Anthem Blue Cross (Anthem) providers should now submit changes to their practice profile using our online Provider Maintenance Form.  

Online update options include: add an address location, name change, tax ID changes, provider leaving a group or a single location, phone/fax numbers, closing a practice location, etc. Visit the Provider Maintenance Form landing page to review more.

The new online form can be found the redesigned provider site www.anthem.com/ca, select the Providers tab then select Provider Maintenance Form in the sub bullets. In addition, the Provider Maintenance Form can be accessed through the Availity Web Portal by selecting California> Payer Spaces-Anthem Blue Cross> Resources tab >Provider Maintenance Form.

Important information about updating your practice profile:

• Change request should be submitted using the online Provider Maintenance Form
• Submit the change request online. No need to print, complete and mail, fax or email demographic updates
• You will receive an auto-reply e-mail acknowledging receipt of your request and another email when your submission has been processed
• For change(s) that require submission of an updated IRS Form w-9 or other documentation, attach them to the form prior to submitting
• Change request should be submitted with advance notice
• Contractual agreement guidelines may supersede effective date of request

You can check your directory listing on the Anthem Blue Cross: “Find a Doctor tool”. The Find a Doctor tool at Anthem is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans. To ensure Anthem has the most current and accurate information, please take a moment to access the Find A Doctor tool (www.anthem.com/ca, select the Providers tab, then select the Find A Doctor in the sub bullets) and review how you and your practice are being displayed.

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Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. For a complete listing of our workshops, seminars, webinars and job aids, log on to the Anthem Blue Cross website: www.anthem.com/ca. Select Providers, under Communications go to Education and Training. Scroll down to view Training, Educational and Resource offerings.

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Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before with our Provider News publication. Provider News is our web tool for sharing vital information with you. It features short topic summaries and links that let you dig deeper into timely critical business information:

• Important website updates
• System changes
• Fee Schedules
• Medical policy updates
• Claims and billing updates
• …and much more!

Registration is fast and easy. There is no limit to the number of subscribers who can register for Provider News, so you can submit as many email addresses as you like.

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Anthem Blue Cross (Anthem) has network leasing arrangements with a variety of organizations, which we call Other Payors. Other payors and affiliates use the Anthem network.

Under the terms of your provider agreement, members of other payors and affiliates are treated like Anthem members. As such, they are entitled to the same Anthem billing considerations, including discounts and freedom from balance billing. You can obtain the Other Payors list on the Availity web portal, at www.Availity.com. From the Availity site, select Home > Anthem California > Education and Reference Center, or email us at CAContractSupport@Anthem.com.

It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137) requires that Anthem Blue Cross (Anthem) provide our members accurate and up-to-date provider directory data. As a result, Anthem will be conducting ongoing outreaches to all practices to confirm the information we have on file is accurate. Without verification from you that our Provider Directory information is accurate, we will be required to remove your practice from the directories we make available to our members. We appreciate your attention to this matter.

Anthem Blue Cross (Anthem) is committed to providing digital first solutions. Our health care teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem has the answers before you ask the questions. With an initial focus on claim-level insights, Anthem has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to completion. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOB.

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.

Anthem has made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online – all in one place.

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem is using digital technology to improve the health care experience.

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Anthem Blue Cross (Anthem) is launching a new Anthem High Performance/Blue High Performance Network (Blue HPN^®) in January 2021.  Blue HPN is part of a national network of Blue High Performance networks being created in collaboration with the Blue Cross Blue Shield Association.

Blue HPN participation will be displayed in provider profiles in our provider directory on or prior to January 1, 2021. If you are not sure whether your practice will be part of Blue HPN as of January 1, 2021, or you have questions about this network, please use the following contact information below:

1. Behavioral Health for existing contracted providers: CABHNetworkRelations@Anthem.com
2. Commercial Medical Groups/IPAs & Facilities for existing contracted providers: CAContractSupport@Anthem.com
3. Enterprise Ancillary Networks (Acupuncturists, Cardiac Event Monitoring (CEM), Ground and Air Ambulance, Skilled Nursing, Lab, Hospice, Home Health, Home Infusion, Dialysis, DME, PT/OT/SP Therapy, Registered Dietitians, Audiology/Hearing Aid Suppliers): EnterpriseAncillary@Anthem.com

Select the link below for the full article in the October 2020 newsletter:

Anthem Inc. and Quest Diagnostics have entered into a strategic relationship by collaborating on a variety of outcomes-based programs designed to create an improved health care experience for consumers and providers beginning August 1, 2020.

Anthem and Quest will work together to improve efficiency in care delivery and reduce overall costs by leveraging a broad range of tools and programs to drive operational improvements, create pricing transparency, and enhance health care consumer engagement and outcomes.  The strategic relationship will focus on consumers in California, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, New York, Ohio, Virginia, and Wisconsin.  

Please note that the joint press release may be accessed at  https://newsroom.questdiagnostics.com/2020-08-17-Anthem-and-Quest-Diagnostics-Form-Strategic-Relationship.

We are excited to announce our expansion of both EPO and HMO offerings to new regions.

EPO Plans and Network

For the 2021 benefit year, Anthem Blue Cross (Anthem) will continue to offer EPO Individual on exchange and off exchange plans in Covered California’s rating regions 1, 7, 9, 10 and 12.  We are also very pleased to announce the expansion of our Individual EPO on and off exchange plans into rating regions 13 and 14. 

Below is a list of counties located in those regions where Anthem will be offering 2021 EPO on and off exchange Individual plans.

Providers in Regions 1, 7, 9, 10 and 12

If you are already participating in the Pathway (on and off exchange) network located in one of these regions, you will continue to provide services to Anthem patients who have purchased coverage on and off exchange as you currently do under your Anthem provider agreement. 

Providers in Region 13 and 14

If you participated in the Pathway (on and off exchange) network in 2017, we have reinstated your participation in the Individual Pathway EPO network under your Anthem provider agreement.  We have further extended participation to providers who previously did not participate in the Anthem Individual Pathway EPO network.  A communication has been sent to both previously participating providers and new providers in the Pathway EPO network.

HMO Plans and Network

Anthem Blue Cross (Anthem) is excited to re-enter rating region 18 with our HMO Individual on exchange and off exchange plans in addition to regions 11, 15, 16 and 17.  The Pathway HMO network providers have been selected and agreements executed.  Below is a list of counties located in the regions where Anthem will be offering 2021 Individual on and off exchange HMO plans.

These changes do not impact Anthem CA Individual “grandfathered” business. 

Anthem appreciates your partnership and continued participation in our Individual Pathway EPO and HMO networks. 

If you have any questions regarding this information please contact Anthem’s Network Relations Department via email at CAContractSupport@Anthem.com.

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As of December 1, 2020, the providers listed below are participating air ambulance providers with Anthem Blue Cross (Anthem).  That means, for members picked up in California, these participating providers have contractually agreed to accept the Anthem Rate as payment in full for approved and medically necessary transport and will bill those members for cost-shares only.

Some air ambulance providers choose not to participate with Anthem.
 

• These air ambulance providers may, and often do, charge members rates that are significantly higher than the Anthem contracted provider rates.
• These non-contracted air ambulance providers attempt to collect from Anthem members the difference between Anthem’s allowed amount and their billed amount.

To help Anthem members avoid the high costs of air transportation from y non-contracted providers, we ask that, whenever possible, you choose a participating air ambulance provider for your patients who are Anthem members.  Utilizing participating providers: 
 

• Protects the member from balance billing for what may be excessive amounts,
• Assures the most economical use of the member’s benefits, and
• Is consistent with your contractual obligations to refer to in-network providers where available.

To schedule fixed wing or rotary wing air ambulance services, please

1. Contact Anthem for precertification for all non-emergent transports, using the number on the back of the member’s ID card, then
2. Call one of the phone numbers listed below.

Please have the following information ready when you call one of the contracted air ambulance providers

• Basic medical information about the patient, including the patient’s name and date of birth or age.  If the service was not precertified with Anthem, the air ambulance provider will also need to receive a full medical report from the attending facility.
• Current location of the patient, the name of the hospital or facility caring for the patient and its address (city and state)
• Location where patient is to be transported, including the name of the destination hospital/facility and address
• Approximate transport date or timeframe
• Special equipment or care needs

Should you have questions regarding the air ambulance network, including providers contracted for air ambulance pickups outside of Maine, please contact your Provider Network Manager.

Fixed Wing (Airplane) Providers (HCPCS Codes: A0430 and A0435)

Rotary Wing (Helicopter) Providers (HCPCS Codes: A0431 and A0436)

To arrange air transport originating outside the U.S., U.S. Virgin Islands, and Puerto Rico, please call 1-800-810-BLUE for BCBS Global Core (formerly BlueCard Worldwide)

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The Provider Digital Engagement Supplement is another example of how Anthem Blue Cross (Anthem) is using digital technology to improve the health care experience. The Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits all in one comprehensive resource. We want providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.

Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:

• File claims
• Check statuses
• Verify eligibility and benefits
• Submit prior authorizations

Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website.

Get payments faster

• Electronic Funds Transfer (EFT) eliminate the need for paper checks. Payments are deposited directly to your bank account. It is safe, secure and you receive payments faster.

Eliminate paper remittances

• Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.

Member IDs go digital

Having a member email their ID card directly to you for file upload eliminates the need for you to scan or print, making it easier for you and the member. Member ID cards can also be accessed from the Availity. Save time by accepting the digital member ID cards when presented by the member via their App or email.

