I am pleased to announce that our shareholders voted to approve our parent company's name change from Anthem, Inc. to Elevance Health, Inc. (NYSE Ticker Symbol — ELV) effective June 28, 2022.

 

Here is what you can expect:

A bold new vision for the future of health

We chose the name Elevance Health to better reflect our business as we elevate the importance of whole health and advance health beyond healthcare for consumers, their families, and our shared communities. This new vision fuels our transformation from a traditional health benefits organization to a health company that looks beyond the traditional scope of physical health.
 

• No action is needed by you, and we remain committed to helping you deliver whole-person care for your patients, our customers. Importantly, there is no impact or changes to your contract, reimbursement, or level of support. For your patients, it will not change their plan or coverage or change how they receive their medications. Provider networks will not be changing. 

A more holistic approach to health that improves affordability and outcomes
Bringing together a broad portfolio of health plans, including pharmacy, behavioral, clinical, and complex care provider partners, we can deliver integrated, holistic health solutions to meet the increasing needs of our customers and care provider partners. This includes two notable changes:

• Our healthcare service partners will operate under a new brand called Carelon. This includes Beacon Health Options, AIM Specialty Health_®, CareMore, and IngenioRx. You can find us at Carelon.com.
• IngenioRx, our pharmacy benefit management partner, will become CarelonRx on
  January 1, 2023. This name change will not impact your patient’s benefits, coverage, or how their medications are filled. We will communicate detailed information about this change soon.

A simpler brand portfolio that makes it easier to do business with us

We have streamlined and simplified the complexity of our health plan and service businesses and reduced the number of brands we have in the market, so our partners and customers clearly understand where we serve, who we serve, and what our brands do.

 

What does this mean for care providers?

We will operate as Anthem Blue Cross or Anthem Blue Cross and Blue Shield in our 14 Blue-licensed markets. Our existing Anthem-branded health plans are not changing and will continue to operate in their current states. There will be no impact to plans, coverage, or level of support.

 

Looking forward together

As your partner, we will continue to keep you updated with new information as soon as it becomes available. In the meantime, you can visit us at ElevanceHealth.com or contact your provider representative with any questions.

 

Thank you for joining us on this exciting path forward as we reimagine what is possible for every moment of health.

 

Sincerely,

Bryony Winn

President, Health Solutions

CABC-CDCRMMPCM-001852-22-CPN1793

Current provider directory information helps Anthem Blue Cross members find the most up-to-date information available. As a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.

If changes are needed, please take the time to update your information by submitting updates and corrections to us on our online Provider Maintenance Form. Online update options include:

• Adding/changing 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 Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.

 

The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Thank you for doing your part in keeping our provider directories current.

CABC-COMM-001911-22

Anthem Blue Cross (Anthem) participating providers are required to acknowledge (annually) that member grievance and appeals forms, a description of grievance procedures, and assistance in filing grievances are readily available at each contracted provider location.

 

To complete this year’s required attestation, due by July 17, 2022, please follow the steps below. The process takes approximately five minutes.
 

1. Select the survey questionnaire and attestation.
2. Answer the questions and provide the information
3. Complete the attestation and submit.

 

All pertinent information related to this requirement, including access to forms (in multiple languages) and procedures, is located at anthem.com/ca/forms.

1. Go to View by Topic and select the drop-down menu.
2. Select Grievance & Appeals.
3. Select the desired resource link.

We appreciate your cooperation and support. For additional information regarding member grievance and appeals requirements, please see below.

 

The Department of Managed Health Care’s (DMHC) routine medical survey includes evaluation of a health plan’s compliance with California Health and Safety Code section 1368(a)(2); 28 CCR 1300.68(b)(6) and (7). These regulations require health plans to ensure that grievance forms, a description of grievance procedures, and assistance in filing grievances are readily available at each contracting provider’s office, contracting facility, or plan facility.

 

Please review and distribute the Anthem grievance form to all your participating offices. It is important to implement processes to provide grievance forms and assistance to Anthem members promptly upon request.

