Effective for professional claims (CMS-1500) processed on or after November 18, 2018, Anthem Blue Cross (Anthem) will enhance our editing systems to automate edits supported by correct coding guidelines, as documented in industry sources such as CPT, HCPCS Level II, and International Classification of Diseases 10 (ICD-10).  As a result, there will be greater focus on identifying incorrect or inappropriate billing of services by multiple providers within the same tax identification number for the same patient on the same day. This enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

Below are examples of claim edits that will be automated:

• Accurate reporting of modifiers, including LT, RT, 54, 55, 56, 62,76, 77, 78, 79, 80, 81, 82, and AS, which are often reported for the billing of services rendered by the same provider or multiple providers.
• Ensuring global, professional (modifier 26) and technical components (modifier TC) are billed appropriately by one or more providers in facility and office settings.
• Assessing whether services considered once in a lifetime have been billed more than once.
• Ensuring the reporting of procedures and the associated diagnosis codes are correctly reported together. 

We’ve heard it all our lives. To be fair you should treat everybody the same. But the challenge is that everybody is not the same – and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well.

The reality is burden of illness, premature death, and disability disproportionately affects certain populations.1 MyDiversePatients.com features robust educational resources to help support you in addressing these disparities. You will find:

• CME learning experiences about disparities, potential contributing factors and opportunities for you to enhance care.
• Real life stories about diverse patients and the unique challenges they face.
• Tips and technique for working with diverse patients to promote improvement in health outcomes.

While there’s no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com is to start reversing these trends…one patient at a time. Accelerate your journey to becoming your patients’ trusted health care partner by visiting MyDiversePatient.com today.

1Centers for Disease Control and Prevention. (2013, Nov 22). CDC Health Disparities and Inequalities Report – United States, 2013. Morbidity and Mortality Weekly Report. Vol 62 (Suppl 3); p3.

The Interactive Care Reviewer (ICR) tool offers a streamlined process to request inpatient and outpatient procedures as well as locate information on previously submitted requests for Anthem Blue Cross (Anthem) members via the Availity Portal.

As you know the ICR tool provides many benefits including fax reduction, authorization determination and a comprehensive view of all your authorization requests. In addition to these benefits, the ICR tool has recently completed some enhancements to improve convenience and efficiency.

Enhancements to the ICR tool include:

• Increase in saved Favorites: The number of favorites that can be saved increased to 25 for all provider types including requesting, servicing, facility DME, and refer to providers.

• Changes to ICR Dashboard tabs: The Authorization Referral Inquiry tab at the top of the dashboard changed to Check Case Status The Search Organization Requests changed to Search Submitted Requests.

Check Case Status: The ability to view any cases submitted that are associated with the tax IDs on the request. This includes submission by phone, fax, and etc.

Search Submitted Requests: The ability to search for any ICR case requested by your organization or a request that your organization is associated with. This includes requests with a status of review not required.

• Changes to Check Case Status tab: The Search by Reference Referral Number changed to Search by Reference/Authorization Request Number.

Search by Reference Authorization Request Number: The ability to search by reference request number or authorization request number and a tax ID associated with the case.

To learn more about the ICR tool:

• Attend one of the monthly ICR webinars by registering HERE.

Try our ICR tool today!

Anthem Blue Cross (Anthem) has partnered with Availity to become our designated EDI Gateway.  The effort is currently underway, and both are committed to providing transparency for our customers.

All EDI submissions currently received today via the Anthem EDI Gateway are all now available on the Availity EDI Gateway.  There is no impact to the provider’s participation status with Anthem and no impact on how claims adjudicate.

If you are connected to Availity you can use your same connection for your EDI submissions.

If you are using another clearinghouse, contact your clearinghouse to validate their transition dates. If your clearinghouse notifies you of changes regarding connectivity, workflow, or the financial cost of EDI transactions, there is a no-cost option available to you – You can submit claims directly through Availity.

