Beginning with claims processing on or after August 31, 2024, Anthem will implement revised claims editing logic tied to Excludes1 notes from ICD-10-CM 2020 coding guidelines. To help ensure the accurate processing of claims, care providers are encouraged to use ICD-10-CM coding guidelines when selecting the most appropriate diagnosis for member encounters. Please remember to code to the highest level of specificity. For example, if there is an indication at the category level that a code can be billed with another range of codes, it is imperative to look for Excludes1 notes that may prohibit billing a specific code combination.

The concept of Excludes1 notes is one of the unique attributes of the ICD-10-CM code set and coding conventions. An Excludes1 note indicates that the excluded code identified in the note should not be billed with the code or code range listed above the Excludes1 note. These notes appear below the affected codes; if the note appears under the category (the first three characters of a code), it applies to the entire series of codes within that category. If the Excludes1 note appears beneath a specific code (three, four, five, six, or seven characters in length) then it applies only to that specific code.

In ICD-10-CM, when a category includes an Excludes1 note, it outlines what codes should not be billed together. Examples of this code scenario would include but are not limited to the following:

• Reporting Z01.419 with Z12.4:
  • 41X (encounter GYN exam w/out abnormal findings) has an Excludes1 note below that includes Z12.4 (encounter for screening malignant neoplasm cervix).
• Reporting Z79.891with F11.2X:
  • 891 (long-term use of opiates) has an Excludes1 note after it for F11.2X (opioid dependence).
• Reporting M54.2 with M50.XX:
  • 2 (cervicalgia) has an Excludes1 note below it for M50.XX (cervicalgia due to intervertebral disc disorder).
• Reporting M54.5 with S39.012X and/or M54.4x:
  • 5 (low back pain) has an Excludes1 note below it, which includes S93.012X (strain of muscle, fascia and tendon of lower back), M54.4X (low back pain), and M51.2X (lumbago due to intervertebral disc disorder).
• Reporting J03.XX with J02.XX, J35.1, J36, J02.9:
  • Acute tonsillitis has an Excludes1 note below it, which includes J02.- (acute sore throat), J35.1 (hypertrophy of tonsils), and J36 (peritonsillar abscess).
  • Reporting N89 with R87.62X, D07.2, R87.623, N76.XX, N95.2N89 (other inflammatory disorders of the vagina) has an Excludes1 note below the category for R87.62X (abnormal results from vaginal cytological exam), D07.2 (vaginal intraepithelial neoplasia), R87.623 (HGSIL of vagina), N76.XX inflammation of the vagina), N95.2 (senile [atrophic] vaginitis), and A59.00 (trichomonal leukorrhea).

Finally, if you believe an Excludes1 note denial is incorrect, please consult the ICD-10-CM code book to verify appropriate use of the billed codes and provide supporting documentation through the normal dispute process to indicate why the billed diagnoses codes are appropriately used together.

If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.

Beginning with claims processing on or after September 1, 2024, Anthem will update their claims editing process for professional claims to support mutually exclusive places of service edits.

According to CMS policy, the place of service (POS) code used should indicate the setting in which the patient received a face-to-face encounter or where the technical component of a service was rendered in the case of an interpretation. However, when a patient is in a registered inpatient status, all services billed by all providers should reflect and acknowledge the patient's inpatient status. A physician/practitioner/supplier furnishing services to a patient who is a registered inpatient shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient receives the face-to-face encounter.

For additional information, please visit CMS.gov:

• CMS Transmittal 2679; R2679CP | CMS.
• CMS Transmittal 1170; R1170OTN | CMS.

If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.

Please review your online provider directory information on a regular basis to ensure that it’s correct. Access your online provider directory information by visiting our California provider homepage. At the top, select Find Care. Review your information and let us know if any of your directory information has changed.

Updating your information

Anthem uses the Provider Data Management (PDM) application in Availity Essentials to update your care provider or facility data. Using Availity’s PDM capability meets the quarterly attestation requirement to validate care provider demographic data set by the Consolidated Appropriations Act (CAA).

