As you know, Anthem Blue Cross (Anthem) monitors member access to a provider’s care through several mechanisms, including provider and member surveys. These surveys are conducted by Anthem and external entities, such as Sutherland Healthcare Solutions, North American Testing Organization, and the CAHPS^® program.  

Surveys give insight:

• In surveying compliance with After Hours standards, participating providers’ offices are called outside of normal business hours to determine if callers are given appropriate emergency instructions and have a mechanism to reach a provider after regular hours for urgent situations.
• In surveying compliance with Appointment Availability standards, participating providers’ offices are called within normal business hours and are asked when the next available appointment for urgent and non-urgent care would be.
• Members are also surveyed via mail. The surveys, in addition to monitoring member complaints, help us to identify whether access to care is available to our members after or before normal business hours.

 The key to our 2022 success is…you!

If you have already taken steps to comply with the standards - thank you. This year’s surveys are now under way, and with your continued support and commitment, we can achieve the best results possible for 2022.

Take a minute to review the 2021 survey results in the table below. We hope sharing them with you provides a better understanding of how you can help improve 2022 results.

Provider After Hours results - 2021 survey

Provider Appointment Availability Survey (PAAS) results - 2021 Survey

 You make a difference:

• Review the Commercial Access Standards under the Legal and Administrative Requirements section in your Anthem Blue Cross California Facility and Professional Provider Manual. Make sure your practice policy and procedures comply with the standards.
• Ensure your after-hours office staff, answering service, or answering machine message specifically informs callers when their urgent (nonemergent) calls will be returned.
• Ensure your after-hours office staff, answering service, or answering machine message directs callers to dial 911 or go to the nearest emergency room if they are experiencing an emergency.
• Ensure that your office staff are aware of and able to comply with the appointment availability standards when setting appointments for our members.

If your office was surveyed in 2021 and was found noncompliant with these standards, a letter with recommended compliance measures was sent to an active mailing address on file for you.

If you have questions, email your Provider Experience representative for assistance from the Contact Us page. Select Provider Experience team to open the email form and make sure to enter the words, 2021 Survey After Hours and PAAS Results in the subject field.  Visit us online to view other contact options.

Professional system updates for 2023

As a reminder, we will update our claim editing software for professional services throughout 2023 with most updates occurring at a minimum quarterly. These updates apply to any provider, provider group (tax identification number) and/or across providers and claim type (professional/facility) and include, but are not limited to:

The addition of new, and revised codes (for example, CPT^®, HCPCS, ICD-10, modifiers) and associated edits such as:

• ICD-10 laterality
• Add-on procedures (indicated by + sign)
• Code book parenthetical statements and other directives about appropriate code use (for example, separate procedure, do not report, list separately in addition to, etc.)
• Updates to editing for multiple procedure reduction calculations based on relative value unit (RVU) as designated and updated by the Centers for Medicare & Medicaid (CMS) in the physician fee schedule relative value (PFSRV) files
• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to incidental, mutually exclusive, and unbundled (re-bundle) edits
• Updates to code edits associated with reimbursement policies including, but not limited to, updates to the edits that allow/disallow for assistant surgeon/co-surgeon/team surgeon, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by CMS

As a reminder, we will update our claim editing software for outpatient facility services throughout 2023 with most updates occurring at a minimum quarterly. These updates will include, but are not limited to:

• The addition of new and revised codes (for example, CPT^®, HCPCS, ICD-10, modifiers, revenue codes) and associated edits.
• Updates related to the appropriate use of various code combinations, which can include, but are not limited to, CPT/HCPCS code to revenue code, type of bill to procedure code, type of bill to CPT/HCPCS code, and CPT/HCPCS code to modifier.
• Updates to National Correct Coding Initiative edits (NCCI) and Facility Outpatient Hospital Services Medically Unlikely Edits (MUEs).
• Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC) and the Centers for Medicare & Medicaid Services (CMS).

Why is this important?

Each year, a random sample of enrolled members receive a CAHPS* Survey or a Qualified Health Plan Enrollee Survey asking them to evaluate their experiences with healthcare. The surveys ask members to rate their experiences with:

1. Their health plan.
2. Their personal provider.
3. Their specialist.

Several responses are combined and evaluated for the following:

• Getting needed care
• Receiving care quickly
• Communicating with providers
• Sharing in the decision-making process

The responses give us an idea of how your patients and our members perceive us and provide opportunities for us to improve the way we deliver services. Our engagement and interaction with patients and members are critical. Together, we can provide positive experiences for our shared members and patients.

Members receive the survey either by mail or phone between February and May. Some of the questions they are asked include:

• In the last six¹ months, how often did your personal provider explain things in a way that was easy to understand?
• In the last six¹ months, how often did your personal provider listen carefully to you?
• In the last six¹ months, how often did your personal provider show respect for what you had to say?
• In the last six¹ months, how often did your personal provider spend enough time with you?
• Using any number from zero to 10, where zero is the worst personal provider possible, and 10 is the best personal provider possible, what number would you use to rate your personal doctor?
• We want to know your rating of the specialist you saw most often in the last six¹  Using any number from zero to 10, where zero is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate the specialist?

Every interaction with a patient is an opportunity to make their healthcare experience positive.

We thank you for striving to provide quality care for our members and for the continued focus on improving our member experience.

Additional information

Continuing medical education (CME) education opportunities: http://www.mydiversepatients.com.

¹The commercial survey asks the same questions, but for the last 12 months vs. 6 months and language on the Medicaid Child Survey is slightly different to reflect asking a parent/guardian about their child’s experience.

In November 2022, we shared information about updates to claim status inquiries denial descriptions. You should now see these expanded descriptions on your explanation of payment remittance advice. These simplified descriptions should make it easier to understand why your claim denied and how to update your claim with the information needed for processing.

We’re phasing in clear, concise, and simplified denial descriptions that explain in greater detail why the claim or claim line has denied and what to do next. We’ve even included details about how to provide us with information digitally, to move the claim further along in the claims process.

Continuing to improve

The new denial descriptions will be phased in over the next few months. We’re starting with those claims or claim lines that have caused the most confusion based on your feedback. If new denial reasons are added, those descriptions will be expanded, as well.

Save time. Increase efficiency. Go digital! If you’re not enrolled in Availity* Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity.com.

HEDIS^® measurement year 2023 documentation for Childhood Immunization Status (CIS)

Measure description: The percentage of children who turn 2 years of age in the measurement year who had the following vaccines on or before their second birthday:

• Four DTaP (diphtheria, tetanus, and acellular pertussis)
• Three IPV (polio)
• One MMR (measles, mumps, and rubella)
• Three HiB (haemophilus influenza type B)
• Three hep B (hepatitis B)
• One VZV (chicken pox)
• Four PCV (pneumococcal conjugate)
• One hep A (hepatitis A)
• Two or three RV (rotavirus)
• Two flu (influenza)

The measure calculates a rate for each vaccine and three combination rates.

HEDIS measurement year 2023 documentation for Lead Screening in Children (LSC)

Measure description: The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday.

In provider medical records, we look for the following:

• Immunization records from birth (Department of Health immunization records are acceptable).
• If available, newborn inpatient records documenting hepatitis B.
• For immunizations not recorded on the immunization record, provide progress notes for:
  • Immunizations administered.
  • Patient’s history of disease (chickenpox, hep A, hep B, measles, mumps, rubella).
• Lead testing results and date (capillary or venous) on or before the second birthday.
• Evidence of hospice services in 2023.
• Evidence patient expired in 2023.

Helpful hints:

• Childhood immunizations and lead blood tests must be completed by child’s second birthday.
• Assess immunization needs at every clinical encounter and, when indicated, immunize.
• Ensure immunization records include all vaccines that were ever given including hospitals, health departments, and all former providers, including refusals and contraindications.
• Record the immunizations in your state immunization registry.
• FluMist (LAIV) vaccination (only approved for ages 2 to 49) may be used for the second vaccination; however, it must be given on the child’s second birthday to be compliant.

As previously communicated in Anthem Blue Cross’s letter dated November 1, 2022, AIM Specialty Health_® (AIM) will apply additional code updates to the AIM Specialty Health™ Diagnostic Coronary Angiography and Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. That code update expansion has been delayed. The codes listed below will go into effect April 1, 2023, not February 1, 2023, as originally communicated.

Percutaneous coronary intervention:

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

• Access AIM’s ProviderPortal_SM directly at www.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.
• Call the AIM Contact Center toll-free number at 877-291-0360, Monday through Friday, from 7 a.m. to 7 p.m. Pacific time.

If you have questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Background:

Providers are a trusted resource for patients when it comes to vaccine advice. As information on the monkeypox outbreak changes and vaccination and testing guidance is released, we’re committed to keeping you informed.

Some providers may have seen a message on their provider Explanation of Payment (EOP) stating that Anthem Blue Cross does not recognize the vaccine product codes for monkeypox and smallpox that became effective July 26, 2022. We’re updating the provider fee schedules to reflect the new vaccine product codes as quickly as possible. The EOP message did not impact payment for administration of the vaccines, which is reimbursable; however, since the monkeypox and smallpox vaccines are provided by the government at no charge, the vaccine products are non-reimbursable.

To aid in processing claims for the monkeypox and smallpox vaccine products, providers must include these three elements on claims, even if vaccine products were received from the federal government at no charge:

1. Product code (90611 or 90622)
2. Applicable ICD-10-CM diagnosis code
3. Administration code

More detail on codes and cost-sharing

Providers are encouraged to use:

• Product code 90611 for smallpox and monkeypox vaccine.
• Product code 90622 for vaccinia (smallpox) virus vaccine.
• Code 87593 for laboratory testing.

When billing the monkeypox and smallpox vaccine products, providers should submit those codes with a $0.01 charge.

Cost-sharing for the vaccine and administration is waived.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your assigned Provider Experience associate or call one of our Medi-Cal Customer Care Centers at:

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

You can read more information on monkeypox online.

Why is this important?

Each year, a random sample of enrolled members receive a CAHPS* Survey or a Qualified Health Plan Enrollee Survey asking them to evaluate their experiences with healthcare. The surveys ask members to rate their experiences with:

1. Their health plan.
2. Their personal provider.
3. Their specialist.

Several responses are combined and evaluated for the following:

• Getting needed care
• Receiving care quickly
• Communicating with providers
• Sharing in the decision-making process

The responses give us an idea of how your patients and our members perceive us and provide opportunities for us to improve the way we deliver services. Our engagement and interaction with patients and members are critical. Together, we can provide positive experiences for our shared members and patients.

Members receive the survey either by mail or phone between February and May. Some of the questions they are asked include:

• In the last six¹ months, how often did your personal provider explain things in a way that was easy to understand?
• In the last six¹ months, how often did your personal provider listen carefully to you?
• In the last six¹ months, how often did your personal provider show respect for what you had to say?
• In the last six¹ months, how often did your personal provider spend enough time with you?
• Using any number from zero to 10, where zero is the worst personal provider possible, and 10 is the best personal provider possible, what number would you use to rate your personal doctor?
• We want to know your rating of the specialist you saw most often in the last six¹  Using any number from zero to 10, where zero is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate the specialist?

Every interaction with a patient is an opportunity to make their healthcare experience positive.

We thank you for striving to provide quality care for our members and for the continued focus on improving our member experience.

Additional information

Continuing medical education (CME) education opportunities: http://www.mydiversepatients.com.

¹The commercial survey asks the same questions, but for the last 12 months vs. 6 months and language on the Medicaid Child Survey is slightly different to reflect asking a parent/guardian about their child’s experience.

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:

• Population Needs Assessment report
• Remind your patients to update their Medi-Cal Managed Care information

Anthem Blue Cross (Anthem) is implementing two new Medicare Advantage plans in 2023. With each plan, our goal is to deliver on our missing of improving the lives of our members. With the new plans, we are excited to continue to offer strong plans that meet our members’ needs. The plans will help connect Medicare Advantage members to the care, support, and resources they need to lead healthy lives. The two new plans are named Anthem MediBlue Prime (HMO) and Anthem MediBlue Full Dual Advantage (HMO D-SNP). 

