December 2014
In this issue
Page
Announcements

IMPORTANT REMINDER: Some functionality and access to Point of
Care moves to Availity beginning December 12
3
Coverage and clinical guideline update

Coverage and clinical UM guidelines effective
March 1, 2015
5
Business update
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New modifiers XE, XP, XS and XU effective January 1, 2015
6
Company delays and clarifies post-service reviews of MRIs in the ED;
new effective date is first quarter 2015
6
Health Diagnostic Laboratory to leave network in February
7
Important information regarding use of Clinical UM Guidelines 7
Updates to Blue Physician Recognition Program
8
Creating a LGBT friendly practice – Online experience available 8
Important postpartum visit for OB/GYNs
Misrouted protected health information
10
We believe in continuous improvement
10
HEDIS® 2014 results are in
10
Case Management Program
14
Coordination of Care
15
Members’ rights and responsibilities
15
Important information about utilization management
16
Clinical practice and preventive health guidelines on the Web 17
Health care reform update (including Health Insurance Exchange)

Refer to anthem.com for information about health care reform and the
Exchange
17
FEP update

FEP 2015 benefit information available online
18
eBusiness

Receive e-mail notifications via our Network eUPDATE in 2015 18
1 of 48
anthem.com
Important phone numbers
VAPENABSNL (12/14)
In this issue, continued
Page
Medicaid information
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Effective January 1, 2015: Changes in diabetic supplies coverage for Anthem HealthKeepers Plus
members
19
Reimbursement policy for venipuncture service
20
Required forms and coverage for abortion, sterilization and hysterectomy procedures
20
Coverage Guidelines update
20
Reminder: Coverage guidelines update for prevention of respiratory syncytial virus infections
22
Clinical Utilization Management Guidelines update
22
Clinical Utilization Management Guidelines update – Urine drug testing
23
Quarterly pharmacy formulary change notice
24
Patient360 lets you access member records in just a few clicks
26
New precertification requirements for Anthem HealthKeepers Plus members for cervical fusions go into effect
January 1, 2015
27
Flu vaccines are critical to the health of high-risk patients
28
Reminder: Upcoming changes to durable medical equipment precertification requirements
29
Medicare information
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Hyaluronate agents require prior authorization
29
Individual Medicare Advantage membership moves to new claims processing system January 1, 2015
30
New for 2015: Anthem introduces new benefits, plans for Medicare Advantage members
33
Advanced Notices of Non-coverage for Medicare Advantage members
34
OrthoNet to conduct medical necessity reviews, professional service coding reviews
35
Anthem, Optum collaborating to help ensure members receive regular exams, preventive screenings
36
Prior authorizations required for CMS-designated high-risk medications
36
Clearinghouse helps ensure timely and accurate claims payment for vaccines covered by Medicare Part D 37
New federally qualified health center billing guidelines in effect for original Medicare
37
Speaking the language of ICD-10
38
CMS mandated Opioid Overutilization Program
39
CuraScript moved to Accredo brand effective November 24, 2014
40
Prior authorization required for members
41
Encourage exercise to prevent falls
41
2015 Virginia Medicare Advantage plan changes
43
Pharmacy update
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Clarification of CoramRx/CVS Caremark change
Pharmacy information available on anthem.com
December 2014
48
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Announcements
IMPORTANT REMINDER: Some functionality and access to Point of Care moves to Availity
beginning December 12
Take the necessary steps today to prepare your organization for the transition to the Availity Web
Portal
What you need to know

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On December 12, 2014, member eligibility, benefit, claim status and electronic 151s functions are moving
exclusively to the Availity Web Portal at www.availity.com from Point of Care* in Virginia.
Direct access to Point of Care will no longer be available after December 12, 2014.
Secure Messaging functionality on Availity will replace
the Anthem electronic 151 inquiry. You can now access
the link - “Do you have a question about this claim?” at
the bottom of the claim detail page.
Medical management functionality, reports including
remittances, and access to prior electronic 151s will
remain on Point of Care. However, access to these
functions will need to be via single sign-on through
Availity.
Anthem HealthKeepers Plus (Medicaid/FAMIS) providers
who currently access “Provider Self Service” (PSS) via
Point of Care will have access to PSS via the Availity Web Portal beginning Monday, December 15, 2014. Effective
December 15, the link to PSS will be viewable for all users on the left navigation on Availity under “My Payer Portal”
and then choose “Provider Self Service.”
Please make sure that all of your users are registered for Availity today.
* Note: Electronic transactions submitted via our Enterprise EDI Gateway are unaffected; you may continue to submit all X12
transactions through your current EDI transmission channels. Electronic transactions submitted via Provider Self Service
(PSS) -- the secure provider website for Anthem HealthKeepers Plus (Medicaid/FAMIS) -- are unaffected at this time.
Anthem Blue Cross and Blue Shield has partnered with Availity to offer a multi-payer portal solution that gives you secure,
single sign-on access to multiple payers' information. You can access eligibility, benefits, claims status, claim submission,
secure messaging (comparable to electronic 151 functionality), patient care summary, care reminders and member certificate
booklets (evidence of coverage) on the Availity Web Portal at no charge. You can also access Point of Care via the My
Payer Portal link for your existing functionality, such as online remittances, medical management functionality etc.
December 2014
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Where to start
Contact your current Point of Care administrator to assist in determining if your organization is already registered for Availity.
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Access to existing Point of Care functions will need to be via single sign-on through Availity.
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All current Point of Care users need to be registered for Availity.
If your organization is NOT currently registered for Availity
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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.
If all of your organization’s users are not registered on Availity Web Portal, the Primary Access Administrator (PAA) needs to
do so.
Please remember: Every individual MUST have his or her own individual User ID and password for Availity. Logins
CANNOT be shared. Have your organization’s PAA click here and we'll walk through setting up a new user(s).
Once users are registered for access to the Availity Web Portal, each user must have their Point of Care and Availity
accounts connected via Anthem Services Registration.
a.
If Anthem Services Registration has not been completed by your PAA, each user's Point of Care user ID must be
entered into the Anthem Services Registration piece on Availity.
b.
Please note: The user's first and last names in Availity MUST match exactly to those in Point of Care. If the name is
incorrect in Availity, click Account Administration/ Maintain User to correct the user's name.
You’re ready to go
Log in to the Availity Web Portal, go to My Payer Portals/Anthem Point of Care on the Availity Web Portal and navigate to
Point of Care without entering another login and password. You now have access to easily navigate to medical management
functionality, reports including remittances, and access to prior electronic 151s which will remain on Point of Care.
Free training
Once you log into the Availity Web Portal, you'll have access to many resources to help jump start your learning, including
free live training, on-demand training, frequently asked questions, and comprehensive help topics. To view the current
training resources, click Free Training at the top of any page in the Availity Web Porta or click
www.rsvpbook.com/availitytraining to find a current schedule of FREE Availity workshops and webinars.
December 2014
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Questions?
If you have questions, please contact Availity Client Services toll free at 1-800-282-4548 or via email at
virginiapocmigration@availity.com for assistance.
Availity, an independent company, provides claims management services for Anthem Blue Cross and Blue Shield.
Coverage and clinical guideline update
Coverage guideline effective March 1, 2015
Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., will implement the following new
coverage guideline effective March 1, 2015. This guideline was among those recently approved at the quarterly Medical
Policy and Technology Assessment Committee meeting held on November 13, 2014.
Guideline
Analysis of PIK3CA Status
(GENE.00044)
Description/Explanation
This new coverage guideline addresses DNA testing used to determine the
PIK3CA status in individuals with cancer.
Analysis of PIK3CA status is considered investigational for all indications.
Effective March 1, 2015, CPT code 81404 will be subject to review based on
the position statement in this coverage guideline.
The services addressed in this coverage guideline will require authorization for all of our HealthKeepers products. A predetermination can be requested for our PPO products.
These new and revised coverage guidelines and clinical UM guidelines are available for review on our website at
www.anthem.com.
December 2014
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Business update
New modifiers XE, XP, XS and XU effective January 1, 2015
Effective January 1, 2015, CMS is adding four new HCPCS modifiers to selectively identify subsets of modifier 59 for Distinct
Procedural Services as follows:

XE Separate Encounter: A service that is distinct because it occurred during a separate encounter

XP Separate Practitioner: A service that is distinct because it was performed by a different practitioner

