As a reminder, Anthem Blue Cross’s current Outpatient Prepay Itemized Bill Review Program reviews outpatient claims more than $100,000 billed at a percent of charge prior to reimbursement to ensure items and services included on the claim are reimbursable. We are expanding the prepay program launched in 2021 requiring an itemized bill review for all outpatient services as follows:

• Effective for dates of service on or after July 1, 2022, we will add host claims and ambulatory surgery centers (ASCs) in scope.

Submitting your updates promptly helps ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information we show in our online directory has changed.

If updates are needed, you can use our online Provider Maintenance Form. Using this form, you can update:

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

Once you submit the Provider Maintenance Form, you will receive an email acknowledging that we received your request. See the Provider Maintenance Form for complete instructions.

The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.

As a reminder, effective January 1, 2022, California Senate Bill (SB) 306 requires healthcare service plans and insurers to provide coverage for home test kits for sexually transmitted diseases (STD), including the test kit and any laboratory costs of processing the kit that are deemed medically necessary or appropriate. The kit must be ordered directly by a clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs at zero-dollar cost share to Anthem Blue Cross members.

For purposes of this bill, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.

If you have any questions, contact your assigned Provider Experience associate, or visit the Contact Us page on our provider website for up-to-date contact information.

CABC-COMM-000861-22

Anthem Blue Cross would like to remind you of the procedures to follow for inpatient claim denials:

• If claim is billed as inpatient bill type in error, a replacement bill xx7 is a replacement of the same type of bill (ex. x11 and x17, or x31 and x37; you may not use a x37 to replace a x11 or a x17 to replace a x31).

• If you are changing the bill type from inpatient to outpatient or outpatient to inpatient, the original claim will need to be voided by using a frequency type 8 (void).
• The void request must be submitted first by the provider, or in conjunction with a frequency type 1 (original) inpatient or outpatient claim before the outpatient bill type claim will be processed.
• This can be done electronically or with a provider adjustment request (PAR) form.
• Further instructions are included in the provider manual.

It is inappropriate to re-bill an outpatient claim when receiving a denial/upheld appeal response for ancillary services rendered in the inpatient setting for commercial polices. This includes, but is not limited to, emergency department, imaging, laboratory services, specialty pharmacy, and surgeries.

Claims should be coded and billed based on the medical record and the physician order.

For complete information on electronic claims processing procedures, visit the Electronic Data Interchange (EDI) page on our website.

Note: This update does not apply to Medicaid or Medicare Advantage.

CABC-CM-003640-22

Reductions in missed appointments are significant

Telehealth visits are having a significant impact on missed appointments according to a study published in Counselling Psychology Quarterly. Prior to transitioning to health, clinicians in the study “Psychotherapy at a public hospital in the time of COVID-19: telehealth and implications for practice ⁱ 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.

https://www.tandfonline.com/doi/full/10.1080/09515070.2020.1777390

“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 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. ⁱⁱ

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 seven 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 National Committee for Quality Assurance (NCQA) website.

i 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

ii 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.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CABC-CM-003427-22-CPN-3427

The National Committee for Quality Assurance (NCQA) has changed, revised, and retired HEDIS^® measures for measurement year 2022. Below is a summary of some of the key changes.

Diabetes measures

NCQA has separated the Comprehensive Diabetes Care indicators into stand-alone measures:

• Hemoglobin A1c Control for Patients with Diabetes (Two rates reported: HbA1c Control (< 8%) and Poor Control HbA1c) (> 9%) (HBD)
• Eye Exam for Patients with Diabetes (EED)
• Blood Pressure Control for Patients with Diabetes (BPD)

The process measure Comprehensive Diabetes HbA1c testing was retired as the goal is to move toward more outcome-based measures.

Race/ethnicity stratification

An important step to address healthcare disparities is reporting and measuring performance. Given this, NCQA has added race and ethnicity stratifications to the following HEDIS measures:

• Colorectal Cancer Screening (COL)
• Controlling High Blood Pressure (CBP)
• Hemoglobin A1c Control for Patients with Diabetes (HBD)
• Prenatal and Postpartum Care (PPC)
• Child and Adolescent Well Care Visits (WCV)

NCQA plans to expand the race and ethnicity stratifications to additional HEDIS measures over several years to help identify and reduce disparities in care among patient populations. This effort builds on NCQA’s existing work dedicated to advancing health equity in data and quality measurements.