PDM features include:

• Updating care provider demographic information for all assigned payers in one location.
• Attesting to and managing current care provider demographic information using directory verification or roster submission.
• Monitoring submitted demographic updates in real-time with a digital dashboard when roster option is used.
• Reviewing the history of previously verified data.

Accessing the PDM application

To begin using PDM, log on to Availity and select My Providers > Provider Data Management. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

PDM training is available

From the Availity Essentials homepage, go to Help & Training > Find Help to locate articles and step-by-step guides. Search for provider data management and select the resulting link.

Listen to the recording of our roster automation template and rules of engagement training (on24.com) on our provider learning hub.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and secure. There is no cost for care providers to register or to use any of our digital applications. Start by going to Availity > New to Availity > Get Started at the top of the homepage to access the registration page. If you have more than one tax ID number (TIN), please ensure that you have registered all TINs associated with your account.

If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY (800-282-4548).

2024 surveys

Each year, Anthem and other health plans in California conduct provider appointment availability (PAAS) and after-hours surveys. These surveys are administered to randomly selected network providers. The PAAS survey helps measure if members can secure appointments within the timeframes mandated by the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI). The after-hours survey measures providers’ compliance with emergency and after-hours service availability standards.

The 2024 PAAS, currently in process, is administered by Anthem’s contracted vendor, Sutherland Healthcare Solutions. They will conduct the 2024 PAAS and after-hours surveys from July 1 through December 31, 2024.

Understanding how to comply

If Sutherland Healthcare Solutions contacts your office (via fax, email, or telephone) for a survey about urgent and non-urgent appointment availability, refer to the charts that follow for specific standards:

• Compliant — The provider offers an appointment within the required appointment timeframes.
• Non-compliant — The provider fails to offer an appointment within any of the required timeframes or refuses survey participation, leading to a Corrective Action Plan by Anthem.
• The next available appointment date and time can be either in-person or by telehealth services.

Please review and share the following access standards tables that follow with your team.

Access standards for medical professionals and ancillary providers

Access standards for behavioral health and EAP providers

* The DMHC timely access standard is 15 business days for psychiatrists; however, to comply with the NCQA accreditation standard of 10 business days, Anthem uses the more stringent standard.

Access standards for after-hours

• Only appropriately qualified staff such as a physician, physician assistant, nurse practitioner, or registered nurse may provide triage or screening clinical advice.
• Interpreter services are coordinated by Anthem or its delegated network provider or other delegated entity with scheduled appointments for healthcare services in a manner that ensures the provision of interpreter services at the time of the appointment without imposing a delay in scheduling the appointment. Anthem requires providers and provider office staff to document members’ request, acceptance, or refusal of interpreter services in the medical record.
• Referrals to a specialist by a primary care provider or another specialist must meet applicable timely access standards.

In 2023 DMHC expanded the list of physicians and service type providers in the PAAS. The table below identifies an updated list of these providers.

Keeping you informed

SB 221 introduced new legislation beginning January 1, 2023, which created requirements for a referral to a specialist by a primary care or another specialist provider to comply with the required timeframe standards.

Why is this important?

Anthem is required by law to gather network appointment availability information from our providers to ensure members receive appointments within specific timeframes. We are regulated by the DMHC and CDI to monitor our provider network for prompt access to care and corrective action is taken if standards are not met or when providers refuse to participate in the survey. In certain circumstances, time-elapsed requirements may not be met, and Anthem recognizes these exceptions:

• Extending appointment wait time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.

• Preventive care services and periodic follow-up care: Preventive care services and periodic follow‑up care are not subject to the appointment availability standards. These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease.

• Advanced access: The primary care appointment availability standard may be met if the PCP’s office provides advanced access. Advanced access means offering an appointment to a patient with a PCP (or nurse practitioner or physician’s assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day). Note: This exception does not apply to commercial behavioral health.

24/7 NurseLine gives peace of mind

Anthem members can access our 24/7 NurseLine, to get advice from a registered nurse anytime. The toll-free phone number is listed on the back of the member ID card and the wait time cannot exceed 30 minutes.

