As we communicated in October, November, and December 2023, Availity Essentials Provider Data Management (PDM) and Symphony file-based data exchange are now the only two options for care providers to submit demographic change requests, including submitting roster uploads. Availity Essentials PDM and Symphony will replace all previous intake channels for demographic change requests and roster submissions as of January 1, 2024.

While there are two options available, providers only need to use one or the other. The Availity Essentials PDM application option is available at no cost to providers, and the Symphony option is a premium service available for an additional cost if providers choose to sign up for it. 

Providers should continue to use the Provider Enrollment application in Availity Essentials to submit requests to add new practitioners under existing groups that require credentialing. 

Training is available

Availity Essentials PDM application specific training:

• An Availity Essentials account is required for accessing these training options. If not registered yet, see information below for registration details. Note: You must log in to Availity Essentials first. Then, select the link:
• Learn about and attend one of our live webinars here.
• View the Availity Essentials PDM quick start guide here.

Roster Automation Template and Rules of Engagement specific training:

• If you missed one of our trainings throughout November and December 2023, register and listen to a recording here.

Option one: Availity Essentials PDM application via Availity Essentials (available at no cost to care providers)

The Availity Essentials PDM application allows you the flexibility to request data updates via either one of the following options within Availity Essentials PDM:

• Multi-payer platform option: Allows providers to make updates once and have that information sent to all participating health plans, submitting each change separately
• Roster upload option: Allows providers to submit multiple updates within one spreadsheet via the Upload Rosters feature:
• The Upload Roster feature is currently only available and shared with, Anthem Blue Cross.

Benefits to our care providers using Availity Essentials PDM

The benefits of the Availity Essentials PDM application include the following:

• Ability to attest and manage current provider demographic information
• Provides consistently updated data
• Decreased turnaround time for updates
• Compliance with federal and/or state mandates
• Improved data quality through standardization
• Increased provider directory accuracy

Option two: Symphony file-based data exchange (premium service available to care providers for a fee)

As we communicated in February, Anthem is participating with Symphony, California’s centralized platform for provider directory data, led by the nonprofit organization, Integrated Healthcare Association. Providers can choose to work directly with Symphony for file-based data exchange and for multi-plan data submission, attestation, and reporting. Symphony benefits medical groups by reducing administrative burden, improving data quality, and supporting compliance. Contact the Symphony team here if you are interested in learning more.

Benefits to our care providers using Symphony:

• Submit and attest to data for many health plans at one time with 17 health plans currently participating.
• Improve data quality through standardization and reports that highlight data discrepancies.
• Comply with federal and/or state mandates as well as with health plan requirements.
• Partner with Symphony Client Success team members who advocate for each Symphony participant’s unique needs.

Want to submit a roster using Availity Essentials PDM?

Now you can. Roster Automation is the new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation today:

1. Use the Roster Automation Standard Template:
   • For your convenience, there is a standard roster Excel document. Find it online here.
2. Follow the Roster Automation Rules of Engagement:
   • This reference document is available to ensure error-free submissions, driving accurate and more timely updates through automation. Find it online here.
   • More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide).
3. Upload your completed roster via the Availity Essentials PDM application.

How to access the Availity Essentials PDM application

Log on to Availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts.

Availity administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by your Availity administrator. To find your Availity administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by logging into Availity.com and selecting the Register icon at the top of the home screen, or you can use this link to access the registration page. If you have more than one TIN, please ensure you have registered all TINs associated with your account.

If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY (800-282-4548).

Exclusions

Behavioral health providers assigned to Carelon Behavioral Health of California, Inc. will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health of California.

We are focused on reducing administrative burdens, so you can do what you do best – care for our members.

Now accepting Medicaid and Medicare member claims

As a care provider taking advantage of digital requests for additional information (Digital RFAI), you know it is the most efficient way to send the required documentation to process your Commercial member claims. As of mid-November, you also can receive Digital RFAI notifications for your Medicaid and Medicare member claims.