Measure changes

Colorectal Cancer Screening (COL): Measures the percentage of members 45 to 75 years of age who had appropriate screening for ectal cancer. The Medicaid product was added to the administrative data collection method for this measure and the age range was changed to 45 to 75 years of age. Any of the following meet criteria:

• Fecal occult blood test during the measurement year
• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year
• Colonoscopy during the measurement year or the nine years prior to the measurement year
• CT colonography during the measurement year or the four years prior to the measurement year
• Stool DNA (sDNA) with FIT test during the measurement year or the two years prior to the measurement year

This measure can also be reported as an Electronic Clinical Data Reporting System measure: Colorectal Cancer Screening (COL-E).

Antibiotic Utilization for Respiratory Conditions (AXR): A newly added metric which measures the percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event. This measure was added because antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse.

Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic use. Given this new measure, the broader Antibiotic Utilization measure has been retired.

Use of Imaging Studies for Low Back Pain (LBP): This measure was expanded to the Medicare line of business, and the upper age limit for this measure was expanded to age 75. Additional exclusions to the measure were also added.

For a complete summary of 2022 HEDIS changes, visit: https://www.ncqa.org/hedis/measures/.

Email is the quickest and most direct way to receive important information from Anthem Blue Cross. To start receiving email from us (including some sent in lieu of fax or mail), submit your information via our online form (https://bit.ly/3lLgko8).

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

Chances are, one of these teenagers has chlamydia. According to the Centers for Disease Control (CDC), one of the largest growing populations for chlamydia are teens and young adults. Chlamydia infection is often asymptomatic, and screening for asymptomatic infection is a cost-effective strategy to reduce transmission and prevent pelvic inflammatory disease among females.

Talking to a teenager about sexual health issues like chlamydia can be difficult. But, left untreated, an affected individual may develop conditions such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. To help get the conversation started, visit the National Chlamydia Coalition website at http://chlamydiacoalition.org for a free Chlamydia How-To Implementation Guide for Healthcare Providers.

Facts about chlamydia:

• The United States Preventive Services Task Force (USPSTF) recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at risk for infection.
• Chlamydia is the most commonly reported sexually transmitted disease (STD) with over
• 8 million cases reported in 2019.
• Young women account for 43% of reported cases and face the most severe consequences of an undiagnosed infection.
• It is estimated that undiagnosed STDs cause infertility in more the 20,000 women each year.

Chlamydia Screening in Women (CHL) HEDIS^® Measure

This HEDIS measure looks at the percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year, including teens and women who:

• Made comments or talked to you about sexual relations.
• Had a pregnancy test.
• Were prescribed birth control (even if used for acne treatment).
• Received gynecological services.
• Have a history of sexually transmitted diseases.
• Have a history of sexual assault or abuse.

Customer Care Centers:

• Medi-Cal Managed Care: 800-407-4627 (outside L.A. County)
• A. Care: 888-285-7801 (inside L.A. County)

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
ACA-NU-0438-22

COVID-19 impact on opioid and substance use disorders

As a result of the COVID-19 pandemic, there has been a 20% increase in substance use nationwide, and nearly 100,000 opioid overdose related deaths between 2020 and 2021.¹ Black Americans have been disproportionately affected by this increase in overdoses.² Increasing screening, brief intervention, and referral to treatment (SBIRT) may help provide an opportunity to engage those with emerging and existing substance use disorders through proactive identification and connection to professional services when indicated.

SBIRT Resources for providers

A provider toolkit for SBIRT is available on the Anthem Blue Cross provider portal. This toolkit includes SBIRT collateral materials for your use, which outline recommended screening tools, a guided SBIRT process, and resources to help identify appropriate referrals.

