Provider Seminars Spring 2015 Nevada. Presented by: Jackie Ferguson Network Education and Communication

Transcription

1 Provider Seminars Spring 2015 Nevada Presented by: Jackie Ferguson Network Education and Communication

2 Anthem Blue Cross and Blue Shield (Anthem): Agenda Network News: Anthem Choice PPO (Pathway Tiered Network) Boyd Gaming refresh Teamsters Security Fund for Southern Nevada Hotel & Casino Workers Networks at a Glance Who Should I Contact? Commonly Requested Forms ICD-10 updates Availity Web Portal E&B redesign HRA/Remaining Deductible Secure messaging Provider Connectivity ProviderAccess Remittance Advice updates AIM online authorizations enhancements ProviderAccess Change Forms revamped Anthem Services Registration Wrap Up 2

3 Network News

4 Network News Anthem Choice PPO (Pathway Tiered Network) New effective April 1, 2015 Boyd Gaming Effective January 1, 2015 Teamsters Security Fund for Southern Nevada Hotel & Casino Workers Effective June 1, 2015 Networks at a Glance 4

5 Anthem Choice PPO (Pathway Tiered Network) New Effective April 1, 2015

6 Anthem Choice PPO (Pathway Tiered Network) NEW! Starting April 1, 2015, we are now offering our new Anthem Choice PPO which is a Pathway Tiered PPO product Offers different copay levels for members helping provide options for greater health care savings. Currently this product will only be available for large group clients We have a group enrolled in this product effective in April 1, Note: The tiered network options tied to Anthem Choice PPO (Pathway Tiered Network) provide statewide coverage, but may not be sold in all areas. 6

7 Anthem Choice PPO (Pathway Tiered Network) A three tier PPO option: Tier 1 Pathway PPO: Lower copays and highest benefit level. Network includes: Hospitals = 32, excludes St. Rose Dominican Hospitals (Siena, San Martin, and DeLima) PCPs = more than 654 Specialists = more than 2,946 Tier 2 PPO: All other PPO providers not already considered Pathway PPO, at a reduced benefit level. Network includes: Hospitals = 3 in addition to Tier 1, includes St. Rose Dominican Hospitals (Siena, San Martin, and DeLima) PCPs = more than 739 in addition to Tier 1 Specialists = more than 2,120 in addition to Tier 1 Tier 3 out of network: All other providers not participating in Pathway PPO or our Standard PPO network, at a significantly reduced benefit level. 7

8 Identifying Members accessing: Anthem Choice PPO (Pathway Tiered Network) Network Name Product type Agreement needed for participation Alpha Prefix Anthem Choice PPO (Pathway tiered Network) PPO Tier 1 = Pathway PPO Tier 2 = all other PPO providers not already considered Pathway PPO (our Standard PPO) YFX The Network Name Anthem Choice PPO (Pathway Tiered Network) may be listed slightly different on the Member ID cards as either: Anthem Choice PPO 1 Pathway Tiered Network, or Anthem Choice PPO 2 Pathway Tiered Network This depends on the Health Benefit Plan option selected by the employer group. Currently there are 2 benefit plan options offered, but this may expand in the future. Important Note: Regardless of the benefit plan option, the network utilized will be the same. 8

9 Anthem Choice PPO (Pathway Tiered Network) sample ID cards Anthem Choice PPO 1 Pathway tiered Network sample YFX123X

10 Anthem Choice PPO (Pathway Tiered Network) sample ID cards Anthem Choice PPO 2 Pathway tiered Network sample YFX123X

11 Boyd Gaming Effective January 1, 2015

12 Network News: Anthem new payer for Boyd Gaming Anthem is pleased to announce that Boyd Gaming is a new client effective January 1, Boyd Gaming is accessing Anthem s PPO network. Exception: In Las Vegas, Boyd Gaming is utilizing the Coalition s hospital network rather than Anthem s PPO Network. - Note: St. Rose Hospitals are not in the Coalition s hospital network. Therefore, they are considered out-of-network for Boyd Gaming at this time. Boyd Gaming is offering 3 different PPO plan options. Choice Plan PPO Plan Value Plan This new group has a unique alpha prefix of BYM for each of the PPO plan options. Important Note: We included this information in our Fall 2014 seminars. These members may have a Health Reimbursement Account (HRA). Please ensure you are accessing real-time HRA account information online through Availity. 12

13 Network News: Anthem new payer for Boyd Gaming Sample copy of PPO health plan ID card CHOICE PLAN Note: the ID card above is just a sample, and does not include actual member information such as copays, but is included when the ID cards are generated and sent to members prior to the effective date. 13

14 Network News: Anthem new payer for Boyd Gaming Sample copy of PPO health plan ID card PPO PLAN Note: the ID card above is just a sample, and does not include actual member information such as copays, but is included when the ID cards are generated and sent to members prior to the effective date. 14

