On June 14, 2022, the California Department of Managed Health Care issued All Plan Letter (APL 22‑017) to provide guidance on how commercial health plans are expected to comply with requirements to cover COVID-19 therapeutics.

 

This notification is to inform network providers that at Anthem Blue Cross (Anthem), COVID-19 therapeutics are covered services when medically necessary to treat an enrollee.

 

Anthem follows guidance issued by the federal Department of Health and Human Services, the National Institutes of Health, and the CDC regarding COVID-19 therapeutics that can be effective when administered within five to seven days of the onset of symptoms. Accordingly, Anthem considers access to COVID-19 therapeutics an urgently needed service. To ensure that enrollees for whom a COVID-19 therapeutic is medically necessary have access to these treatments and are given a treatment as soon as possible, Anthem has waived any prior authorization requirements with respect to COVID-19 therapeutics.

 

Providers may visit Anthem’s Provider Communications site for updates on COVID-19.

 

More Information on COVID-19 therapeutics

The California Department of Public Health (CDPH) recently issued a COVID-19 Test-to-Treat Playbook. The playbook provides valuable information regarding COVID-19 therapeutics and outlines best practices for providers and others regarding prescribing, as well as provides resources for educating patients regarding therapeutics. You can find the playbook at CDPH’s website: COVID-19 Test-to-Treat Playbook.

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Please note that the following information applies to Anthem Blue Cross' Commercial health plans.  Please review the Medicare and Medi-Cal specific sites noted below for details about these plans.
 

Commercial:  Provider News Home

Medi-Cal:  Medi-Cal Provider News & Announcements - COVID-19

Medicare:  Medicare Advantage News

 

Information from Anthem for Care Providers about COVID-19 (Updated January 24, 2022)

 

Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company (collectively “Anthem”) are closely monitoring COVID-19 developments and what it means for our customers and healthcare provider partners. Our clinical team is actively monitoring external queries and reports from the Centers for Disease Control and Prevention (CDC) to help us determine what action is necessary on our part.

 

To help address care providers’ questions, Anthem has developed the following updates and frequently asked questions.

 

Contents:

• COVID covered testing – SB510

• Waiver of member cost shares
• Prior authorization
• Telehealth and telephonic-only services
• Coding, billing, and claims
• Claims audits, retrospective review, and policy changes
• Provider credentialing
• Vaccine administration
• Prescription drugs
• General questions

 

COVID 19 covered testing – SB510

 

What COVID-19 testing does the health plan cover under SB510?

Anthem covers COVID-19 diagnostic and screening tests for all fully insured members under DMHC and CDI regulated plans with no out-of-pocket costs.

 

Does SB510 impose specific requirements regarding type of tests covered (antigen or PCR)?

This includes antigen and PCR testing. Home testing is also covered as types of diagnostic and screening testing. To be covered, tests must be FDA approved or have FDA emergency use authorization.

 

How are providers reimbursed for COVID-19 testing under SB510?

In-network providers will be reimbursed at the negotiated rate. For out-of-network providers, we do not have a negotiated rate for COVID-19 diagnostic and screening tests, and SB 510 requires that reimbursement be based on a reasonable rate. Federal law also mandates reimbursement rates for out-of-network. Under federal law, out-of-network diagnostic tests are required to be reimbursed based on the out-of-network providers posted “cash price.” When federal law applies, Anthem will reimburse the provider based on federal requirements.

 

Out-of-network providers are prohibited from seeking reimbursement from members for COVID-19 diagnostic and screening testing services.

 

Is COVID-19 testing cost a delegated capitated service based on SB510?

The cost associated with COVID-19 testing under SB510 will remain with Anthem unless a new agreement with the delegated provider is reached.

 

Does SB510 requirements apply retroactively?

Recent law requires health plans to cover the cost of COVID-19 tests for screening and diagnostic retroactively, beginning from the Governor's declared State of Emergency related to COVID-19 on March 4, 2020, and onward.

Anthem has and will continue to advocate for affordable access to quality health care for our members and for all Californians. As such, we support the California Association of Health Plans’ (CAHP) decision to file suit against the State of California over this recent law and the retroactive components. We do not challenge the application of the law from its effective date of January 1, 2022, and forward. The retroactivity components of the law may result in an increase in healthcare premiums and for these reasons, CAHP is asking the court to halt the retroactive components of this law. Anthem is a member of CAHP and supports this effort.

 

Waiver of member cost shares

 

Will Anthem waive member cost shares related to COVID-19 including screening, testing, and treatment?

• Screening & testing: Yes, as of March 5, 2020, and until further notice, cost shares, inclusive of copays, coinsurance, and deductibles for COVID-19, will be waived by Anthem or its delegated entities for screening and testing for COVID-19. Tests samples may be obtained in many settings including a physician’s office, urgent care, ER or even drive-thru testing once available. While a test sample cannot be obtained through a telehealth visit, the telehealth provider can help a member get to a provider who can do so. The waivers apply to members who have individual, employer-sponsored, Medicare and Medicaid plans. 
• Treatment: Yes, effective April 1, 2020, through January 31, 2021, Anthem and its delegated entities waived cost shares for members undergoing treatment related to a COVID-19 diagnosis.

 

Anthem will reimburse healthcare providers according to standard reimbursement rates, depending on provider participation and benefit plan, for fully insured, individual, Medicaid and Medicare members. Anthem will continue to monitor and comply with state and federal guidelines. Self-insured plan sponsors will have the choice to participate

 

Prior authorization

 

Does Anthem require a prior authorization for screening or testing for COVID-19?

No, prior authorization is not required from Anthem or its delegated entities for screening or testing related to COVID-19 testing.

 

Is Anthem changing its requirements for prior authorization?

Anthem recognizes the intense demands facing physicians, hospitals, and all healthcare providers in the face of the COVID-19 pandemic and has put in place a temporary waiver. As of January 10, 2022, through January 31, 2022, Anthem and its delegated entities will suspend select prior authorization requirements to allow healthcare providers to focus on caring for patients diagnosed with COVID-19. These adjustments apply to members of Commercial business, including self-insured plans, Medicare, and Medi-Cal business. The suspension of select prior authorization is inclusive of the following:

 

Inpatient and respiratory care

• To assist the removal of administrative burden on hospitals during the COVID-19 pandemic, medical reviews are suspended for all confirmed and suspected COVID-19 inpatient cases.
• Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities, acute rehabilitation, and long-term acute care. These changes are effective January 10, 2022, through January 31, 2022. These adjustments apply for our fully-insured and self-funded employer, Individual, Medicare and Medi-Cal plan members receiving care from in-network providers. While prior authorization is not required for facility transfers to lower levels of care, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers. Anthem encourages providers to continue to follow normal processes and obtain prior authorization and reminds providers that patient transfers should be to in-network facilities when possible.
• Prior authorization requirements were suspended for patient transfers through February 18, 2021:  All hospital inpatient transfers to lower levels of care (by land only). Although prior authorization was not required, Anthem requested voluntary notification via the usual channels to aid in our members’ care coordination and management.
• The 21-day inpatient requirement before transferring a patient to a long-term acute care hospital was suspended through February 18, 2021.
• Extended the length of time a prior authorization issued on or before May 30, 2020, was in effect for elective inpatient and outpatient procedures an additional 180 days. This helped prevent the need for additional outreach to Anthem to adjust the date of service covered by the authorization.
• Concurrent review for discharge planning will continue unless required to change by federal or state directive.
• Prior authorization requirements were suspended for COVID-19 durable medical equipment through February 18, 2021, including oxygen supplies, respiratory devices, and continuous positive airway pressure (CPAP) devices for patients diagnosed with COVID-19, along with the requirement for authorization to exceed quantity limits on gloves and masks.
• Respiratory services for acute treatment of COVID-19 will be covered. Prior authorization requirements were suspended where previously required through February 18, 2021.

 

Telehealth and telephonic services

 

What member cost shares will be waived by Anthem for virtual care through telehealth and telephone-only?

For COVID-19 treatments via telehealth visits, Anthem and its delegated entities will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares until further notice.

 

For in-network providers, effective March 17, 2020, through September 30, 2020, Anthem and its delegated entities waived member cost share for telehealth (video + audio) and telephone-only visits for services not related to the treatment of COVID-19 from in-network providers, including visits for behavioral health, for our fully-insured employer, individual and Medicaid plans where permissible. For Medicare plans, in-network providers, effective March 17, 2020, through December 31, 2020, Anthem and its delegated entities waived member cost share for telehealth (video + audio) and telephone-only visits for services not related to the treatment of COVID-19 from in-network providers, including visits for behavioral health.

 

For out-of-network providers, Anthem waived cost shares for services received from March 17, 2020, through June 14, 2020. Cost sharing will be waived for members using Anthem’s telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program.

 

Will Anthem cover virtual care through telehealth and telephone-only?

Effective March 17, 2020, and until further notice, for COVID-19 related services, Anthem and its delegated entities will cover telehealth and telephone-only medical and behavioral health services from in-network providers and out-of-network providers.

 

Effective March 17, 2020, and until further notice, for services not related to the treatment of COVID-19, Anthem and its delegated entities will cover telehealth and telephone-only medical and behavioral health services from in-network providers. For telehealth and telephonic services received from a non-contracted provider, Anthem and its delegated entities will cover such services when there is an out-of-network benefit.

 

Self-insured plan sponsors may opt out of this program.

 

Is the option to deliver services via telehealth available for all types of services?

Yes, until further notice, so long as it is medically appropriate to render the services via telehealth.

 

Exceptions for Medi-Cal members include chiropractic services, physical, occupational, and speech therapies. At this time, the Department of Health Care Services (DHCS) has not authorized these services for telehealth or telephone.

 

Does the provider have to be physically present in their office when providing services via telehealth?

No. If the provider can effectively deliver services via telehealth from another location (for example, the provider’s home), while also maintaining the patient’s privacy the services are payable.

 

What is the reimbursement rate for telehealth and telephonic-only services?

As required by the State of California, telehealth and telephonic services must be paid at the same rate, whether a service is provided in-person or through telehealth or telephonically, if the service is the same regardless of the modality of delivery, as determined by the provider’s description of the service on the claim.

 

Can all contracted providers provide telehealth and telephonic-only services?

Yes.  All Anthem contracted providers can provide telehealth and telephonic services if clinically appropriate.  