Read more about going digital with Anthem in the Provider Digital Engagement Supplement available online. Go to anthem.com/ca, select Providers, under the Provider Resources heading select Forms and Guides. From the Category drop down, select Digital Tools, then Provider Digital Engagement Supplement.

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As you know, Anthem Blue Cross (Anthem) monitors member access to a provider’s care through a number of mechanisms, including provider and member surveys. These surveys are conducted by Anthem and external entities such as Sutherland Healthcare Solutions, North American Testing Organization (NATO), and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program.  In surveying compliance with After Hours standards, participating providers’ offices are called outside of normal business hours to determine if callers are given appropriate emergency instructions and have a mechanism to reach a provider after regular hours for urgent situations.  In surveying compliance with appointment availability standards, participating providers’ offices are called within normal business hours and are asked when would be the next available appointment for urgent and non-urgent care.

Members are also surveyed via mail. The surveys, in addition to monitoring member complaints, help us to identify whether access to care is available to our members after or before normal business hours.

The key to our 2020 success is…YOU!

We thank those of you who have already taken steps to comply with the standards. Your efforts make a direct positive impact on the level of service and access to care for our members. We need your continued support and commitment in helping us achieve the best results possible for our 2020 surveys, which are currently being conducted.

In an effort to improve our results for 2020, Anthem is sharing the 2019 results below.

Provider After Hours Results – 2019 Survey

PAAS Results – 2019 Survey

How Can You Make a Difference?

• Review Anthem’s Access Standards under the Legal and Administrative Overview section of your Anthem California Facility and Professional Provider Manual. Make sure your practice policy and procedures comply with the standards.
• Ensure your After Hours office staff, answering service and/or answering machine message specifically informs callers when their urgent (non-emergent) calls will be returned.
• Ensure your After Hours office staff, answering service and/or answering machine message directs callers to dial 911 or go to the nearest emergency room if they are experiencing an emergency.
• Ensure that your office staff are aware of and able to comply with the appointment availability standards when setting appointments for our members.

If your office was surveyed in 2019 and found non-compliant with these standards, a letter with recommended compliance measures was sent to your mailing address on file with Anthem 

We value your participation in the Anthem Blue Cross Network and appreciate your efforts to meet compliance with established access standards.

If you have questions, please email the Network Relations team that meets your needs. 

1. Medical inquiries - CAContractSupport@anthem.com
2. Behavioral Health inquiries - CABHNetworkRelations@anthem.com

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The impact of COVID-19 in 2020 prohibited Anthem Blue Cross (Anthem) from conducting our annual after-hours access studies to assess phone messaging for our members for perceived emergency or urgent situations after regular office hours.  We will resume the survey in the second quarter of 2021 and expect when your office is contacted, you will be able to accommodate a member’s urgent concerns after hours.

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, such as:

Emergency situations

The compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects the caller directly to the doctor.  

Urgent situations

The compliant response for urgent needs would direct the caller to Urgent Care or ER, to call 911 or connect the caller to their doctor or the doctor on call.  Messaging gives member information when to expect to receive a call back.

Messaging that only gives callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions is not complaint, as there is no direct connection to their health care practitioner. This prompt can be used in addition to, but not in place of the emergency and urgent instructions.  

Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form, on Anthem.com/ca.

Is your practice compliant?

Are you looking for creative ways to talk to your patients about certain preventive care services such as breast cancer screening and adolescent vaccinations including the HPV vaccination?  As flu season approaches, do you want a way to educate your patients about the dangers of antibiotic resistance?  Short educational videos, approximately two minutes in length, are available on anthem.com > Providers > Forms and Guides > under the Category heading, select Patient Care. 

By providing education and addressing common fears and concerns, these brief videos offer an alternative approach to patient engagement on these important topics.  Take a look today!

A medical necessity review may be called many things - including utilization review (UR), utilization management (UM) or medical management - within the Evidence of Coverage or benefit booklet. Requirements for medical necessity review vary based on the member’s benefit plan. Reviews of a medical service may occur:

• when it is requested or planned (prospective or pre-service review)
• during the course of care (inpatient or outpatient ongoing care review)
• after services have been delivered (retrospective or post-service review)

With so many variables, it may help to get a clear picture of what to expect and how the process works.

Timing is Important

We are committed to deciding cases quickly and professionally. Here are several time frames you can expect:

Urgent Pre-service Review Requests

An urgent pre-service review request is a request for pre-service review that in the view of the treating provider or any physician with knowledge of the member’s medical or behavioral condition could without such care and treatment subject the member to adverse health consequences, pose an imminent and serious threat to the member’s life or health or their ability to regain maximum function, or seriously jeopardize the life, health or safety of the member or others due to the member’s psychological state. 

