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 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. We cover emergency services that are necessary to screen and stabilize a condition. No authorization or pre-certification is needed. A member should be directed to call the telephone number on the back of their health plan 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 the services were never performed. Answering machine instructions and after-hours answering service staff of all HMO and PPO practitioners must direct members to call 911 or go directly to the nearest emergency room if they reasonably believe they are experiencing an emergency.

• Based on member plans, medical necessity reviews are conducted pre-service, ongoing, or
  post-service.
• Professional reviewers use guidelines to ensure services are medically necessary, with clear decision communication.
• Members can request guidelines, appeal decisions, and access services in their preferred language.

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 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 a 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 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 decide, we will try to get it from the physician or other healthcare provider requesting the service, medical procedure, or equipment. If a delay is anticipated because the information is not readily available, we will notify the member and the requesting physician or other healthcare provider in writing. Delay letters include a description of the information we need to decide and specify when the decision can be expected once the information is received. Suppose we do not receive the necessary information. In that case, we will send a final letter explaining that we cannot approve access to benefits due to the lack of the information requested.

We use professional, qualified reviewers

Experienced clinicians review service requests 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 healthcare professionals qualified and clinically competent to evaluate the specific clinical aspects of the request and treatment under review. PCRs are licensed in California and are in the same category as the requesting physician or other healthcare 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, our medical director or PCR is available at 800-794-0838. If the PCR cannot approve a service, the requesting physician, another healthcare 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 healthcare provider within two business days of the decision. This written notice includes the following:

• A clear and concise explanation of the reason for the decision;
• The name of the criteria and guidelines used to make the decision;
• The name and phone number of the PCR who decided on peer-to-peer discussion;
• Instructions for how to appeal a decision; and
• Specific provisions of the contract exclude coverage if the denial is based on benefit coverage.

Access to criteria

Our Medical Policy and Clinical UM Guidelines for specific services are available to members, member representatives, healthcare providers, and the public. Members may call the number on the back of their ID card for a free copy of the guidelines used to determine their case. The 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 are provided free of charge.

A determination of medical necessity does not guarantee payment or coverage

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

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

Decisions about coverage of service

Our UM decisions are based on the appropriateness of the care and service needed and the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing coverage, service, or care denials. 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 that result in underutilization.

We are available for questions

If you need to request precertification or 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 voicemail message. Please leave your name and phone number; we will return your call by the next business day during the abovementioned hours unless other arrangements are made. Calls received after midnight will be returned the same business day. When making or returning calls, our UM associates identify themselves to all callers by first name, title, and company name. Are there different business hours for FEP? There are no changes.

Language assistance recommends adding that members can call the customer service number on their ID card to request language assistance

For those who request language services, we provide service in the requested language through bilingual staff or an interpreter to help members with their UM issues. Language assistance is provided free of charge. Oral interpretation is available at all points of member contact regarding UM issues. To request language assistance, members can call the toll-free number on the back of their ID card.

TDD/TTY services

A TDD (telecommunications device for people who are deaf or hard of hearing) 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 a member has a hearing or speech loss, they can call 711 to use the National Relay Service or 800-855-7100 (English TTY/ English voice) for the California Relay Service. A special operator will contact us to help with the member's needs.

For the Federal Employee Program, the member can call the number on the back of their ID card. We administer UM in California.

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.

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

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 2024 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 2024.

Take a minute to review the 2023 survey results in the table below. We hope sharing them with you provides a better understanding of how you can help improve 2024 results.

Provider after hours results — 2023 survey

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, 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 2023, 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 Provider Relations team for assistance from the Contact Us section of our provider website. Under the section Additional support, select the link send us a message to open an email form. Make sure to enter the words 2023 Survey After Hours and PAAS Results in the subject field. Visit us online to view other contact options.

Coordination of care among providers is vital to good treatment planning and ensures appropriate diagnosis, treatment, and referral. We want to take this opportunity to stress the importance of communicating with your patients’ other healthcare practitioners, including PCPs/PMPs, medical specialists, and behavioral health practitioners.

Coordination of care is essential for patients who use general medical services extensively and those referred to a behavioral health specialist by another healthcare practitioner. We urge all our practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other healthcare practitioners when treatment begins.

We expect all healthcare 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 the necessary information; if you furnish a referral, report appropriate information to the referring practitioner.
6. Document evidence of clinical feedback (for example, a 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 at https://www.Anthem.com/provider/forms/ 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
• Resources for provider collaboration and integrated care, including Practice Guidelines, assessment tools, suicide awareness, and multicultural education and guidance

The following behavioral health forms, brochures, and screening tools for substance use disorder and attention‑deficit/hyperactivity disorder (ADHD) are also available at https://www.Anthem.com/provider/forms/:

• 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 are committed to finding solutions that help our care provider partners offer quality services to our members.

We want to remind you of the important announcement about Direct HMO, featured in our November newsletter. This new Pathway HMO (on and off exchange products) fee-for-service network design will officially launch on January 1, 2025.

Here's what you need to know:

• ID cards: Members will get an ID card marked Pathway HMO at the bottom right. In the center, the card will display Direct HMO and the name of their assigned Direct HMO PCP. They can also access their cards virtually through the Sydney^SM Health app.
• Updated coverage area: Pathway HMO plans, including Direct HMO as of January 1, 2025, will serve Los Angeles, Riverside, San Bernardino, Orange, and San Diego counties in California.
• Provider Directory: Utilize our online directory, Find Care, at anthem.com/ca to locate providers in the Direct HMO network.
• Referrals: Required for specialty care (except for behavioral health and other specific services to the extent outlined in the member’s plan (for example, reproductive or sexual healthcare services, and obstetrical/gynecological care consultations as described in the member’s Evidence of Coverage for complete benefit information). Make sure to refer only to the extensive network of Direct HMO specialists.
• Utilization management: Coordinate all non-urgent and emergent services with Pathway HMO contracted providers. To ensure smooth care coordination, work with our HMO Clinical Operations Team for effective care coordination on all referral and authorization requests.
• Updated FAQ: The FAQ document has been updated and includes a December date in the footer. Always refer to the most current version for the latest information and guidance.

For more information read the detailed November newsletter article or contact us directly:

• Contract questions: Email SpecialNetworkReq@anthem.com with Direct HMO in the subject line.
• Behavioral health utilization management: Call toll-free 800-274-7767.
• Utilization/medical management: Call toll-free 866-757-8211, fax 866-461-2401, or email hmocomanagement@anthem.com.
• General inquiries: Visit anthem.com/ca > Contact Us.

Thank you for working together in delivering high-quality care to our members. Stay informed and prepared for the exciting rollout of Direct HMO.

We are dedicated to ensuring compliance with NCQA accessibility standards by providing members with phone access to their PCPs beyond regular business hours. The annual after‑hours access study assesses adequate phone messaging for our members with perceived emergencies or urgent situations after office hours. Most of our plans measured still fall short of the after‑hours access expectations that patients have phone access to their practitioners 24 hours a day, 7 days a week, 365 days a year.

The current after‑hours messaging requirement is: When a patient calls after hours, a live person directs them to the practitioner or the on‑callpractitioner, or a recording or live person directs the patient to an urgent care center, 911, or the ER.

If a patient reaches a practitioner’s voicemail, compliant messaging is imperative to assist the patient in gaining access to appropriate care.

We continue to work towards identifying simplified ways to access care.

Managing any illness can be challenging. Knowing who to contact, what test results mean, and how to access needed resources is important but can be overwhelming.

We are available to help with our case management program. Our case managers are part of an interdisciplinary team of clinicians and professionals who support members, families, primary care physicians, behavioral health practitioners, and caregivers. The case management process utilizes the experience and expertise of the care coordination team, whose goal is to educate and empower our members to increase their self-management skills, understand their illness, and learn about care choices to access quality, efficient healthcare.

Members or caregivers can refer themselves or family members for physical health services by calling the number 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 levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals. This voluntary program is private and offered at no cost to our members. They can opt out anytime if they change their mind about participating in the program.

For behavioral health or substance use disorder services, members can contact their health plan to verify benefits and access at Anthem.com or if they are Federal Employee Program (FEP) members, https://www.fepblue.org/ to search for and access behavioral health providers. To ensure privacy, having the member or member’s family contact our department directly is best.

How do you contact us?

The member can contact customer service for assistance for commercial and exchange members.

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

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

The new provider manual is now live on our provider website. This recently updated manual contains everything you need to know about our programs and how we work with you to provide quality care to our members. Several important updates were made this year, and we encourage you to review them below.

4: General benefits:

• Benefit Programs and Populations (4.1):
  • The California Major Risk Medical Insurance Program (MRMIP) is scheduled to end on December 31, 2024.
• Sensitive Services (4.7):
  • Moved disease surveillance language to Provider’s Role in Compliance, Ethics, Privacy, and Hotline Reporting.

8: Provider procedures and responsibilities:

• Subcontractor Network Certifications (8.2):
  • New language added for the Alternative Access Standard process.
• Access to Care, Appointment Standards, and After-Hour Services (8.3):
  • Starting January 1, 2025, requests for an urgent examination include weekends and holidays when requested within 48 hours for no authorization and 96 hours if authorization is required.
• Preventive Healthcare (8.6):
  • Additional language was added on immunization to comply with APL 24-008.

14: Claims and encounters:

• Electronic Visit Verification (14.4):
  • No language changes, but electronic visit verification was moved to its own subsection.
• Alternative Payment Methodology (14.12):
  • The Department of Health Care Services (DHCS) has developed the state's new Alternative Payment Model (APM) for participating federally qualified health centers (FQHCs) in a manner to incentivize delivery system and practice transformation through the flexibilities available under a fully capitated reimbursement model on a per member per month (PMPM) basis.

15: State-directed payments:

• Proposition 56 (15.1):
  • The value-based payment and physician services program has ended. We have a formal procedure for the acceptance, acknowledgment, and resolution of care provider grievances related to the processing or nonpayment of a directed payment. For questions regarding Proposition 56 payments, providers can contact Anthem at prop56@anthem.com.

16: Targeted rate increase (new):

• New section and language added.

17: Grievances, appeals, disputes:

• Independent Review Organization (17.5)
  • New subsection and language added.

18: Compliance and regulatory requirements:

• Provider’s Role in Compliance, Ethics, Privacy, and Hotline Reporting (18.1):
  • Two new subdivisions were added on the topics of disease surveillance and the California Health and Human Services data exchange framework.
• Delegation Oversight (18.6):
  • No new language was added, but the subsection was reworded.
• Provider Financial Oversight (18.7):
  • Language changes made to provision for incurred but not reported (IBNR) claims.

While we strive to keep our provider manual current, be sure to check our provider website > Resources > Provider Manuals, Policies & Guidelines for the most up-to-date plan policy information.

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 has adopted a Members’ Rights and Responsibilities statement.

The statement can be found on our website on the FAQ page. To access it, go to Anthem.com and select For Providers. From there, select Policies, Guidelines & Manuals under Provider Resources. Select your state and scroll down to Member Rights and Responsibilities under More Resources. Select the Read about member rights link. Then, under Laws and Rights that Protect You, select the question that says What are my rights as a member?

Practitioners may access the Federal Employee Plan (FEP) member portal at fepblue.org/memberrights to view the FEP Member Rights and Responsibilities statement.

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 care 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 under For Providers. Select Policies, Guidelines & Manuals under Provider Resources. Select your state, then scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines. 

Annual benefit changes for Medicare Advantage plan members under Anthem Blue Cross will be effective January 1, 2025.

Refer to attachment to view full details.

On June 20, 2024, the Department of Health Care Services (DHCS) published Targeted Rate Increases (TRI) APL 24-007 for professional primary care, obstetric care, and nonspecialty mental health services retroactive to January 1, 2024. We are now reimbursing eligible claims submitted by in-scope providers at the new TRI Fee Schedule rate. With this change, we are no longer administering Proposition 56 Physician Services payments for dates of service on or after January 1, 2024.

Professional services defined as the financial risk of the primary medical group (PMG)/independent physician association (IPA) must also adhere to the requirements outlined in APL 24-007 and reimburse network providers at no less than the TRI Fee Schedule rate for clean claims received after December 31, 2024, for dates of service on or after January 1, 2024. We have engaged each of the PMG/IPA organizations to work towards full compliance with the requirements outlined in APL 24‑007.

List of provider types defined by DHCS as eligible for TRI (based on primary taxonomy code):

• Physicians
• Physician assistants
• Nurse practitioners
• Podiatrists
• Certified nurse midwives
• Licensed midwives
• Doula providers
• Psychologists
• Licensed professional clinical counselor
• Licensed clinical social workers
• Marriage and family therapists

PMG/IPA must pay all claims for dates of service from January 1 to December 31, 2024, for in-scope services at the TRI Fee Schedule rate by December 31, 2024, in addition to paying a clean claim received after December 31, 2024, at the TRI Fee Schedule rate.

Federally qualified health centers (FQHCs), rural health clinics (RHCs), and American Indian Health Service Programs, as well as cost-based reimbursement clinics, are not eligible for TRI Fee Schedule rates.

The current payment methodology allows Anthem to reimburse the supervising physician for services rendered by a nurse practitioner or physician assistant. As outlined in APL 24-007, it is a requirement for qualifying services rendered by a nurse practitioner or physician assistant to be reimbursed at no less than the TRI Fee Schedule rate. It is the responsibility of the supervising physician who holds a contractual agreement with the nurse practitioner or physician assistant to ensure that the rendering provider is receiving reimbursement for services at no less than the TRI Fee Schedule rate.

