You may have a relationship with CareMore Health as a partner in caring for your patients. CareMore delivers personalized, whole-person care to improve the quality of life for your patients, ensuring better outcomes and lowering costs to improve the health standards of the healthcare system. Soon, CareMore Health will have a new name: Carelon Health.

Although the name will become Carelon Health, patients will still receive the same provider-led, patient-centered, compassionate care from the same trusted doctors and nurses they see today.

Carelon Health neighborhood care centers will continue to offer medical, behavioral, and wellness services in one location. Carelon Health’s advanced primary care can help you further enhance whole-person care.

There’s nothing that you or your patients need to do

Nothing will change regarding patient referrals or your professional relationships with clinical staff. Carelon Health will continue to provide comprehensive and integrated care to address all aspects of patients’ health. If you are a current CareMore Health provider, you will receive a notification to update the name of CareMore Health to Carelon Health in your Provider Agreement in the coming months.

Current CareMore Health patients will see the transition to Carelon Health in their fall 2023 enrollment materials.

As the physician of our members who have Affordable Care Act (ACA) health plans, you play a vital role in the success of this initiative and our compliance with ACA requirements. When members visit your practice or office, we encourage you to document all of the members’ health conditions, especially chronic diseases. As a result, there is ongoing documentation to indicate that these conditions are being assessed and managed. Ensuring proper coding on the claim is to the greatest level of specificity can help reduce the number of medical chart requests in the future.

Ensure all codes captured in your electronic medical record (EMR) system are included on the claim and not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes. However, a claim system may only have the ability of capturing four. If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being captured.

Best practices and documenting guidelines: Use clear terminology.

Include a brief statement that updates the status of each diagnosis. For example, use words such as continue, increase, add, name of medication treating the condition, refer to, return to center, follow up, and so on. This informs the coder the condition is current. Include orders for each condition if applicable.

For every medication refilled, document a diagnosis and address it in the progress note. Chronic conditions should be evaluated at least once per year.

Use the words history of to mean the condition no longer exists. For example: Document the patient has diabetes and hypertension rather than the patient has a history of diabetes and hypertension.

Please see forms and guides for a more comprehensive Commercial Risk Adjustment coding brochure.

Contact our Commercial Risk Adjustment Network Education representative if you have any questions:

Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment.

To be considered for reimbursement of reference laboratory services, the referring laboratory must be an independent clinical laboratory. Modifier 90 must be submitted to denote the referred laboratory procedure. Per the Centers for Medicare & Medicaid (CMS), an independent clinical laboratory that submits claims in paper format may not combine non-referred or self-performed and referred services on the same CMS-1500 claim form. Thus, when the referring laboratory bills for both non-referred and referred tests, it must submit two separate paper claims: one claim for non-referred tests and the other for referred tests. If submitted electronically, the reference laboratory must be represented in the 2300 or 2400 loop, REF02 element, with qualifier of F4 in REF01.

Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form.

Laboratory procedures must be rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code, does not have complete servicing provider demographic information and applicable reference laboratory provider demographic information, will be considered incomplete and rejected or denied.

If you have questions, please contact your Provider Relationship Management representative.

Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment. 

To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent for clinical laboratory services. The CLIA certificate identification number must be submitted in one of the following manners:

To be considered for reimbursement of reference laboratory services, the referring laboratory must be an independent clinical laboratory. Modifier 90 must be submitted to denote the referred laboratory procedure. Per the Centers for Medicare & Medicaid (CMS), an independent clinical laboratory that submits claims in paper format may not combine non-referred or self-performed and referred services on the same CMS-1500 claim form. Thus, when the referring laboratory bills for both non-referred and referred tests, it must submit two separate paper claims: one claim for non-referred tests and the other for referred tests. If submitted electronically, the reference laboratory must be represented in the 2300 or 2400 loop, REF02 element, with qualifier of F4 in REF01.

Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form. 

Laboratory procedures must be rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code, does not have complete servicing provider demographic information and/or applicable reference laboratory provider demographic information, will be considered incomplete and rejected or denied. 

If you have questions, please contact your Provider Relationship Management representative. 

To support the health of our members, Anthem Blue Cross (Anthem) is sending urinary tract infection (UTI) tool kits to select members who were seen in the ER for a UTI. This kit contains:

• A water bottle to help your patient stay hydrated.
• UTI test strips with instructions on use if having symptoms. These test strips are available over the counter (OTC). 
• Basic instructions on how to use the tool kit and on reasons to seek care.