 

Is Anthem’s vendor, LiveHealth Online, prepared for the number of visits that will increase to telehealth?

As there is a heightened awareness of COVID-19 and more cases are being diagnosed in the United States, LiveHealth Online is increasing physician availability and stands ready to have physicians available to see the increase in patients, while maintaining reasonable wait times.

 

What is the best way that providers can get information to Anthem’s members on Anthem’s alternative virtual care offerings?

Anthem.com/ca and Anthem’s COVID-19 site (https://www.anthem.com/ca/coronavirus/) are great resources for members with questions and are being updated regularly.

 

Anthem members have access to telehealth 24/7 through LiveHealth Online. Members can access LiveHealth Online at https://livehealthonline.com/ or download the LiveHealth Online app from the App Store or Google Play.

 

Anthem members also can call the Anthem 24/7 NurseLine at the number listed on their Anthem ID card to speak with a registered nurse about health questions.

 

For COVID-19 treatments via telehealth visits, Anthem and its delegated entities will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares until further notice.

 

From March 17, 2020, through September 30, 2020, Anthem and its delegated entities waived any member cost share for telehealth or telephonic visits provided by in-network provider, including visits for mental health, for our fully insured employer, individual and Medicaid plans.

 

For Medicare plans, in-network providers, effective March 17, 2020, and December 31, 2020, Anthem and its delegated entities waived member cost share for telehealth (video + audio) and telephone-only visits from in-network providers, including visits for behavioral health.

 

Cost shares will be waived for members using Anthem’s telemedicine service, LiveHealth Online, as well as care received from other telehealth providers. Self-insured plan sponsors will have the choice to participate.

 

Coding, billing, and claims

 

How should a provider bill for services delivered via telehealth or telephone during the State of Emergency, when the provider would normally deliver the services in-person?

During the COVID-19 State of Emergency, when a provider delivers a service via telehealth that the provider would normally deliver in-person, the provider should document and bill the service(s) as follows:

 

• Thoroughly document the visit as if the visit had occurred in person.
• Use the CPT code(s) for in-office visit for the particular service(s) rendered. Do not use telehealth or telephonic Current Procedural Terminology (CPT) codes.
• Use Place of Service “02” to designate telehealth.
• Use modifier 95 or GT for synchronous rendering of services, or GQ for asynchronous.
  • Medi-Cal Exception – use modifier 95 for synchronous rendering of services, or GQ for asynchronous.

 

What modifier is appropriate to waive member cost sharing for COVID-19 testing and visits related to testing?

The Centers for Medicare & Medicaid Services (CMS) has provided the Medicare guideline to use the CS modifier: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-10-mlnc-se. Anthem also looks for the CS modifier to identify claims related to evaluation for COVID-19 testing. This modifier should be used for COVID-19 evaluation and testing services in any place of service. 

 

What diagnosis codes would be appropriate to consider for a patient with known or suspected COVID-19?

The CDC has provided coding guidelines related to COVID-19:

https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

 

Should providers who are establishing temporary locations to provide healthcare services during the COVID-19 emergency notify Anthem of new temporary addresses?

Providers do not need to notify Anthem of temporary addresses for providing healthcare services during the COVID-19 emergency. Providers should continue to submit claims specifying the services provided using the provider’s primary service address along with their current tax ID number.

 

How does a provider submit a telehealth visit with an existing patient that lives in a bordering state? 

For providers (for example, in bordering states) who were previously seeing members in approved locations that met state and/or CMS billing requirements, effective March 17, 2020, and until further notice, a provider may submit a telehealth claim using the primary service address where they would have normally seen the member for the face-to-face visit.

 

How is Anthem reimbursing participating hospitals that perform COVID-19 diagnostic testing in an emergency room or inpatient setting?

Reimbursement for COVID-19 testing performed in a participating hospital emergency room or inpatient setting is based on existing contractual rates inclusive of member cost share amounts waived by Anthem. 

 

Claims audits, retrospective review, and policy changes

 

Anthem will adjust the way we handle and monitor claims to ease administrative demands on providers:

• Hospital claims audits requiring additional clinical documentation will be limited through June 24, 2020, though Anthem reserves the right to conduct retrospective reviews with expanded lookback recovery periods. To assist providers, Anthem can offer electronic submission of clinical documents through the provider portal.
• Retrospective utilization management review will also be limited through June 24, 2020, and Anthem reserves the right to conduct retrospective utilization management review of these claims when this period ends and adjust claims as required.
• Our special Investigation programs targeting provider fraud will continue, as well as other program integrity functions that ensure payment accuracy.

 

Anthem will continue to administer claims adjudication and payment in line with our benefit plans and state and federal regulations, including claims denials and appeals where applicable. Our timely filing requirements remain in place, but Anthem is aware of limitations and heightened demands that may hinder prompt claims submission.

 

Provider credentialing

 

Through June 24, 2020, Anthem processed provider credentialing within the standard timeframe. If we were unable to verify provider application data due to disruptions to licensing boards and other agencies, we will verify this information when available.

 

If Anthem finds that a practitioner fails to meet our minimum criteria because of sanctions, disciplinary action etc., we will follow the normal process of sending these applications to committee review which may add to the standard timeframe. We will monitor and comply with state and federal directives regarding provider credentialing.

