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

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

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

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

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

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

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

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

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

Important information about updating your practice profile:

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

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

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

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EPO Plans and Network

As a reminder, for the 2021 benefit year, Anthem Blue Cross (Anthem) will continue to offer EPO Individual on exchange and off exchange plans in Covered California’s rating regions 1, 7, 9, 10 and 12. 

We are also very pleased to announce the expansion of our Individual EPO on and off exchange plans into rating regions 13 and 14.  Below is a list of counties located in those regions where Anthem will be offering 2021 EPO on and off exchange Individual plans.

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

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

Providers in Region 13 and 14

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

HMO Plans and Network

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

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

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

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

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In January we introduced our new Authorization Rules Lookup tool that you can access through Availity Payer Spaces. This new self-service application displays prior authorization rules so you can quickly verify if the outpatient services require prior authorization for members enrolled in Anthem’s commercial plans.

In addition to verifying whether an outpatient authorization is needed, the tool provides the following details that apply to the procedure code:

• Medical Policies and Clinical Guidelines
• Third Party Guidelines, if applicable (such as AIM Specialty Health, IngenioRx)

Steps to access the Authorization Lookup application through Availity Payer Spaces

Access to the tool does not require an Availity role assignment.

1. Select Payer Spaces
2. Select the Anthem Blue Cross tile from the Payer Spaces menu
3. Select the Applications tab
4. Select the Authorization Rules Lookup tile

Once you are in the tool you will need to provide the following information to display the service’s prior authorization rules:

• Tax ID
• National Provider Identifier (NPI)
• Member ID and birth date
• Member’s Group number or Contract Code

(This information can be found on the member’s ID card or through the Eligibility & Benefits return on the Patient Information tab)

• CPT/HCPCS code

Give this new tool a try and discover how much this will improve the efficiency of your authorization process.

Please note: If a prior authorization is required for outpatient services, you can submit the case through Interactive Care Reviewer Anthem’s online authorization tool which you can also access through the Availity Portal.

Anthem Blue Cross (Anthem) will begin publishing a new indicator in our online provider directories to help members easily identify professional providers who offer telehealth services.

We encourage providers who offer telehealth services to utilize the online Provider Maintenance Form to notify us and we will add a telehealth indicator to your online provider directory profile.

Visit anthem.com/ca/ to locate the Provider Maintenance Form. Please contact Provider Services if you have any questions.

Effective January 1, 2021, all NECA/IBEW Family Medical Care Plan (FMCP) members will have new ID numbers.  Please use this new number for services rendered as of January 1, 2021.  FMCP has advised its membership to remember to share this new card/ID # with all their providers for all services obtained after the first of the year. Please contact Anthem Provider Services at 1-833-835-2714 for eligibility and benefit questions and 1-855-343-4851 to request pre-certification. 

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Revised measures:

• The former Well-Child Visits in the First 15 Months of Life (W15) measure was revised to Well‑Child Visits in the First 30 Months of Life (W30). It includes two indicators:
• Well-child visits in the first 15 months — children who turned 15 months during the measurement year with six or more well-child visits

• Well-child visits for ages 15 to 30 months — children who turn 30 months during the measurement year with two or more well-child visits

• The former Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) and Adolescent Well-Care Visits (AWC) measures have been combined into Child and Adolescent Well-Care Visits (WCV):
• The percentage of members 3 to 21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year

Key measure changes:

• Controlling High Blood Pressure (CBP and CDC-CBP)
  Telephone visits, e-visits and virtual check-ins are now acceptable settings for blood pressure (BP) readings. Digital BP readings reported by the member are considered numerator compliant.
• Telehealth updates
  NCQA has updated telehealth guidance in 40 HEDIS^® measures for HEDIS measurement years 2020 and 2021. The purpose of these changes is to:
• Support increased use of telehealth caused by the pandemic.
• Align with guidance from Centers for Medicare & Medicaid Services and other stakeholders.

A list of the 40 measures can be found on the NCQA COVID-19 website at www.ncqa.org/covid.

New Medicaid measures:

Kidney Health Evaluation for Patients With Diabetes (KED) — The percentage of members 18 to 85 years of age with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a uACR identified by both a quantitative urine albumin test and a urine creatinine test with service days four or less days apart during the measurement year

Cardiac Rehabilitation (CRE) — The percentage of members 18 years and older who attended cardiac rehabilitation following a qualifying cardiac event, including myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, heart and heart/lung transplantation, or heart valve repair/replacement; four rates are reported:

• Initiation — The percentage of members who attended two or more sessions of cardiac rehabilitation within 30 days after a qualifying event
• Engagement 1 — The percentage of members who attended 12 or more sessions of cardiac rehabilitation within 90 days after a qualifying event
• Engagement 2 — The percentage of members who attended 24 or more sessions of cardiac rehabilitation within 180 days after a qualifying event
• Achievement — The percentage of members who attended 36 or more sessions of cardiac rehabilitation within 180 days after a qualifying event

Retired Medicaid measures:

• Comprehensive Diabetes Care (CDC) retired sub-measures —
• Medical Attention for Nephropathy (retired for Commercial and Medicaid)
• HbA1c control (< 7.0%) for a selected population
• Adult BMI Assessment (ABA)
• Medication Management for People With Asthma (MMA)
• Children’s and Adolescents’ Access to Primary Care Practitioners (CAP)
  
  

Measure change summary:

For a complete summary, go to https://tinyurl.com/NCQA-measures.