You might be hearing from your patients who are Anthem members. If you have any questions, please 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).

As you are aware, the federal Consolidated Appropriations Act (CAA) of 2021 contains several provisions applicable to health plans and their providers. One of the provisions is commonly referred to as a Gag Clause provision; specifically, Section 201: Increasing Transparency by Removing Gag Clauses on Price and Quality Information.  

Commercial health plans are required to attest annually that their provider agreements are in compliance with the Gag Clause provision. Should your provider agreement with Anthem Blue Cross (Anthem) have language inconsistent with the Gag Clause provision, it is deemed by Anthem as null and void.  

To memorialize this provision in your provider agreement, we are providing a CAA Gag Clause Regulatory Addendum. Please attach this addendum to your provider agreement with Anthem.  

Thank you for the care you provide our members — your patients. 

Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com/ca/provider, then under Provider Overview, select Find Care.

Submit updates and corrections to your directory information by following the instructions on the Provider Maintenance page on our website.

Online update options include:

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

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

On November, 28 2022, the Department of Health Care Services (DHCS) released All Plan Letter (APL) 22-024, Population Health Management (PHM) Policy Guide, and the associated PHM Policy Guide, outlining a common framework and set of expectations for the PHM Program. Anthem Blue Cross (Anthem) and all its subcontractors and network providers are required to comply with the expectations in the PHM Policy Guide, including Transitional Care Services (TCS).

Starting in 2023, the State requires that managed care plans (MCPs) provide TCS to any member undergoing a care transition. Care transitions are defined as a member transferring from one setting or level of care to another, including, but not limited to: discharges from hospitals, institutions, other acute care facilities, and skilled nursing facilities (SNFs) to home- or community-based settings, Community Supports, post-acute care facilities, or long-term care (LTC) settings.

How Anthem will support Transitional Care Services:

How Providers can support Transitional Care Services:

Below are DHCS documentation requirements for Transitional Care Services:

Discharge risk assessment requirements:

Discharge planning document requirements (completed by discharge facility):

Note: Members cannot receive two different discharge documents from discharging facility and from the designated care manager

Please note: Except for members enrolled in Medicare Medicaid Plans (MMPs) or other Dual-Eligible Special Needs Plans (D-SNPs) plans, TCS requirements also apply to Anthem members when Anthem is not the primary source of coverage for the triggering service (for example, hospitalization for a Medicare FFS dual-eligible member, or an inpatient psychiatric admission covered by a County Mental Health Plan).

If you have any questions, reach out to your assigned Provider Relationship Management representative.

On May 10, 2021, the California Department of Health Care Services (DHCS) released APL 21-007, the Third-Party Tort Liability Reporting Requirement All Plan Letter (APL). This APL mandates processes for submitting service and utilization information and copies of paid invoices/claims for covered services related to third-party liability (TPL) torts to DHCS These requirements replace submission procedure previously required by APL 17-021, 11-012, and 01-002.

Providers must submit the requested service and utilization information using only the standardized DHCS Excel template and must compile all service and utilization information for covered services associated with a given Medi-Cal Managed Care member within one Excel file. 

Effective August 2, 2021, all delegated provider medical groups (PMGs) and independent physician associations (IPAs) must submit service and utilization information and, when requested, copies of paid invoices/claims for covered services to Anthem Blue Cross (Anthem) within the time frame outlined in Anthem’s request. This information must contain the following data elements:

• Name of the managed care plan or IPA
• Member name
• Date of birth (provided by DHCS)
• Client index number (CIN)
• Date of injury
• Claim control number
• Claim line number
• Claim type
• Service from date
• Service to date
• Provider legal name
• National provider identifier
• Diagnosis code 1 (primary diagnosis)
• Diagnosis code 2 (secondary diagnosis)
• Drug label name
• Amount billed
• Amount paid: the actual amount the PMG or IPA paid to the provider for services
• Reasonable value: absent the amount paid due to capitated or other service type, the reasonable value of the service must be provided, pursuant to Title 28, California Code of Regulations (CCR), section 1300.71(a)(3)3)
• CPT^® code and type
• Primary/secondary claim denial reason code and description(s)

Effective August 2, 2021, Anthem began to require all PMGs and IPAs to enter the required data into the template and email to SSB_TPL@anthem.com. 