Your organization can register with Availity to submit the following transactions:

1. 837 – Institutional
2. 837 – Professional
3. 837 – Dental
4. 835 – Electronic Remittance Advice
5. 276/277 – Claim Status – real-time
6. 270/271 – Eligibility – real-time

Next steps:

• Anthem and Availity will continue to communicate and provide assistance with this transition going forward.
• Availity will be working directly with all trading partners.
• We do recommend that you register with Availity for your EDI transmissions for a free fully subsidized option.

How to register with Availity:

• If your organization is not already registered with Availity you can go to availity.com, click REGISTER and then follow the steps to register.
• Look for emails, from Availity, containing your log in credentials.
• If your organization is already registered with Availity, you can log in and click My Providers | Enrollments Center if you need to complete new 835 enrollment or make changes.

We look forward to delivering a smooth transition to the Availity EDI Gateway.

If you have any questions please contact Availity Client Services at 1-800-282-4548 Monday through Friday 5:00 a.m. to 4:30 p.m. PT. 

You are about to get some long-overdue relief as Anthem Workers’ Compensation unveils our new Digital Marketplace allowing you to set your price, fill your calendars and get paid faster. Finally there is an awesome alternative to workers’ compensation aggregators!

Just as Priceline and Uber transformed entire industries, the Anthem Workers’ Compensation Marketplace (AWCM) is set to transform workers’ compensation as we know it. We exclusively invite you as an Anthem contracted provider to reserve your place now!

Our Marketplace powered by Transparent Health Marketplace (THM) is an entirely new and transformative way to improve your business. Here are just a few of the exciting ways you will soon realize the benefits:

• Name Your Price - Set an auto-bid and/or adjust pricing in real-time to win business.
• Direct Connections – Appointment scheduling portal, payment monitoring.
• Pre-Authorized – and UR certified - no more calling adjustors!
• Fill Your Calendar – Win bids and maximize your appointment capacity!!
• Grow Revenue - Access new sources of demand from an expanding list of payors.
• Simplified Billing & Get Paid Faster - THM pays you, so you get paid quickly, accurately and electronically.

Subscribe now so we can keep you updated on our progress in preparation for our launch in California late 2018!

It’s Fun and It’s Free!  For Complete Details and to reserve you place, go to http://www.anthemwcm.com/info 

The Anthem Workers’ Compensation Digital Marketplace – The Way Networks Should Be!

By the end of 2018, Anthem Blue Cross (Anthem) members will begin receiving a new explanation of benefits (EOB) that is designed to help members better understand their health care benefits and out-of-pocket expenses. The new design will look more like a health care summary. EOBs will continue to include important information about services rendered, the amount paid to the provider, and the member out-of-pocket expense.

The new EOB will also include:

• Ways members can save on health care expenses
• A preventive care checklist, sharing important screenings that were missed
• A summary of the member’s most recent claims

Learn more about our newly designed EOB.

We invite you to go to our website to learn about the many ways health care reform and health insurance exchange may impact you. New information is added regularly. To view the latest articles on health care reform and/or health insurance exchange, and all archived articles, go to www.anthem.com/ca, scroll down the page to Partners in Health > Tools for Providers. In the middle of the page select the box Find Resources for California. From the Provider Home page, select the link titled Health Care Reform Updates and Notifications or Health Insurance Exchange Information.

The Affordable Care Act (ACA) requires many health plans to cover recommended preventive care services without member cost sharing when the services are rendered by an in-network provider and/or facility. Screening colonoscopies (even when polyps are removed) are included as a covered preventive care service. Since colonoscopies are rendered for both screening and diagnostic purposes, it is very important for providers to use appropriate coding guidelines when reporting colonoscopies. When inappropriate CPT and ICD-10 codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.

