Providers and facilities are required to review all member information received from Anthem Blue Cross (Anthem) to help ensure no misrouted Protected Health Information (PHI) is included. Misrouted PHI includes information about members that a provider or facility is not currently treating. PHI can be misrouted to providers and facilities by mail, fax or e-mail. Providers and facilities are required to immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are providers or facilities permitted to misuse or re-disclose misrouted PHI. If providers or facilities cannot destroy or safeguard misrouted PHI, providers and facilities must contact Anthem’s provider services area to report receipt of misrouted PHI.

Anthem Blue Cross (Anthem) has network leasing arrangements with a variety of organizations, which we call Other Payors. Other payors and affiliates use the Anthem network.

Under the terms of your provider agreement, members of other payors and affiliates are treated like Anthem members. As such, they’re entitled to the same Anthem billing considerations, including discounts and freedom from balance billing. You can obtain the Other Payors list on the Availity web portal, at www.Availity.com. From the Availity site, select Home > Anthem California > Education and Reference Center, or email us at CAContractSupport@Anthem.com.

Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before with our Network eUPDATEs.

Network eUPDATE is our web tool for sharing vital information with you. It features short topic summaries and links that let you dig deeper into timely critical business information:

• Important website updates
• System changes
• Fee Schedules
• Medical policy updates
• Claims and billing updates

……and much more                                                                                                                         

Registration is fast and easy. There is no limit to the number of subscribers who can register for Network eUPDATEs, so you can submit as many e-mail addresses as you like.

Anthem Blue Cross (Anthem) providers should now submit changes to their practice profile using our online Provider Maintenance Form.

Online update options include: add an address location, name change, tax ID changes, provider leaving a group or a single location, phone/fax numbers, closing a practice location, etc. Visit the Anthem.com/ca form page to review more.

The new online form can be found on www.anthem.com/ca/provider/ > Find Resources for California >  Answers@Anthem tab>Provider Forms bullet>Provider Change Forms> Provider Maintenance Form.  In addition, the Provider Maintenance Form can be found on the Availity Web Portal by selecting California> Payer Spaces-Anthem Blue Cross> Resources tab >Provider Maintenance Form.

Important information about updating your practice profile:

• Change request should be submitted using the online Provider Maintenance Form
• Submit the change request online. No need to print, complete and mail, fax or email demographic updates
• You will receive an auto-reply e-mail acknowledging receipt of your request and another email when your submission has been processed
• For change(s) that require submission of an updated IRS Form w-9 or other documentation, attach them to the form online prior to submitting
• Change request should be submitted with advance notice
• Contractual agreement guidelines may supersede effective date of request

You can check your directory listing on the Anthem Blue Cross: “Find a Doctor tool”. The Find a Doctor tool at Anthem is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans. To ensure Anthem has the most current and accurate information, please take a moment to access the Find A Doctor tool (www.anthem.com/ca) and review how you and your practice are being displayed.

To report discrepancies please make correction by completing this Provider Maintenance Form online.

It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137), which went into effect on July 1, 2016, requires that Anthem Blue Cross (Anthem) provide our members accurate and up-to-date provider directory data. As a result, Anthem will be conducting ongoing outreaches to all practices to confirm the information we have on file is accurate. Without verification from you that our Provider Directory information is accurate, we will be required to remove your practice from the directories we make available to our members. We appreciate your attention to this matter.

Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. For a complete listing of our workshops, seminars, webinars and job aids, log on to the Anthem Blue Cross website: www.anthem..com/ca. Scroll down the page to Partners in Health > Tools for Providers. In the middle of the page select the box

Find Resources for California. From the Answers@Anthem page, select the link titled Provider Education Seminars and Webinars link.

In an effort to better service our contracted providers right the first time, Anthem Blue Cross has improved our provider claim escalation process. Just click, Provider Claim Escalation Process to read, print, download and share the improved process with your office staff.

Our Network Relations Team is available by email at CAContractSupport@anthem.com to answer questions you have about the process.

As a reminder, the Workers’ Compensation Physicians Acknowledgments is required by California Code of Regulations §9767.5.1, “Medical Provider Networks” (MPN). The “MPN applicant shall obtain from each physician participating in the MPN a written acknowledgment in which the physician affirmatively elects to be a member of the MPN.” 

To maintain and affirm your participation in all MPNs that you have been selected for and have subscribed to Anthem’s Provider Affirmation Portal, go to Availity and login. Once in, click on the Payer Spaces drop down menu in the top right hand corner, and select Anthem Blue Cross from the options available to you. On the next page click on “Resources” in the middle of the page and look for “MPN Provider Affirmation Portal.”

Availity>Payer Spaces>Anthem Blue Cross>Resources>MPN Provider Affirmation Portal

If you cannot go online, call Anthem Workers’ Compensation at 1-866-700-2168 and we can take action on your behalf in the Provider Affirmation Portal. Please also keep an eye out for email notifications from “Anthem MPN Admin.”