Notification of Delay in Review Determination

If we do not have the information, we need to make our decision, we will try to get it from the physician or other health care provider who is requesting the service, medical procedure or equipment. If a delay is anticipated because the information is not readily available, we will notify the member as well as the requesting physician or other health care provider in writing. Delay letters include a description of the information we need to make a decision and also specify when the decision can be expected once the information is received. If we do not receive the necessary information, we will send a final letter explaining that we are unable to approve access to benefits due to lack of the information requested.

We Use Professional, Qualified Reviewers

Experienced clinicians review requests for services using medical criteria, established guidelines and applicable medical policies. Requests for covered benefits meeting those standards are certified as medically necessary.

Only a Peer Clinical Reviewer May Determine That a Service is Not Medically Necessary

Peer Clinical Reviewers (PCRs) are California licensed health care professionals qualified and clinically competent to evaluate the specific clinical aspects of the request and/or treatment under review. PCRs are licensed in California in the same license category as the requesting physician or other health care provider. If you are the treating practitioner directly involved in the member’s care/treatment plan and need to discuss a medical necessity review decision, an Anthem Blue Cross Medical Director or Peer Clinical Reviewer is available at 800-794-0838.  If the PCR is unable to approve a service, the requesting physician, another health care provider or the member has the right to request an appeal.

Decisions Not to Approve Are in Writing

Written notice is sent to the member and the requesting physician or other health care provider within two business days of the decision. This written notice includes:

• a clear and concise explanation of the reason for the decision
• the name of the criteria and/or guidelines used to make the decision
• the name and phone number of the Peer Clinical Reviewer who made the decision, for peer-to-peer discussion
• instructions for how to appeal a decision
• specific provisions of the contract that excludes coverage if the denial is based upon benefit coverage

Access to Criteria

Anthem Blue Cross Medical Policy and Clinical UM Guidelines for specific services are available to members, member representatives, health care providers and the public. Members may call the number on the back of their ID card for a copy of the guidelines used to determine their case. Anthem Blue Cross Medical Policy and Clinical UM Guidelines are also available at www.anthem.com/ca. Providers can access UM criteria by selecting “Providers” at the top of the screen to access the “Providers Overview” page. Under Provider Resources, select “Policies, Guidelines & Manuals”. Scroll down and select View Medical Policies & UM Guidelines; or call 800-794-0838 to request that a paper copy be sent to you. The requested criteria is provided free of charge.     

A Determination of Medical Necessity Does Not Guarantee Payment or Coverage

The determination that services are medically necessary is based on the clinical information provided. Payment is based on the terms of a member’s coverage at the time of service. These terms include certain exclusions, limitations and other conditions, as outlined in the member’s Evidence of Coverage or benefit booklet. Payment of benefits could be limited for a number of reasons, for example:

• the information submitted with the claim differs from that given at time of review
• the service performed is excluded from coverage
• the member is not eligible for coverage when the service is actually provided

Decisions About Coverage of Service

Our utilization management decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits.  In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. 

We Are Available for Questions

If you need to request precertification, need information about our UM process, or have questions or issues, call our toll-free number: 800-274-7767.  Our associates are available Monday through Friday (except holidays), 8:00 a.m. to 5:00 p.m., Pacific Time.  If you call after hours or do not reach someone during business hours, you may leave a confidential voice mail message. Please leave your name and phone number; we will return your call no later than the next business day during the hours listed above, unless other arrangements are made. Calls received after midnight will be returned the same business day. Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls.

Language Assistance

For those who request language services, Anthem Blue Cross provides service in the requested language through bilingual staff or an interpreter, to help members with their UM issues. Language assistance is provided to members free of charge. Oral interpretation is available at all points of member contact regarding UM issues.

TDD/TTY Services

TDD (telecommunications device for the deaf) or TTY (telephone typewriter, or teletypewriter) is an electronic device for text communication via a telephone line, used when one or more parties have hearing or speech difficulties. If you have a hearing or speech loss, call 711 to use the National Relay Service or the number below for the California Relay Service. A special operator will contact Anthem to help with member needs. 

1-800-855-7100 (English TTY/ English Voice)

For Federal Employee Program, call the number on the member ID card.  Utilization management is administered by Blue Shield of California. 

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The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement.

It can be found on our website, under the FAQ question about “Laws and Rights that Protect You.”  To access, go to anthem.com/ca and select “Provider.”  From there, select “Policies, Guidelines & Manuals” under Provider Resources.  Select your state and scroll down to “Member Rights and Responsibilities” under More Resources.  Click the “Read about member rights” link.  Practitioners may access the FEP member portal at www.fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

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Emergency services are services provided in or out of the service area in connection with the initial treatment of a medical or psychiatric emergency and are available 24 hours a day and seven (7) days a week.