 

Your agreement with Anthem requires you to comply with all applicable laws and regulations and to cooperate with Anthem’s administration of its grievance program which includes annually attesting that member grievance and appeals forms, a description of grievance procedures, and assistance in filing grievances are readily available at each contracting provider’s office, contracting facility, or plan facility.

 

Information can be accessed on the process of submitting member grievances and appeals, grievance forms in multiple languages, and definitions and appeal rights at anthem.com/ca/forms and within the Anthem Blue Cross Provider Manual.

CABC-COMM-000360-22

As an Anthem Blue Cross (Anthem) participating provider, you may have received our prior correspondence, or read the articles in our provider newsletter, Provider News on Anthem Cost Transparency. Transparency tools such as Anthem’s Find Care tool and others are available to members on anthem.com and allow members to estimate their out-of-pocket impact and view the estimated costs for many procedures.

 

In our prior correspondence, we also enclosed a summary of the methodology used to generate the cost information housed in the National Consumer Cost Tool (NCCT), the source data used to display costs in Find Care. The treatment categories for which costs are displayed and the methodology are defined by the Blue Cross Blue Shield Association. As indicated in the correspondence, BCBS Axis (formerly NCCT) cost data is updated twice annually; the most recent update completed in May 2022, and the next update scheduled for November 2022. Please look for more information in our provider newsletters posted to anthem.com/ca.

 

As a reminder, Anthem provider costs are now available in a secure section of the Availity Provider Portal.* Authorized representatives of participating facilities and professional practices can log in to Availity at www.availity.com and register to view the costs for their facility or practice. Costs will be made available to our participating providers no less than 30 days before they become available to our members on anthem.com/ca in the transparency tools such as Anthem Care Comparison.

Should you wish to review the methodology, you may request a copy by sending an email request to your Anthem contract support manager.

 

Should you desire to provide an internet website link on Anthem’s website where this cost information will be displayed, which provides a response to the cost information being displayed, please provide us this link within 30 days of receiving the cost information from us.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross.

CABC-COMM-000336-22

Anthem Blue Cross (Anthem) is committed to improving quality while managing health care costs. One way we achieve this goal is through provider transparency initiatives. This means that Anthem gives certain providers quality, utilization, and cost data about the healthcare providers to whom they may be referring their patients under these programs. The providers who receive this information are enrolled in our Value Based Programs, such as the Enhanced Personal Health Care program or Bundled Payment Program. These providers are known as Value Based Program Providers or Payment Innovation Providers.

 

If a provider is higher quality and/or lower cost, a component of our programs is that they may receive more referrals from Value Based Program Providers. The converse should be true if providers are lower quality and/or higher cost.

 

Anthem provides this data, including comparative cost information, to Value Based Program Providers to help them make more informed decisions about managing health care costs and maintaining and improving quality of care. The data also helps providers succeed under the terms of the Programs.

 

Employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Value Based Program Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This gives them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Anthem will share the data on which it relied in making these quality/cost/utilization evaluations upon request and will discuss it with Referral Providers — including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant.

 

CABC-COMM-000433-22

In a recent study published by Pediatrics, economic hardship, school closing, and shutdowns led to sedentary lifestyles and increases in childhood obesity. The research analyzed doctor visits pre-pandemic then during the pandemic period, and the increases were dramatic. Overall obesity increased from 13.7% to 15.4% in patients 5 to 9 years. Increases from 1% in children aged 13 to 17 to 2.6% for those aged 5 to 9 years were observed.

 

The study recommended new approaches to Weight Assessment and Counseling. These include recommending virtual activities that promote increased physical activity. Focusing on ways to remain safe and active with outside activities, such as park visits, walks, and bike riding were also suggested.

 

The Centers for Disease Control and Prevention has a great resource called Ways to Promote Health with Preschoolers. This fun flyer shows how we can all work together to support a healthy lifestyle. You can download a copy here.

