 Provider News CaliforniaApril 1, 2025 April 2025 Provider NewsletterAt a glance: - Providers must participate in PAAS and After‑Hours Surveys to ensure compliance with appointment availability standards.
- Access to care standards outline maximum wait times for urgent and non‑urgent appointments, ensuring timely service availability.
- Language assistance services are offered to non‑English speakers, requiring provider scheduling three days in advance for interpreters.
Each year, we conduct the Provider Appointment Availability (PAAS) Survey and After‑Hours Survey. These surveys are administered to selected network care providers. The PAAS Survey helps measure whether members can secure appointments within time frames mandated by the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI). The After‑Hours Survey measures care providers’ compliance with emergency and after‑hours service availability standards. The surveys are administered by our contracted vendor, Sutherland Healthcare Solutions. They will conduct both surveys from July 1, 2025, through December 31, 2025. Understanding how to complyPlease review the appointment availability standards, as you may be contacted by Sutherland Healthcare Solutions for a survey: - Compliant — The care provider offers an appointment within the required appointment timeframes.
- Non‑compliant — The care provider does not offer an appointment within any of the required time frames or refuses survey participation, leading to a corrective action plan by the health plan.
- The next available appointment date and time can be either in‑person or by telehealth services.
Please review and share the following Access Standards tables with your team. Access standards for medical professionals and ancillary providers Appointment type | Maximum wait time for an appointment request | Non-urgent primary care physician (PCP) | 10 business days | Non-urgent specialty care physician (SCP) | 15 business days | Non-urgent appointment for ancillary services (for diagnosis or treatment of injury, illness, or other health condition) | 15 business days | Urgent care (not requiring prior authorization) | 48 hours | Urgent care (requiring prior authorization) (SCP) | 96 hours |
Access standards for Behavioral Health and Employee Assistance Programs (EAP) providersAppointment type | Maximum wait time for an appointment request | Non-life-threatening emergency care | Six hours Or Direct members to 911 or nearest emergency room. | Urgent care (not requiring prior authorization) | 48 hours | Urgent care (requiring prior authorization) | 96 hours | Routine office visit/non-urgent appointment | Psychiatrists: 10 business days* Non-physician mental health care/substance use disorder appointment: 10 business days Non-physician mental health care/substance use disorder follow-up:10 business days from the prior appointment for those undergoing a course of treatment EAP: Five business days |
* The DMHC Timely Access standard is 15 business days for psychiatrists; however, to comply with the NCQA accreditation standard of 10 business days, we use the more stringent standard. Access standards for after‑hours Emergency care We expect every provider’s after-hours answering service staff to instruct the caller to dial 911 or go directly to the emergency room if the caller is experiencing an emergency. Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency. | Direct members to dial 911 or go to the nearest emergency room. | Urgent requests | Available 24 hours, seven days a week. Member to reach a recorded message or live voice response providing emergency instructions. For non-emergent (urgent) matters, a mechanism to reach a medical professional or a practitioner (non-MD) with information as to when to expect a call back. |
Guidelines for Clinical Advice, Interpreter Services, and Referrals- Only appropriately qualified staff such as a physician, physician’s assistant, nurse practitioner, or registered nurse are allowed to provide triage or screening clinical advice.
- Interpreter services are coordinated by the health plan, its delegated network provider, or other delegated entity with scheduled appointments for healthcare services in a manner that ensures the provision of interpreter services at the time of the appointment without imposing a delay on the scheduling of the appointment. We require providers and office staff to document members’ requests, acceptance, or refusal of interpreter services in the medical record.
- Referrals to a specialist by a primary care provider or another specialist must meet applicable timely access standards.
The DMHC expanded the list of physicians and service‑type providers in the PAAS Survey. The table below identifies the list of the providers whose appointment availability must be assessed and reported. Primary care providers: - Primary care physicians
- Non‑physician medical practitioners providing primary care
Non‑physician mental health care (NPMH) providers: - Licensed clinical social worker
- Licensed marriage and family therapist
- Licensed professional clinical counselor (LPCC)
- Marriage and Family Therapist
- Master of social work
- Psychologist (PhD‑level)
Psychiatrists, who practice in one or more of the following specialties or subspecialties: - Psychiatry
- Additional psychiatry
- Child and adolescent psychiatry
- Geriatric psychiatry
Specialist physicians, who practice in one or more of the following specialties or subspecialties: - Cardiovascular disease and pediatric cardiology
- Dermatology and pediatric dermatology
- Endocrinology and pediatric endocrinology
- Epilepsy, neurology, and pediatric neurology
- Gastroenterology and pediatric gastroenterology
- Oncology and pediatric hematology/oncology
- Ophthalmology
- Otolaryngology and pediatric otolaryngology
- Pediatric pulmonology and pulmonology
- Urology and pediatric urology
Ancillary service providers that provide appointments to the following services: - Mammogram
- Physical therapy
Keeping you informedTo comply with the required timeframe standards, referrals to a specialist by a primary care or another specialist provider should abide by the legislation introduced by SB221 Health care coverage: timely access to care. What happens if healthcare appointment standards are not met by providers? We are required by law to gather network appointment availability information from our providers to ensure members receive appointments within specific time frames. We are regulated by the DMHC and CDI to monitor our provider network for prompt access to care. If standards are not met or providers refuse to participate in the surveys, corrective action may be initiated. In certain circumstances, time‑elapsed requirements may not be met, and we recognize the following exceptions: - Extending appointment wait times: The applicable waiting time for a particular appointment may be extended if the referring provider or medical staff member has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.
- Preventive care services and periodic follow‑up care: Preventive care services and periodic follow‑up care are not subject to the appointment availability standards. Periodic follow‑up care includes but is not limited to standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac, or mental health conditions, and laboratory and radiological monitoring for the recurrence of disease.
- Advanced access: The availability standard may be met if the provider offers an appointment to a patient within the same or the next business day from the appointment request.
