June 2020 Anthem Provider News - Virginia Page 1 of 50

Virginia Provider NewsJune 2020 Anthem Provider News - Virginia

Administrative:

Products & Programs:

Behavioral Health:

Pharmacy:

Coverage and Clinical Guidelines:

Medicaid:

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A special thank you to Care Providers 3

Anthem introduces lower cost Anthem Health Access Plans onJune 1 in response to COVID-19 crisis

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Provider contract and fee schedule notifications coming soon 4

Availity Portal Notification Center 7

Quality Corner: CPT® Category II codes - Collaborating forenhanced patient care

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Anthem Commercial Risk Adjustment (CRA) Program Update:Retrospective Program Begins; Prospective ProgramContinues

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Quality Corner: Follow-up after Hospitalization for MentalIllness

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National Drug Code requirement on outpatient claims 17

Anthem prior authorization updates for specialty pharmacy areavailable

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Pharmacy information available on anthem.com 20

Coverage guidelines effective September 1, 2020 20

Modifier use reminders 22

2020 affirmative statement concerning utilization managementdecisions

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Coding Spotlight: An Anthem HealthKeepers Plus providerguide to code social determinants of health

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June 2020 Anthem Provider News - Virginia Page 2 of 50

Medicare:

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO productsunderwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. InMissouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company(HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten byHMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada:Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. In New Hampshire:Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten byMatthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as AnthemBlue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east ofState Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), which underwrites or administers the PPO and indemnity policiesand underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation(Compcare) underwrites or administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers WellPriority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of AnthemInsurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation. Use of the Anthem websites constitutes your agreement with our Terms of Use.

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Follow-up after Hospitalization for Mental Illness 32

Complex Case Management program 34

Important information about utilization management 35

Anthem HealthKeepers Plus Members’ Rights andResponsibilities Statement

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Medicaid patients can make the switch to the AnthemHealthKeepers Plus plan

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Updates to AIM Sleep Disorder Management ClinicalAppropriateness Guideline

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Keep up with Medicaid news 40

Modifier use reminders 40

Anthem working with Optum to collect medical records for riskadjustment

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2020 Medicare risk adjustment provider training 42

Diabetes HbA1c < 8 HEDIS guidance 45

Updates to AIM Sleep Disorder Management ClinicalAppropriateness Guideline

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Keep up with Medicare news 50

June 2020 Anthem Provider News - Virginia Page 3 of 50

A special thank you to Care ProvidersPublished: Jun 1, 2020 - Administrative

We want to express our most sincere thanks for your dedication to serving the patients inyour care. Please take a moment to watch this brief thank you message from Anthem BlueCross and Blue Shield.

URL: https://providernews.anthem.com/virginia/article/a-special-thank-you-to-care-providers-5

Anthem introduces lower cost Anthem Health Access Plans onJune 1 in response to COVID-19 crisisPublished: Jun 1, 2020 - Administrative

Like many, Anthem Blue Cross and Blue Shield and affiliate HealthKeepers, Inc. are closelymonitoring COVID-19 developments and what it means for our customers and our healthcare provider partners. Anthem is working to help employers who are facing tough decisionson furloughing or reducing hours of their workforce. Anthem is doing this by creating healthinsurance options that provide continued access to care. We continue to seek ways tosupport our customers by offering affordable alternate products with more flexibility whileensuring members can continue to see their established physicians. Beginning June 1, 2020, Anthem is introducing our Anthem Health Access Plans for certainlarge group employers currently enrolled in our commercial lines of business only. Anthem Health Access Plans cover the diagnosis and treatment for COVID-19 at 100% inaccordance with Anthem guidelines. These benefit plans cover preventive care, unlimited telemedicine, office visits, prescriptions,and more. In addition, members enrolled in these plans have digital ID cards and access toSydney Health and Sydney Care (Anthem’s mobile app that runs on intelligence – as part ofour digital strategy). These plans include some coverage exclusions or limitations. For information abouteligibility, available benefits, and a list of exclusions, please visit Availity – our Web-basedprovider tool at www.availity.com.

June 2020 Anthem Provider News - Virginia Page 4 of 50

We are committed to working with our provider partners to help our members focus on theirhealth and well-being. The new Health Access plans give your patients the needed coverageto manage their everyday health needs. NOTE: As with all eligibility and benefits inquiries on Availity, providers must have themember ID number (including the three-character prefix) and one or more search options ofdate of birth, first name and last name.

URL: https://providernews.anthem.com/virginia/article/anthem-introduces-lower-cost-anthem-health-access-plans-on-june-1-in-response-to-covid-19-crisis-4

Provider contract and fee schedule notifications coming soonPublished: Jun 1, 2020 - Administrative

We are pleased to announce the release of Provider Contract and Fee ScheduleNotifications. Starting in mid-June, when Anthem notifies you of a statewide fee scheduleupdate or provider contract amendment, you can log into Availity.com and download a digitalcopy of your content. Over the last few months, we have been tirelessly working to streamline our businessprocesses and believe that online Provider Contract and Fee Schedule Notifications will helpimprove your business interactions with Anthem even more. Based on your feedback, we will no longer send large printed paper mailings or CDs in themail. In order to be ready for the digital downloads that start as early as June 15, you shouldlog in to Availity, access the Provider Online Reporting application and register yourauthorized users. See details below on how to log in and access your reports.

Provider Online Reporting Reference Guide: How to get started This document will familiarize you with the Provider Online Reporting application found onthe Availity Portal. Using our web-based reporting application, you will be able to accessregularly updated reports.

For Availity Administrators – How to assign access

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For Users – How to navigate to the reports

If your organization is not currently registered for the Availity Portal, go to www.availity.comand select Register to complete the online application. Your Administrator will need to take the following steps to assign access to ProviderOnline Reporting:

1. Assign the user role of Provider Online Reporting to your Availity access.

2. Select Payer Spaces in the navigation bar and then choose the payer tile thatcorresponds to the market.

3. Accept the User Agreement (once every 365 days).

4. On the Applications tab, select Provider Online Reporting.

5. Choose the organization and select Submit.6. In the Provider Online Reporting application, register the tax ID by selectingRegister/Maintain Organization.

7. Last, register users to the program by selecting Register Users and completing therequired fields.

Accessing reports:

1. After logging in to Availity, select Payer Spaces in the navigation bar and then choosethe payer tile that corresponds to the market.

2. Accept the User Agreement (once every 365 days).

3. On the Applications tab, select Provider Online Reporting.

4. Choose the organization and select Submit.5. Select Report Search, choose the type of report, and then launch your program’sreporting application.

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June 2020 Anthem Provider News - Virginia Page 7 of 50

For further assistance with Availity, please contact AvailityClient Services at 1-800-282-4548.

For other questions, contact your local contract advisor,consultant or Provider Relations representative.

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URL: https://providernews.anthem.com/virginia/article/provider-contract-and-fee-schedule-notifications-coming-soon

Availity Portal Notification CenterPublished: Jun 1, 2020 - Administrative

Anthem Blue Cross and Blue Shield is now using the Notification Center on the AvailityPortal home page to communicate vital, time sensitive information. A Take Action call outand a red flag in front of the message will make it easy to see that there is something newrequiring your attention.