The process will not change for Medicaid and Medicare member claims. You will still follow the same fast and easy process for our Medicaid and Medicare member claims as you do for your commercial member claims. The only change is that your Medicaid and Medicare member claims will not pend. Medicaid and Medicare member claims will deny when additional documentation is needed to process the claim.

Notifications will remain on your dashboard for up to 30 days as they do today. Submit the documentation at your convenience (most care providers submit documents within seven to 14 days).

Your notifications will continue to arrive on your dashboard each morning, making it convenient to plan your work; no need to check your dashboard throughout the day.

Learn more!

In collaboration with Availity, we’ve developed training for your organization’s administrators about how to update the Medical Attachment registration:

Availity administrators can use this link to register for live training or to view the training on demand.

For associates who are responsible for sending attachments, we’ve developed an enhanced training session that walks through the Attachments Dashboard and many of the unique features that make it most efficient:

Availity users with the Medical Attachments and Claims Status role assignment can use this link to register for live training, or to view the live training on-demand.

Contact Availity Customer Support at availity.com/Contact-Us or your provider relationship representative if you have any questions.

Not a Digital RFAI care provider?

If you’re not already using the Digital RFAI process and want to take advantage of faster claims processing, participation is easy.

We are committed to finding solutions that help our care provider partners offer quality services to our members.

As communicated in the November 2023, provider newsletter, effective April 1, 2024, Carelon Medical Benefits Management, Inc., a specialty health benefits company, will expand multiple Carelon Medical Benefits Management programs to perform medical necessity reviews for additional procedures for Anthem Blue Cross members, as further outlined below. Carelon Medical Benefits Management works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management Expanded Cardiology, Genetic Testing, Radiology, Musculoskeletal, Surgical, and Radiation Therapy programs.

Refer to attachment to view full details

Summary: On May 19, 2023, August 18, 2023, and August 30, 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 August 18, 2023, and August 30, 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.

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.

The Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines below have been updated.

Effective for dates of service on and after November 5, 2023, the following updates apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for medical necessity review for Anthem Blue Cross:

• Musculoskeletal Guidelines:
  • Joint Surgery
  • Small Joint Surgery
  • MSK Level of care

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. If you have questions about this communication or need assistance with any other item, call one of our Medi-Cal Customer Care Centers at 800-407-4627 (outside L.A. County) or 888-285-7801 (inside L.A. County).

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

Effective for dates of service on and after April 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.

As a reminder, ordering and servicing care providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

• Access the Carelon Medical Benefits Management ProviderPortal_SM directly at providerportal.com:
1. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access Carelon Medical Benefits Management via Availity Essentials at Availity.com

For questions related to guidelines, please contact via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

After-hours physician exchanges (answering service)

The after-hours survey for Anthem Blue Cross (Anthem) commenced in October 2023. A common barrier to survey compliance is that providers’ after-hours physician exchanges (answering service) are instructed not to participate in after-hours surveys, leading to a non-compliant survey result.

Providers must instruct their after-hours answering service to answer Anthem’s after-hours survey questions.

Non-compliant providers are subject to contractual enforcement actions, such as corrective action plans (CAP) or escalated contractual sanctions for breach of contract.

After-hours calls:

• The answering service or after-hours personnel must ask the member if the call is an emergency. In the event of an emergency, the member must be immediately directed to dial 911 or to proceed directly to the nearest hospital emergency room.
• If staff or answering service is not immediately available, an answering machine may be used. The answering machine message must instruct members with emergency healthcare needs to dial 911 or go directly to the nearest hospital emergency room. The message must also give members an alternative contact number so they can reach the primary care physician (PCP) or on-call provider with medical concerns or questions.
• In an urgent but not emergency situation, where the member requests to speak with an on-call provider, the provider must return the member’s call within 30 minutes.
• In a nonemergency situation, members should receive instruction on how to contact the on-call provider. If an answering service is used, the service should know where to contact a telephone interpreter.
• Non-English-speaking members who call their PCP after hours should expect to get language-appropriate messages. In the event of an emergency, these messages should direct the member to dial 911 or proceed directly to the nearest hospital emergency room.