Note: This exception does not apply to Commercial behavioral health. We hope this information explains our expectations, your obligations, and offers support on compliance. Resources 24/7 NurseLineMembers can access our 24/7 NurseLine to get advice from a registered nurse anytime. The toll‑free phone number is listed on the back of the member ID card, and the wait time cannot exceed 30 minutes. For patients with DMHC‑regulated health plansIf you or your patients are unable to obtain a timely referral to an appropriate provider or for more information about the regulations, visit the DMHC website at https://dmhc.ca.gov or call toll‑free 888‑466‑2219 for assistance. For patients with CDI‑regulated health plansIf you or your patients are unable to obtain a timely referral to an appropriate provider or for more information about the regulations, visit the CDI website at http://insurance.ca.gov or call toll‑free 800‑927‑4357 for assistance. Language Assistance ProgramFor members whose primary language is not English, we offer a no‑cost language assistance service through interpreters and other written languages. Providers can contact Provider Services during business hours and members can contact Member Services during business hours to language assistance services. For after hours, they will need to contact the 24/7 NurseLine. Additionally, providers need to request interpreters for face‑to‑face visits 3 business days ahead of time with at least 24 hours for cancellations. Questions
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 https://Availity.com, log in, 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 of our provider website for the appropriate contact. We hope this clarifies Anthem’s expectations and your obligations regarding compliance with timely access to care regulations and the importance of survey participation. Let us work together to meet the requirements with the least amount of difficulty and member abrasion. Achieving compliance is possible with your participation as our valued network provider. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CM-077750-25 At a glance:- The Provider Enrollment and Network Management tool on Availity offers streamlined data submission and real‑time status tracking.
- Administrators can manage access via Availity Essentials, enabling roles for provider enrollment and network management features.
- Practice profile changes are facilitated electronically through the Provider Data Management application on Availity Essentials
Starting April 24, 2025, we will add additional provider specialties and network management functionality to our Provider Enrollment and Network Management application available in Payer Spaces after logging in to Availity Essentials at https://Availity.com. Features of the Provider Enrollment and Network Management application include:- Ability to enroll as a new care provider.
- Ability to request to join our network. After review, a contract can be sent back to you digitally for an electronic signature. This eliminates the need for paper applications or paper contracts.
- A dashboard for the real‑time status of the submitted applications.
- Streamlined complete data submission.
- Additional options to manage your network.
How to use the online Provider Enrollment and Network Management applicationThe online application will guide you throughout the provider enrollment and network management process, providing status updates using My Dashboard within the Provider Enrollment and Network Management application. As a result, you know where you are in the process without having to call or email for a status. Note: For any changes to your practice profile and demographics, use the Provider Data Management (PDM) application on Availity Essentials, which allows you to electronically submit any changes to your practice profile and demographics. Availity Essentials administrators and assistant administrators can access it by going to Availity Essentials > My Providers > Provider Data Management. Accessing the Provider Enrollment application:- Log on to Availity Essentials and select Payer Spaces > Anthem > Applications > Provider Enrollment and Network Management to begin the enrollment process.
- If your organization is not currently registered for Availity Essentials, the person in your organization designated as the Availity Essentials administrator should go to https://Availity.com and select Register.
- For organizations already using Availity Essentials, your organization's Availity Essentials administrator should go to My Account Dashboard from the Availity Essentials home page to register new users and update or unlock accounts for existing users. Staff who need access to the Provider Enrollment tool need to be granted the role of Provider Enrollment.
Availity Essentials administrators and User administrators will automatically be granted access to Provider Enrollment. - If you are using Availity Essentials today and need access to provider enrollment, work with your organization’s administrator to update your Availity Essentials role. To determine who your administrator is, you can go to My Account Dashboard > My Administrators.
Contact usAvaility 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 https://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 of our provider website for the appropriate contact. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, Anthem BC Health Insurance Company, and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. CABC-CDCRCM-075195-24-CPN74723, CABC-CDCRCM-080073-25-CPN79727 We’re excited to introduce two new Payment Integrity trainings available on our Digital Solutions Learning Hub: - Payment Integrity: Emergency Dept Evaluation and Management Services
- Payment Integrity: Outpatient Evaluation and Management Services
With an initial focus on these two key educational initiatives, our purpose is to amplify your billing and coding accuracy. More trainings will be announced throughout the year. Discover what our Digital Solutions Learning Hub has to offer. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, Anthem BC Health Insurance Company, and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. CABC-CDCRCM-072237-24-CPN72085, CABC-CDCRCM-075926-24-CPN75258, CABC-CDCRCM-077812-25-CPN77515, CABC-CDCRCM-080161-25-CPN79720 When working with diabetic patients, it is essential to consider various factors to help them maintain their health and well‑being. Led by Dr. Daniel Brunner and Dr. Ann Marie Parker, this webinar will focus on adapting standardized guidelines for diabetes treatment and finding ways to overcome potential obstacles. Apply the knowledge you gain from this webinar to improve your organization’s overall quality. Key measures to be highlighted: - Diabetes Care — Blood Sugar Controlled
- Diabetes Care — Eye Exam
- Medication Adherence for Diabetes Medications
- Statins Use in Persons with Diabetes (SUPD)
- Kidney Evaluation for Patients with Diabetes (KED)
| Tuesday, April 8, 2025
Noon Eastern time
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This session is approved for one American Academy of Family Physicians credit. Register today!* * Registration page opens best in the Google Chrome browser. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, Anthem BC Health Insurance Company, and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. CABC-CDCRCM-080246-25-CPN79397 Our goal is to create and source materials to help support care providers understand and address the diverse needs of patients while maintaining professionalism, trust, and respect. Health equity means everyone has the opportunity to reach their highest level of health, and barriers must be removed. How do cultural factors influence a person's approach to illness and healthcare?Culture, including behaviors, language, beliefs, and values, shapes an individual's approach to illness. Experiences, education, and spiritual beliefs also play a role. Patients may perceive illness differently than healthcare providers. Recognizing these differences can improve health outcomes while ignoring them can lead to misunderstandings and non‑compliance. How can we address health disparities?Health disparities refer to differences in health outcomes linked to unequal social, economic, and environmental opportunities.1 Achieving health equity and optimal health outcomes involves eliminating barriers related to race, ethnicity, gender, religion, socioeconomic status, disability, and geographic location.2 Addressing these disparities fosters healthier communities, enhances quality of life, and supports economic growth by creating a more productive and resilient population. It is essential to meet people where they are in their health journeys and provide tailored healthcare access to address patients' unique needs, and we are committed to supporting our providers in this effort. Cultural competency resourcesYou can find cultural competency resources available on our provider website: - Cultural Competency and Patient Engagement:
- A training resource to increase cultural and disability competency to help effectively support the health and healthcare needs of all your patients.
- Caring for Diverse Populations Toolkit:
- A comprehensive resource to help providers and office staff increase effective communication by enhancing knowledge of the values, beliefs, and needs of all patients.