June 2020 Anthem Provider News - Virginia Page 8 of 50

The Notification Center is currently being used to notify you if there are payment integrityrequests for medical records or recommended training in the Custom Learning Center.Select the Take Action icon to instantly access the custom learning recommended course. For membership where the disputes tool is available, Availity will also post a message in thenotification center when a dispute request you have submitted is finalized. Selecting theTake Action icon will allow easy access to your appeals worklist for details. Viewing the Notification Center updates should be included as part of your regular workflowso you are always aware of any outstanding action items and can respond timely. 457-0620-PN-VA

URL: https://providernews.anthem.com/virginia/article/availity-portal-notification-center-5

Quality Corner: CPT® Category II codes - Collaborating forenhanced patient carePublished: Jun 1, 2020 - Administrative

The American Medical Association has an alphabetical listing of clinical conditions withwhich measures and CPT Category II codes are associated. The use of CPT Category IICodes and ICD-10-CM codes can reduce the number of medical records that we requestduring the HEDIS® medical record review season (January – May each year), thus reducingthe administrative burden on physician offices. Below are some commonly used codes for your convenience.

June 2020 Anthem Provider News - Virginia Page 9 of 50

Measure Description CPT II Code ExclusionsComprehensiveDiabetes Care

Whether or not patient age 18-75had screening ormonitoring fordiabetic retinaldisease

· 2022F - Dilated retinal eyeexam with interpretation byophthalmologist oroptometrist documented andreviewed with evidence ofretinopathy

· 2023F - Dilated retinal eyeexam with interpretation byophthalmologist oroptometrist documented andreviewed without retinopathy

· 3072F - Low risk forretinopathy (no evidence ofretinopathy in the prior year)

· Documentation ofgestationaldiabetes or steroid-induced diabetes

ComprehensiveDiabetes Care

For patient age18-75, whether ornot the mostrecent A1c levelis controlled

· 3044F - Most recenthemoglobin A1c level lessthan 7.0%

· 3051F - Most recenthemoglobin A1c (HbA1c)level greater than or equal to7.0% and less than 8.0%

· 3052F Most recenthemoglobin A1c (HbA1c)level greater than or equal to8.0% and less than or equalto 9.0%

· 3046F Most recenthemoglobin A1c levelgreater than 9.0%

· Report one of thefour Category IIcodes listed anduse the date ofservice as the dateof the test, not thedate of thereporting of theCategory II code.

· Documentation ofmedical reasons fornot pursuing tightcontrol of A1c level(i.e., steroid-induced orgestationaldiabetes, frailtyand/or advancedillness)

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ComprehensiveDiabetes Care

Whether or notpatient age 18-75received urineprotein screeningor medicalattention fornephropathy

· 3060F - Positivemicroalbuminuria testdocumented and reviewed

· 3061F - Negativemicroalbuminuria test resultdocumented and reviewed

· 3062F - Positivemacroalbuminuria test resultdocumented and reviewed

· 3066F - Documentation oftreatment for nephropathy

· Documentation ofgestationaldiabetes or steroidinduced diabetes

June 2020 Anthem Provider News - Virginia Page 11 of 50

ControllingHigh BloodPressure

During the mostrecent visit,whether or not apatient age 18years or olderwith a diagnosisof hypertensionhad:

· a bloodpressure readingless than 140 mmHg systolic andless than 90 mmHg diastolic OR

· a bloodpressure readinggreater than orequal to 140 mmHg systolic andless than 90 mmHg diastolic, andprescribed 2 ormore anti-hypertensiveagents

· 3074F - Most recentsystolic blood pressure <130 mm Hg

· 3075F - Most recentsystolic blood pressure 130to 139 mm Hg

· 3077F - Most recentsystolic blood pressure ≥140 mm Hg

· 3078F - Most recentdiastolic blood pressure < 80mm Hg

· 3079F - Most recentdiastolic blood pressure 80 –89 mm Hg

· 3080F - Most recentdiastolic blood pressure ≥ 90mm Hg

· 4145F - Two or more anti-hypertensive agentsprescribed or currently beingtaken

· Report one of thethree systoliccodes.

· Report one of thethree diastoliccodes.

· Documentation ofreason(s) for notprescribing 2 ormore anti-hypertensivemedications:

Medical (i.e.,allergy, intolerant,posturalhypotension orother reason)

Patient (i.e., patientdeclined, or otherpatient reason)

System (i.e.,financial or othersystem reason)

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Timelinessof PrenatalCare

Women who hadlive birthsbetweenNovember 6 ofthe year prior tothe measurementyear andNovember 5 ofthe measurementyear, who werecontinuouslyenrolled at least43 days prior todelivery through56 days afterdelivery

· 0500F - Initial prenatalcare visit (report at firstprenatal encounter withhealth care professionalproviding obstetrical care.(Report also date of visitand, in a separate field, thedate of the last menstrualperiod – (LMP)) · 0501F - Prenatal flowsheet documented inmedical record by firstprenatal visit (documentationincludes at minimum bloodpressure, weight, urineprotein, uterine size, fetalheart tones, and estimateddate of delivery). Reportalso: date of visit and, in aseparate field, the date ofthe LMP (Note: If reporting0501F Prenatal flow sheet, itis not necessary to report0500F Initial prenatal carevisit)

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TimelinessofPostpartumCare

Number ofwomen in thedenominator whohad a postpartumvisit on orbetween 21 daysand 56 days afterdelivery.Denominator:Women who hadlive birthsbetweenNovember 6 ofthe year prior tothe measurementyear andNovember 5 ofthe measurementyear

· 0503F - Postpartum carevisit

CPT® is a registered trademark of the American Medical Association Copyright 2020 American Medical Association. All rightsreserved.

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URL: https://providernews.anthem.com/virginia/article/quality-corner-cpt-category-ii-codes-collaborating-for-enhanced-patient-care-5

Anthem Commercial Risk Adjustment (CRA) Program Update:Retrospective Program Begins; Prospective Program ContinuesPublished: Jun 1, 2020 - Products & Programs

Anthem is committed to collaborating with the provider community and offering flexibleoptions to meet the needs of both the retrospective program and the prospective program. The retrospective program focuses on medical chart collection. The prospective programfocuses on member health assessments for patients with undocumented HierarchicalCondition Categories (HCC’s), in order to help close patients’ gaps in care.

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Retrospective Chart Requests We appreciate that care providers across the country on the front line are committed toproviding care during these challenging times, and as such, that care results in a visit wherewe may need the medical chart. Medical chart collection must be done to obtainundocumented HCC’s on your patients in order to be compliant with the provisions of theAffordable Care Act, (ACA), that require our company to collect and report diagnosis codedata for ACA membership. This process will begin in June. In order to make these chartrequests the most efficient for your office, we have electronic options available: EMR Interoperabilityo Allscripts (Opt in – signature required)o NextGeno Athenahealtho MEDENTRemote/Direct Anthem accessVendor virtual or onsite visit (if the offices are opened back up from COVID-19closures)Secure FTP

The goal of these electronic options is to both improve the medical record data extractionand the experience for Anthem’s providers. If you are interested in this type of set up or anyother remote access options, please contact the Commercial Risk Adjustment NetworkEducation Representative listed below. Prospective Patient Outreach(Incentive opportunity for properly completed health assessments: Physicians are eligible to receive $100 for electronic submissions or $50 for paper inaddition to the office visit reimbursement.) We encourage members to form a relationship with their Primary Care Physician tocomplete a clinical assessment to ensure you have a clearer picture of your patients’ health. Telehealth visits are an acceptable format for seeing your patients and assessing if theyhave risk adjustable conditions. Previous Anthem news updates have given telehealthreimbursement guidance to follow when submitting the claim.

