For the most up-to-date information from Anthem about COVID-19, please bookmark Provider News Home and check back often.

Anthem completed its acquisition of Beacon Health Options, a large behavioral health organization that serves more than 36 million people across the country. The company will operate as a wholly owned subsidiary of Anthem.

Bringing together our existing solid behavioral health business with Beacon’s successful model and support services creates one of the most comprehensive behavioral health networks in the country. It is also an opportunity to offer best-in-class behavioral health capabilities and whole person care solutions in new and meaningful ways to help people live their best lives.

From the standpoint of our customers and providers at this time, it is business as usual:

• Members should continue to call the customer service number on the back of their membership card or access their health plan’s website for online self-service.
• Providers should continue to use the provider service contact information, websites and online self-service portals as part of their agreement with either Anthem or Beacon.
• There will be no immediate changes to the way Anthem or Beacon manage their respective provider networks, contracts and fee arrangements. Anthem and Beacon provider networks, contracts and fee arrangements will remain separate at this time.

We know our providers continue to expect more of their healthcare partner, and at Anthem, we aim to deliver more in return.

For more details, please see the press release.

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways is through Anthem’s value-based programs such as Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, and so on – called the “Programs.”  Certain providers (“Value-Based Program Providers” also known as “Payment Innovation Providers”) in Anthem’s various value-based programs receive quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value-Based Program Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs may result in the provider getting more referrals from Value-Based Program Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

Providing this type of data, including comparative cost information, to Value Based Program Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Value Based Program Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant.

As an Anthem Blue Cross (“Anthem”) participating provider, you may have received our prior correspondence, or read the articles in Provider News (formerly Network Update) on Anthem Cost Transparency. Transparency tools such as Anthem Care Comparison and others are available to members on anthem.com  and allow members to estimate their out-of-pocket impact and view the estimated costs for many procedures

In our prior correspondence, we also enclosed a summary of the methodology used to generate the cost information housed in the National Consumer Cost Tool (NCCT), the source data used to display costs in Anthem Care Comparison.  The treatment categories for which costs are displayed and the methodology are defined by the Blue Cross Blue Shield Association. As indicated in the correspondence, BCBS Axis (formerly NCCT) cost data is updated twice annually; the most recent update completed in November 2019, and the next update scheduled for May 2020. Please look for more information in our provider newsletters posted to anthem.com/ca.

As a reminder, Anthem provider costs are now available in a secure section of the Availity provider portal. Authorized representatives of participating facilities and professional practices can login to Availity at www.availity.com, and register to view the costs for their facility or practice. Costs will be made available to our participating providers no less than 30 days before they become available to our members on anthem.com/ca in the transparency tools such as Anthem Care Comparison.

Should you wish to review the methodology, you may request a copy by sending an e-mail request to the Anthem California contract support team at CAContractSupport@anthem.com.

Should you desire to provide an Internet Web site link on Anthem’s website where this cost information will be displayed, which provides a response to the cost information being displayed, please provide us this link within thirty (30) days of receiving the cost information from us.

As a current Anthem therapy provider, you should have received in the mail your exclusive invitation in January to subscribe to the Anthem Marketplace, powered by Transparent Health Marketplace™ (THM). This revolutionary marketplace is not like a traditional PPO, it is a connected end-to-end technology platform, which incorporates familiar ways of electronically transacting business. If you already started your subscription, we will send you an email link to make completing it a breeze! 

It is quick, easy and only takes “one click” to connect to new patients!

Subscribing is easy!  Visit us today at www.anthem-wc.com/oneclick/invite 
PS:  Freestanding Imaging providers’ invitations are coming soon!

With several national payor partners signed up and hundreds of providers already subscribed, the platform has experienced triple-digit growth in select California markets. Now, we are launching statewide in California.  We hope you will embrace our movement, love our platform, tell your friends and colleagues, take back control of your practice, and help us lead the transformation of the workers’ compensation system. Are you in?

The Department of Managed Health Care’s (DMHC) routine medical survey includes evaluation of a Health Plan’s compliance with California Health and Safety Code section 1368(a)(2); 28 CCR 1300.68(b)(6) and (7). These regulations require Health Plans to ensure that grievance forms, a description of grievance procedures, and assistance in filing grievances are readily available at each contracting provider’s office, contracting facility, or Plan facility.