15 Network News: Anthem new payer for Boyd Gaming Sample copy of PPO health plan ID card VALUE PLAN Note: the ID card above is just a sample, and does not include actual member information such as copays, but is included when the ID cards are generated and sent to members prior to the effective date. 15

16 Network News: Anthem new payer for Boyd Gaming Operational procedures for Boyd Gaming are the same as any other Local Plan members. Claims should be filed directly to your Local Blue Cross and Blue Shield office, either electronically or mailed to: Anthem Blue Cross and Blue Shield P.O. Box 5747 Denver, CO Online self-service options are available to providers which provide patient specific information, such as eligibility, benefits, claim status, line-level detail, and payment information. These options include: Availity: a multi-payer secure provider portal available at Electronic Data Interchange (EDI): Interactive Voice Response (IVR)/Provider Customer Service: is available at Authorizations/Pre-certifications are available at: (separate unit handling for Boyd Gaming) NOTE: While authorizations may be required, referrals to a specialist are not required for HMO members. 16

17 Network News: Anthem new payer for Boyd Gaming Accessing HRA information via Availity s Web Portal Access HRA information when submitting an Eligibility and Benefits Inquiry from Availity. Select Eligibility and Benefits (E&B), then Eligibility and Benefits Inquiry from the left side navigation menu Enter all required fields indicated by * In Benefit/Service Type field, select Health Benefit Plan Coverage. 17

18 Network News: Anthem new payer for Boyd Gaming Accessing HRA information via Availity s Web Portal Example when HRA funds are remaining From the E&B Results Page, click the Remaining Deductible link. The window shown will display. If the member has an HRA, it will show how much is remaining in the member s account which will be paid by the Health Plan, as well as, the balance that is member s responsibility to meet the deductible. 18

19 Network News: Anthem new payer for Boyd Gaming Accessing HRA information via Availity s Web Portal Example when HRA funds are exhausted From the E&B Results Page, click the Remaining Deductible link. The window shown will display. If the member has an HRA, it will show how much is remaining in the member s account which will be paid by the Health Plan, as well as, the balance that is member s responsibility to meet the deductible. 19

20 Teamsters Security Fund for Southern Nevada Hotel & Casino Workers Effective June 1, 2015

21 Network News: Anthem new payer for Teamsters Hotel & Casino Workers Anthem is pleased to announce that Teamsters Security Fund for Southern Nevada Hotel & Casino Workers will be a new client effective June 1, Anthem is working diligently with Teamsters Hotel & Casino Workers to ensure a flawless transition. An important part of our implementation strategy is to communicate to providers so you can be aware of this new client. Teamsters Hotel & Casino Workers will be accessing Anthem s PPO network. Exception: In Las Vegas, Teamsters Hotel & Casino Workers will be utilizing the Health Services Coalition, Diversified Dental, Harmony Health Care and Radiology Network s rather than Anthem s PPO Network. Important Note: All St. Rose facilities including hospital and surgical centers are not in the Health Services Coalition s hospital network. In addition, Teamsters Hotel & Casino Workers has excluded these facilities from their network. 21

22 Network News: Anthem new payer for Teamsters Hotel & Casino Workers While Teamsters Hotel & Casino Workers it accessing Anthem s PPO network, it is utilizing its own unique benefit plan. As always, we encourage you to verify eligibility and benefits for specific details for these (or any) members, prior to rendering services. Teamsters Hotel & Casino Workers will be offering a PPO plan option for its approximately 3,000 members comprised of employees from Teamsters Local 986-Las Vegas and administration from the Hotel & Casino Workers Trust Fund employed by Zenith American Solutions. Teamsters employees will be identified by group number Zenith employees will be identified by group number Note: ID Cards will look the same for all members with the exception of the group numbers. These new members will have a unique alpha prefix of TDG for all employees and covered dependents. 22

23 Network News: Anthem new payer for Teamsters Hotel & Casino Workers Sample copy of health plan ID card TDG123A45678 Note: the ID card above is just a sample, and does not include actual member information such as copays, but will be included when the ID cards are generated and sent to members prior to the effective date. 23

24 Network News: Anthem new payer for Teamsters Hotel & Casino Workers This group will also have a unique ID card sleeve as indicated by the sample below: Note: The Anthem ID card will slide into the sleeve for convenience and should always remain together. 24

25 Network News: Anthem new payer for Teamsters Hotel & Casino Workers Operational procedures for Teamsters Hotel & Casino Workers are the same as any other Local Plan members except where indicated below: Claims should be filed directly to your Local Blue Cross and Blue Shield office, either electronically using Payor ID 00265, or mailed to Anthem Blue Cross and Blue Shield, P.O. Box 5747, Denver, CO Exception: Send all carve-out network claims for Health Services Coalition, Diversified Dental, Harmony Health Care and Radiology Network to: Zenith American Solutions, P.O. Box 26779, Las Vegas, NV as indicated on the member ID card sleeve. Exception: Submit prescription claims online to: EnvisionRXOptionsPharmacy, Help Desk , as indicated on the member ID card sleeve. 25