To access these resources, go to the provider website > Resources > Training Academy. Our provider manual also has details about available resources and how to access them. Prevalent non‑English languages (based on population data)Like you, we want to effectively serve the needs of diverse patients. We must all be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the top 15 non‑English languages spoken by 5% or 1,000 individuals in the state.3 Prevalent non‑English languages in California by 5% or 1000 individuals | Spanish | French (including Cajun) | Russian | Armenian | Persian (including Farsi, Dari) | Hindi | Chinese (including Mandarin, Cantonese) | Korean | Vietnamese | Japanese | Tagalog (including Filipino) | Arabic | Punjabi | Portuguese | Ilocano, Samoan, Hawaiian, or other Austronesian languages |
Language support servicesWe provide free language assistance services for our members with limited English proficiency (LEP) or hearing, speech, or visual impairments. Telephone interpreters During business hours, providers can call Provider Services to connect to an interpreter on behalf of the member. After business hours, call the 24/7 NurseLine on the back of a member ID card. Face‑to‑face interpreters If you would like to request an interpreter, including sign language, on behalf of your patient, please call Provider Services. Three business days are required to schedule services, and 24 business hours are required to cancel. TTY and relay services For members with hearing or speech loss, members may call the TTY line on the back of a member ID card or 711. After business hours, they should call the 24/7 NurseLine. Leverage the knowledge, skills, values, strategies, and techniques available to foster a trusted partnership with your patients. Access these resources today to enhance your shared journey in healthcare. Sources
1 Office of Disease Prevention and Health Promotion. (2022, Feb 6). Health Equity in Healthy People 2030. Retrieved from https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health
2 Elevance Health. (2022, Feb 7). What Are Health Disparities? Retrieved from https://elevancehealth.com/our‑approach‑to‑health/health‑equity/what‑are‑health‑disparities
3 American Community Survey, 2024 American Community Survey 1‑Year Estimates, Table B16001, generated July 2024. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, Anthem BC Health Insurance Company, and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. CABC-CDCRCM-076835-24-CPN75666 Effective on June 30, 2025, the following Carelon Medical Benefits Management Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements. Please share this notice with other members of your practice and office staff. The following guideline updates have a publish date of March 23, 2025: - Genetic Testing:
- Carrier Screening in the Reproductive Setting
- Genetic Testing for Inherited Conditions
- Hereditary Cancer Testing
- Radiology:
- Imaging of the Abdomen and Pelvis
- Imaging of the Chest
- Oncologic Imaging
- Radiation Oncology:
- Perirectal Hydrogel Spacer for Prostate Radiotherapy
- Proton Beam Therapy
- Radiation Therapy (excludes Proton)
You may access and download a copy of the current and upcoming guidelines here. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CD-075888-24-CPN74705 Summary: The Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
Please share this notice with other members of your practice and office staff. Please note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective Date | Clinical Criteria Number | Clinical Criteria Title | New or Revised | March 28, 2025 | CC-0274 | Bizengri (zenocutuzumab-zbco) | New | March 28, 2025 | CC-0275 | Ziihera (zanidatamab-hrii) | New | March 28, 2025 | CC-0276 | Tryngolza (olezarsen) | New | March 28, 2025 | CC-0072 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | Revised | March 28, 2025 | CC-0185 | Oxlumo (lumasiran) | Revised | March 28, 2025 | CC-0198 | Relizorb (immobilized lipase) cartridge | Revised | March 28, 2025 | CC-0256 | Rivfloza (nedosiran) | Revised | March 28, 2025 | CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised | March 28, 2025 | CC-0063 | Ustekinumab Agents (Stelara, Selarsdi, Imuldosa, Pyzchiva, Otulfi, Wezlana, Yesintek) | Revised | March 28, 2025 | CC-0058 | Bynfezia Pen, Sandostatin, or Sandostatin LAR (Octreotide) / Octreotide Agents | Revised | March 28, 2025 | CC-0130 | Imfinzi (durvalumab) | Revised | March 28, 2025 | CC-0094 | Pemetrexed | Revised | March 28, 2025 | CC-0003 | Immunoglobulins | Revised |
Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, and Anthem BC Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CR-077226-25-CPN76946 Summary: The Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
Please share this notice with other members of your practice and office staff. Please note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective Date | Clinical Criteria Number | Clinical Criteria Title | New or Revised | May 28, 2025 | CC-0272 | Aucatzyl (obecabtagene autoleucel) | New | May 28, 2025 | CC-0273 | Vyloy (zolbetuximab-clzb) | New | May 28, 2025 | CC-0223 | Imjudo (tremelimumab-actl) | Revised | May 28, 2025 | CC-0056 | Selected Injectable 5HT3 Antiemetic Agents | Revised | May 28, 2025 | CC-0148 | Agents for Hemophilia B | Revised | May 28, 2025 | CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised | May 28, 2025 | CC-0065 | Agents for Hemophilia A and von Willebrand Disease | Revised | May 28, 2025 | CC-0124 | Keytruda (pembrolizumab) | Revised | May 28, 2025 | CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised | May 28, 2025 | CC-0187 | Breyanzi (lisocabtagene maraleucel) | Revised | May 28, 2025 | CC-0204 | Tivdak (tisotumab vedotin-tftv) | Revised | May 28, 2025 | CC-0226 | Elahere (mirvetuximab) | Revised | May 28, 2025 | CC-0125 | Opdivo (nivolumab) | Revised | May 28, 2025 | CC-0128 | Tecentriq (atezolizumab) | Revised | May 28, 2025 | CC-0011 | Ocrevus (ocrelizumab)/Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq) | Revised | May 28, 2025 | CC-0173 | Enspryng (satralizumab-mwge) | Revised | May 28, 2025 | CC-0170 | Uplizna (inebilizumab-cdon) | Revised | May 28, 2025 | CC-0199 | Empaveli (pegcetacoplan) | Revised | May 28, 2025 | CC-0041 | Complement Inhibitors | Revised | May 28, 2025 | CC-0071 | Entyvio (vedolizumab) | Revised | May 28, 2025 | CC-0064 | Interleukin-1 Inhibitors | Revised | May 28, 2025 | CC-0042 | Monoclonal Antibodies to Interleukin-17 | Revised | May 28, 2025 | CC-0066 | Monoclonal Antibodies to Interleukin-6 | Revised | May 28, 2025 | CC-0050 | Monoclonal Antibodies to Interleukin-23 | Revised | May 28, 2025 | CC-0078 | Orencia (abatacept) | Revised | May 28, 2025 | CC-0063 | Ustekinumab Agents | Revised | May 28, 2025 | CC-0062 | Tumor Necrosis Factor Antagonists | Revised | May 28, 2025 | CC-0003 | Immunoglobulins | Revised | May 28, 2025 | CC-0073 | Alpha-1 Proteinase Inhibitor Therapy | Revised | May 28, 2025 | CC-0043 | Monoclonal Antibodies to Interleukin-5 | Revised | May 28, 2025 | CC-0029 | Dupixent (dupilumab) | Revised | May 28, 2025 | CC-0105 | Vectibix (panitumumab) | Revised | May 28, 2025 | CC-0095 | Bortezomib (Boruzu, Velcade) | Revised | May 28, 2025 | CC-0161 | Sarclisa (isatuximab-irfc) | Revised | May 28, 2025 | CC-0201 | Rybrevant (amivantamab-vmjw) | Revised | May 28, 2025 | CC-0120 | Kyprolis (carfilzomib) | Revised | May 28, 2025 | CC-0197 | Jemperli (dostarlimab-gxly) | Revised | May 28, 2025 | CC-0255 | Loqtorzi (toripalimab-tpzi) | Revised | May 28, 2025 | CC-0001 | Erythropoiesis Stimulating Agents | Revised | May 28, 2025 | CC-0002 | Colony Stimulating Factor Agents | Revised |