The HEDIS^® measure Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) requires a nutritional evaluation and pro-active guidance as part of a routine health visit:

• When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.
• When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.
• Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.

HEDIS^® measure WCC looks at the percentage of members, 3 to 17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:

• Body mass index (BMI) percentile (percentage, not value).
• Counseling for nutrition.
• Counseling for physical activity.

 

Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.

 

Code services correctly to measure success.

 

These diagnosis and procedure codes are used to document BMI percentile, weight assessment, and counseling for nutrition and physical activity:

Description	CPT®	ICD-10-CM	HCPCS
BMI percentile		Z68.51-Z68.54
Counseling for nutrition	97802, 97803, 97804	Z71.3	G0270, G0271, G0447, S9449, S9452, S9470
Counseling for physical activity		Z02.5, Z71.82	G0447, S9451
Codes to identify outpatient visits: CPT — 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456, 99483 HCPCS — G0402, G0438, G0439, G0463, T1015

 

American Academy of Pediatrics. American Academy of Pediatrics raises concern about children’s nutrition and physical activity during pandemic. Available at: http://services.aap.org/en/news-room/news-releases/aap/2020/american-academy-of-pediatrics-raises-concern-about-childrens-nutrition-and-physical-activity-during-pandemic/. Accessed December 10, 2020.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CABC-CM-002324-22-CPN1916

3072F: new language about two-year compliance

The Comprehensive Diabetes Care HEDIS^® measure Retinal Eye Exam (DRE) valuates the percent of adult members ages 18 to 75, with diabetes (type 1 and type 2), who had a retinal eye exam during the measurement year.

 

Changes to 3072F

The definition for the code 3072F (negative for retinopathy) has been redefined to low risk for retinopathy (no evidence of retinopathy in the prior year). This can be particularly confusing because it would not be used at the time of the exam. It would be used the following year, along with the exam coding for the current year, to indicate that retinopathy was not present the previous year.

 

A simpler coding solution

Using these three codes count toward the DRE measurement if they are billed in the current measurement year or the prior year. This means you can submit the appropriate code at the time of the exam, and it covers both years:

2023F	Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)
2025F	7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed: without evidence of retinopathy (DM)
2033F	Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed: without evidence of retinopathy (DM)

For more about diabetic retinopathy, visit CMS.gov or use this link to read more. 

 

Meeting the measurement for all diabetes care

These exams are also important in evaluating the overall health of diabetic patients, as well as meeting the Comprehensive Diabetes Care HEDIS measure:

• Hemoglobin A1c (HbA1c) testing

• HbA1c poor control (> 9.0%)
• HbA1c control (< 8.0%)
• Retinal Eye exam performed
• Blood Pressure control (< 140/90 mm Hg)

 

Record your efforts in the member’s medical records for the HbA1c tests and results, retinal eye exam, blood pressure, urine creatinine test, and the estimated glomerular filtration rate test. Meeting the mark and closing gaps in care is key to good health outcomes.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CABC-COMM-002329-22-CPN1921

This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).

In an effort to deliver on Anthem’s purpose to improve the health of humanity, we now have a program for in-home patient care for acute conditions.

 

Anthem’s Hospital in Home program can advise capable, innovative hospital partners in developing their own hospital in home programs. Once implemented, patients can recover in a more comfortable environment, allowing hospitals to keep beds available for patients with more complex needs.

 

Inpatient level of care in the home can be a welcome alternative to traditional hospital settings. Patients may find acute care at home to be more convenient and less stressful, and studies have shown acute care at home can be safe and allow for smoother transition to self-care management after the acute illness. Hospital in Home clinical trials demonstrate a 25% decrease in readmissions and a 50% reduction in time spent in bed.¹

 

Anthem’s Hospital in Home program has a set of minimum requirements that are designed to promote patient safety. These requirements include aspects of the member’s home environment, the clinical scenario, remote monitoring capabilities, and plans for program evaluation.

 

Please contact your Anthem contracting representative to learn more about Anthem’s Hospital in Home program.