26 Network News: Anthem new payer for Teamsters Hotel & Casino Workers Operational procedures continued: Exception: Separate operational phone unit handling Teamsters Hotel & Casino Workers: Interactive Voice Response (IVR)/Provider Customer Service (different than Local members) Authorizations/Pre-certifications (different than Local members) Online self-service options are available to providers, giving you access to the same information you receive when calling customer service, and provides patient specific information, such as eligibility, benefits, claim status, line-level detail, and payment information. These options include: Availity: a multi-payer secure provider portal available at Electronic Data Interchange (EDI): Exception: Pharmacy claims can be viewed at as indicated on the ID card sleeve. 26

27 FAQ about HMO plans which require PCP selection

28 FAQ about HMO plans which require PCP selection Can a member see a PCP within the member s specific HMO network (e.g. HMO Nevada, Pathway HMO, or Pathway X HMO) if a different PCP is listed on the Member s ID card? Yes, because none of our HMO networks require a referral, they are all considered open access. Therefore, a member may see a different PCP other than the one listed on their Member ID card, as long as the other PCP is in the same network. For Example: If the member has a product aligned with our Pathway HMO network and they would like to see a PCP other than the one indicated on their ID card, he/she must see another PCP within the Pathway HMO network. 28

29 Networks at a Glance

30 Network News: Networks at a Glance Evolution of our Networks See Handout in your packet 30

31 Network News: Networks at a Glance Provider customizable version As our marketplace has gotten more complex, we ve made a customizable version of this document to make doing business with us easier, and help ensure Provider s staff can easily identify the networks for which they participate. To request a copy: Please our NV Provider Relations Team at nvproviderrelations@anthem.com with your Tax ID number.

32 Who should I contact? Escalation Contact List

33 Who should I contact? Customer Service Credentialing ERA/EFT Provider Relations 33

34 Escalation Contact List: Customer Service 1. Access Anthem s self-service tools For Eligibility/Benefits, Claims Status inquiries, etc. access via: Availity at EDI transactions Interactive Voice Response (automated phone system) 2. Contact Customer Service Reminder: You can also ask a question about a claim through Secure Messaging (via the Claims Status Detail page on Availity) 3. Ask to speak to a Customer Service Supervisor If our self-service tools and Provider Customer Service representatives are unable to provide you with the support you need, ask to speak with a Provider Customer Service supervisor and your call will be escalated. If a supervisor is unable to assist you immediately, you will receive a call back within 2 business days. IMPORTANT NOTE: An issue cannot be escalated without a reference number and asking to speak to a supervisor from Provider Customer Service 34

35 Escalation Contact List: Credentialing To check credentialing status of a new provider Please have the following information ready to include with your inquiry: Your name Provider s name CAQH ID number Reason for inquiry Contact information: Credentialing@wellpoint.com Phone:

36 Escalation Contact List: EFT/ERA Electronic Remittance Advice (ERA), Electronic Funds Transfer (EFT) Registration and Contact Info Type of Transaction How to Register, Update, or Cancel For registration related questions, contact: EFT only Use EnrollHub EnrollHub Help Desk at EFT and ERA (both) ERA only Use the EnrollHub Use the EDI Website at EnrollHub Help Desk at e-solutions at To resolve issues after registration, contact: Local Provider Customer Service at NOTE Providers should allow 4-6 weeks from successful EFT registration before contacting Provider Customer Service. For EFT questions, contact Local Provider Customer Service at NOTE Providers should allow 4-6 weeks from successful EFT registration before contacting Provider Customer Service. For ERA questions, contact e-solutions at or NOTE Providers should allow 4-6 weeks from successful ERA registration before contacting e-solutions. e-solutions at or NOTE Providers should allow 4-6 weeks from successful ERA registration before contacting e-solutions. EnrollHub url: 36

37 ERA (only) Registration form Go to Select Nevada and enter Select the Register tab Then click ERA (only) Registration Form 37

38 ERA (only) Registration form Submit as indicated on the top of the form Important Note: Requests to stop Paper Remits must be requested separately at this time. send to In the include that you would like to disable your paper remittance advices and include the Tax ID number. 38

39 Escalation Contact List: Provider Relations Provider Relations: Provider education, such as: How to utilize online tools (e.g. Availity, ProviderAccess, anthem.com, etc.) How to access our forms (e.g. adjustments, appeals, etc.) Questions about policies (e.g. medical, reimbursement, etc.) Networks at a Glance need to know networks for which you participate Demographic updates, adding/terming providers Assistance utilizing Provider Maintenance Form f or Tax ID changes, address changes, etc. Service issues not resolved after contacting Customer Service Must have a reference number and have asked to speak to a supervisor first to assist in escalating an issue Contact information: nvproviderrelations@anthem.com (shared phone) or (fax) 39

