 800-860-2156
FAX 800 732-8318 (UM)
FAX 877 606-3807 (ABD)
To Discuss Peer-to-Peer
UM Denials
1-800-533-1120
Prompts 2,5,4,4,1
To Request
UM Criteria
1-800-533-1120
Prompts 2,5,4,4,1
Behavioral Health:
1-800-991-6045
Behavioral Health:
1-800-991-6045
Federal Employee
Program
Phone 800-860-2156
Federal Employee
Program
Phone 800-860-2156
FAX 800 732-8318 (UM)
FAX 877 606-3807 (ABD)
TTY/TDD
711 or
TTY: 800-828-1120(T)
Voice: 800-828-1140(V)
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.
December 2015
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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 Web site. To access, go to the "Provider" home page at anthem.com. From there, select “Provider”
and Virginia> then Health & Wellness> Quality > Member Rights & Responsibilities.
Clinical practice and preventive health guidelines available on the Web
As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted
nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our
website. The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are
reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. All
guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website. To access
the guidelines, go to the "Provider" home page at www.anthem.com. From there, select “Provider” and Virginia> then Health
& Wellness> Practice Guidelines.
Or, for Anthem HealthKeepers Plus (Medicaid/FAMIS), select this LINK.
GeoBlue: BlueCard provider outreach
GeoBlue, in partnership with Blue Cross Blue Shield of Michigan, began serving over 3,000 internationally-based General
Motors employees effective January 1, 2015. Many of these members will be seeking care in the U.S. and presenting the
GeoBlue identification card. These members are enrolled in a Blue Cross Blue Shield product and have full access to the
BlueCard provider network. The identification card follows all BlueCard specifications and all BlueCard processes apply. If
you have any questions, please contact our Customer Service team at 1-855-282-3517.
December 2015
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Behavioral health update
Documentation and reporting guidelines for applied behavior analysis (ABA) and treatments for
Autism Spectrum Disorder
Anthem implemented the new ABA CPT codes effective January 1, 2015. Anthem’s new policy is effective December 1,
2015, and outlines the health plan’s documentation and reporting guidelines for ABA and treatments for autism spectrum
disorder utilizing this code set. Please refer to the AMA’s CPT codebook and Anthem’s documentation policies to ensure
your practice is in compliance with these documentation requirements. The documentation policies can be found at
anthem.com. Please review the policy and ensure that all aspects are being addressed.
Health care reform (including health insurance exchange)
Refer to anthem.com for information about health care reform and the exchange in 2016
With the new year rapidly approaching, we want to share information regarding our plans that members can purchase on or
off the Health Insurance Marketplace also called the exchange. We will include the following for 2016:

Member ID Card Update for ACA-compliant Health Plans

Virginia Individual Plan Guide

Virginia Small Group Product Guide
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.
December 2015
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eBusiness
Receive e-mail notifications via our Network eUPDATE
Our provider newsletter, Network Update, is our primary source for providing important information to health care providers
and professionals. Network Update is published bi-monthly and is posted to our website on the Virginia provider section of
anthem.com for easy 24/7 access
Note that in addition to this newsletter and our website, we also use our e-mail service – Network eUPDATE – to
communicate new information. If you are not yet signed up to receive Network eUPDATEs, we encourage you to enroll now
so you’ll be sure to receive all information we will be sending about the Health Insurance Marketplace or commonly called
exchanges and other pertinent topics.
Reminder notifications sent via e-mail
When you sign up, you’ll not only receive an e-mail reminder for each newsletter posted online, you’ll also be notified of
other late breaking news and important information you’ll need when providing services and filing claims for our members.
It’s easy to sign up – just select Virginia and access the provider home page. There, you’ll find a link to register for our
Network eUPDATE.
Updated contact information for ERA and EFT registration
Please note that we have updated the contact information for providers registering for Electronic Remittance Advice (ERA)
and Electronic Funds Transfer (EFT). Anthem Blue Cross and Blue Shield in Virginia continues to use EnrollHub™, a CAQH
Solution™ for the enrollment of EFT and ERA as noted below, but we have updated the amount of time a provider should
wait before contacting Provider Services to resolve any EFT registration issues.
December 2015
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Electronic Remittance Advice, Electronic Funds Transfer Registration and Contact Information
Type of
Transaction
EFT only
EFT and ERA
(both)
How to Register, Update,
or Cancel
Use EnrollHub
Use the EnrollHub
For registration related
questions, contact:
EnrollHub Help Desk
at
1-844-815-9763
EnrollHub Help Desk
at
1-844-815-9763
To resolve issues after registration, contact:
Local Provider Services:
Outside the Richmond area, dial toll free
800-533-1120
Richmond area, dial 804-342-0010
For EFT questions, contact Local Provider
Services:
Outside the Richmond area, dial toll free
800-533-1120
Richmond area, dial 804-342-0010
NOTE – Providers should allow one week
from the date Anthem receives the EFT
enrollment from EnrollHub, as reflected on the
EnrollHub EFT enrollment summary screen.
For ERA questions, contact E-Solutions at 1800-470-9630 or
e-solutions.support@anthem.com
ERA only
Use the EDI website at
www.anthem.com/edi
E-Solutions at
1-800-470-9630
NOTE – Providers should allow four to six
weeks from successful ERA registration
before contacting E-Solutions.
E-Solutions at 1-800-470-9630 or
e-solutions.support@anthem.com
NOTE – Providers should allow four to six
weeks from successful ERA registration
before contacting E-Solutions.
December 2015
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Medicaid information
(Anthem HealthKeepers Plus offered by HealthKeepers, Inc.)
Attention Medicaid Providers: ICD-10 coding for diabetic complications
A benefit of ICD-10 codes is that providers can now report more clinical details concerning diabetic complications than they
could in ICD-9. The increased specificity is possible because ICD-10 contains expanded combination codes for diabetic
complications. A combination code describes two or more conditions within a single code. The ICD-10 code categories E08E13 contain the combination codes for diabetic complications. The codes include the type of diabetes mellitus, the body
system affected and the complications affecting that body system.
Get this useful ICD-10 coding tip sheet for diabetic complications here.
Coverage guidelines and Clinical Utilization Management Guidelines
update
The Medical Policy and Technology Assessment Committee (MPTAC) approved
Anthem Blue Cross and Blue Shield Medicaid coverage guidelines and Clinical
Utilization Management (UM) Guidelines, developed or revised to support clinical
coding edits for Medicaid members. These approved medical policies and Clinical UM
Guidelines are publicly available on the provider website.
Update: Home and hydration therapy medical necessity reviews
Effective January 1, 2016, precertification requirements will change for certain home therapy codes for Anthem
HealthKeepers Plus members. Requests must be precertified beginning January 1, 2016. Get the Home Therapy codes
requiring precertification here.
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Update: Scoliosis and spinal deformity medical necessity reviews
Effective January 1, 2016, surgical interventions for scoliosis and spinal deformity procedure requests for Anthem
HealthKeepers Plus members must be reviewed for precertification. Please submit all required clinical information at least 14
days before the requested procedure to allow a thorough clinical analysis. For precertification instructions, use this link.
Home health and outpatient therapies will require separate authorizations
Effective January 1, 2016, requests for home health and outpatient therapies for Anthem HealthKeepers Plus members will
require a separate precertification for each skill requested.
Providers are required, for dates of service beginning January 1, 2016, to submit each skill request separately to ensure
there are no delays in processing. If providers are faxing in the precertification request, a separate Precertification Form for
each skill request should be sent. Providers who use the Provider Self Service tool on http://www.Availity.com must submit a
separate precertification request for each skill requested.
For questions about these communications, contact Anthem HealthKeepers Plus Provider Services at
1-800-901-0020.
Medicare-Medicaid Plan update
This section of the newsletter addresses information about the Anthem HealthKeepers Medicare-Medicaid Plan or MMP.
Members are enrolled in both Medicare and Medicaid under the Commonwealth Coordinated Care Plan, also known as the
Duals Demonstration (“Demonstration”) Program.
CDC predicts another moderately severe flu season predominated by influenza A (H3N2)
HealthKeepers, Inc. is launching an annual member outreach campaign to encourage high-risk members enrolled in the
Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan, to visit their providers for a
flu vaccine. Outreach includes automated outbound telephone calls, text messages and newsletter articles. Providers may
experience an increase in phone calls and early appointments for the flu vaccine as a result of this outreach campaign. Along
with details about our outreach efforts, we’ve included highlights about the Centers for Disease Control and Prevention’s
(CDC) 2015 report on influenza activity and the composition of the 2015/2016 vaccine, Read more about the impacts of flu
season on your practice.
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ICD-10 coding supports MMP providers in reporting more clinical details for diabetic complications
In the preceding Medicaid section of this edition of the Network Update, we share information regarding the benefit of ICD-10
codes in that providers can now report more clinical details concerning diabetic complications than they could in ICD-9. The
information also applies to providers who participate in our MMP network. See page 32 for the full article or select this LINK.
Medicare information
(Anthem’s Medicare Advantage and Medicare Supplement plans)
Avoid denials of Medicare Advantage diagnostic claims by completing item 20 (CMS-1500)
correctly – Individual membership only
The Centers for Medicare & Medicaid Services (CMS) requires that providers billing for