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As a reminder, the May Provider News mentioned incentives for prospective programparticipation ($100 or $50). We would be happy to meet and review incentive opportunitiesalong with other flexible options for program participation and chart collection. Pleasecontact the Commercial Risk Adjustment network education representative listed below toset up a meeting. Alicia.Estrada@anthem.com Thank you for your continued efforts with the CRA Program.

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URL: https://providernews.anthem.com/virginia/article/anthem-commercial-risk-adjustment-cra-program-update-retrospective-program-begins-prospective-program-continues-2

Quality Corner: Follow-up after Hospitalization for Mental IllnessPublished: Jun 1, 2020 - Products & Programs / Behavioral Health

As a provider, we understand you are committed to providing the best care for our members,including follow up appointments with members after a behavioral health (BH) inpatient stay.Since regular monitoring, follow up appointments and making necessary treatmentrecommendations or changes are all part of excellent care, we would like to provide anoverview of the related HEDIS measure. The Follow-up after Hospitalization for Mental Illness (FUH) HEDIS measure evaluatesmembers (6 years and older) who were hospitalized for treatment of selected mental illnessdiagnoses and who had a follow-up visit with a mental health practitioner. Two areas of importance for this HEDIS measure are:

The percentage of behavioral health inpatient discharges for which the memberreceived follow-up within 7 days after discharge.

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The percentage of behavioral health inpatient discharges for which the memberreceived follow-up within 30 days after discharge.

On a regular basis, we continue to monitor if these two consecutive follow-up appointmentsare being recommended and scheduled during the inpatient stay as part of dischargeplanning by the eligible behavioral health facilities (such as psychiatric hospitals,freestanding mental health facilities and acute care hospitals with psychiatric units), as wellas practicing behavioral health providers.

Please consider the following for improving member outcomes for this measure:

1. Earliest follow up with a BH provider can help with continuing treatment after leaving thehospital.

1. With greater emphasis on care coordination, primary care providers can help facilitatethe BH follow up appointments.

1. Weekend member discharges have shown to have very inconsistent follow up afterdischarge. Start discharge planning as soon as possible while members are inpatient sothose who are discharged on weekends have scheduled follow up appointments.

1. In addition, other social determinants of health pertinent to the member such ashousing, food, living in a rural area, transportation, job schedule, family and social support,child care, etc., can impact follow-up opportunities. Please address these needs andissues; refer to resources that can help support the member.

1. Social workers at the facilities can contact Anthem member services to learn ifadditional sources of assistance are available through Anthem such as case managementand other referrals.

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1. Telehealth services have been identified as part of follow up for this HEDIS measureavailable in certain parts of the country. Telehealth follow up may not be the best choicefor everyone; however, not having a BH follow up for several weeks can be detrimental tothe member can be a reason for relapse.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

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URL: https://providernews.anthem.com/virginia/article/quality-corner-follow-up-after-hospitalization-for-mental-illness-3

National Drug Code requirement on outpatient claimsPublished: Jun 1, 2020 - Products & Programs / Pharmacy

Anthem Blue Cross and Blue Shield (Anthem) values the quality and commitment with whichyou serve your patients and our members. In this edition of Provider News, we are notifyingyou about a National Drug Code (NDC) requirement for drugs administered in a physician’soffice or outpatient facility setting for Local Plan and BlueCard member claims only. Thisnotice EXCLUDES claims for members enrolled in the Blue Cross and Blue Shield ServiceBenefit Plan (also called the Federal Employee Program or FEP) and Coordination ofBenefits/secondary claims. For dates of service on and after September 1, 2020, all providers are required tosupply the 11-digit NDC – along with the information below – when billing forinjections and other drug items on the CMS-1500 and UB-04 claim forms as well as on837 electronic transactions.

1. The applicable HCPCS code or CPT code

2. Number of HCPCS code or CPT code units

3. The 11-digit NDC(s), including the N4 qualifier4. Dosage Unit of Measurement (F2, GR, ML, UN, ME)

5. Number of NDC Units dispensed (must be greater than 0)

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To assist with accurate and timely claims payments, it is important that you provide the NDCinformation as outlined above when filing claims to us. Anthem will reject any line itemson claims with dates of service on and after September 1, 2020, when the aboveinformation is not included regarding drugs. If you have further questions, please contact the telephone number on the back of themember’s ID card. 485-0620-PN-VA

URL: https://providernews.anthem.com/virginia/article/national-drug-code-requirement-on-outpatient-claims-3

Anthem prior authorization updates for specialty pharmacy areavailablePublished: Jun 1, 2020 - Products & Programs / Pharmacy

Prior authorization updates

Effective for dates of service on and after September 1, 2020, the following specialtypharmacy codes from current or new clinical criteria documents will be included in our priorauthorization process.

Please note, inclusion of National Drug Code (NDC) on your claim will shorten the claimprocessing time of drugs billed with a Not Otherwise Classified (NOC) code.

Access the clinical criteria information.

For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., priorauthorization of these specialty pharmacy drugs will be managed by Anthem. Drugs used forthe treatment of oncology will still require pre-service clinical review by AIM SpecialtyHealth (AIM), a separate company.

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Clinical Criteria HCPCS orCPT Code(s)

Drug

ING-CC-0161 C9399J3490J3590J9999

Sarclisa

*ING-CC-0058 J2354 Bynfezia * Non-oncology use is managed by Anthem’s medical specialty drug review team; oncologyuse is managed by AIM. Step therapy updates Effective for dates of service on and after September 1, 2020, the following specialtypharmacy codes from current or new clinical criteria documents will be included in ourexisting specialty pharmacy medical step therapy review process. Access the step therapy drug list. For Anthem Blue Cross and Blue Shield along with our affiliate HealthKeepers, Inc., priorauthorization clinical review of these specialty pharmacy drugs will be managed by Anthem.Drugs used for the treatment of Oncology will still require pre-service clinical review by AIMSpecialty Health (AIM), a separate company. This would apply to members with PreferredProvider Organization (PPO), HealthKeepers (HMO), POS AdvantageOne, Act Wise (CDHplans).” Clinical Criteria Status Drug(s) HCPCS

Code(s)ING-CC-0003 Non-preferred Panzyga J1599ING-CC-0003 Non-preferred Xembify J3490

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URL: https://providernews.anthem.com/virginia/article/anthem-prior-authorization-updates-for-specialty-pharmacy-are-available-4

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Pharmacy information available on anthem.comPublished: Jun 1, 2020 - Products & Programs / Pharmacy

For more information on copayment/coinsurance requirements and their applicable drugclasses, drug lists and changes, prior authorization criteria, procedures for genericsubstitution, therapeutic interchange, step therapy or other management methods subject toprescribing decisions, and any other requirements, restrictions, or limitations that apply tousing certain drugs, visit anthem.com/pharmacyinformation. The commercial Virginia andmarketplace drug lists are posted to the website quarterly (the first of the month for January,April, July and October). To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “SelectDrug Lists.” This drug list is also reviewed and updated regularly as needed. Federal Employee Program Pharmacy updates and other pharmacy related information maybe accessed at www.fepblue.org > Pharmacy Benefits. 463-0620-PN-VA