40 Commonly Requested Forms

41 Commonly Requested Forms Reminder: we have online forms for the following: Provider Maintenance Form Replaces the Provider Change Form no longer accepting New Provider Application Form Replaces Provider Data Sheet no longer accepting - Does not apply to Behavioral Health CAQH ProView now available! Replaces CAQH ID Number Request form Reminder: Please remember to use the Provider Maintenance Form when a provider is leaving your practice. Often times we receive a New Provider Application when a provider is joining a new group or going solo, but if that same provider has left a group, we do not always receive the term from the previous group. 41

42 Provider Maintenance Form How to access the form online: Go to anthem.com Select the Provider link in the top center of page Select Nevada from drop down list and enter From the Provider Home tab, select the link titled Download Commonly Requested Forms Then select Provider Maintenance Form (formerly known as Provider Change Form) 42

43 New Provider Application Form How to access the form online: Go to anthem.com Select the Provider link in the top center of page Select Nevada from drop down list and enter From the new Join Our Networks tab, select the link titled Medical Professional Providers and Ancillary Providers Then select New Provider Application Form Reminder: To check credentialing status of a new provider Credentialing@wellpoint.com, or call

44 CAQH ID Number Request CAQH numbers can be requested now through CAQH as of March 1, 2015: Please see instructions and link below of how to request your CAQH number. Website URL: Click Register Now Once you have obtained a CAQH ID and completed your application, you will need to communicate with Anthem so the provider can be added to our roster. 44

45 Additional Information Requested form Welcome feedback!

46 Additional Information Requested Last fall we introduced a new form called Additional Information Requested form, and we d love to hear your feedback if any of you have utilized it. When more information is needed to process a claim, providers will usually see a remark code indicating Additional Information Requested. Often times we end up with a situation of solicited vs. unsolicited records and/or documentation. We are trying to improve this process and have developed a new form to hopefully assist. 46

47 Additional Information Requested New Form! Process Improvements Created a new form called Additional Information Requested form Posted online in a Word document form, so you can type your information New form requires you to check off what method you have completed to obtain the additional information needed to process your claim: Secure Messaging Customer Service Note: Available for all lines of business (including Local, BlueCard, HIM/ACA), except FEP at this time. 47

48 Additional Information Requested New Form! Access form online: Go to anthem.com Select the Provider link (top of the page) Select Nevada from the drop down list, and click Enter From the Provider Home page, look for the link titled Download Commonly Requested forms Select the link titled Additional Information Requested form Mailing instructions: For Local Plans, Health Insurance Marketplace/ACA Plans, and BlueCard Plans, mail to Anthem Blue Cross and Blue Shield, P.O. Box 5747, Denver, CO, Note: not available for Federal Employee Program (FEP) Plans at this time. 48

49 Medical Records Submission Guidelines In the scenarios listed within this document, Anthem will always request medical records. Providers can submit the appropriate information needed along with the original claim. When these appropriate types of records come in with the original claim, it helps delay any processing time requesting these items on the back end. Listed in our Provider Manual online at anthem.com. Go to anthem.com, select Provider link. Select Nevada from drop down list, and enter. From the Provider Home page, select the link titled Provider and Facility Manual. See page

50 ICD-10 Updates April 2015

51 ICD-10 Compliance Date The U.S. Department of Health and Human Services (HHS) has issued a rule finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. This deadline allows providers, insurance companies, and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on October 1, The final rule also requires the continued use of ICD-9 through September 30, No delay (so far so good ) 51

52 ICD-10 Claims Processing No mixed claims: Consistent with CMS guidelines, we will not accept mixed claims (claims filed with ICD-9 and ICD-10 codes on the same claim). ICD-10 codes: We will not accept ICD-10 codes for dates of service (DOS) or dates of discharge (DOD) prior to October 1, ICD-9 codes: HIPAA will not allow the use of ICD-9 codes for claims with DOS or DOD on or after October 1, Resubmitting claims: When resubmitting claims, providers should utilize the code set that is valid for the DOS/DOD. With the ability to dual-process, we will leverage that functionality as appropriate to the mandate. 52

53 ICD-10 Pre-Authorizations Starting June 1, 2015, we will begin accepting and processing pre-authorization requests containing ICD-10 codes for services scheduled on or after October 1, ICD-9 codes must continue to be used to pre-authorize services scheduled through September 30, Some pre-authorizations may span the October 1, 2015 compliance date. The code set of the pre-authorization will vary, depending on the scenario. See the chart on the next two slides for guidance (available on Anthem s ICD-10 webpage) 53