Please also be advised the Provider Affirmation Portal will also notify participating medical providers when an MPN is terminating its relationship with Anthem and/or the Division of Workers Compensation.

In a continuation of our CRA reporting update in March 2019, Anthem Blue Cross (Anthem) requests your assistance with respect to our Commercial Risk Adjustment (CRA) reporting processes. There are two approaches that we take (Retrospective and Prospective) that work to improve risk adjustment reporting accuracy.  We are focusing on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), to close the documentation and coding gaps that we are seeing with our members enrolled in our Affordable Care Act (ACA) compliant plans.

With both our Prospective and Retrospective approaches, accurate documentation and coding are what we are encouraging physicians to achieve. As a physician for our members with ACA compliant plans, you play a vital role in the success of our CRA reporting processes and ACA compliance.  When members visit your office, we encourage you to document ALL of the members’ health conditions, especially chronic diseases on the claim.  As a result, there will be ongoing documentation that indicates these conditions are being properly assessed and managed.   Additional benefits of accurate coding include:

• Reduced volume in medical chart requests in the future due to the increased level of specificity in documentation and coding, as part of our Retrospective approach; and 

• Reduced volume of health assessment requests by ensuring your patients with our ACA compliant plans are seen for their annual exams each and every year, as part of our Prospective approach.

Please Note:  It’s important to ensure that all diagnosis codes captured in your EMR system are included on the claims, and are not being truncated by your claims software management system.  For example, some EMR systems may capture up to 12 diagnosis codes, but a claim system may only have the ability of capturing 4.  If your claim system is truncating some of the listed diagnosis codes, please work with your vendor/clearing house to ensure all codes are being captured.

Reminder about ICD-10 CM coding

As you may be aware, the ICD-10 CM coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits. Additionally, Anthem uses ICD-10 CM codes submitted on health care claims to monitor health care trends and costs, disease management and clinical effectiveness of medical conditions.

We encourage you to follow the principles below for diagnostic coding to properly demonstrate medical necessity and complexity:

• Code the primary diagnosis, condition, problem or other reason for the medical service or procedure in the first diagnosis position of the claim whether on a paper claim form or the 837 electronic claim transaction, or point to the primary diagnosis by using the correct indicator/pointer.
• Include any secondary diagnosis codes that are actively managed during a face-to-face, provider-patient encounter, or any condition that impacts the provider’s overall management or treatment of that patient in the remaining positions. 
• Include all chronic historical codes, as they must be documented each year under the ACA.  (E.g. an amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).

Anthem Blue Cross (Anthem) continues to make it easier and more convenient to become a participating provider. The Digital Provider Enrollment application has been designed to speed up the enrollment process, allow providers to submit data at one time, and obtain real-time updates on the status of an application.

Access to the new application is available through Availity, Anthem’s secure web-based provider portal. New and current Availity users should ensure their user ID has the correct access. Please ensure that you have been assigned to Provider Enrollment.

Digital provider enrollment offers many benefits:

• Supports enrollment of professional providers, whose organizations do not have a credentialing delegation agreement with Anthem
• New individual providers or groups can request a contract
• Existing groups can add providers to their existing contract
• Providers can check the status of an application in real-time using the enrollment dashboard

To use the new Digital Enrollment application, please ensure your provider data on CAQH is current and in a complete or re-attested status, then log into Availity and use the following navigation: Choose your state > Payer Spaces > Provider Enrollment.

You will soon see updates to the claim status screens on the Availity Portal. Use the Go To menu on the patient eligibility and benefit detail page to navigate seamlessly to the new look.

Check Claim Status Image

The new claim status look includes color coded patient ID cards and easy to read claim detail.

Secure Messaging Changes

A new Actions menu on the updated Claim Status page will be used to access the Secure Provider Messaging tool. The link Do you have a question about this claim? will no longer be available with the new claim screen. You can also use the Actions menu to edit or print the claim screen.

Actions Image

For more information on the changes, Claim Status – Training Demo is now available in the Availity Learning Center. Providers can access the training demo through Help & Training | Get Trained.

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our website.  The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website. To access the guidelines, go to https://www.anthem.com/ca/provider/.   From there, scroll down and click on Read Polices.  This will take you to Medical Policy, Clinical UM Guidelines (for Local Plan M, and Pre-Certification Requirements. Then click on the Practice Guidelines on the Health & Wellness tab.

CPT Category II codes are supplemental tracking codes used to support quality patient care and performance management. CPT II codes are:

• Billed in the procedure code field in the same way as CPT Category I codes.
• Used to describe clinical components usually included in evaluation, management or clinical services.
• Billed with a $0 billable charge amount since they are not usually associated with any relative value.

Under this new incentive program, Anthem will reimburse contracted Medicare Advantage providers for submitting select HEDIS®-related CPT Category II codes for eligible members.