XS Separate Structure: A service that is distinct because it was performed on a separate organ/structure
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XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual
components of the main service
Anthem and our affiliate HealthKeepers, Inc. will accept the new modifiers for claims processed on or after January 1, 2015.
However, for commercial lines of business only, and until further notice, the modifiers will be treated as informational only
and will not override any claim edits unless they are accompanied with modifier 59. For commercial lines of business,
continue using modifier 59 to report distinct procedural services. A separate communication will be sent later for our
government lines of business (such as Medicare Advantage, Medicaid and the Medicare-Medicaid Plan) regarding the
preceding modifiers.
Company delays and clarifies post-service reviews of MRIs in the ED; new effective date is first
quarter 2015
As we shared with you in previous communications and editions of the Network Update, Anthem Blue Cross and Blue
Shield (Anthem) and our affiliate – HealthKeepers, Inc. – conduct periodic reviews of claims and chart information on behalf
of members enrolled in our health plans. Our data on procedures performed in the emergency department (ED) shows
significant increases in the utilization of high-tech imaging over the past few years, mirroring what is reported in the
literature. In particular, Magnetic Resonance Imaging (MRI) is increasingly being performed on patients in the ED.
Therefore, Anthem Radiology Utilization Management will conduct post-service reviews of all claims with MRIs performed on
patients in the ED for members enrolled in Anthem’s Virginia commercial group and individual policies. Beginning first quarter
2015, all claims for MRIs will be pended for clinical review, and records will be requested if not submitted with the claim.
Payment for those studies which do not meet the American Imaging Management’s appropriateness criteria will be denied as
not medically necessary. Furthermore, as specified in provider contracts, the member cannot be balanced billed in these
situations and will be held harmless.
December 2014
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Again, these post-service reviews will begin first quarter 2015. Thank you for your cooperation, as we continue to work
together to provide access to safe, quality care for our members – your patients – in all settings. We hope this clarifies the
post-service review. If you have questions about this initiative, please contact Cathy Belcher at
cathy.belcher@anthem.com. For any claims issues, contact your Anthem network manager.
Health Diagnostic Laboratory to leave network in February
Effective February 1, 2015, Health Diagnostic Laboratory, Inc. will no longer be participating in Anthem’s laboratory network.
For a complete list of network-participating laboratory providers, please visit www.anthem.com and use our provider finder
tool (“Find a Doctor”). Or if you prefer, you can call the customer service number on the back of the member’s ID card.
Important information regarding use of Clinical UM Guidelines
Anthem Blue Cross and Blue Shield recognizes the importance of preventing, detecting and investigating fraud, waste and
abuse. We are committed to protecting and preserving the integrity and availability of health care resources for our
members, clients and business partners. Anthem has business processes in place to review claims before and after the
claims are processed to detect fraud, waste and abuse.
Beginning December 2014, Anthem will include the following language in all Clinical Utilization Management Guidelines on
the provider website at anthem.com about the use of Clinical UM Guidelines for a variety of purposes. For example, Clinical
UM Guidelines may be generally adopted for reviewing the medical necessity of services; used for provider education; and
used for reviewing the medical necessity of services by a provider who has received notice about certain billing practices or
claims, even if a guideline is not used for all providers delivering that service to Anthem’s members. The language states the
following:
Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general
adoption by plans or lines of business for consistent review of the medical necessity of services related to the
clinical guideline. Alternatively, commercial or FEP plans or lines of business which determine there is not a need
to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of
business’ members may instead use the clinical guideline for provider education and/or to review the medical
necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical
necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in
some other manner.
Please refer to your provider manual for further details on a new program to deter fraud, waste and abuse that is scheduled
to be rolled out throughout 2015 for our commercial business and the Blue Cross Blue Shield Service Benefit Plan, also
known as the Federal Employee Program (FEP).
December 2014
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Updates to Blue Physician Recognition Program
Anthem Blue Cross and Blue Shield in Virginia 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.
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 network manager.
Creating a LGBT friendly practice – Online experience available
What you may not know about your Lesbian, Gay, Bisexual, or Transgender (LGBT) patients may be putting their health at
risk. Studies have shown that many LGBT patients fear they will be treated differently in health care settings and that this
fear of discrimination prevents them from seeking primary care. Anthem Blue Cross and Blue Shield joins you in striving for
the best clinical outcomes for everyone, including LGBT populations. That’s why Anthem has created an online experience
that provide strategies, tools and resources to providers interested in attracting or maintaining a LGBT patient panel.
Hopefully, as a result of increasing LGBT-friendly practices, Anthem, along with the entire health care industry, will see an
increase in primary care and disease prevention among LGBT patients. Like you, Anthem strives to meet the needs of our
diverse membership and upholds access to consistently high quality standards across our networks. We believe that by
offering our providers these types of experiences, we can help keep all our members healthy. In addition, this online
experience reinforces our commitment to equality for our LGBT members as referenced in our provider contractual nondiscrimination provisions.
Visit the provider pages at anthem.com for free 24/7 access to the experience – either via your computer, tablet or
smartphone. You will gain an increased understanding of how to create an LGBT-friendly practice, which may improve the
health of your patients.
December 2014
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Important postpartum visit reminder for OB/GYNs
As you may know, the National Committee for Quality Assurance (NCQA) specifies that the postpartum visit should be
completed 21 to 56 days (3 to 8 weeks) after delivery. This visit is distinct from the cesarean section visit or incision check
your patient may have had before that time.
The most current data shows that postpartum visits occur in a timely manner, overall. When reviewing a random sample of
2013 medical charts, we found postpartum visits between 21 and 56 days in Virginia occurred 86% and 75% of the time for
HealthKeepers and PPO plans, respectively. The top 10% of health plans nationally have a compliance rate of at least 91%
among HMO members and at least 87% among PPO members.
2013 Medical Chart Review Findings from a Sample of the Non-Compliant Women in Virginia:
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52% of patients enrolled in a HealthKeepers plan and 47% of PPO patients had insufficient evidence of postpartum
care, with a majority (78% of HealthKeepers and 72% of PPO) not documenting the date of the postpartum visit.
23% and 28% of women enrolled in HealthKeepers and PPO plans, respectively, with a documented date were not
seen in the appropriate timeframe:
— 5% of HealthKeepers and 15% of PPO were seen before 21 days
— 3% of HealthKeepers and 5% of PPO were seen between 56 and 63 days
— 15% of HealthKeepers and 8% of PPO were seen one or more months after the 56th day

2% of the women with a HealthKeepers plan had a caesarian section check only, without a postpartum visit.
What can you do?

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
Make sure that every woman who delivers has a postpartum visit scheduled between 21 and 56 days after
delivery. If possible, schedule the mother’s postpartum visit upon or prior to hospital discharge. You may even be
able to schedule it at the “last” prenatal visit, or two weeks prior to the expected delivery date. A study published in
March 2011 found that postpartum follow-up rates were significantly higher (86.1% compared with 71.7%, P=.012)
when a visit was scheduled prior to discharge (Tsai, Pai-Jong, et. Al. “Postpartum Follow-Up Rates Before and
After the Post-Partum Follow-up Initiative at Queen Emma Clinic.” Hawaii Medical Journal. March 2011; 70(3): p
56-59).
Specify the postpartum visit date on the claim and use the Category II CPT Code 0503F (indicating a postpartum
visit) on the global delivery code with the delivery date. Using this supplemental tracking code would reduce the
time and disruption to your office that the health plan would need to request to review patient charts for evidence of
postpartum care.
When you see a woman for their postpartum visit, remember to clearly indicate the date, complete physical
findings, and counseling/discussion points in the patient’s chart. For your convenience, the “Quick Reference
Guide for Clinicians” for Postpartum visits/counseling by the Association of Reproductive Health Professionals can
be accessed by the following link: https://www.arhp.org/uploadDocs/QRGPostpartumCounseling_Checklist_1.pdf.
Please take less than 30 seconds to give us your feedback: https://www.surveymonkey.com/r/8H3G8JF
December 2014
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Misrouted protected health information
As a reminder, providers and facilities are required to review all member information received from Anthem Blue Cross and
Blue Shield to help ensure no misrouted protected health information (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 provider services area to report
receipt of misrouted PHI.
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.
HEDIS® 2014 results are in
Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) data collection for
2014. 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 by signing in to www.anthem.com and clicking on “Provider”, followed by “Health and
Wellness”, “Quality”, and finally “HEDIS”. You will find reference documents entitled “HEDIS 101 for Providers” and “HEDIS
Documentation Guidelines”.
The table below shows a comparison of some of our key measure rates to the NCQA Quality Compass® National Averages.
The rates in bold in the HEDIS 2014 column show an increase from 2013 rates.
December 2014
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Commercial HMO/POS Measures
Effectiveness of Care – Prevention and Screening
Adult BMI Assessment
Breast Cancer Screening
Childhood Immunization Status - IPV
Childhood Immunization Status - HIB
Childhood Immunization Status - PCV
Childhood Immunization Status - ROTAVIRUS
Childhood Immunization Status - INFLUENZA
Childhood Immunization Status – TDAP/TD
Immunizations for Adolescents - MENINGITIS
Immunizations for Adolescents – TDAP/TD
Weight Assessment and Counseling – BMI TOTAL
Weight Assessment and Counseling – Nutritional Counseling TOTAL
Weight Assessment and Counseling – Physical Activity- TOTAL
Effectiveness of Care – Respiratory Conditions
Antibiotic Treatment Adults w/ Acute Bronchitis
Appropriate Testing for Children w/ Pharyngitis
Appropriate Treatment Children w/ URI
Spirometry Testing for COPD
Utilization & Relative Resource Use - Utilization
Well-Child Visits in the first 15 Months of Life (6+ visits)
Effectiveness of Care - Cardiovascular
Persistence of Beta-Blocker Treatment after AMI
Effectiveness of Care - Diabetes
Comprehensive Diabetes Care – HbA1c Testing
Comprehensive Diabetes Care – Poor HbA1c Control (>9)*
Comprehensive Diabetes Care – Eye Exams
Comprehensive Diabetes Care – Blood Pressure Control
<140/80
Comprehensive Diabetes Care – Blood Pressure Control
<140/90
Effectiveness of Care - Musculoskeletal
Use of Imaging Studies for Low Back Pain
Effectiveness of Care – Behavioral Health
Antidepressant Medication Mgmt – Acute
Antidepressant Medication Mgmt – Continuation
Follow Up Care Children’s ADHD Medication – Initiation
Follow Up Care Children’s ADHD Medication - Continuation
*lower rate is better
December 2014
HEDIS 2014 Rate
(Percent)
Comparison to
National Average
83.28
71.65
92.21
96.35
88.08
87.35
73.97
77.34
62.84
94.01
45.01
55.47
↓
=
↑
↑
↑
↑
↓
↓
↑
↑
↓
44.53
↓
15.69
90.03
75.52
35.30
↓
↑
↓
↓
89.54
↑
87.50
↑
91.24
25.30
51.58
40.15
↑
↓
↓
↓
69.10
↓
65.50
↓
59.43
44.79
36.15
40.94
↓
↓
↓
↓
↑
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Commercial PPO Measures
Effectiveness of Care – Prevention and Screening
Adult BMI Assessment
Breast Cancer Screening
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 – HEP A
Childhood Immunization Status – ROTAVIRUS
Childhood Immunization Status – INFLUENZA
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
Access / Availability of Care
Adults’ Access to Preventive/Ambulatory Health – TOTAL
Children’s & Adolescents’ Access to PCP (25 mos-6 yrs)
Children’s & Adolescents’ Access to PCP (7-11 yrs)
Children’s & Adolescents’ Access to PCP (12-19 yrs)
Effectiveness of Care – Respiratory Conditions
Antibiotic Treatment Adults w/ Acute Bronchitis
Appropriate Testing for Children w/ Pharyngitis
Appropriate Treatment Children w/ URI
Spirometry Testing for COPD
Utilization & Relative Resource Use - Utilization
Well-Child Visits in the first 15 Months of Life (6+ visits)
Adolescent Well-Care Visits
Effectiveness of Care - Cardiovascular
Cholesterol Management – LDL-C Control <100
Effectiveness of Care - Diabetes
Comprehensive Diabetes Care – HbA1c Testing
Comprehensive Diabetes Care – Poor HbA1c Control (>9)*
Comprehensive Diabetes Care – Eye Exams
Comprehensive Diabetes Care – LDL-C Screening
Comprehensive Diabetes Care – LDL-C Controlled (LDL-C<100
mg/dL)
December 2014
HEDIS 2014 Rate
(Percent)
Comparison to
National Average
73.48
71.66
85.89
89.05
92.46
91.73
83.70
91.48
86.13
80.29
80.78
64.72
64.69
57.66
87.59
37.71
51.09
↑
↑
↑
↑
↑
↑
↑
↑
↑
↓
↑
↑
↑
↓
↑
↑
↑
46.47
↑
92.86
91.63
92.28
88.22
↓
↑
↑
↑
16.53
80.58
74.82
38.82
↓
↑
↑
↓
82.33
38.67
↑
↓
49.15
↓
91.24
33.33
52.80
84.43
46.23
↑
↑
↑
↑
↑
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Comprehensive Diabetes Care – Medical attention for
nephropathy
Comprehensive Diabetes Care – Blood Pressure Control
<140/80
Comprehensive Diabetes Care – Blood Pressure Control
<140/90
Effectiveness of Care - Musculoskeletal
Use of Imaging Studies for Low Back Pain
Effectiveness of Care – Behavioral Health
Antidepressant Medication Mgmt – Acute
Antidepressant Medication Mgmt – Continuation
Follow Up Care Children’s ADHD Medication - Continuation
*lower rate is better
84.18
↑
42.34
↑
63.50
↑
70.92
↓
62.24
46.12
42.75
↓
↓
↓
In Virginia, many scores for our commercial HealthKeepers line of business improved and exceeded the national average,
especially those in Adult Body Mass Index Well-Child visit in the first 15 months of life (6+ visits), and Appropriate Testing for
Children with Pharyngitis, with the largest rate increases noted in Childhood Immunization Status-Haemophilus Influenzae
type b, Immunization for Adolescent TDAP/TD and Comprehensive Diabetes Care-Hemoglobin A1c. In the PPO line of
business, there were also many improved scores that exceeded the national average, especially those in Childhood
Immunization Status-Inactivated Poliovirus Vaccine, Immunization for Adolescents-TDAP/TD and Children’s & Adolescent’s
Access to PCP ( 25 months- 6 years ), with the largest rate increases noted in Children’s & Adolescent’s Access to PCP ( 711 years ), Childhood Immunization Status- Measles, Mumps & Rubella Vaccine and Childhood Immunization StatusHaemophilus Influenzae type b.
Although many rates were above the national average, this year the commercial HealthKeepers/PPO plans had the greatest
number of decrease in rates. There are opportunities for improvement for the measures with the most significant decreases
in rates including: childhood Immunization Status TDAP/TD, Appropriate Treatment Children with Upper Respiratory
Infection, Breast Cancer Screening in the HealthKeepers plan and Adult Access to Preventive/Ambulatory Health Total,
Childhood Immunization Status-Hepatitis A Vaccine and Use of Imaging studies for Low Back Pain in the PPO plan.
Each year, our goal is to improve our process for requesting and obtaining medical records for our HEDIS project, and to
demonstrate the exceptional care that you have provided to our members.
In an effort to improve our scores, you and your office staff can help facilitate the HEDIS process improvement by:




Responding to our requests for medical records within five days
Providing the appropriate care within the designated timeframes
Accurately coding all claims
Documenting all care in the patient’s medical record
Again, we thank you and your staff for demonstrating teamwork and partnership as we work together to improve the health of
our members and your patients. We look forward to working with you next HEDIS season.
The source for data contained in this publication is Quality Compass® 2014 and is used with the permission of the National
Committee for Quality Assurance (NCQA).Quality Compass 2014 includes certain CAHPS data. Any data display, analysis,
December 2014
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interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility
for any such display, analysis, interpretation, or conclusion. Quality Compass is a registered trademark of NCQA. CAHPS® is
a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
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 health care 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 health care decisions and goals.
How to contact us?
Case Management
Telephone Number
1-877-332-8193
(Local/Commercial
only)
Medicare
1-866-797-9884
National
1-877-447-6481
FEP
1-800-537-7371
December 2014
Email Address
Business Hours
VA.CM@anthem.com
Monday - Friday
8 a.m. – 5 p.m.
CMconcierge@wellpoint.com
VANatlAcctsCM@wellpoint.com
Monday - Friday
8 a.m. – 5 p.m. EST
Monday - Friday
8 a.m. – 5 p.m.
Monday - Friday
8 a.m. – 4:30 p.m. EST
14 of 48
Coordination of care
Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment
and referral. Anthem Blue Cross and Blue Shield would like to take this opportunity to stress the importance of
communicating with your 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.
2.
3.
4.
5.
6.
Discuss with the patient the importance of communicating with other treating practitioners.
Obtain a signed release from the patient and file a copy in the medical record.
Document in the medical record if the patient refuses to sign a release.
Document in the medical record if you request a consultation.
If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate
information back to the referring practitioner.
Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
— Diagnosis
— Treatment plan
— Referrals
— Psychopharmacological medication (as applicable)
In an effort to facilitate coordination of care, Anthem has several tools available on the Provider website including a
Coordination of Care template and cover letters for both Behavioral Health and other Healthcare Practitioners.* In addition,
there is a Provider Toolkit on the website with information about Alcohol and Other Drugs which contains brochures,
guidelines and patient information.**
*Access to the forms and cover letters are available at anthem.com>Providers>Provider Home>Answers@Anthem
**Access to the Toolkit is available at anthem.com>Providers>Provider Home>Health and Wellness
Members’ rights and responsibilities
The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans.
One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our
commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue
Shield has adopted a Members’ Rights and Responsibilities statement.
It can be found on our website. To access, go to the "Provider" home page at www.anthem.com. From there, select
“Provider” and Virginia> then Health & Wellness> Quality > Member Rights & Responsibilities.
December 2014
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Important information about utilization management
Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the
member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of
coverage, service or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the
idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to
encourage decisions resulting in underutilization. Anthem’s Coverage and Clinical UM Guidelines are available on Anthem’s
website at anthem.com.
You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a
UM denial decision with a physician reviewer by calling us toll-free at the numbers listed below. UM criteria are also
available on our website. Just select “Coverage & Clinical UM Guidelines, and Pre-Cert Requirements” from the Provider
home page at anthem.com.
We work with providers to answer questions about the utilization management process and the authorization of care. Here’s
how the process works:



Call us toll free from 8 a.m. - 5 p.m. Eastern. Monday through Friday (except on holidays). For the Blue Cross Blue
Shield Service Benefit Plan (also known as the Federal Employee Program or FEP), the business hours are 8 a.m. –
4:30 p.m. EST.
After business hours, you can leave a confidential voicemail message. Please leave your contact information so one
of our associates can return your call the next business day.
Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.
The following phone lines are for physicians and their staffs. Members should call the customer service number on their
health plan ID card.
To discuss UM
Process
and Authorizations
To Discuss Peerto-Peer
UM Denials with
Physicians
To Request
UM Criteria
1-800-533-1120
1-800-533-1120
1-800-533-1120
Behavioral Health:
1-800-991-6045
Behavioral Health:
1-800-991-6045
Behavioral Health:
1-800-991-6045
TTY/TDD
711
or
TTY: 800-8281120(T)
Voice: 800-8281140(V)
For Medicare:
1-866-797-9884 opt 1
1-866-959-1537 – Fax
1-888-449-4642 – Fax (for providers who previously used 1-800-266-3504 or 1-877236-5173)
FEP: 1-800-860-2156
December 2014
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For language assistance, members can simply call the Customer Service phone number on the back of their ID card
and a representative will be able to assist them.
Our utilization management associates identify themselves to all callers by first name, title and our company name when
making or returning calls. They can inform you about specific utilization management requirements, operational review
procedures, and discuss utilization management decisions with you.
Clinical practice and preventive health guidelines 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&l
abel=Practice%20Guidelines
Health care reform (including Health Insurance Exchange)
Refer to anthem.com for information about health care reform and the Exchange
We continue to post information on our dedicated Web pages regarding health care reform and the health plans
HealthKeepers, Inc. is offering on and off the Exchange. Click either of these Web pages Health Care Reform or Health
Insurance Exchange for more information, and refer back to these pages often.
December 2014
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FEP update
FEP 2015 benefit information available online
To view the 2015 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal
Employee Program® (FEP), go to anthem.com/fep>select state>Coverage Options>Standard or Basic Option. Here you will
find the Service Benefit Plan Brochure and Plan Benefit Summary information for year 2015. For questions, please contact
FEP Customer Service at 800-552-6989.
eBusiness
Receive e-mail notifications via our Network eUPDATE in 2015
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 for easy 24/7 access. In 2015,
there will be publications posted in February, April, June, August, October and December on the Virginia provider
section of anthem.com.
Note that in addition to this newsletter and our website, we also use our email service, Network eUPDATE to communicate
new information. If you are not yet signed up to receive Network eUPDATEs, we encourage you to enroll now so you’ll be
sure to receive all information we’ll be sending about Exchanges and other pertinent topics in 2015.
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.
December 2014
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Medicaid information
Effective January 1, 2015: Changes in diabetic supplies coverage for Anthem HealthKeepers Plus
members
Effective January 1, 2015, HealthKeepers, Inc. will no longer cover certain diabetic supplies purchased from durable medical
equipment (DME) providers for Anthem HealthKeepers Plus members. Impacted members will be sent a letter notifying them
of the changes and will need to get a new prescription for supplies by January 1, 2015.
The following HCPCS codes will not be covered through DME providers. Supplies will be covered under the member’s
pharmacy benefit:




A4253
E0607
E2100
E2101
–
–
–
–
Blood glucose test strips
Home blood glucose monitor
Blood glucose monitor with integrated voice synthesizer
Blood glucose monitor with integrated lancing/blood sample
The following supplies will be covered through members’ pharmacy benefit beginning January 1, 2015:



Nipro Diagnostics TRUEresult® Meter
Nipro Diagnostics TRUEtest™ Strips
A limit of 100 blood glucose test strips per month
Other blood glucometer or blood glucose test strip brands, or quantities of more than 100 test strips per month, are not
covered unless medically necessary for treatment. Providers must submit a request to continue using another brand or larger
quantity.
If a member is currently using Nipro Diagnostics blood test strips or glucometer products and is using an in-network retail or
mail order pharmacy supplier, you don’t need to do anything.
If a member is not using Nipro Diagnostics blood test strips or glucometer products or is not using an in-network retail or mail
order pharmacy supplier, then the member will need a new prescription for supplies by January 1, 2015, for items to be
covered by HealthKeepers, Inc.
We encourage you to discuss coverage changes and possible new prescriptions with members. If it is medically necessary
for a member to continue using a different brand of blood test strips or glucometer and/or more than 100 blood test strips per
month, request an exception by submitting a Pharmacy Prior Authorization Form.
Find the Pharmacy Prior Authorization Form under the Pharmacy tab on our provider website at
https://mediproviders.anthem.com/Documents/VAVA_CAID_PriorAuthorizationForm.pdf.
This benefit information is a brief summary, not a complete description of benefits. Limitations and restrictions may apply. If
you have any questions about these benefit changes, call Provider Services at 1-800-901-0020.
December 2014
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Reimbursement policy for venipuncture service
Effective January 1, 2015, the Anthem HealthKeepers Plus reimbursement policy for venipuncture service will change.
Providers are currently reimbursed for one venipuncture code per member per date of service. For dates of service on and
after January 1, 2015, venipuncture will be reimbursed only if the provider draws blood and sends it to Laboratory
Corporation of America (LabCorp).
Venipuncture will be denied as incidental for providers who perform in their office a blood lab test that is on the provider
office lab list.
For more information, contact Provider Services at 1-800-901-0020.
Required forms and coverage for abortion, sterilization and hysterectomy procedures
On August 1, 2014, HealthKeepers, Inc. began exclusively utilizing the Department of Medical Assistance Services (DMAS)
consent forms for sterilization and hysterectomy for Anthem HealthKeepers Plus members.
Any claim submitted without a properly executed consent form or documentation showing medical necessity will be pended
while the analyst performs a review to determine if a copy of the necessary form can be found on file. If not, a request will be
submitted to your office to submit the form.
If appropriate information is not received within 30 days of the request for the information, the claim will be denied. The
originating physician is required to supply a copy of the appropriate DMAS form to other billing providers.
For instructions for completing the sterilization and hysterectomy consent form (DMAS-3004 and DMAS-3005) and
information about consent form requirements, please review the DMAS provider manual. The DMAS provider manual can be
found at www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual.
DMAS consent forms can be found at www.virginiamedicaid.dmas.virginia.gov/wps/portal/
ProviderFormsSearch.
Coverage Guidelines update
On August 14, 2014, the Medical Policy and Technology Assessment Committee (MPTAC) approved and adopted the
following coverage guidelines applicable to Anthem HealthKeepers Plus members, offered by HealthKeepers, Inc. These
coverage guidelines were developed or revised to support clinical coding edits.
December 2014
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The coverage guidelines were made publicly available on the Anthem provider website on the effective dates listed below.
Visit www.anthem.com/cptsearch_shared.html to search for specific policies.
Existing precertification requirements have not changed.
Coverage
Guideline effective
date
Coverage
Guideline
number
Coverage Guideline
October 1, 2014
October 1, 2014
DRUG.00064
DRUG.00065
October 1, 2014
October 1, 2014
GENE.00039
GENE.00042
October 1, 2014
October 1, 2014
OR-PR.00005
DME.00011
October
October
October
October
October
2014
2014
2014
2014
2014
DRUG.00024
DRUG.00043
DRUG.00057
DRUG.00058
GENE.00010
October 1, 2014
GENE.00021
October 1, 2014
MED.00064
October
October
October
October
October
October
MED.00112
SURG.00007
SURG.00020
SURG.00055
SURG.00122
DME.00037
Levodopa/Carbidopa Intestinal Infusion
Recombinant Coagulation Factor IX, Fc Fusion Protein
(rFIXFc)
Genetic Testing for Frontotemporal Dementia (FTD)
Genetic Testing for Cerebral Autosomal Dominant
Arteriopathy with Subcortical Infarcts and
Leukoencephalopathy (CADASIL) Syndrome
Upper Extremity Myoelectric Orthoses
Electrical Stimulation as a Treatment for Pain and Related
Conditions: Surface and Percutaneous Devices
Omalizumab (Xolair®)
Tocilizumab (Actemra®)
Canakinumab (Ilaris®)
Pharmacotherapy for Hereditary Angioedema (HAE)
Genotype Testing for Genetic Polymorphisms to Determine
Drug-Metabolizer Status
Chromosomal Microarray Analysis (CMA) for Developmental
Delay, Autism Spectrum Disorder, Intellectual Disability
(Intellectual Developmental Disorder) and Congenital
Anomalies
Transcatheter Ablation of Arrhythmogenic Foci in the
Pulmonary Veins as a Treatment of Atrial Fibrillation
(Radiofrequency and Cryoablation)
Autonomic Testing
Vagus Nerve Stimulation
Bone-Anchored and Bone Conduction Hearing Aids
Cervical Artificial Intervertebral Discs
Venous Angioplasty with or without Stent Placement
Cooling Devices and Combined Cooling/Heating Devices
LAB.00011
Analysis of Proteomic Patterns
1,
1,
1,
1,
1,
1,
1,
1,
1,
1,
1,
2014
2014
2014
2014
2014
2014
October 1, 2014
December 2014
Coverage
Guideline
(New/Revised)
New
New
New
New
New
Revised
Revised
Revised
Revised
Revised
Revised
Revised
Revised
Revised
Revised
Revised
Revised
Revised
Revised
Revised
21 of 48
Reminder: Coverage guidelines update for prevention of respiratory syncytial virus infections
On August 18, 2014, the Medical Policy and Technology Assessment Committee approved the following Coverage Guideline,
which is applicable to Anthem HealthKeepers Plus members. Anthem HealthKeepers Plus is offered by HealthKeepers, Inc.
This Coverage Guideline was developed or revised to support clinical coding edits.
The Coverage Guideline was made publicly available on the Anthem provider website on the effective date listed below. Visit
www.anthem.com/cptsearch_shared.html to search for specific policies. Existing precertification requirements have not
changed. Please share this notice with other members of your practice and office staff.
Coverage Guideline
effective date
Coverage Guideline
number
Coverage Guideline
Coverage Guideline
(New/Revised)
August 18, 2014
DRUG.00015
Prevention of Respiratory Syncytial
Virus Infections
Revised
If you have questions about this communication or need assistance with any other items, call our Provider Services team at
1-800-901-0020.
Clinical Utilization Management Guidelines update
On August 14, 2014, the Medical Policy and Technology Assessment Committee approved the following Clinical Utilization
Management (UM) Guidelines. These clinical guidelines were developed or revised to support clinical coding edits. This list
represents the guidelines approved and adopted by the WellPoint Medical Operations Committee on August 12, 2014.
The clinical UM guidelines are publicly available on the Anthem Medical Policies and Clinical UM Guidelines subsidiary
website. Use this link to access the site: www.anthem.com.
Existing precertification requirements have not changed.
December 2014
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Effective date
Clinical UM
Guideline number
August 18, 2014
August 18, 2014
CG-BEH-09
CG-BEH-10
August 18, 2014
August 18, 2014
August 18, 2014
August 18, 2014
October 14, 2014
October 14, 2014
CG-BEH-11
CG-BEH-12
CG-BEH-13
CG-SURG-43
CG-DME-36
CG-SURG-44
August 18, 2014
CG-SURG-38
October 14, 2014
October 14, 2014
CG DRUG-05
CG-DRUG-28
Clinical UM Guideline title
Assertive Community Treatment (ACT)
Basic Skills Training/Social Skills
Training
Mental Health Support Services
Psychosocial Rehabilitation Services
Targeted Case Management (TCM)
Knee Arthroscopy
Pediatric Gait Trainers
Coronary Angiography and Cardiac
Catheterization in the Outpatient Setting
Lumbar Laminectomy, Hemi-Laminectomy,
Laminotomy and/or Discectomy
Recombinant Erythropoietin Products
Alglucosidase alfa (Lumizyme®, Myozyme®)
Guideline
New or Revised
New
New
New
New
New
New
New
New
Revised
Revised
Revised
Please share this information with other members of your practice and office staff. For more information on this topic or for
general questions call our Provider Services team at 1-800-901-0020.
Clinical Utilization Management Guidelines update – Urine drug testing
Effective January 1, 2015, the policy regarding qualitative and quantitative urine drug testing will change. The Medical Policy
and Technology Assessment Committee originally approved the Clinical Utilization Management (UM) Guideline, CG-LAB-09
Drug Testing or Screening in the Context of Substance Abuse and Chronic Pain, on November 14, 2013.
We identified certain CPT codes are being used incorrectly when submitting claims. This includes codes 80100, 80101,
80104, G0430 and G0434. The revised guideline provides clarity on the policy regarding qualitative and quantitative urine
drug testing.
December 2014
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Policy update
Qualitative urine drug testing to verify compliance with treatment, identify undisclosed drug use or abuse, or evaluate
aberrant behavior is considered medically necessary up to 24 times per calendar year as part of a routine monitoring
program for individuals who are:

Receiving treatment for chronic pain with prescription opioid or other potentially abused medications.

Undergoing treatment for, or monitoring for relapse of, opioid addiction or substance abuse
Qualitative urine drug testing is also considered medically necessary in the following situations:

To assess an individual when clinical evaluation suggests use of nonprescribed medications or illegal substances.

On initial entrance into a pain management program or substance abuse recovery program
Quantitative urine drug testing is considered medically necessary when all of the following criteria are met:




Qualitative urine drug testing was done for a medically necessary reason.
The qualitative test is negative for prescribed medications, positive for a nonprescribed prescription drug with abuse
potential, or positive for an illegal drug (e.g., methamphetamine or cocaine).
The specific quantitative test(s) ordered are supported by documentation specifying the rationale for each
quantitative test ordered.
Clinical documentation reflects how the results of the test(s) will be used to guide clinical care
Medical necessity:
The use of qualitative or quantitative testing panels is considered not medically necessary unless all components of the
panel meet the definition of medical necessity based on the criteria above. However, individual components of a panel may
be considered medically necessary when criteria above are met.
Existing precertification requirements have not changed.
The Clinical UM Guidelines are publicly available on the Anthem Medical Policies and Clinical UM Guidelines subsidiary
website. To access this site, use this link www.anthem.com.
Please share this information with other members of your practice and office staff. For more information on this topic or for
general questions, call our Provider Services team at 1-800-901-0020.
December 2014
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Quarterly pharmacy formulary change notice
Summary of change
The formulary changes listed in the table below were reviewed and approved at the second quarter pharmacy and
therapeutics (P&T) committee meetings held on June 2, 2014, and June 18, 2014.
Effective for all patients on October 1, 2014
Therapeutic class
Medication
Formulary status change
Potential alternatives
(formulary products)
Diabetic agents
Proglycem
Nonformulary
Glucose tablets
Direct thrombin inhibitors
Fragmin
Prior authorization
required
Warfarin or Enoxaparin
Arixtra
Prior authorization
required
Warfarin or Enoxaparin
What this means to you



Effective October 1, 2014 formulary changes will apply.
Effective December 1, 2014 non-formulary changes and PA requirements will apply.
This notice applies to benefits for Anthem HealthKeepers Plus members.
Action needed
Please review these changes and work with your Anthem HealthKeepers Plus patients to transition them to formulary
alternatives. If you determine formulary alternatives are not clinically appropriate for specific patients, you will need to obtain
prior authorization to continue coverage beyond the applicable effective date.
Need assistance?
We recognize the unique aspects of patients’ cases. If your Anthem HealthKeepers Plus patient cannot be converted to a
formulary alternative, call us at 1-800-901-0020. You can find the preferred drug list (formulary) on our provider website at
https://mediproviders.anthem.com/Documents/VAVA_CAID_Formulary.pdf.
If you need further assistance, contact your local Provider Relations representative or call Provider Services at
1-800-901-0020.
Health and Acute Care Program
In December 2014, the Department of Medical Assistance Services (DMAS), the Virginia Medicaid state agency, will
implement the Health and Acute Care Program (HAP). This initiative will transition approximately 2,700 Medicaid-eligible
members with the Elderly or Disabled with Consumer Direction (EDCD) waiver, a home- and community-based waiver, to
December 2014
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managed care organizations. This is one of five waivers that offer support services to members who would otherwise be at
risk for institutionalization (i.e., care in a nursing home or intermediate care facility).
HealthKeepers, Inc. expects to enroll into our Anthem HealthKeepers Plus product approximately 1,000 additional EDCD
waiver members with this program. We currently serve about 1,400 previously enrolled EDCD waiver members, and the
majority of those members are in the aged, blind or disabled aid category. We will cover primary and acute care services.
Waiver-related support services will continue to be provided by the Virginia Medicaid fee-for-service program.
If there are questions regarding the HAP implementation, providers and members can email DMAS at
HAP@dmas.virginia.gov or call 1-800-643-2273.
Please call Member & Provider Services at 1-800-901-0020 for questions regarding services provided by HealthKeepers, Inc.
for Anthem HealthKeepers Plus members.
We are working to ensure a smooth transition for both providers and members as these additional EDCD waiver members
transition to HealthKeepers, Inc. If you currently offer services to these members but are not a participating provider in our
Medicaid network, we encourage you to contact us about joining the network. To initiate network enrollment, please contact
Provider Services at 1-800-901-0020.
Patient360 lets you access member records in just a few clicks
HealthKeepers, Inc. added a new feature to our provider website that lets you quickly and easily retrieve records about your
Anthem HealthKeepers Plus patients. The dashboard gives you a robust picture of a patient’s health and treatment history
and will help you facilitate care coordination.
What is Patient360?
Patient360 is a read-only dashboard available through our secure
provider website that gives you instant access to detailed information
about your Anthem HealthKeepers Plus patients. 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.
December 2014
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
Care management-related activities — assessment, care plans and care goals.
Additional benefits
Patient360 is a multifaceted perspective on member utilization and pharmacy patterns. With this level of detail at your
fingertips, you’ll avoid duplicating services, identify care gaps and trends, and coordinate care more effectively. In addition,
accessing this data electronically will reduce the number of faxes sent between PCPs and case managers, as well as
significantly increase patient confidentiality.
To access Patient360




