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

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

Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before with our Network eUPDATEs.

Network eUPDATE is our web tool for sharing vital information with you. It features short topic summaries and links that let you dig deeper into timely critical business information:

• Important website updates
• System changes
• Fee Schedules
• Medical policy updates
• Claims and billing updates

……and much more                                                                                                                         

Registration is fast and easy. There is no limit to the number of subscribers who can register for Network eUPDATEs, so you can submit as many e-mail addresses as you like.

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

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

The new online form can be found on www.anthem.com/ca/provider/ > Find Resources for California >  Answers@Anthem tab>Provider Forms bullet>Provider Change Forms> Provider Maintenance Form.  In addition, the Provider Maintenance Form can be found on the Availity Web Portal by selecting California> Payer Spaces-Anthem Blue Cross> Resources tab >Provider Maintenance Form.

Important information about updating your practice profile:

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

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

To report discrepancies please make correction by completing this Provider Maintenance Form online.

It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137), which went into effect on July 1, 2016, requires that Anthem Blue Cross (Anthem) provide our members accurate and up-to-date provider directory data. As a result, Anthem will be conducting ongoing outreaches to all practices to confirm the information we have on file is accurate. Without verification from you that our Provider Directory information is accurate, we will be required to remove your practice from the directories we make available to our members. We appreciate your attention to this matter.

Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. For a complete listing of our workshops, seminars, webinars and job aids, log on to the Anthem Blue Cross website: www.anthem..com/ca. Scroll down the page to Partners in Health > Tools for Providers. In the middle of the page select the box  Find Resources for California. From the Answers@Anthem page, select the link titled Provider Education Seminars and Webinars link.

In an effort to better service our contracted providers right the first time, Anthem Blue Cross has improved our provider claim escalation process. Just click, Provider Claim Escalation Process to read, print, download and share the improved process with your office staff.

Our Network Relations Team is available by email at CAContractSupport@anthem.com to answer questions you have about the process.

As a reminder, the Workers’ Compensation Physicians Acknowledgments is required by California Code of Regulations §9767.5.1, “Medical Provider Networks” (MPN). The “MPN applicant shall obtain from each physician participating in the MPN a written acknowledgment in which the physician affirmatively elects to be a member of the MPN.” 

To maintain and affirm your participation in all MPNs that you have been selected for and have subscribed to Anthem’s Provider Affirmation Portal, go to Availity and login. Once in, click on the Payer Spaces drop down menu in the top right hand corner, and select Anthem Blue Cross from the options available to you. On the next page click on “Resources” in the middle of the page and look for “MPN Provider Affirmation Portal.”

Availity>Payer Spaces>Anthem Blue Cross>Resources>MPN Provider Affirmation Portal

If you cannot go online, call Anthem Workers’ Compensation at 1-866-700-2168 and we can take action on your behalf in the Provider Affirmation Portal. Please also keep an eye out for email notifications from “Anthem MPN Admin.”

Please also be advised the Provider Affirmation Portal will also notify participating medical providers when an MPN is terminating its relationship with Anthem and/or the Division of Workers Compensation.

To help ensure the accurate processing of submitted claims, keep in mind ICD-10-CM Coding Guidelines, when selecting the most appropriate diagnosis for patient encounters.  Remember ICD-10-CM has two different types of excludes notes and each type has a different definition.  In particular, one of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 Notes.  An Excludes 1 Note is used to indicate when two conditions cannot occur together (Congenital form versus an acquired form of the same condition). An Excludes 1 Note indicates that the excluded code identified in the note should not be used at the same time as the code or code range listed above the Excludes 1 Note. These notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note applies to all codes in the section.

Beginning in May 2019, Anthem Blue Cross will enhance its’ claims editing systems to include outpatient facility editing.

