Anthem Blue Cross Medicare Advantage FFS HMO network guidance

Anthem Blue Cross (Anthem) expanded its Medicare Advantage network in 2018 by amending Prudent Buyer Agreements to include all Medicare Advantage products (including Medicare Advantage HMO). We are providing this information as a reminder of how these plans operate. 

Background

Anthem amended Prudent Buyer Agreements with the Medicare Advantage PPO to add all Medicare Advantage plans in order to expand our product offerings in California. There will be no change in reimbursement. This allows Anthem to expand our product offerings across the state and provide our members with access to quality providers. Traditionally, HMO networks are administered through a provider medical group (PMG). PMGs contract with Anthem to act on its behalf in several ways, including provider network contracting and management (providers are employed/contracted with the PMG and reimbursed by them). In the fee-for-service (FFS) HMO model, providers are directly contracted with Anthem in a manner similar to the PPO network. See below for more information.

Effective date

The contract amendment effective date was February 1, 2018.

Out-of-scope areas

Amendments to the Prudent Buyer Agreements for Anthem were out-of-scope for the following geographical areas due to a robust network of contracted provider medical groups (PMGs): Los Angeles, Riverside, Orange, San Bernardino, and San Diego. 

Anthem product lines for Medicare Advantage:

1. PPO and HMO plans (includes both Individual and Group Retiree members): Medicare Advantage (Part C) includes Part A hospital coverage and Part B medical coverage in a convenient, all-in-one plan that also includes prescription drug coverage (Part D). Plans vary by region.  
2. Dual-Eligible Special Needs Plan (D-SNP): For individuals who have both Medicare Part A and Part B and receive state medical assistance.
3. End-stage renal disease (ESRD) Chronic Condition Special Needs Plan (C-SNP): Medicare SNPs are a Medicare Advantage plan (like a HMO or PPO). ESRD C-SNP limits membership to people with
   end-stage renal disease. Benefits, provider choices and drug formularies are tailored to best meet the specific needs of ESRD patients.

PCP assignment for HMO members

In some areas, members have the option to choose a primary care physician (PCP) through a PMG or a PCP directly contracted with Anthem through their amended Prudent Buyer Agreement:

• Members assigned to a PCP through an Independent Practice Association (IPA) or PMG will have an ID card indicating the PCP name and IPA/Group name. Reimbursement and referrals are coordinated through the PMG. Members assigned to a PCP through an IPA/PMG must use the IPA/PMG’s contracted network and care coordinate through them.
• Members may select a PCP directly contracted with Anthem. The member ID card will indicate the assigned PCP and will not indicate an IPA/PMG. Providers are reimbursed fee-for-service at the rate indicated in the Prudent Buyer Agreement for Anthem for Medicare products. See below for details regarding reimbursement, referrals, and claims.

Eligibility verification:

• Review member’s ID card
• Online via Availity* at https://www.availity.com
• Call 888-230-7338

 

Copays and deductibles

 

Copays and deductibles vary by plan. Please refer to the resources listed above in the Eligibility Verification section to confirm for each member.

Reimbursement

Services rendered to Medicare Advantage PPO members and Medicare Advantage HMO members through the Prudent Buyer Agreement for Anthem are paid according to the Medicare Advantage fee-for-service fee schedule.

Services rendered to Medicare Advantage HMO members through an IPA/PMG agreement are reimbursed according to the terms of the agreement with the IPA/PMG.

Claims submission (except those related to IPA/PMG contracted services)

Submit claims directly to Anthem:

Anthem Blue Cross

P.O. Box 60007

Los Angeles, CA 90060-0007

 

Referral process

 

Directly contracted providers

For members who have selected a directly contracted PCP, Anthem does not require referrals to in-network specialists.

IPA/PMG contracted providers

For providers contracted through an IPA/PMG arrangement, continue to follow your current referral process. 

Authorizations

 

Directly contracted providers

Anthem requires prior authorization for some procedures, and providers should obtain a list of procedures requiring prior authorization. The function of our authorization process is to confirm member eligibility, plan coverage, medical necessity, and appropriateness of care to identify members who may need care management and disease prevention services. Our Innovative Care Management Model supports patients’ healthiest outcomes.

 

IPA/PMG contracted providers

For providers contracted through an IPA/PMG arrangement, continue to follow your current authorization process. 

What if I have questions or need more information?

Claims, membership, benefits, and eligibility questions should be directed to the Provider Services phone number listed on the member’s ID card.

If you have any questions, contact your assigned Provider Experience associate or visit the Contact Us page on our provider website for up-to-date contact information: https://www.anthem.com/ca/provider/contact-us/.

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