Log in to our secure provider website at www.anthem.com/vamedicaiddoc.
Select Medicaid at the top.
Select Patient360.
Enter a specific Anthem HealthKeepers Plus member’s information.
What if I need assistance?
If you have questions contact your network manager or call our Provider Services team at 1-800-901-0020.
New precertification requirements for Anthem HealthKeepers Plus members for cervical fusions go
into effect January 1, 2015
The following codes will be added to precertification effective January 1, 2015.
Code
22548
22590
Description
Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without
excision of odontoid process
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other
than for decompression); cervical below C2
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other
than for decompression); each additional interspace (List separately in addition to code for primary
procedure)
Arthrodesis, posterior technique, craniocervical (occiput-C2)
22595
Arthrodesis, posterior technique, atlas-axis (C1-C2)
22600
Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment
22614
Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment
(List separately in addition to code for primary procedure)
22554
22585
Please note that you will continue to submit your request for Preauthorization through the provider portal or through 1-800901-0020 for phone requests or 1-800-964-3627 for faxed requests.
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Flu vaccines are critical to the health of your high-risk patients
Flu season is upon us, and patients with certain chronic conditions, including asthma,
diabetes and chronic heart disease, are at increased risk for illnesses and hospitalizations
caused by seasonal flu. The Centers for Disease Control and Prevention (CDC) estimates
more than 200,000 people are hospitalized from flu complications annually, and between
3,000 and 49,000 die each year from flu-related causes.
An ounce of prevention
While the CDC recommends everyone six months of age and older receive the vaccine, flu
shots are especially important for your high-risk patients. Encourage them to be
vaccinated as soon as possible — a flu shot is still the best prevention method. Those at
highest risk include:
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Children younger than 5, but especially younger than 2 years old
— Children between the ages of 6 months and 8 years of age who are receiving a flu vaccine for the first time
will need to have two doses with at least 4 weeks between doses
Adults 65 and older
Women who are pregnant or expect to become pregnant
Patients with certain chronic diseases
Native Americans and Alaska Natives
Encourage your patients to get a flu vaccine. Please educate your patients about the risks of the flu and provide flu vaccines
as appropriate. Remember, adult members with Anthem HealthKeepers Plus pharmacy benefits can get a free flu shot. They
just need to show their member ID cards at participating pharmacies during flu shot clinic hours. Coverage for children’s
vaccines varies, so contact your local Provider Relations representative to learn more.
Antiviral drugs
If patients do get sick, antiviral drugs not only lessen flu duration and symptoms but decrease the risk for flu-related
complications. Antiviral drugs, as well as many cough and cold products, are on our formulary posted at
https://mediproviders.anthem.com/va. Restrictions apply.
Stay informed
Find the latest flu updates, health care recommendations and printable patient education materials at www.cdc.gov/flu.
Remember to protect yourself and your patients by getting your vaccine, too.
1 Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report
August 15, 2014
Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States,
2014–15 Influenza Season
http://www.cdc.gov/mmwr/mmwr_wk/wk_cvol.html (accessed September 25, 2014)
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Reminder: Upcoming changes to durable medical equipment precertification requirements
Beginning January 1, 2015, HealthKeepers, Inc. precertification requirements will change for certain durable medical
equipment (DME) items covered by a member’s Anthem HealthKeepers Plus benefit plan. Federal and state law, state
contracts and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract
provisions/exclusions, take precedence over these precertification rules and must be considered first when determining
coverage.
Noncompliance with new requirements may result in denied claims. Please share this information with staff and other
providers in your practice. Not all changes are listed here – to find precertification and code-specific requirements, visit
www.anthem.com/vamedicaiddoc.
Precertification requirements will be added to specific services in the following categories:
Hospital beds
Lifts
Wheelchair/wheelchair accessories
Custom DME
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Note: All DME rentals will continue to require precertification.
For more information please call our Provider Services team at 1-800-901-0020.
Medicare information
Hyaluronate agents require prior authorization
Effective immediately, the following drugs should not be billed under the members Part D benefit. Ordering physicians should
call the Specialty Pharmacy Part B department at 866-797-9884 option 5 to obtain precertification for these drugs:
J7323
J7326
J7324
J7325
J7321
–
–
–
–
–
Euflexxa, Monovisc
Gel-One
Orthovisc, Hyaluronan
Synvisc, Synvisc One
Supartz, Hyalgan
If these drugs are taken to a retail pharmacy and attempted to be billed to Part D benefits, the pharmacist will see a message
that rejects the claim and asks to have the prescribing physician call their Part B carrier for prior authorization.
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Individual Medicare Advantage membership moves to new claims processing system January 1,
2015
Starting January 1, 2015, Anthem Blue Cross and Blue Shield in Virginia will move Individual (non-group) Medicare
Advantage members to a new claims processing system. Please review the following information so that you and your staff
have the information you need to help ensure your claims are processed accurately and efficiently.
Group sponsored Medicare Advantage plan members are not affected by these changes: In most cases, this
information will not apply to Anthem group sponsored Medicare Advantage members unless separately noted.
As of January 1, 2015, members with the following prefixes on their member card will represent group sponsored business
only and will remain on the current claims processing platform:
JQF JWM VZM VZP WGK WSP
XDK XDT XGH XGK XKJ XVJ XVL YCG
YGJ YGS YLR YLV YRA YRE YRU
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Pricing differences between individual and group sponsored Medicare Advantage members: Beginning
January 1, 2015, providers may see differences in pricing between Medicare Advantage Individual and group
sponsored member claims. The reasons for the potential differences are based on the following:
— Claims for Medicare Advantage individual and group sponsored members will be processed on different
platforms.
— Timing of Original Medicare pricing software updates may vary by platform.
— Administration of claims edits and sequestration.
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Code editing enhancements: As reported in the previous Network Update, effective January 1, 2015, we are
updating our individual Medicare Advantage claims editing by enhancing our code-editing technology to better align
to existing payment guidelines. Individual Medicare Advantage claims will be reviewed to:
Reinforce compliance with standard code edits and rules
Ensure correct coding and billing practices are being followed
Ensure all CMS required informational and reimbursement modifiers are billed
Determine the appropriate relationship between thousands of medical, surgical, radiology, laboratory, pathology
and anesthesia codes
— Ensure compliance with industry standards
—
—
—
—
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Reimbursement policy changes: Highlights of the changes to the reimbursement policies can be found here.
These changes are effective January 1, 2015. The complete set of policies is available here.
A complete overview of code editing enhancements and reimbursement policy changes can be found here.
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On-demand patient records: Patient 360 is a read-only dashboard available through Availty to give you instant
access to detailed information about Anthem’s individual Medicare Advantage members. 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
Patient 360 will be available January 1, 2015. For more information, call 1-866-805-4589.
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Changes to sequestration reduction: Beginning January1, 2015, we will change how we administer the
sequestration reduction for Medicare Advantage claims processed on the new system.
— Claims for individual members
o We will continue the existing reduction for contracted providers paid according to Medicare reimbursement
methodologies.
o We will begin reducing payments to non-contracted providers.
o For both contracted and non-contracted providers, we will subtract the sequestration reduction from the
final amount to be paid to the provider after the Medicare Advantage member cost share has been applied.
So, the final amount to be paid to the provider is the plan allowance, minus any member cost-sharing,
minus the sequestration reduction.
— Claims for group members
o We will continue the existing reduction for contracted providers paid according to Medicare reimbursement
methodologies.
o
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Since group member claims are not migrating to the new claims processing system at this time, we will
continue our current methodology for applying the sequestration reduction to the plan allowance.
Please file two separate claims for members who have both an Anthem Medicare Advantage plan and other
Anthem health benefits: If you treat an Anthem Medicare Advantage member who has Anthem Medicare
Advantage coverage in addition to health benefits with another Anthem plan, you will have to file the claim with both
plans separately. Please use the same electronic claims submission or address and P.O. Box you use today for
Anthem claims filing.
New requirements effective January 1, 2015, for individual Medicare Advantage ambulance, anesthesia,
clinical laboratory and mammography claims: Effective January 1, 2015, Anthem individual Medicare Advantage
front-end claims editing will return claims billed without CMS required criteria to the provider who submitted the
claim. These new front-end edits will include:
— Ambulance claims billed without the ambulance pickup location – Reference Medicare Claims Processing
Manual, Chapter 15, Section 10.3 Point of Pickup
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— Anesthesia claims billed without an appropriate modifier – Reference Medicare Claims Processing Manual,
Chapter 12, Section 50 K Anesthesia Claims Modifiers
— Anesthesia claims billed with a unit-of-measure of “units”
— Clinical laboratory claims billed without a Clinical Laboratory Improvement Amendment (CLIA) certification
number in Box 23 on the CMS 1500
— Mammography claims billed without a mammography certification number in Box 23 on the CMS 1500
Please ensure your billing staff is aware of this change. If you have any questions, please contact the Provider Services
number on the back of the member’s ID card.
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Continue to use current phone number for 2015 precertification requests: Individual Medicare Advantage
members will be issued new ID cards effective January 1, 2015. The new cards will have a new Provider Service
phone number. The new number on the ID cards will be used for all provider inquiries except precertification. For
precertification, please continue to call the same numbers currently in place – as listed below. If you call the
number on the back of the member’s card for precertification, you will be directed back to the number below. To
avoid this inconvenience, please note that the numbers below should be used for precertification requests
throughout 2015.
Phone
Fax
866-797-9884
800-959-1537
Submit all required clinical information at least three business days before the requested procedure to allow a thorough
clinical analysis. For Institutional Admissions, all facilities must notify us within 24 hours or the next business day (whichever
is earlier) after admission. In an urgent or emergent situation, the above time frames will be waived. Please provide notice to
the plan as soon as possible.
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Continue to reach provider customer service by calling the number on the back of the member’s ID card.
Continue to use Availty or Point of Care: Depending on the information requested, you may need to access one
of our online provider tools – Availity or Point of Care. Availity can be accessed in the same manner as before and
will continue to have information about both individual Medicare Advantage and group sponsored Medicare
Advantage members. (Medical management functionality, reports including remittances, and access to prior
electronic Claim Information/Adjustment Request 151 Forms will remain on Point of Care. HOWEVER, access to
these functions will need to be via a single sign-on through Availity.)
Continue to use the same mailing address, Electronic Data Interchange gateway as you do today: Claims and
correspondence should continue to be submitted to same EDI gateway and the same Post Office Box address that
you use today.
Please check Important Medicare Advantage Updates on your provider portal for additional information in 2015.
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New for 2015: Anthem introduces new benefits, plans for Medicare Advantage members
Anthem also will introduce new benefits for our Medicare Advantage members and new types of Medicare Advantage plans.
The information below highlights what’s new for 2015. For more details now and throughout 2015, please refer to Important
Medicare Advantage Updates on your provider portal.
For a more detailed overview of 2015 changes in plan benefits, co-pays, service areas and more, please see the 2015
Product Update for your state under Important Medicare Advantage Updates.
Referrals
A referral may be required for individual Medicare Advantage HMO members to see a specialist. In most situations, our
individual Medicare Advantage HMO members may need to receive a referral from their Primary Care Physician before they
can use specialists in the plan’s network. However, referrals from a PCP are not required for emergency care or urgently
needed care. Certain routine care can be obtained without having an approval in advance from their PCP, such as routine
women’s health care (breast exams, screening mammograms, Pap tests and pelvic exams) and routine dental and vision
care. Providers are required to periodically review and comply with the latest Medicare Advantage Referral requirements
found at www.anthem.com/medicareprovider on the document named: Medicare Advantage Referral Requirements.
Please visit our website for more detailed product information or contact Provider Services at the number on the back of the
member’s ID card. You can find Important Medicare Advantage Updates here. Contact your provider representative for
participation details for our contracted plans.
Precertification requirements updated for 2015
Please refer to your provider agreement, provider manual and the Medicare Advantage Precertification Guidelines found at
the Medical Policy, UM Guidelines and Precertification Requirements link on the Anthem provider home page at anthem.com
for further information on existing precertification requirements and new precertification requirements for 2015.
Submit all required clinical information at least three business days before the requested procedure to allow a thorough
clinical analysis. For institutional admissions, all facilities must notify us within 24 hours or the next business day (whichever
is earlier) after admission. In an urgent or emergent situation, the above time frames will be waived. Please provide notice to
the plan as soon as possible.
Precertification requests can be obtained at the following phone or fax numbers for individual and group-sponsored Medicare
Advantage plans:
Phone
Fax
866-797-9884
800-959-1537
To verify member eligibility, benefits or account information, please call the telephone number listed on the back of the
member’s identification card.
For individual Medicare Advantage members who can’t get to the physician’s office – an online alternative
Live Health Online allows individual Medicare Advantage members to visit a board certified physician of their choice, from a
selected group of independent physicians, on a secure connection over the Internet via a smart phone, tablet or computer.
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Members can see physicians on their own schedule in non-emergency situations without having to leave their homes. If
medically appropriate, physicians using LiveHealth Online can send prescriptions directly to a nearby pharmacy. A summary
of each visit is created and can be forwarded to patients’ primary care physicians with their permission, supporting continuity
of care and collaboration among providers.
Advanced illness planning
The Vital Decisions program provides counseling by telephone to help individual Medicare Advantage members with
advanced illness identify their goals, share them with loved ones and take steps toward meeting them.
Advanced Notices of Non-coverage for Medicare Advantage members
The Centers for Medicare & Medicaid Services (CMS) issued recent guidance concerning Advanced Notices of NonCoverage. CMS advised Medicare Advantage plans that contracted providers are required to provide a coverage
determination for services that are not covered by the member’s Medicare Advantage plan. This will ensure that the member
will receive a denial of payment and accompanying appeal rights. Please note that this guidance is not entirely consistent
with Anthem’s provider agreements. The provider agreements only require that you notify the member in writing in advance
of providing non covered services and that you provide an estimate of the member’s financial liability. Anthem asks that you
follow the CMS requirements immediately. Anthem will amend your provider agreement to reflect this change in guidance
through a future communication. If you have any doubt about whether a service is not covered, please seek a coverage
determination from the plan.
A written coverage determination will help ensure that a claim for non-covered care from a contracted provider is paid
accurately. According to CMS, if the appropriate written notice of denial of payment is not given to the Medicare Advantage
member regarding a non-covered service, the claim may be denied and the member cannot be held financially responsible.
Therefore, your failure to provide an appropriate coverage determination could result in a denial of payment for the noncovered service.
Contracted providers seeking a coverage determination for Anthem Medicare Advantage members should call the telephone
number listed on the back of the member’s identification card for assistance.
Y0071_14_22176_I_002_10/22/14
OrthoNet to conduct medical necessity reviews, professional service coding reviews
Anthem is collaborating with OrthoNet, LLC to conduct medical necessity reviews for physical therapy, occupational therapy
and spine and back pain management for our Individual Medicare Advantage members.
What does this mean to you?
Effective January 1, 2015, the following services/treatment requests must be reviewed by OrthoNet for precertification.
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
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Physical therapy
Occupational therapy
Spine and Back Pain Management procedures:
— Epidurals
— Facet Blocks
— Pain Pumps
— Neurostimulators
— Spinal Fusion
— Spinal Decompression
— Vertebro/Kyphoplasty
In addition, OrthoNet will conduct post-service prepayment coding review of professional services, including:
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Orthopedic Surgery
Plastic Surgery
Neurosurgery
Sports Medicine
Podiatry
Hand Surgery
Neurology
Pain Management
Psychiatry/ Physical Medicine and Rehabilitation (PM&R)
ENT
General Surgery
Dermatology
Cardiology
Urology
Percutaneous Coronary Intervention (PCI)
Please submit all required clinical information at least three business days before the requested procedure to allow a
thorough clinical analysis. For institutional admissions, all facilities must notify us within 24 hours or the next business day
(whichever is earlier) after admission. In an urgent or emergent situation, the above time frames will be waived. Please
provide notice to the plan as soon as possible.
Precertification requests can be obtained at the following phone or fax numbers:
Phone
Fax
866-797-9884
800-959-1537
A complete list of precertification requirements can be found at the Provider Forms section of the Anthem Medicare
Advantage Public Provider Portal (www.anthem.com/medicareprovider).
To verify member eligibility, benefits or account information, please call the telephone number listed on the back of the
member’s identification card. That number also may be used to obtain precertification.
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Anthem, Optum collaborating to help ensure members receive regular exams, preventive
screenings
Anthem is collaborating with Optum to educate members on the importance of annual wellness exams and preventive health
screenings. Optum appointment specialists will place a three-way call to help our members schedule an appointment with
your office. In addition, the health plan may provide a list of recommended annual tests or screenings based on the
member’s medical history. This program applies to individual and group-sponsored Medicare Advantage plans.
Members identified for these calls are those who:
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Have not visited a provider in the last 12 months.
Had office visit(s) but not an annual wellness exam or annual wellness visit and have potential chronic conditions
not reported in the current year.
Appear to be overdue for one or more CMS-recommended preventive health screening which may be conducted in
your office or require a referral to another facility.
Suggested screenings typically conducted in the primary care physician setting include:

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Body Mass Index – BMI
Cardiovascular care-cholesterol screening
Diabetes -- HbA1c
Diabetes – Hypertension control
Diabetes – LDL-C
Diabetes – Nephropathy Screening
Rheumatoid Arthritis/DMARD
Suggested screenings that are typically conducted in a non-primary care physician setting and may require a referral include:

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Breast cancer screening
Colorectal cancer screening
Osteoporosis management – bone density test
For more information on the campaign, please contact Optum’s Provider Support Center at 1-877-751-9207.
Prior authorizations required for CMS-designated high-risk medications
The Centers for Medicare & Medicaid Services (CMS)/Medicare regulations require Medicare Prescription Drug plans to
monitor the use of drugs which pose a higher risk to individuals more than 64 years old. To help ensure patient safety,
Anthem requires prior authorization for certain high-risk medications. Please refer to your Medicare Advantage members’ List
of Covered Medicare Prescription Drugs (formulary) to see which drugs need prior approval.
To ensure providers are aware of any high-risk medications prescribed for our individual and group-sponsored Medicare
Advantage members, we also send a fax to providers when their patients fill a prescription for a high-risk medication.
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Anthem also distributes a monthly report to prescribers detailing the number of members on high-risk medications and the
number of high-risk medications prescribed year-to-date. We also contact members who have filled prescriptions for high-risk
medications and suggest that they discuss the prescription with their physician and ask if there is a safer alternate drug.
If you receive a high-risk medication fax or report from us, please review it and help us support safe medication choices.
Alternatives to these high-risk medications are listed on www.anthem.com/maprovidertoolkit.
Clearinghouse helps ensure timely and accurate claims payment for vaccines covered by Medicare
Part D
Providers who have administered a shingles or tetanus vaccine to our individual and group-sponsored Medicare Advantage
plan members with pharmacy benefits may encounter a denial because the claim is covered under Medicare Part D only.
To streamline your claim processing and payment (as applicable) for these and other preventive vaccines covered under Part
D, providers may use TransactRX, a clearinghouse for claims submission.
To use TransactRX, please contact the clearinghouse at the website (http://www.transactrx.com) or call Customer Service at
866-522-3386. Physicians, facilities, health clinics and pharmacies may use this clearinghouse to process Part D claims.
There is no charge to providers who use electronic funds deposit to receive payment. There is a service fee of $2.50 for
check payments on claims.
The Centers for Medicare & Medicaid Services provides more information on Part D vaccines here.
New federally qualified health center billing guidelines in effect for original Medicare
Medicare introduced a new Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) October 1, 2014.
FQHCs that are non-contracted and those contracted to Medicare rates will be reimbursed the lesser of actual charges or the
PPS rate, less any cost sharing amounts. This will apply to Anthem individual and group-sponsored Medicare Advantage
plans.