A member who considers a medical or psychiatric condition to be an emergency should be instructed to call 911 or go to the nearest hospital emergency room immediately. Anthem Blue Cross (Anthem) covers emergency services that are necessary to screen and stabilize a condition. No authorization or pre-certification is needed if the member reasonably believes that an emergency medical or psychiatric condition exists. A member should be directed to call the Member Services/Customer Service telephone number on the back of their Anthem ID card with any questions.

An emergency is an unexpected acute illness, injury, or medical or psychiatric condition that could endanger health if not treated immediately. Examples of medical/psychiatric emergencies include:

• Severe pain
• Chest pains
• Heavy bleeding
• Sudden weakness or numbness of the face, arm or leg on one side of the body
• Difficulty breathing or shortness of breath
• Sudden loss of consciousness 
• Active labor 
• Attempted suicide
• Suicidal/homicidal ideation 
• Acute psychosis
• Hazardous drug reactions/interactions

California law requires a health plan to provide coverage for emergency services to screen and stabilize a condition unless there is evidence to show that either the services were never performed or the member did not require emergency services and reasonably should have known that an emergency did not exist. Answering machine instructions and after-hours answering service staff of all HMO and PPO practitioners must direct members to call 911 or go directly to the nearest emergency room if they reasonably believe they are experiencing an emergency.

For more information on the 2019 After Hours and PAAS Survey Results for Behavioral Health. 

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Accurate and up-to-date information about your practice in our directories is important. As a result, Anthem conducts semi-annual outreaches to confirm the information we have on file is accurate. Without verification from you that our provider directory information is accurate, we will be required to remove your practice from the directories we make available to our members. For any questions about updating your practice, send an email to CABHNetworkRelations@anthem.com

Detailed information about submitting practice changes is available in our Behavioral Health Guides. Go online to anthem.com/ca/behavioralhealth > Behavioral Health Guides.

You should always submit claims to Anthem Blue Cross. Be sure to include the member’s complete identification number when you submit the claim. The complete identification number includes the three-character alpha/numeric prefix. Do not make up alpha prefixes. Claims with incorrect or missing alpha prefixes and/or member identification numbers cannot be processed.

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The BlueCard® Program provides a valuable service that lets you file all claims for members from other Blue Plans with Anthem Blue Cross. Here are some key points to remember:

• Make a copy of the front and back of the member’s ID card.
• Look for the three-character prefix that precedes the member’s ID number on the ID card.
• Call BlueCard Eligibility at 1-800-676-BLUE (2583) to verify the patient’s membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to Anthem Blue Cross.
• Submit the claim to Anthem Blue Cross. Always include the patient’s complete identification number, which includes the three-character prefix.
• For claims inquiries, contact Anthem Blue Cross.

Behavioral Health providers can participate (contract) under three different types of agreements:

• Commercial Behavioral Health
• Medi-Cal Behavioral Health
• Employee Assistance Program (EAP).

It is important to understand that you might contract under one, two or all three agreements as a participating network provider, and that each agreement is different, has a specific fee schedule and a dedicated operational area to answer your unique network questions.

Network Relations answers questions about the fee schedule, agreement (contract) language or requirements as specified in the provider manual. Each network has a devoted Network Relations team to service specific needs.

Contact information for each team follows below.

• Commercial Behavioral Health - CABHNetworkRelations@anthem.com
• Medi-Cal Behavioral Health - BHMedi-CalNetworkRelations@anthem.com
• EAP - EAPProviderNetworks@anthem.com

Submission of claims in overlapping Blue Plan service areas is dependent on what plan(s) the provider contracts within that state, the type of contract the provider has for example, PPO, Traditional, etc., and the type of contract the member has with their Home Plan.

In other states, a company may carry the Blue Cross and Blue Shield name together, as a single entity. In California, there are two separate and independent Blue Cross Blue Shield companies. One is Anthem Blue Cross (Anthem), and the other is Blue Shield of California.

• If you contract with both Plans in California, you may file an out-of-area Blue Plan member’s claim with either Plan.
• If you contract with one Plan but not the other, file all out-of-area claims with your contracted Plan.

Use the Anthem Payer ID number that was assigned to you, not the Blue Shield of California Payer ID number. If you submit an Anthem member claim with the Blue Shield of California Payer ID number instead of the Anthem Payer ID number, the claim will process as out-of-network.

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If you have an issue or question about a claim, your first step is to call Claims Customer Service or send an online secure message via Availity. If after contacting a Customer Service representative, supervisor, or sending an Availity secure messaging and your claim issue remains unresolved, submit a provider dispute including any reference number(s) supporting any previous calls about your issue.

Use the Provider Dispute Resolution Request (PDR) form to initiate the formal dispute process for a claim already adjudicated or when you, the provider disagrees with an Anthem billing determination.