Prop 56 Physician Services update

All procedure codes included in the Proposition 56 Physician Services program (APL 23-019) are found on the TRI Fee Schedule effective January 1, 2024. The TRI Fee Schedule rates are defined by DHCS as being inclusive of the Proposition 56 Physician Services directed payment amount and the Prop56 Physician Services program under APL 23-019 is effectively terminated as of December 31, 2023.

Historical claims adjustment: dates of service on/after January 1, 2024

Claims received by Anthem are being adjusted to pay at no less than the TRI Fee Schedule rate. The adjustment of an eligible claim may result in an additional check and remittance advice (RA) reflecting the new payment.

Reference the sample RA below, including the retraction of Prop56 Physician Services supplemental payment and the issuance of the new TRI Fee Schedule rate.

Sample remittance

First record: retraction of previously paid amount

In the example above, procedure code 99392 previously paid $37.39 with a Prop56 supplemental payment amount of $79, for a total of $116.39, which has been retracted.

Second record — issuance of the new TRI Fee Schedule rate

The TRI Fee Schedule rate for 99392 is defined by DHCS as the Medi-Cal Base Rate plus the Prop56 Physician Services supplemental payment amount ($37.39 + $79 = $116.39). Therefore, there is no net positive adjustment to the payment on this sample claim.

Skilled nursing facilities (SNF) compensated based on the prospective payment system for outpatient Medicare Advantage claims may see a change in vaccine serum reimbursement. Beginning March 1, 2025, Part B‑covered vaccines will be reimbursed based on the CMS‑published vaccine serum rates.

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

The Department of Health & Human Services (HHS) requires health plans to report whether or not our in-network providers offer telehealth services.

If you provide telehealth services, please tell us by submitting your information to us through Availity.com. Updating your telehealth status will not affect your participation with us. We will add a telehealth indicator to your online provider directory profile, allowing our members to know you offer telehealth services.

If you have questions about submitting your information, please see the instructions below.

If your organization is not currently registered with Availity, you will need to create an account. The person(s) designated as your administrator(s) should go to Availity.com and select Get Started in the upper right corner of the webpage. You may also navigate directly to Availity’s registration website by selecting here.

Begin your application here. To update your application:

1. Log in to Availity Essentials.
2. Select My Providers.
3. Select Provider Data Management.

Please update your telehealth information at the service location.

Maintaining your online provider directory information is essential for member and healthcare partners to connect with you when needed. Access your online provider directory information by visiting anthem.com/ca/provider. Then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information has changed.

Updating your information

Anthem uses the provider data management (PDM) capability available on Availity Essentials to update your care provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate care provider demographic data set by the Consolidated Appropriations Act (CAA).

PDM features include:

• Updating care provider demographic information for all assigned payers in one location.
• Attesting to and managing current care provider demographic information.
• Monitoring submitted demographic updates in real-time with a digital dashboard.
• Reviewing the history of previously verified data.

Accessing the PDM application

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

PDM training

PDM training is available:

• Log on to Availity.com to learn about and attend one of our training opportunities.
• On Availity.com, you can view the Availity PDM quick start guide.
• Roster Automation Standard Template and Roster Automation Rules of Engagement training:
• Listen to our recorded webinar on Availity.com.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your care providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account. If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

The BlueCard Program provides a valuable service that lets you file all claims for members from other Blue Plans with 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 toll-free at 800-676-BLUE (2583) to verify the patient’s membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) through Availity.
• Submit the claim to Anthem. Always include the patient’s complete identification number, which includes the three-character prefix.
• For claim inquiries, contact Anthem.

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.

Our Sleep Apnea Program offers clinical and behavioral health support.

Creating the best health outcomes for your patients — our consumers — takes our combined efforts. That’s why we’re dedicated to partnering with care providers to focus on holistic, integrated care. This includes connecting behavioral and physical health, such as through our Sleep Apnea Program.

Untreated obstructive sleep apnea is related to physical conditions such as high blood pressure and behavioral health conditions such as anxiety and depression.^{[1], [2]} Through our Sleep Apnea Program, consumers receive support from our case managers and lifestyle coaches who collaborate with their specialty care providers to help better manage their overall health. The program helps address the multifaceted impact obstructive sleep apnea can have on consumers and their families.

Program eligibility

It’s available to over 15,000 of our consumers across all lines of business, ages  60 to 75.^[3] Eligibility is determined by diagnosis of both obstructive sleep apnea and a behavioral health condition, alongside at least two of the following:

• Hyperlipidemia
• Hypertension
• Obesity
• Substance use disorder
• Type 1 diabetes
• Type 2 diabetes

No patient referral is required; those who qualify are automatically identified through claims information and enrolled in the program. Be sure to talk with your patients who may be eligible and encourage them to participate.

