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, 7 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 covers emergency services that are necessary to screen and stabilize a condition. No authorization or pre-certification 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/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/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.

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

Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com/ca/, then at the top of the webpage, select Find Care.

Submit updates and corrections to your directory information by following the instructions on the Provider Maintenance Form online. Update options include:

• add/change an address location
• name change
• phone/fax number change
• provider leaving a group or a single location
• closing a practice location

The Consolidated Appropriations Act (CAA) 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 share a health vision with our care providers that means real change for consumers.

We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same — and these differences can lead to critical disparities not only in how patients access healthcare, but their outcomes as well. The COVID-19 pandemic has reignited public attention about the serious public health risks, the consequences of disparities, and the critical need for health equity.

Health equity means everyone has the opportunity to reach their highest level of health, and barriers to doing so must be removed. Health disparities are health differences that are closely linked with social, economic, and/or environmental disadvantage.¹ Achieving health equity requires focus on the elimination of barriers and disparities associated with factors such as race, ethnicity, gender, gender identity, religion, socioeconomic status, disability, and even where you live.² As a result it is imperative to offer access to care that is tailored to the unique needs of patients, and Anthem Blue Cross is committed to supporting our providers in this effort.

Cultural competency resources

Here is an overview of the cultural competency resources available on our provider website:

• Cultural competency and member engagement:
  • A training resource to increase cultural and disability competency to help effectively support the health and healthcare needs of your diverse patients
• Caring for Diverse Populations toolkit:
  • A comprehensive resource to help providers and office staff increase effective communication by enhancing knowledge of the values, beliefs, and needs of diverse patients
• MyDiversePatients:
  • Offers resources, information, and techniques to help provide access to the individualized care every patient deserves regardless of their diverse backgrounds
  • Includes free continuing medical education (CME) credit for learning experiences on topics related to cultural competency and disparities
  • Free accessibility from any device (desktop computer, laptop, phone, or tablet), with no account or login required

Stronger Together is the microsite that offers free resources to support the diverse health needs of all people where they live, learn, work, and play. These resources were created in collaboration with national organizations and are available for you to share with your patients and communities.

While there is no single, easy answer to address healthcare disparities, the vision of MyDiversePatients and Stronger Together is to start reversing these trends one person at a time.

Prevalent non-English languages (based on population data)

Like you, Anthem wants to effectively serve the needs of diverse patients. It’s important for us all to be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the top 15 non-English languages spoken by 5% or 1,000 individuals in California.

Source: American Community Survey, 2023 American Community Survey 1-Year Estimates, Table B16001, generated July 2023.

Language support services

As a reminder, Anthem provides language assistance services for our members with limited English proficiency (LEP) or hearing, speech, or visual impairments. Please see the provider manual for details about the available resources and how to access them. In addition, the cultural competency resources shared above provide guidance on communicating and serving diverse populations effectively.

Embrace the knowledge, skills, ideals, strategies, and techniques to accelerate your journey to becoming your patients’ trusted healthcare partner by using these resources today.

References:

1. Office of Disease Prevention and Health Promotion. (2022, Feb 6). Healthy People - Disparities. Retrieved from https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities.
2. ThinkAnthem.com. (2022, Feb 7). Why We Need Health Equity. Retrieved from https://www.thinkanthem.com/health-equity/what-are-health-disparities/.

This is a reminder that providers are required to call to reschedule an appointment within 48 hours after a missed appointment. Please ensure your office’s policies and procedures and training are updated to include this requirement. Providers may be surveyed on a random sample to ensure compliance with this standard.

Background

In February 2022, updates to Clinical Utilization Management (UM) Guidelines were published with an August 1, 2022, effective date. These updates included changes to clinical coding edits for the lab test indicated below.

Update

The updated guidelines state that only medically necessary lab testing will be covered. Effective March 1, 2024, coverage for these labs will be denied unless medically necessary:

Notes:
* ADA, ACOG, and USPSTF recommendations about individuals who have overweight or obesity
** Populations with high prevalence of diabetes mellitus

What if I have questions?

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section at the bottom of our provider's website for the appropriate contact.

Summary

On September 21, 2023, and October 4, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. 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 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.

On September 21, 2023, and October 4, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross (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 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.

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management associate or call one of our Medi-Cal Customer Care

Centers:

• Outside L.A. County: 800-407-4627
• Inside L.A. County: 888-285-7801

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes. Select here for our conversation guide for tips on how to engage patients who may be from a culture different from your own.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management associate or call Provider Services on the back of your patient’s member ID card.

Through our efforts, we can help deliver high quality, equitable healthcare.

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes. Select here for our conversation guide for tips on how to engage patients who may be from a culture different from your own.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management associate or call Provider Services on the back of your patient’s member ID card.

Through our efforts, we can help deliver high quality, equitable healthcare.