The annual behavioral health access studies will see a change in 2024 as a new vendor, Center for the Study of Services (CSS) in Washington, D.C., will be performing the office level survey and making calls during the first through third quarters. The survey will be conducted in the same manner as in the past and your cooperation is expected and appreciated. The purpose is to assess adequate appointment wait times for our members with an urgent condition or for routine services.

Consequently, we ask that you update office information using the PDM application on Availity Essentials or follow processes if assigned to Carelon Behavioral Health, Inc., and that you participate in quality programs, such as this critical survey, as a condition of your contract. The main challenges the vendor encounters are incorrect or non-working phone numbers; practitioner moved, retired, or is deceased; the practice has left their Anthem Blue Cross (Anthem) contract, accepts private pay only, or is no longer in practice; and staff refusing to participate in the survey. Please take time to update information for each practitioner associated with the practice phone number(s), past or present.

Your contract compels access for all covered individuals to obtain timely needed appointments. The leading timeframes are below. See your Anthem provider manual for details. And don’t forget your compliant after-hours emergency or urgent messaging 24/7. For emergency situations, instruct (by a recording or a live person) caller/patient to hang up and dial 911 or go the nearest emergency room. For urgent issues, directly connect patient with a practitioner or give a timeframe when the on-call practitioner will call the patient back.

California behavioral healthcare appointment access

We are committed to helping patients more easily access the care they need.

As a reminder, we will update our claim editing software for outpatient facility services throughout 2024, with many updates occurring quarterly. These updates include, but are not limited to:

• The addition of new and revised codes (for example, CPT^®, HCPCS, ICD-10, modifiers, revenue codes) and associated edits.

• Updates related to the appropriate use of various code combinations, including but not limited to, CPT/HCPCS code to revenue code, type of bill to procedure code, type of bill to CPT/HCPCS code, and CPT/HCPCS code to modifier.
• Updates to National Correct Coding Initiative edits (NCCI) and facility outpatient hospital services medically unlikely edits (MUEs).
• Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC) and the Centers for Medicare and Medicaid Services (CMS).

As a reminder, we will update our claim editing software for professional services throughout 2024, with most updates occurring quarterly. These updates apply to any provider, provider group (identified by tax identification number), and/or across providers and claim type (such as, professional or facility) and include, but are not limited to:

• The addition of new, and revised codes (for example, CPT^®, HCPCS, ICD-10, modifiers) and associated edits such as:
  • ICD-10 laterality
  • Add-on procedures (indicated by + sign)
  • Code book parenthetical statements and other directives about appropriate code use (for example, separate procedure, do not report, list separately in addition to, etc.)
• Updates to editing for multiple procedure and bilateral reduction calculations based on relative value unit (RVU) as designated and updated by the Centers for Medicare & Medicaid (CMS) in the physician fee schedule relative value (PFSRV) files
• 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 code edits associated with reimbursement policies including, but not limited to, bundled services, global surgery preoperative, and post-operative periods assigned by CMS, edits that allow/disallow for assistant surgeon/co-surgeon/team surgeon, and frequency edits.

The National Committee on Quality Assurance (NCQA) has advised Durable Medical Equipment (DME) providers are to be considered within the scope of an entity’s credentialing program for accreditation purposes. Starting February 2024, recredentialing of the existing Durable Medical Equipment Providers and Prosthetic and Orthotic Suppliers (DMEPOS) network will begin. You will receive communication asking you to either complete an application or to supply us with any of the following information:

• Copy of all federal, state, and/or local licenses required to operate as a healthcare facility (by location).

• Copy of accreditation certificate or letters if accredited.
• Copy of most recent CMS or state survey (with deficiencies) including cover letter from CMS or state agency stating facility is in substantial compliance or Corrective Action Plan if deficiencies were cited if not accredited is required.

Please respond to these communications as quickly as possible so no disruption in service to our members or to you occurs. Contact information for questions related to this change will be included in the outreach sent.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare. The Credentialing team looks forward to working with you.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relationship Management representative or call one of our Medi-Cal Customer Care Centers at 800-407-4627 (outside L.A. County); 888-285-7801 (inside L.A. County); or refer providers to the number on the back of their patient’s member ID card for Provider Services.

Managing any illness can be a difficult thing to do. Knowing who to contact, what test results mean, or how to get needed resources is very important and can be overwhelming.

Anthem Blue Cross (Anthem) is available to help with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and professionals that are here to support members, families, primary care physicians, behavioral health practitioners, and caregivers. The case management process uses the 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 healthcare.

For physical health services, members or caregivers can refer themselves or family members by calling the number located below. They will be transferred to a team member based on their immediate need. Physicians can also refer their patients 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 members and caregivers are better prepared and informed about healthcare decisions and goals.

For behavioral health or substance use disorder services, members can contact their health plan to verify benefits and access Anthem.com, or if an FEP member, fepblue.org, to search for and access behavioral health providers. It is best to have the member or member’s family contact our department directly to ensure privacy.

How do you contact us?

For commercial and exchange members, the member can contact customer service for assistance.

For FEP members, physical and behavioral health practitioners can refer to Anthem behavioral health case management with member consent by calling 800-711-2225 option 3.

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 healthcare practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners (BH).

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

• Discuss with the patient the importance of communicating with other treating practitioners.
• Obtain a signed release from the patient and file a copy in the medical record:
  • Document in the medical record if the patient refuses to sign a release.
• Document in the medical record if you request a consultation.
• If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
• Document evidence of clinical feedback (in other words, consultation report) that includes, but is not limited to:
  • Diagnosis
  • Treatment plan
  • Referrals
  • Psychopharmacological medication (as applicable)

To facilitate coordination of care, we have several tools available on our Provider website for BH 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 use and attention-deficit/hyperactivity disorder (ADHD) are also available on our 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

We ask that you review your online provider directory information on a regular basis to ensure it is accurate. Access your information by visiting anthem.com/ca/provider, then select the Find Care button at the top right of the webpage.

Submit updates and corrections to your directory information by following the instructions on our Provider Maintenance webpage. We will send you an email acknowledging receipt of your request. Online update options include:

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

The Consolidated Appropriations Act (CAA) of 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Reviewing your information on a regular basis is the best way to help ensure your online provider directory information is current.

With your help, we can continually build towards a future of shared success.

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 (Anthem) Medical Director or Peer Clinical Reviewer is available toll-free 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 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 Medical Policy and Clinical UM Guidelines are also available at 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 & Clinical UM Guidelines; or call toll-free 800-794-0838 to request that a paper copy be sent to you. The requested criteria is provided at no extra cost.

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 UM 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., 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 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) toll free.

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

An overview of notable 2024 benefit changes and service area updates are now available at the link below:

California 2024 Medicare Advantage plan changes

Please continue to check our website for the latest Medicare Advantage information.

Medi-Cal Managed Care (Medi-Cal) members have access to new and improved services that address the whole person – going beyond the doctor’s office or hospital visit to provide care. California Advancing and Innovating Medi-Cal (CalAIM) is a significant opportunity for collaboration between community-based organizations (CBOs), local government agencies, and the Medi-Cal system. People who work in these settings have significant knowledge, expertise, and connections with communities and are skilled at addressing patients’ physical health, behavioral health, and social needs. CalAIM creates an avenue for these organizations to contract with Medi-Cal and be reimbursed for services they have experience providing.

Two major initiatives, Enhanced Care Management (ECM) and Community Supports (CS), are now available to members under the CalAIM umbrella.

Enhanced Care Management

Enhanced Care Management (ECM) provides a whole-person approach to care that addresses the clinical and non-clinical circumstances of a high-need Medi-Cal member. The ECM benefit provides comprehensive care management and achieves better health outcomes for the highest need beneficiaries in Medi-Cal. Learn more about ECM.

ECM eligibility

ECM focuses on specific Populations of Focus (PoFs), serving adults, children, and youth. Anthem Blue Cross (Anthem) members who meet any of the ECM PoFs criteria should be referred to participate.

ECM referrals

Members, ECM providers, community providers, or primary care physicians (PCPs) can refer to ECM. Submit completed ECM Referral Form via:

• Provider website
• Secure email: CalAIMReferrals@anthem.com
• Fax: 877-734-1854
• Customer Care Center: 800-407-4627 (TTY 711) (outside L.A. County)
• Customer Care Center: 888-285-7801 (TTY 711) (inside L.A. County)

ECM authorization process

A referral (authorization request) is ideally submitted to Anthem at the point of care. After submission, the referral is either incomplete, approved, or denied. The standard turnaround time is five business days. In urgent cases, a referrer may request an expedited review, and Anthem will provide a response within three business days of receiving all documentation. In the case of expedited review, Anthem may retroactively start the authorization period up to three days prior to the date that the authorization was approved so that the ECM provider can submit claims for ECM services provided during that period.

Community Supports

Community Supports (CS) are voluntary, flexible, wrap-around services or settings provided by Anthem. They are medically appropriate and cost-effective alternatives to services covered under the state plan. The Department of Health Care Services (DHCS) has approved 14 CS services for individuals with complex physical behavior, developmental, and social needs. Learn more about CS

Community Supports eligibility

Anthem members who meet the criteria of any of the 14 DHCS-approved CS services should be referred to participate.

Community Supports referrals

Members, ECM providers, CS providers, community providers, and PCPs can refer to CS. Submit completed CS Referral Forms:

• Provider website
• Secure email: CalAIMReferrals@anthem.com
• Fax: 877-734-1857
• Customer Care Center: 800-407-4627 (outside L.A. County)
• Customer Care Center: 888-285-7801) (inside L.A. County)

A referral (authorization request) is ideally submitted to Anthem at the point of care. After submission the referral is either incomplete, approved, or denied. The standard turnaround time is five business days. In urgent cases, the referrer may request an expedited review and Anthem will provide a response within three business days of receiving all documentation.

Enhanced Care Management or Community services questions?

If you have questions about ECM or CS technical support, contact:

• L.A. County: teresa.samuels@anthem.com
• Northern California michele.ellington@anthem.com
• Central California: Rolando.reyes@elevancehealth.com

Contracted ECM providers with non-technical questions should contact their assigned Practice Transformation liaison.

Join CalAIM

If you are interested in becoming a CalAIM provider or have other CalAIM questions, email CalAIM@anthem.com.]More information about CalAIM and other supporting programs from Anthem can be found at: California Provider - Anthem Blue Cross.

Anthem Blue Cross (Anthem) monitors member access to a provider’s care through several 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.

Surveys give insight:

• 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 2023 success is you:

If you have already taken steps to comply with the standards — Thank you! This year’s surveys are now under way, and with your continued support and commitment, we can achieve the best results possible for 2023.

Take a minute to review the 2022 survey results in the table below. We hope sharing them with you provides a better understanding of how you can help improve 2023 results.

Provider After Hours results — 2022 survey:

Provider Appointment Availability Survey (PAAS) Results — 2022 survey

You make a difference:

• Review the Commercial Access Standards under the Legaland 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 or answering machine message specifically informs callers when their urgent (non-emergent) calls will be returned.
• Ensure your After-Hours office staff, answering service 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 2022 and found non-compliant with these standards, a letter with recommended compliance measures was sent to an active mailing address on file for you.

If you have questions, email our Healthcare Networks team for assistance from our Contact Us webpage. Under the section Additional support, select the link send us a message to open an email form. Make sure to enter the words, “2022 Survey After Hours and PAAS Results” in the subject field. Visit us online to view other contact options.

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 https://www.anthem.com/ca/provider/ and select Resources > Medical Policies and Clinical UM Guidelines.

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

Balance billing Medi-Cal Managed Care (Medi-Cal) beneficiaries is prohibited by federal and state law. Medi-Cal beneficiaries should not pay for physician visits and other medical care when they receive covered services from a provider in their provider network. This means beneficiaries cannot be charged for co-pays, co-insurance, or deductibles. This applies to both Medicare and Medi-Cal providers.

Billing Medi-Cal beneficiaries violates federal law as outlined in section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997. This section of the act is available at: http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. Protections are also found in California Welfare and Institutions Code section 14019.4.

The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare 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 has adopted a Members’ Rights and Responsibilities statement.

This statement can be found on our website under the FAQ question about Laws and Rights that Protect You. To access the statement, visit anthem.com 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. Then select the Read about member rights link. For federal employees, practitioners may access the FEP member portal at www.fepblue.org/memberrights to view the FEPDO Member Rights Statement.

Get help navigating the BlueCard^® program and information about claim filing, eligibility, preauthorization, and contact information from the BlueCard Program Provider Manual. Learn more on our website by navigating to anthem.com/ca, then > For Providers > Provider Resources > Policies, Guidelines & Manuals > select Download the Manual and then Access previous versions and other manuals > Blue Card Provider Manual. You can also select this link to directly access the Provider Manual Library.

Also, you have access to online supplemental education materials (SEM) via the Provider Education and Training webpage for Anthem Blue Cross. SEM#10 — BlueCard (Out-of-Area) provides helpful tips to improve your claim experience, facts about ID cards, and much more.

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:

• Always request a current ID card from the member and make a copy of the front and back of the member’s identification (ID) card.
• Look for the three-character prefix that precedes the member’s ID number on the ID card. It is critical for confirming membership and coverage.
• Call BlueCard^® Eligibility at 800-676-BLUE (2583) toll free 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 status 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 healthcare providers notify health plans within five days when their Accepting New Patients status changes.

Refer to the Anthem Blue Cross — California Facility and Professional Provider Manual for timeframes and information about reporting your practice status and other related information about your practice.

Our online directories identify professional providers who offer telehealth services in their practice.

We encourage you to use the online Provider Maintenance Form to notify us about your telehealth services. We will then add a telehealth indicator to your online provider directory profile.

Refer to attachment to view full details.

Keeping you informed:

• Each year, we communicate the Anthem Blue Cross (Anthem) Timely Access Regulations and Language Assistance Program to our commercial medical and behavioral health networks via an annual provider mailing. The 2023 mailing was completed in January.
• Effective July 1, 2022, Anthem implemented SB 221 – Timely Access Requirements for
  Non-Physician Mental Health/Substance Use Disorder Appointments. See the access standards charts on the pages that follow for more information.
• Effective January 1, 2023, a referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard.

Why is this important?

These are California state regulations.

Blue Cross of California dba Anthem Blue Cross and Anthem Blue Cross Life & Health Insurance Company (collectively, Anthem) is committed to keeping you, our network partners, updated on our activities related to our compliance with the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) Timely Access to Non-Emergency Health Care Services Regulations (the Timely Access Regulations), respectively.

To ensure compliance with these timely access regulations, three surveys are conducted annually. The surveys include, but are not limited to the following:

• Provider Appointment Availability Survey
• Provider Satisfaction Survey
• Provider After – Hours Survey

In 2023, the annual surveys will begin in July or August and will continue through December 31.

Beginning with the 2023 Provider Appointment Availability Survey (PAAS), the DMHC expanded the types of specialist physicians who are included in the PAAS. Below is a complete list of provider types and specialties who will be included in the PAAS.

Fact Sheet: 2024 Medicare Advantage California EAE DSNP Changes

Refer to attachment to view full details

As a contracted provider for special needs plan (SNP) from Anthem Blue Cross (Anthem), you are required to participate in an annual model of care training for providers per CMS regulations. This training includes a detailed overview of Anthem special needs plans and program information — highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Please remember this training is specific to our plans and delivery of care for members ensuring their specific care needs are met. Your participation is critical for improved quality and health outcomes.

Training for SNP product for Anthem is self-paced and available at availity.com.

The training must be completed by December 31, 2023.

How to access the Custom Learning Center on the Availity Essentials website:

1. Log in to Availity Essentials website at availity.com:
   • At the top of Availity Essentials website, select Payer Spaces and select the appropriate payer.
2. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
3. In the Custom Learning Center, select Required Training.
4. Select Special Needs Plan and Model of Care Overview.
5. Select Enroll.
6. Select Start.
7. Once the course is completed, select Begin Attestation and complete.

Not registered for Availity Essentials?

Have your organization’s designated administrator register your organization for the Availity Essentials website:

1. Visit availity.com to register.
2. Select 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 documents: https://apps.availity.com/availity/Demos/Registration/index.htm for complete registration instructions.

As outlined in All Plan Letter (APL) 23-021 that supersedes All Plan Letter (APL) 19-011, health plans are required to conduct a multi-year Population Needs Assessment (PNA) process with Local Health Departments (LHD) and submit an annual Population Health Management (PHM) strategy that will demonstrate meaningful engagement in responding to community needs. The goal of this redesigned process seeks to establish a cohesive, statewide framework of expectations for health plans and their subcontractors and/or network providers, to prioritize prevention and whole-person care, as well as respond to members’ medical and social needs and preferences across the continuum of care within the communities in which they live.