Help is a phone call away

For general questions or need help with referrals, please call the toll-free phone number on the back of the member ID card to speak with the member services team. Representatives are available within 10 minutes during normal business hours.

For patients with DMHC-regulated health plans

If you or your patients cannot obtain a timely referral to an appropriate provider or for more information about the regulations, visit the DMHC website at dmhc.ca.gov or call toll-free 888‑466‑2219 for help.

For patients with CDI-regulated health plans

If you or your patients cannot obtain a timely referral to an appropriate provider or for more information about the regulations, visit the CDI website at insurance.ca.gov or call toll-free 800‑927‑4357 for help.

Language assistance program

For members whose primary language is not English, Anthem offers free, language assistance services through interpreters and other written languages. If you or the member is interested in these services, please call the member services number listed on the member ID card for help (TTY/TDD: 711).

Questions

If you have questions about this communication, contact your assigned provider relationship management representative or visit anthem.com/ca/provider/contact-us for additional contact information.

We hope this clarifies Anthem’s expectations and your obligations regarding compliance with timely access to care regulations and the importance of survey participation. Let us work together to meet the requirements with the least difficulty and member abrasion. Achieving compliance is possible with your participation as our valued network provider.

We share a health vision with our care providers that means real change for consumers.

Did you know your Anthem patients can access no cost internet based cognitive behavioral therapy (iCBT) programs online 24/7?

The programs help with:

• Resilience
• Stress, Anxiety & Worry
• Social Anxiety
• Depression
• Insomnia
• Substance Use
• Panic

Improve equity and access to Mental Health Programs and services for your patients with Learn to Live. Here are some important tips to share with patients so they get the most out of it.

The self-directed programs are confidential and convenient. Learn to Live is accessible via a web browser or the app. Members can use the programs anytime - day or night.

Stick with it

Research shows the most significant improvement is seen after completing three or more lessons. In the first few lessons members may still be figuring out their goals, learning about iCBT, and learning basic tools. The more lessons they complete, the more likely they'll stick with it and feel improvement.

Work with a coach

One of the best ways to maximize the benefits of a Learn to Live program is to work with a personal coach. And it’s free! Users who work with a coach see 44% more improvement compared to those who go it alone.

Live and on-demand webinars

Learn to Live creates webinars on a wide variety of topics. They can be accessed on-demand for convenience. Watching webinars is an easy way for members to learn about mental health topics from experts.

Encourage your patients to check out our online mental health programs!

Available at no cost to members, ages 13+

To access, patients should visit:

www.learntolive.com/welcome/CAAnthem and enter code: CAAnthem

We are thrilled to announce the upcoming launch of Payment Integrity's new innovative tool, the Provider e-Learning Resource Center (PeRC). This is an exciting upgrade exemplary of our ongoing commitment to providing the best resources for your billing and coding success. PeRC is an educational platform:

• Dedicated to accurate coding initiatives, with the goal of resulting in reduced errors.
• That promotes a well-informed care provider community, enhances healthcare services, and improves outcomes.

Stay tuned for the official launch date and more details about the Provider e-Learning Resource Center from the Provider Education team.

We are committed to a future of shared success.

On August 6, 2011, the U.S. Breastfeeding Committee (USBC) officially declared August as National Breastfeeding Month.¹

In recognition of August as National Breastfeeding Month, we are introducing resources published by numerous trusted sources, including My Diverse Patients. The first is an eLearning experience, developed for care providers, nurses, office staff, and other healthcare professionals. It is titled Promoting Birth Equity. You can find it on the Maternal Health Disparities page. In addition, within the Current Trends section, we offer access to an education resource via an externally published special series called Lost Mothers: Maternal Mortality In The U.S. It includes a resource by the National Public Radio entitled Black Mothers Keep Dying After Giving Birth. Shalon Irving's Story Explains Why.