Please review and distribute the Anthem Blue Cross (Anthem) grievance form to all your participating offices. It is important to implement processes to provide grievance forms and assistance to Anthem members promptly upon request.

Your agreement with Anthem requires you to comply with all applicable laws and regulations and to cooperate with Anthem’s administration of its grievance program.

Information can be accessed on the process of submitting member grievances and appeals, grievance forms, definitions and appeal rights, on Anthem’s website at www.anthem.com/ca/forms. Go to View by Topic and click on the drop down menu and select Grievance & Appeals, and then select the desired resource link.

In addition, grievanceforms, grievanceproceduresand additionalinformationabout Anthem’sexpeditedgrievanceandappealsreviewprocess,canbefoundinyourProviderOperationsManual.

Anthem Blue Cross has posted a required learning course via Availity Portal (login required) to ensure provider offices have implemented processes to provide grievance forms and assistance to enrollees. Please make sure to complete this course and the required attestation by November 30, 2019:

1. Log in to Availity Portal at availity.com.
2. At the top of Availity Portal, click Payer Spaces > Anthem Blue Cross.
3. On the payer spaces landing page, click Access Your Custom Learning Center from the Applications tab.
4. Search for the Member Grievance Form and Attestation - Online Course using keyword grievance.
5. Enroll and complete the course, including the required attestation module.

Refer to this guide for more information.

Not registered for the Availity Portal?

Have your organization’s designated administrator register your organization for the Availity Portal.

1. Visit availity.com to register
2. Click Register
3. Select your organization type
4. In the Registration wizard, follow the prompts to complete the registration for your organization. Refer to these PDF documents for complete registration instructions.

Patient360 is a real time dashboard you can access through the Availity Portal that gives you a robust picture of your Anthem Blue Cross (Anthem) patient’s health and treatment history and will help you facilitate care coordination.

If, an Anthem patient has a Care Gap Alert your medical practice can locate Active Alerts on the Member Summary page of the Patient360 application.

What’s new:  Medical providers now have the option available on Patient360 to include feedback for each gap in care that is listed on the patient’s active alerts.

However, to be able to access the Care Gap Alert Feedback you will need to provide an individual NPI. If you select an NPI from Express Entry menu, the feedback options will not be available.

Once you have completed all the required fields you will land on the Member Summary page of the application. To provide feedback, select the Resolution Health Index (RHI) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry screen. You can choose the feedback menu option that applies to your patient’s care gap.

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

First, you need to be assigned to the Patient360 Role which your Availity Administrators can locate within the Clinical Roles options.

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

At Anthem Blue Cross (Anthem), we continue to make changes to our public provider website to make it easier for you to find the information you need. The end of Q1 brings a few updates for the site at www.anthem.com/ca:

• Information has been added to our website regarding Patient-Centered Specialty Care (PCSC) – Anthem’s value-based payment program for cardiology, endocrinology and obstetrics/gynecology providers. You can find this information online as an extension of our broader patient-centered, value-based care program – Enhanced Personal Health Care (EPHC).
• Documents listed on the Prior Authorization page can be conveniently accessed via online links.
• Medicare Advantage will be live in the coming days. You will be able to view updated Medicare Advantage pages on the commercial public sites.
• Medical Policies (MP) and Clinical Utilization Management Guidelines (CUMG) now display on our newly designed Web pages.
• Clear and easy access to training and education materials via a new California Training and Education page was released in March.

If you have any questions, please contact Michelle Fraser at michelle.fraser@anthem.com or Nick Kizirnis at nick.kirzinis@anthem.com.

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, select “Providers” and under Communications, select Education and Training. Scroll down the page to Training & Education Offerings.

It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137) 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.

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 Provider Maintenance Form landing page to review more.

The new online form can be found the redesigned provider site www.anthem.com/ca, select the Providers tab then select Provider Maintenance Form in the sub bullets. In addition, the Provider Maintenance Form can be accessed through 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 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, select the Providers tab, then select the Find A Doctor in the sub bullets) and review how you and your practice are being displayed.