 

Vaccine administration

 

How is Anthem reimbursing U.S. Food and Drug Administration (FDA)-approved COVID-19 vaccines?

The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government.

 

Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines in accordance with Federal and State mandates.

 

Recently CMS shared (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that for members of Medicare Advantage plans, the COVID-19 vaccine administration should be billed to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost-sharing for the administration of the vaccine.

 

For members of our fully-insured employer and individual plans as well as self-funded plans, Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency.

 

Department of Managed Health Care (DHMC) issued regulation directing financial risk to the health plans for delegated entities.

• Delegated Entities – Unless covered under the Division of Financial Responsibility (DOFR), Anthem will be responsible for the vaccine administration cost and will reimburse at the Prudent Buyer rate, which is the same as the Medicare national rate.
• In-Network Providers – Anthem will reimburse at the contracted rate
• Out of Network – Anthem will reimburse at the Medicare national rate

 

For members of Medicaid plans, Medicaid state-specific rules and other state regulations may apply.

 

Prescription drugs

 

Can members obtain an extra 30-day refill of a prescription drug?

Yes. We are also allowing members to obtain an extra 30-day supply of medication when medically appropriate and permitted by state and federal law. We are also encouraging that when member plans allow that they switch from 30-day home delivery to 90-day home delivery.

 

General questions

 

Does Anthem have recommendations for reporting, testing and specimen collection?

The CDC updates these recommendations frequently as the situation and testing capabilities evolve. See the latest information from the CDC: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html

 

Does Anthem have recommendations for COVID-19 preventive health and clinical guidance?

Refer to the latest information found on the CDC COVID-19 website: https://www.cdc.gov/coronavirus/2019-nCoV as well as information found on local County Department of Public Health websites.

 

In case of mass pandemic, how can you ensure that your contracted providers can still provide services?

Anthem is committed to working with and supporting its contracted providers. Our benefits already state that if members do not have appropriate access to network physicians that we will authorize coverage for out-of-network physicians as medically necessary.

 

In addition, Anthem’s telehealth provider, LiveHealth Online, is another safe and effective way for members to see a physician to receive health guidance related to COVID-19 from their home via mobile device or a computer with a webcam.

 

Are you aware of any limitations in coverage for treatment of an illness/virus/disease that is part of a pandemic?

Our standard health plan contracts do not have exclusions or limitations on coverage for services for the treatment of illnesses that result from a pandemic.

 

What financial assistance is available for care providers during the COVID-19 crisis?

The CARES Act provides financial relief to lessen the impact of the COVID-19 crisis. Included in the law are new resources to address the economic impact of COVID-19 on employers of all sizes. The Act expands existing federal loan programs, creates new tax credits, postpones employment tax payments, and includes additional tax relief. To help care providers navigate the resources available to them, Anthem has complied information on programs we have learned about that could provide additional financial relief during this crisis. This information can be found in the Federal Resources Available for Care Providers and Employers in the Federal CARES Act article in Anthem Provider News.

 

Does Anthem expect any slowdown with claim adjudication because of COVID-19?

We are not seeing any impacts to claims payment processing at this time.

 

Do these guidelines apply to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan commonly referred to as the Federal Employee Program (FEP®)?

Where permissible, these guidelines apply to FEP members. For the most up-to-date information about the changes FEP is making, go to https://www.fepblue.org/coronavirus.

 

Please note that the above information applies to Anthem Blue Cross’ Commercial health plans. Please review the Medicare and Med-Cal specific sites noted below for details about these plans.

 

Commercial:  Provider News Home

Medi-Cal:  Medi-Cal Provider News & Announcements - COVID-19

Medicare: Medicare Advantage News

 

If you have additional questions or need more information, please call the phone number on the member’s ID card.

623-0122-WP-CA

Please be advised that, while awaiting further guidance from the DMHC regarding SB510, Anthem Blue Cross (Anthem) will process Commercial claims for COVID-19 testing or vaccine administration incurred on or after January 1, 2022, regardless of risk type.

 

Once we receive additional DMHC guidance, and update the payment systems, the claims payments will be reconciled if necessary.

 

If you have any questions about this communication, contact your assigned Provider Experience associate or visit https://providers.anthem.com/ca > Contact Us to view additional contact options. 

1200-0222-WP-CA

Webinar recording now available for providers on how to leverage telehealth to care for Behavioral Health patients during COVID-19 and beyond

 

Anthem Blue Cross hosted a provider webinar to assist Behavioral Health providers in maximizing the telehealth experience.

 

The webinar recording for How to leverage telehealth to care for Behavioral Health patients during COVID-19 and beyond is now available.

 

Webinar summary:

The psychological effects of COVID-19 reach far beyond those who have fallen ill with COVID-19 or lost a loved one to the virus. The need for behavioral health services will increase due to the fear and life-altering changes the pandemic has created. And for those who are already in treatment for behavioral health or other medical conditions, those appointments have been interrupted or even discontinued due to the pandemic. 

 

Using telehealth can be a better way to continue caring for your patients or help patients access care, while promoting social distancing.

