In the November 2021 edition of Provider News, Anthem Blue Cross (Anthem)  announced that we would be implementing a more streamlined provider payment dispute process for claims for our Commercial lines of business. The process is already in place for claims for our members enrolled in our Anthem Medicaid and Medicare Advantage benefit plans.

Originally scheduled for November 20, 2021, the implementation date is now delayed and will be announced at a later date. To ensure ease of use of the system, we are enhancing the process and training to meet your needs in delivering this important information to you. We regret any inconvenience this delay may have caused. 

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As a reminder, we will upgrade our claim editing software for professional services monthly throughout 2022, with most updates occurring quarterly. These upgrades may apply to same provider, provider group (tax identification number). They may also apply across providers and across claim types (professional/facility) and include, but are not limited to:

• addition of new, and revised codes (e.g., CPT, HCPCS, ICD-10, modifiers) and their associated edits such as:
  • ICD-10 laterality and Excludes1 notes
  • Add-on procedures (indicated by + sign)
  • Code book parenthetical statements and other directives about appropriate code use (e.g., “separate procedure”, “do not report”, “list separately in addition to”, etc...)
• updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• updates to incidental, mutually exclusive, and unbundled (re-bundle) edits
• updates to assistant and co-surgeon eligibility in accordance with the policy
• updates to edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
  

As a reminder, Anthem Blue Cross (Anthem) will continue to upgrade our claim editing software for outpatient facility services monthly throughout 2022, with most updates occurring quarterly. These upgrades will include, but are not limited to:

• Addition of new and revised codes (for example CPT, HCPCS, ICD-10, modifiers, and revenue codes) and their associated edits

• Updates related to the appropriate use of various code combinations, which can include, but are not limited to:

• Procedure code to revenue code
• HCPCS to revenue code
• Type of bill to procedure code
• Type of bill to HCPCS code
• Procedure code to modifier
• HCPCS to modifier

• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC)

As we announced in the October 2021 edition of Provider News, Anthem Blue Cross (Anthem) is working to comply with the requirements of the Consolidated Appropriations Act, or CAA.

Improving the accuracy of provider directory information

As part of the CAA, soon providers will be asked to verify their online provider directory information on a regular basis to help ensure Anthem members can locate the most current information for in-network providers and facilities. It is important that you keep your information up to date. Here’s what you can do now:

• Review your online provider directory information on a regular basis to ensure it is correct. You can check your directory listing on Anthem’s Find Care tool. Consumers, members, brokers, and providers use the Find Care tool to identify in-network physicians and other healthcare providers supporting member health plans. To ensure we have your most current and accurate information, please take a moment to access Find Care. Go to anthem.com/ca, select Providers, then under Provider Overview, choose Find Care.
• Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:
• add/change an address location
• name change
• tax ID changes
• provider leaving a group or a single location
• phone/fax number changes
• closing a practice location

Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.

Consolidated Appropriations Act implementation

The Consolidated Appropriations Act does not preempt state law requirements. This means that the CAA applies in addition to any state l aw requirements of providers to update their provider directory information.

On August 20, 2021, the Tri-Agencies (Departments of Labor, Health and Human Services and the Treasury) announced that regulations to implement the provider directory requirements would be issued on or after January 1, 2022. Health plans are expected to implement the provider directory requirements based on a good faith, reasonable interpretation of the requirements by January 1, 2022, with a primary focus on ensuring that members who rely on provider directory information that inaccurately depicts a provider’s network status are only liable for in-network cost sharing amounts. Anthem is moving forward with compliance of this good faith, reasonable interpretation of the requirements while awaiting additional regulatory guidance.

Watch for upcoming editions of Provider News in 2022 for updates on our ongoing efforts to comply with the CAA requirements.

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EPO Plans and Network

For the 2022 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, 12, 13 and 14. 

Providers in Regions 1, 7, 9, 10, 12, 13 and 14

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 Regions 2, 3, 4, 5, 6 and 8

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 will continue to offer Individual on and off exchange HMO plans in the below regions in 2022.

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 questions or need additional information, contact your assigned Provider Experience associate, or visit the Contact Us page on our provider website for up-to-date contact information. Log onto Anthem.com/ca > For Providers > Communications / Contact Us: https://www.anthem.com/ca/provider/contact-us/.

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The annual after-hours access studies performed by our vendor, North American Testing Organization based in California, were resumed, and fielded in the third quarter of 2021. The purpose is to assess adequate phone messaging for our members with perceived emergency or urgent situations after regular office hours. Unfortunately, most of the Anthem Blue Cross (Anthem) Plans assessed fell short of the expectation of having a live person or a directive in place after hours.

The main challenges the vendor encounters while attempting to collect this required, essential data are related to an inability to reach the provider and/or the lack of after-hours messaging altogether. They include:

• inaccurate provider information in Anthem’s demographic database to allow assessment of the after-hours messaging
• no voicemail or messaging at all
• voicemail not reflecting the practitioner’s name, and/or
• calls being auto forwarded with no identification, no voicemail or messaging

To help both your patients’ and Anthem’s ability to reach your practice, we ask that you update your office information using the online Provider Maintenance Form and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.

What does this mean for our members and your patients? The annual member experience survey of Anthem enrollees indicated of those needing advice, a sizable number sometimes, or never, reached the provider’s office for urgent instructions. To improve upon these instances of failing to meet our member’s needs, implement these three steps:

1. Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital or have the appropriate messaging for the caller.
2. Be sure to turn on the messaging mechanism when you leave the office.
3. Be sure you are using the acceptable messaging for compliance with your contract.

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

Emergency situations

Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER.  

Urgent situations

Compliant responses for urgent needs after hours:

• Live person, via a service or hospital, advises practitioner or on call practitioner is available and connects.
• Live person or recording directs caller/patient to Urgent Care, ER or call 911 and, if also directing caller/patient (via cell phone, pager, text, email, voicemail, etc.) to contact their health care practitioner, provide specific information when to expect to receive a call back.

Non-compliant responses for urgent needs after hours:

• No provision for after-hours accessibility.
• Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. (Not a direct connection to their practitioner.)

Is your practice compliant?

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One in every 10 Americans have diabetes, but one in every five don’t know they have it. That makes annual testing important to those who have symptoms. For those patients who are diagnosed, testing is vitally important to reducing serious health complications and the costs associated with them.

It isn’t always easy to help patients understand the need for annual testing. The Centers for Disease Control and Prevention has resources you can use in your practice to educate, inform, and hopefully motivate your patients. Visit their website cdc.gov and use their Health Care Providers section to access patient education programs, prevention toolkits and more.

Measure up

Comprehensive Diabetes Care (CDC): This HEDIS® measure evaluates members aged 18 to 75 years with type 1 or type 2 diabetes. Each year, members with type 1 or type 2 diabetes should have:

• Hemoglobin A1c (HbA1c) testing - HbA1c control (< 8%)
• Eye exam (retinal) performed
• Medical attention for nephropathy
• BP control (< 140/90 mm Hg)

Anthem Blue Cross wants to share the information needed to close CDC gaps in care. For a list of your patients who need testing, contact Anisha Dua or Jeffrey Chin at Anisha.dua@anthem.com or Jeffrey.chin@anthem.com. Together we can improve the outcome for members with diabetes.

A snapshot: Diabetes in the United States cdc.gov/diabetes/images/library/socialmedia/diabetes-infographic.jpg

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Chances are that one out of every four patients you see in your office has low back pain. The Centers for Disease Control and Prevention (CDC) reports that in the last three months, 25% of U.S. adults report having low back pain, making it second only to the common cold as a cause for lost work time and a primary reason for a doctor’s visit.¹ Back pain will usually go away on its own. About 90 percent of patients with low back pain recover within six weeks.² For this reason, the National Committee for Quality Assurance (NCQA) recommends avoiding imaging for patients when there is no indication of an underlying condition. In a study published by the CDC, Early imaging for acute low back pain, the findings indicated not only was early imaging not associated with better outcomes, it also indicated that certain early imaging (MRI) was associated with an increased likelihood of disability and its duration.³

Low Back Pain resources are available to share

Take advantage of the many publications and patient organization resources available on the National Institute of Health website “Back Pain Information Page.” This Low Back Pain brochure explains everything from types to self-management and is available as a pdf on the NIH website.