54 ICD-10 Pre-Authorizations ICD-10 Coding Guidelines for Pre-authorizations and Claims Submission by Type of Service Type of Service Begins Ends Pre-Authorization Claim Inpatient Admission begins on or after the compliance date. Discharge on or after the compliance date. Pre-authorization must be requested with ICD-10 codes. Claim for services rendered on or after the compliance date must be billed with ICD-10 codes. Inpatient with unknown discharge date Admission begins before the compliance date. Unknown at the time of admission, then discharge occurs on or after the compliance date. Pre-authorization must be requested with ICD-9 codes. This pre-authorization will be valid for the entire admission. The code set used on the claim will be based on the discharge date, so the entire claim must be billed with ICD-10 codes. Inpatient with known discharge date Admission begins before the compliance date. Known discharge on or after the compliance date. Pre-authorization should be requested with ICD-10 codes. The code set used on the claim will be based on the discharge date, so the entire claim must be billed with ICD-10 codes. 54

55 ICD-10 Pre-Authorizations ICD-10 Coding Guidelines for Pre-authorizations and Claims Submission by Type of Service Type of Service Begins Ends Pre-Authorization Claim Outpatient Services Service on or after the compliance date. N/A Pre-authorization should be requested with ICD- 10 codes. Claim must be filed with ICD- 10 codes. Long-term Outpatient Services (such as Physical Therapy, Radiation Therapy, Chemotherapy, etc.) Services begin before the compliance date. Services end on or after the compliance date. Pre-authorization obtained in ICD-9 will be valid for services rendered on or after the compliance date. The claims for these services need to be separated and filed with the correct code set for the date(s) of service. Claims with both codes sets, or mixed claims, will not be accepted. 55

56 Medical Policies with ICD-10 Codes Our medical policies and clinical UM guidelines have been updated to include proposed ICD-10 coding. The ICD-10 coding is available within the Coding section of the Medical Policies on the Anthem provider webpage. Please note that at this time, the ICD-10 code list may not be all inclusive and is subject to change. 56

57 Anthem s Testing Activity with Providers Claim File Acceptance Testing Access from Anthem s ICD-10 webpage Anthem is conducting claim file acceptance testing for EDI direct submitters. The testing tool, Validator, offers unlimited testing of your EDI HIPAA transactions. This self-guided, web-based processing application is equipped to test file formats and edits as they pertain to ICD-10. Registration is required. If you are not a direct submitter, please inform your claims submission vendor (clearinghouse, billing company, etc.) of this opportunity to test with us. 57

58 Anthem s Testing Activity with Providers As part of our approach to discovering, understanding and predicting the impact of ICD-10, we have conducted extensive End-to-End Testing with selected providers and clearinghouses. The test claims included inpatient, outpatient and professional claims for various specialties. 58

59 ICD-10 End-to-End Testing: Overall Testing Strategy We asked providers to create natively ICD-10 coded claims by recoding previously processed ICD-9 claims from the original medical records. All file submissions followed the live process of submitting 837 files electronically to clearinghouses, which we received through our electronic gateway. We processed and adjudicated the claims, delivering L2 reports and 835 files back to the providers. 59

60 ICD-10 End-to-End Testing: Who Tested With Us Number of provider organizations facility/professional 44 Provider Organizations (63 entities) 36 Hospitals 25 Professional Provider Groups Number of clearinghouses 13 Clearinghouses 60

61 ICD-10 End-to-End Testing: Lessons Learned #1 Anthem can accept and deliver electronic claim files with ICD-10 codes through our EDI gateway We successfully received 91% of claims submitted for testing The types of claims and files validated or supported 837I (Facility) 837P (Professional) 835 remits EDI L2 Reports (TXT) The 13 Clearinghouses who tested with us AthenaHealth ClaimLogic Emdeon Gateway EDI GE Health MedAssets Navicure NEBO/Passport Quadax RealMed/Availity RelayHealth SSI Zirmed 61

62 EDI claim files: What to watch for EDI errors found during testing Incorrect ICD E-code usage We educated clearinghouses on how to map E-codes with correct Qualifier and how to interpret the EDI edit per CMS guidelines. This accounted for most of the errors. Incomplete ICD-10 codes Some claims had the last few characters of the ICD-10 codes trimmed while populating claims data on HIPAA 837 files Invalid ICD-10 codes submitted by providers Invalid data Incorrect usage of some of the 837 fields to populate the information 62

63 ICD-10 End-to-End Testing: Lessons Learned #2 Anthem can process claim files with ICD-10 codes on all claims systems tested We successfully processed over 6,900 test claims submitted by providers Inpatient 65% Outpatient 11% Professional 23% Claim edits performed as expected in our test environment Internal Anthem Systems Tested Local Platforms for our 14 Blue Markets Aces CS90 CHIPs Facets WGS National Platforms FEP NASCO 63

64 Claims: What to watch for Inpatient Claims Approximately 15% of inpatient claims tested demonstrated some DRG shifts in certain categories, consistent with industry findings. Industry analysis of these DRG shifts has resulted in corrections in the subsequent DRG grouper versions so that the shifts are no longer happening. Outpatient Claims and Professional Claims In reviewing the outpatient and professional claims tested, we found no significant shifts in the ICD-10 coded claims. There was no shift in benefit categories (i.e., preventive, emergency, etc.). 64