Failure to provide the required information timely may result in issuance of a corrective action plan.

Overview

We’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes.

Engagement Hub objectives:

• Learn strategies to help you and your care team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
• Offer care providers a convenient way to earn CME credits at a time that works best for them.

Browse the listing of free CME webinars.*

* Sessions in this series are approved for one American Academy of Family Physicians credit each.

On August 19, 2022, and March 23, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross (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
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

Please share this notice with other providers in 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 policy. 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.

On August 19, 2022, and March 23, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross (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
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

Please share this notice with other providers in 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 policy. 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.

Healthcare Effectiveness Data Information Set (HEDIS^®) is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). These are used to drive improvement efforts surrounding best practices.

The Pharmacotherapy Management of COPD Exacerbation (PCE) measure assesses chronic obstructive pulmonary disease (COPD) exacerbations for adults 40 years of age and older who had appropriate medication therapy to manage an exacerbation. A COPD exacerbation is defined as an acute inpatient discharge or emergency department visit with a primary discharge diagnosis of COPD. Two rates are reported: 

• Dispensed a systemic corticosteroid (or there is evidence of an active prescription) within 14 days of the event
• Dispensed a bronchodilator (or there is evidence of an active prescription) within 30 days of the event¹

COPD is a debilitating lung condition that affects one in eight Americans age 45 and older. More than 16 million Americans have been diagnosed with COPD, and millions more have it without knowing. ² 

COPD exacerbations make up a significant portion of the costs associated with the disease. 

Appropriate prescribing of medication following exacerbation can prevent future flare-ups, improve health outcomes, and reduce the healthcare burden of COPD.³

Who has COPD?⁴

COPD action plan 

A COPD action plan is a personalized patient tool that includes the important steps to help manage COPD. It allows patients to track how they are doing and note any concerns to discuss with their provider. It addresses medications, exercise, diet, and avoidance of triggers, such as tobacco products and other inhaled irritants. The plan should be discussed at each visit and updated as needed.⁵ 

HEDIS helpful tips:

• Schedule a follow-up appointment after discharge and confirm that the patient has the appropriate medications. 
• Reconcile patients’ medications with those prescribed at discharge when you receive the discharge summary.
• Ask the patient if they have any barriers that prevent them from filling their prescriptions. 
• Assure patients with COPD are up to date on their vaccinations, including flu, pneumococcal, and COVID-19. 
• Provide a COPD action plan for the patient, including daily medications, trigger avoidance, and what to do when flare-ups do occur:
  • American Lung Association COPD Action Plan & Management Tools

Resources: 

1. NCQA. Pharmacotherapy Management of COPD Exacerbation. Pharmacotherapy Management of COPD Exacerbation - NCQA
2. National Heart, Lung and Blood Institute. COPD National Action Plan. https://tinyurl.com/4sphb6fy
3. Pasquale, M.K., S.X. Sun, F. Song, H.J. Hartnett, and S.A. Stemkowski. Impact of exacerbations on health care cost and resource utilization in chronic obstructive pulmonary disease patients with chronic bronchitis from a predominantly Medicare population. International Journal of COPD 7:757-64. doi: 10.2147/COPD.S36997. https://tinyurl.com/yma3yt7r
4. Chronic Obstructive Pulmonary Disease and Smoking Status— United States, 2017, Morbidity and Mortality Weekly Report (MMWR),68(24), pp. 533-538 (June 21, 2019), Centers for Disease Control and Prevention (CDC). 
5. American Lung Association. COPD Action Plan & Management Tools. American Lung Association COPD Action Plan & Management Tools

Section: Member Quality of Care/Quality of Service Investigations, Page 95 of the Manual, is updated as set forth below. The Subsections of the Manual titled Severity Levels for Quality Assurance and Trend Threshold for Analysis are deleted.

Member Quality of Care/Quality of Service Investigations

OVERVIEW

The Grievances and Appeals department develops, maintains and implements policies and procedures for identifying, reporting and evaluating potential quality of care/service (“QOC”/”QOS”) concerns or sentinel events involving Anthem Blue Cross (Anthem) Members. This includes cases reviewed as the result of a grievance submitted by a Member and potential quality issues (“PQI”) reviewed as the result of a referral received from an Anthem clinical associate. All Anthem associates who may encounter clinical care/service concerns or sentinel events are informed of these policies.