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CD-076580-25-CPN76226 The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third‑Party Criteria below were developed and/or revised with expanded rationales, medical necessity indications, or criteria. Some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary. Please share this notice with other members of your practice and office staff. To view a guideline, visit the Medical Policies and Clinical UM Guidelines website. Medical PoliciesThe Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These medical policies take effect April 12, 2025. Publish date | Medical Policy number | Medical Policy title | New or revised | October 1, 2024 | DME.00011 | Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | Revised | October 1, 2024 | DME.00052 | Brain Computer Interface Rehabilitation Devices | New | October 1, 2024 | LAB.00026 | Systems Pathology and Multimodal Artificial Intelligence Testing for Cancerous and Precancerous Conditions
Previously titled: Systems Pathology and Multimodal Artificial Intelligence Testing for Prostate Cancer | Revised | October 1, 2024 | LAB.00051 | Per‑ and Polyfluoroalkyl Substances PFAS Testing | New | October 1, 2024 | MED.00150 | Hepzato Kit™ (melphalan hepatic delivery system) | New | October 1, 2024 | SURG.00032 | Patent Foramen Ovale and Left Atrial Appendage Closure Devices
Previously titled: Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention | Revised | October 1, 2024 | TRANS.00023 | Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias | Revised |
Clinical UM GuidelinesThe MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Medicare Advantage members. These guidelines take effect April 12, 2025. Publish date | Clinical UM Guideline number | Clinical UM Guideline title | New or revised | October 1, 2024 | CG‑LAB-33 | Carcinoembryonic Antigen Testing | New | October 1, 2024 | CG‑LAB-35 | Cancer Antigen 19‑9 Testing | New | October 1, 2024 | CG‑MED-39 | Bone Mineral Density Testing Measurement | Revised | October 1, 2024 | CG‑SURG-01 | Colonoscopy | Revised | October 1, 2024 | CG‑SURG-122 | Lingual Frenotomy for Ankyloglossia‑Related Feeding Difficulties | New | October 1, 2024 | CG‑SURG-57 | Diagnostic Nasal Endoscopy | Revised |
Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, and Anthem BC Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CR-075679-24-CPN74692 Effective July 1, 2025, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicaid 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. If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through Availity Essentials or by calling Provider Services at 800‑407‑4627 (TTY 711) outside L.A. County or 888‑285‑7801 (TTY 711) inside L.A. County with additional information, which may include medical records. Prior authorization requirements will be added for the following code(s): Code | Description | 31574 | Laryngoscopy, flexible; with injection(s) for augmentation (such as, percutaneous, transoral), unilateral | 65778 | Placement of amniotic membrane on the ocular surface; without sutures | 65779 | Placement of amniotic membrane on the ocular surface; single layer, sutured | 65780 | Ocular surface reconstruction; amniotic membrane transplantation, multiple layers | A2006 | Novosorb synpath dermal matrix, per square centimeter | A2007 | Restrata, per square centimeter | A2008 | Theragenesis, per square centimeter | A2009 | Symphony, per square centimeter | A2010 | Apis, per square centimeter | A2014 | Omeza collagen matrix, per 100 mg | A2015 | Phoenix Wound Matrix, per sq cm | A2016 | Permeaderm b, per square centimeter | A2017 | PermeaDerm Glove, each | A2018 | Permeaderm c, per square centimeter | A2022 | InnovaBurn or InnovaMatrix XL, per sq cm | A2023 | InnovaMatrix PD, 1 mg | A2024 | Resolve matrix or xenopatch, per square centimeter | A2025 | Miro3D, per cu cm | A2027 | Matriderm, per square centimeter | A2028 | Micromatrix flex, per mg | A2029 | Mirotract wound matrix sheet, per cubic centimeter | A4100 | Skin substitute, FDA-cleared as a device, not otherwise specified | C1832 | Autograft suspension, including cell processing and application, and all system components | C9361 | Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 cm length | Q4117 | Hyalomatrix, per square centimeter | Q4118 | Matristem micromatrix, 1 mg | Q4121 | Theraskin, per square centimeter | Q4151 | Amnioband or guardian, per square centimeter | Q4154 | Biovance, per square centimeter | Q4159 | Affinity, per square centimeter | Q4160 | Nushield, per square centimeter | Q4166 | Cytal, per square centimeter | Q4167 | Truskin, per square centimeter | Q4168 | Amnioband, 1 mg | Q4169 | Artacent wound, per square centimeter | Q4170 | Cygnus, per square centimeter | Q4171 | Interfyl, 1 mg | Q4173 | Palingen or palingen xplus, per square centimeter | Q4174 | Palingen or promatrx, 0.36 mg per 0.25 cc | Q4175 | Miroderm, per square centimeter | Q4183 | Surgigraft, per sq cm | Q4184 | Cellesta, per sq cm | Q4185 | Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc | Q4186 | Epifix, per sq cm | Q4187 | Epicord, per sq cm | Q4188 | AmnioArmor, per sq cm | Q4189 | Artacent AC, 1 mg | Q4190 | Artacent AC, per sq cm | Q4191 | Restorigin, per sq cm | Q4192 | Restorigin, 1 cc | Q4193 | Coll-e-Derm, per sq cm | Q4194 | Novachor, per sq cm | Q4195 | PuraPly, per sq cm | Q4196 | PuraPly AM, per sq cm | Q4197 | PuraPly XT, per sq cm | Q4198 | Genesis Amniotic Membrane, per sq cm | Q4199 | Cygnus matrix, per square centimeter | Q4200 | SkinTE, per sq cm | Q4201 | Matrion, per sq cm | Q4202 | Keroxx (2.5g/cc), 1cc | Q4203 | Derma-Gide, per sq cm | Q4204 | XWRAP, per sq cm | Q4205 | Membrane graft or membrane wrap, per square centimeter | Q4206 | Fluid flow or fluid GF, 1 cc | Q4208 | Novafix, per square cenitmeter | Q4209 | Surgraft, per square centimeter | Q4211 | Amnion bio or Axobiomembrane, per square centimeter | Q4212 | Allogen, per cc | Q4213 | Ascent, 0.5 mg | Q4214 | Cellesta cord, per square centimeter | Q4215 | Axolotl ambient or axolotl cryo, 0.1 mg | Q4216 | Artacent