65 ICD-10 End-to-End Testing: Lessons Learned #3 Anthem s systems can process pre-authorizations containing ICD-10 codes Anthem Care Management (ACM) conducted a successful testing effort with providers. Pre-authorizations processed with no issues. #4 From a medical management perspective, there was virtually no impact due to ICD-10 codes Claims were reviewed for pay/pend/deny status to see if this would change with using ICD-10 codes. No changes were found. 65

66 Future Testing with Providers These test results were from the 2014 End-to-End Testing with providers and clearinghouses. Though we consider this testing successful, we will continue to verify our findings with additional internal analysis and a limited external testing effort in Participants for testing have already been identified for this year s testing. No additional providers are needed. 66

67 Our continued support of your implementation For our latest news on ICD-10 and links to resources, visit our ICD-10 Updates webpage Questions? If you have any questions about ICD-10, or surveys for us to reply to, please us: Anthem s ICD-10 webpage. Go to anthem.com, select the Provider link (top of the page), select Nevada from the drop down list, and click Enter. From the Provider Home page, look for the link titled ICD-10 Updates 67

68 Resources: Coding Practice Tool Anthem is offering professional providers a coding practice tool that can be accessed on Anthem s ICD-10 webpage Launched in April 2015 Available until September 2015 BASICS OF THE CODING TOOL 1. ICD-10 coding scenarios are made available to providers 2. Provider registers with an address and indicates specialty 3. Up to nine (9) coding scenarios are presented for numerous physician specialties 4. Provider or their designated coder reviews specialty-based scenario and codes scenarios in ICD-10 AFTER SCENARIOS ARE CODED 1. Providers can review their coding results against their peers who have also completed coding scenarios (by specialty) 2. We will review aggregate results to assess Provider readiness 3. We will take action as appropriate to communicate results to larger physician network 68

69 Resources: Coding Practice Tool Available on Anthem s ICD-10 webpage. Go to anthem.com Select the Provider link (top of the page), Select Nevada from the drop down list, and click Enter From the Provider Home page, look for the link titled ICD-10 Updates Then select the link titled Attention Professional Providers! Coding Practice Tool Available 69

70 Resources: Anthem s ICD-10 e-cast (available in April 2015) Preparing for ICD-10: A Provider s Perspective This 10 minute e-cast is a planning resource for professional providers, designed to help physician offices understand: Impacts of ICD-10 to office staff, processes and technology Changes required to accommodate ICD-10 in day-to-day office operations What offices can do to prepare for ICD-10 Available on Anthem s ICD-10 webpage. Go to anthem.com, select the Provider link (top of the page), select Nevada from the drop down list, and click Enter. From the Provider Home page, look for the link titled ICD-10 Updates 70

71 Resources: CMS s Road to 10 Road to 10: CMS Online Tool for Small Practices CMS created Road to 10, an online resource built with the help of providers in small practices intended to help small medical practices jumpstart their ICD-10 transition. Includes specialty references and gives providers the capability to build ICD-10 action plans tailored for their practice needs Access free Medscape Education modules Continuing medical education (CME) and continuing education (CE) credits are available to physicians and nurses who complete the learning modules. Available on the CMS webpage 71

72 Resources: ICD-10 Monitor (powered by Panacea Healthcare Solutions, Inc.) ICD10monitor is an online news and information source created to help healthcare providers make informed decisions as they transition to ICD-10 Talk Ten Tuesdays are weekly live broadcasts where relevant ICD-10 topics are discussed with industry experts. 72

73 Questions? Still have ICD-10 questions? Contact us at 73

74 Availity s Web Portal Take it away Emely and Benita!

75 Availity Contact Information 800.AVAILITY ( ) Emely Arienza Market Specialist CA, CO, NV, National Deployment P: Benita Abraham Market Executive CA, CO, NV, National Deployment P: Your Anthem Provider Relations Representative can answer general questions. 75

76 Provider Connectivity Anthem specific functionality

77 ProviderAccess and Availity s Web Portal ProviderAccess (Anthem s secure provider portal) Available for Anthem business only Includes Local Plan, Health Insurance Marketplace/ACA Compliant Plans, BlueCard, and Federal Employee Program (FEP) members Availity s Web Portal Available for Anthem membership Includes Local Plan, Health Insurance Marketplace/ACA Compliant Plans, BlueCard, and Federal Employee Program (FEP) members Access other payers in Nevada along with Anthem information on one portal Reminder: Please ensure that every individual has his/her own individual User ID and password. Logins cannot be shared! Each individual User will need to be registered in both ProviderAccess and Availity. 77