 

During the webinar recording, you’ll hear about:

• The impact of COVID-19 on behavioral health in general and within at-risk populations
• Lessons learned from past epidemics and quarantines
• Best practices for caring for behavioral health patients virtually
• Telehealth 101 tips for providers looking to get started

 

Providers of all specialties are invited to attend this webinar, which places emphasis on leveraging telehealth for behavioral health services.

 

As the COVID-19 pandemic continues to spread throughout the United States, we appreciate that care providers across the country on the front line are committed to providing care to our members and communities.

 

During these challenging times, Anthem remains committed to living our values and supporting those we serve, which includes making it as easy as possible for care providers  to focus on what’s important right now, keeping the country healthy.  In addition to the proactive steps Anthem has already taken to support care providers and protect our members, associates and communities against COVID-19, Anthem announced, effective April 1 that we will expand coverage for our members undergoing treatment related to COVID-19 diagnosis.

 

The expansion covers the waiver of cost shares for COVID-19 treatment received through December 31, 2020. Anthem will reimburse health care providers at in-network rates or Medicare rates, as applicable, for Anthem’s affiliated health plan fully insured, Individual, Medicaid and Medicare Advantage members. Anthem encourages self-funded employer participation; however, self-insured employers will be able to opt out of participation.

 

Anthem continues to closely monitor the COVID-19 developments and listen to the needs of our communities, Anthem associates and all of the members and care providers we serve.  We will continue to update you as we receive new information and guidance.

 

Like many, Anthem Blue Cross (Anthem) is closely monitoring COVID-19 developments and what it means for our customers and our health care provider partners.  Anthem is working to help employers who are facing tough decisions on furloughing or reducing hours of their workforce.  Anthem is doing this by creating health insurance options that provide continued access to care. We continue to seek ways to support our customers by offering affordable alternate products with more flexibility while ensuring members can continue to see their established physicians.

Beginning June 1, 2020, Anthem is introducing our Anthem Health Access Plans for certain large group employers currently enrolled in our commercial lines of business only.

 

Anthem Health Access Plans cover the diagnosis and treatment for COVID-19 at 100% in accordance with Anthem guidelines. 

 

These benefit plans cover preventive care, unlimited telemedicine, office visits, prescriptions, and more.  In addition, members enrolled in these plans have digital ID cards and access to Sydney Health and Sydney Care Anthem's mobile app that runs on intelligence – as part of our digital strategy). 

 

These plans include some coverage exclusions or limitations. For information about eligibility, available benefits, and a list of exclusions, please visit Availity – our Web-based provider tool at www.availity.com. 

 

We are committed to working with our provider partners to help our members focus on their health and well-being. The new Health Access plans give your patients the needed coverage to manage their everyday health needs.

 

NOTE:  As with all eligibility and benefits inquiries on Availity, providers must have the member ID number (including the three-character prefix) and one or more search options of date of birth, first name and last name.

We are committed to helping care providers learn how you can secure resources to support yourselves and your business during the COVID-19 crisis. Anthem hosted a provider webinar to share information and resources with its network providers regarding opportunities providers have to access loans through the U.S Small Business Administration (SBA) and other federal programs in response to the economic impact of COVID-19 on care providers that are also small employers.

 

The Small Business Loan Opportunities for Providers webinar recording is now available.

 

After registering, use the password “health” to access the webinar.

 

Webinar summary:

The federal Coronavirus, Aid, Relief and Economic Security (CARES) Act included an initial $350 billion Paycheck Protection Program (PPP) that provides 100% federally guaranteed loans to small employers. These loans may be forgiven if borrowers maintain or restore their payrolls to pre-COVID-19 levels. On Monday, April 27, 2020, the SBA resumed accepting applications for PPP loans in response to an additional $320 billion added to the program. This webinar recording shares information about federal financial relief for providers in response to the COVID-19 crisis. Use the password “health” to access the webinar.

 

The information and resources provided here and during webinar recordings is educational and informational only, which providers can use to learn about resources and opportunities that may be available, and do not constitute and should not be considered legal advice. Anthem cannot be held responsible for any errors or omissions.

As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED.

Future updates regarding COVID-19 will appear in the monthly Provider News publication.

For the latest COVID-19 information, please check our websites often:

Commercial:  Provider News Home

Medi-Cal:  Medicaid Provider News - COVID-19

Medicare: Medicare Advantage Provider News Archives

 

Please note that the following information applies to Anthem’s Commercial health plans. Medicare plans are included when not otherwise required under State and/or Federal mandates. Please review the Medicare specific site noted above for details about these plans.

 

COVID-19 Update: Guidance for telehealth (audio + video) and telephonic-only care for Behavioral Health services (Updated April 17, 2020)

 

Anthem is closely monitoring COVID-19 developments and what it means for our customers and our healthcare provider partners. Our clinical team is actively monitoring external queries and reports from the Centers for Disease Control and Prevention (CDC) to help us determine what action is necessary on our part. We have made changes to how behavioral health providers can utilize and be compensated for telehealth (audio + video) and telephonic-only care with their patients.

 

To help address care providers’ questions regarding Behavioral Health services, Anthem has developed the following frequently asked questions:

 

Contents:

• Telehealth care (audio + video)
• Telephonic-only care
• Coding, billing, and claims

 

Telehealth care (audio + video)

What member cost-shares will be waived by Anthem for virtual care through telehealth?