URL: https://providernews.anthem.com/virginia/article/pharmcy-information-available-on-anthemcom

Coverage guidelines effective September 1, 2020Published: Jun 1, 2020 - Guideline Updates / Coverage and Clinical Guidelines

Anthem Blue Cross and Blue Shield in Virginia and our affiliate, HealthKeepers, Inc., willimplement the following new and revised coverage guidelines effective September 1, 2020. These guidelines impact all our products – with the exception of Anthem HealthKeepers Plus(Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCCPlus) plan, and the Blue Cross and Blue Shield Service Benefit Plan (also called the FederalEmployee Program or FEP). Furthermore, the guidelines were among those recentlyapproved at the Medical Policy and Technology Assessment Committee meeting held onFebruary 20, 2020. The services addressed in these coverage guidelines in this section and in the attachment under "Article

Attachments" on the right will require authorization for all of our HealthKeepers, Inc. products with the

June 2020 Anthem Provider News - Virginia Page 21 of 50

exception of Anthem HealthKeepers Plus (Medicaid), the Anthem CCC Plus plan, Medicare Advantage,

and the Federal Employee Program.

A pre-determination can be requested for our PPO products. Services related to specialty pharmacy drugs (non-cancer related) require a medicalnecessity review, which includes site of care criteria, as outlined in the applicable coverageor clinical UM guideline.

Guidelines addressed in this edition of Provider News are:

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface andPercutaneous Devices (DME.00011)

Low Intensity Therapeutic Ultrasound for the Treatment of Pain (DME.00041)

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting(GENE.00053)

Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose andManage Cancer (GENE.00054)

Patent Foramen Ovale and Left Atrial Appendage Closure Devices for StrokePrevention (SURG.00032)

Surgical and Ablative Treatments for Chronic Headaches (SURG.00096)

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Microsurgical Procedures for the Treatment of Lymphedema(SURG.00154)

Cryoneurolysis for Treatment of Peripheral Nerve Pain(SURG.00155)

Mobile Device-Based Health Management Applications (CG-ANC-08)

Surgical and Minimally Invasive Treatments for BenignProstatic Hyperplasia (BPH) (CG-SURG-107) (PreviouslySURG.00028)

473-0620-PN-VA

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Coverage guidelineseffective September1, 2020.pdfapplication/pdf - 164.64

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URL: https://providernews.anthem.com/virginia/article/coverage-guidelines-effective-september-1-2020

Modifier use remindersPublished: Jun 1, 2020 - State & Federal / Medicaid

Billing for Anthem HealthKeepers Plus member treatment can be complex, particularly whendetermining whether modifiers are required for proper payment. HealthKeepers, Inc.’sreimbursement policies and correct coding guidelines explain the appropriate use of codingmodifiers. We would like to highlight the appropriate use of some commonly used modifiers. Things to remember

June 2020 Anthem Provider News - Virginia Page 23 of 50

Review the CPT Surgical Package Definition found in the current year’s CPTProfessional Edition. Use modifiers such as 25 and 59 only when the services are notincluded in the surgical package.

Review the current CPT Professional Edition Appendix A — Modifiers for theappropriate use of modifiers 25, 57 and 59.

When an evaluation and management (E&M) code is reported on the same date ofservice as a procedure, the use of the modifier 25 should be limited to situations wherethe E&M service is “above and beyond” or “separate and significant” from any proceduresperformed the same day.

When appropriate, assign anatomical modifiers (Level II HCPCS modifiers) to identifydifferent areas of the body that were treated. Proper application of the anatomicalmodifiers helps ensure the highest level of specificity on the claim and show that differentanatomic sites received treatment.

Use modifier 59 to indicate that a procedure or service was distinct or independent ofother non-E&M services performed on the same date of service. The modifier 59represents services not normally performed together, but which may be reported togetherunder the circumstances.

If you feel that you have received a denial after appropriately applying a modifier undercorrect coding guidelines, please follow the normal claims dispute process and includemedical records that support the use of the modifier(s) when submitting claims forconsideration. HealthKeepers, Inc. will publish additional articles on correct coding in providercommunications.

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June 2020 Anthem Provider News - Virginia Page 24 of 50

If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. AVA-NU-0229-20

URL: https://providernews.anthem.com/virginia/article/modifier-use-reminders-15

2020 affirmative statement concerning utilization managementdecisionsPublished: Jun 1, 2020 - State & Federal / Medicaid

All associates who make utilization management (UM) decisions regarding membersenrolled in Anthem HealthKeepers Plus are required to adhere to the following principles:

UM decision making is based only on appropriateness of care and service andexistence of coverage.

We do not specifically reward practitioners or other individuals for issuing denials ofcoverage or care. Decisions about hiring, promoting or terminating practitioners or otherstaff are not based on the likelihood or perceived likelihood that they support, or tend tosupport, denials of benefits.

Financial incentives for UM decision makers do not encourage decisions that result inunderutilization or create barriers to care and service.

If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. AVA-NU-0238-20

URL: https://providernews.anthem.com/virginia/article/2020-affirmative-statement-concerning-utilization-management-decisions-3

June 2020 Anthem Provider News - Virginia Page 25 of 50

Coding Spotlight: An Anthem HealthKeepers Plus provider guideto code social determinants of healthPublished: Jun 1, 2020 - State & Federal / Medicaid

What are social determinants of health (SDOH)?

The World Health Organization (WHO) defines SDOH as “conditions in which people are born, grow, work

and age. These circumstances are shaped by the distribution of money, power and resources at global,

national and local levels. The social determinants of health are mostly responsible for health inequalities.”

Capturing SDOH is becoming a necessary element of documentation.

Official coding guidelines for SDOH — new update For 2019, the ICD-10-CM Official Guidelines for Coding and Reporting has been updated toallow reporting SDOH using the documentation of clinicians other than the patient’s provider.Most of the patient-specific SDOH information is captured by ancillary staff supporting thephysicians. Do SDOH affect everyone?

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The SDOH codes are very powerful tools in capturing the complexity of patient populationsand allowing application of more accurate care. These conditions affect patient care. Thispublicly reported data will also improve capture of conditions that impact readmissionreduction and mortality metrics. SDOH diagnosis codes are one of the few tools that are shared collectively to measure andevaluate SDOH on a national scale. How can providers address SDOH issues for the members?

