April 2015
In this issue
Page
Announcements


Availity to launch new eligibility and benefits functionality
Anthem’s 2015 webinars and seminars on tap
3
3
Coverage and clinical guideline update

Coverage guidelines effective July 1, 2015
4
Business update

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
ConditionCare Program benefits patients and physicians
11
Company delays implementation of post-service reviews of MRIs
in the ED until further notice
11
Missing 1099 IRS Form?
12
Anthem commits more than $3.3 million health improvements in
2014
12
Clinical practice and preventive health guidelines available on
the Web
13
ICD-10 update

ICD-10 updates: Free coding practice tool; End-to-end testing
results
13
Health care reform update (including health insurance exchange)


Integrated care model for plans purchased on the Health Insurance
Marketplace benefits patients and physicians
14
Refer to anthem.com for information about health care reform and the
exchange
15
eBusiness

Reminder – Access your anthem paper remittances online through the
Availity Web Portal
15
FEP update

Federal Employee Program® Medical Policy
17
anthem.com
Important phone numbers
1 of 38
VAPENABSNL (04/15)
In this issue, continued
Page
Medicaid information
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Well-child and well-baby FAMIS coverage
Reminders for providers serving FAMIS members
ICD-10 efforts and our Medicaid business
New value-added benefit: Sports physical reimbursement
New contraception benefit available
All Patient Refined-Diagnosis-Related Groups (APR-DRG) inpatient pricing
Assistant surgeon reimbursement change
Diagnostic testing professional component compared to evaluation and management medical decision
Making
ClaimCheck® version 55 and version 56 upgrades
18
18
18
19
19
20
21
21
23
Medicaid-Medicare plan update
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About this section of the Network Update
Upgrades to Claim Check® 10.1 apply to MMP
24
24
Medicare information
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Anthem encourages Medicare Advantage members to stay up-to-date on preventive care
ACIP updates pneumococcal vaccine policy
ClaimCheck® upgraded for individual Medicare Advantage members
CMS weighs monitoring statin use among diabetics
Precertification required on four new Part B injectables
OrthoNet to conduct post-service prepay medical necessity reviews for select cardiac procedures
Precertification requests and information available through Availity
Find medical record information through Patient360
Medicare Advantage reimbursement policy changes posted on anthem.com/medicareprovider
Clinical practice guidelines assist with chronic condition management
ICD-10-CM: Breathe easy with these coding tips for COPD
Reminder: Individual Medicare Advantage membership moved to new claims system
25
26
26
26
27
28
28
29
29
30
30
31
Pharmacy update
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Pharmacy information available on anthem.com
31
Bulletin board
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Onsite medical office seminar scheduled for May 14 – register today
Onsite medical office seminar and registration form
Anthem webinars and registration form
2015 Community involvement and events
April 2015
32
34
35
36
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Announcements
Availity to launch new eligibility and benefits functionality
Watch for changes coming second quarter 2015 to the Availity Web Portal. These changes include the launch of new online
functionality and features, helping to make eligibility and benefits inquiries easier and faster. Here’s a list of the new
features:
Feature
New request page
Patient history list
Menu by benefit type
Organization-wide view of
E&B transactions
Organization drop down
menu
Payer section
Description
A new design makes it easier for users to find and focus on tasks at hand. Now users can
submit multiple member inquiries without having to wait for individual results before starting
another request.
The results list automatically summarizes user’s most recent member inquiries and stays
visible for 24 hours. Just click the member name and see the results. Plus only information
relevant to that member is displayed.
Located under the ‘Coverage and Benefits’ tab, this interactive list includes key coverage
elements and only shows information that is returned from the payer.
Users can see transactions by other users within their organization (shared history). This
means less duplication of work.
Users responsible for more than one organization can switch organizations while staying on
the same page, resulting in a convenient, streamlined workflow.
Includes value-added services on one page so that users can access value-added services,
such as patient care summary, from the same page.
Availity will offer training to learn more about these time-saving
features. Details will be shared soon.
Please refer to our “eBusiness Update” section of the newsletter on
page 15 for an article regarding the access of paper remittances
through the Availity Web Portal.
Availity, an independent company, provides claims management services for Anthem
Blue Cross and Blue Shield.
April 2015
Anthem’s 2015 webinars and
seminars on tap
Our 2015 webinars and medical office
seminars are under way. For your
convenience, we offer the webinars in hourly
sessions online to eliminate travel time and
help minimize disruptions to your office or
practice. If you prefer in-person sessions,
we have those, too. Please see the
schedules and registration forms at the end
of this edition to sign up today for a webinar
or seminar that’s convenient for you.
3 of 38
Coverage and clinical guideline update
Coverage guidelines effective July 1, 2015
Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will implement the following new and
revised coverage and clinical UM guidelines effective July 1, 2015. These guidelines impact all our products – with the
exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage and the Medicare-Medicaid Plan (MMP or Dual
Integration product). Furthermore, the guidelines were among those recently approved at the quarterly Medical Policy and
Technology Assessment Committee meeting held on February 5, 2015.
The services addressed in these coverage guidelines will require authorization for all of our HealthKeepers products. A predetermination can be requested for our PPO products.
The guidelines presented in this edition of the Network Update are:

Alpha-1 Proteinase Inhibitor Therapy (DRUG.00072)

Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management (MED.00115)

Prothrombin Time Self-Monitoring Devices (CG-DME-30)

Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status (GENE.00010)

Dihydroergotamine Mesylate (DHE) Injection for the Treatment of Migraine or Cluster Headaches in Adults (CGDRUG-14)

Treatments for Urinary Incontinence (SURG.00010)

Naltrexone (Vivitrol®) Injections for the Treatment of Alcohol and Opioid Dependence (CG-DRUG-21)

Natalizumab (Tysabri®) (CG-DRUG-43)

Pegloticase (Krystexxa®) (CG-DRUG-44)

Iontophoresis for Medical Indications (CG-Med-28)

Ancillary Services for Pregnancy Complications (CG-MED-32)

Ambulatory and Inpatient Video Electroencephalography (CG-MED-46)

Ambulance Services: Ground; Non-Emergent (CG-ANC-06) – REMINDER
April 2015
4 of 38
SPECIAL NOTE
The services addressed in ALL the coverage guidelines presented in this section (pages 4 through 10)
will require authorization for all of our HealthKeepers products. A pre-determination can be requested
for our PPO products.
Guideline
Alpha-1 Proteinase Inhibitor
Therapy (DRUG.00072)
Description/Explanation
This new coverage guideline outlines the medical necessity criteria for the
use of alpha-1 proteinase inhibitors as therapy for individuals with a
deficiency of alpha-1 antitrypsin (AAT).
The HCPCS codes currently associated with this coverage guideline are
J0256 and J0257.
Guideline
Outpatient Cardiac
Hemodynamic Monitoring using
a Wireless Sensor for Heart
Failure Management (MED.00115)
Description/Explanation
This new coverage guideline addresses outpatient cardiac hemodynamic
monitoring for the management of heart failure using a wireless pressure
sensor device to measure pulmonary artery pressure.
Outpatient cardiac hemodynamic monitoring using an implantable pulmonary
artery pressure measurement sensor device for management of individuals
with heart failure is considered investigational.
Currently, there is not a specific CPT code for the implantation of a wireless
pressure sensor in the pulmonary artery. Code 93799, unlisted cardiovascular
service or procedure, is listed to represent this service. Current HCPCS
codes C2624 and C9741 are associated with this new coverage guideline.
Guideline
Prothrombin Time SelfMonitoring Devices (CG-DME-30)
Description/Explanation
This clinical UM guideline outlines the medical necessity criteria for the use of
battery-operated prothrombin time self-monitoring devices used by individuals
in the home to monitor blood-clotting rates.
HCPCS codes associated with this clinical UM guideline are G0248, G0249,
and G0250. Effective July 1, 2015, these codes will be subject to review
based on the position statements in the clinical UM guideline.
April 2015
5 of 38
Guideline
Genotype Testing for Genetic
Polymorphisms to Determine
Drug-Metabolizer Status
(GENE.00010)
Description/Explanation
This coverage guideline was revised to include genotype testing for
identification of the CYP2D6 variant of Cytochrome P450 to determine the
drug-metabolizer status of individuals being considered for treatment with
eliglustat (Cerdelga™) and of individuals with Huntington’s disease being
considered for treatment with a dosage of tetrabenazine (Xenazine®) greater
than 50 mg per day as medically necessary.
Genotype testing for genetic polymorphisms to determine drug-metabolizer
status has been revised to include individuals initiating therapy with Olysio
(simeprevir) plus Sovaldi® (sofosbuvir) and opioids and narcotics as
investigational.
Testing panels for genetic polymorphisms to determine drug-metabolizer
status have been revised to include the following as investigational.