These edits will: 

• help ensure correct coding and billing practices are being followed
• help ensure compliance with industry standards such as American Medical Association (AMA), National Uniform Billing Committee (NUBC), and national specialty and academy guidelines
• reinforce compliance with standard code edits and rules (i.e., CPT, HCPCS, ICD-10, NUBC)

Our December 15, 2018, notification stated an effective date of March 15, 2019 for the AIM Physical Therapy, Occupational Therapy and Speech Therapy services.  Please note the new effective date of March 25, 2019.  Beginning with dates of service on and after March 25, 2019, Anthem Blue Cross (Anthem) will require prior authorization for rehabilitative (restoring function) and habilitative (enhancing function) services. AIM Specialty Health® (AIM), a separate company, will manage these Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (OT) medical necessity reviews using Anthem Clinical UM Guidelines (CG-REHAB-04 Physical Therapy, CG-REHAB-05 Occupational Therapy, CG-REHAB-06 Speech-Language Pathology Services).  Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis.   A complete list of CPT codes requiring prior authorization is available on the Anthem Blue Cross Provider portal Clinical UM Guidelines page. The AIM Rehab microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists and FAQs.

AIM will begin accepting prior authorization requests on March 18, 2019, for dates of service on and after March 25, 2019.

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com.
• Call the AIM Contact Center toll-free number 1-877-291-0360, Monday–Friday, 7:00 a.m.–5:00 p.m. PT.

The Rehabilitation ProviderPortalSM Experience Webinar Training Details for Anthem Commercial providers

Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM.  Go to www.providerportal.com to register. If you have previously registered for other services managed by AIM, there is no need to register again. The next training session will be held Wednesday, February 6, 2019, at 12:00 p.m. PT.  The training will be recorded and can be viewed at a time convenient for you.  Access to the recording is available after the February 6th training session on the AIM Rehab microsite.

Anthem Blue Cross (Anthem) conducts an annual satisfaction survey of our Member’s behavioral health outpatient service experience. The random survey is conducted based on receipt of claims. We have recently reviewed the 2018 survey experience results and wanted to share highlights with our network of behavioral health providers. The survey inquires about the member’s satisfaction with timeliness of treatment, practitioner service/attitude and office environment, care coordination (among the member’s various providers), prescriptions/medication management process (if applicable), financial and billing process, and their perceived clinical improvement. Our member is also asked to give an overall rating of the experience. The 2018 overall practitioner rating was 86% in CA based on the survey results.

We were pleased to see overall improvement in the survey results. In particular, two areas of focus over the last year, access and coordination of care. Members responding to the survey, indicated that obtaining an appointment was fairly easy and many respondents indicated that care was being coordinated among their providers, including medical. Care coordination and collaboration, particularly medical-behavioral integration, is a key focus at Anthem. We also encourage ongoing understanding of an individual’s cultural, spiritual and religious beliefs while in treatment.

While we are pleased with our member’s experience with our participating provider network and thank you for your network participation and the services you provide, we’d like to remind you of two key areas to maintain and improve satisfaction:

Member’s Access to Behavioral Health Care

As a participating provider please be reminded of Anthem’s expectation, based on NCQA definitions, of access to behavioral healthcare to help ensure our members have prompt access to behavioral health care:

• Non-Life Threatening Emergency Needs - must be seen, or have appropriate coverage directing the Member, within 6 hours. When the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
• Urgent Needs - must be seen, or have appropriate coverage directing the Member, within 48 hours. Urgent calls concern members whose ability to contract for their own safety, or the safety of others may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. Urgent needs have the potential to escalate into an emergency without clinical intervention.
• Routine office visit - must be within 10 business days. Routine calls concern members who present no immediate distress and can wait to schedule an appointment without any adverse outcomes.

We use several methods to monitor adherence to these standards.  Monitoring is accomplished by a) assessing the availability of appointments via phone calls and surveys by our staff or designated vendor to the provider’s office; b) analysis of member complaint data and c) analysis of member satisfaction. Providers are expected to make best efforts to meet these access standards for all members.  Anthem continues to look at gaps, barriers and alternative options to improve access to behavioral healthcare including tele-health services. 

Members Held Harmless 

As a participating provider in Anthem’s behavioral health provider network, a participating provider shall look solely to Anthem for compensation for covered services and under no circumstances shall render a bill or charge to any member except for applicable co-payments, deductibles and coinsurance and for services that are not medically necessary or are otherwise not covered, provided that the Provider obtains the consent of the Member before providing such service. We recommend that consent be in writing and dated, in order to protect our members and providers from disputes.

In addition, Anthem also reminds our participating providers that Anthem members must be advised of missed or cancelled appointment policies at the onset of treatment.  We also recommend that the advisement be acknowledged by the member in writing, and that acknowledgement is dated. 

Thank you again for the services that you provide to our members.