 

 

1  Levine, D. M., Ouchi, K., Blanchfield, B., Saenz, A., Burke, K., Paz, M., Diamond, K., Pu, C. T., & Schnipper, J. L. (2020). Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Annals of internal medicine, 172(2), 77–85. https://doi.org/10.7326/M19-0600.

CABC-CRCM-00181-22-CPN-1554

Effective August 1, 2022, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by Anthem Blue Cross. Federal and state law, as well as state contract language, and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

• 81432: Hereditary breast cancer-related disorders (such as hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, and MLH1
• L6026: Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes, and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device
• L6715: Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement

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

• Availity: * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then select Authorizations or Auth/Referral Inquiry, as appropriate.
• Fax: 800-754-4708
• Medi-Cal Phone: 888-861-2246
• MCAP/MRMIP Phone: 877-273-4193

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://providers.anthem.com/ca. Contracted and noncontracted providers who are unable to access Availity may call one of our Customer Care Centers at one the following numbers for assistance with PA requirements:

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

 

Email is the quickest and most direct way to receive important information from Anthem Blue Cross.

To start receiving email from us (including some sent in lieu of fax or mail), submit your information via our online form (https://bit.ly/3lLgko8).

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross.

ACA-NU-0434-22

Effective September 1, 2022, we will upgrade to the 26th edition of MCG care guidelines for the following modules: Inpatient/surgical care (ISC). The below tables highlight new guidelines and changes.

 

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

 

Goal length of stay (GLOS) for ISC

Guideline	MCG code	25th edition GLOS	26th edition GLOS
*Aortic Valve Replacement, Transcatheter	S-1320 [W0133]	2 days postoperative	1 day postoperative
*Apnea, Neonatal (Non-Preterm Infants)	P-15	3 days	2 days
*Renal Failure, Chronic	M-325	3 days	2 days
*Subarachnoid Hemorrhage, Nonsurgical Treatment	M-79	4 days	3 days
*Craniotomy, Supratentorial	S-410	3 days postoperative	2 days postoperative
*Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF)	S-100	Ambulatory or 1 day postoperative	Ambulatory
*Hip Arthroplasty	S-560 [W0105]	Ambulatory or 2 days postoperative	Ambulatory or 1 day postoperative
*Humerus Fracture, Closed or Open Reduction	S-632	Ambulatory or 1 day postoperative	Ambulatory
*Knee Arthroplasty, Total	S-700 [W0081]	Ambulatory or 2 days postoperative	Ambulatory or 1 day postoperative
*Lumbar Laminectomy	S-830 [W0100]	Ambulatory or 1 day postoperative	Ambulatory
*Nephrectomy	S-870	3 days postoperative	2 days postoperative
*Prostatectomy, Radical	S-960	1 day postoperative	Ambulatory or 1 day postoperative
Dehydration	M-123	1 day	2 days
Esophageal Disease	M-550	1 day	2 days
Gastritis and Duodenitis	M-560	1 day	2 days
Pneumothorax, Neonatal	P-355	2 days	3 days
Seizure	M-327	1 day	2 days
Back Pain	M-63	1 day	2 days

New Guidelines ISC

Body system	Guideline title	MCG code
Hospital-at-Home	Cellulitis: Hospital-at-Home	M-70-HaH
Hospital-at-Home	Chronic Obstructive Pulmonary Disease: Hospital-at-Home	M-100-HaH
Hospital-at-Home	Heart Failure: Hospital-at-Home	M-190-HaH
Hospital-at-Home	Pneumonia: Hospital-at-Home	M-282-HaH
Hospital-at-Home	Urinary Tract Infection (UTI): Hospital-at-Home	M-300-HaH
Observation Care	Pancreatitis: Observation Care	OC-065
Observation Care	Renal Failure, Acute: Observation Care	OC-066
Observation Care	Stroke: Ischemic: Observation Care	OC-067

Anthem Blue Cross customizations to MCG care guidelines 26th edition

To view a detailed summary of customizations, go to https://www.anthem.com/ca/provider/policies/clinical-guidelines, scroll down to Other Criteria, and select Customizations to MCG Care Guidelines 26^th Edition.