Quality of care grievances and PQIs are processed by clinical associates. Medical records and a response from the Provider and/or Facility are requested. Requests for information, including medical records, must be returned by Providers on or before the due date on the request letter so that a determination can be made regarding the severity of the Potential QOC/QOS concern. Failure to return or timely return the requested information may result in escalation of the issue and potential corrective action, up to and including, review for termination of contract and removal from the network.

If the clinical associate determines, based on the circumstances and applicable review of records, that the matter is a non-issue with no identifiable quality concern or that the evidence suggests a known or recognized complication, the clinical associate may assign a severity level consistent with such a finding. If the circumstances and/or evidence suggests a QOC concern beyond a known or recognized complication, then the clinical associate will prepare and send a summary to the appropriate Medical Director for review.

Specialty matched reviewers evaluate the matter and an appropriate Medical Director makes a determination of the severity of the QOC matter. If the QOC matter was initiated by a Member, the Member is advised that a resolution was reached but the details and outcome of the review are protected by peer review statutes and will not be provided.

The Provider and/or Facility will also receive a letter advising of the QOC/QOS determination and any associated corrective action.

Significant quality of care issues and/or failure to participate or respond to information requests may be elevated for additional review and appropriate action including, but not limited to, referrals to the Credentialing Committee.

Providers and Facilities are contractually obligated to actively cooperate with QOC/QOS reviews/investigations.

Allegations of quality concerns regarding the care of our members requires review of relevant materials, including, but not limited to, records of member treatment and internal investigations performed by Providers and Facilities in connection with the allegations received. This information is protected by Peer Review confidentiality which will be maintained during Anthem’s QOC review.

CORRECTIVE ACTION PLANS (“CAP”)

When corrective action is required, Providers and/or Facilities will be notified of appropriate follow-up interventions which can include one or more of the following: development of a CAP from the Provider and/or Facility to address the reviewed issues of concern, Continuing Medical Education, chart reviews, on-site audits, tracking and trending, Provider and/or Facility counseling, and/or referral to the appropriate committee for additional action. Providers and Facilities that fail to comply with requests associated with potential QOC/QOS allegations, such as the request for information for investigations, the completion of corrective action plans by the noticed deadline and/or failure to comply with the terms of a corrective action plan will be referred to the Credentialing Committee for further actions, up to and including, termination of contract and removal from the network.

REPORTING

G&A leadership reports grievance and PQI rates, categories, and trends; to the appropriate Quality Improvement Committee on a bi-annual basis or more often as appropriate. Quality improvement or educational opportunities are reported, and corrective measures implemented, as applicable. Results of corrective actions are reported to the Committee. The Quality Council reviews these trends annually during the process of prioritizing quality improvement activities for the subsequent year.

The problem

In 2021, there were 2,855 cases of congenital syphilis reported for a rate of 77.9 per 100,000 live births. From 2012 to 2021, the number of cases of congenital syphilis increased 754.8% (334 to 2,855 cases), concurrent with a 676.2% increase (2.1 to 16.3 per 100,000 lives) in the rate of primary and secondary syphilis among women aged 15 to 44 years.¹

Maternal syphilis is associated with a 21% increased risk for stillbirth, 6% increased risk for preterm delivery, and 9% increased risk for neonatal death.²

Optimal treatment of syphilis during pregnancy is estimated to reduce the risk of congenital syphilis by 98%, stillbirth by 82%, preterm birth by 64%, and neonatal mortality by 80%.³ Syphilis is treatable and curable with penicillin. One in two newborn syphilis cases in the United States occur due to gaps in testing and treatment during prenatal care.³

Congenital syphilis: missed prevention opportunities¹

You can make a difference — screen appropriately² and treat early⁴!

Universal screening: All pregnant women at their first prenatal visit. Treat immediately.

High risk screening: Twice in third trimester (28 weeks and at delivery). Ask, document, rescreen:

• History of sex with multiple partners
• Sex in conjunction with drug use or transactional sex
• No prenatal care or late entry
• Methamphetamine or heroin use
• Unstable housing or homelessness
• Incarceration of the woman or her partner
• Prior syphilis diagnosis

High prevalence screening: Twice in third trimester (28 weeks and at delivery) for pregnant women who live in communities with high rates of syphilis. For more information, visit https://gis.cdc.gov/grasp/nchhstpatlas/maps.html.