diagnostic tests subject to the anti-markup payment limitation complete Item 20 on the
CMS-1500 form. A “YES” check indicates that an entity other than the entity billing for
the service performed the diagnostic test. A "NO" check indicates "no anti-markup
tests are included on the claim." When "YES" is annotated, Item 32 is required to be
completed.
Claims for Anthem individual Medicare Advantage members received with Item 20
checked as “YES” and incomplete or missing information in Item 32 will be denied with
denial Z01 “Claim must be billed with Provider’s NPI”. To prevent unnecessary denial
of claims, only complete Item 20 when you are billing diagnostic tests subject to the
anti-markup payment limitation.
For more information on diagnostic tests subject to the anti-markup payment limitation
refer to Medicare Claims Processing Manual, Chapter 35, Section 30.
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Please include modifiers to help ensure accurate payment
Codes not recognized by original Medicare are considered by Anthem Medicare Advantage as not reimbursable unless
otherwise noted for both individual and group-sponsored claims.
During the past year, some providers have found that certain individual and group-sponsored claims are denied for missing
or inconsistent modifiers as the claims are not consistent with Centers for Medicare & Medicaid Services (CMS) payment
guidelines. Please ensure you use the most current and appropriate CMS codes and modifiers when submitting your claims.
Check Important Medicare Advantage Updates at www.anthem.com/medicareprovider for additional information.
Oxygen DME precertifications will be reduced in 2016
Providers who prescribe durable medical equipment for oxygen delivery for Anthem individual and group-sponsored Medicare
Advantage members will find that fewer items will require precertification in 2016. Detailed precertification requirements for
individual Medicare Advantage members are available to the contracted provider by accessing the Provider Self-Service Tool
within Availity. Go to Auths and Referrals/Authorizations from the left navigation menu. Select Anthem Medicare Advantage
from the drop down box. You will be directed to the Medicare Advantage Precertification site which includes the
precertification submissions and inquiries link and Patient360, which can be found under the Patient Information tab.
Providers will find precertification requirements there as well via the Precertification look-up tool.
Please visit www.anthem.com/medicareprovider to learn more about this online provider self-service tool.
Precertification Guidelines found at the Medical Policy, UM Guidelines and Precertification Requirements link on the Anthem
provider home page at www.anthem.com for further information on existing precertification requirements.
Anthem to review ER level 5 professional claims
Anthem is initiating a review of ER professional claims billed with a level 5 ER E/M code (99285 or G0384) to ensure the
documentation meets or exceeds the components necessary to support its billing. The review for the necessary components
will be based on the coding guidelines outlined in the American Medical Association (AMA) CPT coding reference.
Documentation will be requested and the review will be performed on a pre-pay basis. The review for selected ER
professional claims with level 5 E/M codes is scheduled to begin January 1, 2016.
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Register for imaging site scores by March 1, 2016, to avoid unnecessary line-item denials
Please note: The following information does not apply to providers with delegated risk agreements
On November 1, 2015, Anthem Medicare Advantage plans began collecting information about the imaging capabilities of all
Anthem Medicare Advantage contracted providers who provide the technical component of a number of outpatient diagnostic
imaging services for our individual Medicare Advantage members.
AIM’s online registration tool, OptiNet®, will continue to collect modality-specific data from providers who render imaging
services in areas such as: facility qualifications, technician and physician qualifications, accreditation, equipment, and
technical registration. This information is used to determine conformance to industry-recognized standards, including those
established by the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC).
This data will continue to be used to calculate site scores for providers who render imaging services to our individual
Medicare Advantage members. Each modality or piece of equipment will receive its own score. Providers with an imaging site
score of 76 or higher for the applicable modality will see no change in reimbursement. Providers who score less than 76 or
who do not complete the survey by March 1, 2016, will receive a line-item denial for the technical component of the
outpatient diagnostic imaging service only. Globally billed claims will deny in total if the provider scores less than 76 or if the
provider does not complete the survey. If billing globally and the claim is denied, the provider has the option to resubmit a
corrected claim for the professional component (interpretation) with modifier 26 for payment consideration. Other services on
the claim, including the professional component of the outpatient diagnostic imaging service, will be processed as usual as
long as required authorizations are in place.
Anthem strongly encourages any provider who scores below 76 to improve his or her site score for the applicable
modality before the line-item denial of claims begins on claims submitted for dates of service on or after March 1,
2016. Providers who have not registered and therefore have no score also will be subject to line-item denials for
claims submitted for dates of service on or after March 1, 2016.
The provider registration is available online at www.aimspecialtyhealth.com/goweb. Simply select Anthem MA from the drop
down menu. If you have questions or need help completing the registration, please call AIM Customer Service at 800-2522021.
Please note that the line-item denial for a site score below 76 for the applicable modality applies only to individual Medicare
Advantage claims at this time.
Check Important Medicare Advantage Updates at www.anthem.com/medicareprovider for additional information.
56997WPPENMUB 10/21/2015
December 2015
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More $0 copay medications available to Medicare Advantage members with chronic conditions
Individual Medicare Advantage prescription drug plans in 2016 will continue to offer select drugs at a $0 member co-pay for
the following conditions: high blood pressure, high cholesterol and diabetes. The 2015 medication list (glipizide, lisinopril,
losartan, metformin, and simvastatin) will continue to be included. New medications on this list in 2016 include benazepril,
enalapril, enalapril-hctz, lisinopril-hctz, glimepiride, glipizide ER, losartan-hctz, metformin ER, atorvastatin, lovastatin and
pravastatin.
Group-sponsored plans will continue to offer the Select Generics benefit, which offers $0 copay for select generic drugs.
Avastin for ophthalmic use – C9257 can be billed in office setting for network providers
Beginning January 1, 2016, C9257, Avastin 0.25mg (for ophthalmic use), will be payable for facilities and professional
providers when other criteria are met for individual Medicare Advantage claim. In addition, Anthem will no longer require a
prior authorization for Avastin for ophthalmic injection. Check Important Medicare Advantage Updates at
www.anthem.com/medicareprovider for more information.
Enhanced reimbursement available for certain Part B injectable drugs
Beginning first quarter 2016, Anthem individual Medicare Advantage plans will reimburse providers with enhanced payments
for using less expensive but therapeutically equivalent select Part B injectable drugs. The reimbursement change is specific
to only the following drugs:

Therapeutic Class – Antiemetics. HCPCS (drug) – J1626 (Kytril), J2405 (Zofran)

Therapeutic Class – Folinic Acid. HCPCS (drug) – J0640 (Leucovorin)

Therapeutic Class – Osteoporosis. HCPCS (drug) – J3489 (Reclast)
Check Important Medicare Advantage Updates at www.anthem.com/medicareprovider for additional information.
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Anthem place of service claims adjudication mirrors CMS guidelines
CMS recently revised place of service (POS) code sets by adding new POS code 19 for “Off Campus-Outpatient Hospital”
and revising POS code 22 from “Outpatient Hospital” to “On Campus-Outpatient Hospital.” Please ensure your claims
include these new and revised POS codes where applicable. Anthem mirrors CMS guidelines when performing Place of
Service claims adjudication.
Anthem individual Medicare Advantage plan names changing for 2016
Anthem has introduced a standard nomenclature to its affiliated Medicare Advantage plans. In most instances, plan names
start with the local brand name, followed by the word “MediBlue,” then a plan descriptor, such as “Access,” and finally the
plan type. For instance, a standard HMO would be referred to as “Anthem MediBlue Essential (HMO),” while a standard PPO
would be called “Anthem MediBlue Access (PPO).” Group-sponsored Medicare Advantage plans are not impacted by these
changes. No member ID prefixes are changing for 2016. Check Important Medicare Advantage Updates at
www.anthem.com/medicareprovider for a list of current and 2016 plan names.
Keep up with Medicare Advantage news at Important Medicare Advantage Updates
Please continue to check Important Medicare Advantage Updates at www.anthem.com/medicareprovider for the latest
Medicare Advantage information, including:

Important 2016 coverage changes for diabetic supplies

Medicare Advantage reimbursement policies

2016 Medicare Advantage plan changes

ICD-10-CM Educational Material Now Available

Providers Must Enroll with Medicare to be able to Prescribe Part D Beginning June 1, 2016

Anthem encourages high-risk members to get annual flu shot
6815WPPENMUB 10/16/2015
December 2015
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Pharmacy update
CVS/specialty is the exclusive 1 in-network specialty pharmacy for
Anthem members with medical benefit coverage for specialty
medications
As the exclusive Anthem provider for specialty injectable and infusion medication,
CVS/specialty is able to ship to a physician’s office or to the patient’s location of choice.
Coram, a division of CVS/specialty, can also administer infusion drugs in one of its
infusion suites or in the patient’s home. Whether it is an infusion or injection medication,
CVS/specialty can support ongoing patient care.
Injectables
Patients have 24/7 access to a pharmacist-led Care Team that includes
specially-trained nurses, nutritionists, and support staff. This team
supports, motivates and educates patients and caregivers throughout
treatment.
Patients can have their specialty medications delivered to the location of
their choice which may be their home or physician’s office. CVS/specialty
is the only pharmacy that can ship medications to physicians’ offices. If the
treating provider does not use CVS/specialty for specialty drugs shipped to
the physician’s’office, claims will process according to the member’s outof-network benefits as applicable.
Phone, fax or e-scribe your prescription to any CVS/pharmacy or CVS/specialty pharmacy.

Phone 1-800-237-2767 | fax 1-800-323-2445
Infusions
As a division of CVS/specialty, Coram’s infusion nurses are experienced in administering infusion
medications to complex patients with rare or autoimmune disorders.
Patients can choose to receive infusions from experienced staff nurses in the convenience of their home,
or at a local Coram infusion suite. Both options may reduce the risk of infection and help patients save
money by moving infusions to lower cost sites of care.
Coram offers convenient care nationwide in more than 65 infusion suites. To find a Coram infusion suite
near you, go to coramhc.com/locations.
Phone or fax your infusion referral to Coram.

Phone 1-866-899-1661 | fax 1-866-843-3221
1
Subject to applicable state law.
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Searchable Formulary Tool gives providers easier access to formulary/drug list information
Anthem Blue Cross and Blue Shield (Anthem) recently launched a new Searchable Formulary Tool, providing access to all
relevant medication information about five of Anthem’s drug lists, including – clinical edits like prior authorization or step
therapy, dosage/strength options, and details about brands and generics.
Providers can quickly access the Searchable Formulary Tool through the Pharmacy site where Anthem’s drug lists are
housed. The following five drug lists are set up with searchable capabilities:

National

Select

Preferred

Essential

Generic Premium
Once you select the applicable drug list, you can search the drug list for a wealth of information including:

Tier status

Clinical programs/edits including quantity limits, dose optimizations, prior authorizations and step therapies

Drug label name

Generic drug name

Generic drug indicator

Therapeutic class and category

Available dosage/strength options
If needed, you can also access printable versions of these drug list PDFs.
Additionally, members with our pharmacy benefit will have the added functionality of benefit-specific drug list search
capabilities, which eliminates the need to identify and select the drug list that applies to their pharmacy benefit.
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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 commercial drug list is reviewed and updates are posted to the website quarterly (the first of the month for January,
April, July and October). For Anthem HealthKeepers Plus (Medicaid), visit SSB Pharmacy Information.
To locate the “Marketplace Select Formulary” and pharmacy information for health plans offered on the Health Insurance
Marketplace (also called the exchange), go to Customer Support, select your state, Download Forms and choose “Select
Drug List.”
For State-sponsored Business, visit SSB Pharmacy Information. Website links for the Federal Employee Program formulary
Basic and Standard Options are Basic Option: https://www.caremark.com/portal/asset/z6500_drug_list807.pdf; and Standard
Option: https://www.caremark.com/portal/asset/z6500_drug_list.pdf. This drug list is also reviewed and updated regularly as
needed.
For the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program or FEP), FEP Pharmacy
Policy updates have been added to the FEP Medical Policy Manual and may be accessed at www.fepblue.org > Benefit Plans
> Brochures and Forms > Medical Policies.
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