Anthem Provider Newsletter – December, 2022

December 02, 2022

Anthem Provider Newsletter – Missouri December 2022

This month’s featured articles:


  • CAA: Timely updates help keep our provider directories current
  • Attention lab providers: COVID-19 update regarding reimbursement
  • Clinical practice and preventive health guidelines available on
  • Member assessment of PCP after-hours messaging in 2022
  • Important information about utilization management
  • Members’ rights and responsibilities
  • Member’s assessment of behavioral healthcare after-hours messaging in 2022
  • Coordination of care
  • Case management program
  • IngenioRx will become CarelonRx on January 1, 2023

Policy Updates:

  • Reminder – updated AIM Musculoskeletal program effective January 1, 2023 – site of care reviews


  • Pharmacy information available on the provider website
  • Specialty pharmacy updates – December 2022

Medical Policy & Clinical Guidelines:

  • AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT Code List update
  • AIM Specialty Health Genetic Testing Clinical Appropriateness Guidelines CPT Code List update
  • Medical Policies and Clinical Guidelines updates – December 2022
  • Reimbursement policy update: Multiple Surgery – Facility
  • Reimbursement policy update: Bundled Services and Supplies – Professional
  • Reimbursement policy update: Treatment Rooms with Office Evaluation and Management Services – Facility


  • Keep up with Medicare News – December 2022
  • 2023 Medicare Advantage service area and benefit updates
  • Personal home helper benefit ending

Cigna Reimbursement Update – Frequency Limits to Outpatient Facility Claims

November 28, 2022

Cigna – Reimbursement Policy Update – Outpatient Facility Frequency Limits

We routinely review our coverage, reimbursement, and administrative
policies for potential updates. In that review, we take into consideration
one or more of the following: Evidence-based medicine, professional
society recommendations, Centers for Medicare & Medicaid Services
(CMS) guidance, industry standards, and our other existing policies.

As a result of a recent review, we will update the way we process
outpatient facility claims that are subject to medically unlikeiy edits
(MUE), or frequency limits. We will administratively deny reimbursement
for the portion of a claim that is above the MUE limit set by CMS.
Denials will include administrative appeal rights.

This update is effective for dates of service on or after February 18,
2023. We will update the Code Editing Policy and Guidelines to reflect
this change.

Please click on the above link to view the complete announcement.

Direct Contract Termination – Commerce Bank

November 28, 2022

Effective December 31, 2022, the direct agreement between Mercy and Commerce Bank will terminate. However, members will still have access to Mercy providers at their tier 1 benefit level through standard UHC and BCBS/Anthem plans.

Please make sure that you request to see new identification cards when employees of this group present for care.

Home State Health – Medicare Prior Authorization

November 18, 2022

List Effective January, 2023

Wellcare and Wellcare by Allwell require prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Wellcare and Wellcare by Allwell.

Wellcare and Wellcare by Allwell are committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization. 

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on our website at: and

Cigna – Digital ID Card Information

November 18, 2022

Cigna – Digital ID Cards

Cigna has shared the following information regarding their increased use of digital ID cards.

Starting in 2022 you will be seeing more members with Digital ID Cards.  You might have received an email with the same information.  To ensure all correct team/contacts received the information I am sending it out again.

Cigna continues to leverage the power of technology and data to accelerate its transition to fully adopt digital-only ID cards* by 2024. This approach to digital ID cards is the next step in our journey to offer more digital-first solutions for our customers and providers.

What this means to you
Digital ID cards are not new for Cigna or the industry overall. Over the past several years, you may have noticed patients starting to present their ID cards to you in a digital format – typically on their phone from the myCigna® app or from the® website. This experience for you and your front-office staff should not change.

However, you may start to see more patients who have a digital-only ID card beginning in 2023. As they do today, your patients will have the option to:

Share their digital ID card image on a phone screen in your office
Relay the information verbally over the phone to preregister for their appointment
Upload a digital ID card image to your health portal (as technology allows)
Email the digital ID card image directly to your office from the myCigna app
Print a copy of their digital ID card and share it with your office


Importantly, please note the digital ID card will look the same as the physical ID card does today and will contain the same benefit information.

If the member does not have access to a smart phone or computer.  Your office staff can always look up the digital card on  You are able to search by the members first and last name with their Date of Birth.

SumnerOne, Inc Direct Contract Termination Notice

November 17, 2022

Effective 12/31/2022 SumnerOne, Inc will be terming their direct contract with Mercy. We have been advised that they will be moving to the UnitedHealthcare Core Network effective January 1, 2023.

****Keep in mind that the Mercy North Central region-which includes the Springfield, Joplin and Rolla area-is out of network with the UHC Core plan.******

UnitedHealthcare 2023 Individual Exchange plans

November 17, 2022

Beginning January 1st, 2023 UnitedHealthcare will be offering a new Individual Exchange plan in the North Central and East markets. Our Mercy providers will be enrolled.

They have provided a link to the Individual Exchange plan which I have added below as well as link to the Quick Reference Guide.  The Reference Guide provides a wide range of information including a sample ID card, where to find eligibility and benefit information, as well as claim submission information.  You will also find several links on the Plan Page.

Please review and ensure your staff is aware.

UHC Individual Exchange Plan Page

Quick Reference Guide

Home State Health – Clinical and Payment Policy Updates

November 14, 2022

HSH Clinical and Payment Policy Updates 111422

Home State Health has announced that they will be implementing the following clinical and payment policy updates.  Please click on the link above to view the complete announcement.

  • Biopsychosocial Treatment of Obesity
  • Pulmonary Function Testing

You are invited: Healthy Blue Medicaid FUH Initiative Virtual Provider Munch & Learn

November 14, 2022

Please review the announcement from Health Blue Medicaid regarding several interactive sessions they’re hosting related to the Follow-Up After Hospitalization (FUH) Collaboration initiative.  This is primarily geared towards Behavioral Health providers and additional details and registration information can be found on the attachment.


Attached is an invitation for upcoming interactive Munch and Learn sessions that Healthy Blue MO will be hosting to educate behavioral health providers about the MHD Follow-Up After Hospitalization (FUH) Collaboration initiative.  Should you would like to participate please follow the directions on the flyer by sending a email to the mailbox indicated but be sure to put this in the subject line: FUH Initiative Virtual Provider Munch & Learn to insure that you register for the correct series.

Please share this invite with any and all associates within your organization that would benefit from these sessions including leadership, providers, behavioral health clinical staff, discharge coordinators, etc.



Healthy Blue Medicaid Professional Rates***Update***

November 10, 2022

Please review the update from Healthy Blue Medicaid regarding the rate changes and claim payment disputes.

Healthy Blue would like to provide you with information regarding the professional fee schedule rate updates that were effective 7/1/22. Although state bulletins were recently published with increased rates that were retro-effective 7/1/22, please note that the updates were still pending CMS approval. As a health plan, Healthy Blue could not implement the rate increases without CMS approval, which is why claims have continued to pay the old rates.


CMS has since approved the rates, and the approved fee schedules were published on the state’s site on 10/31/22. Currently, Healthy Blue is diligently working on auditing the updated fee schedules and loading them into our claims processing system. Once this is complete, Healthy Blue will reprocess incorrectly paid claims from 7/1/22 to pay the updated rates. Please discontinue submitting claim payment disputes regarding the updated rates as Healthy Blue will be reprocessing all incorrectly paid claims upon system update.