cord, per square centimeter | Q4217 | Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioWound Xplus, per square centimeter | Q4218 | Surgicord, per square centimeter | Q4219 | Surgigraft-dual, per square centimeter | Q4220 | BellaCell HD or Surederm, per square centimeter | Q4221 | Amniowrap2, per square centimeter | Q4222 | Progenamatrix, per square centimeter | Q4226 | MyOwn skin, includes harvesting and preparation procedures, per square centimeter | Q4227 | AmnioCoreTM, per sq cm | Q4229 | Cogenex Amniotic Membrane, per sq cm | Q4230 | Cogenex Flowable Amnion, per 0.5 cc | Q4231 | Corplex P, per cc | Q4232 | Corplex, per sq cm | Q4233 | SurFactor or NuDyn, per 0.5 cc | Q4234 | XCellerate, per sq cm | Q4235 | AMNIOREPAIR or AltiPly, per sq cm | Q4237 | Cryo-Cord, per sq cm | Q4238 | Derm-Maxx, per sq cm | Q4239 | Amnio-Maxx or Amnio-Maxx Lite, per sq cm | Q4240 | CoreCyte, for topical use only, per 0.5 cc | Q4241 | PolyCyte, for topical use only, per 0.5 cc | Q4242 | AmnioCyte Plus, per 0.5 cc | Q4245 | AmnioText, per cc | Q4246 | CoreText or ProText, per cc | Q4247 | Amniotext patch, per sq cm | Q4248 | Dermacyte Amniotic Membrane Allograft, per sq cm | Q4251 | Vim, per sq cm | Q4252 | Vendaje, per sq cm | Q4253 | Zenith Amniotic Membrane, per sq cm | Q4259 | Celera dual layer or celera dual membrane, per square centimeter | Q4260 | Signature apatch, per square centimeter | Q4261 | Tag, per square centimeter | Q4272 | Esano a, per square centimeter | Q4273 | Esano aaa, per square centimeter | Q4274 | Esano ac, per square centimeter | Q4275 | Esano aca, per square centimeter | Q4276 | Orion, per square centimeter | Q4278 | Epieffect, per square centimeter | Q4279 | Vendaje ac, per square centimeter | Q4280 | Xcell amnio matrix, per square centimeter | Q4281 | Barrera sl or barrera dl, per square centimeter | Q4282 | Cygnus dual, per square centimeter | Q4283 | Biovance tri-layer or biovance 3l, per square centimeter | Q4284 | Dermabind sl, per square centimeter | Q4285 | NuDYN DL or NuDYN DL MESH, per sq cm | Q4286 | NuDYN SL or NuDYN SLW, per sq cm | Q4287 | Dermabind dl, per square centimeter | Q4288 | Dermabind ch, per square centimeter | Q4289 | Revoshield + amniotic barrier, per square centimeter | Q4290 | Membrane Wrap-Hydro, per sq cm | Q4291 | Lamellas xt, per square centimeter | Q4292 | Lamellas, per square centimeter | Q4293 | Acesso dl, per square centimeter | Q4294 | Amnio quad-core, per square centimeter | Q4295 | Amnio tri-core amniotic, per square centimeter | Q4296 | Rebound matrix, per square centimeter | Q4297 | Emerge matrix, per square centimeter | Q4298 | Amnicore pro, per square centimeter | Q4299 | Amnicore pro+, per square centimeter | Q4300 | Acesso tl, per square centimeter | Q4301 | Activate matrix, per square centimeter | Q4302 | Complete aca, per square centimeter | Q4303 | Complete aa, per square centimeter | Q4304 | Grafix plus, per square centimeter | Q4311 | Acesso, per sq cm | Q4312 | Acesso AC, per sq cm | Q4313 | DermaBind FM, per sq cm | Q4314 | Reeva FT, per sq cm | Q4315 | RegeneLink Amniotic Membrane Allograft, per sq cm | Q4316 | AmchoPlast, per sq cm | Q4317 | VitoGraft, per sq cm | Q4318 | E-Graft, per sq cm | Q4319 | SanoGraft, per sq cm | Q4320 | PelloGraft, per sq cm | Q4321 | RenoGraft, per sq cm | Q4322 | CaregraFT, per sq cm | Q4323 | alloPLY, per sq cm | Q4324 | AmnioTX, per sq cm | Q4325 | ACApatch, per sq cm | Q4326 | WoundPlus, per sq cm | Q4327 | DuoAmnion, per sq cm | Q4328 | MOST, per sq cm | Q4329 | Singlay, per sq cm | Q4330 | TOTAL, per sq cm | Q4331 | Axolotl Graft, per sq cm | Q4332 | Axolotl DualGraft, per sq cm | Q4333 | ArdeoGraft, per sq cm | Q4334 | Amnioplast 1, per square centimeter | Q4335 | Amnioplast 2, per square centimeter | Q4336 | Artacent c, per square centimeter | Q4337 | Artacent trident, per square centimeter | Q4338 | Artacent velos, per square centimeter | Q4339 | Artacent vericlen, per square centimeter | Q4340 | Simpligraft, per square centimeter | Q4341 | Simplimax, per square centimeter | Q4342 | Theramend, per square centimeter | Q4343 | Dermacyte ac matrix amniotic membrane allograft, per square centimeter | Q4344 | Tri-membrane wrap, per square centimeter | Q4345 | Matrix hd allograft dermis, per square centimeter |
To request a PA, you may use one of the following methods: - Web: once logged in to Availity Essentials at https://Availity.com
- Fax: 800‑754‑4708
- Phone:
- MediCal: 888‑831‑2246
- MRMIP: 877‑273‑4193
Not all PA requirements are listed here. Detailed PA requirements are available to providers at https://providers.anthem.com/ca on the Resources tab or for contracted providers by accessing Availity Essentials at https://Availity.com. Providers may also call Provider Services at one of the following Customer Care Centers for assistance with PA requirements: - Outside Los Angeles County: 800‑407‑4627
- Inside Los Angeles County: 888‑285‑7801
UM AROW A2025M2989 Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CD-077301-25 Effective July 1, 2025, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage 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 precertification rules and must be considered first when determining coverage. If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through https://Availity.com or by calling the Provider Services number for Anthem with additional information, which may include medical records. Prior authorization requirements will be added for the following code(s): Code | Description | 15150 | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less | 15155 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less | 15271 | Application Of Skin Substitute Graft To Trunk, Arms, Legs, Total Wound Surface Area Up To 100 Sq Cm; First 25 Sq Cm Or Less Wound Surface Area | 15273 | Application Of Skin Substitute Graft To Trunk, Arms, Legs, Total Wound Surface Area Greater Than Or Equal To 100 Sq Cm; First 100 Sq Cm Wound Surface Area, Or 1% Of Body Area | 15275 | Application Of Skin Substitute Graft To Face, Scalp, Eyelids, Mouth, Neck, Ears, Orbits, Genitalia, Hands, Feet, And/Or Multiple Digits, Total Wound Surface Area Up To 100 Sq | 15277 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | 31574 | Laryngoscopy, flexible; with injection(s) for augmentation (for example, percutaneous, transoral), unilateral | 46707 | Repair of anorectal fistula with plug (for example, porcine small intestine submucosa [SIS]) | 65778 | Placement of amniotic membrane on the ocular surface; without sutures | 65779 | Placement of amniotic membrane on the ocular surface; single layer, sutured | 65780 | Ocular surface reconstruction; amniotic membrane transplantation, multiple layers | A2001 | Innovamatrix ac, per square centimeter/Original description: Miscellaneous with Motor >49.15., without comorbidities,10/2019 description: Miscellaneous M >=66.50., without