In an effort to better service our contracted providers right the first time, Anthem Blue Cross has improved our provider claim escalation process. Following the steps below.

• All inquiries related to eligibility and claims payment should be obtained by utilizaing Anthem Blue Cross’ seld-service tools or by contacting Provider Care.
• Please use the Provider Care phone number on the back of the member’s ID card for any information that you are unable to obtain via our self-service or web-based tools.
• In the event our self-service tools and Provider Care representatives are unable to assist you, you may ask for your inquiry to be escalated to a Provider Care Supervisor.
• If a Supervisor is unable to assist you immediately, you will receive a call back within 2 business days.
• Provider Care will provide an inquiry number for your phone call. Be sure to retain this number for any future inquiries. Please ask the representative to provide you with your inquiry tracking number at the beginning of your call, to avoid inconveniences to you, in the event your call is disconnected.
• Going forward, all claim inquiries must be handled via the escalation process within Provider Care. Network Relations will only assist with issues that have been addressed via this process. Escalations to Network Relations must include both a phone inquiry tracking reference number and a two business day period without response from a Supervisor.

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

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

Provider News 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 Provider News, so you can submit as many e-mail addresses as you like.

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.

Anthem Blue Cross (Anthem) notified our contracted Applied Behavior Analysis (ABA) providers on November 26, 2019, of an update regarding ABA reimbursement scheduled to take effect on March 1, 2020.

On February 28, 2020, a provider notification was sent to those impacted ABA providers notifying them that Anthem is temporarily delaying the March 1, 2020 fee schedule adjustments for ABA providers. Until further notice, Anthem will honor the rates for ABA services in their current Agreement with Anthem.

While system updates are being made to ensure claims are processed correctly, Anthem suggests that claims with dates of service between March 1, 2020 and March 10, 2020 are not submitted until March 11, 2020 to avoid underpayments.

It is important to remember that your reimbursement is proprietary information that should remain confidential, and is specific to your Agreement with Anthem.

Please call the Autism Spectrum Disorder Program toll-free at 1-844-269-0538 for questions regarding utilization management for ABA.

If you have general questions about your reimbursement or Agreement, email our commercial Behavioral Health Network Relations team at cabhnetworkrelations@anthem.com. 

      Click here for more information about the New MA Opioid Treatment Program benefit.

 Click here for more information about the Medical Policies and Clinical Utilization Management Guidelines update.

Click here for more information about Prior authorization requirements: new 2020 codes for coverage and precertification.

The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

Medicare Risk Adjustment and Documentation Guidance (General)

• When: The trainings will be offered the first Wednesday of each month from 1 p.m. to 2 p.m. ET (from January 8, 2020, to December 2, 2020).
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity has been reviewed and is acceptable for up to 1 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:

Medicare Risk Adjustment and Documentation Guidance (General)

Note: Dates may be modified due to holiday scheduling.

Medicare Risk Adjustment, Documentation and Coding Guidance (Condition Specific)

• When: The trainings will be offered on the third Wednesday of every other month from noon to 1 p.m. ET (from January 15, 2020, to November 18, 2020).
• Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
• Credits: This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

1. Red Flag HCCs Part 1 (January 15, 2020) — register for a recording of the session: Training will cover HCCs most commonly reported in error as identified by CMS (Chronic Kidney Disease Stage 5, Ischemic or Unspecified Stroke, Cerebral Hemorrhage, Aspiration and Specified Bacterial Pneumonias, Unstable Angina and Other Acute Ischemic Heart Disease, End-Stage Liver Disease).

• Link: Red Flag Hierarchical Condition Categories (HCCs), part one

• Link: Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 2

• Link: Neoplasms

• Link: Acute, Chronic and Status Conditions

• Link: Diabetes Mellitus and Other Metabolic Disorders

• Link: Topic TBD

507941MUPENMUB

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting November 2019. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.

507833MUPENMUB

On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting December 2019. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.*

508037MUPENMUB

Click here for more information about the COVID-19 Virus Talking Points.