Uses for the Provider Dispute Resolution Request (PDR) form:

• Dispute the resolution of an adjudicated claim
• Appeal a medical necessity or Utilization Management decision
• Respond to a notice of overpayment or to appeal an overpayment withhold of an adjudicated claim
• Submit documentation for a contract dispute
• When there’s a denial of medical group responsibility
• For submissions of similar multiple claims, billing, or contractual disputes, which may be batched as a single dispute, utilizing the second page of the PDR form to detail the attachments
• For other submissions that occur after adjudication of the claim

Prompt written notice of a closed practice prevents member servicing delays. Are you accepting new patients? Your practice status - open or closed must be reflected accurately in our provider directories. California law requires that participating health care providers notify health plans within five days when their “Accepting New Patients” status changes.

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Practice information helps us direct referrals and members who access care directly. It’s key in delivering timely access to care. You play a big role in keeping our provider directories up-to-date.

Is your practice information (e.g. practice address, areas of expertise, etc.) accurate? Prevent member servicing delays and notify us of any practice changes promptly. The Practice Update Form and the Practice Profile are convenient online options for updating your practice information.

Use the Practice Update Form to change the following information:

• Email address
• Phone and fax number
• Check/EOB/billing/ reimbursement address
• Open /closed practice status
• Mailing/correspondence address
• Tax ID (include a W-9 form with your change)
• Practice/service address

Use the Practice Profile when updating:

• Self-reported areas of expertise
• Open/closed practice status
• Psychiatrists update ECT, TMS, Suboxone, and anti-psychotic injectable management if applicable.
• Age ranges treated
• Additional languages spoken
• Provider ethnicity (optional)

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

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

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

Information can be accessed on the process of submitting member grievances and appeals, grievance forms, definitions and appeal rights, on Anthem’s website at anthem.com/ca/forms. Go to View by Topic and click on the drop down menu and select Grievance & Appeals, and then select the desired resource link.

In addition, grievance forms, grievance procedures, Anthem’s expedited grievance and appeals review process, can be found in the Anthem Blue Cross Facility and Professional Provider Manual

Anthem has posted a required learning course via Availity Portal (login required) to ensure provider offices have implemented processes to provide grievance forms and assistance to enrollees. Please make sure to complete this course and the required attestation by June 1, 2020:
 

1. Log in to Availity Portal at com.
2. At the top of Availity Portal, click Payer Spaces> Anthem Blue Cross.
3. On the payer spaces landing page, click Access Your Custom Learning Centerfrom the Applications
4. Search for the Member Grievance Form and Attestation - Online Courseusing keyword grievance.
5. Enroll and complete the course, including the required attestation module.

Refer to this guide for more information.

Not registered for the Availity Portal?

Have your organization’s designated administrator register your organization for the Availity Portal.

1. Visit comto register.
2. Click Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization. Refer to these PDF documentsfor complete registration instructions.

Getting Started

When you log in to Availity Portal for the first time, Availity prompts you to:

• Accept privacy and security statements
• Accept a confidentiality agreement
• Choose three security questions and answers
• Create a new password
• Verify your email address

For questions regarding the Availity Portal, call Availity Client Services toll-free at 1-800-282-4548.

We appreciate your cooperation and support.

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As communicated in the June and October 2020 editions of Anthem Blue Cross’ (Anthem) Provider News, effective December 1, 2020, Anthem will transition the clinical criteria for medical necessity review of certain rehabilitative services to AIM Rehabilitative Service Clinical Appropriateness Guidelines.  Clinical criteria will include certain physical therapy, occupational therapy and speech therapy services.  

Update: We previously advised that the effective date of this transition was October 13, 2020. We have now updated the effective date of this transition to December 8, 2020.

Effective December 8, 2020, Anthem Blue Cross will transition the clinical criteria for medical necessity review of certain outpatient rehabilitative services from our clinical guidelines for physical therapy CG-REHAB-04, occupational therapy CG-REHAB-05 and speech language pathology CG-REHAB-06 to AIM Specialty Health_®* Rehabilitative Service Clinical Appropriateness Guidelines. These reviews will continue to be completed by the CA utilization management team.

Access and download a copy of the current and upcoming guidelines here.

This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

Introducing the Anthem Provider Digital Engagement Supplement to the provider manual

Using our secure provider portal or EDI submissions (via Availity*), administrative tasks can be reduced by more than 50% when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, just go here for EDI or here for the secure provider portal (Availity).

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and will deliver payments to you faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the Availity Provider Portal or the EDI 835 remittance, which meets all HIPAA mandates — eliminating the need for paper remittances.

Member ID cards go digital

Members who are transitioning to digital member ID cards, will find it is easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available by going to https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx > Manuals, Training & More > Resources > Provider Digital Engagement, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid, including medical, dental and vision benefits.

