The Controlling High Blood Pressure (CBP) HEDIS^® measure can be challenging as it not only requires proof of a blood pressure (BP) reading, but also that the patient’s blood pressure is adequately controlled. CBP care gaps can open and close throughout the year depending on if the patient’s most recent BP reading is greater than 140/90 mmHG. As we start a new year, it’s important that we have record of your patients’ blood pressure readings and that you continue to monitor patients with elevated readings.

Tips when scheduling members to close CBP care gaps:

• When scheduling appointments, have staff ask patients to avoid caffeine and nicotine for at least an hour before their scheduled appointment time.
• If possible, update your scheduling app and/or your reminder text message campaigns to include reminders about abstaining from caffeine and nicotine prior to appointment time as well as a reminder to arrive early to avoid a sense of rushing.

Tips for lower BP readings during the appointment:

• Ask the patient if they tend to get nervous at appointments and have higher readings as a result. If they do, take their blood pressure at both the start and end of the appointment and document the lower reading.
• Readings can also vary arm to arm. If slightly elevated in one arm, try the other and document the lower reading.

Getting credit for adequately controlled blood pressure readings:

• Submit readings via Category II CPT^® codes on claims.

• Ensure readings are carefully and appropriately documented within your electronic medical record system.
• If you have questions on how to submit readings, speak to your care or practice consultant.
• Also, be sure to adequately code patients who meet the exclusion criteria:
  • Exclusions:
    • Palliative care
    • Enrolled in hospice
    • Frailty and/or advanced illness
    • Living in long-term care
  • Optional exclusions:
    • Dialysis (ESRD), kidney transplant, nephrectomy
    • Female members with a diagnosis of pregnancy
    • Non-acute inpatient admissions

In March 2023, AIM Specialty Health_®* will transition to Carelon Medical Benefits Management Inc. This transition is a name change only, and there will be no process changes. The new name will not impact the way AIM works with health plans and providers. In March, any operational assets that mention AIM Specialty Health (such as determination letters) will adopt the new Carelon Medical Benefits Management Inc. name. 

Provider brand transition FAQ

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. Anthem Blue Cross (Anthem) covers emergency services that are necessary to screen and stabilize a condition. No authorization or prior authorization is needed if the member reasonably believes that an emergency medical or psychiatric condition exists. A member should be directed to call the Member Services or Customer Service telephone number on the back of their Anthem ID card with any questions.

An emergency is an unexpected acute illness, injury, or medical or psychiatric condition that could endanger health if not treated immediately. Examples of medical or psychiatric emergencies include:

• Severe pain.
• Chest pains.
• Heavy bleeding.
• Sudden weakness or numbness of the face, arm, or leg on one side of the body.
• Difficulty breathing or shortness of breath.
• Sudden loss of consciousness. 
• Active labor. 
• Attempted suicide.
• Suicidal/homicidal ideation. 
• Acute psychosis.
• Hazardous drug reactions/interactions.

California law requires a health plan to provide coverage for emergency services to screen and stabilize a condition unless there is evidence to show that either the services were never performed, or the member did not require emergency services and reasonably should have known that an emergency did not exist. 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.

The Consolidated Appropriations Act, implemented in 2021, contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current.

We ask that you to review your online provider directory information on a regular basis to ensure it is correct. To access your information, go here. Then, under Provider Overview, select Find Care. 

Submit updates and corrections to your directory information by using our online Provider Maintenance Form. Online update options include:

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

Once you submit the form, we will send you an email acknowledging receipt of your request.

Anthem Blue Cross is making LiveHealth Online available at no-cost to all California residents dealing with the damage caused by the winter storms, regardless of insurance status.

If you need care for common conditions that don't require an in-person visit, you can see a doctor from home with a virtual visit on LiveHealth Online. Download the LiveHealth Online app or go to https://www.livehealthonline.com to create an account. Once the account is created, you can access medical or psychology health services by selecting the practice website, Natural Disaster Relief. The no cost visit offer will be available through the California State of Emergency.
 
Customer Support is at 888-LIVEHEALTH (888-548-3432).

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

• Prior authorization updates for medications billed under the medical benefit (Enjaymo, Kimmtrak, Tezspire, Voxzogo)
• Medical Policies and Clinical Utilization Management Guidelines update
• Prior authorization updates for medications billed under the medical benefit (Pluvicto, Opdualag, Alymsys, Yusimry)
• Introducing the Provider Learning Hub

Effective January 1, 2023, many Peralta Community College District retirees who are eligible for Medicare Parts A & B will be enrolled in a Medicare Preferred (PPO) plan through Anthem Blue Cross. The plan allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. In addition, Peralta Community College District retirees pay the same cost share for both in-network and out-of-network services. 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, LiveHealth Online,* and SilverSneakers^®.*

The prefix on Peralta Community College District member ID cards will be MBL. The ID cards will also show the Peralta Community College District logo.

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

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

Effective for dates of service on and after February 1, 2023, the specialty Medicare part B drug listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and guidelines from the Centers for Medicare & Medicaid Services (CMS), including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Effective for dates of service on and after February 1, 2023, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Effective for dates of service on and after April 1, 2023, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Effective March 1, 2023, the status of Infed in current criteria documents will change in our existing specialty pharmacy medical step therapy review process. This update is to notify that Infed will change to non-preferred.

Also, effective for dates of service on or after January 1, 2023, Feraheme (ferumoxytol) will change to preferred for both brand and generic.

Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below.

Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.

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

• Introducing the Provider Learning Hub
• Updates to AIM Specialty Health Rehabilitative and Habilitative Services Clinical Appropriateness Guidelines
• Updates to AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines
• Updates to AIM Specialty Health Radiation Oncology Clinical Appropriateness Guidelines
• Updates to AIM Specialty Health Musculoskeletal - Interventional Pain Management Clinical Appropriateness Guidelines
• AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT Code List update
• Prior authorization requirement changes effective April 1, 2023
• Medical Policies and Clinical Utilization Management Guidelines update
• Name change announcement: myNEXUS will transition to Carelon Post Acute Solutions on March 1, 2023