Long wait times

Wait times:

• When a provider's office receives a call from an Anthem member during regular business hours as well as after hours for assistance and possible triage, the provider or another healthcare professional must either take the call or call the member back within 30 minutes of the initial call.
• When an Anthem member arrives on time to an appointment, the member should be seen within 15 minutes of the scheduled appointment.
• When Anthem members and/or prospective members call a physician’s office, they should not be placed on hold for longer than 10 minutes.

Schedule of timely access surveys

Provider Appointment Availability Survey (PAAS):

• Survey subject(s): appointment availability
• Contractor conducting survey: Sutherland
• Schedule: July 2023 through November 2023

After Hours and Appointment Availability Survey:

• Survey subject(s): emergency and urgent after-hours calls
• Contractor conducting survey: SPH Analytics
• Schedule: October 2023 through November 2023

Primary Care and Specialty Care Appointment Availability Survey:

• Survey subject(s): appointment availability, interpretation services
• Schedule:
  • Q1: January to March
  • Q2: April to June
  • Q3: July to September
  • Q4: October to December

Non-compliant providers are subject to contractual enforcement actions, such as CAP or escalated contractual sanctions for breach of contract.

Effective April 1, 2024, prior authorization (PA) requirements will change for the following code. The medical code listed below will require PA by Anthem Blue Cross for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code:

To request PA, you may use one of the following methods:

• Web: Once logged in to Availity at Availity.com.
• Fax: 800-754-4708
• Phone:
  • Medi-Cal Managed Care: 888-831-2246
  • MRMIP: 877-273-4193

Not all PA requirements are listed here. Detailed PA requirements are available to providers on providers.anthem.com/ca on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at one of the following numbers for assistance with PA requirements:

• 800-407-4627 outside of Los Angeles County
• 888-285-7801 within Los Angeles County

Effective April 1, 2024, prior authorization (PA) requirements will change for the following code. The medical code listed below will require PA by Anthem Blue Cross for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

To request PA, you may use one of the following methods:

• Web: Availity Essentials platform at Availity.com.
• Fax: 800-754-4708
• Phone: Medi-Cal: 888-831-2246
              MRMIP: 877-273-4193

Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://providers.anthem.com/ca on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call one of the following numbers for Provider Services for assistance with PA requirements:

• Outside of Los Angeles County: 800-407-4627
• Within Los Angeles County: 888-285-7801

As a reminder, based on our October 1, 2023, provider notice, effective with dates of service on or after January 1, 2024, Anthem Blue Cross will implement the following updates:

New reimbursement policy: Bundled Services and Supplies — Facility

Anthem will implement a new facility reimbursement policy titled Bundled Supplies and Services — Facility. This policy identifies certain services and/or supplies ineligible for separate reimbursement when reported by a facility. These identified services and/or supplies are an integral component to the overall procedure.

The Related Coding section of the policy lists and describes the CPT® and HCPCS Level II codes that are considered always bundled and not eligible for reimbursement when they are reported as a stand-alone service or with another service. No modifiers will override the denial for the always bundled services and/or supplies.

Reimbursement policy update: Treatment Rooms — Facility

Anthem will expand the current policy to include two additional revenue codes (760 and 769) and add HCPCS code G0463 to the Related Coding section. The code description for G0463 is hospital outpatient clinic visits or assessment and management of a patient. G0463 is not eligible for reimbursement when reported with revenue code 760, 761, or 769.

Reimbursement policy update: Place of Service and Evaluation and Management —Facility

Anthem will update the policy language to indicate the following:

• The title of the policy will be renamed place of service — facility.
• Professional services billed under revenue codes 960 to 989 are non-reimbursable when submitted on a UB-04.
• Preventive counseling CPT codes 99401 to 99404, 99411, and 99412 are non-reimbursable when billed in an outpatient setting.