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. To access the guidelines, go to https://www.anthem.com/ca/provider/.   From there, scroll down and click on Read Polices.  This will take you to Medical Policy, Clinical UM Guidelines (for Local Plan M, and Pre-Certification Requirements. Then click on the Practice Guidelines on the Health & Wellness tab.

Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.

This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.

Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.

If you have questions or feedback, please use this email link.

Effective for dates of service on and after May 1, 2019, the specialty pharmacy drugs and corresponding codes from current clinical criteria noted below will be included in our medical step therapy precertification review process. Step therapy review applies upon precertification initiation or renewal in addition to the current medical necessity review (as is done currently).

The clinical criteria below have been updated to include the requirement of a preferred agent effective May 1, 2019.

The clinical criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific clinical criteria.

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call one of our Medi-Cal Customer Care Centers at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County).

In ICD-10-CM, diabetes is classified in categories E8 through E13. The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected and the complications affecting the body system. To read more about diabetes coding, please view the full article here.

Please continue to check Important Medicare Advantage Updates at anthem.com/ca/medicareprovider for the latest Medicare Advantage information, including:

2019 risk adjustment provider training  

New provider learning opportunity: Put the AIM ProviderPortal to work for you  

New provider service phone number beginning January 1, 2019  

Medicare Advantage reimbursement policy provider bulletin  

CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019  

Effective for dates of service beginning January 1, 2019, the following Medicare Part B devices will be preferred to support cost-effective benefits. During precertification initiation or renewal, providers requesting a nonpreferred device will be encouraged to switch to a preferred product. The preferred and nonpreferred products are listed below.

Refractions and routine eye exams are not covered under medical insurance for Anthem members. These benefits may be available through the member’s supplemental insurance. These services must be billed to the supplemental vendor. Check your patient’s Anthem ID card for the name of the vendor.

Additional information, including billing modifiers and documentation requirements, will be available at anthem.com/ca/medicareprovider under Important Medicare Advantage Updates.

AIM Specialty Health® groups CPT codes on authorizations so they can be reviewed together to support a procedure or therapy. Grouped codes are used for radiology, cardiology, and sleep and radiation therapy programs. The groupings can be found at http://aimspecialtyhealth.com/ClinicalGuidelines.html by selecting the appropriate solution and then the exam or therapy being performed. Additional information is available at anthem.com/ca/medicareprovider under Important Medicare Advantage Updates.

Anthem is required to follow all clinical and reimbursement policies established by Original Medicare in the processing of claims and determining benefits. Anthem follows all Original Medicare local coverage determinations, national coverage determinations, Medicare rulings, code editing logic and the Social Security Act. 

Anthem may offer additional benefits that are not covered under Original Medicare. Certain benefits are only covered when provided by a vendor selected by Anthem. More information can be found at anthem.com/ca/medicareprovider. You may also contact Provider Services at the phone number on the back of the member ID card.

Effective January 1, 2019, Los Angeles Unified School District (LAUSD) began offering an Anthem Medicare Preferred (PPO) plan. Retirees with Medicare Parts A and B are eligible to enroll in the Anthem Medicare Preferred (PPO) plan. The plan includes the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare.

Non-contracted providers may continue treating LAUSD members and will be reimbursed 100% of Medicare’s allowed amount for covered services, less any member cost share. 

LAUSD members’ copay or coinsurance percentage are the same whether his/her provider is in- or out-of-network. Locally or nationwide, doctors or hospitals, in- or out-of-network — the member’s cost share doesn’t change.

The MA plan offers the same hospital and medical benefits that Medicare covers and also covers additional benefits that Medicare does not, such as an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online and SilverSneakers®.

The prefix on LAUSD cards is MBL. The cards also show the LAUSD logo and National Access Plus icon.

Providers may submit claims electronically using the electronic payer ID for the Blue Cross and Blue Shield plan in their state or submit a UB-04 or CMS-1500 form to the Blue Cross and Blue Shield plan in their state. Claims should not be filed with Original Medicare. Contracted and non-contracted providers may call the provider services number on the back of the member ID card for benefit eligibility, prior authorization requirements and any questions about LAUSD member benefits or coverage.

Detailed prior authorization requirements also are available to contracted providers by accessing the Provider Self-Service Tool at Availity.com.