 

Email is the quickest and most direct way to receive important information from Anthem Blue Cross. To start receiving email from us (including some sent in lieu of fax or mail), submit your information via our online form (https://bit.ly/3lLgko8).

ACA-NU-0435-22

This communication applies to the Medicaid, and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

 

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

 

Please share this notice with other members of your practice and office staff.

To view a guideline, visit
https://www.anthem.com/ca/provider/policies/clinical-guidelines/search.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• *CG-LAB-20 — Thyroid Testing:
• Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing.
• *CG-LAB-21 — Serum Iron Testing:
• Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing.
• *LAB.00043 — Immune Biomarker Tests for Cancer:
• Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications.
• *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
• Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications.
• *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
• The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
• Endometrial receptivity analysis
• Sperm-capacitation test
• Sperm deoxyribonucleic acid (DNA) fragmentation test
• Sperm penetration assay
• Uterine natural killer (uNK) cells test
• *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
• Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease.
• Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary.
• Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.
• *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
• Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications.
• *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
• Revised Position Statement to include the prevention of lymphedema.
• *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
• The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications.
• *TRANS.00038 — Thymus Tissue Transplantation:
• Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue.

 

Effective August 10, 2022, Anthem will begin using the AIM Specialty Health^®1 Clinical Appropriateness Guidelines for medical necessity review of the below services. Please note, the Anthem Utilization Management team will complete these reviews using the AIM Clinical Appropriateness Guidelines:

• Musculoskeletal guidelines:
• Spine surgery
• Joint surgery
• Small joint surgery
• Sacroiliac joint fusion
• Radiology guidelines:
• Spine imaging
• Extremity imaging
• Vascular imaging
• Sleep disorder management guideline
• Rehabilitative services:
• Occupational therapy
• Physical therapy
• Speech therapy

 

Medical Policies

On February 17, 2022, the Medical Policy, and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These guidelines take effect August 10, 2022.

Publish date	Medical Policy number	Medical Policy title	New or revised
04/13/2022	*LAB.00043	Immune Biomarker Tests for Cancer	New
04/13/2022	*LAB.00044	Saliva-based Testing to Determine Drug-Metabolizer Status	New
04/13/2022	*LAB.00045	Selected Tests for the Evaluation and Management of Infertility	New
04/13/2022	*LAB.00046	Testing for Biochemical Markers for Alzheimer’s Disease	New
04/13/2022	*RAD.00067	Quantitative Ultrasound for Tissue Characterization	New
04/13/2022	*SURG.00160	Implanted Port Delivery Systems to Treat Ocular Disease	New
03/25/2022	*TRANS.00038	Thymus Tissue Transplantation	New
04/13/2022	GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	Revised
04/1/2022	SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
02/24/2022	SURG.00036	Fetal Surgery for Prenatally Diagnosed Malformations	Revised
04/13/2022	SURG.00096	Surgical and Ablative Treatments for Chronic Headaches	Revised
04/13/2022	*SURG.00154	Microsurgical Procedures for the Prevention or Treatment of Lymphedema	Revised

Clinical UM Guidelines

On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for our members on March 24, 2022. These guidelines take effect August 10, 2022.

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
04/13/2022	*CG-LAB-20	Thyroid Testing	New
04/13/2022	*CG-LAB-21	Serum Iron Testing	New
04/13/2022	CG-ANC-03	Acupuncture	Revised
04/13/2022	CG-GENE-14	Gene Mutation Testing for Cancer Susceptibility and Management	Revised
04/13/2022	CG-MED-73	Hyperbaric Oxygen Therapy (Systemic/Topical)	Revised
04/13/2022	CG-SURG-36	Adenoidectomy	Revised
02/24/2022	CG-SURG-86	Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection	Revised

 

ACA-NU-0440-22

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:

 

• What is an e-Consult?
• Prior authorization updates for medications billed under the medical benefit

Beginning with claims processed on or after August 1, 2022, Anthem Blue Cross will implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service (CPT^® codes 99381 to 99397) is billed with a problem-oriented E/M service (CPT codes 99202 to 99215) and appended with Modifier 25 (for example, CPT code 99393 billed with CPT code 99213 to 99225).