The following services are covered with no member cost share:

• The colonoscopy screening procedure.
• Anesthesia charges when anesthesia is billed with the appropriate screening CPT code (even when polyps are removed).
• Other associated facility charges when the colonoscopy is billed with an appropriate screening diagnosis code.
• When polyps are removed during a screening colonoscopy - the removal, examination and analysis of the polyps.

In the instance where a screening colonoscopy starts out as screening but turns into a diagnostic procedure due to polyps being removed, Anthem Blue Cross follows CPT guidelines for our Commercial members, not Medicare guidelines. The CPT® 2018 Professional Edition manual shares the following information regarding the billing of anesthesia for any screening colonoscopy, “Report 00812 to describe anesthesia for any screening colonoscopy regardless of ultimate findings.”

As we previously communicated, we’re pleased to announce the launch of our new provider newsletter format, designed to make it easier to read, search, and print specific articles of interest to you.  To introduce this new format, we’ve re-published the content from the August 2018 issue of Network Update, shared with you via email on August 6, in the new newsletter format we’ll use for future publications.  

Please take the opportunity to view the new format!

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

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

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

Are you an Anthem Blue Cross (Anthem) provider that needs help transitioning to using Availity’s Gateway solutions? Are you looking for SFTP or other batch upload options? If yes, check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session.

During this fast-paced hour, you’ll learn how to:

• Understand Availity’s EDI Gateway and Clearinghouse workflow
• Enroll for and manage 835 ERA delivery with Availity
• Use the Availity Portal to manage file transfers, set up EDI reporting preferences, and more.
• Access and navigate the Availity EDI Guide.

…and more.

It’s easy to enroll in one of our webinars:

1. Log in to the Availity portal.
2. Click Help & Training l Get Trained
3. In the Catalog, select Sessions
4. Scroll through Your Calendar to view upcoming live events

For your convenience is a list of upcoming webinars:

• Monday, August 20, 2018 I 12:00 p.m. to 1:00 p.m. PT
• Thursday, August 23, 2018 I 10:00 a.m. to 11:00 a.m. PT
• Tuesday, September 25, 2018 I 9:00 a.m. to 10:00 a.m. PT
• Thursday, September 27, 2018 I 12:00 p.m. to 1:00 p.m. PT

Tip: You can search the Catalog by keyword to access live and on-demand training recommendations curated by Availity Learning especially to help you with this transition. The keyword is “song” for Anthem.

A key goal of Anthem Blue Cross’ (Anthem) provider transparency efforts is to improve quality while controlling health care costs. One of the ways this is done is by giving primary care physicians (PCPs) in the Enhanced Personal Health Care (EPHC) Program quality and/or cost information about the health care providers to which the PCPs refer their Attributed Members (the “Referral Providers”). If a Referral Provider is higher quality and/or lower cost, this component of the program should result in their getting more referrals from PCPs. The converse should be true if Referral Providers are lower quality and/or higher cost. Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost information so that they can better understand how their health care dollars are being spent. This will 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.

Cost Opportunity Report

• The Cost Opportunity Report is available for EPHC providers to access via Provider Care Management Solutions (PCMS).
• The report was created to help users quickly identify meaningful and actionable opportunities to optimize costs and help achieve shared savings targets within the EPHC Program.
• By providing a standard set of potential cost opportunity metrics, the Cost Opportunity Report can be used to help evaluate the relative success of providers within the EPHC Program.
• Metrics are selected based on size of financial opportunity, ability of PCPs to affect changes, mix of impacted service types, mix of utilization and unit price impact.
• Metrics are reviewed on a periodic basis and may be added, changed or removed.

Anthem will share data on which it relied in making these quality/cost evaluations upon request, and will discuss it with Referral Providers including any opportunities for improvement. For questions or support, please contact Network Relations at CAContractSupport@anthem.com.

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

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

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

The new online form can be found on www. Anthem.com/ca.  Scroll down the page to Partners in Health > Tools for Providers. In the middle of the page select the box Find Resources for California. From the Answers@Anthem tab, select Provider Forms > Provider Change Forms > Provider Maintenance Form. In addition, the Provider Maintenance Form can be found on the Availity Web Portal by selecting California> Payer Spaces-Anthem Blue Cross> Resources tab >Provider Maintenance Form.