On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

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On August 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

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On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

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Click here for more information about IBEW Local 234, CA moves to Medicare Advantage plan under Anthem Blue Cross.

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Click here for more information about PN for UM AROW Item 1330.

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Click here for more information about the new specialty pharmacy medical step therapy requirements.

Now, you can select Additional Benefit Notes, on the Availity Portal* Eligibility and Benefits results screen to find more descriptive benefit information.

Benefits are listed in alphabetical order, making it easier to search for specific benefits. Capabilities include full benefit descriptions, vendor information associated with the benefit and the option for the provider to print out the benefit information.

Digital member ID cards

The digital member ID card allows easy, low-touch access to view additional information or confirm basic membership details.

When conducting an eligibility and benefits inquiry for Medi-Cal Managed Care members, simply select View Member ID Card on the Eligibility and Benefits results page. Note: The Availity Portal requires you to enter the member’s ID number, as well as a date of birth or the member’s first and last name into the search options in order to submit an eligibility and benefits inquiry.

Try both of these valuable tools today!

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross.

On November 15, 2019, February 21, 2020, May 15, 2020, August 21, 2020, August 28, 2020, and September 24, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting September and October 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

Effective April 1, 2021, Anthem Blue Cross will require prior authorization (PA) for the below additional injectable drugs. Please refer to the Precertification Look Up Tool for authorization requirements. Noncompliance with the new requirements may result in denied claims.

PA requirements will be added to the following codes:

• A9543 Injection, Yttrium Y-90 ibritumomab tiuxetan (Zevalin)
• A9590 Injection, Iodine I-131, iobenguane, 1 mCi (Azedra)
• A9513 Injection, Lutetium Lu 177, dotatate, therapeutic, 1 millicurie (Lutathera)
• A9606 Injection, Radium ra-223 dichloride, therapeutic, per microcurie (Xofigo)

Please use one of the following methods to request PA:

• Web: https://www.availity.com*
• Phone: 1-800-282-4548

Federal and state law, as well as state contract language, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage.

Click here for more information about prior authorization requirements for 55899.

This provider bulletin is an update about information in the Anthem Blue Cross (Anthem) Medicaid Business Provider Operations Manual (POM). For access to the latest manual, go online to https://providers.anthem.com/ca. Please note that the manual is considered part of your provider agreement and its provisions are contractual requirements.

The California Department of Health Care Services (DHCS) requires Managed Care Plans (MCPs) to meet the 50th percentile or Minimum Performance Level (MPL) for a select set of quality measures also known as the Managed Care Accountability Set (MCAS). When the MPL is not met on any measure within MCAS, DHCS may impose the following actions on the MCP:

• Corrective Action Plan (CAP)
• Sanctions
• Plan Do Study Act cycle (PDSA)/Performance Improvement Plan (PIP)

As a result, Anthem has implemented quality performance requirements that require all applicable network providers, including safety net clinics, independent practitioners, Primary Medical Groups/Individual Practice Associations, public hospitals and other health systems to meet the MPL for all measures with the DHCS selected MCAS measures. Anthem will closely monitor performance and hold providers accountable for meeting the MPL. Low performing providers will be subject to the following process:

• Anthem will send provider notice for non-compliance or CAP.
• Provider will have 10 days to respond with an improvement action plan.
• Anthem will continuously monitor provider’s performance throughout the year.
• Provider will have four months to improve rates.
• Failure to improve rates will result in formal contractual actions.

Anthem will be monitoring and strictly enforcing this process effective immediately.

Click here for more information about the update to Clinical Practice Guidelines and Preventive Health Care Guidelines.

For more information about Utilization Management Authorization Rule Operations Workgroup Item 1326.

CAHPS is an annual standardized survey conducted from January to May to assess consumers’ experience with their provider and health plan. A random sample of your adult and child patients may get the survey. Providers directly impact the majority of questions used for scoring.

These questions are:

• When you needed care right way, how often did you get it?
• How often did you get an appointment for a check-up or routine care as soon as you needed it?
• How often was it easy to get the care, tests, or treatment you needed?
• How often did you get an appointment to see a specialist as soon as you needed it?
• How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
• How would you rate your primary care doctor?
• How would you rate the specialist you see most often?

To learn more about CAHPS and how you can improve the patient experience, review the CAHPS Overview training by visiting https://mediproviders.anthem.com/ca.

Customer Care Centers:

• Medi-Cal Managed Care (outside L.A. County): 1-800-407-4627
• Medi-Cal Managed Care (inside L.A. County): 1-888-285-7801

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

Currently, Anthem Blue Cross (Anthem) allows reimbursement for applicable services for a covered member prior to admission to an inpatient hospital (referred to as the payment window) unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Emergency and observation services are included in the inpatient reimbursement and, therefore, are not separately reimbursable expenses when performed within 24 hours prior to and including the day of the member’s admission.

Effective May 1, 2021, the following changes will occur:

1. For admitting hospitals, preadmission services are included in the inpatient reimbursement for the three days prior to and including the day of the member’s admission. Therefore, they are not separately reimbursable expenses.
2. Anthem will not consider the following services to be included in the payment window prior to an inpatient stay for preadmission services:

• Ambulance services
• Maintenance renal dialysis services
• Services provided by:
  • Skilled nursing facilities
  • Home health agencies
  • Hospices
• Unrelated nondiagnostic services

For additional information, please review the Preadmission Services for Inpatient Stays reimbursement policy at https://mediproviders.anthem.com/ca.