Click here for more information about the Coding tip for psychological and neuropsychological testing.

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting November 2019. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.*

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross.

On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting December 2019. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

Please share this notice with other members of your practice and office staff.

To view a guideline, visit https://mediproviders.anthem.com/ca  > Provider Support > Education & Resources > Communications & Updates > Provider Bulletins > 2019.

• Updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• *SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
  • o Revised scope of document to only address benign prostatic hyperplasia (BPH)
  • o Revised medically necessary criteria for transurethral incision of the prostate by adding "prostate volume less the 30 mL”
  • o Added transurethral convective water vapor thermal ablation in individuals with prostate volume less than 80 mL and waterjet tissue ablation as medically necessary indication
  • o Moved transurethral radiofrequency needle ablation from medically necessary to not medically necessary section
  • o Moved placement of prostatic stents from standalone statement to combined not medically necessary statement
• *SURG.00037 - Treatment of Varicose Veins (Lower Extremities)
  • o Added the anterior accessory great saphenous vein (AAGSV) as medically necessary for ablation techniques when criteria are met
  • o Added language to the medically necessary criteria for ablation techniques addressing variant anatomy
  • o Added limits to retreatment to the medically necessary criteria for all procedures
• *SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
  • o Expanded scope to include gastroparesis
  • o Added gastric peroral endoscopic myotomy or peroral pyloromyotomy as investigational and not medically necessary
• *SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
  • o Expanded scope of document to include vertebral body tethering
  • o Added vertebral body tethering as investigational and not medically necessary
• *CG-LAB-14 - Respiratory Viral Panel Testing in the Outpatient Setting
  • o Clarified that respiratory viral panel (RVP) testing in the outpatient setting is medically necessary when using limited panels involving 5 targets or less when criteria are met
  • o Added RVP testing in the outpatient setting using large panels involving 6 or more targets as not medically necessary
• *CG-MED-68 - Therapeutic Apheresis
  • o Added diagnostic criteria to the condition "chronic inflammatory demyelinating polyradiculoneuropathy" (CIDP) when it is treated by plasmapheresis or immunoadsorption
• The following AIM Specialty Clinical Appropriateness Guidelines have been approved, to view an AIM guideline, visit the AIM Specialty Health® page:
  • o *Joint Surgery
  • o *Advanced Imaging—Vascular Imaging

Medical Policies

On November 7, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross (Anthem). 

Click on the attachment to view the list of medical policies and clinical guidelines.

Disease Management programs are designed to assist PCPs and specialists in caring for members with chronic health care needs. Anthem Blue Cross provides members with continuous education on self-management, assistance in connecting to community resources, and coordination of care by a team of highly qualified professionals whose goal is to create a system of seamless health care interventions and communications for members.

Who is eligible?                                                                                                                          

Disease Management case managers provide support to members with:

• Behavioral health conditions such as depression, schizophrenia, bipolar disorder and substance use disorder.
• Diabetes.
• Heart conditions such as congestive heart failure, coronary artery disease and hypertension.
• HIV/AIDS.
• Pulmonary conditions such as asthma and chronic obstructive pulmonary disease.

Our case managers use member-centric motivational interviewing to identify and address health risks such as tobacco use and obesity to improve condition-specific outcomes. Interventions are rooted in evidence-based clinical practice guidelines from recognized sources. We implement continuous improvement strategies to increase evaluation, management and health outcomes.

We welcome your referrals. To refer a member to Disease Management:

• Call 1-888-830-4300 to speak directly to one of our team members.
• Fill out the Disease Management Form located on the provider website and fax it to 1-888-762-3199 or submit electronically via the Availity Portal.

Your input and partnership are valued. Once your patient is enrolled, you will be notified by the assigned Disease Management case manager. You can also access your patient’s Disease Management care plan, goals and progress at any time via the Availity Portal through Patient360.

We are happy to answer any questions. Our registered nurse case managers are available Monday to Friday from 8:30 a.m. to 5:30 p.m. local time, and our confidential voicemail is available 24 hours a day, 7 days a week.