78 Why do I still need to be registered for ProviderAccess and have my own User ID? If you access any of the functionality remaining on ProviderAccess: Remittance Advice Inquiry Contracted Pricing Tool Clear Claim Connection Reimbursement Policies Active User Report Note: 1. You must be a registered ProviderAccess User to have access to the value-added features listed below via Availity 2. Your Primary Access Administrator (PAA) must also complete the Anthem Services Registration step in Availity to view this functionality via Availity Or you need any of these value-added features via Availity: Secure Messaging Allows you to send a question online about a claim via Availity AIM Specialty Health (AIM) Link to AIM for online pre-certification for Imaging and Specialty Rx Provider Portal Single Sign On Navigate easily between Availity s Web Portal and ProviderAccess 78

79 Remittance Advice Inquiry tool enhancements Remittance Advice Inquiries are available for the following member types Local Plan members including Health Insurance Marketplace/Affordable Care Act members BlueCard/Out-of-area members Federal Employee Program (FEP ) members CalPers Now available! Includes historical remittances up to 18 months after the issue date Now available to search by Check Number and Paid Amount! Includes historical remittances up to 18 months after the issue date 79

80 ProviderAccess Change Forms Updated! We have updated our ProviderAccess Change Forms, and now have 2 more user friendly forms: 1 ProviderAccess Account Administrator Change/Update form (2 nd page now includes the ProviderAccess Account Agreement) Use to change your Account Administrator Note: If changing your Account Administrator, the ProviderAccess Account Administrator Change/Update form must be submitted with a signed ProviderAccess Account Agreement Both completed forms must be ed or faxed to Anthem for processing ( /fax directions are included on form). 80

81 ProviderAccess Change Forms Updated! We have updated our ProviderAccess Change Forms, and now have 2 more user friendly forms: 2 ProviderAccess Organization Maintenance Change/Update form Use to change the following for your organization: 1. Adding Alternate Tax ID(s) 2. Changing Tax ID number 3. Updating NPI not associated with TAX ID Both forms available online: Go to anthem.com Select the Provider link (top of the page) Select Nevada from the drop down list, and click Enter From the Provider Home page, select Download Commonly Requested forms Then select the link titled ProviderAccess Account Administrator Change/Update form or ProviderAccess Organization Maintenance Change/Update form 81

82 AIM Specialty Health (AIM)

83 Agenda AIM programs How to obtain an Order Request online (Ordering/Servicing Providers) New for Servicing Providers! How to check status of an Order Inquiry (Order/Servicing Providers) OptiNet Registration (Servicing Providers) The Availity Web Portal Anthem Services Registration for accessing AIM AIM Provider Resources and Tutorials 83

84 AIM Specialty Health Overview of programs managed through AIM

85 AIM Specialty Health (AIM) Real-time Requests and Inquiries online 24/7/365 Discover why so many of our users have switched from the phone to the web for their specialty benefit orders and lookups. Why use the web? Over 75% of requests are authorized immediately Faster than calling in most cases Available anytime day or night even holidays! Work at your own pace Free up the phone line for patients Printable summaries for patient chart Lookup and confirm status of specialty benefit requests 85

86 AIM Solutions Addressing today s most complex tests and treatments Today your practice may be submitting case requests to AIM across a range of clinical programs Radiology Cardiology Sleep Oncology Specialty Drugs AIM Specialty Health administers programs on behalf of Anthem 86

87 AIM Specialty Health How to obtain an authorization (Ordering/Servicing Providers)

88 AIM Specialty Health (AIM): How to use AIM Simple Process: From case registration to authorization Case registration member identification and patient information Clinical information test/treatment requested and diagnosis Site selection directing service to high quality, cost effective testing sites Case status authorization, order summary, preview, updates Peer to Peer support consultation on case requests 88

89 AIM Specialty Health (AIM): How to obtain an Order Request NEW! Effective May 11, 2015, AIM will enable servicing providers (those free-standing or hospital facilities that perform imaging procedures) to initiate and complete radiology exam authorization requests online through the Availity Web Portal. Previously, servicing providers could only initiate requests for radiology exam authorizations by phone. As a reminder, servicing providers should continue to coordinate care with the member s ordering provider. You can also submit your request by calling the AIM Call Center. 89

90 AIM Specialty Health (AIM): How to obtain an Order Request Access online through Link directs you to AIM portal for: Note: The user must have an active User ID on ProviderAccess to access the AIM system through Availity. Authorizations or inquiries for: The Availity PAA must complete the Anthem Diagnostic imaging Services Specialty Rx Registration for each Radiation Therapy User to access AIM. Sleep Management Cancer Care Quality Program OptiNet registration for Servicing Providers Registration allows Ordering Providers to select the Servicing Provider for authorizations 90

91 AIM Specialty Health (AIM): How to obtain an Order Request Identify the member 91

92 AIM Specialty Health (AIM): How to obtain an Order Request Member not covered Note: AIM administers programs on behalf of not only Anthem, but many Blues plans across the country. We encourage you to utilize AIM for all of your members. If a member is not administered by AIM, you may see a message similar to the one shown below. Example of messaging if member is not covered for type of service requested. Messaging may change slightly depending on service type. 92