Do you know the law in your state? Check your state health department website for updated recommendations.

Do you practice in a high prevalence area? Universal screening in the third trimester and at birth are recommended.

Anthem is committed to ensuring all our members have controlled blood pressure. We’re encouraging you to recheck any elevated readings taken at the start of the appointment again before the patient leaves, in hopes of obtaining a reading of less than 140/90 mmHg. If the second reading continues to be elevated, have the member return in a few weeks for a blood pressure recheck.

We’ve created a guide to help incorporate this practice into your office’s daily workflow with minimal disruption to your day. You can find the Healthy Blood Pressure Recheck Guide here. Please join us in making 2023 our members’ happiest and healthiest year yet!

Section: Member Quality of Care/Quality of Service Investigations, found on Page 95 of the Anthem Blue Cross (Anthem) Provider Manual, is updated as set forth below. The subsections of the manual titled, Severity Levels for Quality Assurance and Trend Threshold for Analysis are deleted. 

The Grievances and Appeals (G&A) department develops, maintains, and implements policies and procedures for identifying, reporting, and evaluating potential quality of care/service (QOC/QOS) concerns or sentinel events involving Anthem Members. This includes cases reviewed as the result of a grievance submitted by a Member and potential quality issues (PQI) reviewed as the result of a referral received from an Anthem clinical associate. All Anthem associates who may encounter clinical care/service concerns or sentinel events are informed of these policies.

Quality of care grievances and PQIs are processed by clinical associates. Medical records and a response from the Provider and/or Facility are requested. Requests for information, including medical records, must be returned by Providers on or before the due date on the request letter so that a determination can be made regarding the severity of the Potential QOC/QOS concern. Failure to return or timely return the requested information may result in escalation of the issue and potential corrective action, up to and including, review for termination of contract and removal from the network.

If the clinical associate determines, based on the circumstances and applicable review of records, that the matter is a non-issue with no identifiable quality concern or that the evidence suggests a known or recognized complication, the clinical associate may assign a severity level consistent with such a finding. If the circumstances and/or evidence suggests a QOC concern beyond a known or recognized complication, then the clinical associate will prepare and send a summary to the appropriate Medical Director for review.

Specialty matched reviewers evaluate the matter, and an appropriate Medical Director makes a determination of the severity of the QOC matter. If the QOC matter was initiated by a Member, the Member is advised that a resolution was reached but the details and outcome of the review are protected by peer review statutes and will not be provided.

The Provider and/or Facility will also receive a letter advising of the QOC/QOS determination and any associated corrective action.

Significant quality of care issues and/or failure to participate or respond to information requests may be elevated for additional review and appropriate action including, but not limited to, referrals to the Credentialing Committee.

Providers and Facilities are contractually obligated to actively cooperate with QOC/QOS reviews/investigations.

Allegations of quality concerns regarding the care of our members requires review of relevant materials, including, but not limited to, records of member treatment and internal investigations performed by Providers and Facilities in connection with the allegations received. This information is protected by Peer Review confidentiality which will be maintained during Anthem’s QOC review.

Corrective action plans (CAP)

When corrective action is required, Providers and/or Facilities will be notified of appropriate follow-up interventions which can include one or more of the following: development of a CAP from the Provider and/or Facility to address the reviewed issues of concern, Continuing Medical Education, chart reviews, on-site audits, tracking and trending, Provider and/or Facility counseling, and/or referral to the appropriate committee for additional action. Providers and Facilities that fail to comply with requests associated with potential QOC/QOS allegations, such as the request for information for investigations, the completion of corrective action plans by the noticed deadline, and/or failure to comply with the terms of a corrective action plan will be referred to the Credentialing Committee for further actions, up to and including, termination of contract and removal from the network.

Reporting

G&A leadership reports grievance and PQI rates, categories, and trends to the appropriate Quality Improvement Committee on a bi-annual basis or more often as appropriate. Quality improvement or educational opportunities are reported, and corrective measures implemented, as applicable. Results of corrective actions are reported to the Committee. The Quality Council reviews these trends annually during the process of prioritizing quality improvement activities for the subsequent year.