HEDIS® Measure: Use of Imaging Studies for Low Back Pain (LBP)

Description:  The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. The higher compliance score indicates appropriate treatment of low back pain.

Exclusions include cancer, recent trauma, IV drug abuse, neurologic impairment, HIV, spinal infection, major organ transplant and prolonged use of corticosteroids.

Coding tips: Here are a few of the approved codes for the diagnosis and services associated with the LBP measure. For a complete list, visit ncqa.org.

¹ https://www.cdc.gov/acute-pain/low-back-pain/index.html#:~:text=25%25%20of%20U.S.%20adults%20report,the%20most%20common%20pain%20reported.

² https://abcnews.go.com/Health/CommonPainProblems/story?id=4047737#:~:text=Answer%3A%20Back%20pain%20usually %20goes,people%20recover%20faster%20than%20others

³ http://dx.doi.org/10.1097/BRS.0b013e318251887b

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
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Talking to a teenager about Chlamydia can be difficult. But, if untreated, this typical teenager could develop Pelvic Inflammatory Disease (PID) or worse, infertility, ectopic pregnancy, and chronic pelvic pain. Provider resources can help get the conversation started. For a free Chlamydia How-To  Implementation Guide for Healthcare Providers, visit the National Chlamydia Coalition website at  http://chlamydiacoalition.org.

One of the largest growing populations for Chlamydia are teens and young adults aged 15 to 24. Through annual screening – a simple urine test in your office or in an off-site lab – teens and young adults can maintain good health.

Chlamydia Screening in Women (CHL): HEDIS® recommends annual screenings for teens starting at age 16 and for women up to aged 24. Sexually active teens and women as well as those who meet any of the following criteria should be tested each calendar year:

• Made comments or talked to you about sexual relations
• Taken a pregnancy tested
  • Been prescribed birth control (even if used for acne treatment)
• Received Gynecological services
• A history of sexually transmitted diseases
• A history of sexual assault or abuse

Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a healthcare puzzle that for some, are frightening and complex issues to handle.

Anthem Blue Cross (Anthem) is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  They will be transferred to a team member based on the immediate need.  Physicians can also refer by contacting us telephonically or through electronic means.  No issue is too big or too small.  We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

How do you contact us?

For referrals call 888-613-1130, and Transplant Oncology at 888-574-7215.

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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 the next available appointment for urgent and non-urgent care would be.

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 2021 success is…YOU!

If you have already taken steps to comply with the standards – thank you! Your efforts make a direct positive impact on the level of service and access to care for our members. This year’s surveys are under way and with your continued support and commitment, we can achieve the best results possible for 2021.

Take a minute to review the 2020 survey results in the table below.  We hope sharing them with you provides a better understanding of how you can help improve 2021 results.

Provider After Hours Results – 2020 Survey

PAAS Results – 2020 Survey

How Can You Make a Difference?

• Review the Commercial Access Standards under the Legal and Administrative Requirements section in your Anthem Blue Cross 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 2020 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 provider network and appreciate your efforts to meet compliance with established access standards.

If you have questions, please email your Provider Experience representative for assistance from the Contact Us page. Select Provider Experience team to open the email form and make sure to enter the words, ‘2020 Survey After Hours and PAAS Results’ in the subject field.  Visit us online to view other contact options.

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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 (Anthem) has adopted a member rights and responsibilities statement.

To read the member rights and responsibilities statement, visit the Policies, Guidelines and Manuals page of our provider website. Scroll down the page and select “Read about member rights.” Under the FAQ question titled “Laws and Rights that Protect You” you can find information about Anthem member rights and responsibilities.

Practitioners may access the FEP member portal at fepblue.org/memberrights  to view the FEPDO Member Rights Statement.

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Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment, and referral.  Anthem Blue Cross (Anthem) would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner.  Anthem urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other health care practitioners at the time treatment begins.

We expect all health care practitioners to:

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:

• Diagnosis
• Treatment plan
• Referrals
• Psychopharmacological medication (as applicable)

In an effort to facilitate coordination of care, Anthem has several tools available on our anthem.com/ca Provider website for behavioral health and other medical practitioners including:

• Coordination of Care Form
• Coordination of Care Letter Template - Behavioral Health
• Coordination of Care Letter Template - Medical

The following behavioral health forms, brochures, and screening tools for substance abuse and attention-deficit/hyperactivity disorder (ADHD) are also available on our anthem.com/ca Provider website:

• Alcohol Use Assessment Brochure
• Antidepressant Medication Management
• Edinburgh Postnatal Depression Scale
• Opioid Use Assessment Brochure
• Substance Brief Intervention/Referral Tool (SBIRT)
• Vanderbilt ADHD Diagnostic Parent Rating Scale

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances, and recent medical research. 

All guidelines are reviewed annually and updated as needed. The current guidelines are available on our website at anthem.com/ca > For Provider > Select Policies, Guidelines & Manuals under Provider Resources> scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.

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Within the member’s Evidence of Coverage or benefit booklet, a medical necessity review may be referred to as any of the following: utilization review (UR), utilization management (UM) or medical management. 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)

Because of these variables, we’d like to provide a summary of what to expect and how the process works.

Timing is important

We are committed to determining cases quickly and professionally. Here are the 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 the “For Providers” drop down at the top of the screen. 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 a.m. to 5 p.m., PT. 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. 

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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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. Members 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. All HMO and PPO practitioners must have answering machine instructions and after-hours answering service staff to direct members to call 911 or go directly to the nearest emergency room if they reasonably believe they are experiencing an emergency.

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You may already be familiar with the Availity multi-payer Authorization app because thousands of providers are already using it for submitting prior authorizations for other payers. Anthem Blue Cross (Anthem) is eager to make it available to our providers, too. On December 13, 2021, you can begin using the same authorization app you use for other payers. We hope to make it easier than ever before to submit prior authorization requests to Anthem.

ICR is still available

If you need to refer to an authorization that was submitted through ICR, you will still have access to that information. We’ve developed a pathway to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization app.

Innovation in progress

While we grow the Availity Authorization app to provide you with Anthem-specific information, you can still access ICR for:

• Appeals
• Behavioral health authorizations
• FEP authorizations
• Medical specialty Rx

Notices in the Availity Authorization App will guide you through the process for accessing ICR for Reserved Auth/Appeals functions.

Training is available

If you aren’t already familiar with the Availity Authorization app, training is available.

You can always log onto Availity.com and view the webinar at your convenience. From Help & Training select Get Trained to access the Availity Learning Center. You can use “AvAuthRef” for a keyword search or select the Session tab to see all upcoming live webinars.

Now, give it a try!

Accessing the Availity Authorization app is easy. Just log onto Availity.com and the Authorization icon is on the home screen. You can also access the App through the Patient Registration tab by selecting Authorizations and Referrals.

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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.

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Our Provider network education team offers quality materials specially designed for our providers. Log on to the Anthem Blue Cross website: www.anthem.com/ca Select For Providers, under Communications go to Education and Training. Scroll down to view Training, Educational and Resource offerings.

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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.

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Easily update demographic changes and much more, by simply submitting your updates through Anthem Blue Cross (Anthem) 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. Visit the Provider Maintenance Form landing page to review more.

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

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 the next available appointment for urgent and non-urgent care would be.

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 2021 success is…YOU!

If you have already taken steps to comply with the standards – thank you! Your efforts make a direct positive impact on the level of service and access to care for our members. This year’s surveys are under way and with your continued support and commitment, we can achieve the best results possible for 2021.

Take a minute to review the 2020 survey results in the table below.  We hope sharing them with you provides a better understanding of how you can help improve 2021 results.

Provider After Hours Results – 2020 Survey

PAAS Results – 2020 Survey

How Can You Make a Difference?

• Review the Commercial Access Standards under the Legal and Administrative Requirements section in your Anthem Blue Cross 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 2020 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 your Provider Experience representative for assistance from theContact Uspage. SelectProvider Experience team to open the email form and make sure to enter the words, ‘2020 Survey After Hours and PAAS Results’ in the subject field.  Visit us onlineto view other contact options.

Submission of claims in overlapping Blue Plan service areas is dependent on what plan(s) the provider contracts with in 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, 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 Anthe Blue Cross Payer ID number that was assigned to you, not the Blue Shield of California Payer ID number. If you submit an Anthem Blue Cross member claim with the Blue Shield of California Payer ID number instead of the Anthem Blue Cross Payer ID number, the claim will process as out-of-network.

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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 (Anthem). 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.
• Submit the claim to Anthem. Always include the patient’s complete identification number, which includes the three-character prefix.
• For claims inquiries, contact Anthem.

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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Visit Pharmacy Information for Providers on anthem.com/ca for more information on:

• Copayment/coinsurance requirements and their applicable drug classes
• Drug lists and changes
• Prior authorization criteria
• Procedures for generic substitution
• Therapeutic interchange
• Step therapy or other management methods subject to prescribing decisions
• Any other requirements, restrictions, or limitations that apply to using certain drugs

The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July, and October).

To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.

Effective November 1, 2021, EnrollSafe is available as the electronic funds transfer (EFT) enrollment portal for providers participating with Anthem Blue Cross (Anthem). CAQH Enrollhub is no longer offering EFT enrollment to new users.

CAQH Enrollhub is the only CAQH tool decommissioned.  All other CAQH tools are not impacted.

EnrollSafe:  Secure and available 24-hours a day

If you need to change an EFT enrollment previously submitted through CAQH, or enroll a new bank account for EFT, visit the EnrollSafe portal at https://enrollsafe.payeehub.org and select “Register.”  Once you have completed registration, you’ll be directed through the EnrollSafe secure portal to the enrollment page.  There, you’ll provide the required information to receive direct payment deposits.  

There is no fee to register for EFT via EnrollSafe.

Already enrolled in EFT through CAQH Enrollhub?

Please note if you’re already enrolled in EFT through CAQH Enrollhub, no action is needed.  Your EFT enrollment information is not changing as a result of the new enrollment hub.

If you ever have changes to make to your bank account, use EnrollSafe going forward to update your EFT bank account information.

We’re here to help – EFT and ERA registration and contact information

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

We have enhanced your ability to search, review, and download a copy of the remittance advice on Availity* when there is not an associated payment. For remit advice with payment, you can continue to search with the Check/EFT number.

Below are images reflecting the scenarios that have been enhanced:

Paper remittance

Electronic remittance advice (ERA/835)

What has changed?

1. Non-payment number display in the Check Number and Check/EFT Number fields:

• Old — There were two sets of numbers for the same remittance advice. The paper remittance displayed 10 bytes (9999999999 or 99########) and the corresponding 835 (ERA) displayed 27 bytes (9999999999 — [year] #############).
• Enhancement — The updated numbering sequence for the paper remittance and corresponding 835 (ERA) now contain the same 10-digit number beginning with 9 (9XXXXXXXXX). Each non-payment remittance issued will be assigned a unique number.

2. Searching for non-payment remittance:

• Old — When using Remit Inquiry to locate paper remittance, the search field required a date range and tax ID to locate a specific remittance due to same number scenario (10 bytes (9999999999) being used for every non-payment remittance.
• Enhancement — Once the unique ERA non-payment remittance number is available, it can be entered in the check number field in Remit Inquiry. This new way of assigning check numbers provides a faster and simplified process to find the specific remittance.