More about the SBIRT approach

SBIRT is a “comprehensive, integrated public health approach to the delivery of early intervention and treatment services for persons with substance use disorders (SUD), as well as those who are at risk of developing these disorders,” according to the Substance Abuse and Mental Health Service Administration (SAMHSA). The goal of SBIRT is to reduce the potential consequences of SUDs.³ 

SBIRT encounters include a brief screening and intervention that identifies:

• One or more behaviors related to risky alcohol or drug use.
• Right type and amount of treatment. 

The screening is a brief set of questions that identify the patient’s risk of SUD-related problems. The brief intervention is a short (15 to 30 minutes) counseling session to raise awareness of the risks. By leveraging motivation enhancement techniques, this seeks to work with the patient where they are at and with what they are ready and willing to do to address identified substance misuse. Referral to treatment helps the patient access specialized treatment when indicated.

The purpose of the encounter is to facilitate change with the patient’s immediate behavior or thoughts about a risky behavior. In addition, SBIRT results help those with higher levels of need to obtain long-term care, including referrals to specialty providers. This evidence-based program (EBP) has been shown to result in a $2 to 4 healthcare savings for every $1 spent.⁴ 

Healthcare providers who encounter an at-risk member have an opportunity for early intervention and referral to appropriate treatment. The core goal is to reduce and prevent problematic use, abuse, and dependence on alcohol, opioids, and other substances. SBIRT has been proven effective regardless of age, gender, race, and culture in children, adolescents, and adults.  

Encounters with patients in need of SBIRT may occur in public health, non-substance use treatment settings including primary care centers, hospital emergency rooms, trauma centers, and community health settings. Primary care providers (MD/DOs, PAs, ARNPs), behavioral health providers (therapists, counselors, psychiatrists, clinical social workers), and nurses may provide SBIRT.

Recommended screening tools include:

• Alcohol use disorder identification test (AUDIT)⁵ for adults with alcohol risk.
• Drug abuse screening test (DAST-10)⁶ for adults with drug risk.
• Car, relax, alone, forget, family or friends, trouble (CRAFFT)⁷ for children and adolescents.
• Tolerance, worried, eye opener, amnesia, k/cut down (TWEAK)⁸ for pregnant people.

Below is the SBIRT process flow.

If you need assistance connecting patients to SUD treatment, or have questions about implementing SBIRT in your practice, call one of our Medi-Cal Customer Care Centers at:

• 800-407-4627 (outside L.A. County) or
• 888-285-7801 (inside L.A. County).

1 Centers for Disease Control and Prevention (2022) https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

2 Larochelle et al. (2021) https://doi.org/10.2105/AJPH.2021.306431

3 Substance Abuse and Mental Health Services Administration (2021) https://www.samhsa.gov/sbirt

4 Gentilello et al. (2005) https://doi.org/10.1097/01.sla.0000157133.80396.1c

5 World Health Organization (1987) https://apps.who.int/iris/handle/10665/62031

6 Addiction Research Foundation (1983) https://www.drugabuse.gov/sites/default/files/audit.pdf

7 Knight et al. (1999) https://doi.org/10.1001/archpedi.153.6.591

8 Russel (1994) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6876474/

CABC-CAID-002075 and ACA-NU-0422-22

This provider bulletin is an update about information in the Medicaid Business Provider Operations Manual (POM) for Anthem Blue Cross (Anthem). For access to the latest manual, go online to https://providers.anthem.com/ca. Please note that the manual is considered part of your provider agreement, and its provisions are contractual requirements.

The California Department of Health Care Services (DHCS) requires managed care plans (MCPs) to meet the 50th percentile or minimum performance level (MPL) for a select set of quality measures also known as the Managed Care Accountability Set (MCAS). When the MPL is not met on any measure within MCAS, DHCS may impose the following actions on the MCP:

• Corrective Action Plan (CAP)
• Sanctions
• Plan Do Study Act cycle (PDSA)/Performance Improvement Plan (PIP)

As a result, Anthem has implemented quality performance requirements that require all applicable network providers, including safety net clinics, independent practitioners, primary medical groups/individual practice associations, public hospitals, and other health systems to meet the MPL for all measures with the DHCS selected MCAS measures. Anthem will closely monitor performance and hold providers accountable for meeting the MPL. Low performing providers will be subject to the following process:

• Anthem will send provider Notice of Noncompliance or Corrective Action Plan (CAP)
• Provider will have 30 days from CAP issuance to respond with a data driven improvement action plan.
• Anthem will continuously monitor provider’s performance throughout the
• Provider will have through the end of the current measurement year in which the CAP is issued to improve HEDIS^®
• The CAP will remain in place until final HEDIS rates are available in the following year and can be ongoing based on HEDIS performance.
• Failure to improve rates will result in formal contractual

Anthem will be monitoring and strictly enforcing this process effective immediately. If you have any questions, please contact your local quality associate contact.

Email is the quickest and most direct way to receive important information Anthem Blue Cross. To start receiving email from us (including some sent in lieu of fax or mail), submit your information using our online form (https://bit.ly/3lLgko8).

CABC-CD-002498-22

The total economic cost of alcohol use disorder (AUD) was estimated to be $249 billion as of 2019, according to the CDC¹ with $27 billion coming from healthcare costs.² The CDC projected the total AUD economic impact on society to b $807 per person, per year.³

AUD and healthcare spending

Alcohol contributes to the highest amount of health plan spending related to substance use 36% of Medicaid substance use claims were related to alcohol in 2020, accounting for over $129 million – an increase of 16% from 2019. Additionally, people with AUD are more likely to be high-cost claimants. In government and commercially insured patients across the country, the top 5% of high-cost claimants have either an existing AUD or health conditions resulting from alcohol use.⁴

AUD and the workforce

AUD also has a significant economic effect on the workforce by way of tardiness, absenteeism, employee turnover, and conflict. It causes a reduction in potential employees, customer base, and the taxpayer base. ⁵

AUD and mortality

Alcohol use was directly tied to 95,000 deaths annually between 2011 and 2015, according to the CDC. This was more than all other illicit substances combined including opioids, heroin, fentanyl, and methamphetamines. The CDC estimates that alcohol-attributed disease resulted in almost 685,000 years of potential life lost (YPLL) for the same period. YPLL is the estimation of the average time a person would have lived had they not died prematurely.⁶

Below is the YPLL related directly or indirectly to AUD

What if I need assistance?

If you need assistance connecting your patients to AUD or substance, use treatment, please contact of our Medi-Cal Customer Care Centers at: 800-407-4627 (outside L.A. County) or 888-285-7801 (inside L.A. County).

Email is the quickest and most direct way to receive important information Anthem Blue Cross. To start receiving email from us (including some sent in lieu of fax or mail), submit your information using our online form (https://bit.ly/3lLgko8).

1 Center for Disease Control and Prevention, 2019 https://www.cdc.gov/alcohol/features/excessive-drinking.html

2 National Institute on Drug Use, 2018 https://archives.drugabuse.gov/trends-statistics/costs-substance-abuse

3 Center for Disease Control and Prevention, 2019

4 Internal Claims Data, 2022

5 National Institute on Drug Use, 2018

6 Center for Disease Control, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6939a6.htm

ACA-NU-0423-22

Effective November 1, 2022, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by Anthem Blue Cross. Federal and state law, as well as state contract language, and CMS 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:

• 81432: Hereditary breast cancer-related disorders (such as hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, and MLH1
• L6026: Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device
• L6715: Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement

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

• Availity:* Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then select Authorizations or Auth/Referral Inquiry, as appropriate.
• Fax: 800-754-4708
• Medi-Cal Phone: 888-861-2246
• MCAP/MRMIP Phone: 877-273-4193

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://providers.anthem.com/ca. Contracted and noncontracted providers who are unable to access Availity may call one of our Customer Care Centers at one the following numbers for assistance with PA requirements:

• Outside L.A. County: 800-407-4627
• Inside L.A. County: 888-285-7801

Email is the quickest and most direct way to receive important information Anthem Blue Cross. To start receiving email from us (including some sent in lieu of fax or mail), submit your information using our online form (https://bit.ly/3lLgko8).\

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross.