As a crucial part of our commitment to providing the highest quality care and ensuring accuracy and timelines in the processing of claims, please remember to obtain prior authorization for neonatal intensive care unit (NICU) services at the level you intend to provide services.

Obtaining prior authorization helps us:

• Ensure timely and appropriate care for our smallest and most vulnerable patients.
• Streamline the claims process, thereby reducing delays and potential denials.
• Facilitate accurate and efficient billing, which saves time and resources for everyone involved.

Please ensure all nonemergent NICU services are prior authorized before the commencement of treatment and continue to provide updates concurrently. This proactive step is essential for maintaining smooth and efficient operations. Prior authorization is not required for emergent NICU services or NICU services provided in the first 48 hours following birth for vaginal delivery and 96 hours following birth for cesarian delivery.

Should you have any questions or need further assistance with the authorization process, please do not hesitate to contact Provider Services via the number on the back of our member ID card.

In May, we will add new functionality to the provider enrollment and network management tool hosted on Availity Essentials to improve the correspondence experience. We will start posting letters related to your credentialing directly in the Communication Center and you will be able to download the correspondence as a PDF.

How will this help you:

• Convenience — reduced time spent sorting through mailed documents
• Faster access — no need to wait for mail service delivery
• Ease of access — access your correspondence 24/7 digitally
• Environmental benefits — saving paper and printing costs helps you and the planet

Before you begin

If your organization is not currently registered for Availity Essentials, the person in your organization designated as the Availity administrator should go to https://Availity.com and select Get Started. If you need assistance registering with Availity Essentials, visit https://www.availity.com/customer-support.

For organizations already using Availity Essentials, your administrator(s) will automatically be granted access to the provider enrollment tool.

Staff using the provider enrollment tool need to be granted the user role Provider Enrollment by an administrator. To find yours, go to My Account Dashboard >My Account > Organization(s) > Administrator Information.

At this time, Carelon Behavioral Health is out‑of-scope for this implementation.

Accessing the Communication Center

1. Log in to https://Availity.com.

2. Select your market.

3. Select Payer Spaces in the top menu.

4. Select the brand that corresponds to your market.

5. Accept the User Agreement (once every 365 days).

6. On the Applications tab, select Provider Enrollment and Network Management.

7. Select the Communication Center link under the My Communications option on the side menu.

8. Enter your TIN and NPI to access the letters.

We’re excited to introduce two new Payment Integrity trainings available on our Digital Solutions Learning Hub:

• Payment Integrity: Emergency Dept Evaluation and Management Services
• Payment Integrity: Outpatient Evaluation and Management Services

With an initial focus on these two key educational initiatives, our purpose is to amplify your billing and coding accuracy.

More trainings will be announced throughout the year.

Discover what our Digital Solutions Learning Hub has to offer.

The CA Department of Health Care Services (DHCS) released All‑Plan Letter (APL) 23‑005, Requirements for Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi‑Cal Members Under the Age of 21, that introduces the new name for EPSDT services in California, L.A. Care for Kids & Teens. Along with the new name, there are some new requirements for all providers who care for this population of members.

Beginning in 2024, it was determined that all providers who care for this population must complete the DHCS required training on MediCal for Kids & Teens at least every two years. The goal of the training is to strengthen understanding and awareness of and increase access to these services for L.A. Care members under age 21 years.

This comprehensive training covers preventive EPSDT services, references the American Academy of Pediatrics Bright Futures Periodicity Schedule, defines medical necessity for this population, and highlights behavioral health services, California Children’s Services (CCS) program, and skilled nursing services.

Anthem offers the training on our provider webpage and requires an attestation that the training was completed and understood. The eLearning training is available through the health plan’s Provider Training Academy in the Provider Pathways link. If you have already registered for Provider Pathways, enter your username and password to access the training.

Provider Training Academy | California Provider

Providers must register to access the Provider Pathways training. To register, select the Register Now link in the Provider Training Academy and enter the requested information. The NPI field is required and can be an individual, group, or clinic‑level NPI, or you can enter a zero followed by your Medicaid identification number or nine digits.

DHCS allows Managed Care Plans (MCPs) that share providers in a county to share their training attestation data to reduce duplicative provider trainings. When providers log in to the Anthem training, they have the option to complete an attestation form that indicates they have completed the training from another MCP in California. Providers who have not completed the training will be directed to the presentation. Following completion of the training, an Anthem attestation will need to be filled out that can then be shared with other MCPs.

Summary:

• 2025 Clinical Quality in Practice is a webinar series for clinicians that covers a wide range of topics.
• Participants will have the opportunity to engage with experienced practitioners and thought leaders.
• Visit our engagement hub to view a detailed schedule.

We are excited to announce our 2025 Clinical Quality in Practice, a continuing education webinar series. This comprehensive series will cover a diverse range of critical topics designed to equip clinicians with the latest strategies and best practices in patient care.

The webinar series will explore essential areas, such as:

• Clinical strategies to care for patients with diabetes.
• Clinical strategies to care for patients with cardiovascular disease and hypertension.
• Post acute care management.
• Motivating patients to adhere to cancer prevention and screenings.
• Clinical strategies to increase flu vaccinations.
• Clinical strategies for screening and preventive care.
• Enhancing coordination of care.

Participants will have the opportunity to engage with experienced practitioners and thought leaders, gaining valuable insights that can be immediately applied in clinical settings.

For a detailed schedule of live events and a full listing of available on‑demand webinars that you can start viewing now, visit our Engagement Hub. Don’t miss this chance to advance your clinical expertise and enhance patient outcomes.

The National Committee Quality Assurance (NCQA) develops and collects Healthcare Effectiveness Data and Information Set (HEDIS^®) measurements to set performance and drive improvement in quality‑of-care outcomes. The AAB measure is one of the priority measures that have many opportunities to optimize antibiotic prescribing.

The Federal Employee Program (FEP) is continuously working toward improving clinical quality of care and performance outcomes. To improve HEDIS AAB compliance, the FEP takes this opportunity to ask for your commitment to promote appropriate use of antibiotic prescription in protecting your patients from harmful side effects and possible resistance to antibiotics over time.

According to the CDC, in U.S. doctors’ offices and emergency departments, at least 28% of antibiotic prescriptions each year are unnecessary and an estimated 80 to 90% of antibiotic prescriptions occur in the outpatient setting, which makes improving antibiotic prescribing and use a national priority. The national guidelines recommend against prescribing antibiotics bronchitis/bronchiolitis for healthy people.

What is the HEDIS AAB measure?

The AAB measure looks at the percentage of episodes for members ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.

If a patient is diagnosed with an acute bronchitis/acute bronchiolitis and medically requires an antibiotic prescription due to comorbid conditions at time of the visit, it is important to document the comorbid conditions/diagnosis by using the appropriate ICD‑10-CM on the same visit claim which will remove the patient from the HEDIS AAB measure.

The table below lists the common ICD‑10-CM diagnosis codes for outpatient visits that trigger patients to be included in the HEDIS AAB measure:

Common ICD‑10-CM codes that exclude patients from the HEDIS AAB measure are:

Note: These lists are not all‑inclusive. This information is not about a change in policy but a reference to quality improvement activities.

The CDC is an excellent source for antibiotic information and awareness. In fact, the CDC leads in the Antibiotics Stewardship Training. We encourage you to take advantage of these continuing education opportunities:

• Free continuing education credit courses are available through the Stewardship Training Course: https://cdc.gov/antibiotic‑use/hcp/training/index.html
• Enjoy the CDC AAB online seminar. This session is approved for one AAFP credit. Use this link: https://bit.ly/improvingantibioticuse. Note: This site works best in Google Chrome.

Helpful tips:

• If a patient insists on an antibiotic:
• Refer to the illness as a chest cold rather than bronchitis; patients tend to associate the label with a less‑frequent need for antibiotics.
• Write a prescription for symptom relief, such as an over‑the-counter medicine.
• Reiterate the CDC’s recommendation that antibiotics do not work against viruses that cause most chest colds or bronchitis.
• Treat with antibiotics if patient has a competing diagnosis listed above.
• Document accurately and use the correct ICD‑10-CM diagnosis codes.
• Use correct exclusion codes when appropriate.
• Maintain timely submission of claims and encounter data.