Further and in accordance, the U.S. Centers for Disease Control and Prevention (CDC) offers these key points about breastfeeding:

• Breastfeeding is the best source of nutrition for most infants.
• Breastfeeding can reduce the risk of certain health conditions for both infants and mothers.
• Only one in four infants are exclusively breastfed as recommended until they are six months old.
• CDC supports and promotes breastfeeding across the United States.

Infants who are breastfed and mothers who breastfeed have reduced risk of:

• Asthma and severe lower respiratory disease.
• Obesity.
• Type 1 diabetes.
• Acute otitis media (ear infections).
• Sudden infant death syndrome (SIDS).
• Gastrointestinal infections, which can cause diarrhea and vomiting.
• Necrotizing enterocolitis (NEC) (death of intestinal tissue) for preterm infants.

Mothers who breastfeed also have reduced risk of high blood pressure, Type 2 diabetes, ovarian cancer, and breast cancer.² 

Whole health

We are taking a holistic view that can transform health. Maternal-child health includes the entire pre‑pregnancy, pregnancy, delivery, and postpartum journey of a parent and child up to one year after birth.³

Healthy babies start with healthy pregnancies. The United States has a robust healthcare infrastructure, spending more per capita on healthcare than any other nation, but maternal health in the U.S. has lagged behind that of other developed countries.⁴ 

Certified doula care can help improve maternal and infant health outcomes

Research shows that doulas — trained professionals who counsel pregnant people before, during, and after their babies are born — can help improve maternal health outcomes by offering information and education, as well as physical, social, and emotional support. Such care has been found to reduce the rate of cesarean births, preterm births, and postpartum depression, while also improving breastfeeding rate.⁴

We look forward to working together to deliver high-quality, equitable healthcare. If you have any questions about this communication, visit the Contact Us section of our provider website.

Participating providers are responsible for offering members access to covered services 24/7. Access includes regular office hours on weekdays and the availability of a provider or designated agent by telephone after regular office hours, on weekends, and on holidays. When unavailable, providers must arrange for on-call coverage by another participating provider. Providers are also required to meet appointment access standards as described below.

After-hours calls:

• Providers must instruct their after-hours answering service to answer Anthem’s After Hours Survey questions. Non-compliant providers are subject to contractual enforcement actions, such as Corrective Action Plans (CAP) or escalated contractual sanctions for breach of contract.
• The answering service or after-hours personnel must ask the member if the call is an emergency. In the event of an emergency, the member must be immediately directed to dial 911 or to proceed directly to the nearest hospital emergency room.
• If staff or answering service is not immediately available, an answering machine may be used. The answering machine message must instruct members with emergency healthcare needs to dial 911 or go directly to the nearest hospital emergency room. The message must also give members an alternative contact number so they can reach the primary care physician (PCP) or on-call provider with medical concerns or questions.
• Non-English-speaking members who call their PCP after hours should expect to get language-appropriate messages. In the event of an emergency, these messages should direct the member to dial 911 or proceed directly to the nearest hospital emergency room.
• In a non-emergency situation, members should receive instruction on how to contact the on-call provider. If an answering service is used, the service should know where to contact a telephone interpreter. All calls taken by an answering service must be returned.

Appointment access

Note: The next available appointment date and time can be either in person or by telehealth services.

Healthcare providers must make appointments for members from the time of request as follows:

SB221 — As of July 1, 2022, non-physician mental health/SUD appointments are subject to the timely access standards outlined in the chart above. This bill also requires that all health plans ensure that enrollees who are undergoing a course of treatment for an ongoing mental health or SUD condition can schedule a follow-up appointment with their non-physician mental healthcare or SUD provider within 10 business days of the prior appointment.

Specialists

The following guidelines are in place for our specialists:

• For urgent care, the specialist should see the member within 96 hours of receiving the request.
• For routine care, the specialist should see the member within 15 business days of receiving the request.
• A copy of the medical records and/or results of the visit should be sent to the PCP’s office to allow continuity of care.

Wait times

When a provider's office receives a call from an Anthem member during regular business hours — as well as after-hours — for assistance and possible triage, the provider or another healthcare professional must either take the call or call the member back within 30 minutes of the initial call.

