Participating providers with Anthem Blue Cross (Anthem) are required to annually acknowledge that each of the following are readily available at each contracted provider location:

• Consumer grievance and appeals forms
• A description of grievance procedures

Please follow the steps below to complete this year’s required attestation, which is due by
April 24, 2023. The process takes approximately five minutes.

1. Select the survey questionnaire and attestation: https://s-us.chkmkt.com/?e=308180&d=e&h=E24536B225BCE5C&l=en.
2. Answer all four questions and provide the information.
3. Complete the attestation and submit. 

Access to consumer grievance and appeals forms (in multiple languages) and procedures are located on the Anthem website at https://www.anthem.com/ca/forms.

1. Go to View by Topic and select the drop-down menu.
2. Select Grievance & Appeals.
3. Select the desired resource link/form.

We appreciate your cooperation and support. If you have any questions regarding this requirement, please contact Elisa.Hangarter@anthem.com.

For additional information regarding consumer grievance and appeals requirements, please see below.

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 consumer grievance and appeals forms and a description of grievance procedures are readily available at each contracting provider’s office, contracting facility, or plan facility.

Please review and distribute the Anthem consumer grievance and appeals forms to all your participating offices. It is important to implement processes to provide consumer grievance and appeals forms to Anthem consumers 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, which includes annually attesting that consumer grievance and appeals forms, and a description of grievance procedures are readily available at each contracting provider’s office, contracting facility, or plan facility.

Information can be accessed on the process of submitting consumer grievances and appeals, grievance forms in multiple languages, definitions, and appeal rights, on the Anthem website at https://www.anthem.com/ca/forms and within the Anthem Blue Cross provider manual.

On March 26, 2023, Carelon Medical Benefits Management Inc. (formerly AIM Specialty Health)* released operational enhancements to the ProviderPortal_SM for the Medical Oncology Program for Anthem Blue Cross. These enhancements are geared towards creating an easier intake process for users. You may notice the clinical intake screens look and function differently.

A few updates will include:

• Improved look and feel of the case entry screens.
• Removal of unnecessary biomarker questions for specific clinical scenarios.
• Revised drug dosing screens for easier input of cycle ranges and days of administration.

Resources, training, and support 

To familiarize yourself with the enhanced medical oncology authorization request process, Carelon will be hosting a series of provider training sessions. Please register to receive a unique meeting invite.

For more information 

Carelon has a designated email address for provider questions about the ProviderPortal and case entry process; please use MedicalOncologySolution@carelon.com. All member eligibility or claims questions should be directed to your health plan network representative. Thank you for your continued support of this program.

How to submit or check a prior authorization request

For DMEPOS services, Carelon Post Acute Solutions will begin receiving requests on Tuesday, June 20, 2023, for dates of service July 1, 2023, and after. 

Providers are encouraged to request authorization using NexLync. Go to https://providers.carelonmedicalbenefitsmanagement.com/postacute to get started. You can upload clinical information and check the status of your requests through this online tool 24 hours a day, seven days a week. If you are unable to use the link or website, you can call the Carelon Post Acute Solutions Provider Call Center at 844-411-9622 from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to Carelon Post Acute Solutions at 833-311-2986.

Please note: Carelon Post Acute Solutions will not review authorization requests for products/services that do not fall under Medicare-covered products/services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living, such as personal home helper services offered under essential/everyday extras.

To learn more about Carelon Post Acute Solutions and upcoming training webinars, visit https://providers.carelonmedicalbenefitsmanagement.com/postacute/provider-materials/anthem-provider-resources/ or email provider_network@carelon.com.

* Carelon Post-Acute Solutions, LLC is an independent company providing services on behalf of the health plan.

The Statin Therapy Exclusions for Patients With Cardiovascular Disease (SPC) HEDIS^® measures examines the percentage of patients with atherosclerotic cardiovascular disease (SPC) who received and adhered to statin therapy throughout the measurement year. However, statin therapy does not work for everyone, and alternative therapies are necessary to minimize their risk for future complications. If you have patients who cannot tolerate statin therapy, it is important that you document and notify us annually so we can exclude the patients from your list of open care gaps. Refer to NCQA guidelines for a complete listing of exclusion criteria.

How to submit exclusion data:

• Indicate the appropriate ICD-10 code for encounters.
• Use standard data file submission or EMR/EHR access for supplemental data collection.

Exclusions are applied based on diagnosis codes on the date of service provided on the claim or through supplemental data collection. Based on the timing of your data submission and when reports are generated, it may take several weeks for exclusions to be reflected on your reports.

Please note, if exclusions are not coded properly or given to Anthem Blue Cross (Anthem) in the proper format, the care gap will remain open until the failure reason is corrected. Patients listed on the open care gap report are assumed to tolerate statin therapy and will have their care gaps closed after claims for moderate to high intensity statins are adjudicated by Anthem.