 

According to the American Medical Association (AMA) CPT Guidelines, E/M services must be “significant and separately identifiable” in order to appropriately append Modifier 25. Based upon review of the submitted claim information, if the problem-oriented E/M service is determined not to be a significant, separately identifiable service from the preventive service, the problem-oriented E/M service will be bundled with the preventive service.

 

Providers that believe their medical record documentation supports a significant and separately identifiable E/M service should follow the Claims Payment Dispute process (including submission of such with the dispute) as outlined in the provider manual.

 

If you have questions on this program, contact your contract manager or Provider Experience.

ABCCRNU-0248-22 

This communication applies to the Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

 

Effective September 1, 2022, we will upgrade to the 26th edition of MCG care guidelines for the following modules: Inpatient/surgical care (ISC). The below tables highlight new guidelines and changes.

 

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

 

Goal length of stay (GLOS) for ISC

Guideline	MCG code	25th edition GLOS	26th edition GLOS
*Aortic Valve Replacement, Transcatheter	S-1320 [W0133]	2 days postoperative	1 day postoperative
*Apnea, Neonatal (Non-Preterm Infants)	P-15	3 days	2 days
*Renal Failure, Chronic	M-325	3 days	2 days
*Subarachnoid Hemorrhage, Nonsurgical Treatment	M-79	4 days	3 days
*Craniotomy, Supratentorial	S-410	3 days postoperative	2 days postoperative
*Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF)	S-100	Ambulatory or 1 day postoperative	Ambulatory
*Hip Arthroplasty	S-560 [W0105]	Ambulatory or 2 days postoperative	Ambulatory or 1 day postoperative
*Humerus Fracture, Closed or Open Reduction	S-632	Ambulatory or 1 day postoperative	Ambulatory
*Knee Arthroplasty, Total	S-700 [W0081]	Ambulatory or 2 days postoperative	Ambulatory or 1 day postoperative
*Lumbar Laminectomy	S-830 [W0100]	Ambulatory or 1 day postoperative	Ambulatory
*Nephrectomy	S-870	3 days postoperative	2 days postoperative
*Prostatectomy, Radical	S-960	1 day postoperative	Ambulatory or 1 day postoperative
Dehydration	M-123	1 day	2 days
Esophageal Disease	M-550	1 day	2 days
Gastritis and Duodenitis	M-560	1 day	2 days
Pneumothorax, Neonatal	P-355	2 days	3 days
Seizure	M-327	1 day	2 days
Back Pain	M-63	1 day	2 days

New Guidelines ISC

Body system	Guideline title	MCG code
Hospital-at-Home	Cellulitis: Hospital-at-Home	M-70-HaH
Hospital-at-Home	Chronic Obstructive Pulmonary Disease: Hospital-at-Home	M-100-HaH
Hospital-at-Home	Heart Failure: Hospital-at-Home	M-190-HaH
Hospital-at-Home	Pneumonia: Hospital-at-Home	M-282-HaH
Hospital-at-Home	Urinary Tract Infection (UTI): Hospital-at-Home	M-300-HaH
Observation Care	Pancreatitis: Observation Care	OC-065
Observation Care	Renal Failure, Acute: Observation	OC-066
Observation Care	Stroke: Ischemic: Observation Care	OC-067

Anthem Blue Cross customizations to MCG care guidelines 26th edition

To view a detailed summary of customizations, go to https://www.anthem.com/ca/provider/policies/clinical-guidelines, scroll down to the Other Criteria section, and select Customizations to MCG Care Guidelines 26^th Edition.