comor | A2002 | Mirragen advanced wound matrix, per square centimeter/Original description: Miscellaneous with Motor >38.75 & Motor < 49.15., without comorbidities,10/2019 description: Miscella | A2004 | Xcellistem, 1 mg/Original description: Miscellaneous with Motor < 27.85, without comorbidities,10/2019 description: Miscellaneous M < 46.50 and A >=77.50., without comorbidities | A2005 | Microlyte matrix, per square centimeter/Miscellaneous M < 46.50 and A < 77.50., without comorbidities | A2006 | Novosorb synpath dermal matrix, per square centimeter | A2007 | Restrata, per square centimeter | A2008 | Theragenesis, per square centimeter | A2009 | Symphony, per square centimeter | A2010 | Apis, per square centimeter | A2011 | Supra SDRM, per sq cm | A2012 | SUPRATHEL, per sq cm | A2013 | Innovamatrix FS, per sq cm | A2014 | Omeza collagen matrix, per 100 mg | A2015 | Phoenix Wound Matrix, per sq cm | A2016 | Permeaderm b, per square centimeter | A2017 | PermeaDerm Glove, each | A2018 | Permeaderm c, per square centimeter | A2022 | InnovaBurn or InnovaMatrix XL, per sq cm | A2023 | InnovaMatrix PD, 1 mg | A2024 | Resolve matrix or xenopatch, per square centimeter | A2025 | Miro3D, per cu cm | A2027 | Matriderm, per square centimeter | A2028 | Micromatrix flex, per mg | A2029 | Mirotract wound matrix sheet, per cubic centimeter | C1832 | Autograft suspension, including cell processing and application, and all system components | C5271 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | C5273 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | C5275 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | C5277 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | C9352 | Microporous collagen implantable tube (NeuraGen Nerve Guide), per cm length | C9353 | Microporous collagen implantable slit tube (NeuraWrap Nerve Protector), per cm length | C9354 | Acellular pericardial tissue matrix of nonhuman origin (Veritas), per sq cm | C9355 | Collagen nerve cuff (NeuroMatrix), per 0.5 cm length | C9356 | Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per sq cm | C9358 | Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm | C9361 | Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 cm length | C9363 | Skin substitute (Integra Meshed Bilayer Wound Matrix), per square cm | C9364 | Porcine implant, Permacol, per sq cm | Q4101 | Apligraf, per square centimeter | Q4102 | Oasis wound matrix, per square centimeter | Q4103 | Oasis burn matrix, per square centimeter | Q4104 | Integra bilayer matrix wound dressing (bmwd), per square centimeter | Q4105 | Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm | Q4106 | Dermagraft, per square centimeter | Q4107 | Graftjacket, per square centimeter | Q4108 | Integra matrix, per square centimeter | Q4110 | Primatrix, per square centimeter | Q4111 | Gammagraft, per square centimeter | Q4112 | Cymetra, injectable, 1cc | Q4113 | GRAFTJACKET XPRESS, injectable, 1cc | Q4114 | Integra flowable wound matrix, injectable, 1 cc | Q4115 | Alloskin, per square centimeter | Q4116 | Alloderm, per square centimeter | Q4117 | Hyalomatrix, per square centimeter | Q4118 | Matristem micromatrix, 1 mg | Q4121 | Theraskin, per square centimeter | Q4122 | Dermacell, per square centimeter | Q4124 | OASIS ultra tri-layer wound matrix, per sq cm | Q4125 | Arthroflex, per sq cm | Q4128 | FlexHD, or AllopatchHD, per sq cm | Q4130 | Strattice TM, per sq cm | Q4132 | Grafix Core and GrafixPL Core, per sq cm | Q4133 | Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm | Q4134 | Hmatrix, per square centimeter | Q4136 | Ez-derm, per square centimeter | Q4137 | AmnioExcel, AmnioExcel Plus or BioDExcel, per sq cm | Q4138 | Biodfence dryflex, per square centimeter | Q4139 | Amniomatrix or biodmatrix, injectable, 1 cc | Q4140 | Biodfence, per square centimeter | Q4141 | Alloskin ac, per square centimeter | Q4142 | Xcm biologic tissue matrix, per square centimeter | Q4143 | Repriza, per square centimeter | Q4145 | Epifix, injectable, 1 mg | Q4146 | Tensix, per square centimeter | Q4147 | Architect extracellular matrix, per square centimeter | Q4148 | Neox Cord 1K, Neox Cord RT, or Clarix Cord 1K, per sq cm | Q4149 | Excellagen, 0.1 cc | Q4150 | Allowrap ds or dry, per square centimeter | Q4151 | Amnioband or guardian, per square centimeter | Q4152 | Dermapure, per square centimeter | Q4153 | Dermavest, per square centimeter | Q4154 | Biovance, per square centimeter | Q4155 | Neoxflo or clarixflo, 1 mg | Q4156 | Neox 100 or Clarix 100, per sq cm | Q4157 | Revitalon, per square centimeter | Q4158 | Kerecis Omega3, per sq cm | Q4159 | Affinity, per square centimeter | Q4160 | Nushield, per square centimeter | Q4161 | Bio-connekt wound matrix, per square centimeter | Q4162 | WoundEx Flow, BioSkin Flow, 0.5 cc | Q4163 | WoundEx, BioSkin, per sq cm | Q4164 | Helicoll, per square centimeter | Q4165 | Keramatrix, per square centimeter | Q4166 | Cytal, per square centimeter | Q4167 | Truskin, per square centimeter | Q4168 | Amnioband, 1 mg | Q4169 | Artacent wound, per square centimeter | Q4170 | Cygnus, per square centimeter | Q4171 | Interfyl, 1 mg | Q4173 | Palingen or palingen xplus, per square centimeter | Q4174 | Palingen or promatrx, 0.36 mg per 0.25 cc | Q4175 | Miroderm, per square centimeter | Q4176 | Neopatch or Therion, per sq cm | Q4177 | FlowerAmnioFlo, 0.1 cc | Q4178 | FlowerAmnioPatch, per sq cm | Q4179 | FlowerDerm, per sq cm | Q4180 | Revita, per sq cm | Q4181 | Amnio Wound, per sq cm | Q4185 | Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc | Q4186 | Epifix, per sq cm | Q4187 | Epicord, per sq cm | Q4188 | AmnioArmor, per sq cm | Q4192 | Restorigin, 1 cc | Q4195 | PuraPly, per sq cm | Q4196 | PuraPly AM, per sq cm | Q4197 | PuraPly XT, per sq cm | Q4199 | Cygnus matrix, per square centimeter | Q4201 | Matrion, per sq cm | Q4203 | Derma-Gide, per sq cm | Q4205 | Membrane graft or membrane wrap, per square centimeter | Q4213 | Ascent, 0.5 mg | Q4222 | Progenamatrix, per square centimeter | Q4239 | Amnio-Maxx or Amnio-Maxx Lite, per sq cm | Q4246 | CoreText or ProText, per cc | Q4248 | Dermacyte Amniotic Membrane Allograft, per sq cm | Q4250 | Amnioamp-mp, per square centimeter | Q4251 | Vim, per sq cm | Q4252 | Vendaje, per sq cm | Q4253 | Zenith Amniotic Membrane, per sq cm | Q4259 | Celera dual layer or celera dual membrane, per square centimeter | Q4261 | Tag, per square centimeter | Q4262 | Dual layer impax membrane, per square centimeter | Q4264 | Cocoon membrane, per square centimeter | Q4285 | NuDYN DL or NuDYN DL MESH, per sq cm | Q4286 | NuDYN SL or NuDYN SLW, per sq cm | V2790 | Amniotic Membrane |
