Anthem Blue Cross’ (Anthem) participating providers are REQUIRED to acknowledge (annually) that Member Grievance and Appeals forms, a description of grievance procedures, and assistance in filing grievances are readily available at each contracted provider location(s).

All pertinent information related to this requirement, including access to forms (in multiple languages) and procedures, is located on Anthem’s website at anthem.com/ca/forms.

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

 

To complete this year’s required attestation, by September 15, 2021, please follow the steps below.

The process takes approximately five (5) minutes.   

1. Log into Availity: https://www.availity.com/
2. Select Payer Spaces> Anthem Blue Cross.
3. On the landing page, select Access Your Custom Learning Center from the Applications
4. Search (using keyword grievance) for the Member Grievance Form and Attestation
5. Enroll and Complete the attestation.

 

Not yet registered for the Availity Portal?

1. Visit https://www.availity.com/
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete registration. 

 

For complete registration instructions Refer to these PDF documents. For any additional questions regarding the Availity Portal, call Client Services toll-free at 1-800-282-4548.

 

We appreciate your cooperation and support.For additional information regarding member grievance and appeals requirements, please see below.

 

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

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

 

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

• Annually attesting to Member Grievance and Appeals forms,
• Provide a description of grievance procedures
• Assistance in filing grievances are readily available (at each contracting provider’s office, contracting facility, or Plan facility)

 

Information can be accessed on the process of submitting member grievances and appeals, grievance forms in multiple languages, definitions and appeal rights, on Anthem’s website at anthem.com/ca/forms and within the Anthem Blue Cross Provider Manual.

1243-0821-PN-CA

Telehealth visits are having a significant impact on missed appointments according to a study published in Counselling Psychology Quarterly. Prior to transitioning to telehealth, clinicians in the study “Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice,¹” experienced a 14.25% missed appointment rate. After transitioning to telehealth, the missed appointment rate fell to 5.63%.

Rate of missed appointments before and after transitioning to telehealth
The graph below illustrates the changes in the average rate of missed appointments (cancellations and no-show) for each of the eight clinicians in the study between the periods before and after the transition to telehealth.

“While there are a number of limitations to consider regarding this data, [which is further discussed in the study], the statistically significant reduction in missed appointments pre-and-post [digital] transition is striking,” cited in the study report.

Telehealth and telephone visits with members after a behavioral health (BH) inpatient stay meet HEDIS^® criteria for the measure: Follow-up after Hospitalization for Mental Illness (FUH). With transportation being one of the barriers to after hospitalization follow-up, telehealth visits could be an ideal solution.²

 

The FUH HEDIS measure evaluates:

• Members (6 years and older) who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner.

 

Two areas of importance for this HEDIS measure are:

1. The percentage of behavioral health inpatient discharges for which the member received follow-up within 7 days after discharge.
2. The percentage of behavioral health inpatient discharges for which the member received follow-up within 30 days after discharge.

 

These two consecutive follow-up appointments are paramount to positive outcomes as well as meeting this HEDIS measure. Telehealth visits can greatly increase the likelihood of keeping follow-up appointments leading to reduced numbers of rehospitalization and more favorable outcomes for these patients. To learn more about the FUH HEDIS measure, visit the NCQA website.

 

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

 

¹ Counselling Psychology Quarterly. Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice https://www.tandfonline.com/doi/full/10.1080/09515070.2020.1777390

² Traveling towards disease: transportation barriers to health care access. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/#:~:text=Transportation%20barriers%20are%20often%20cited,and%20thus%20poorer%20health%20outcomes

1264-0821-PN-CA 

The Comprehensive Diabetes Care HEDIS^® Measure Retinal Eye Exam (DRE) valuates the percent of adult members ages 18 to 75, with diabetes (type 1 and type 2), who had a retinal eye exam during the measurement year.

Changes to 3072F

The definition for the code 3072F (negative for retinopathy) has been redefined to: Low risk for retinopathy (no evidence of retinopathy in the prior year). This can be particularly confusing because it would not be used at the time of the exam. It would be used the following year, along with the exam coding for the current year, to indicate that retinopathy was not present the previous year.

A simpler coding solution

Using these three codes count toward the DRE measurement if they are billed in the current measurement year, or the prior year. This means you can submit the appropriate code at the time of the exam, and it covers both years:

·         2023F	Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)
·         2025F	7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed: without evidence of retinopathy (DM)
·         2033F	Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed: without evidence of retinopathy (DM)

For more about diabetic retinopathy, visit CMS.gov or use this link to read more. 

Meeting the measurement for all diabetes care

These exams are also important in evaluating the overall health of diabetic patients, as well as meeting the Comprehensive Diabetes Care HEDIS measure:

• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (>9.0%)
• HbA1c control (<8.0%)
• Retinal Eye exam performed
• Blood Pressure control (<140/90 mm Hg)

 

Record your efforts in the member’s medical records for the HbA1c tests and results, retinal eye exam, blood pressure, urine creatinine test and the estimated glomerular filtration rate test. Meeting the mark and closing gaps in care is key to good health outcomes.

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

1265-0821-PN-CA

Overview:

Join us throughout the year in a new Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving STARs ratings.

 

Program objectives:

• Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s quality and STARs ratings.

 

Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.

 

REGISTER HERE for our upcoming clinical quality webinars!

1275-0821-PN-CA

We want you to have the information you need when filing claims for our Medicare Advantage members, so your payments are received quickly and effortlessly. The shingles vaccine and the administration of the vaccine is commonly billed in error under the member’s Medicare Part B medical benefit. The shingles vaccination is a Medicare Part D pharmacy benefit, which requires the member to pay in advance of reimbursement. The member then submits the prescription drug claim form to their Medicare Part D plan for reimbursement. 

 

You can also refer the member to the pharmacy for the vaccine. The claim is usually filed for the member by the pharmacy provider using a clearinghouse platform that enables Medicare Part D claims transactions. Or, if you have access to clearinghouse platforms that enable you to file pharmacy transactions, that is another option for administering the vaccination in your office and for further serving the member.

 

The Centers for Medicare & Medicaid Services (CMS) has a helpful resource, MLN Fact Sheet: Medicare Part D Vaccines, that offers an all-inclusive look into patient access, vaccine administration, and reimbursement. Use this link to download a copy. 

 

We want you to have all the information you need to know best. For more information about filing claims, visit this link.

 

ABCCARE-0599-21

519173MUPENMUB

Learn more about the prior authorization requirement changes effective October 1, 2021 – UM AROW 1907.

ABCCRNU-0167-21519127MUPENMUB

Learn more about Infliximab Step Therapy - Effective 7/15/2021.

 

ABCCRNU-0167-21518927MUPENMUB