Federally Qualified Health Centers (FQHC) will be transitioned to the FQHC Prospective Payment System (PPS)
based on their cost reporting periods.
— FQHCs whose cost reporting period began on or after October 1, 2014, will be reimbursed using the new PPS
system.
— FQHCs whose cost reporting period began before October 1, 2014, will be reimbursed using the current allinclusive rate until their new cost reporting period beings.
— PPS and non-PPS dates of service cannot be billed on the same claim. This means two separate claims must
be billed.
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
We would like to remind providers that CMS established five new HCPCS which are required for FQHC PPS billing.
—
—
—
—
—
G0466
G0467
G0468
G0469
G0470
–
–
–
–
–
FQHC
FQHC
FQHC
FQHC
FQHC
visit,
visit,
visit,
visit,
visit,
new patient (Revenue code 0519 or 052X)
established patient (Revenue code 0519 or 052X)
IPPE or AWV (Revenue code 0519 or 052X)
mental health, new patient (Revenue code 0900 or 0519X)
mental health, established patient (Revenue code 0900 or 0519X)
For more information, please refer to Medicare Learning Network (MLN) SE1039
Speaking the language of ICD-10
The Department of Health and Human Services has formally changed the compliance date for conversion to ICD-10
diagnostic and procedure codes from October 1, 2014, to October 1, 2015. The delay provides us with an opportunity to
continue our readiness efforts for the transition to come. We encourage you to continue your ICD-10 readiness activities.
In our previous articles, we shared with you some basic information and recommendations to help you begin your journey of
learning to speak the language of ICD-10. We realize that this journey will not be an easy one as the ICD-10 code sets
include greater detail, changes in terminology, and expanded concepts for injuries, laterality, and other related factors. As
you make this journey, please be reminded that complete and accurate medical record documentation and diagnosis coding
plays a critical role in managing our Medicare Advantage membership. Because your coding and record documentation
efforts have a direct impact on accurate risk adjusted payment, we want to share with you specific ICD-10 coding tips related
to risk adjustment-related diagnosis codes (also referred to as hierarchical condition categories, or HCCs).
For this article we will use diabetes mellitus as an example:
Type 2 Diabetes
Diabetes, no complication,
controlled
Diabetic Retinopathy with Macular
Edema
Diabetic Neuropathy
Diabetic Peripheral Angiopathy
December 2014
ICD-9 Code(s)
250.00- DM without complications, not
stated as uncontrolled
ICD-10 Code(s)
E11.9- DM without complications
*ICD-10 does not reference controlled vs
uncontrolled DM
250.50- DM with ophthalmic
manifestations
362.01- Diabetic neuropathy NOS
362.07- Diabetic macular edema
250.60- DM with neurological
complications
357.2- Polyneuropathy in DM
E11.311- DM with unspecified diabetic
retinopathy with macular edema
250.70- DM with peripheral circulatory
disorders
443.81- Peripheral angiopathy in
diseases classified elsewhere
E11.51- DM with diabetic peripheral
angiopathy without gangrene
E11.40- DM with diabetic neuropathy,
unspecified
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In future articles, we will continue to bring you helpful coding tips to assist as you and your coding staff transition from ICD-9
to ICD-10.
Please note that CMS will not accept ICD-9 codes beginning October 1, 2015. This will be critical, as all encounters/claims
submitted with ICD-9 codes will reject beginning October 1, 2015, resulting in delay or denial of payment. We must all be
prepared to meet CMS guidelines. To further assist you in your preparation, we are providing the following references,
helpful links and additional resources:
The one-page reference sheet produced by AAPC shows how the code sets are organized, with easy color coding to help you
find what you're looking for. It also has mnemonic tips (such as "C is for cancer" and "T is for toxicity") to help you remember
where the new codes are located.
American Medical Association physician resource page
Centers for Medicare & Medicaid Services (CMS) Provider Resources
AAPC ICD-10 Implementation and Training Opportunities
CMS mandated Opioid Overutilization Program
CMS expects Part D sponsors to have effective programs to address opioid overutilization to protect beneficiaries and to
reduce fraud, waste and abuse in the Part D program. CMS expects plans to continue to improve retrospective DUR
programs and case management as related to medication overutilization. As of March 12, 2012, the Food and Drug
Administration (FDA) placed fentanyl-containing products under a new Risk Evaluation and Mitigation Strategy (REMS),
which is now called TIRF REMS. The TIRF drugs include Abstral, Actiq, Fentanyl Citrate, Fentanyl Oralet, Fentora, Lazanda,
Onsolis and Subsys. They are approved for the management of breakthrough cancer pain in patients who are already
receiving and who are tolerant to around-the-clock opioid therapy for their underlying persistent cancer pain.
Anthem will mail and/or call providers upon identification of members with suspected patterns of opioid overutilization due to
multiple prescribers and multiple pharmacies. During the phone call, our pharmacists attempt to facilitate a conversation with
providers about the appropriate use, medical necessity and safety of the high opioid dosage for their patient.
Our goal is to work with providers to prevent overutilization and to determine the appropriate amount of opioids for our
members.
For more information, please reference:
1.
GAO-11-699, http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/GAOInstancesofQuestionableAccesstoPrescriptionDrugs.pdf
2.
CMS Supplemental Guidance, http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/HPMSSupplementalGuidanceRelated-toImprovingDURcontrols.pdf
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3.
HPMS Memo, Medication Part D Overutilization Monitoring System, http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/HPMSmemo_MedicarePartDOverutilizationMonitoringSystem0117
14.pdf
CuraScript moved to Accredo brand effective November 24, 2014
Express Scripts’ acquisition of Medco Health Solutions in 2012 resulted in the merger of ESI’s CuraScript Specialty
Pharmacy and Medco’s Accredo Specialty Pharmacy. Starting in 2014, unified pharmacy operations were under the Accredo
name and license. Members of our Medicare Advantage Prescription Drug plans transitioned to the Accredo brand on
November 24, 2014.
Some of the limited changes members will experience:

They will see the Accredo name and label on their medication shipments and pharmacy letters.

Expanded pharmacy hours – Monday-Friday, 8 a.m. – 11 p.m. ET, Saturday, 8 a.m. – 5 p.m., ET.

Upgraded assessments to include therapy-specific questions for improved adherence
How providers will be impacted – frequently asked questions
Q. What changes will impact providers as a result of the brand transition to Accredo?
A. Referral forms will be updated to reflect the change to Accredo and will be available on the Accredo website. However, if
providers continue to use CuraScript-branded referral forms, Accredo can accept them and there will be no disruption in
service.
Q. Will the fax number remain the same?
A. Yes, providers will continue to use the same fax number, 1-800-824-2642.
Q. Will the provider contact number remain the same?
A. Yes, providers will continue to use the same phone number, 1-800-870-6419.
Q. Will the pharmacy hours remain the same?
A. The Accredo Specialty Pharmacy will have expanded hours, Monday-Friday, 8 a.m. – 11 p.m. ET, Saturday, 8 a.m. – 5
p.m. ET.
Q. Will prior authorization phone numbers change?
A. No. Prior authorization phone numbers will stay the same.
Q. Will the process for ordering office-administered drugs change?
A. No, the process for ordering office-administered drugs will not change.
Q. If providers or their staffs have questions about the brand change to Accredo, who should they contact?
A. Providers and their staffs should contact the CuraScript provider help desk, just as they would today.
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Q. How will providers be notified about the change?
A. In addition to this article, a letter will be faxed by CuraScript to prescribing providers prior to member notification,
alerting providers to the change.
Pharmacy information available on online
Visit our website for more information on our Medicare Advantage Prescription Drug plans, including formularies, Part D
conditions and limitations and forms. For pharmacy information on group sponsored plans, please contact Customer Service.
Y0071_14_21910_I 10/06/14
Prior authorization required for members
As a reminder, providers are required to request a prior authorization for Medicare Advantage members for services that
require prior authorization. Failure to obtain a prior authorization will result in an administrative denial. The 2015 prior
authorization requirements were posted to the Provider Forms section of the Anthem Medicare Advantage Public Provider
Portal October 4, 2014.
Members cannot be balance billed for an administrative denial.
To obtain prior authorization or to verify member eligibility, benefits or account information, please call the telephone number
listed on the member’s plan membership card.
Please visit the Provider Forms section of the Anthem Medicare Advantage Public Provider Portal at
www.anthem.com/medicareprovider to see the prior authorization list that is effective for 2015 as well as prior authorization
requirements for 2014.
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49480MUPENMUB
Encourage exercise to prevent falls
Falls are the leading cause of injury in older adults. Each year, more than one-third of U.S. adults 65 and older experience a
fall and, in more than 20 percent of those cases, the falls lead to injuries like joint problems, bone fractures and brain
trauma. 1 Recovery can be difficult and, in many cases, falls lead to a decline in independence and in overall health. 2
Poor eyesight, dizziness caused by medication and tripping hazards in the home are common reasons for falls. Many times,
however, falls are simply caused by imbalance or a lack of strength. Some people who fall, even if they are not injured,
develop a fear of falling, causing them to limit their activities, which in turn increases their actual risk of falling. It’s just one
more reason to emphasize the benefits of leading an active, healthy lifestyle at any age.
Exercise can help reduce the risk of falling by
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Improving balance and strength
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Decreasing the need for medication that affects balance
Increasing the confidence needed to live an active lifestyle, which reduces the risk of falling
As well, regular physical activity makes bones stronger so they’re less likely to break in the event of a fall, or heal faster if
they do break.
Prescribe an exercise program to build strength, improve balance and increase confidence
The facts are decisive, but convincing older patients to adopt an exercise program can be challenging. Healthways
SilverSneakers® Fitness program, included as a benefit for your Anthem Blue Cross and Blue Shield (Anthem) patients at
no extra cost, makes it easier to turn a medical recommendation into a reality. As you advise patients to “eat right and
exercise,” you can direct them to a comprehensive program that provides encouragement, direction and support every step of
the way. With more than 2 million members, SilverSneakers is the nation’s leading physical activity program designed
exclusively for Medicare members.
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SilverSneakers members have access to more than 11,000 fitness locations nationwide (including Alaska, Hawaii
and Puerto Rico), where they can use all basic amenities and take SilverSneakers group fitness classes led by
certified instructors specially trained in older-adult fitness. They can use any location any time they want, so even
when traveling they can still work out.
In addition, SilverSneakers FLEX™ offers classes such as Latin dance, tai chi, walking groups and yoga in
members’ neighborhoods – local parks, recreation centers, medical campuses and adult-living communities. FLEX
participants can attend their favorite SilverSneakers fitness location concurrently.
For members who can’t get to a SilverSneakers location or FLEX class, SilverSneakers Steps® offers a choice of
four fitness kits for at-home use – general fitness, strength, walking or yoga.
The SilverSneakers member website offers members tools to assess their health and track their activity, fitness
advice, meal plans and downloadable health recipes, and connection with the SilverSneakers online community for
additional support.
SilverSneakers members have the tools and support they need to improve strength, balance and coordination, and the
confidence to continue being active. In fact, SilverSneakers members report experiencing fewer falls than older adults
nationally. Among Anthem members, 15 percent reported having a fall in 2013, compared to 26 percent of older adults
nationally. And only 11 percent of members reported having to be hospitalized compared to 17 percent of national older
adults. 3
Please encourage your patients to take advantage of this valuable benefit. To learn more, visit silversneakers.com or contact
Stephanie Williams by phone (678.458.6371) or e-mail (stephanie.williams@healthways.com). Staff trainings and
SilverSneakers marketing materials are available for your office.
Resources:
1. http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html
2. http://stopfalls.org/what-is-fall-prevention/fp-basics/
3. SilverSneakers Annual Member Survey, 2013.
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December 2014
SilverSneakers® is a registered trademark of Healthways, Inc. © 2014 Healthways, Inc.
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2015 Virginia Medicare Advantage plan changes
Annual benefits changes for Medicare Advantage plan members will be effective January 1, 2015. Each year, we renew our
contract with the Centers for Medicare & Medicaid Services (CMS), and CMS re-evaluates and approves the benefits we’ll
offer to our Medicare Advantage members for the upcoming year.
The following changes apply to members enrolled in Anthem Medicare Preferred
Core (PPO). You can help members manage their health care costs by being aware
of these changes. In addition, remember to check members’ identification cards at
the beginning of each calendar year, as the member may have changed plans.
Notable 2015 benefits changes and highlights by plan type.
Anthem Medicare Preferred Core (PPO) Highlighted Plan Changes
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2015 Plans may include changes to Medical and Part D benefits,
copayments and/or coinsurance, deductibles, formulary coverage,
pharmacy network, premium and out-of-pocket maximums. Please check
the member’s benefits for the new Plan year changes by visiting our
website at www.anthem.com/medicareprovider or calling provider services
at the number on the back of the member’s ID card.
If members receive two or more services from the same provider during the same visit and/or on the same day,
members will be responsible to pay the copay for each applicable service. This includes but is not limited to lab
services, diagnostic procedures and test, X-rays, Radiology, Part B drugs.
Our plan will no longer cover unlimited inpatient days for acute care illness or injury.
This plan will offer a new benefit called LiveHealth Online. LiveHealth Online provides convenient access for
members to interact with a doctor via live, two-way video on a computer or mobile device.
This plan will offer one routine physical exam in addition to the Medicare-covered “Welcome to Medicare” exam or
Annual Wellness Exam. The examination for this visit is multi-system, and the exact content and extent of the exam
is based on the patient’s age, gender, and identified risk factors; face-to-face visit. The comprehensive history
obtained as part of the preventive medicine E/M service is not problem-oriented and does not involve a chief
complaint or present illness. It does, however, include a comprehensive system review and comprehensive or
interval past, family, and social history as well as a comprehensive assessment/history of pertinent risk factors. It
also includes clinical laboratory tests. Providers should bill 99381-99397 (Preventive Medicine Services) for the
routine physical exam. When the routine physical is completed by an in-network provider, there are no out-ofpocket costs for the member. Physicals completed by out-of-network providers will be subject to member co-pay as
applicable by the member’s plan.
Preventive dental consisting of 1 exam and 1 cleaning and preventive vision consisting of 1 eye exam are new
covered benefits in 2015. Members have the option of purchasing an optional supplemental benefit package beyond
this coverage.
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
Please check the member ID card for any identification and/or group number changes that may affect claim
submissions.
New Plans and Service Area Changes:
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The Anthem Medicare Preferred Core (PPO) will be non-renewing in Roanoke City for 2015.
Group Sponsored Medicare Advantage Health Benefit Plans are not impacted by the service area changes described
above for PPO plans.
Optional Supplemental Benefits (OSB)
For 2015, many of our Medicare Advantage plans will offer three Optional Supplemental Benefit (OSB) packages for an
additional premium. OSB packages allow the Medicare Advantage plan to be tailored for additional dental and vision
coverage.
We will offer the below Optional Supplemental Benefit (OSB) packages on select plans. Members will have up to 90 days
from their plan effective date to enroll in one of the below packages:
1.
2.
3.
Preventive Dental Package
Dental and Vision Package
Enhanced Dental and Vision Package
Diabetic Supplies:
Effective January 1, 2015, all of our individual Medicare Advantage plans will only cover certain diabetic supplies if they are
purchased at one of our network pharmacies or through our mail-order service. Durable Medical Equipment (DME) providers
as well as physicians will no longer be able to bill for these supplies.
HCPCS codes that will no longer be covered when purchased through a DME provider or other physicians:

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
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A4253
E0607
E2100
E2101
blood
home
blood
blood
glucose test strips
blood glucose monitor
glucose monitor with integrated voice synthesizer
glucose monitor with integrated lancing/blood sample
Members impacted by this change will be notified in October through their Annual Notice of Change and Evidence of
Coverage plan benefit materials.
To be covered for a $0 copay, the members must purchase these supplies at an in-network retail or mail-order pharmacy
supplier.
Covered blood glucometers and blood glucose test strips in 2015:



LifeScan, Inc., OneTouch®
Roche Diagnostics, ACCU-CHEK®
A limit of 100 blood glucose test strips per month
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Other blood glucometer or blood glucose test strip brands or quantities of more than 100 test strips per month are not
covered unless you as the physician or provider tell us another brand or a larger quantity is medically necessary for the
member’s treatment. No other brand or larger quantity limit will be covered.
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If our member is currently using LifeScan, Inc, OneTouch® or Roche Diagnostics, ACCU-CHEK® blood test strips or
glucometer products and using an in-network retail or mail-order pharmacy supplier, you don’t need to do anything.
If our member is not using LifeScan, Inc, OneTouch® or Roche Diagnostics, ACCU-CHEK® blood test strips or
glucometer products or using an in-network retail or mail-order pharmacy supplier, then our member will need to get
new prescriptions for the supplies by January 1 for these claims to be covered by us.
You should discuss these coverage changes and possible new prescriptions with our member/your patient. If it is
medically necessary for them to continue using a different brand of blood test strips or glucometer and/or more than
100 blood test strips per month, you will need to communicate this to us by requesting an exception. If your patients
purchase their supplies through the pharmacy or the ESI mail-order service, exceptions may be requested by calling
1-800-338-6180.
The benefit and brand limitations described above generally do not apply to our Group Sponsored Medicare
Advantage Health Benefit Plans. Please contact provider services for benefit information.
Insulin Exclusivity:
As a reminder for 2015, individual Medicare Advantage Part D (MAPD) plans have an insulin exclusivity contract with Eli Lilly,
the manufacturer of Humulin and Humalog human insulins. Other insulins are considered non-formulary and are not eligible
for coverage.
New Year; new formulary changes:
Each year we evaluate our benefits and formulary and may make changes to update them. Formulary changes in
the upcoming year include: tier changes, drug removals, and new Prior Authorization and Quantity Limit
requirements.
Your patients will have formulary changes and will need your help to ensure they get their needed treatments at
the most affordable cost.
Please encourage your patients to review the 2015 formulary information within their Annual Notice of Change
(ANOC) mailing, or to view the information online when it is available, beginning October 1. Ask them if the
coverage for any of their prescriptions has been changed and consider alternative medications in a lower costsharing tier that may meet their needs.
Pharmacy Network Changes:
The pharmacy network includes preferred and other network retail pharmacies. Member’s save more by paying a
lower cost-sharing amount at preferred cost-sharing pharmacies. Our preferred cost-sharing pharmacies include
CVS/Pharmacy (participating pharmacies include CVS and Longs Drugs), Giant Eagle Pharmacy, Hannaford
Brothers (participating pharmacies include Hannaford and Food Lion), Harris Teeter Supermarkets, Kroger
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(Kroger Co. participating preferred pharmacies include Kroger, Fred Meyer, King Soopers, City Market, Fry’s,
Smith’s, Dillons, Ralph’s, QFC, Baker’s, Scott’s, Owen’s, Pay Less, Gerbes and JayC), Target and Wal-Mart
(Walmart participating preferred pharmacies include Walmart, Neighborhood Market and Sam’s Club. Members
can fill a prescription at a network retail pharmacy, but their cost-sharing amount may be higher.) Please note:
Ride Aid will no longer offered preferred cost sharing for member, but will continue as part of the standard retail
network
Rx Benefit Changes:
Tier 6 has select care drugs at a $0 to low cost share for the following conditions: high blood pressure, high
cholesterol and diabetes and will have the following drugs on it: GLIPIZIDE, LISINOPRIL, LOSARTAN
POTASSIUM, METFORMIN HCL, and SIMVASTATIN.
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Group Sponsored Medicare Advantage Health Benefit Plans are not impacted by the changes
described above for Pharmacy plans.
Balance Billing Reminder:
The Centers for Medicare & Medicaid Services and our plan does not allow you to “balance bill” Medicare Advantage HMO
and PPO members for Medicare covered services. CMS provides for an important protection for Medicare beneficiaries and
our members such that, after our members have met any plan deductibles, they only have to pay the plan’s cost-sharing
amount for services covered by our plan. As a Medicare provider and/or a plan provider, you are not allowed to balance bill
members for an amount greater than their cost share amount. This includes situations where we pay you less than the
charges you bill for a service. This also includes charges that are in dispute.
Employer or Union Group Retiree Changes:
Group Sponsored Medicare Advantage Benefit Plan benefits vary from Anthem Medicare Preferred Core (PPO) plan
mentioned here. Employer or Union Group Plan names and benefit changes may be different than what is described
above. For Group Sponsored Medicare Advantage Health Benefit Plan members, please refer to the member’s Evidence of
Coverage or call Provider Services at the number on the member ID card for more benefit detail. Medicare Advantage
member ID cards contain a CMS identifier in the lower right corner of the card. The number will be five characters (XXXXX)
followed by three characters (XXX). The member is in a Group Sponsored Medicare Advantage Health Benefit Plan when the
last three digits start with an eight (8XX).
Providers should reference the member’s ID card for changes at every visit to help ensure proper billing. You can also assist
your patients by passing on any ID card prefix or benefit change information to any ancillary providers who will be asked to
serve your patient.
What does the Annual Wellness Visit (AWV) cover?
All of our Medicare Advantage plans cover the AWV. Members are encouraged to use this annual benefit as one way to help
assess current health status and future needs.
For the first visit, providers should bill G0438 for the AWV which includes the Personalized Prevention Plan Service.
Thereafter, providers should bill G0439 for the AWV and Personalized Prevention Plan Service, subsequent visit.
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Annual Wellness Visit:
All Medicare Advantage plans cover the AWV. Members are encouraged to use this annual benefit as one way to help assess
current health status and future needs.
What if Additional Services Are Provided at the Same Time As the AWV?
If other evaluation and management services are provided in conjunction with the AWV, use CPT Modifier 25 (Significant,
separately identifiable evaluation and management service by the same physician on the same day of the procedure or other
service) as appropriate.
Prior Authorization Updates for Medicare Advantage Plans:
Providers are required to periodically review and comply with the latest Medicare Advantage Prior Authorization requirements
found at www.anthem.com/medicareprovider on the document named: Medicare Advantage Precertification Requirements
(updated 10/01/2013)]
Referral Process Updates for Individual Medicare Advantage Plans:
In most situations, our members may need to receive a referral from their PCP before they can use specialists in the Plan’s
network. Examples of specialists include Cardiologists, Dermatologists, Orthopedic Surgeons, Oncologists and Urologists.
However, referrals from a PCP are not required for emergency care or urgently needed care. There are also other kinds of
care members can obtain without having approval in advance from their PCP.
Please visit our website at www.anthem.com/medicareprovider for more detailed product information or contact Provider
Services at the number on the back of the member’s ID card. You can find important Medicare Advantage updates in the
Plan & Administrative Changes/Update section. Contact your provider representative for participation details for our
contracted plans.
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Pharmacy update
Clarification of CoramRx/CVS Caremark change
In the August 2014 issue of Network Update, the ARTICLE , “CoramRX/CVS Caremark change for specialty drugs covered
under the medical benefit,” announced CVS Caremark’s purchase of CoramRx. This is to clarify that information in that article
only applies to CVS Caremark/Coram’s internal processes when triaging medications for health plan members.
CVS Caremark’s purchase of Coram does not impact contracted home infusion/ambulatory infusion suite providers who
supply specialty medications and home infusion services for health plan members through the medical benefit.
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”.
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