Effective March 17, 2020, and until further notice, Anthem and its delegated entities will waive member cost share for telehealth (video + audio) visits, including visits for behavioral health, for our fully-insured employer, individual, Medicare and Medicaid plans where permissible. Cost sharing will be waived for members using Anthem’s telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program.

 

How is Anthem approaching the provision of mental health outpatient, substance abuse outpatient, PHP, IOP, ABA, and Psychological Testing services via telehealth (audio + video) visits?

As of March 17, 2020, and until further notice, Anthem has adjusted policy to expand telehealth (audio + video) access. All mental health outpatient, substance abuse outpatient, IOP, PHP, ABA, and Psychological Testing services provided via telehealth (audio + video) is expected to be provided within benefits limits, authorization limits, medical necessity criteria, licensure requirements, and within state and federal regulatory requirements, including HIPAA compliance and the regulations regarding how substance use information is handled.

Are there any recommendations around the delivery of Partial Hospitalization Program (PHP) level of care using telehealth (audio+ video)? 

• PHP programs should continue to deliver the same level of service and clinical value using telehealth.
• Telehealth refers to use of audio + video, not solely telephonic (audio only). Telephonic-only interactions are not appropriate for PHP level of care. 
• Expectation of telehealth PHP services being delivered includes but is not limited to:

• Maintain daily psychiatric management and active treatment comparable to that provided in an inpatient setting
• Ensure full day  telehealth PHP program is delivered in the same way as an in –person face to face PHP program, including therapeutically intensive acute treatment within a therapeutic milieu including individual and group therapy
• Routine discharge processes are followed, including scheduling after care appointments no more than 7 days from a member’s discharge from PHP and ensuring that members discharged on medication receive at least one psychiatric medication monitoring appointment no more than 14 days after discharge
• Group therapy takes place at the same levels as delivered in PHP face to face program
• Group therapy size should be the same as when PHP  program is delivered in-person face to face
• Clinical assessment of the member takes place once daily
• Educational and activity therapies are included as indicated on the treatment plan
• Treatment planning and progress notes documentation of services delivered
• Documentation that services were provided via telehealth (audio +video)
• Protocols in place to address risk behavior and decompensation
• Process in place to respond to crisis for members
• Consent and privacy controls are put in place when patients are participating in group telehealth (audio+ video) sessions
• Protocols in place to address risk behavior and decompensation in the patient’s home

• Utilization Management Process for PHP:
  • Providers are expected to follow any required prior authorization and concurrent review process for the PHP authorization process. 

Are there any recommendations around the delivery of Intensive Outpatient Program (IOP) level of care using telehealth (audio+ video)? 

• IOP programs should continue to deliver the same level of service and clinical value using telehealth.
• Telehealth refers to use of audio +video, not solely telephonic. Telephonic-only interactions are not appropriate for IOP level of care. 
• Expectation of telehealth IOP services being delivered includes but is not limited to:

• Maintain timely admittance to the program within one business day of evaluation, along with timely completion of initial treatment plan and discharge plan
• Ensure telehealth psychiatric management is comparable to face- to-face IOP care.
• Routine discharge processes are followed, including scheduling after care appointments no more than 7 days from a member’s discharge from IOP and ensuring that members discharged on medication receive at least one psychiatric medication monitoring appointment no more than 14 days after discharge
• Ensure access to multidisciplinary treatment team (e.g., clinical master’s degree staff; RN; and psychiatrist)
• Continue to provide daily management and active treatment
• Maintain a written schedule of program activities
• Treatment planning and progress notes documentation of services delivered
• Documentation that services were provided via telehealth (audio + video)
• Protocols in place to address risk behavior and decompensation
• Process in place to respond to crisis for members
• Consent and privacy controls are put in place when patients are participating in group telehealth (audio + video) sessions

• Utilization Management Process for IOP:
  • Providers are expected to follow any required prior authorization and concurrent review process for the IOP authorization process.

Are ABA providers allowed to use the hours approved in a current authorization for telehealth (audio + video) ABA services?

If an ABA provider is not requesting changes to existing authorized codes or units they can continue to use the authorization they have on file. No further action is required by the provider.

 

If an ABA provider is requesting changes to the authorization we have in place, such as changes to units or codes, they must submit a request for the change by submitting a new treatment request form outlining the changes they are requesting, please include current authorization reference number and date of change being requested.

 

If an ABA provider is requesting new authorization of code or units, they should follow the process already in place by submitting the request by fax or via Anthem’s electronic portal.

Telephonic-only care

What member cost-shares will be waived by Anthem for virtual care through telephonic-only? Effective March 19, 2020, and until further notice, Anthem will cover telephone-only behavioral health services from in-network providers and out-of-network providers. Anthem will waive associated cost shares for in-network providers only except where a broader waiver is required by law.  Associated cost shares will be waived for out of network providers when providing COVID-19 related screening and testing only. Self-insured plan sponsors may opt out of this program.

How is Anthem approaching the provision of mental health outpatient and substance abuse outpatient services via telephonic-only visits?