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Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT^® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override. 

For additional information, please review the Drug Screen Testing reimbursement policy at

https://providers.anthem.com/ca.

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

Anthem is transitioning to Availity* Authorization

You may already be familiar with the Availity Authorization App because thousands of providers are already using it for submitting prior authorization requests for other payers. Anthem is eager to make it available to our providers, too. On December 13, 2021, you can begin using the same authorization app you may use for other payers. We hope to make it easier than ever before to submit prior authorization requests to Anthem.

Current prior authorization tool (ICR) is still available

If you need to refer to an authorization that was previously submitted through the Interactive Care Reviewer (ICR) tool, you will still have access to that information. We’ve developed a pathway for you to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization App.

Innovation in progress

While we grow the Availity Authorization App to provide you with Anthem-specific information, we’ve provided access to ICR for:

• Appeals
• Behavioral health authorizations
• FEP authorizations
• Clinician administered drugs
• AIM

Notices in the Availity Authorization App will guide you through the process for accessing ICR for Reserved Auth/Appeals functions.

Training is available

If you aren’t already familiar with the Availity Authorization App, training is available.

You can always log onto https://availity.com and view the webinar at your convenience. From Help & Training, select Get Trained to access the Availity Learning Center. You can use AvAuthRef for a keyword search or select the Session tab to see all upcoming live webinars.

Now, give it a try!

Accessing the Availity Authorization App is easy. Just log onto https://availity.com, and the Authorizations and Referrals icon is on the home screen. You can also access the App through the Patient Registration tab by selecting Authorizations and Referrals.

If you have questions, please reach out to Availity at 800-282-4548.

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Please continue to check for important Medi-Cal Managed Care updates at https://providers.anthem.com/california-provider/communications/news-and-announcements for the latest Medi-Cal Managed Care information, including:

• Durable medical equipment prior authorization requirement changes effective February 1, 2021

• Prior authorization requirement changes

• Medical drug benefit Clinical Criteria updates

• Managed care organization pharmacy benefits transitioning to the Medi-Cal Rx program

• Medical Policies and Clinical Utilization Management Guidelines update

Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT^® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override.
 

For additional information, please review the Drug Screen Testing reimbursement policy at

https://www.anthem.com/ca/medicareprovider.

Effective for dates of service on and after March 13, 2022, the following updates will apply to the listed AIM Specialty Health_® (AIM)* Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates by guideline:

• Imaging of the Brain:

• Acoustic neuroma — removed indication for CT brain and replaced with CT temporal bone
• Meningioma — new guideline establishing follow-up intervals
• Pituitary adenoma — removed allowance for CT following nondiagnostic MRI in macroadenoma
• Tumor, not otherwise specified — added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

• Imaging of the Head and Neck:
• Parathyroid adenoma — specified scenarios where surgery is recommended based on American Association of Endocrine Surgeons guidelines
• Temporomandibular joint dysfunction — specified duration of required conservative management
• Imaging of the Heart:
• Coronary CT angiography — removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
• Imaging of the Chest:
• Pneumonia — removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
• Pulmonary nodule — aligned with Lung-RADS for follow-up of nodules detected on lung cancer screening CT
• Imaging of the Abdomen and Pelvis:
• Uterine leiomyomata — new requirement for ultrasound prior to MRI; expanded indication beyond uterine artery embolization to include most other fertility-sparing procedures
• Intussusception — removed as a standalone indication
• Jaundice — added requirement for ultrasound prior to advanced imaging in pediatric patients
• Sacroiliitis — defined patient population in whom advanced imaging is indicated (predisposing condition or equivocal radiographs)
• Azotemia — removed as a standalone indication
• Hematuria — modified criteria for advanced imaging of asymptomatic microhematuria based on AUA guideline
• Oncologic Imaging:
• National Comprehensive Cancer Network (NCCN) recommendation alignments for breast cancer, Hodgkin and Non-Hodgkin lymphoma, neuroendocrine tumor, melanoma, soft tissue sarcoma, testicular cancer, and thyroid cancers.
• Cancer screening — new age parameters for pancreatic cancer screening; new content for hepatocellular carcinoma screening
• Breast cancer — clinical scenario clarifications for diagnostic breast MRI and PET/CT