Using these CPT Category II codes for Medicare Advantage members will:

• Help providers address clinical care opportunities.
• Facilitate timely and accurate claims payments.

Detailed information about this program, including a list of applicable codes, will be sent to providers.

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Click here for additional information about the Health education classes and language assistance programs.

Click here for additional information about the Nicotine replacement products

Click here for additional information about the Clinical Criteria updates

Click here for additional information about the Regulatory updates

Click here for additional information about the Appointment access standards

Click here for additional information about the Medical necessity review for appropriate level of care

Click here for additional information about the Tobacco cessation requirements for Medi-Cal Managed Care (Medi-Cal) providers

Click here for additional information about the Diabetes Prevention Program

Each year, we may reach out to you to ask what we are doing well and how we can continue to improve our services. We use this feedback to continually improve our operations and strengthen our relationship with our providers.

Thank you for participating in our network, for providing quality health care to our members and for your timely completion of any surveys you receive.

For important information about practitioners’ rights during credentialing, click here.

Review updates to the Medical Policies and Clinical Utilization Management (UM) Guidelines using this link.

For more information about Modifier 22 click here.

Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

• Prior authorization requirements for DME repair and portable oxygen concentrator  
• Revision to Facility Emergency Department Reimbursement Policy  
• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ 
• Group Retiree members and National Access Plus
• Update: 2019 Risk Adjustment provider trainings  
• Special Need Plans training required

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As currently outlined in your provider manual, providers can submit claim payment reconsiderations verbally, in writing or electronically. We are reaching out to notify you about some exciting new tools for electronic submission that will become available through the Availity Portal. In addition, the Medicare Advantage provider manual has been updated with new information regarding claim remediation tools through the Availity Portal.

Beginning April 15, 2019, providers will have the ability to submit claim reconsideration requests through the Availity Portal with more robust functionality. For you, this means an enhanced experience when:

• Filing a claim payment reconsideration.
• Sending supporting documentation.
• Checking the status of your claim payment reconsideration.
• Viewing your claim payment reconsideration history.

New Availity Portal functionality will include:

• Acknowledgement of submission at the time of submission.
• Notification when a reconsideration has been finalized by Anthem Blue Cross (Anthem).
• A worklist of open submissions to check a reconsideration status.

With the new electronic functionality, when a claim payment reconsideration is submitted through the Availity Portal, we will investigate the request and communicate an outcome through the Availity Portal. Once an outcome has been determined, the Availity Portal user who submitted the claim payment reconsideration will receive notification through Availity informing the user the reconsideration review has been completed. If you are not satisfied with the reconsideration outcome, continue to follow the process to file a claim payment appeal, as outlined in your provider manual.

You can get a jump start on your training and be ready to go as soon as the tool is fully launched. To learn more about the claim payment dispute tool, register for a live webinar or view a previous recording:

1. Log in to Availity at https://www.availity.com and select Help & Training | Get Trained.
2. Type Appeals in the search field.
3. Enroll in a course.

Effective March 1, 2019, Laborers Health and Welfare Trust Fund for Northern California began offering an Anthem Blue Cross Medicare preferred PPO plan. Retirees with Medicare Parts A and B are eligible to enroll in the Medicare preferred PPO plan. The plan includes the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare.

Non-contracted providers may continue treating Laborers Health and Welfare Trust Fund for Northern California members and will be reimbursed 100% of Medicare’s allowed amount for covered services, less any member cost share.

In addition, Laborers Health and Welfare Trust Fund for Northern California retirees pay the same cost share for both in-network and out-of-network services. Locally or nationwide, doctors or hospitals, in- or out-of-network — the member’s cost share doesn’t change.

The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers, and also covers additional benefits that Medicare does not, such as an annual routine physical exam, hearing, LiveHealth Online and SilverSneakers®.

The prefix on Laborers Health and Welfare Trust Fund for Northern California member ID cards will be MBL. The cards will also show the Laborers Health and Welfare Trust Fund for Northern California name and National Access Plus icon.

Providers may submit claims electronically using the electronic payer ID for the Blue Cross Blue Shield plan in their state or submit a UB-04 or CMS-1500 form to the Blue Cross Blue Shield plan in their state. Claims should not be filed with Original Medicare. Contracted and non-contracted providers may call the provider services number on the back of the member ID card for benefit eligibility, prior authorization (PA) requirements and any questions about Laborers Health and Welfare Trust Fund for Northern California member benefits or coverage.

Detailed PA requirements also are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com.

Additional information is available here.

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Anthem has identified that providers often bill a duplicate Evaluation and Management (E/M) service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group TIN) recently billed a service or procedure which included an E/M for the same or similar diagnosis. The use of modifier 25 to support separate payment of this duplicate service is not consistent with correct coding or Anthem’s policy on use of modifier 25.

Beginning with claims processed on or after May 1, 2019 Anthem may deny the E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.

If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant and separately identifiable E/M service, please submit those medical records for consideration.

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