Using the CMS Screening Tool, which can be found at:

https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf

Submitting ICD-10-CM codes from Chapter 21 (Z00 to Z99) to identify issues that mayimpact member health via claims

Coding SDOH SDOH codes are represented in ICD-10-CM code categories Z55 to Z65 — persons withpotential health hazards related to socioeconomic and psychosocial circumstances. Codesin the Z55 to Z65 groupings include the following:

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Code grouping ExamplesZ55 — Problems related toeducation and literacy

Illiteracy/low level of literacy, schoolingunavailable

Z56 — Problems related toemployment andunemployment

Unemployment, change of job, threat of jobloss, military deployment status, sexualharassment on the job

Z57 — Occupationalexposure to risk factors

Occupational exposure to noise, radiation,dust, tobacco, toxic agents in agriculture,extreme temperature

Z59 — Problems related tohousing and economiccircumstances

Homelessness, inadequate housing, discordwith neighbors, extreme poverty, low income

Z60 — Problems related tosocial environment

Adjustment to lifestyle transition, problemsliving alone, acculturation difficulty, socialexclusion and rejection

Z62 — Problems related toupbringing

Inadequate parental supervisions andcontrol, parental overprotection, institutionalupbringing

Z63 — Other problemsrelated to primary supportgroup, including familycircumstances

Problems with spousal or other relationship,absence of a family member, alcoholism ordrug addiction in family

Z64 — Problems related tocertain psychosocialcircumstances

Problems with unwanted pregnancy,problems related to multiparity, discord withcounselors

Z65 — Problems related toother psychosocialcircumstances

Conviction, imprisonment, victim of crime orterrorism

SDOH diagnosis code reference Z55 problems related to education and literacy:

Z55.0 — Illiteracy and low-level literacy

Z55.1 — Schooling unavailable and unattainable

Z55.2 — Failed school examinations

Z55.3 — Underachievement in school

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Z55.4 — Educational maladjustment and discord with teachers and classmates

Z55.8 — Other problems related to education and literacy

Z55.9 — Problems related to education and literacy, unspecified

Problems related to employment and unemployment:

Z56.0 — Unemployment, unspecified

Z56.1 — Change of job

Z56.2 — Threat of job loss

Z56.3 — Stressful work schedule

Z56.4 — Discord with boss and workmates

Z56.5 — Uncongenial work

Z56.6 — Other physical and mental strain related to work

Z56.8 — Other problems related to employment:

Z56.81 — Sexual harassment on the job

Z56.82 — Military deployment status

Z56.89 — Other problems related to employment

Z56.9 — Unspecified problems related to employment

Occupational exposure to risk factors:

Z57.0 — Occupational exposure to noise

Z57.1 — Occupational exposure to radiation

Z57.2 — Occupational exposure to dust

Z57.3 — Occupational exposure to other air contaminants:

Z57.31 — Occupational exposure to environmental tobacco smoke

Z57.39 — Occupational exposure to other air contaminants

Z57.4 — Occupational exposure to toxic agents in agriculture

Z57.5 — Occupational exposure to toxic agents in other industries

Z57.6 — Occupational exposure to extreme temperature

Z57.7 — Occupational exposure to vibration

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Z57.8 — Occupational exposure to other risk factors

Z57.9 — Occupational exposure to unspecified risk factor

Problems related to housing and economic circumstances:

Z59.0 — Homelessness

Z59.1 — Inadequate housing

Z59.2 — Discord with neighbors, lodgers and landlord

Z59.3 — Problems related to living in residential institution

Z59.4 — Lack of adequate food and safe drinking water

Z59.5 — Extreme poverty

Z59.6 — Low income

Z59.7 — Insufficient social insurance and welfare support

Z59.8 — Other problems related to housing and economic circumstances

Z59.9 — Problem related to housing and economic circumstances, unspecific

Problems related to social environment:

Z60.0 — Problems of adjustment to life-cycle transitions

Z60.2 — Problems related to living alone

Z60.3 — Acculturation difficulty

Z60.4 — Social exclusion and rejection

Z60.5 — Target of (perceived) adverse discrimination and persecution

Z60.8 — Other problems related to social environment

Z60.9 — Problem related to social environment, unspecified

Problems related to upbringing:

Z62.0 — Inadequate parental supervision and control

Z62.1 — Parental overprotection

Z62.2 — Upbringing away from parents:

Z62.21 — Child in welfare custody

Z62.22 — Institutional upbringing

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Z62.29 — Other upbringing away from parents

Z62.3 — Hostility towards and scapegoating of child

Z62.6 — Inappropriate (excessive) parental pressure

Z62.8 — Other specified problems related to upbringing:

Z62.81 — Personal history of abuse in childhood:

Z62.810 — Personal history of physical and sexual abuse in childhood

Z62.811 — Personal history of psychological abuse in childhood

Z62.812 — Personal history of neglect in childhood

Z62.813 — Personal history of forced labor or sexual exploitation in childhood

Z62.819 — Personal history of unspecified abuse in childhood

Parent-child conflict:

Z62.820 — Parent-biological child conflict

Z62.821 — Parent-adopted child conflict

Z62.822 — Parent-foster child conflict

Other specified problems related to upbringing:

Z62.890 — Parent-child estrangement NEC

Z62.891 — Sibling rivalry

Z62.898 — Other specified problems related to upbringing

Z62.9 — Problem related to upbringing, unspecified

Other problems related to primary support group, including family circumstances:

Z63.0 — Problems in relationship with spouse or partner

Z63.1 — Problems in relationship with in-laws

Z63.3 — Absence of family member:

Z63.31 — Due to military deployment

Z63.32 — Other absence of family member

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Z63.4 — Disappearance and death of family member

Z63.5 — Disruption of family by separation and divorce

Z63.6 — Dependent relative needing care at home

Z63.7 — Other stressful life events affecting family and household:

Z63.71 — Stress on family due to return of family member from military deployment

Z63.72 — Alcoholism and drug addiction in family

Z63.79 — Other stressful life events affecting family and household

Z63.8 — Other specified problems related to primary support group

Z63.9 — Problem related to primary support group, unspecified

Problems related to certain psychosocial circumstances:

Z64.0 — Problems related to unwanted pregnancy

Z64.1 — Problems related to multiparity

Z64.4 — Discord with counselors

Problems related to other psychosocial circumstances:

Z65.0 — Conviction in civil and criminal proceedings without imprisonment

Z65.1 — Imprisonment and other incarceration

Z65.2 — Problems related to release from prison

Z65.3 — Problems related to other legal circumstances

Z65.4 — Victim of crime and terrorism

Z65.5 — Exposure to disaster, war and other hostilities

Z65.8 — Other specified problems related to psychosocial circumstances

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Z65.9 — Problem related to unspecified psychosocialcircumstances.

ResourcesWorld Health Organization, About social determinants of health,found online at:https://www.who.int/social_determinants/sdh_definition/en. ICD-10-CM Expert for Physicians, the complete official code set,Optum360, LLC. 2020. AVA-NU-0240-20

Article Attachments

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URL: https://providernews.anthem.com/virginia/article/coding-spotlight-an-anthem-healthkeepers-plus-provider-guide-to-code-social-determinants-of-health

Follow-up after Hospitalization for Mental IllnessPublished: Jun 1, 2020 - State & Federal / Medicaid

We understand providers are committed to providing our members enrolled in AnthemHealthKeepers Plus with quality care, including follow-up appointments after a behavioralhealth (BH) inpatient stay. Since regular monitoring, follow-up appointments and makingnecessary treatment recommendations or changes are all part of quality care, we would liketo provide an overview of the related HEDIS measure. The Follow-up after Hospitalization for Mental Illness (FUH) HEDIS measure evaluatesmembers 6 years and older who were hospitalized for treatment of selected mental illnessdiagnoses and who had a follow-up visit with a mental health practitioner. Two areas of importance for this HEDIS measure are:

The percentage of BH inpatient discharges for which the member received follow-upwithin seven days after discharge.

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The percentage of BH inpatient discharges for which the member received follow-upwithin 30 days after discharge.

On a regular basis, we continue to monitor if these two consecutive follow-up appointmentsare recommended and scheduled during the inpatient stay as part of discharge planning bythe eligible BH facilities (such as psychiatric hospitals, freestanding mental health facilitiesand acute care hospitals with psychiatric units), as well as by practicing BH providers. Please consider the following for improving member outcomes for this measure:

Earliest follow-up with a BH provider can help with continuing treatment after leavingthe hospital.