When an Anthem member arrives on time to an appointment, the member should be seen within 15 minutes of the scheduled appointment.

When Anthem members and/or prospective members call a physician’s office, they should not be

placed on hold for longer than 10 minutes.

Interpretation services

When a provider’s office receives a call from an Anthem member, the provider’s office should know where to contact a telephone interpreter to communicate in the member’s preferred language.

Noncompliance

Ensure that you comply with the standards described; compliance with these standards is a contractual requirement. Anthem monitors compliance through a number of mechanisms, including annual telephonic surveys, to determine if participating provider offices meet the above standards.

For additional details, review the provider manuals on our website.

As of 2023, delegated network providers are measured based on a compliance threshold of 70% as outlined in CCR 1300.67.2.2. Delegates scoring below 70% compliance for Non-Urgent

and Urgent appointment availability will be subject to corrective action, up to and including, termination of the contract.

Required timely access training course — to be released in measurement year 2024

Rescheduling missed appointments — Los Angeles county providers only

This is a reminder that Los Angeles county providers are required to call to reschedule an appointment within 48 hours after a missed appointment. Ensure your office’s policies and procedures and training are updated to include this requirement. Providers may be surveyed on a random sample to ensure compliance with this standard.

Schedule of timely access surveys

Provider Appointment Availability Survey (PAAS):

• Survey subject(s): appointment availability
• Managed Care Plan: Anthem
• Contractor conducting survey: Sutherland
• Regulatory agency: Department of Managed Health Care (DMHC)
• Schedule: July through November 2024

After Hours and Appointment Availability Survey:

• Survey subject(s): emergency and urgent after-hours calls
• Managed Care Plan: Anthem
• Contractor conducting survey: TBD
• Regulatory agency: National Committee for Quality Assurance (NCQA); DMHC
• Schedule: October through November 2024

Primary Care and Specialty Care Appointment Availability Survey:

• Survey subject(s): appointment availability, interpretation services
• Conducting/regulatory agency: Department of Health Care Services (DHCS)
• Schedule:
• Q1: January through March
• Q2: April through June
• Q3: July through September
• Q4: October through December

DHCS administers the surveys and Anthem is provided the surveys after each quarter.

Non-compliant providers are subject to contractual enforcement actions, such as Corrective Action Plans (CAP) or escalated contractual sanctions for breach of contract.

Per APL 23-020, Anthem will pay all claims within contractually mandated statutory timeframes and in accordance with the timely payment standards in the Contract for clean claims within 45 working days of receipt. If Anthem does not pay a clean claim within 45 working days of receipt, Anthem will owe the provider interest at the rate of 15% per annum beginning on the first day after a period of 45 working days.

For additional information, see the provider manuals at the link below.

Summary: On May 17, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or for 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.

Effective on October 20, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates for medical necessity review, will apply for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. This does not equate to the presence of a prior authorization requirement. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

• Cardiology:
  • Cardiac Resynchronization Therapy
  • Endovascular Revascularization
  • Imaging of the Heart
  • Implantable Cardioverter Defibrillators
  • Percutaneous Coronary Intervention
  • Permanent Implantable Pacemakers
• Genetic Testing:
  • Pharmacogenomic Testing
  • Predictive and Prognostic Polygenic Testing
  • Chromosomal Microarray Analysis
  • Whole Exome Sequencing and Whole Genome Sequencing
  • Somatic Tumor Testing
• Musculoskeletal:
  • Spine Surgery
  • Sacroiliac Joint Fusion
• Radiology:
  • Imaging of the Spine
  • Imaging of the Extremities
  • Vascular Imaging
  • Imaging of the Brain
• Sleep:
  • Sleep Disorder Management

Please share this notice with other members of your practice and office staff.

Effective November 1, 2024, Anthem will use MCG B-806-T (Behavioral Health Care [BHG] Applied Behavioral Analysis (Original MCG Guideline) for medical necessity and clinical appropriateness reviews.

If you have questions, contact the Provider Services number on the back of the member's ID card.