As a reminder, evaluation and management (E/M) services and professional services (excluding E/M services rendered in the emergency room and billed with ER revenue codes) must be billed on a
CMS-1500 form.

To view the reimbursement policies, log in to Availity.com, select Anthem in the Payer Spaces menu, then select Information Center. Select Administrative Support, then select the Reimbursement Policies — Facility and Professional link. Reimbursement policies are listed in alphabetical order.

If you are not registered for Availity, go to Availity.com and go to the upper right-hand corner to complete the registration process.

To view the reimbursement policies, log in to anthem.com/ca. Go to For Providers > Policies, Guidelines & Manuals. Scroll down to Reimbursement Policies and select Access Policies. Policies are listed in alphabetical order.

In addition, several facility edits will be implemented with effective dates of service on or after January 1, 2024, to ensure that correct coding guidelines are being followed when submitting UB-04 claim forms. These edits are essential for ensuring accurate and efficient billing processes to support member benefits, data collection, and correct payment in accordance with provider contracts.

The edits that will be implemented are as follows:

1. Revenue codes that are required by National Uniform Billing Committee (NUBC) guidelines to be submitted with a CPT or HCPCS code will be denied if the appropriate CPT/HCPCS is not submitted. Please ensure that facility claims are submitted in accordance with Anthem’s outpatient facility revenue code billing requirements — facility policy.
2. Revenue codes that are submitted with an inappropriately cross-walked CPT or HCPCS code according to NUBC guidelines will be denied.
3. Claims submitted with units above the medically unlikely units according to the National Correct Coding Initiative (NCCI) medically unlikely edits (MUE) may be denied as these edits are being adopted as a correct coding best practice by Anthem.
4. Edits supporting the policies outlined in this article.

These edits aim to streamline billing procedures, enhance data accuracy, and align with the evolving healthcare landscape. It is essential that all healthcare facilities and on campus providers comply with these requirements to avoid any disruptions or delays in reimbursement processes.

To assist you in understanding and implementing these changes effectively, we have compiled the following resources and policies for reference:

1. NUBC guidelines: NUBC.org
2. CMS NCCI FAQ Library: cms.gov/ncci-medicare/medicare-ncci-faq-library
3. For the below policies, you can easily access these policies on Anthem’s website by selecting Policies, Guidelines & Manuals from the menu and scrolling down to reimbursement policies. You can also go to anthem.com/provider/policies/reimbursement:

       a. Outpatient Facility Revenue Code Billing Requirements — Facility, Policy ID C-18003

       b. Place of Service — Facility, Policy ID C-15004

       c. Bundled Services and Supplies — Facility, Policy ID C-23001

       d. Clinic Charges — Facility, Policy ID C-14002

       e. Treatment Rooms with Office Evaluation and Management Services, Policy ID C-20005

We strongly encourage all healthcare providers to review the NUBC guidelines and CMS National Correct Coding Initiative MUEs, as well as the policies listed above. It is essential that your billing department or team implement these guidelines promptly to ensure compliance and minimize any potential revenue disruptions.

Welcome to our monthly provider newsletter: stay informed

We are thrilled to include our dental providers in our monthly provider newsletter. In these monthly publications, we will communicate important updates, informative educational articles, and more.

New articles are published on the first business day of each month, so be sure to bookmark this location and visit this page regularly for updates. Our dedicated team is committed to making important information easy for you to find, so that you can continue providing excellent care to your patients.

Consolidated Appropriations Act provider directory federal mandate – provider directories effective January 1, 2022

As required by the Consolidated Appropriations Act (CAA) and several state laws, we must ensure our provider directories are accurate. Your patients, our members, need the most up-to-date information to reach you. Please keep us informed of any changes impacting you or your office, especially those changes impacting the directory.

We will reach out to our contracted providers as required by Federal and State laws to verify contact information. As a contracted provider, you must respond to the notification by providing updated contact information.

We appreciate your due diligence in keeping us informed of any changes impacting you or your office. Working together, we ensure your patients, our members, can reach you quickly while we meet our compliance obligations.