Anthem MediBlue Prime (HMO) will be offered in Fresno, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Mateo, and Ventura counties. With the introduction of the new plan, current members in Riverside and San Bernardino counties with the 2022 plans below will transition to the Anthem MediBlue Prime (HMO) plan automatically on January 1, 2023:

Members enrolled in the new plan in San Bernardino and Riverside counties will have $0 monthly premium as well as $0 copay for PCP visits, specialist visits, and inpatient hospital stays. Beneficiaries in Fresno, Sacramento, San Diego, San Francisco, San Mateo, and Ventura counties will have the option to enroll in the new plan and their plan benefit design may differ. All plan benefits for the Anthem MediBlue Prime can be found online. Our goal is to improve the healthcare of our members and pursue a simpler, more effective healthcare experience.

Anthem MediBlue Full Dual Advantage (HMO D-SNP) will be offered in Los Angeles and Santa Clara counties. This plan is an exclusively aligned enrollment dual special needs plan (EAE D-SNP). The plan was created to support the state of California’s Advancing and Innovating (CalAIM) initiative. The plan offers an integrated approach to care and care coordination. The matching Medicare D-SNP and Medi-Cal plans will work together to deliver all covered benefits to their members. Additionally, as all members in the plan are also enrolled in the matching managed care plan, they can receive integrated member materials, such as one integrated member ID card. Current members enrolled in Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) will be transitioned to the new Anthem MediBlue Full Dual Advantage (HMO D‑SNP) in 2023. The goal is to improve care coordination and person-centered care for beneficiaries who are eligible for both Medicare and Medi-Cal.

Anthem has pursued best efforts to keep all members with their current PCP with both plans. Anthem anticipates the provider networks will be the same or better in these plans for our members. Anthem strives to offer members a full comprehensive network to meet all their healthcare needs. Participating providers in the plans will receive a notification with additional information. If you have any questions about the plans, please contact us. Additional details regarding the plans can be found on our provider website at https://www.anthem.com/ca/medicareprovider.

Why is this important?

Each year, a random sample of enrolled members receive a CAHPS* Survey or a Qualified Health Plan Enrollee Survey asking them to evaluate their experiences with healthcare. The surveys ask members to rate their experiences with:

1. Their health plan.
2. Their personal provider.
3. Their specialist.

Several responses are combined and evaluated for the following:

• Getting needed care
• Receiving care quickly
• Communicating with providers
• Sharing in the decision-making process

The responses give us an idea of how your patients and our members perceive us and provide opportunities for us to improve the way we deliver services. Our engagement and interaction with patients and members are critical. Together, we can provide positive experiences for our shared members and patients.

Members receive the survey either by mail or phone between February and May. Some of the questions they are asked include:

• In the last six¹ months, how often did your personal provider explain things in a way that was easy to understand?
• In the last six¹ months, how often did your personal provider listen carefully to you?
• In the last six¹ months, how often did your personal provider show respect for what you had to say?
• In the last six¹ months, how often did your personal provider spend enough time with you?
• Using any number from zero to 10, where zero is the worst personal provider possible, and 10 is the best personal provider possible, what number would you use to rate your personal doctor?
• We want to know your rating of the specialist you saw most often in the last six¹  Using any number from zero to 10, where zero is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate the specialist?

Every interaction with a patient is an opportunity to make their healthcare experience positive.

We thank you for striving to provide quality care for our members and for the continued focus on improving our member experience.

Additional information

Continuing medical education (CME) education opportunities: http://www.mydiversepatients.com.

¹The commercial survey asks the same questions, but for the last 12 months vs. 6 months and language on the Medicaid Child Survey is slightly different to reflect asking a parent/guardian about their child’s experience.

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

• Prior authorization requirement changes
• New specialty pharmacy medical step therapy requirement
• Anthem Blue Cross expands specialty pharmacy precertification list

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

• Prior authorization requirement changes
• New specialty pharmacy medical step therapy requirements
• Anthem Blue Cross expands specialty pharmacy precertification list