Tips for implementing best practices and improving your quality scores:

• Educate your patients on the importance of adhering to their statin therapy regime and on potential side effects. If they start to experience muscle pain or weakness, have them contact you to discuss their options.
• Statin therapy should also be accompanied by lifestyle modifications, such as a healthy diet and exercise. Work with your patients to proactively identify and overcome any barriers that may prevent lifestyle modifications. Discuss creating a realistic, individualized exercise routine based on the patient’s ability and interests. Encourage a healthy diet based on the patient’s culture and locally available produce, stores, and resources.

If you have any questions or concerns about Anthem Blue Cross contact one of our Medi-Cal Customer Care Centers at 800-407-4627 (outside L.A. county) or 800-285-7801 (inside L.A. county). For L.A. care only: 800-285-7801. Providers can refer to the number on the back of the patient’s member ID card for Provider Services.

CABC-CDCRCM-015183-22-CPN14452

Reimbursement changes to COVID-19 laboratory services codes for Commercial, and Medicare Advantage and Medicaid 

Beginning with dates of service on or after May 12, 2023, representing the end of the COVID Public Health Emergency (PHE), or if extended, such later date, reimbursement for COVID-19 laboratory services codes will be reduced for laboratory providers contracted as Independent Laboratory (Ancillary) providers and participating in an Anthem Blue Cross (Anthem) independent laboratory provider network.

New COVID-19 laboratory service codes were implemented and reimbursed at rates to meet the needs of laboratory providers during the PHE. This notice is to inform you that reimbursement will be revised to Anthem’s standard reimbursement methodology for Independent laboratory providers for the following codes once the PHE has ended: 

The revised standard fee schedule for the COVID-19 laboratory services codes outlined above to take effect upon the expiration of the PHE, May 11, 2023, can be viewed on Availity.com.

If you have any questions regarding this notice, please contact your designated Ancillary Provider Network Manager. Please incorporate this notice into your Anthem provider agreement folder.

Make sure your correspondence includes one of these elements

The best way to send supporting documents when disputing, appealing, or sending us additional information about a claim is to use the digital applications available on Availity.com.* Using Availity.com to send attachments, such as medical records or an itemized bill, is:

• We’ll receive the documents needed faster than through the mail.
• Less expensive. No need to pull records, copy them, and then mail them. Digital submissions can be uploaded directly to the claim.
• Submitting attachments digitally is the easiest way to send them and the best way for us to receive them.
• More accurate. The information needed to identify the claim is automated, so the risk associated with submitting incorrect information on paper is eliminated.

However, if you choose to send documentation through the mail, it is important that you include at least one of the three following elements; otherwise, we will not be able to match the document to the claim and the correspondence will be returned to you, causing further delays:

1. Valid claim number and valid member ID
   or

2. Valid member ID with prefix and correct dates of service
   or

3. Valid member ID with prefix and billed charges

For a clinical appeal, ensure these elements are included:

1. Valid claim number and valid member ID
   or

2. Valid member ID with prefix and correct dates of service
   or

3. Valid member ID with prefix and billed charges
   or

4. Member name, member date of birth, and correct dates of service
   or

5. Member name, member date of birth, and authorization or reference number

This is important: We cannot match the attachment to the correct claim or member if these elements are not included with your non-digital (fax or mail) submission.

The preferred method for submitting supporting documentation is digitally because the documents are attached directly to the claim. This reduces the possibility that incorrect information is included on the paper submission.

To attach documents to your claim digitally, go to Availity.com and use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim and use the Submit Attachments button to upload your supporting documentation.

For a claim dispute or an appeal, from Availity.com, use the Claims & Payments tab to access Claims Status. Enter the necessary information to find your claim, use the Dispute button, and upload your supporting documentation. If the Dispute button capability is not available, refer to the provider manual for information about how to file a claim dispute/appeal.

If you do send supporting documentation through the mail or fax, you must include the elements noted above. It is preferable that you include this information on the first page of the correspondence you send to us. If this information is not included on your paper correspondence, we will return the correspondence to you because we are not able to validate the documentation.

For information about submitting attachments digitally, use this link to access Availity: Learn about the new claim attachments workflow.

As a reminder, Assembly Bill 1184 (AB), confidential communication of medical information codified in Civil Code §§ 56.05, 56.35 and 56.107, requires health plans, on or after July 1, 2022, to protect the confidentiality of a subscriber or enrollee’s medical information, to not require a protected individual to obtain the primary subscriber or other enrollee’s authorization to receive sensitive services or submit a claim for sensitive services if the protected individual has the right to consent to care. 

AB 1184 also requires plans to direct certain communications regarding a protected individual’s receipt of sensitive services directly to the protected individual receiving care and requires plans to notify subscribers and enrollees that they may request a confidential communication in the following methods:

• Upon initial enrollment and annually thereafter upon renewal
• In the explanation of coverage (EOC)
• On the plan’s website 

The law also prohibits plans from disclosing medical information relating to sensitive health services provided to a protected individual to the primary subscriber or any plan enrollees other than the protected individual receiving care, absent express written authorization from the protected individual receiving care.

Maintaining your online provider directory information is essential for members and healthcare partners to connect with you when needed. Please review your information frequently and let us know if any of your information we show in our online directory has changed.