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AIBioTech® CardioloGene Genetic Panel
AIBioTech® Pain Management Panel
AIBioTech® PsychiaGene Genetic Panel
AIBioTech® Urologene Panel
Millennium PGT
Proove® Drug Metabolism test panel
Proove® Narcotic Risk test panel
SureGene Test for Antipsychotic and Antidepressant Response
(STA²R)
Vysis ALK Break Apart FISH Probe Kit
The CPT and HCPCS codes associated with this revised guideline are 81225,
81226, 81227, 81291, 81350, 81355, 81381, 81400, 81401, 81479, 87902,
and G9143.
Guideline
Dihydroergotamine Mesylate
(DHE) Injection for the Treatment
of Migraine or Cluster
Headaches in Adults (CG-DRUG14)
April 2015
Description/Explanation
This clinical UM guideline outlines the medical necessity criteria for the use of
intravenous or subcutaneous administration of dihydroergotamine mesylate
DHE) for the acute treatment of migraine headaches with or without aura and
the acute treatment of cluster headache episodes in adults.
The HCPCS code associated with this clinical UM guideline is J1110.
Effective July 1, 2015, the code J1110 will be subject to review based on the
position statements in the clinical UM guideline.
6 of 38
Guideline
Treatments for Urinary
Incontinence (SURG.00010)
Description/Explanation
This coverage guideline was revised to include the implantation of an artificial
urinary sphincter device as medically necessary in male adults following
prostate surgery to treat urinary incontinence due to reduced outlet resistance
(Intrinsic Sphincter Deficiency) when the symptoms of incontinence have
been refractory to at least 6 months of conservative medical treatment.
Implantation of an artificial urinary sphincter device is considered not
medically necessary for all other indications including:


Treatment of ISD in women and children whose incontinence has
been refractory to conservative medical treatment or other surgical
treatments; and
Treatment of ISD in men who have not undergone prostate surgery
CPT and HCPCS codes 53445, 53446, 53447, 53448, 53449, and C1815
have been added to the revised coverage guideline and will be subject to
review based on the position statements in this coverage guideline.
Guideline
Naltrexone (Vivitrol®) Injections
for the Treatment of Alcohol and
Opioid Dependence (CG-DRUG21)
Description/Explanation
This clinical UM guideline outlines the medical necessity criteria for extendedrelease, injectable naltrexone. Naltrexone is an opioid antagonist that binds to
opioid receptors, blocking the euphoric effects of exogenous opioids in those
who are opioid or alcohol dependent.
Effective July 1, 2015, the code J2315 will be subject to review based on the
position statements in the clinical UM guideline.
Guideline
Natalizumab (Tysabri®) (CGDRUG-43)
Description/Explanation
This new clinical UM guideline outlines the medical necessity for natalizumab
(Tysabri®). Natalizumab is a recombinant humanized monoclonal antibody
known as an alpha-4 integrin antagonist.
Effective July 1, 2015, the code J2323 will be subject to review based on the
position statements in the clinical UM guideline.
April 2015
7 of 38
Guideline
Pegloticase (Krystexxa®) (CGDRUG-44)
Description/Explanation
This new clinical UM guideline outlines the medical necessity of pegloticase
(Krystexxa®), a pegylated biosynthetic (recombinant DNA) uric acid specific
enzyme (Urate oxidase/uricase) used in adults with chronic, treatmentrefractory gout.
The HCPCS code associated with this new clinical UM guideline is J2507.
Effective July 1, 2015, the code J2507 will be subject to review based on the
position statements in the clinical UM guideline.
Guideline
Iontophoresis for Medical
Indications (CG-Med-28)
Description/Explanation
This clinical UM guideline addresses the use of iontophoresis as a technique
for drug delivery.
Iontophoresis is considered medically necessary for the administration of
local anesthesia prior to a venipuncture or dermatologic procedure. However,
Anthem in Virginia considers reimbursement for local anesthesia
administration included in the payment for the primary procedure
regardless of the method of delivery.
The use of iontophoresis is considered not medically necessary for all other
indications (other than those described above).
The CPT code associated with this clinical UM guideline is 97033. Effective
July 1, 2015, the code 97033 will be subject to review based on the position
statements in the clinical UM guideline.
Guideline
Ancillary Services for Pregnancy
Complications (CG-MED-32)
Description/Explanation
This revised clinical UM guideline was updated to include continuous and/or
intermittent subcutaneous or intravenous anti-coagulant therapy as not
medically necessary for treatment of antepartum thromboembolytic disease
when the medical necessity criteria are not met.
Continuous and/or intermittent subcutaneous, intravenous, and/or enteral
anti-emetic/hydration/nutrition therapy is considered not medically necessary
when the medical necessity criteria are not met.
Coding was updated to include HCPCS codes representing methylprednisone
acetate, ondansetron hycrochloride, and metoclopramide HCL. Effective July
1, 2015, the codes J1020, J1030, J1040, J2405, and J2765 will be subject to
review based on the position statements in the clinical UM guideline.
April 2015
8 of 38
Guideline
Ambulatory and Inpatient Video
Electroencephalography (CGMED-46)
Description/Explanation
This revised clinical UM guideline was updated to include observation or
inpatient video electroencephalography (EEG) testing.
Observation or inpatient video EEG is considered medically necessary for any
of the following indications:
1.
2.
3.
Anti-epileptic drug treatment modification; or
Pre-surgical evaluation for epilepsy surgery for localization of
epileptic foci; or
Differentiating epileptic from non-epileptic seizures.
Observation or inpatient video EEG is considered not medically necessary for
all other indications.
CPT codes associated with this revised clinical UM guideline are 95950,
95951, 95953, and 95956.
All of the preceding coverage and clinical UM guidelines are available for review on our website at www.anthem.com after
April 7, 2015
Reminder: Ambulance Services
Guideline
Ambulance Services: Ground;
Non-Emergent (CG-ANC-06) –
REMINDER
Description/Explanation
This clinical UM guideline addresses the use of ground ambulances in nonemergency situations only.
The use of non-emergency ground ambulance services is considered
medically necessary when the following criteria are met (1, 2, AND 3 must
be met):
The ambulance must have the necessary equipment and supplies to address
the needs of the individual; and
The individual’s condition must be such that any other form of transportation
would be medically contraindicated; and
Either of the following circumstances exists:
a.
April 2015
Transportation to or from one hospital or medical facility to another
hospital or medical facility, skilled nursing facility, or free-standing
dialysis center in order to obtain medically necessary diagnostic or
therapeutic services is required [for example magnetic resonance
imaging, computed tomography scan, acute interventional
cardiology, intensive care unit (ICU) services (including neonatal
ICU), Cobalt therapy, etc.] provided such services are unavailable at
9 of 38
the facility where the individual initially resides; or
b.
Transfer from an acute care facility to an individual’s home or a
skilled nursing facility is required.
The use of non-emergency ground ambulance services is considered not
medically necessary when:
1.
The criteria and circumstances above have not been met; or
2.
The services are primarily for the convenience of the individual or
the individual’s family or physician; or
3.
The services are for a transfer of a deceased individual to a funeral
home, morgue, or hospital, when the individual was pronounced
dead at the scene.
In January 2014, member certificate language was updated and now
requires pre-certification for certain non-emergent ground ambulance
services. The pre-certification requirement is based on pick-up and dropoff locations.
The following destinations require pre-certification:
Modifier
PN
NP
HR
HE
PR
RP
JR
RJ
EP
HP
GY
GZ
April 2015
Description
Physician’s Office to skilled nursing facility ( SNF)
SNF to Physician’s Office
Hospital to Residence
Hospital to Residential, domiciliary, custodial facility (nursing
home, not skilled nursing facility)
Physician’s Office to Residence
Residence to Physician’s Office
Non-Hospital based dialysis facility to Residence
Residence to Non-Hospital based dialysis facility
Residential, domiciliary, custodial facility (nursing home, not
skilled nursing facility) to Physician’s Office
Hospital – Physician Office
Item or service statutorily excluded
Item or service expected to be denied
10 of 38
Business update
Company delays implementation of
post-service reviews of MRIs in the
ED until further notice
ConditionCare Program benefits patients and
physicians
Anthem members have additional resources available to help
them better manage chronic conditions. The ConditionCare
program is designed to help participants improve their health and
enhance their well-being. The program is based on nationally
recognized clinical guidelines and serves as an excellent adjunct
to physician care.
The ConditionCare program helps members better understand
and control certain medical conditions like diabetes, COPD, heart
failure, asthma and coronary artery disease. A team of nurses
with added support from other health professionals such as
dietitians, pharmacists and health educators work with members
to help them understand their condition(s), their physicians’
orders and how to become a better self-manager of their
conditions. 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.
Round-the-clock phone access to registered nurses.
Guidance and support from nurse coaches and other
health professionals.
Physician benefits:


Saves time for physicians and staffs by answering
patient questions and responding to concerns, freeing
up valuable time for the physicians and their staffs.
Supports the doctor-patient relationship by
encouraging participants to follow their physicians’
treatment plans and recommendations.
April 2015
As we shared with you in the past, Anthem
and our affiliate – HealthKeepers, Inc. –
conduct periodic reviews of claims and chart
information on behalf of members enrolled in
our health plans. In the December 2014
edition of our Network Update provider
newsletter, we notified you that our Anthem
Radiology Utilization Management area
would begin conducting post-service reviews
of all claims with MRIs performed on
patients in the emergency department (ED)
for members enrolled in Anthem’s Virginia
commercial group and individual policies
beginning first quarter 2015.
Today, we are writing to inform you that
we have postponed the implementation of
this initiative until further notice, as we
continue to work to update the American
Imaging Management’s (AIM)
appropriateness criteria guidelines
regarding this topic. This means we will
NOT be implementing post-service reviews
of claims with MRIs performed in the ED at
this time as originally planned and
communicated in December.
Once available, new AIM guidelines for the
ED setting will be published for review and
posted on our website at anthem.com.
Going forward, we will notify you in advance
in a future edition of the Network Update
with details about the implementation so you
will have ample time to review the AIM
guidelines.
11 of 38
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Informs the physician with updates and reports on the patient’s progress in the program.
The goal of our nurse coaches is to encourage participants to follow their physicians’ 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 us on the Web at anthem.com to find more information about the program such as program guidelines,
educational materials and other resources. Go to anthem.com and select Providers > Virginia > Enter > Health and Wellness
> ConditionCare. Also on our website is the Patient Referral Form that you can use to refer other patients you feel may
benefit from our program.
If you have questions or comments about the program, call toll free 877-681-6694. Our nurses are available Monday-Friday,
8 a.m. to 9 p.m., and Saturday, 9 a.m. to 5:30 p.m.
Please note that we also have a care management program specifically for members with health plans purchased on the
Health Insurance Marketplace (also called the exchange). More information is available in the article entitled “Integrated
care model for plans purchased on the Health Insurance Marketplace benefits patients and physicians” in this edition of the
Network Update.
Missing 1099 IRS Form?
Use the link
www.1099dept@anthem.com for
information. Or, if you prefer, call toll
free 1-888-246-4893.
Anthem commits more than $3.3 million health
improvements in 2014
Anthem Blue Cross and Blue Shield’s work to improve health and
strengthen local communities continued in 2014, as the company
directed more than $3.3 million and hundreds of volunteer hours to
health-improving causes, organizations and programs in Virginia.
“Anthem is committed to transforming health care with trusted and caring
solutions, and that extends directly to our work in communities
throughout Virginia,” said C. Burke King, president, Anthem Blue Cross
and Blue Shield. “We’re proud to support the organizations and
programs that are working to help our friends and neighbors live their healthiest lives possible.”
Through its State Health Index – a compilation of public health measures – and Healthy Generations grant program, Anthem
and its foundation work to identify the health issues impacting our local communities and in most need of attention and then
direct charitable support and volunteer efforts toward improving those areas.
Major areas of focus for Anthem in 2014 included promoting active lifestyles and working to reduce the devastating impact of
chronic illnesses such as diabetes, heart disease, and cancer on Virginia children, adults and seniors.
“We know that as our local communities change and grow so do the diverse needs of our residents,” said King. “What hasn’t
changed is our commitment to serving our members and advancing health in Virginia. It is a true honor to work with so many
great people and organizations and we look forward to doing so again in the year ahead.”
April 2015
12 of 38
For a summary of Anthem’s community efforts with such organizations as American Heart Association, American Diabetes
Association, Virginia Health Care Foundations and others, visit us on the Web HERE.
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 the
following link:
http://www.anthem.com/wps/portal/ahpprovider?content_path=provider
/va/f2/s2/t0/pw_a035223.htm&state=va&rootLevel=1&label=Practice%
20Guidelines
ICD-10 update
ICD-10 updates: Free coding practice tool; End-to-end testing results
Visit Anthem’s ICD-10 webpage for these resources as well as our latest information on ICD-10:


Free coding practice tool available to code medical scenarios in ICD-10: Starting in April, we are offering a free
scenario-based coding practice tool designed to give physicians and their coders the opportunity to test their
knowledge of the ICD-10 codes set by applying it to medical scenarios. These customized scenarios are based on
provider type and specialty, so you can practice using codes relevant to you. Registration is required. This tool will
be available until September 2015.
End-to-end testing results: In 2014, we conducted extensive end-to-end claims testing with facility providers,
professional providers and clearinghouses. Visit our ICD-10 webpage to learn about the insights we gained during
the testing. We’ve also included a list of clearinghouses with which we’ve successfully tested.
April 2015
13 of 38
Health care reform (including health insurance exchange)
Integrated care model for plans purchased on the Health Insurance Marketplace benefits patients
and physicians
An integrated care model affords members with plans purchased on the Health Insurance Marketplace (also called the
exchange) the ability to have continuity of care with each care management case. A single primary care nurse provides case
and disease assessment and management. This continuity provides opportunity for members to get assistance working
through an acute phase of an illness and then work with their nurses on the necessary behavioral changes needed to
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 integrated care model helps members with exchange health plans to better understand and control certain medical
conditions like diabetes, COPD, heart failure, asthma and coronary artery disease. Our nurse care managers are part of an
interdisciplinary team of clinicians and other resource professionals who are there to support members, families, primary care
physicians and caregivers. The integrated model 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.
Nurse care managers 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.
Members or caregivers can refer themselves or family members by calling the number 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. We can help with transitions across level of care so that patients and caregivers are better prepared and informed
about health care decisions and goals.
How do you contact Case Management (CM)?
CM Telephone Number
877-332-8193 (toll free)
(Local/Commercial business only)
CM e-mail Address
VA.CM@Anthem.com
CM Business Hours
Monday - Friday
8 a.m. – 9 p.m.
Saturday
9 a.m. – 5:30 p.m.
April 2015
14 of 38
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.
eBusiness
Reminder – Access your Anthem paper remittances online through the Availity Web Portal
Are you accessing your Anthem Blue Cross and Blue Shield paper remittances online through the Availity Web
Portal? If not, take the following steps now to begin accessing your paper remittances online.
If your organization is NOT currently registered for the Availity Web Portal:



The designated administrator for your organization should go to www.availity.com.
Click on Get Started under Register now for the Availity Web Portal, and then complete the online registration
wizard.
The administrator will receive an e-mail from Availity with a temporary password and next steps.
Not sure if your organization is registered?
Call Availity Client Services toll free at 800-AVAILITY (800-282-4548) for registration status of your tax ID.
Once registered on Availity, complete the Anthem Services Registration within the Availity Web Portal:
This registration process grants Availity users who are set up with a Point of Care Health Plan User ID to access paper
remittances on Point of Care through the Availity Web Portal by using a single sign on feature.

On Availity, from the left navigation menu, select My Account | then Anthem Services Registration.

Select the user’s organization (if applicable).

Select Non-Registered Users.


From the Non-Registered Users list, locate your user and type in their Point of Care Health Plan User ID; repeat this
step for additional registrations.
Click Register.
April 2015
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
Log out and log back into Availity in order for the new access to take effect.
Important Note: The user's first and last name must exactly match what is registered in Point of Care. If an exact match is
not made, the registration will be rejected.
Take the following steps to update the user’s name in Availity

From the Availity menu, select Account Administration | then Maintain User.

Locate the user and type in the changes.
Don’t know your Anthem Health Plan User ID?
You may call the Anthem eBusiness Helpdesk at 1-866-755-2680 to obtain this information.
How does a user receive an Anthem Health Plan User ID?
Your organization’s Point of Care administrator for the Point of Care provider portal will need to register a user for the
Point of Care Web portal in order to issue a Point of Care Health Plan User ID. Once the Point of Care Health Plan User ID
has been issued to a user, the Anthem Services Registration described in Step 1 can be completed. The Point of Care
administrator should take the following steps to register users for the Point of Care Web portal:

Log into Availity at www.availity.com.

Click My Payer Portal | then select Anthem Point of Care| then select “I Agree” to link out to Point of Care.

From Point of Care, select the Administration Tab |the select Administer Users to add a user

The new user will be sent an e-mail containing an activation code and a link.


The user should click the link and use the activation code to register for Point of Care and create a Point of Care
Health Plan user ID.
The user gives his or her new Point of Care Health Plan user ID to the PAA to register on the Availity Web Portal.
The Point of Care Administrator can also retrieve a user’s Point of Care Health Plan user ID by selecting Active
Health Plan User ID from the Point of Care Administration Tab.
NOTE: Only network providers who participate with Anthem Blue Cross and Blue Shield can register for Point of
Care.
Access your paper remittances through the Availity Web Portal
Users can now follow the steps below to access your organization’s paper remittances:

Log into Availity at www.availity.com.
April 2015
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