• AIM’s ProviderPortal_SM directly at com.
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• The Availity* Portal at com.
• Phone at 800-714-0040, Monday through Friday from 5 a.m. to 5 p.m. PT.

If you have questions related to guidelines, email AIM at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines online.

An overview of notable 2022 benefit changes and services area updates are now available here. Please continue to check https://www.anthem.com/ca/provider/medicare-advantage/ for the latest Medicare Advantage information.

Beginning January 1, 2022, Medicare Advantage Organizations (MAOs) and Medicare-Medicaid Plans

(MMPs) are responsible for adjudicating claims for COVID-19 vaccines and their administration and for

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

Anthem is transitioning to Availity* Authorization

You may already be familiar with the Availity Authorization App because thousands of providers are already using it for submitting prior authorization requests for other payers. Anthem is eager to make it available to our providers, too. On December 13, 2021, you can begin using the same authorization app you may use for other payers. We hope to make it easier than ever before to submit prior authorization requests to Anthem.

Current prior authorization tool (ICR) is still available

If you need to refer to an authorization that was previously submitted through the Interactive Care Reviewer (ICR) tool, you will still have access to that information. We’ve developed a pathway for you to access your ICR dashboard. You will simply follow the prompts provided through the Availity Authorization App.

Innovation in progress

While we grow the Availity Authorization App to provide you with Anthem-specific information, we’ve provided access to ICR for:

• Appeals
• Behavioral health authorizations
• FEP authorizations
• Clinician administered drugs
• AIM

Notices in the Availity Authorization App will guide you through the process for accessing ICR for Reserved Auth/Appeals functions.

Training is available

If you aren’t already familiar with the Availity Authorization App, training is available.

You can always log onto https://availity.com and view the webinar at your convenience. From Help & Training, select Get Trained to access the Availity Learning Center. You can use AvAuthRef for a keyword search or select the Session tab to see all upcoming live webinars.

Now, give it a try!

Accessing the Availity Authorization App is easy. Just log onto https://availity.com, and the Authorizations and Referrals icon is on the home screen. You can also access the App through the Patient Registration tab by selecting Authorizations and Referrals.

If you have questions, please reach out to Availity at 800-282-4548.

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Training is available

If you aren’t already familiar with the Availity Authorization App, training is available.

Please continue to check for important Medicare Advantage updates at https://www.anthem.com/ca/provider/medicare-advantage/ for the latest Medicare Advantage information, including:

• Updates to AIM Specialty Health musculoskeletal interventional pain management clinical appropriateness guideline
• Medical drug benefit Clinical Criteria updates
• Protocol for providers serving members with hearing aid coverage administered by Hearing Care Solutions
• New York City Medicare Advantage announcement
• Medical Policies and Clinical Utilization Management Guidelines update
• Medical Policies and Clinical Utilization Management Guidelines update

Effective March 1, 2022, separate reimbursement is not allowed for specimen validity testing when utilized for drug screening. Reimbursement is included in the CPT^® and HCPCS code descriptions for presumptive and definitive drug testing. Modifier 59, XE, XP, XS, and XU will not be allowed to override. 

For additional information, please review the Drug Screen Testing reimbursement policy at https://providers.anthem.com/ca.

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Please continue to check for important Cal MediConnect updates at https://providers.anthem.com/california-provider/communications/news-and-announcements for the latest Cal MediConnect information, including:

• Medical Policies and Clinical Utilization Management Guidelines update
• Medical drug benefit Clinical Criteria updates