Anthem Blue Cross allows reimbursement to professional providers and facilities for multiple and bilateral surgery. Reimbursement is based on multiple and bilateral procedure rules in accordance with contracts and/or state guidelines for applicable surgical procedures performed at the same session by the same provider.

Effective May 1, 2020, the policy has been updated to reflect that multiple procedure guidelines for multiple surgeries do not apply to facility claims.

Please visit https://mediproviders.anthem.com/ca to view the Multiple and Bilateral Surgery reimbursement policy for additional information regarding percentages and reimbursement criteria.

The HEDIS® measure, Use of Imaging Studies for Low Back Pain (LBP), analyzes the percentage of patients 18 to 50 years of age during the measurement year with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. The measure is used to determine whether imaging studies are overused to evaluate members with low back pain. The measure is an inverted rate. A higher score indicates appropriate treatment of low back pain.

Clinical guidelines for treating patients with acute low back pain recommend against the use of imaging in the absence of red flags (in other words, indications of a serious underlying pathology such as a fracture or tumor). Unnecessary or routine imaging is problematic because it is not associated with improved outcomes and exposes patients to unnecessary harms such as radiation exposure and further unnecessary treatment.

Measure exclusions:

Helpful tips:

Hold off on doing imaging for low back pain within the first six weeks, unless red flags are present.

Consider alternative treatment options prior to ordering diagnostic imaging studies, such as:

• Nonsteroidal anti-inflammatory drugs.
• Nonpharmacologic treatment, such as heat and massage.
• Exercise to strengthen the core and low back or physical therapy.

Other available resources:

• National Committee for Quality Assurance — NCQA.org
• Choosing Wisely — Choosingwisely.org
• American Academy of Family Physicians — AAFP.org

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

Effective for dates of service on and after June 1, 2020, the following medical injectable drugs and corresponding codes will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation or renewal in addition to other current medical necessity review of all drugs noted below. Haegarda® and Takhzyro™ will be the preferred prophylactic agents over Cinryze®. 

The Clinical Criteria below will be updated to include the required trial of the preferred drug:

Clinical Criteria is made publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.

 For questions or additional information, use this email.

Effective for dates of service on and after June 1, 2020, Anthem Blue Cross will include the specialty pharmacy drugs and corresponding codes from current clinical criteria noted below in our medical step therapy precertification review process. Step therapy review applies upon precertification initiation or renewal in addition to the current medical necessity review (as is done currently).

The clinical criteria below have been updated to include the requirement of a preferred agent effective June 1, 2020.

The clinical criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific clinical criteria.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call one of our Medi-Cal Customer Care Centers at 1‑800‑407‑4627 (outside L.A. County) or 1‑888‑285‑7801 (inside L.A. County).

Participating providers are responsible for offering members access to covered services 24/7. Access includes regular office hours on weekdays and the availability of a provider or designated agent by telephone after regular office hours, on weekends and on holidays. When unavailable, providers must arrange for on-call coverage by another participating provider. Providers are also required to meet appointment access standards as described below.

After-hours calls:

• The answering service or after-hours personnel must ask the member if the call is an emergency. In the event of an emergency, the member must be immediately directed to dial 911 or to proceed directly to the nearest hospital emergency room.
• If staff or answering service is not immediately available, an answering machine may be used. The answering machine message must instruct members with emergency health care needs to dial 911 or go directly to the nearest hospital emergency room. The message must also give members an alternative contact number so they can reach the primary care physician (PCP) or on-call provider with medical concerns or questions.
• Non-English-speaking members who call their PCP after hours should expect to get language-appropriate messages. In the event of an emergency, these messages should direct the member to dial 911 or proceed directly to the nearest hospital emergency room.
• In a nonemergency situation, members should receive instruction on how to contact the on-call provider. If an answering service is used, the service should know where to contact a telephone interpreter. All calls taken by an answering service must be returned.

Appointment access

Health care providers must make appointments for members from the time of request as follows:

Click on the attachment to view appointment access time requirements.

Specialists

The following guidelines are in place for our specialists:

• For urgent care, the specialist should see the member within 24 hours of receiving the request.
• For routine care, the specialist should see the member within 15 business days of receiving the request.
• A copy of the medical records and/or results of the visit should be sent to the PCP’s office to allow continuity of care.