 

Customer Care Centers:

• Cal MediConnect Plan: 855-817-5786
• Medicare Advantage: Call the number on the back of the member ID card.

ACAD-NU-0382-22

The Cancer Care Navigator (CCN) program is a comprehensive cancer support solution for oncologists and Anthem Blue Cross (Anthem) members who are at high risk for complications during treatment. This program is aimed at helping to simplify the complexities of cancer care for members.

 

Practices are given a single point of contact to connect the practice to the right people at Anthem to help lessen administrative burdens. CCN also gives the practice access to Anthem’s advanced predictive analytics to help identify patients at high risk for complications, in turn allowing providers the opportunity to take preventive action and guide targeted interventions.

Patients are provided with a wealth of support through supplemental services (dietitians, pharmacists, etc.), medication adherence assistance, individualized care plans, and goal setting, as well as after-hours telephonic and digital support.

CCN is the ultimate support service to improve the care experience and quality of life to allow patients time to focus on overall health and well-being. Please feel free to reach out to the CCN team at 866-649-0669.

CABCCARE-001237-22

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:

 

• New specialty pharmacy medical step therapy requirements

This communication applies to the Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

 

Effective September 1, 2022, we will upgrade to the 26th edition of MCG care guidelines for the following modules: Inpatient/surgical care (ISC). The below tables highlight new guidelines and changes.

 

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

 

Goal length of stay (GLOS) for ISC

Guideline	MCG code	25th edition GLOS	26th edition GLOS
*Aortic Valve Replacement, Transcatheter	S-1320 [W0133]	2 days postoperative	1 day postoperative
*Apnea, Neonatal (Non-Preterm Infants)	P-15	3 days	2 days
*Renal Failure, Chronic	M-325	3 days	2 days
*Subarachnoid Hemorrhage, Nonsurgical Treatment	M-79	4 days	3 days
*Craniotomy, Supratentorial	S-410	3 days postoperative	2 days postoperative
*Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF)	S-100	Ambulatory or 1 day postoperative	Ambulatory
*Hip Arthroplasty	S-560 [W0105]	Ambulatory or 2 days postoperative	Ambulatory or 1 day postoperative
*Humerus Fracture, Closed or Open Reduction	S-632	Ambulatory or 1 day postoperative	Ambulatory
*Knee Arthroplasty, Total	S-700 [W0081]	Ambulatory or 2 days postoperative	Ambulatory or 1 day postoperative
*Lumbar Laminectomy	S-830 [W0100]	Ambulatory or 1 day postoperative	Ambulatory
*Nephrectomy	S-870	3 days postoperative	2 days postoperative
*Prostatectomy, Radical	S-960	1 day postoperative	Ambulatory or 1 day postoperative
Dehydration	M-123	1 day	2 days
Esophageal Disease	M-550	1 day	2 days
Gastritis and Duodenitis	M-560	1 day	2 days
Pneumothorax, Neonatal	P-355	2 days	3 days
Seizure	M-327	1 day	2 days
Back Pain	M-63	1 day	2 days

New Guidelines ISC

Body system	Guideline title	MCG code
Hospital-at-Home	Cellulitis: Hospital-at-Home	M-70-HaH
Hospital-at-Home	Chronic Obstructive Pulmonary Disease: Hospital-at-Home	M-100-HaH
Hospital-at-Home	Heart Failure: Hospital-at-Home	M-190-HaH
Hospital-at-Home	Pneumonia: Hospital-at-Home	M-282-HaH
Hospital-at-Home	Urinary Tract Infection (UTI): Hospital-at-Home	M-300-HaH
Observation Care	Pancreatitis: Observation Care	OC-065
Observation Care	Renal Failure, Acute: Observation Care	OC-066
Observation Care	Stroke: Ischemic: Observation Care	OC-067

 

Anthem Blue Cross customizations to MCG care guidelines 26th edition

To view a detailed summary of customizations, go to https://www.anthem.com/ca/provider/policies/clinical-guidelines, scroll down to the Other Criteria section, and select Customizations to MCG Care Guidelines 26^th Edition.