The Provider Digital Engagement Supplement to the provider manual is another example of how Anthem is using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now by going to https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx > Manuals, Training & More > Resources > Provider Digital Engagement, and go digital with Anthem.

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Reimbursement is based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure. Currently:

• Modifier 54 (surgical care only) is reimbursed at 80%.
• Modifier 55 (postoperative management only) is reimbursed 20%.
• Anthem Blue Cross does not allow separate reimbursement for Modifier 56.

Effective March 1, 2021, Anthem Blue Cross will continue to reimburse on a percentage of the fee schedule or contracted negotiated rates for the surgical procedure. However, the following rates have been amended:

• Modifier 55 (postoperative management only) will be reimbursed at 30%.

For additional information, review the Split-Care Surgical Modifiers reimbursement policy at https://mediproviders.anthem.com/ca.

Consumer Assessment of Healthcare Providers and Systems (CAHPS)^® is an annual standardized survey conducted to assess consumer experience with their health care services and health plan. Providers and their staff play a key role in the member experience. Several questions specific to the member’s experience with their provider are included in the CAHPS survey. Education about the CAHPS survey, the importance of focusing on the patient experience and ways to improve the patient experience are included in the Provider Orientation and available by visiting https://mediproviders.anthem.com/ca.

This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

Effective February 4, 2020, Anthem will transition the clinical criteria for medical necessity review of CG-SURG-74 Total Ankle Replacement services to AIM Specialty Health_®* small joint guidelines. These reviews will continue to be completed by the Anthem Utilization Management team.

You may access and download a copy of the AIM Small Joint Guidelines here.

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Click here for more information about Anti-VEGF Medical Step Therapy Notice.

Across the nation, too many women continue to experience pregnancy-related complications and death. More than 700 women die each year in the United States as a result of complications related to pregnancy or delivery.¹ Many of these deaths are preventable. In addition, significant racial and ethnic disparities exist in maternal morbidity and mortality. For example, Black/African American and American Indian/Alaska Native women are two to three times more likely to die from pregnancy-related complications compared to White women.²  Anthem Blue Cross recognizes your role at the front lines of defense to support your diverse pregnant and postpartum patients. We want to ensure you have the right tools and resources to help your patients understand their risks and key maternal warning signs.

The Centers for Disease Control and Prevention (CDC) recently launched the Hear Her campaign to raise awareness of pregnancy-related complications, risks and death. The Hear Her campaign aims to increase knowledge of the symptoms women should seek medical attention for during pregnancy and in the year after delivery, such as vision changes and chest pain. Resources are available for pregnant and postpartum women, partners, families and friends, and health care providers.

The Hear Her campaign reminds us of the importance of listening to women. As a health care provider, you have an opportunity to listen to pregnant women, engage in an open conversation to make certain their concerns are adequately addressed, and help your patients understand urgent maternal warning signs. You can find more information on the CDC's Hear Her campaign at www.cdc.gov/hearher.

In addition, the Council on Patient Safety in Women's Health Care developed a tool to help women identify urgent maternal warning signs. The Urgent Maternal Warning Signs tool helps women recognize the symptoms they may experience during and after pregnancy that could indicate a life-threatening condition. The tool also provides additional information on the symptoms and conditions that place women at increased risk for pregnancy-related death. You can find the Council on Patient Safety in Women's Health Care Urgent Maternal Warning Signs tool at www.safehealthcareforeverywoman.org/urgentmaternalwarningsigns.

If you have a pregnant member in your care who would benefit from case management, please call one of our Medi-Cal Customer Care Centers at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County). Members can also call our 24/7 NurseLine at the number on their member ID card.

References

1              Centers for Disease Control and Prevention. (2020, August 13). Reproductive Health: Maternal Mortality. Retrieved from https://www.cdc.gov/reproductivehealth/maternal-mortality/index.html.

2              Centers for Disease Control and Prevention. (2019, September 5). Racial and Ethnic Disparities Continue in

The purpose of this article is to provide additional information regarding submission of the Clinical Laboratory Improvement Amendments (CLIA) number on claims for laboratory services that include QW or 90 modifiers. As a reminder, claims filed without the CLIA number are considered incomplete and will reject.

Both paper and electronic claim formats accommodate the CLIA number.

• On the CMS-1500 form, box 23 (Prior Authorization) is reserved for the CLIA
• On the 837P, REF segments are available: REF (X4) in loops 2300 and 2400, and REF (F4) in loop 2400.

Note: The CLIA number for the referring clinical laboratory should be included in REF (F4).

The following examples illustrate how the CLIA number as well as procedure code modifiers QW and 90 should be filed.

Additional information regarding CLIA is available on the CMS website at https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA. If you have additional questions, please call the telephone number on the back of the member’s identification card.