Wait times

When a provider's office receives a call from an Anthem Blue Cross (Anthem) member during regular business hours for assistance and possible triage, the provider or another health care professional must either take the call or call the member back within 30 minutes of the initial call.

Noncompliance

Please ensure that you comply with the standards described; compliance with these standards is a contractual requirement. Anthem monitors compliance through a number of mechanisms, including annual telephonic surveys, to determine if participating provider offices meet the above standards. For additional details, please review the provider operations manual at https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx. 

Effective June 1, 2020, prior authorization (PA) requirements will change for the following services to be covered for Anthem Blue Cross members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following codes:

• 0156U — Copy number (for example, intellectual disability, dysmorphology), sequence analysis
• 0157U — APC (APC regulator of WNT signaling pathway) (for example, familial adenomatosis polyposis [FAP]) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0158U — MLH1 (mutL homolog 1) (for example, hereditary nonpolyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0159U — MSH2 (mutS homolog 2) (for example, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0160U — MSH6 (mutS homolog 6) (for example, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0161U — PMS2 (PMS1 homolog 2, mismatch repair system component) (for example, hereditary nonpolyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0569T — Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis
• 0570T — Transcatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session (list separately in addition to code for primary procedure)
• 0571T — Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed
• 0572T — Insertion of substernal implantable defibrillator electrode
• 0587T — Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 0588T — Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 64624 — Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
• 81277 — Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities
• E0787 — External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing
• E2398 — Wheelchair accessory, dynamic positioning hardware for back
• J0179 — Injection, brolucizumab- dbll, 1 mg

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-754-4708
• Phone: 1-888-831-2246

Not all PA requirements are listed here. PA requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com by visiting https://mediproviders.anthem.com/ca > Login. Contracted and noncontracted providers who are unable to access Availity* may call one of our Medi-Cal Managed Care Customer Care Centers at 1‑800‑407‑4627 (outside L.A. County) or 1‑888‑285‑7801 (inside L.A. County) for PA requirements.

Click here for more information about Prior authorization requirements: new 2020 codes for coverage and precertification.

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting November 2019. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.*

507833MUPENMUB

On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting December 2019. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.

508037MUPENMUB

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

Please share this notice with other members of your practice and office staff.

To view a guideline, visit https://www11.anthem.com/ca_search.html.

Updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• *SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
  • o Revised scope of document to only address benign prostatic hyperplasia (BPH)
  • o Revised medically necessary criteria for transurethral incision of the prostate by adding "prostate volume less the 30 mL”
  • o Added transurethral convective water vapor thermal ablation in individuals with prostate volume less than 80 mL and waterjet tissue ablation as medically necessary indication
  • o Moved transurethral radiofrequency needle ablation from medically necessary to not medically necessary section
  • o Moved placement of prostatic stents from standalone statement to combined not medically necessary statement
• *SURG.00037 - Treatment of Varicose Veins (Lower Extremities)
  • o Added the anterior accessory great saphenous vein (AAGSV) as medically necessary for ablation techniques when criteria are met
  • o Added language to the medically necessary criteria for ablation techniques addressing variant anatomy
  • o Added limits to retreatment to the medically necessary criteria for all procedures
• *SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
  • o Expanded scope to include gastroparesis
  • o Added gastric peroral endoscopic myotomy or peroral pyloromyotomy as investigational and not medically necessary
• *SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
  • o Expanded scope of document to include vertebral body tethering
  • o Added vertebral body tethering as investigational and not medically necessary
• *CG-LAB-14 - Respiratory Viral Panel Testing in the Outpatient Setting
  • o Clarified that respiratory viral panel (RVP) testing in the outpatient setting is medically necessary when using limited panels involving 5 targets or less when criteria are met
  • o Added RVP testing in the outpatient setting using large panels involving 6 or more targets as not medically necessary
• *CG-MED-68 - Therapeutic Apheresis
  • o Added diagnostic criteria to the condition "chronic inflammatory demyelinating polyradiculoneuropathy" (CIDP) when it is treated by plasmapheresis or immunoadsorption