The Sleep Apnea Program is one example of how we’re working to transform healthcare with the goal of lowering costs and improving well-being.

Through our shared health vision, we can affect real change.

If you have any questions, contact your Anthem provider relationship management representative.

2024 surveys

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

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

Understanding how to comply

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

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

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

Access standards for medical professionals and ancillary providers

Access standards for behavioral health and EAP providers

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

Access standards for after-hours

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

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

Keeping you informed

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

Why is this important?

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

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

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

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

24/7 NurseLine gives peace of mind

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

Help is a phone call away

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

For patients with DMHC-regulated health plans

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

For patients with CDI-regulated health plans

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

Language assistance program

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

Questions

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

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

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

To reduce billing errors for Blue High Performance Network^® (BlueHPN^®) members, effective December 14, 2024, we will begin using a new claim message when claims are submitted to the incorrect plan.

Key aspects of the message will be:

We have denied this claim because a BlueHPN contracted provider has submitted the claim to an overlapping service area for which they do not have a BlueHPN contract. Please resubmit the claim to the plan where the contract is held. For the simplest way to review the status of the original claim, from https://Availity.com/, select the Claims & Payments tab. Find the original claim using the claim number or the dates of service.

Submitting claims to the correct local plan streamlines payment processing and eliminates delays in resolving incorrect billing. This also improves member satisfaction and eliminates unexpected explanations of payment and medical invoices with the BlueHPN provider.

For more information on BlueHPN, please review the newsletter article published on the provider website in April 2024. If you have specific questions about your participation or this process, please contact your provider relationship management representative or Provider Services.

We are focused on reducing administrative burdens so you can do what you do best — care for our members.

The Inflation Reduction Act and its impact on Part D Rx HCC model for 2025

On August 16, 2023, President Biden signed the Inflation Reduction Act (IRA) into law. This act brought about crucial reforms in the U.S. healthcare system, specifically impacting Medicare Advantage and Medicare Part D programs.

Starting January 1, 2025, the Part D Rx Hierarchical Condition Categories (HCC) risk adjustment (RA) model will undergo significant updates, reflecting the redesigned Part D benefits mandated by the IRA. This Medicare model helps categorize beneficiaries based on their overall health status and expected prescription drug costs. It will use diagnosis and drug utilization data to help predict healthcare costs associated with managing chronic conditions such as hypertension, COPD, and depression.

As part of the Part D Rx HCC model, it is essential for clinicians to thoroughly assess their patients’ active chronic conditions for presence or absence during each encounter and at least once each year. By maintaining comprehensive, accurate, and complete documentation during patient visits and coding to the highest level of specificity, providers can significantly enhance:

• Submission of accurate and complete clinical documentation, coding, and data,
• Appropriate resources to support effective management of costs,
• Quality of patient care, and
• Adherence to compliance regulations.

Thank you for your attention to these important updates. As clinicians, your commitment to accurate and complete documentation and compliant coding practices is essential. Together, we can navigate these changes and support the ongoing delivery of quality patient care.

If you have any RA Part D Rx HCC questions, please contact your Provider Success point of contact to coordinate efforts with the Enterprise Risk Adjustment team. For more detailed Part D model information, please visit the CMS website by clicking this link.

As a participating provider, you may have received our prior correspondence or read the articles in Provider News about cost transparency. Transparency tools such as our Find Care tool and others are available to members on Anthem.com. They allow members to estimate their out-of-pocket impact and view the estimated costs for many procedures.

In our prior correspondence, we also enclosed a summary of the methodology used to generate the cost estimate information housed in the National Consumer Cost Tool (NCCT), the source data used to display some of the costs in Find Care. For additional information, visit Provider News.

As a reminder, care provider cost estimates from NCCT data (currently known as BCBS Axis data) are now available in a secure section of the Availity Essentials website. Authorized representatives of participating facilities and professional practices can log in at Availity.com and register to view the cost estimates for their facility or practice. Cost estimates will be made available to our participating care providers no less than 30 days before they become available to our members on Anthem.com through transparency tools such as our Care Comparison.

As you may know, federal law also impacts the costs we display on our Find Care tool. Some of our tool’s costs come from our contracted provider rates, which are available in machine-readable files posted on our public website as required by the Transparency in Coverage regulation.

If you have any questions about this matter, you can email your provider relationship management representative.

Care providers who wish to share their cost estimate information with members on our website can submit a link to us within 30 days of receipt.

Summary: On August 16, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

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

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Summary:

On August 16, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

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

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

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

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

• The Clinical Criteria listed below apply only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that have been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.