Anthem Blue Cross’ Population Health Management strategy submission includes the following requirements:

• Attestation of engagement with LHD and initial meeting and planning conducted with LHD in each jurisdiction the health plan will serve as the prime health plan in 2024
• Attestation of collaboration with LHD on community specific SMART goal creation
• Health plan annual PNA requirement will be met through the publication in each county of the LHD Community Health Assessment (CHA)/Community Health Improvement Plan (CHIP) itself. Health plans will be expected to publish all LHD CHAs/CHIPs in their areas of operation on their website along with a brief description of how they participated in the CHA/CHIP process

Providers should be aware of upcoming health insurance benefit enhancements for certain members. Starting January 1, 2024, the CalPERS PERS Platinum and PERS Gold PPO Basic plans will offer enhanced lab benefits and feature designated primary care physicians on member ID cards.

Enhanced lab benefits

PERS Platinum and Gold plans will include 100% coverage for all lab services provided at a Quest Diagnostics or Labcorp facility. This means there will be no member cost share or $0 copayment for laboratory services provided at Quest Diagnostics and Labcorp facilities.

Primary care physician and ID card updates

PERS Platinum and Gold members will select a PPO primary care physician (PCP) at the time of enrollment. Beginning January 1, 2024, the name of the member’s designated PCP will be listed on their ID card, and their plan design will remain unchanged.

With this enhancement, members will not be required to use their designated PCP. They will still be able to:

• Receive services from any provider in or outside of their plan’s network.
• Self-refer to specialists.
• Change their PPO PCP at any time.

For more information regarding the PERS PPO plans, visit our website or call our dedicated CalPERS Customer Service Department at 877-737-7776.

About Anthem Blue Cross (Anthem) and CalPERS

Anthem has been serving CalPERS members since 1999 with a large, ever-growing network of quality doctors and hospitals throughout California. With Anthem, members can count on
industry-leading benefit plans with personalized digital tools and wellness programs that make accessing quality, lower-cost care easier and more intuitive. We take pride in helping CalPERS members and their families meet their health goals with personalized care and support.

HEDIS^® measure data is collected by one or more methods:

• Administrative method — claims and supplemental data
• Hybrid method — administrative and medical record data
• Survey method — Health Outcomes Survey(HOS) & Consumer Assessment of Healthcare Providers & Systems (CAHPS^®)
• Electronic Clinical Data Systems (ECDS) — HEDIS reporting standard that leverages electronic data from multiple sources. See below.

The HEDIS Electronic Clinical Data Systems (ECDS) Reporting Standard was introduced in HEDIS 2016 (measurement year 2015) by the National Committee of Quality Assurance (NCQA) and encourages health information exchange, which is the secure sharing of patient medical information electronically. ECDS data collection is part of NCQA’s nationwide plan to capture information regarding aspects of care quality with less reliance on clinical medical record review.

There are four types of ECDS:

1. Electronic Health Record (EHR)/Personal Health Record (PHR): Real-time, patient-centered records that make information available instantly and securely to authorized users. EHRs eligible for this category of ECDS reporting include the NCQA eMeasure certification program or any system that meets the 2015 Edition Base Electronic Health Record (EHR) definition.
2. Health Information Exchange (HIE)/Clinical Registry: HIEs and clinical registries eligible for this reporting category include state HIEs, immunization information systems (IIS), public health agency systems, regional HIEs (RHIO), Patient-Centered Data Homes™ or other registries developed for research or to support quality improvement and patient safety initiatives. Doctors, nurses, pharmacists, other health care providers and patients can use HIEs to access and share vital medical information, with the goal of creating a complete patient record. Clinical registries can be sponsored by a government agency, nonprofit organization, health care facility or private company, and decisions regarding use of the data in the registry are the responsibility of the registry’s governing committee.
3. Case Management System: A shared database of member information collected through a collaborative process of member assessment, care planning, care coordination or monitoring of a member’s functional status and care experience. Case management systems eligible for this category of ECDS reporting include any system developed to support the organization’s case/disease management activities, including activities performed by delegates.
4. Administrative: Includes data from administrative claim processing systems for all services incurred (in other words, paid, suspended, pending and denied) during the period defined by each measure’s participation as well as member management files, member eligibility and enrollment files, electronic member rosters, internal audit files, and member call service databases.

Having more time to focus on patient care rather than responding to medical record requests is possible by participating in Electronic Clinical Data Systems (ECDS). We are focused on reducing administrative burdens, so you can do what you do best – care for our members. Let us help by granting EMR Direct Remote access to our EMR team.

Need more information or ready to sign up?

Please email us today at: Centralized_EMR_Team@anthem.com.