Submit updates and corrections to your online directory information by using our online Provider Maintenance Form. Once you submit the form, we will send you an email acknowledging receipt of your request. Update options include:

• Add/change an address location
• Name change
• Provider leaving a group or a single location
• Phone/fax number changes
• Closing a practice location

The Consolidated Appropriations Act (CAA) implemented in 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Reviewing your information helps us ensure your online provider directory information is current.

It’s time for some of your patients to renew their Medi-Cal benefits. As states begin to recommence Medi-Cal renewals, we want to ensure you have the information needed to help your Medi-Cal patients renew their healthcare coverage. Some patients have never had to renew their coverage at all, while other patients may have forgotten the process entirely.

We’re here to help.

What steps do my patients need to take?

• Ready: Patient gets their documents ready.
• Set: Patient ensures their form is all set.
• Renew: Patient sends renewal form:
  • Via phone: Call your local county office.
  • Via mail: Send to your local county office.
  • Via in person: Patient can find their local county office by visiting https://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx.

What if I need assistance?

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials,* go to availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact.

If your practice is looking for ways to improve your vaccination strategy and help protect the health of your patients through vaccines, we can help. Let’s Vaccinate provides ready-to-use resources and strategies to help your care team increase vaccination rates.

Let’s Vaccinate https://www.letsvaccinate.org/ was redesigned to help you increase vaccination rates among your patients through ready-to-use resources that focus on the two main strategies that most directly impact your vaccination rates: one) optimizing your office workflows and two) enhancing patient engagement.  

Optimizing office workflows

Let’s Vaccinate can help your care team improve office workflows during and after office visits, as well as for proactive patient outreach. The website includes resources and strategies for:

• Leveraging electronic health record systems (EHR) to help with vaccine assessments, reminders, and documentation.
• Customizing outreach to influence your patients’ decisions to get vaccinated.
• Implementing recommended office workflows to help ensure that patients are getting the vaccines they need.

Enhancing patient engagement

Let’s Vaccinate can help your care team improve patient communication by allowing them to better understand the many social, geographic, political, economic, and environmental factors that create challenges to vaccination access, and address patients’ feelings about vaccine safety. The website includes resources and strategies for:

• Making strong recommendations.
• Addressing vaccine hesitancy and disparities.
• Using effective patient education handouts and toolkits.

Keeping your patients healthy and safe requires the collaboration of your entire care team. The power is in your hands. So, let’s get started!

Let’s Vaccinate is a collaboration of health plans, HealthyWomen, and Pfizer Inc.

Q: What is Pay Doctor Bill? 

A: Anthem contracted with a vendor to deliver options for consumers to view their claims and pay their out-of-pocket responsibility to doctors from the Sydney Health mobile app or from https://www.anthem.com/ca/provider. This is not related to the payment of health insurance premiums.

Q: What is happening with the Pay Doctor Bill option? 

A: Anthem will stop offering this option to consumers effective March 31, 2023.

Q: Why is Pay Doctor Bill going away?

A: This was not a good overall consumer (and provider) experience. We are always committed to keeping consumers at the center of everything we do and will be exploring other options.

Q: What other options will consumers have to pay doctor bills? 

A: Even though this option will no longer be available, consumers still have other ways of paying doctors:

• Through a Health Savings Account (HSA) or Flexible Spending Account (FSA) if they have this type of account
• Through the consumer’s bank’s bill pay feature on a mobile app or website
• Directly through the doctor’s secure payment website or at the doctor’s office with a debit or credit card

Q: How will consumers be notified that the feature is going away? 

A: A month prior to the Pay Doctor Bill option being removed from the Sydney Health mobile app and the Anthem website, we will notify consumers within these applications.

Q: How will providers be notified that the feature is going away? 

A: Providers will be notified about these changes in the March 1, 2023, provider newsletter.

Q: Who is the vendor that provides consumers with access to this provider payment option?

A: InstaMed* is the name of the vendor.

Please continue to check for important Medi-Cal Managed Care updates at https://providers.anthem.com/california-provider/communications/news-and-announcements for the latest Medi-Cal Managed Care information, including:

• Clinical Criteria updates
• Important: Continuity of Care updates

Medicare Advantage allows coverage of online evaluation and management services for an established patient when all requirements have been met. The communication between patient and doctor is a cumulative of seven days and with at least the minimum of the minutes for the CPT^® code being billed. Any services amounting to less than five minutes would not be appropriate to bill as an e-visit

Here is a communication by CMS to help with further questions,

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.

Please continue to check for important Medicare Advantageupdates at https://www.anthem.com/ca/provider/medicare-advantage/for the latest Medicare Advantage information, including:

• Clinical Criteria Updates
• Anthem Blue Cross expands specialty pharmacy precertification list (Imjudo, Pedmark, Tecvayli, Tzield, Vegzelma)
• Anthem Blue Cross expands specialty pharmacy precertification list (Elahere)
• New specialty pharmacy medical step therapy requirements
• Genetic testing CPT code list update for Carelon Medical Benefits Management (formerly AIM Specialty Health)
• Clinical Criteria updates