With greater emphasis on care coordination, PCPs can help facilitate the BH follow-upappointments.

Weekend discharges have shown to have very inconsistent follow-up appointmentsafter discharge. Start discharge planning as soon as possible during inpatient stay sothose who are discharged on weekends have already scheduled follow-up appointments.

In addition, facilitate discussion of other social determinants of health (such as housing,food, living in a rural area, transportation, job schedules, family and social support, childcare, etc.) which can influence follow-up opportunities. Please address these needs andissues during the behavior health inpatient stay.

Social workers at the facilities can contact Member Services for HealthKeepers, Inc. tolearn if additional sources of assistance are available through case management or otherreferrals.

June 2020 Anthem Provider News - Virginia Page 34 of 50

Telehealth services may be considered as part of follow-up for this HEDIS measure ifpermitted in your state for BH follow-up and must be based on your clinical evaluationsince this may not be the best choice of follow up for everyone.

However, it is also extremely important to note that telehealth services are subject tostate and federal policies, coding and other requirements.Please follow required guidelines and policies related to telehealth services specific tothis measure.

Our goal is continuity of care and treatment within seven days of inpatient BHdischarge, followed by another visit within 30 days.

Please note this bulletin is for informational purposes only, as a resource for BH HEDISfollow up guidelines. If you have any questions about this communication, call Provider Services at1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

AVA-NU-0242-20

URL: https://providernews.anthem.com/virginia/article/follow-up-after-hospitalization-for-mental-illness-6

Complex Case Management programPublished: Jun 1, 2020 - State & Federal / Medicaid

Managing illness can be a daunting task for Medallion and FAMIS members enrolled inAnthem HealthKeepers Plus. It is not always easy to understand test results, to know how toobtain essential resources for treatment, or to know whom to contact with questions andconcerns.

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HealthKeepers, Inc. is available to offer assistance in these difficult moments with ourComplex Case Management program. Our care managers are part of an interdisciplinaryteam of clinicians and other resource professionals working to support members, families,PCPs and caregivers. The Complex Case Management process uses the experience andexpertise of the Case Coordination team to educate and empower our members byincreasing self-management skills. The Complex Case Management process can helpmembers understand their illnesses and learn about care choices to ensure they haveaccess to quality, efficient health care. Members or caregivers can refer themselves or family members by calling the MemberServices number located on the back of their ID card. They will be transferred to a teammember based on the immediate need. In addition, physicians can refer their patients bycontacting us telephonically or through electronic means. We can help with transitionsacross levels of care so that patients and caregivers are better prepared and informed abouthealth care decisions and goals. If you have questions or would like additional information, you can contact us by phone at 1-800-901-0020. Case Management business hours are Monday through Friday, 8 a.m. to 6p.m. ET. AVA-NU-0243-20

URL: https://providernews.anthem.com/virginia/article/complex-case-management-program-11

Important information about utilization managementPublished: Jun 1, 2020 - State & Federal / Medicaid

Utilization management (UM) decisions for members enrolled in Anthem HealthKeepersPlus are based on the appropriateness of care and service needed, as well as the member’scoverage according to their health plan. We do not reward providers or other individuals forissuing 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 denybenefits. In addition, we do not offer financial incentives for UM decision makers toencourage decisions resulting in underutilization. Our medical policies are available on ourprovider website at https://mediproviders.anthem.com/va/Pages/medical.aspx.

June 2020 Anthem Provider News - Virginia Page 36 of 50

You can request a free copy of our UM criteria from our Medical Management department.To access UM criteria online, go to:

https://mediproviders.anthem.com/va/Pages/medical.aspx

Providers can discuss a UM denial decision with a physician reviewer by calling us toll freeat the numbers listed below. We are staffed with clinical professionals who coordinate our members’ care. Staff areavailable during business hours, Monday through Friday, 8:30 a.m. to 5 p.m. ET to acceptprecertification requests. Secured voicemail is available during off-business hours; a clinicalprofessional will return your call within the next business day. Our staff will identifythemselves by name, title and organization name when initiating or returning calls regardingUM issues. You can submit precertification requests by:

Calling Provider Services at 1-800-901-0020 or calling Anthem CCC Plus ProviderServices at 1-855-323-4687.

Faxing to 1-800-964-3627.

Visiting https://www.availity.com.*

* Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

AVA-NU-0244-20

URL: https://providernews.anthem.com/virginia/article/important-information-about-utilization-management-31

June 2020 Anthem Provider News - Virginia Page 37 of 50

Anthem HealthKeepers Plus Members’ Rights andResponsibilities StatementPublished: Jun 1, 2020 - State & Federal / Medicaid

The delivery of reliable health care requires cooperation between Anthem HealthKeepersPlus patients, their providers and their health care benefit plans. One of the first steps is forpatients and providers to understand their rights and responsibilities. Therefore, in line withour commitment to involve the health plan, participating practitioners and members in oursystem, HealthKeepers, Inc. has adopted a Members’ Rights and ResponsibilitiesStatement, which is located in the provider manual. If you need a physical copy of the statement, call us at 1-800-901-0020 or Anthem CCC PlusProvider Services at 1-855-323-4687. AVA-NU-0245-20

URL: https://providernews.anthem.com/virginia/article/anthem-healthkeepers-plus-members-rights-and-responsibilities-statement-1

Medicaid patients can make the switch to the AnthemHealthKeepers Plus planPublished: Jun 1, 2020 - State & Federal / Medicaid

HealthKeepers, Inc. is the brand Virginians have trusted for more than 20 years. Open enrollment for Central Virginia is April 19 to June 31, 2020. Your Medicaid patientsreceive all the same Medallion or FAMIS benefits, like doctor visits, prescriptions and our24/7 NurseLine at no cost. Anthem HealthKeepers Plus members also receive:

No-cost GED testing.

Rides to grocery stores and farmers’ markets.

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Weight Watchers * membership.

Boys & Girls Club of America * memberships (where available).

Now including dental benefits for adults ages 21 to 64 — one cleaning, one exam and onebitewing X-ray per year. Assist your patients in switching enrollment to the state’s largest Medicaid plan now For more information, your patients can visit https://coverva.org, download the VirginiaMedallion mobile app or call the Managed Care Helpline at 1-800-643-2273 (TTY 711) toswitch to the Anthem HealthKeepers Plus plan. * Weight Watchers® is an independent company providing weight management on behalf of HealthKeepers, Inc. Boys & Girls Club ofAmerica® is an independent company providing after-school programs for young people on behalf of HealthKeepers, Inc.

AVA-NU-0249-20

URL: https://providernews.anthem.com/virginia/article/medicaid-patients-can-make-the-switch-at-no-additional-cost-to-the-anthem-healthkeepers-plus-plan

Updates to AIM Sleep Disorder Management ClinicalAppropriateness GuidelinePublished: Jun 1, 2020 - State & Federal / Medicaid

Effective for dates of service on and after August 16, 2020, the following updates forAnthem HealthKeepers Plus providers will apply to the AIM Specialty Health * (AIM) SleepDisorder Management Clinical Appropriateness Guideline. Sleep Disorder Management Clinical Appropriateness Guideline updates by section:

®

®

®

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Bi-Level Positive Airway Pressure (BPAP) Devices:

Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and alignmentwith Medicare requirements for use of BPAPMultiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing:

Style change for clarity

Code changes: none As a reminder, ordering and servicing providers may submit prior authorization (PA) requeststo AIM by:

Accessing AIM’s ProviderPortal directly at providerportal.com. Online access isavailable 24/7 to process orders in real time, and is the fastest and most convenient wayto request PA.