Not all PA requirements are listed here. Detailed PA requirements are available for contracted providers by accessing https://Availity.com. Providers may also contact Provider Services via the number on the back of our member ID card for assistance with PA requirements. UM AROW A2025M2995 Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, and Anthem BC Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CR-078896-25-CPN77344 Effective July 1, 2025, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicare Advantage 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 precertification rules and must be considered first when determining coverage. If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through Availity or by calling Provider Services with additional information which may include medical records. Prior authorization requirements will be added for the following code(s): Code | Description | 0108U | Gastroenterology (Barrett's esophagus), whole slide‑digital imaging, including morphometric analysis, computer‑assisted quantitative immunolabeling of 9 protein biomarkers (p16, AMACR, p53, CD68, COX‑2, CD45RO, HIF1a, HER‑2, K20) and morphology, formalin‑fixed paraffin‑embedded tissue, algorithm reported as risk of progression to high‑grade dysplasia or cancer | 0394U | Perfluoroalkyl substances (PFAS) (for example, perfluorooctanoic acid, perfluorooctane sulfonic acid), 16 PFAS compounds by liquid chromatography with tandem mass spectrometry (LC‑MS/MS), plasma or serum, quantitative | 0457U | Perfluoroalkyl substances (PFAS) (for example, perfluorooctanoic acid, perfluorooctane sulfonic acid), 9 PFAS compounds by LC‑MS/MS, plasma or serum, quantitative | 0479U | Tau, phosphorylated, pTau217 | 0480U | Infectious disease (bacteria, viruses, fungi, and parasites), cerebrospinal fluid (CSF), metagenomic next‑generation sequencing (DNA and RNA), bioinformatic analysis, with positive pathogen identification | 0482U | Obstetrics (preeclampsia), biochemical assay of soluble fms‑like tyrosine kinase 1 (sFlt‑1) and placental growth factor (PlGF), serum, ratio reported for sFlt‑1/PlGF, with risk of progression for preeclampsia with severe features within 2 weeks | 0490U | Oncology (cutaneous or uveal melanoma), circulating tumor cell selection, morphological characterization and enumeration based on differential CD146, high molecular‑weight melanoma‑associated antigen, CD34 and CD45 protein biomarkers, peripheral blood | 0491U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of estrogen receptor (ER) protein biomarker‑expressing cells, peripheral blood | 0492U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of PD‑L1 protein biomarker‑expressing cells, peripheral blood | 0495U | Oncology (prostate), analysis of circulating plasma proteins (tPSA, fPSA, KLK2, PSP94, and GDF15), germline polygenic risk score (60 variants), clinical information (age, family history of prostate cancer, prior negative prostate biopsy), algorithm reported as risk of likelihood of detecting clinically significant prostate cancer | 0503U | Neurology (Alzheimer disease), beta amyloid (AB40, AB42, AB42/40 ratio) and tau‑protein (ptau217, np‑tau217, ptau217/np‑tau217 ratio), blood, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC‑MS/MS), algorithm score reported as likelihood of positive or negative for amyloid plaques | 0517U | Therapeutic drug monitoring, 80 or more psychoactive drugs or substances, LC‑MS/MS, plasma, qualitative and quantitative therapeutic minimally and maximally effective dose of prescribed and non‑prescribed medications | 0518U | Therapeutic drug monitoring, 90 or more pain and mental health drugs or substances, LC‑MS/MS, plasma, qualitative and quantitative therapeutic minimally effective range of prescribed and non‑prescribed medications | 0519U | Therapeutic drug monitoring, medications specific to pain, depression, and anxiety, LC‑MS/MS, plasma, 110 or more drugs or substances, qualitative and quantitative therapeutic minimally effective range of prescribed, non‑prescribed, and illicit medications in circulation | 0915T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator and dual transvenous electrodes/leads (pacing and defibrillation) | 0916T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator only | 0917T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; single transvenous lead (pacing or defibrillation) only | 0918T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; dual transvenous leads (pacing and defibrillation) only | 0919T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); pulse generator only | 0920T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); single transvenous pacing lead only | 0921T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); single transvenous defibrillation lead only | 0922T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); dual (pacing and defibrillation) transvenous leads only | 0923T | Removal and replacement of permanent cardiac contractility modulation‑defibrillation pulse generator only | 0924T | Repositioning of previously implanted cardiac contractility modulation‑defibrillation transvenous electrode(s)/lead(s), including fluoroscopic guidance and programming of sensing and therapeutic parameters | 0925T | Relocation of skin pocket for implanted cardiac contractility modulation‑defibrillation pulse generator | 0926T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation‑defibrillation system | 0927T | Interrogation device evaluation (in person) with analysis, review, and report, including connection, recording, and disconnection, per patient encounter, implantable cardiac contractility modulation‑defibrillation system | 0928T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation‑defibrillation system with interim analysis and report(s) by a physician or other qualified health care professional | 0929T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation‑defibrillation system, remote data acquisition(s), receipt of transmissions, technician review, technical support, and distribution of results | 0930T | Electrophysiologic evaluation of cardiac contractility modulation‑defibrillator leads, including defibrillation‑threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), at time of initial implantation or replacement with testing of cardiac contractility modulation‑defibrillator pulse generator | 0931T | Electrophysiologic evaluation of cardiac contractility modulation‑defibrillator leads, including defibrillation‑threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), separate from initial implantation or replacement with testing of cardiac contractility modulation‑defibrillator pulse generator | 0933T | Transcatheter implantation of wireless left atrial pressure sensor for long‑term left atrial pressure monitoring, including sensor calibration and deployment, right heart catheterization, transseptal puncture, imaging guidance, and radiological supervision and interpretation | 0934T | Remote monitoring of a wireless left atrial pressure sensor for up to 30 days, including data from daily uploads of left atrial pressure recordings, interpretation(s) and