This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

In order to communicate more efficiently with providers, Anthem is now sending some bulletins, policy change notifications, prior authorization update information, educational opportunities and more to providers via email. Email is the quickest and most direct way to receive important information from Anthem.

What do we need from you?

To receive email from Anthem (including some sent in lieu of fax or mail), ensure that we have your email address on record by submitting your information via Provider Maintenance Form located on the provider site: https://mediproviders.anthem.com/ca > Forms > Provider Maintenance Form.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Network Relations Consultant or call Provider Services:

• For Medi-Cal Managed Care:
  
  • In Los Angeles County, please email SouthProviderRelationsMedicaid@anthem.com or call 1‑866‑465‑2272.
  • In Central California counties, please email CentralProviderRelationsMedicaid@anthem.com or call 1‑877‑811‑3113.
  • In Northern California counties, please email NorthProviderRelationsMedicaid@anthem.com or call 1‑888‑252‑6331.
• For Cal MediConnect Plan: 1-855-817-5786
• For Medicare Advantage: Call the number on the back of the member ID card.

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This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

Introducing the Anthem Provider Digital Engagement Supplement to the provider manual

Using our secure provider portal or EDI submissions (via Availity*), administrative tasks can be reduced by more than 50% when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, just go here for EDI or here for the secure provider portal (Availity).

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and will deliver payments to you faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the Availity Provider Portal or the EDI 835 remittance, which meets all HIPAA mandates — eliminating the need for paper remittances.

Member ID cards go digital

Members who are transitioning to digital member ID cards, will find it is easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available by going to https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx > Manuals, Training & More > Resources > Provider Digital Engagement, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid, including medical, dental and vision benefits.

The Provider Digital Engagement Supplement to the provider manual is another example of how Anthem is using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now by going to https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx > Manuals, Training & More > Resources > Provider Digital Engagement, and go digital with Anthem.

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How do I check eligibility and benefits for these members?

Online — Eligibility, benefits, claims, links to secure messaging, commonly used forms and remit information are all available through the Availity* Portal at https://www.availity.com. For questions on access and registration, call Availity Client Services at 1-800-AVAILITY (1-800-282-4548). Availity Client Services is available Monday through Friday, 8 a.m. to 7 p.m. ET (excluding holidays) to answer your registration questions.

Phone — Call the Provider Service number on the back of the member’s ID card. You may also verify a member’s eligibility by calling the BlueCard Eligibility Line at 1‑800‑676‑BLUE (2583) and providing the member’s three-digit alpha prefix located on the ID card.

As new members enroll in Group Retiree Medicare Advantage plans under Anthem Blue Cross, they will receive new ID cards. Additionally, existing members may receive new ID cards as a result of benefit changes. Please continue to check member ID cards to ensure you have the most up-to-date eligibility and benefit information.

Please note that we are experiencing an unusually high volume of changes for an effective date of January 1, 2021. Many of the changes do not affect member prefix, member ID or benefits, but some changes will. Because of this, we encourage providers to request a copy of the member’s ID card, particularly at the beginning of the year when members may have new ID cards.

What are the alpha prefixes for Group Retiree Medicare Advantage PPO members?

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Summary of benefits, evidence of coverage and formularies for 2021 individual Medicare Advantage plans will be available at anthem.com/ca/medicareprovider. An overview of notable 2021 benefit changes will be available at anthem.com/ca/medicareprovider > Read News and Updates. Please continue to check anthem.com/ca/medicareprovider for the latest Medicare Advantage information.

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This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

Effective February 4, 2020, Anthem will transition the clinical criteria for medical necessity review of CG-SURG-74 Total Ankle Replacement services to AIM Specialty Health_®* small joint guidelines. These reviews will continue to be completed by the Anthem Utilization Management team.

You may access and download a copy of the AIM Small Joint Guidelines here.

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Update: We previously advised that the effective date of this transition was October 13, 2020. We have now updated the effective date of this transition to December 8, 2020.

Effective December 8, 2020, Anthem Blue Cross will transition the clinical criteria for medical necessity review of certain outpatient rehabilitative services from our clinical guidelines for physical therapy CG-REHAB-04, occupational therapy CG-REHAB-05 and speech language pathology CG-REHAB-06 to AIM Specialty Health_®* Rehabilitative Service Clinical Appropriateness Guidelines. These reviews will continue to be completed by the CA utilization management team.

Access and download a copy of the current and upcoming guidelines here.

This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

Effective February 4, 2020, Anthem will transition the clinical criteria for medical necessity review of CG-SURG-74 Total Ankle Replacement services to AIM Specialty Health_®* small joint guidelines. These reviews will continue to be completed by the Anthem Utilization Management team.

You may access and download a copy of the AIM Small Joint Guidelines here.

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