Until further notice, Anthem is making adjustments in our policy in the provision of these telephonic-only services to address the need for expanded access outside of telehealth (audio + video) to include telephonic-only visits with in-network providers and out-of-network providers where required. All mental health outpatient and substance abuse outpatient services should be provided within benefits limits, authorization limits, medical necessity criteria, and within state and federal regulatory requirements and licensure requirements, including HIPAA compliance and the regulations regarding how substance use information is handled.

Coding, billing, and claims

 

How should a provider bill for services delivered via telehealth or telephone during the State of Emergency, when the provider would normally deliver the services in-person?

During the COVID-19 State of Emergency, when a provider delivers a service via telehealth that the provider would normally deliver in-person, the provider should document and bill the service(s) as follows:

• Thoroughly document the visit as if the visit had occurred in person.
• Use the CPT code(s) for in-office visit for the particular service(s) rendered. DO NOT USE telehealth or telephonic CPT codes.
• Use Place of Service “02” to designate telehealth.
• Use modifier 95 or GT for synchronous rendering of services, or GQ for asynchronous.
  • Medi-Cal Exception – use modifier 95 for synchronous rendering of services, or GQ for asynchronous.

 Should providers who are establishing temporary locations to provide health care services during the COVID-19 emergency notify Anthem of new temporary addresses?
Providers do not need to notify Anthem of temporary addresses for providing health care services during the COVID-19 emergency. Providers should continue to submit claims specifying the services provided using the provider’s primary service address along with their current tax ID number.

What if I have additional questions pertaining behavioral health telehealth (audio + video) or telephonic-only care visits?

Please contact Anthem Behavioral Health Provider Relations.

 

During the COVID-19 crisis, care providers are working to keep the country running while navigating the financial impact it is having on them. Anthem Blue Cross (Anthem) advocated for Congress to provide sufficient funding for hospitals to be able to address those in need of care and we strongly support federal and state efforts to address the financial needs of care providers. To help care providers navigate the resources available to them Anthem has compiled information on programs we have learned about that could provide additional financial relief during this crisis.

 

The Coronavirus Aid, Relief, and Economic Security (CARES) Act is the third in a series of COVID-19 federal laws designed to assist in addressing COVID-19 and provide financial relief to lessen the impact. The CARES Act includes new resources to address the economic impact of COVID-19 on employers of all sizes, including care providers. The CARES Act provides significant funding specifically for care providers AND expands existing federal loan programs, creates new tax credits, postpones employment tax payments, and includes additional tax relief for employers, including care providers.

 

Funding specifically designated for care providers in the CARES Act includes:

 

• $100 billion grant program for the U.S. Department of Health and Human Services (HHS) to provide direct assistance to hospitals and other eligible Medicare providers and suppliers to cover unreimbursed healthcare-related expenses or lost revenues attributable to the COVID-19 public health emergency;

 

• Advance Medicare payments for care providers and suppliers through Accelerated and Advance Payment Program allowing hospitals to receive 100% of three months of advanced payments through Medicare. Inpatient acute care hospitals, children’s hospitals, and certain cancer hospitals are able to request up to 100% of the Medicare payment amount for a six-month period.  Critical Access Hospitals can request up to 125% of Medicare payment for six months;
• 20% increase in reimbursement to hospitals in the Medicare program for inpatient stays coded as COVID-19, applicable during the emergency period.
• Suspension of the Medicare “sequester cuts” under current law that would have reduced payments to hospitals and providers by 2 percent. This suspension lasts from May 2020 through December 2020 increasing Medicare payments to hospitals and providers by 2 percent.
• Elimination of $8 billion in Medicaid Disproportionate Share Hospital cuts which were scheduled to go into effect on May 23, 2020.

 

Loans and Tax Relief for Employers, including Care Providers

 

Paycheck Protection Program (PPP) for Small Employers

 

This program provides employers, 501(c)(3) nonprofits, veterans organizations and tribal small businesses that generally have fewer than 500 employees with loans of up to $10 million through the U.S. Small Business Administration 7(a) loan program. Both the U.S. Small Business Administration (SBA) and the U.S. Treasury Department have issued guidance on these loans, which can serve as great resources for small employers.

 

Lenders may begin processing PPP loan applications as soon as April 3, 2020, and the program will be available through June 30, 2020. Please note that these loans will be fully forgiven if employees are kept on payroll for eight weeks and the funds are used for payroll costs including health benefits, interest on mortgages, rent, and utilities. Additional details on the PPP program include:

 

• You can apply through any existing SBA 7(a) lender or through any federally insured depository institution, federally insured credit union, and Farm Credit System institution that is participating. Other regulated lenders will be available to make these loans once they are approved and enrolled in the program. You should consult with your local lender as to whether it is participating in the program.
• PPP Loan payments will also be deferred for six months. No collateral or personal guarantees are required.
• Neither the government nor lenders will charge small businesses any fees.
• The business must have been in operation on February 15, 2020.
• Eligible entities also include sole proprietors, independent contractors, and other self-employed individuals.
• PPP Loan amounts are 250% of the average total monthly payroll costs incurred during the one-year period before the date of the loan.
• Allowable uses of the PPP loan include ongoing payroll support (including health care benefits/insurance premiums), as well as mortgage interest, rent, and utility payments.
• All businesses are eligible irrespective of ability to pay, and if the employer maintains employment levels, it is eligible for loan forgiveness equal to the amount spent by the borrower during an 8-week period after the origination date of the PPP loan on payroll costs, mortgage interest, rent/lease, and utilities.
• Mandates all participating lenders to defer payments for at least six months (up to one year).