trend analysis, with adjustments to the diuretics plan, treatment paradigm thresholds, medications or lifestyle modifications, when performed, and report(s) by a physician or other qualified health care professional | 0935T | Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of ureteral sheath(s) and multiple conformable electrodes, contrast injection(s), and fluoroscopy, bilateral | 82542 | Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase | 83921 | Organic Acid, Single, Quantitative | 93701 | Bioimpedance‑derived physiologic cardiovascular analysis | A2027 | Matriderm, per square centimeter | A2028 | Micromatrix flex, per mg | A2029 | Mirotract wound matrix sheet, per cubic centimeter | A4543 | Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month | A4544 | Electrode for external lower extremity nerve stimulator for restless legs syndrome | E0738 | Upper extremity rehabilitation system providing active assistance to facilitate muscle re‑education, includes microprocessor, all components and accessories | J9248 | Injection, melphalan (Hepzato), 1 mg | L5783 | Addition to lower extremity, user adjustable, mechanical, residual limb volume management system | L5841 | Addition, endoskeletal knee‑shin system, polycentric, pneumatic swing, and stance phase control |
Not all PA requirements are listed here. Contracted providers can access the information at https://Availity.com. Providers may also call Provider Services for assistance with PA requirements. UM AROW A2024M2893 Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, and Anthem BC Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CR-076896-25-CPN76474 Effective for dates of service on and after July 1, 2025, the following non-emergency transportation code requires preapproval through Carelon Medical Benefits Management. CPT® code | Description | A0425 | Ground mileage, per statute mile |
As a reminder, ordering and servicing providers may submit preapproval requests to Carelon Medical Benefits Management in one of several ways: - Visit Carelon Medical Benefits Management’s providerportal.com:
- Online access is available 24/7 to process orders in real‑time and is the fastest and most convenient way to request authorization.
- Access via https://Availity.com.
If you have questions, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com or visit https://guidelines.carelonmedicalbenefitsmanagement.com. Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, and Anthem BC Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CR-078790-25-CPN77989 We previously shared the following policy which will be effective for dates of service on/or after January 1, 2024. New reimbursement policy: Bundled Services and Supplies — FacilityAnthem will implement a new facility reimbursement policy titled Bundled Supplies and Services-Facility. This policy identifies certain services and/or supplies ineligible for separate reimbursement when billed by a facility. These identified services and/or supplies are an integral component to the overall procedure. The Related Coding section of the policy includes a list of the CPT® and HCPCS Level II codes that are considered as always bundled and not eligible for reimbursement when reported as a stand‑alone service or with another service. Modifiers are not accepted as an override for reimbursement for always bundled services and/or supplies. To view the reimbursement policies, log in to https://Availity.com, select Anthem Blue Cross in the Payer Spaces, then select Information Center. Select Administrative Support, then select the Reimbursement Policies — Facility and Professional link. Reimbursement policies are listed in alphabetical order. If you are not registered for Availity Essentials, go to https://Availity.com and go to the upper right‑hand corner to complete the registration process. To view the reimbursement policies, log in to https://anthem.com/ca/provider. Go to For Providers > Policies, Guidelines & Manuals. Scroll down to Reimbursement Policies and select Access Policies. Policies are listed in alphabetical order. Contact usAvaility 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 https://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 of our provider website for the appropriate contact. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CABC-CM-078441-25 Effective for dates of service on and after July 1, 2025, the specialty Medicare Part B drugs listed below will be included in our preapproval review process. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these preapproval rules and must be considered first when determining coverage. Please follow the new requirements to ensure your claims are accepted. HCPCS or CPT® codes | Medicare Part B drugs | C9399, J9999 | Aucatzyl (obecabtagene autoleucel) | Q5139 | Bkemv (eculizumab-aeeb) | J3590 | Epysqli (eculizumab-aagh) | C9399, J3590 | Hympavzi (marstacimab-hncq) | J3590 | Imuldosa (ustekinumab-srlf) | J3590 | Otulfi (ustekinumab-aauz) | Q9997 | Pyzchiva IV (ustekinumab-ttwe) | Q9998 | Selarsdi (ustekinumab-aekn) | C9399, J9999 | Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) | C9399, J9999 | Vyloy (zolbetuximab-clzb) |
Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, and Anthem BC Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BC-CR-077629-25-CPN77426 This article was updated on April 1, 2025 to correct the BioPlus telephone number to 833‑549‑2145. Effective April 1, 2025, and upon member consent, specialty pharmacy prescriptions for our Group Retiree Solutions members currently being dispensed by CarelonRx Specialty Pharmacy will be transferred to BioPlus Specialty Pharmacy (BioPlus). Those of our members who will be affected received a letter in February explaining this transition. Next steps:- If the member provides consent to move to BioPlus, they will receive a phone call from BioPlus to review important information related to their prescriptions.
- If you have Group Retiree Solutions patients who choose to move their prescription, BioPlus will contact you to request new prescriptions, refills, or preapprovals.
- If you have patients who choose not to move their prescription, no action is required.
Benefits of working with BioPlusIf your patients move to BioPlus, you can expect: - Faster approvals — know in two hours whether your patient is accepted for treatment.
- Less paperwork for benefits verification and appeals.
- More help with securing patient financial assistance.
We’re here to helpIf you have questions, contact your provider relationship management representative or call BioPlus directly at 833‑549‑2145. CarelonRx Specialty Pharmacy is an independent company providing pharmacy benefit management services on behalf of the health plan. Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, and Anthem BC Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BC-CR-078431-25-CPN78340 |