Important information about updating your practice profile:

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

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

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

As a reminder, the “MPN applicant shall obtain from each physician participating in the MPN a written acknowledgment in which the physician affirmatively elects to be a member of the MPN.” 

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

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

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

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

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

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

……and much more                                                             

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

Anthem Blue Cross (Anthem) 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.

Recently, Anthem Blue Cross (Anthem) partnered with Availity as our designated Electronic Data Interchange (EDI) gateway and E-Solutions Service Desk, and Anthem will not renew existing contracts with clearinghouse vendors. As a result, beginning January 1, 2019, Availity will manage all EDI trading partner relationships on behalf of Anthem. This new partnership will not interrupt your current services.

Transmitting 837 claims

If you currently transmit 837 claims using a clearinghouse, you should contact your clearinghouse as soon as possible to confirm your EDI submission path for Anthem transactions has not changed. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you – You can submit claims directly through Availity.

Direct submitters can also use Availity for their 837 transmissions.

Registering with Availity

If you choose to submit directly through Availity but are not yet a registered user, go to https://www.availity.com and select REGISTER.  The registration wizard will lead you through the enrollment process. Once complete, you will receive an email with your login credentials and next steps for getting started. If you have any questions or concerns please contact Availity at 1-800-AVAILITY (1‑800-282-4548).

It is our priority to deliver a smooth transition to Availity for our EDI services. If you have questions please contact our Customer Care Center at 1-855-817-5786.

Effective September 1, 2018, prior authorization (PA) requirements will change for injectable drug Cabazitaxel (Jevtana) to be covered by Anthem Blue Cross (Anthem). 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:

• Cabazitaxel (Jevtana) — injection, 1 mg (J9043)

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. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool (https://www.availity.com). Contracted and noncontracted providers who are unable to access Availity may call us at

1-800-407-4627 (Outside L.A. County) or 1-888-285-7801 (Inside L.A. County) for PA requirements.

Effective September 1, 2018, prior authorization (PA) requirements will change for injectable/infusible drugs mepolizumab (Nucala®) and reslizumab (Cinqair®). 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:

• Mepolizumab (Nucala) — injection, 1 mg (J2182)
• Reslizumab (Cinqair) — injection, 1 mg (J2786)

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

• Web: https//www.availity.com
• Fax: 1-800-754-4708
• Phone:
  • o 1-888-831-2246 (Medi-Cal Managed Care)
  • o 1-877-273-4193 (Major Risk Medical Insurance Program)

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-888-831-2246 (Medi-Cal Managed Care) or 1-877-273-4193 (Major Risk Medical Insurance Program) for PA requirements.

Effective with dates of service on and after May 7, 2018, Anthem Blue Cross will begin using the 22nd edition of the MCG care guidelines.

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

The Department of Health Care Services (DHCS) periodically communicates information regarding interpretations or changes in policy or procedures, federal or State law, and regulations that impact the delivery of Medi-Cal services. The information is communicated in the form of all-plan letters (APLs) and policy letters (PLs). Anthem Blue Cross has a responsibility to communicate the various changes to our contracted providers. Below are lists of the APLs and PLs that were published during the previous year.

For easy reference, please open the table attachment:  Regulatory Updates - Medical Managed Care Updates, August 2018. 

For copies of the APLs and PLs, please refer to the DHCS website at http://www.dhcs.ca.gov/formsandpubs/pages/MgdCarePlanPolicyLtrs.aspx.

If you have questions about this communication or need assistance with any other item, contact your local Medi-Cal Managed Care (Medi-Cal) Customer Care 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).

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at www.anthem.com/ca/provider by selecting Read Policies in the middle of the page.

