Discover the latest updates to the Provider Operations Manual

• Enhanced provisions in member eligibility such as verifying eligibility, children’s benefits, sensitive services, and telehealth
• Adjustments to special programs including managed long-term services, enhanced care management, street medicine, and palliative care
• Changes in multiple areas such as care provider procedures, administrative procedures, utilization management, care management, claims, state-directed payments, and regulatory requirements

The new Provider Operations Manual is now live on our provider website. This recently updated manual contains everything you need to know about our programs and how we work with you to provide quality care to our members. You can access the provider manual here.

Several important updates were made this year that we encourage you to review. These include the following:

• Member eligibility:
  • Verifying eligibility:
    • New language added reminding care providers they must review Medi-Cal eligibility for every member for the presence of Other Health Coverage (APL 22-027)
    • Updated member ID cards (for Los Angeles and non-Los Angeles) (new design
  • Children’s Benefits (new):
    • New subsection was added to incorporate different types of children’s benefits (California Children’s Services, Medi-Cal for Kids & Teens, and childhood lead exposure testing)
  • Sensitive services:
    • Abortion services are covered by the Medi-Cal program. Anthem will not deny or interfere with a member’s right to choose or obtain an abortion prior to viability of the fetus or when an abortion is necessary to protect the life or health of the pregnant individual. In addition, Anthem will not require a care provider to perform an abortion (APL 24-003).
    • New language added regarding care providers being prohibited from sharing, selling, marketing, or using any medical information about gender-affirming care, abortion, or any related services (AB 254 and AB 352)
  • Telehealth:
    • New language added for care providers who offer telehealth services requiring in-person care or to arrange for a referral to in-person care if member does not want to proceed with a telehealth visit (APL23-007 and AB 1241)
    • Doula, community health, and asthma preventive services can be conducted through telehealth (DHCS Telehealth Manual).
  • Transportation:
    • Members should schedule ride services at least five business days in advance, 10 business days in advance for long-distance appointments (exceptions apply: dialysis, chemotherapy, radiation therapy, urgent care, wound care, or facility discharges) (ModivCare).
• Special Programs:
  • Managed long-term services and supports:
    • Subdivision added to the topic of Intermediate Care Facilities for Developmentally Disabled (ICF/DD) (APL23-023)
  • Enhanced care management:
    • Removed the following population of focus: individuals with intellectual and developmental disabilities and pregnancy and postpartum individuals at risk of adverse perinatal outcomes
  • Street medicine:
    • New subsection added on street medicine (APL 24-001)
  • Palliative care program:
    • Hospice care providers may bill for medically necessary palliative care services for eligible Medi-Cal beneficiaries diagnosed with serious or life-threatening illnesses (DHCS Bulletin).
• Care provider procedures and responsibilities:
  • More language on balance billing added: care providers are prohibited from billing eligible members for covered services and billing dual-eligible beneficiaries for Medicare, and members may not pay for medical care (Cal Code of Regulation, 14019.4)
  • Access to care, appointment standards, and after-hours services:
    • To comply with AB1740, language was added regarding care providers posting a human trafficking notice (AB1740).
  • Required Assessments:
    • Removed CCS language and moved to children’s benefits
• Administrative procedures:
  • Updating provider directories:
    • New language added on updating delegate contact list (new DHCS contract requirement)
• Utilization management and prior authorization:
  • Authorization request and time frames:
    • New language added regarding the preferred method for digital submission of preauthorization requests (Availity Essentials authorization)
  • Transition and discharge planning:
    • New language added regarding ADT data (admission, discharge, transfer) (APL22-026)
• Care management and health programs:
  • Health services programs:
    • Updated language on New Baby, New Life

• Claims and encounters:
  • Claim submissions:
    • Language added regarding how much interest is paid if a clean claim is not processed promptly (APL23-020)
    • New subdivision added on electronic visit verification (APL 22-014)
  • Encounters:
    • Subsection title changed from encounters data to encounters
• State-directed payments:
  • Proposition 56:
    • Language changes made for state-directed payments
• Grievances, appeals, disputes:
  • Member appeals and grievances:
    • Removed Los Angeles County (for L.A. Care) regarding where to file grievances; all grievances must go to a Medi-Cal office now
    • New language added on Medi-Cal member appeals state hearings
• Compliance and regulatory requirements:
  
  • Marketing rules:
    • Anthem will no longer seek approval from Managed Risk Medical Insurance Board (MRMIB) on Anthem-branded marketing materials for Medi-Cal patients.

While we strive to keep our Provider Operations Manual current, please be sure to check our provider website for the most up-to-date plan policy information.

If you have questions about the provider manual or provider bulletins, contact your provider relationship management representative or call one of our Medi-Cal Customer Care Centers at 800‑407‑4627 (outside L.A. County) or 888-285-7801 (in L.A. County).