93 AIM Specialty Health (AIM): How to obtain an Order Request Identify the ordering provider 93

94 AIM Specialty Health (AIM): How to obtain an Order Request Order Type selection 94

95 AIM Specialty Health (AIM): How to obtain an Order Request Exam selection 95

96 AIM Specialty Health (AIM): How to obtain an Order Request Select a diagnosis 96

97 AIM Specialty Health (AIM): How to obtain an Order Request Provide additional details on medical history 97

98 AIM Specialty Health (AIM): How to obtain an Order Request AIM Feedback 98

99 AIM Specialty Health (AIM): Accessing OptiNet Facility quality and cost information Servicing provider quality and cost information is displayed here. *Choosing the lowest cost setting, when quality is comparable among like providers, will both decrease overall costs for your practice for those that participate in payment innovation programs, (e.g. the Enhanced Personal Healthcare) and for the member s cost share. 99

100 AIM Specialty Health (AIM): How to obtain an Order Request Order Summary 100

101 AIM Specialty Health (AIM): How to check status of an Order Inquiry Select Check Order Status Enter required elements Select Find This Order 101

102 AIM Specialty Health (AIM): Quick Reference Guide AIM Quick Reference Guide For Ordering and Servicing Providers Includes information on: AIM Specialty Health Programs Online Pre-authorization Requests (for Ordering and Servicing Providers) Anthem Services Registration OptiNet Registration (for Servicing Providers) Additional Resources 102

103 The Availity Web Portal Anthem Services Registration

104 Anthem Services Registration: Registering an Availity User for Anthem Services Follow these steps: In the Availity portal, click My Account Anthem Services Registration. If prompted, select your organization. In the Display field, click Non-Registered Users. 104

105 Anthem Services Registration: Registering an Availity User for Anthem Services In the table: locate each User you want to register and type the User s valid ProviderAccess User ID in the Health Plan User ID field. Tip: Health Plan User ID is the same as your ProviderAccess User ID. then click Register at the bottom of the page to access the User(s) Registered page. Note: By default, users are registered for all available services. If you want to remove a user s access to a specific service, see the following section Changing Access for Registered Users. 105

106 Anthem Services Registration: Changing Access for Registered Users If necessary, you can also change or remove a User's access to Anthem services on Availity. On the Anthem Service Registration page, click Registered Users, add or remove services as needed, and then click Save Changes. 106

107 Not already registered for Availity? Register Online Go to Click Get Started Follow the online instructions 107

108 AIM Specialty Health Provider Resources and Tutorials

109 AIM Provider Resources Once directed to AIM s portal, there are many provider resources and tutorials to assist you. Provider Resources available that change as new programs roll out in each state. 109

110 AIM Reference Desk and Tutorials Select Reference Desk to view a variety of reference documents or tutorials to make using the online services as easy as possible. 110

111 Interactive Care Reviewer Additional value-added function available only via Availity

112 Interactive Care Reviewer (ICR) Details Our ICR uses cutting-edge IBM Watson technology to bring improved efficiency to the pre-certification process: Physicians and facilities can submit both outpatient and inpatient requests for many members covered by our health plans. Includes Behavioral Health pre-certification requests for many members covered by our health plans. Ordering and servicing physicians and facilities can use the inquiry feature to find information on any pre-certification to which their tax id / organization is affiliated. Available for pre-certification requests that were previously submitted via phone, fax, ICR, or other online tool (for example, AIM Specialty Health (AIM), Behavioral Health, ereview, etc.) Available for patients who are members covered by our affiliated health plans in CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, WI, VA, and portions of NY. Products and services not included on ICR at this time: Medicare Advantage, Medicaid, Federal Employee Program (FEP ), BlueCard and some National Account members Requests involving transplant services Services administered by AIM *For the above requests, follow the same precertification process that you use today. Highlighted features View determination letters for the case Capture favorites in the provider fields for ordering and servicing providers Update cases from the inquiry screen Print a case to PDF or paper from the inquiry options 112

113 Access ICR via Availity Access our ICR tool via the Availity Web Portal at If your practice does not have access, go to and click on Get Started button under Register Now for the Availity Web Portal. Already use the Availity Web Portal? Your Primary Access Administrator (PAA) can grant you access to Authorizations functionality and you can start using right away. Note: Users will need to log out and log back in to view any newly added functionality. 113

114 Free ICR webinar training registration For webinar registration information go to either of the following: Directly to the following URL: me=83vbvn5cvr00ngx4 Or follow these directions: Go to anthem.com Select the Provider link (top center of page) Select Nevada from drop down list and enter. From the Provider Home page, select the link titled Interactive Care Reviewer Click Here for webinar information. 114

115 Wrap Up

116 Wrap Up Evaluation Forms Raffle Remaining Questions Thank you! Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 116