You can request a free copy of our UM criteria from our Medical Management department. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below. To access UM criteria online, go to https://www11.anthem.com/ca/provider and select Read Policies.

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title and organization name when initiating or returning calls regarding UM issues.

You can submit precertification requests by:

• Calling us at 1-888-831-2246 and selecting option 3.
• Faxing to 1-800-754-4708.

Do you have questions about utilization decisions or the UM process?

Call our Clinical team at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A.

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross has adopted a Members Rights and Responsibilities Statement, which is located within your Provider Manual.

If you need a physical copy of the statement, call us at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County).

Obesity is a serious issue in the United States. The obesity rate is rising. Obesity has significant health consequences, contributing to increased incidence of several diseases, including metabolic syndrome, high blood pressure, diabetes, heart disease, high blood cholesterol, sleep disorders and cancers.

For detail information on obesity HEDIS® measurements and coding, please view the full update at https://mediproviders.anthem.com/Documents/CACA_CAID_ObesityCodingSpotlight.pdf.

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

Recently, Anthem Blue Cross (Anthem) partnered with Availity as our designated Electronic Data Interchange (EDI) gateway and E-Solutions Service Desk, and Anthem will not renew existing contracts with clearinghouse vendors. As a result, beginning January 1, 2019, Availity will manage all EDI trading partner relationships on behalf of Anthem. This new partnership will not interrupt your current services.

Transmitting 837 claims

If you currently transmit 837 claims using a clearinghouse, you should contact your clearinghouse as soon as possible to confirm your EDI submission path for Anthem transactions has not changed. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you – You can submit claims directly through Availity.

Direct submitters can also use Availity for their 837 transmissions.

Registering with Availity

If you choose to submit directly through Availity but are not yet a registered user, go to https://www.availity.com and select REGISTER. The registration wizard will lead you through the enrollment process. Once complete, you will receive an email with your login credentials and next steps for getting started. If you have any questions or concerns please contact Availity at 1-800-AVAILITY (1‑800-282-4548).

It is our priority to deliver a smooth transition to Availity for our EDI services. If you have questions please contact your 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).

In applicable circumstances, the appropriate modifier, condition code or value code (identified below) should be used to identify a medically recalled item. This will assist Anthem Blue Cross in identifying medically recalled items and support correct coding guidelines.

Applicable condition codes are 49 and 50. Condition code 49 signifies products replaced within the product lifecycle due to the product not functioning properly, and condition code 50 is used for product replacement for known recall of a product.

When a credit or cost reduction is received by the provider for the replacement device, applicable modifiers are FB and FC. Modifier FB is used when items are provided without cost to the provider, supplier or practitioner, and modifier FC is used when a partial credit is received by the provider, supplier or practitioner for the replacement device.

Note: In circumstances where we have reimbursed the provider for repair or replacement of items or procedures related to items due to a medical recall, we are entitled to recoup or recover fees from the manufacturer and/or distributor as applicable. In circumstances where we have reimbursed the provider the full or partial cost of a replaced device and the provider received a full or partial credit for the device, we are entitled to recoup or recover fees from the provider.

Please refer to CMS and/or your state’s guidelines, and the Medical Recalls reimbursement policy for additional details at https://mediproviders.anthem.com/ca.

Effective November 1, 2018, prior authorization (PA) requirements will change for Part B injectable/infusible drugs Azedra (iobenguane I 131) and Poteligeo (mogamulizumab) to be covered by Anthem Blue Cross for Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) 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:

• Azedra (iobenguane I 131) — for treatment of malignant pheochromocytoma and paraganglioma (J3490, J9999)
• Poteligeo (mogamulizumab) — for treatment of patients with cutaneous T-cell lymphoma (CTCL) who have received at least one prior systemic therapy (J3490, J9999)

Please note, the drugs noted above are currently billed under the not otherwise classified (NOC) HCPCS code J3490, J9999; they are unlisted because no J code has been established at this time. Since these codes include all drugs that are NOC, if the authorization is denied for medical necessity, the plan’s denial will be for the drug and not the HCPCS code.