 

Customer Care Centers:

• Cal MediConnect Plan: 855-817-5786
• Medicare Advantage: Call the number on the back of the member ID card.

 

ACAD-NU-0382-22

 

This communication applies to the Medicaid, and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

 

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

 

Please share this notice with other members of your practice and office staff.

To view a guideline, visit
https://www.anthem.com/ca/provider/policies/clinical-guidelines/search.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• *CG-LAB-20 — Thyroid Testing:
• Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing.
• *CG-LAB-21 — Serum Iron Testing:
• Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing.
• *LAB.00043 — Immune Biomarker Tests for Cancer:
• Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications.
• *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
• Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications.
• *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
• The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
• Endometrial receptivity analysis
• Sperm-capacitation test
• Sperm deoxyribonucleic acid (DNA) fragmentation test
• Sperm penetration assay
• Uterine natural killer (uNK) cells test
• *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
• Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease.
• Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary.
• Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.
• *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
• Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications.
• *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
• Revised Position Statement to include the prevention of lymphedema.
• *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
• The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications.
• *TRANS.00038 — Thymus Tissue Transplantation:
• Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue.

Effective August 10, 2022, Anthem will begin using the AIM Specialty Health^®1 Clinical Appropriateness Guidelines for medical necessity review of the below services. Please note, the Anthem Utilization Management team will complete these reviews using the AIM Clinical Appropriateness Guidelines:

• Musculoskeletal guidelines:
• Spine surgery
• Joint surgery
• Small joint surgery
• Sacroiliac joint fusion
• Radiology guidelines:
• Spine imaging
• Extremity imaging
• Vascular imaging
• Sleep disorder management guideline
• Rehabilitative services:
• Occupational therapy
• Physical therapy
• Speech therapy

 

Medical Policies

On February 17, 2022, the Medical Policy, and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem. These guidelines take effect August 10, 2022.

Publish date	Medical Policy number	Medical Policy title	New or revised
04/13/2022	*LAB.00043	Immune Biomarker Tests for Cancer	New
04/13/2022	*LAB.00044	Saliva-based Testing to Determine Drug-Metabolizer Status	New
04/13/2022	*LAB.00045	Selected Tests for the Evaluation and Management of Infertility	New
04/13/2022	*LAB.00046	Testing for Biochemical Markers for Alzheimer’s Disease	New
04/13/2022	*RAD.00067	Quantitative Ultrasound for Tissue Characterization	New
04/13/2022	*SURG.00160	Implanted Port Delivery Systems to Treat Ocular Disease	New
03/25/2022	*TRANS.00038	Thymus Tissue Transplantation	New
04/13/2022	GENE.00052	Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling	Revised
04/1/2022	SURG.00011	Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting	Revised
02/24/2022	SURG.00036	Fetal Surgery for Prenatally Diagnosed Malformations	Revised
04/13/2022	SURG.00096	Surgical and Ablative Treatments for Chronic Headaches	Revised
04/13/2022	*SURG.00154	Microsurgical Procedures for the Prevention or Treatment of Lymphedema	Revised

 

On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for our members on March 24, 2022. These guidelines take effect August 10, 2022.

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
04/13/2022	*CG-LAB-20	Thyroid Testing	New
04/13/2022	*CG-LAB-21	Serum Iron Testing	New
04/13/2022	CG-ANC-03	Acupuncture	Revised
04/13/2022	CG-GENE-14	Gene Mutation Testing for Cancer Susceptibility and Management	Revised
04/13/2022	CG-MED-73	Hyperbaric Oxygen Therapy (Systemic/Topical)	Revised
04/13/2022	CG-SURG-36	Adenoidectomy	Revised
02/24/2022	CG-SURG-86	Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection	Revised

ACA-NU-0440-22

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:

 

• New specialty pharmacy medical step therapy requirements
• New specialty pharmacy medical step therapy requirements