Click My Payer Portals | then Anthem Point of Care| then click on “I Agree” to link out to Point of Care. You are now
logged directly into Point of Care.
From the Point of Care Home page, select Reports| then Payment Vouchers to access your paper remittances.
One last step
Once you have completed the registration to obtain your online “paper” remittances through the Availity Web Portal and no
longer require the delivery of paper remittances by mail, you can discontinue the mailing of paper remittances by completing
the online form at https://wellpoint-int.columncloud.com/SR/paperSuppressionSR.jsp.
Is training available?
Availity offers a variety of ongoing training options, including live and on-demand webinars, online demonstrations, local
workshops, comprehensive help topics, tip sheets and more. For a full list of learning options, login to the Availity portal and
click Free Training at the top of any page.
Have questions?
If you do not know your Point of Care Health Plan User ID:
Call: Anthem Point of Care eBusiness Helpdesk: 1-866-755-2680
For questions regarding Availity’s Anthem Services Registration:
Call: Availity Client Services toll free at 1-800-282-4548
FEP update
Federal Employee Program® Medical Policy
For the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), the FEP Medical
Policy Manual may be accessed at www.fepblue.org > Benefit Plans > Brochures and Forms > Medical Policies. Here
providers can review specific medical policies that pertain to FEP.
The policies contained in the FEP Medical Policy Manual are developed to assist in administering plan benefits and do not
constitute medical advice. They are not intended to replace or substitute for the independent medical judgment of a
practitioner or other health care professional in the treatment of an individual member.
The Blue Cross and Blue Shield Association does not intend by the FEP Medical Policy Manual, or by any particular medical
policy, to recommend, advocate, encourage or discourage any particular medical technologies. Medical decisions relative to
medical technologies are to be made strictly by members/patients in consultation with their health care providers. The
April 2015
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conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that
FEP covers (or pays for) this service or supply for a particular member.
Medicaid information
Well-child and well-baby FAMIS coverage
HealthKeepers, Inc. reminds providers that all routine baby and well-child care is recommended by the American Academy of
Pediatrics Advisory Committee for our Anthem HealthKeepers Plus FAMIS members. This includes routine office visits with
health assessments and physical exams, routine lab work and age-appropriate immunizations. This also includes blood lead
testing, HGB, HCT or FEP (maximum of two, any combination).
For information about routine baby and well-child care coverage, contact our Provider Services team at 1-800-901-0020 or
visit the Web address: www.anthem.com/vamedicaiddoc
Reminders for providers serving FAMIS members
Hospice care
HealthKeepers, Inc. covers hospice care services to include a
program of home and inpatient care provided directly by or under the
direction of a licensed hospice. Hospice care programs include
palliative and supportive physician, psychological, psychosocial and
other health services to individuals utilizing a medically directed
interdisciplinary team. Hospice care services must be prescribed by
a provider licensed to do so, furnished and billed by a licensed
hospice, and determined to be medically necessary.
Hospice care services are available if the member is diagnosed with
a terminal illness with a life expectancy of six months or less.
Hospice care is available concurrently with care related to the
treatment of the child’s condition with respect to which a diagnosis
of terminal illness has been made.
Organ transplantation
HealthKeepers, Inc. covers organ transplantation services as
medically necessary per industry treatment standards, for all eligible
April 2015
ICD-10 efforts and our Medicaid
business
In the “ICD-10 Update” section of this
edition of the Network Update, we share
information regarding our ongoing efforts
to help ensure our internal systems will
comply with the upcoming ICD-10
requirements set to implement in October
2015. As these efforts also impact our
Medicaid business, you may wish to refer
to the article on page 13 for details about
a free coding practice tool, end-to-end
testing results and a link to other
resources.
18 of 38
individuals, including but not limited to transplants of tissues, autologous, allogeneic or syngeneic bone marrow transplants
or other forms of stem cell rescue for children with lymphoma and myeloma. Kidney transplants for patients with dialysisdependent kidney failure, heart, liver, pancreas and single-lung transplants are also covered, as are procurement/donorrelated services.
HealthKeepers, Inc. is not required to cover transplant procedures determined to be experimental or investigational.
If you have questions about coverage for FAMIS members, call our Provider Services team at 1-800-901-0020.
New value-added benefit: Sports physical reimbursement
HealthKeepers, Inc. is offering a new value-added benefit for our Anthem HealthKeepers Plus members in Virginia. We will
now pay in-network primary care providers to perform sports physicals for our members. One sports physical per calendar
year will be reimbursed for members between the ages of 6-18.
When does the benefit go into effect?
This benefit became effective January 1, 2015.
How do I bill for the physical?
You should use CPT code 99212 with DX V70.3. You can bill for both a well visit and a sports physical if performed during a
single appointment.
Please pass this information along to your staff. For additional information or questions, call our Provider Services team toll
free at 1-800-901-0020.
New contraception benefit available
Effective March 15, 2015, Anthem HealthKeepers Plus offered by HealthKeepers, Inc.
patients have access to immediate postpartum placement of long-acting reversible
contraception (intrauterine devices [IUDs] and etonogestrel implant). This change will
enable providers to place the device of their patients’ choice while in the hospital and
receive the same reimbursement as if the device were placed as an outpatient.
The inpatient facility will provide the device. Please work closely with your obstetrical unit
to understand the logistics of obtaining the device.
Unintended pregnancies continue to be a major health problem in the United States and
are associated with higher rates of maternal and neonatal complications of pregnancy1.
Long-acting contraception methods are more effective at preventing unintended pregnancies, have significantly greater
continuation rates than oral contraceptives, the vaginal contraceptive ring or the contraceptive patch2 and have very low
rates of serious side effects.
April 2015
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Providers are encouraged to discuss with patients the option for immediate postpartum placement of the IUD or implant
during the early third trimester of pregnancy. Providing additional counseling and support to your teenage and young patients
(ages 13-19) is also encouraged as this group is at the greatest risk for early discontinuation of these methods3. It appears
there is lower discontinuation rate at two years of IUD use as compared to the etonogestrel implant4. When clinically
appropriate, IUDs should be considered over the implant.
If you have questions about providing this new benefit to your patients, please contact Provider Services at 1-800-901-0020.
Go to www.anthem.com/vamedicaiddoc for frequently asked questions about long-acting reversible contraception.
1
Hellerstedt WL, Pirie PL, Lando HA, Curry SJ, McBride CM, Grothaus LC, et al. Differences in prenconceptional and prenatal behaviors in women with
intended and unintended pregnancies. AM J Public Health 1998; 88:663-6
2
Winner B, Peipert JF, Zhao Q, Buckel C, Madden T, Allsworth JE, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012; 366
1998-2007
3
Aoun J, Dines VA, Stovall DW, Mete M, Nelson CB, et al. Effects of Age, Parity, and Device Type on Complications and Discontinuation of Intrauterine
Devices. Obstetrics & Gynecology 2014;123:585-92
4
O’Neil-Callahan M, Peipert JF, Zhao Q, Madden T, Secura G. Twenty-Four-Month Continuation of Reversible Contraception. Obstet Gynecol
2013;122:1083-91
All Patient Refined-Diagnosis-Related Groups (APR-DRG) inpatient pricing
Effective June 1, 2015, HealthKeepers, Inc. will be implementing All Patient Refined-Diagnosis-Related Group (APR-DRG)
pricing for claims related to our Anthem HealthKeepers Plus members.
To prepare for the launch of ICD-10 and the implementation of APR-DRG pricing, providers who have been selected to
participate in ICD-10 testing will have their claims priced against APR-DRG during the testing cycle. Our testing team will
assist with the testing process to ensure pre- and post-comparative results are provided.
For more information about APR-DRG pricing for claims related to our Anthem HealthKeepers Plus members, contact our
Provider Services team at 1-800-901-0020.
April 2015
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Assistant surgeon reimbursement change
Effective May 1, 2015, assistant surgeon fees billed for non-physician
providers, billing with an AS modifier, will be no longer reimbursed by
HealthKeepers, Inc.
Assistant surgeon fees billed with an AS modifier by non-physician
providers will deny as incidental to the surgeon fees and will be, therefore,
not eligible for reimbursement. Assistant surgeon services billed by or for
a physician with modifiers 80, 81, or 82 will continue to be eligible for
reimbursement.
This change will align HealthKeepers, Inc. more closely to the Department of Medical Assistance Services’ (DMAS)
reimbursement policies.
For more information about assistant surgeon reimbursement changes, contact our Provider Services team at 1-800-9010020.
Diagnostic testing professional component compared to evaluation and management medical
decision making
One of the many ways HealthKeepers, Inc. supports the quality health care you provide to our Anthem HealthKeepers Plus
members is by giving you information about industry developments and best practices for saving time on administrative work.
We would like to clarify when it is appropriate for providers to bill for the professional component of a diagnostic test on the
same day that they bill for an evaluation and management (E&M) service. Generally, professional diagnosis services are
included in the medical decision making element of the E&M service so that providers should not bill separately for the
professional component of a diagnostic test performed on the same day, but there are exceptions.
Medical decision making, as defined by the Centers for Medicare & Medicaid Services (CMS)* “refers to the complexity of
establishing a diagnosis and/or selecting a management option, which is determined by considering the following factors:


The number of possible diagnoses and/or the number of management options that must be considered;
The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained,
reviewed, and analyzed; and
April 2015
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
The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the
patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.”
Professional component (PC), as defined by CMS, “is for physician work interpreting a diagnostic test or performing a
procedure, Modifier 26 is used with the billing code to indicate that the PC is being billed.”
Modifier 26 is appended to a CPT code if the doctor read the diagnostic test, but did not perform it.
The physician may only report the professional interpretation (Modifier 26) if the X-ray or other diagnostic test has not
already been interpreted and all other criteria for separate payment are met. This may require that documentation be
submitted.
The E&M documentation guidelines address the need for a separate written report if the physician is reporting the
professional interpretation of X-rays or other diagnostic tests.
Per CMS, “the interpretation of a diagnostic procedure includes a written report.” Also, “a professional component
billing…without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet
the conditions for separate payment of the service.”
Case examples
Case 1: X-ray review would be included in medical decision making and inclusive in the E&M service.
While in the hospital, Dr. Ortho was consulted on a patient who was found to have a distal radius fracture. She comes into
the office for routine follow-up. AP and lateral views of the distal radius are obtained and reviewed showing no change when
compared to the films from the hospital.
Plan: Alignment is reasonable and decision is to treat non-operatively.
Case 2: X-ray would be billed separately from E&M with a Modifier 26 if a separate report meeting the criteria was dictated
by the physician.
Patient has been experiencing hand pain 1 week after attempting to break a board in karate. PA, lateral and oblique views
are taken by an X-ray machine in the building but not owned by Dr. Ortho. Dr. Ortho performs full report of the X-ray
interpretation and also documents his full E&M elements.
Case 3: X-ray would be billed separate from E&M without any modifier if a separate report meeting the criteria was dictated
by the physician.
Patient has been experiencing hand pain 1 week after attempting to break a board in karate. PA, lateral and oblique views
are taken by X-ray owned by Dr. Ortho. Dr. Ortho performs full report of the X-ray interpretation and also documents his full
E&M elements.
Source: Centers for Medicare & Medicaid Services website: cms.gov.
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ClaimCheck® version 55 and version 56 upgrades
HealthKeepers, Inc. will complete two upgrades of ClaimCheck® 10.1, a nationally recognized code auditing system for
processing claims for our Anthem HealthKeepers Plus members. The changes included in the version 55 upgrade will
become effective July 2015. The changes included in the version 56 upgrade will be effective in August 2015.
Background information
HealthKeepers, Inc. uses an auditing software product from McKesson to reinforce compliance with standard code edits and
rules. ClaimCheck increases consistency of payment to providers by ensuring correct coding and billing practices are being
followed. Using a sophisticated auditing logic, ClaimCheck determines the appropriate relationship between thousands of
medical, surgical, radiology, laboratory, pathology and anesthesia codes and processes those services according to industry
standards.
Why is this change necessary?
ClaimCheck is updated periodically to conform to changes in coding standards and include new procedure and diagnosis
codes.
HealthKeepers, Inc. uses ClaimCheck to analyze outpatient services, including those that are considered:




Rebundled or unbundled services
Multichannel services
Mutually exclusive services
Incidental procedures




Inappropriately billed medical visits
Fragmented billing of pre- and postoperative care
Diagnosis to procedure mismatch
Upcoded services
Other procedures and categories that are reviewed include:



Cosmetic procedures
Obsolete or unlisted procedures
Age/sex mismatch procedures


Investigational or experimental procedures
Procedures billed with inappropriate modifiers
Questions?
If you have questions about the upgrades, contact our Provider Services team at 1-800-901-0200 or visit us on the Web at
www.anthem.com/vamedicaiddoc.
April 2015
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Medicaid-Medicare plan update
About this section of the Network Update
This section of the newsletter addresses information about the MedicareMedicaid plan or MMP. The Virginia Department of Medical Assistance
Services (DMAS) selected our affiliate HealthKeepers, Inc. as one of the
managed care organizations to enroll and manage the comprehensive health
care benefits of dual eligible individuals. These individuals are enrolled in
both Medicare and Medicaid under the Commonwealth Coordinated Care
Plan, also known as the Duals Demonstration (“Demonstration”) Program.
Watch for notices in upcoming editions of the provider newsletter.
Upgrades to ClaimCheck® 10.1 apply to MMP
In the “Medicaid” section, we share a short notice about upgrades to ClaimCheck 10.1, a nationally recognized code auditing
system. It is important to note that the information presented about the upgrades also applies to providers in the
Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan. Please refer to the
full article on page 23 about the ClaimCheck upgrades. If you have additional questions, contact the MMP Provider Services
team at 1-855-817-5788.
April 2015
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Medicare information
Anthem encourages Medicare Advantage members to stay up-to-date on preventive care
Anthem is committed to helping your Medicare Advantage patients maintain good health habits and stay up-to-date on
preventive screenings. We encourage you to check in with your senior patients about the following issues to help ensure they
are monitoring their own health and receiving needed care.
Physical Health/Monitor Physical Activity

Discuss and encourage the importance and benefits of exercise

Discuss applicable exercise options

Discuss any problems/pain members are having with accomplishing daily
activities
Mental Health

Discuss overall mental health and if physical and emotional health is
affected

Discuss feelings of anxiety, blues, depression

Discuss members’ overall energy level
Bladder Control

Assess whether the member has had any leaking of urine

Advise the member of bladder treatment options such as bladder training, exercises, medication and surgery
Breast Cancer Screening

Women 50-74 need to have a mammogram at least every 24 months
April 2015
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ACIP updates pneumococcal vaccine policy
Anthem would like to make you aware that the Advisory Committee on Immunization Practices (ACIP) has changed its policy
regarding pneumococcal vaccines for persons over the age of 65. Effective September 19, 2014, Anthem covers:


An initial pneumococcal vaccine to all Medicare beneficiaries who have never received the vaccine under Medicare
Part B; and
A different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months
have passed following the month in which the last pneumococcal vaccine was administered).
CMS weighs monitoring statin use among diabetics
ClaimCheck® upgraded for
individual Medicare Advantage
members
Earlier in this edition of the Network Update,
we provided a short notice about upgrades to
ClaimCheck. Refer to the full article on page
23.
Please note that the information regarding
ClaimCheck 10.1 is applicable to claims for
individual Medicare Advantage members only.
It is not applicable to group-sponsored
Medicare Advantage claims.
Endocrinologists and primary care providers (PCPs) please
note: In November of 2013, the ACC/AHA released new
guidelines for the treatment of blood cholesterol to reduce
atherosclerotic cardiovascular risk in adults. One major focus in
this recommendation is reducing the risk of atherosclerotic
cardiovascular disease (ASCVD) in persons with diabetes who are
40-75 years of age. According to the ACC/AHA guideline,
“Moderate-intensity statin therapy should be initiated or continued
for adults 40-75 years of age with diabetes mellitus,” and “Highintensity statin therapy is reasonable for adults 40-75 years of age
with diabetes mellitus with a ≥7.5% estimated 10-year ASCVD risk
unless contraindicated.” *
To align practice standards, the Pharmacy Quality Alliance (PQA)
has developed a measure to support the ACC/AHA guidelines. The
measure is labeled “Statin Use in Persons with Diabetes,” and
calculates the percentage of patients ages 40-75 years who
received a medication for diabetes that also receive a statin medication during the measurement period. The Center for
Medicare & Medicaid Services (CMS) is closely following this measure and is evaluating the addition of this measure as a
future Medicare Part D health plan rating.
Please consider initiating statin therapy in patients who fit these criteria in conjunction with the recommendations from 2013
ACC/AHA Guidelines for the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. The
2013 ACC/AHA Guidelines for the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
can be found at: http://circ.ahajournals.org/content/129/25_suppl_2/S1
*Formulary moderate-intensity statin therapies include atorvastatin 10-20 mg, Crestor 5-10 mg, simvastatin 20-40 mg,
pravastatin 40-80 mg, lovastatin 40 mg; while formulary high-intensity statins include atorvastatin 40-80 mg and Crestor
April 2015
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20-40 mg. Simvastatin currently costs our members $0 to $5 (varies by plan) for a 30-day fill at a preferred pharmacy. This
would be the least expensive option for them.
Precertification required on four new Part B injectables
Anthem is adding the following four new injectable drugs to the 2015 Medicare Advantage list of Part B injectables/ infusibles
requiring precertification. As of March 1, 2015, providers must call for prior authorization of these drugs.
1.
Benlysta (belimumab) for treatment of lupus (SLE) (J0490)
Drugs billed with NOC HCPCS J code (J3490)
2.
Iluvien (fluocinolone acetonide injection): for treatment of diabetic macular edema (DME) (unlisted, no J code
established at this time)
3.
Lemtrada (alemtuzumab injection): for treatment of relapsing forms of multiple sclerosis (MS) (unlisted, no J code
established at this time)
4.
Opdivo (nivolumab) for treatment of unresectable or metastatic melanoma (unlisted, no J code established at this
time)
Please note for drugs currently billed under the Not Otherwise Classified J code (J3490), the plan’s denial will be for the
drug, and not the HCPCS. This applies to all Medicare Advantage Group Sponsored and Individual Medicare Advantage
plans.
To contact the plan for prior authorization of these services, see below:
Phone: 866-797-9884 Option 5
Fax: 866-959-1537
e-mail: maspecialtypharm@anthem.com
51763WPSENABC 02/09/15
April 2015
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OrthoNet to conduct post-service prepay medical necessity reviews for select cardiac procedures
Appropriate care is the key to achieving the best outcomes for our Medicare Advantage members. To help reach that goal
Anthem is collaborating with OrthoNet to help ensure that invasive cardiac procedures are reasonable and necessary for the
diagnosis and/or treatment of coronary artery disease.
Effective April 1, 2015, Anthem is contracted with OrthoNet to conduct post-service prepay medical necessity reviews of
selected cardiac procedures, including reviews of facility and professional Cardiac Catheterizations and Percutaneous
Coronary Interventions (PCIs). These reviews will apply to individual Anthem Medicare Advantage members.
Providers who submit claims for these services for individual Anthem Medicare Advantage members after the effective date
may receive a request for records and related digital images. The process for submitting records and related images will be
streamlined by providing you with a HIPAA-compliant, secure internet portal for uploading the needed information.
Instructions for completing this process will be included with the request.
A board-certified cardiologist will review the records and images to determine if the services were reasonable and necessary
to diagnose and/or treat the patient. Should you receive a medical record request, Anthem would appreciate your timely
compliance.
OrthoNet will use Medicare national coverage determinations, local coverage determinations, Anthem’s medical policies, and
clinical utilization management guidelines to determine medical necessity of the requested therapies. You may access these
coverage determinations, medical policies and clinical guidelines here.
If you have questions about this communication or need assistance with any other item, contact OrthoNet:
Phone: 844-278-5477
Fax: 844-876-4924
To verify member eligibility, benefits or account information, please call the telephone number listed on the back of the
member’s identification card.
Y0071_15_23430_I 02/04/2015
Precertification requests and information available through Availity
Precertifications for Anthem individual Medicare Advantage members can be initiated via the Availity Web portal at
www.Availty.com. To access this new functionality, 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.
April 2015
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Find medical record information through Patient360
Patient360 is a read-only dashboard available through our secure provider portal that gives you instant access to detailed
individual Medicare Advantage member information. By clicking on each tab in the dashboard, you can drill down to specific
items in a patient’s medical record:



Demographic information – member eligibility, other health
insurance, assigned PCP and assigned case managers
Care summaries – emergency department visit history, lab
results, immunization history, and due or overdue preventive
care screenings
Claims details – status, assigned diagnoses and services
rendered

Authorization details – status, assigned diagnoses and assigned services

Pharmacy information – prescription history, prescriber, pharmacy and quantity

Care management-related activities – assessment, care plans and care goals
Medicare Advantage reimbursement policy changes posted on anthem.com/medicareprovider
Anthem Medicare Advantage published Medicare Advantage Reimbursement Policy Changes in your October 2014 provider
newsletter and posted the information under Important Medicare Advantage Updates in August 2014. Anthem has updated
and expanded this initial communication to help address any questions you may have. To view this communication, please
click here.
Medicare Advantage information is located at www.anthem.com/medicareprovider. For Anthem Medicare Advantage
reimbursement policy updates, please visit our website and select Important Medicare Advantage Updates. To review our
complete set of reimbursement policies, select Medicare Advantage Reimbursement Policies. Our reimbursement policies
apply to participating providers who serve Individual Anthem Medicare Advantage business unless provider, federal, or CMS
contracts and/or requirements indicate otherwise.
April 2015
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Clinical practice guidelines
assist with chronic condition
management
Clinical practice guidelines (CPGs) are
resources to assist providers and
members in the management of chronic
medical conditions. They are reviewed by
board-certified practitioners and
distributed to network providers to help
reduce unnecessary variation in care.
Anthem CPGs are located on the
provider website under the Health &
Wellness tab.
ICD-10-CM: Breathe easy with these coding tips for
COPD
In ICD-9, COPD code 496 is not to be used with any code from
categories 491 (chronic bronchitis), 492 (emphysema), or 493
(asthma). In ICD-10, code category J44 encompasses asthma and
bronchitis associated with COPD. Code category J44 includes other
COPD, asthma with COPD, chronic asthmatic (obstructive)
bronchitis, chronic bronchitis with airways obstruction, chronic
bronchitis with emphysema, chronic emphysematous bronchitis,
chronic obstructive asthma, chronic obstructive bronchitis and
chronic obstructive tracheobronchitis.
Furthermore, in ICD-10, there is a note to use an additional code to
identify exposure to environmental tobacco smoke (Z77.22), history
of tobacco use (Z87.891), occupational exposure to environmental
tobacco smoke (Z57.31), tobacco dependence (F17.-), or tobacco
use (Z72.0).
The table below reflects the crosswalk from ICD-9 to ICD-10.
ICD-9
(COPD documented with a more specific respiratory
condition fell under multiple code categories)

491.2-, Obstructive chronic bronchitis

493.2-, Chronic obstructive asthma

496, COPD
ICD-10
(COPD documented with a more specific respiratory
condition falls under one code category)

J44.-, Other chronic obstructive pulmonary disease
o Code also type of asthma, if applicable (J45.-)
In future articles, we will continue to bring you helpful coding tips to assist you and your coding staff with the transition from
ICD-9 to ICD-10.
As a reminder, claims/encounters with dates of service on and after October 1, 2015, must be submitted with ICD-10 codes.
CMS will reject those submitted with ICD-9 codes, resulting in delay or denial of payment. We must all be prepared to meet
CMS guidelines.
Y0071_15_23499_I 02/12/2015
April 2015
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Reminder: Individual Medicare Advantage membership moved to new claims system
Effective January 1, 2015, Anthem moved Individual (non-group) Medicare Advantage members to a new claims processing
system. Please continue to check Important Medicare Advantage Updates on your provider portal for additional information.
Y0071_14_22758_I 12/10/2014
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 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.”
April 2015
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Bulletin board
Onsite medical office seminar scheduled for May 14 – register today
On May 14, we will offer a medical office seminar in Roanoke for Anthem-contracting “professional providers” and their
office staffs. This informative session is 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 non-routine
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 the seminar below or one 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 forms in this edition of the Network Update).
DATE
May 14, 2015
Thursday
TIME
10 a.m. to 1 p.m.
LOCATION
South County Library
SOCO Meeting Rooms 1 & 2
6303 Merriman Road
Roanoke, VA
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
Use of e-tools found on our open Web portal at anthem.com, as well as our secure portal, Availity
New product and/or benefit changes for our PPO, HealthKeepers, Medicaid and Medicare Advantage plans, as well
as the Medicaid-Medicare Plan (Duals) and plans purchased on the Health Insurance Marketplace
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
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

Medical Management; Utilization Management; Pharmacy Management

And/or other topics of timely importance

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 WESTERN Region Seminars ONLY
FAX:
540-853-3065 (Western)
or
MAIL: Anthem Blue Cross and Blue Shield
Attn: WESTERN Medical Office Seminars
Mail Drop VACH01-A000
3800 Concorde Parkway, Suite 2000
Chantilly, VA 20151
For your comfort and convenience:


We highly recommend attendees bring a sweater or jacket for
personal comfort.
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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Onsite medical office seminar and registration form
Please join us for an educational seminar
When: Thursday, May 14, 2015; 10 a.m. -1 p.m.
Where: South County Library
6303 Merriman Road Roanoke, VA
Fax completed form to Michelle Brown at 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, MFTs, 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.