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

• Web: https://www.availity.com
• Fax: 1-866-959-1537
• Phone: 1-855-817-5786

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call one of our Customer Care Centers at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County) for PA requirements.

In applicable circumstances, the appropriate modifier, condition code or value code (identified below) should be used to identify a medically recalled item. This will assist Anthem Blue Cross in identifying medically recalled items and support correct coding guidelines.

Applicable condition codes are 49 and 50. Condition code 49 signifies products replaced within the product lifecycle due to the product not functioning properly, and condition code 50 is used for product replacement for known recall of a product.

When a credit or cost reduction is received by the provider for the replacement device, applicable modifiers are FB and FC. Modifier FB is used when items are provided without cost to the provider, supplier or practitioner, and modifier FC is used when a partial credit is received by the provider, supplier or practitioner for the replacement device.

Note: In circumstances where we have reimbursed the provider for repair or replacement of items or procedures related to items due to a medical recall, we are entitled to recoup or recover fees from the manufacturer and/or distributor as applicable. In circumstances where we have reimbursed the provider the full or partial cost of a replaced device and the provider received a full or partial credit for the device, we are entitled to recoup or recover fees from the provider.

Please refer to CMS and/or your state’s guidelines, and the Medical Recalls reimbursement policy for additional details at https://mediproviders.anthem.com/ca.

We have several incentive programs this year to encourage Medicare Advantage members to obtain preventive screenings. Members may be rewarded when they complete their annual routine physical with their PCP.  Eligible members will receive a gift card for competing their screening mammogram, a colorectal cancer screening or their diabetes retinal exam.  Our members may ask that you confirm these screenings.

To help our members receive the DME equipment they need and help ensure no disruption in care, it is important to document that they physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. Additional details on this requirement and other information that will help ensure that your prior authorization request for a wheelchair is processed efficiently will be available at Important Medicare Advantage Updates at anthem.com/ca/medicareprovider.

Anthem accepts electronic medication prior authorization requests for Medicare plans. This feature reduces processing time and helps determine coverage more quickly. . Some prescriptions are even approved in real time so that your patients can fill a prescription without delay.

Electronic prior authorization (ePA) offers many benefits:

• More efficient review process 
• Ability to identify if a prior authorization is required 
• Able to see consolidated view of ePA submissions in real time
• Faster turnaround times
• A renewal program that allows for improved continuity of care for members with maintenance medication
• Prior authorizations are preloaded for the provider before the expiration date.

Submit ePA requests by logging in at covermymeds.com. Creating an account is FREE.

While ePA helps streamline the prior authorization process, if you must initiate a new PA request by fax or phone, please note that the contact numbers for Medicare Prior Authorization will change September 1, 2018.

If you have other questions, please contact the provider service number on the back of the member ID card.

The Centers for Medicare & Medicaid Services recently issued regulations related to opioid analgesics to help improve patient safety and reduce the misuse of opioid analgesics:  https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf

Beginning January 1, 2019, all short- and long-acting opioids will reject at the point of sale if prescribed for more than seven days.  This edit applies to members who do not have an opioid prescription in the previous 60 days.  The edit excludes members with cancer or members in hospice. 

These edits are intended to allow those with intractable pain an opportunity to maintain their pain control while helping reduce the potential for misuse or addiction among those who are experiencing acute pain.  

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

Inpatient Readmissions Medicare Advantage Update  

Prior authorization requirements for Part B drugs Retacrit, Damoctocog and Ilumya  

Medical Policy Update

Prior authorization requirements for Part B drugs: Azedra and Poteligeo  

Prior authorizations required for new group-sponsored MA membership 

Improve Medicare Advantage members’ medication adherence with 90-day prescriptions 

Prior authorization requirements for cardiovascular services  

Medicare Advantage reimbursement policy provider bulletin  

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