Accessing AIM via the Availity Portal.*

Calling the AIM Contact Center at 1-800-714-0040 from 7 a.m. to 7 p.m. ET.

What if I need assistance? If you have questions related to AIM guidelines, email AIM ataim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copyof the current and upcoming guidelines. * AIM Specialty Health is an independent company providing some utilization review services on behalf of HealthKeepers, Inc. Availity,LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

AVA-NU-0251-20

URL: https://providernews.anthem.com/virginia/article/updates-to-aim-sleep-disorder-management-clinical-appropriateness-guideline-20

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June 2020 Anthem Provider News - Virginia Page 40 of 50

Keep up with Medicaid newsPublished: Jun 1, 2020 - State & Federal / Medicaid

Please continue to check our website https://mediproviders.anthem.com for the latestMedicaid information for members enrolled in HealthKeepers, Inc.’s Anthem HealthKeepersPlus and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) benefit plans. Hereis the topic we’re addressing in this edition: MCG care guidelines – 24 edition, Virginia

URL: https://providernews.anthem.com/virginia/article/keep-up-with-medicaid-news-31

Modifier use remindersPublished: Jun 1, 2020 - State & Federal / Medicare

Billing for patient treatment can be complex, particularly when determining whether modifiersare required for proper payment. Anthem Blue Cross and Blue Shield (Anthem)reimbursement policies and correct coding guidelines explain the appropriate use of codingmodifiers. We would like to highlight the appropriate use of some commonly used modifiers. Things to remember

Review the CPT Surgical Package Definition found in the current year’s CPTProfessional Edition. Use modifiers such as 25 and 59 only when the services are notincluded in the surgical package.

Review the current CPT Professional Edition Appendix A — Modifiers for theappropriate use of modifiers 25, 57 and 59.

When an evaluation and management (E&M) code is reported on the same date ofservice as a procedure, the use of the modifier 25 should be limited to situations where

th

®

June 2020 Anthem Provider News - Virginia Page 41 of 50

the E&M service is “above and beyond” or “separate and significant” from any proceduresperformed the same day.

When appropriate, assign anatomical modifiers (Level II HCPCS modifiers) to identifydifferent areas of the body that were treated. Proper application of the anatomicalmodifiers helps ensure the highest level of specificity on the claim and show that differentanatomic sites received treatment.

Use modifier 59 to indicate that a procedure or service was distinct or independent ofother non-E&M services performed on the same date of service. The modifier 59represents services not normally performed together, but which may be reported togetherunder the circumstances.

If you feel that you have received a denial after appropriately applying a modifier undercorrect coding guidelines, please follow the normal claims dispute process and includemedical records that support the use of the modifier(s) when submitting claims forconsideration. Anthem will publish additional articles on correct coding in provider communications. ABSCRNU-0127-20 509409MUPENMUB

URL: https://providernews.anthem.com/virginia/article/modifier-use-reminders-16

Anthem working with Optum to collect medical records for riskadjustmentPublished: Jun 1, 2020 - State & Federal / Medicare

Risk adjustment is the process by which the Centers for Medicare & Medicaid Services(CMS) reimburses Medicare Advantage plans, based on the health status of their members.Risk adjustment was implemented to pay Medicare Advantage plans more accurately for the

June 2020 Anthem Provider News - Virginia Page 42 of 50

predicted health cost expenditures of members by adjusting payments based ondemographics (age and gender) as well as health status. In 2020, Anthem Blue Cross and Blue Shield (Anthem) will work with Optum,* who isworking with Ciox Health,* to request medical records with dates of service for the targetyear 2019 through present day. Jaime Marcotte, Medicare Retrospective Risk Program Lead, is managing this project. If youhave any questions regarding this program, please contact Jaime atjaime.marcotte@anthem.com or 1-843-666-1970. Additional information, including an FAQ, will be available on the provider website atImportant Medicare Advantage Updates. * Optum and Ciox Health are independent companies providing medical record review services on behalf of Anthem Blue Cross andBlue Shield.

ABSCRNU-0140-20 509218MUPENMUB

URL: https://providernews.anthem.com/virginia/article/anthem-working-with-optum-to-collect-medical-records-for-risk-adjustment

2020 Medicare risk adjustment provider trainingPublished: Jun 1, 2020 - State & Federal / Medicare

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross andBlue Shield offers two provider training programs regarding Medicare risk adjustment anddocumentation guidelines. Information for each training is outlined below. Medicare Risk Adjustment and Documentation Guidance (General) When: Offered the first Wednesday of each month from 1 to 2 p.m. ET Learning objective: This onboarding training will provide an overview of Medicare RiskAdjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category(HCC) Model, with guidance on medical record documentation and coding.

June 2020 Anthem Provider News - Virginia Page 43 of 50

Credits: This live activity, Medicare Risk Adjustment and Documentation Guidance, fromJanuary 8, 2020, to December 2, 2020, has been reviewed and is acceptable for up to oneprescribed credit(s) by the American Academy of Family Physicians. Physicians shouldclaim only the credit commensurate with the extent of their participation in the activity. For those interested in joining us to learn how providers play a critical role in facilitating therisk adjustment process, register for one of the monthly training sessions athttps://bit.ly/2z4A81e.

*Note: Dates may be modified due to holiday scheduling. Medicare Risk Adjustment, Documentation and Coding Guidance (Condition specific) Series: Offered on the third Wednesday of every other month at 12 to 1 p.m. ET Learning objective: This is a collaborative learning event with Enhanced Personal HealthCare (EPHC) to provide in-depth disease information pertaining to specific conditions,including an overview of their corresponding hierarchical condition categories (HCC), withguidance on documentation and coding. Credits: This live series activity, Medicare Risk Adjustment Documentation and CodingGuidance, from January 15, 2020, to November 18, 2020, has been reviewed and isacceptable for credit by the American Academy of Family Physicians. Physicians shouldclaim only the credit commensurate with the extent of their participation in the activity. For those interested in joining us for this six-part training series, please see the list of topicsand scheduled training dates below:

Red Flag HCCs, part one: Training will cover HCCs most commonly reported in erroras identified by CMS (chronic kidney disease stage 5, ischemic or unspecified stroke,cerebral hemorrhage, aspiration and specified bacterial pneumonias, unstable angina andother acute ischemic heart disease, end-stage liver disease) {Recording will play uponregistration.}

https://bit.ly/3ae9znc

June 2020 Anthem Provider News - Virginia Page 44 of 50

Red Flag HCCs, part two: Training will cover HCCs most commonly reported in erroras identified by CMS (atherosclerosis of the extremities with ulceration or gangrene,myasthenia gravis/myoneural disorders and Guillain-Barre syndrome, drug/alcoholpsychosis, lung and other severe cancers, diabetes with ophthalmologic or unspecifiedmanifestation) {Recording will play upon registration.}

https://bit.ly/3abKg52

Neoplasms (recording link will be available later 2020.)

