Network adequacy – subcontractor expectations
Anthem Blue Cross (Anthem) is required to submit the Annual Network Certification (ANC) documentation to the California Department of Health Care Services (DHCS) to demonstrate compliance with network adequacy requirements, in accordance with the DHCS All Plan Letter (APL) 21-006 Network Certification Requirements. Below are specific mandates that subcontractors must comply with. The full APL and Attachment A are also attached for your reference. Network adequacy compliance includes mandatory provider types according to your contract agreement with Anthem. In addition, subcontractors may use nonphysician medical practitioners to meet network expectations; however, a licensed physician must supervise all nonphysician medical practitioners. The associated medical practitioner-to-supervisor and member-to-supervisor ratios are outlined in Attachment A.
Anthem is required to have processes in place to ensure subcontractors comply with network adequacy requirements. If a subcontractor has a network adequacy deficiency, DHCS requires that Anthem impose a Corrective Action Plan (CAP) until all deficiencies are corrected.
Subcontractors are required to maintain evidence of contracting efforts within their contracted service areas where network deficiencies are identified. DHCS requires Anthem to maintain documentation including, but not limited to:
- All correspondence related to provider offers via email/letter.
- Scheduled phone calls.
- Evidence of good faith negotiations.
- Marketing materials and advertisements.
As a delegated entity, Anthem may request the above-listed documentation from you. In addition, relevant policies and procedures must be maintained and provided to Anthem upon request.
If you have any questions regarding network adequacy, please reach out to the Provider Performance Management team at firstname.lastname@example.org.
Network adequacy resources
Your partnership is critical to ensuring adequate network access for our members. Below, you will find a listing of resources that you can use to help solve any gaps identified in your network:
- DHCS Managed Care Plan Provider Network File: https://data.chhs.ca.gov/dataset/managed-care-provider-network
- Fee-for-service open data portal: https://data.chhs.ca.gov
- Health Care Options: https://www.healthcareoptions.dhcs.ca.gov
- Health Care Access and Information (formerly known as Office of Statewide Health Planning and Development): https://hcai.ca.gov/data-and-reports/
- Health Professional Shortage Areas (HPSA): https://data.hrsa.gov/topics/health-workforce/shortage-areas
Out-of-network (OON) requirements:
- In cases where a subcontractor is unable to meet time or distance standards to a core specialist, delegated entities are required to assist any requesting member in obtaining an appointment with an appropriate OON primary and core specialty provider, in accordance with APL 21-006 Attachment A, in person or via telehealth, when contracted for those services.
- When assisting the member, the subcontractor must make their best effort to establish a member‑specific case agreement with an OON core specialist at the Medi-Cal Managed Care fee-for-service rate or a mutually agreed upon rate, unless the subcontractor has already attempted to establish a member‑specific case agreement with the OON core specialist in the most recent fiscal year, and the core specialist has refused to enter into an agreement.
- If this cannot be arranged, the subcontractor must arrange for an appointment with an in‑network provider.
- The OON primary and core specialty provider must be able to provide services to a member within the applicable time or distance and timely access standards and, in cases where the OON primary and core specialty provider are not able to provide services to a member under these standards, the subcontractor must arrange for nonemergency medical transportation or nonmedical transportation.
- Subcontractors are responsible to authorize OON access to medically necessary providers within timely access standards and applicable time or distance standards, regardless of associated transportation or provider costs until the CAP is completed by the subcontractor and closed by Anthem.
DHCS also requires Anthem to ensure providers and subcontractors are trained on the right for members to request OON access for medically necessary services and transportation to providers when ANC requirements are not met.
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June 2022 Anthem Blue Cross Provider News - California