 

Economic Injury Disaster Loan (EIDL) & Emergency Economic Injury Grants

 

• EIDLs allow small businesses to receive immediate cash advance payments of $10,000 in three days and waiver of certain requirements on loans of less than $200,000. To access the advance, the business first applies for an EIDL and then requests the advance. The advance does not need to be repaid under any circumstance and may be used for payroll, to pay for sick leave, or pay business obligations such as rent/mortgage and debt.
• EIDLs are lower interest loans with principal and interest deferment at the SBA Administrator’s discretion.
• Eligible entities are businesses, cooperatives, employee stock ownership plans, and tribal small business concerns with fewer than 500 employees, or any individual operating as a sole proprietor or an independent contractor. Private nonprofit businesses of any size are also eligible.
• An EIDL may be used for payroll and other operating expenses, but cannot be used for the same purposes as a PPP Loan.
• Eligible entities can get both an EIDL and a PPP loan, but any advance amount is subtracted from the amount forgiven in the PPP loan.

 

Small Business Association (SBA) Express Bridge Loans

 

• Express Bridge Loan Pilot Programallows small businesses who currently have a business relationship with an SBA Express Lender to access up to $25,000 quickly.
• These loans can provide vital economic support to small businesses to help overcome the temporary loss of revenue they are experiencing and can be a term loans or used to bridge the gap while applying for a direct SBA Economic Injury Disaster Loan (EIDL).
• If a small business has an urgent need for cash while waiting for decision and disbursement on an EIDL, they may qualify for an SBA Express Bridge Loan.
• Loan will be repaid in full or in part by proceeds from the EIDL

 

Small Business Debt Relief

 

• Eligible small businesses are those with non-disaster Small Business Administration (SBA) loans (loans not made under the Paycheck Protection Program) and others
• The SBA will cover all loan payments on these SBA loans for 6 months.
• This relief is also available to new borrowers who take out eligible loans within 6 months of March 27, 2020.

 

Financial Support for Medium and Large Employers

 

The CARES Act includes $454 billion for the U.S. Treasury Department to be used to capitalize one or more loan facilities, established by the Federal Reserve, to make direct secured business loans to companies, including those with between 500 and 10,000 employees. These loans would be fully secured by the borrower’s assets and that the borrower not engage in stock buybacks or furnish dividends while the loan is outstanding and for 12 months thereafter, and agree to limits on executive compensation. Once additional details and guidance are released, this information will be updated.

 

Employee Retention Tax Credits for all Businesses

 

Any employer or 501(c)(3) tax-exempt organization experiencing more than a 50 percent drop in gross receipts during the COVID-19 crisis is eligible for an advanceable or refundable payroll tax credit for keeping employees on the payroll.  The amount of credit each quarter is up to 50 percent of wages (up to $10,000) (Sec. 2301). The IRS recently released guidance on this tax credit.

 

• Eligible employers are those subject to a full or partial shut-down order due to the COVID-19 pandemic, or those employers who see gross receipts decline by more than 50% when compared to the same quarter in 2019.
• Wages of employees who are furloughed or face reduced hours as a result of their employers' closure or economic hardship are eligible for the credit.
• For employers with 100 or fewer full-time employees, all employee wages are eligible, regardless of whether an employee is furloughed.
• Employers receiving a Paycheck Protection Program loan through the SBA are not eligible.

 

Postponement of Payroll Tax Payments

 

Employers and self-employed individuals can defer paying their share of applicable 2020 payroll taxes to free up cash to fund operations and support retaining employees. 

 

• This is not available to small employers who have had debt forgiven through the Paycheck Protection Program.
• Employer may defer 100% of the 6.2% employer-share of the old age, survivors and disability insurance (OASDI) portion of the Federal Insurance Contribution Act (FICA) taxes due on wages paid after March 27, 2020 through the end of 2020.
• Self-employed individuals may also delay the payment of 50% of the OASDI
• Half of the tax that would have been paid in 2020 can be paid at the end of 2021, and the other half at the end of 2022.

 

Carryback of Net Operating Losses

 

• Allows businesses to carry back for five years 100% of losses for tax years 2018, 2019 and 2020.
• This will allow businesses to offset taxable income and access cash to support business operations in 2020 and future years.

 

Increased Deduction for Interest Expense

 

• For 2019 and 2020 increases the amount of interest expense that businesses (corporations and partners in partnership) are allowed to deduct, by increasing the limitation from 30% of adjusted taxable income to 50%.
• This provision allows businesses to increase liquidity with a reduced cost of capital.

 

Accelerated Depreciation of Qualified Improvement Property

 

• This provision classifies qualified improvement property as 15-year life, which also allows such property to be eligible for bonus depreciation.

For updated information on COVID-19, please continue to check Provider News & Announcements at https://mediproviders.anthem.com/ca/pages/covid.aspx  for the latest Medicaid information, and Important Medicare Advantage Updates at https://www.anthem.com/ca/provider/news/archives/?category=medicareadvantage   for the latest Medicare information.