Acute, Chronic and Status Conditions (July 15, 2020)

https://bit.ly/2ygZfNR

Diabetes Mellitus and Other Metabolic Disorders (September 16, 2020)

https://bit.ly/2XQ9hjZ

TBD - This Medicare Risk Adjustment webinar will cover the critical topics and updatesthat surface during the year (November 18, 2020)

https://bit.ly/2xxjhUj

ABSCRNU-0141-20 509514MUPENMUB

URL: https://providernews.anthem.com/virginia/article/2020-medicare-risk-adjustment-provider-training

June 2020 Anthem Provider News - Virginia Page 45 of 50

Diabetes HbA1c < 8 HEDIS guidancePublished: Jun 1, 2020 - State & Federal / Medicare

Diabetes is a complex chronic illness requiring ongoing patient monitoring. The NationalCommittee for Quality Assurance (NCQA) includes diabetes in its HEDIS measures onwhich providers are rating annually. Since diabetes HbA1c testing is a key measure to assess for future medical conditionsrelated to complications of undiagnosed diabetes, NCQA requires that health plans reviewclaims for diabetes in patient health records. The findings contribute to health plan StarRatings for commercial and Medicare plans and the Quality Rating System measurement formarketplace plans. A systematic sample of patient records is pulled annually as part of theHEDIS medical record review to assess for documentation. Which HEDIS measures are diabetes measures? The diabetes measures focus on members 18 to 75 years of age with diabetes (type 1 andtype 2) who had each of the following assessments:

Hemoglobin A1c (HbA1c) testing

HbA1c poor control (> 9%)

HbA1c control (< 8%)

Dilated retinal exam

Medical attention for nephropathy

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June 2020 Anthem Provider News - Virginia Page 46 of 50

The American College of Physicians’ guidelines for people with type 2 diabetes recommendthe desired A1c blood sugar control levels remain between 7% to 8%. In order to meet the HEDIS measure HbA1c control < 8, providers must document the datethe test was performed and the corresponding result. For this reason, report one of the fourCategory II codes and use the date of service as the date of the test, not the date of thereporting of the Category II code. To report most recent hemoglobin A1c level greater than or equal to 8% and less than 9%,use 3052F. To report most recent A1c level less than or equal to 9%, use codes 3044F,3051F and 3052F:

1. If the most recent hemoglobin A1c (HbA1c) level is less than 7%, use 3044F.

1. If the most recent hemoglobin A1c (HbA1c) level is greater than or equal to 7% and lessthan 8%, use 3051F.

1. If the most recent hemoglobin A1c (HbA1c) level is greater than or equal to 8% and lessthan or equal to 9%, use 3052F.

Continued management and diverse pathways to care are essential in controlling bloodglucose and reducing the risk of complications. While it is extremely beneficial for the patientto have continuous management, it also benefits our providers. As HEDIS rates increase,there is potential for the provider to earn maximum or additional revenue through Pay forQuality, Value-Based Services and other pay-for-performance models.

Racial and ethnic disparities with diabetes It is also important for providers to be aware of critical diabetes disparities that exist fordiverse populations.

Compared to non-Hispanic whites:

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June 2020 Anthem Provider News - Virginia Page 47 of 50

African Americans, Hispanics, and American Indian/Alaska Natives have highermortality rates from diabetes.

African Americans and Hispanics have higher rates of complications from uncontrolleddiabetes, including lower limb amputation and end-stage renal disease.

More than half of Asian Americans and nearly half of Hispanic Americans with diabetesare undiagnosed.

Asian Americans are at risk for type 2 diabetes at a lower body mass index (BMI);therefore, diabetes screening at a BMI of 23 is recommended.

Sources include:

Diabetes prevalence:

2015 State Diagnosed Diabetes Prevalence, https://www.cdc.gov/diabetes/data.

2012 State Undiagnosed Diabetes Prevalence, Dall et al., “The Economic Burden ofElevated Blood Glucose Levels in 2012”, Diabetes Care, December 2014, vol. 37.

Diabetes incidence:

2015 State Diabetes Incidence Rates, https://www.cdc.gov/diabetes/data.

Cost:

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American Diabetes Association, “Economic Costs of Diabetes in the U.S. in 2017”,Diabetes Care, May 2018.

Research expenditures:

2017 National Institute of Diabetes and Digestive and Kidney Diseases funding,https://projectreporter.nih.gov.

2017 CDC diabetes funding, https://www.cdc.gov/fundingprofiles.

https://www.medicalnewstoday.com/articles/321123#An-A1C-of-7-to-8-percent-is-

recommended https://www.ama-assn.org/system/files/2020-01/cpt-cat2-codes-alpha-listing-clinical-

topics.pdf https://www.cms.gov/medicare/quality-initiatives-patient-assessment-

instruments/value-based-programs/value-based-programs.html Office of Minority Health. Minority Population Profiles:

https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlID=26 U.S. Department of Health and Human Services, National Institutes of Health. (2015,

September 8), More than half of Asian Americans with diabetes are undiagnosed. Retrievedfrom https://www.nih.gov/news-events/news-releases/more-half-asian-americans-diabetes-are-undiagnosed. ADA; NCAPIP; AANHPI DC; Joslin Diabetes Center Asian American Diabetes Initiative.

(2015, September). Screen at 23. Retrieved from http://screenat23.org/wp-content/uploads/2015/10/Screenat23package-1.pdf. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

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URL: https://providernews.anthem.com/virginia/article/diabetes-hba1c-8-hedis-guidance-5

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June 2020 Anthem Provider News - Virginia Page 49 of 50

Updates to AIM Sleep Disorder Management ClinicalAppropriateness GuidelinePublished: Jun 1, 2020 - State & Federal / Medicare

Effective for dates of service on and after August 16, 2020, the following updates will applyto the AIM Specialty Health * (AIM) Sleep Disorder Management Clinical AppropriatenessGuideline. Sleep Disorder Management Clinical Appropriateness Guideline updates by section:

Bi-Level Positive Airway Pressure (BPAP) Devices:

Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and alignmentwith Medicare requirements for use of BPAP

Multiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing:

Style change for clarity

Code changes: none

As a reminder, ordering and servicing providers may submit prior authorization (PA) requeststo AIM by:

Accessing AIM’s ProviderPortal directly at com. Online access is available 24/7 toprocess orders in real time, and is the fastest and most convenient way to request PA.

Accessing AIM via the Availity Portal.*

Calling the AIM Contact Center at 1-800-714-0040 from 7 a.m. to 7 p.m. ET.

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June 2020 Anthem Provider News - Virginia Page 50 of 50

What if I need assistance? If you have questions related to guidelines, email AIM ataim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copyof the current and upcoming guidelines. * AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross andBlue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross andBlue Shield.

ABSCRNU-0146-20 509517MUPENMU

URL: https://providernews.anthem.com/virginia/article/updates-to-aim-sleep-disorder-management-clinical-appropriateness-guideline-21

Keep up with Medicare newsPublished: Jun 1, 2020 - State & Federal / Medicare

Please continue to check Important Medicare Advantage Updates for the latest MedicareAdvantage information, including:

Acquisition of Beacon Health OptionsBSCRNU-0134-20 509210MUPENMUB MCG care guidelines — 24th edition ABSCRNU-0136-20 508666MUPENMUB

URL: https://providernews.anthem.com/virginia/article/keep-up-with-medicare-news-139