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 Central, call 804-354-2334;
for Eastern, call 757-326-5152; for Northern and Western, call 703-227-5315.

For personal comfort, we highly recommend attendees bring a sweater or jacket. Limited beverages/snacks will be provided
at all seminars; you may also “brown bag”. 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 selection
is full or has been cancelled will be sent to you via E-MAIL or FAX so it is critical that you
include your e-mail, phone, and fax numbers when completing this form. THANK YOU.
Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and it s service area is all of Virginia except for the City of Fairf ax, the Town of Vienna, and the
area east of State Rout e 123. Anthem Blue Cross and Blue Shield and its aff iliate HealthKeepers, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a
regi stered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbol s are regi st ered marks of the Blue Cross and Blue Shield Associati on.
April 2015
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Anthem webinars and registration form
Due to subject matter content, these webinars will be made available only to “professional providers”, defined as Anthem
network-participating providers and their staffs who submit claims using the 837P or CMS-1500 format, and who have the
following medical credentials: MD, DO, DC, DPM, LCSW, LCP, LPC, LFMT, CNS, CNM, plus DDS, DMD & OD (nonroutine 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 A NTHEM WEBINAR I NVITATION
Provider/Practice Name: ____________________________________________________________
Medical Specialty: ____________________________________
Your Provider Type(s) (circle):
MD, DO, DC, DPM, LCSW, LCP, LPC, LFMT, CNS, CNM, DDS, OD, or OTHER: __________
Location of main office in VA: ________________________________________________________
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 2015 WEBINAR(s) you wish to attend:
 Wednesday, May 20
 Wednesday, August 19
 Wednesday, November 18
(10:30 a.m.-11:30 a.m.) –
(10:30 a.m.-11:30 a.m.) –
(10:30 a.m.-11:30 a.m.) –
Second Quarter Anthem Updates
Third Quarter Anthem Updates
Fourth Quarter Anthem Updates
PLEASE COMPLETE FORM AND FAX IT TO (804) 354-2979
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and it s service area is all of Virginia except for the City of Fairf ax, the Town of Vienna, and the
area east of State Rout e 123. Anthem Blue Cross and Blue Shield and its aff iliate HealthKeepers, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a
regi stered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbol s are regi st ered marks of the Blue Cross and Blue Shield Associati on.
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2015 Community involvement and events
Improving the health of the communities we serve is at the heart of everything we do. It’s why we develop events like those
outlined below that help people get engaged with a healthy lifestyle while also creating opportunities to raise money for
important causes such as efforts to fight heart disease and cancer. We hope you find this information of interest and will
share with your patients as you deem appropriate.
2015 Schedule of Events
Event
Anthem Star K
April 18/Roanoke
Anthem presents the Second
Annual RE Strong Run
April 25/Urbanna
ASK 5K Walk
April 25/Richmond
March for Babies
May 17/Richmond
Relay For Life of Roanoke
May 29/Roanoke
Anthem LemonAid
July 17-19
Richmond/Tidewater
Overview and More Information
This 10K route will test participants’ endurance and strength with equally
challenging uphill and downhill race navigation.
Visit http://blueridgemarathon.com/.
Join us for this event benefiting VCU Massey Cancer Center. The event includes a
5k, 10k and family fun run, post-race festival, live entertainment, participant
medals, t-shirts and more.
For event information, visit www.restrongrun.com
Save the date for the Association for Support of Children with Cancer (ASK) Fun
Walk and Run.
Visit https://www.askweb.org for details.
Supports: Association for Support of Children with Cancer
Take part in this March of Dimes walk that raises funds to improve the health of
babies right within our own community. Walkers who raise at least $200 will be
eligible for prizes.
To form a team, visit www.marchforbabies.org
Join participants to take part in this overnight event where team members take
turns walking or running to show their support for those whose lives have been
touched by cancer.
To learn more, visit: http://www.relayforlife.org/
Anthem LemonAid is an opportunity for families to be part of helping to fight
pediatric cancer.
Visit our website at https:///www,anthemlemonaid.com or call 804-228-5929.
Supports: Children’s Hospital of Richmond and Children’s Hospital of the
King’s Daughters
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Fab 5k at Roanoke County’s
Green Hill Park
For those new to fitness walks, this one is perfect with one of the flattest
courses in Virginia. Plus, this event includes a cash prize for top finishers.
August 15/Roanoke
Anthem Moonlight Ride
Visit www.mountainjunkies.net/Fab_5k.htm for more information.
Celebrate the joy of cycling at the 5th annual Anthem Moonlight Ride.
August 22/Richmond
Visit https://www.sportsbackers.org/events/moonlight/moonlight_ride.htm to learn
more.
Anthem presents Speak Up 5K
September 12/Richmond
Supports: Fit4Kids
Helps raise awareness for the mental health issues impacting children throughout
this country. This 5k race celebrates the life of teen founder, Cameron Gallagher,
and raises funds to support this worthy cause.
Visit http://speakup5k.com for more information.
UCI Road World
Championships
September 19 -27/Richmond
Heart Walks
October 10/Richmond
TBD/Newport News
October 10/Norfolk
TBD/Roanoke
Anthem Go Outside Festival
October 16-18/Roanoke
Anthem Into the Darkness
Night Trail Run at Virginia’s
Explore Park
October 24/Roanoke
Anthem Wicked 10K
October 31/Virginia Beach
Call Federal Credit Union
April 2015
Supports: Childhood depression
Anthem is proud to be one of the sponsors hosting this 9-day world cycling
championship event for athletes from all over the world. This year will mark the first
time this global event has been in the United States since 1986. Twelve World
Championship races will take place throughout the 9 days, with an expected half a
million onsite spectators and media coverage throughout the world.
Visit www.richmond2015.com for more.
Help save lives by joining us for this annual walk that benefits the American Heart
Association’s research to fight heart disease.
Visit www.startwalkingnow.org/start_heart_walk.jsp for more information.
Supports: American Heart Association
By combining the things outdoor enthusiasts love – camping, music, movies, gear,
races, and demos – the Go Outside Festival is a celebration of everything
outdoors.
Visit www.roanokegofest.com to learn more.
Enjoy Roanoke Valley’s only night time trail run at Virginia’s Explore Park. This
four-mile event is perfect for the entire family.
To get more information, visit www.mountainjunkies.net
Easily the largest outdoor Halloween costume party in Virginia Beach. Complete
the race in any pace, with prizes for the best costumes.
Visit www.wicked10k.com for more information.
As part of the Anthem Richmond Marathon, kids can get a head start on the fun by
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Marathon
October 24/Richmond
coming out for this junior marathon occurring two weeks prior. The event is open to
kids between the ages of 4-14, and participants can elect to participate in 0.5 mile,
1-mile or 2-mile race – based on age and ability.
Register at: http://www.sportsbackers.org/events/call-federal-credit-unionmarathon-junior
Anthem Richmond Marathon
November 14/Richmond
Supports: Kids Run RVA
Registrants enjoy a great scenic course that routes through some of Richmond's
most historic neighborhoods, culminating with a downhill finish on the city’s
beautiful riverfront. Registrants can choose from the full 26.2 mile course or opt for
either the half marathon or 8k course.
Learn more by visiting www.richmondmarathon.org.
Supports: Kids Run RVA
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