This quarter, Anthem Blue Cross (Anthem) will release more exciting enhancements to the public provider site. The next wave of changes includes a new Behavioral Health page that will provide easy and clear access to content and resources, including newsletters, collaboration documents, and other relevant information for providers. The image below illustrates the new Behavioral Health page.

We will continue to provide updates as we move forward with migrating content to the new provider pages.

In May 2019, Anthem Blue Cross (Anthem) introduced a new feature on Interactive Care Reviewer (ICR) that lets you request a clinical appeal for denied authorizations.  Now instead of making a phone call or sending a fax you can save time making your request online! This feature is available for authorization requests that were submitted through ICR, phone or fax.                                                                                                                                                

Here’s how easy it is to request a clinical appeal using ICR:

Logon to ICR from the Availity Portal and locate the case from ICR’s dashboard - My Organization Requests or select the Search Submitted Requests tab if you don’t see the request on your dashboard. Locate the case via the Check Case Status tab if the case was submitted by phone or fax.

• Select the Request Tracking ID link to open the case. If the case is eligible for an appeal you will see the Request Appeal menu option on the Case Overview screen.
• Select Request Appeal to open the Appeal Details screen and complete the required fields on the appeal template. (You also have the option of uploading attachments and images to support your request.)
• Select Submit.

Want to check the status of your clinical appeal?

• Select Check Appeal Status from the ICR top menu bar.
• Type the Appeal Case ID and Member ID in the allocated fields (do not include the alpha/numeric prefix).
• Select Submit.

The appeal status and detail of the decision will open on the bottom of the screen.

Additionally, you will be able to access letters associated with the appeal.

Need more information on how to navigate the new ICR Appeals features?

Download the ICR Clinical Appeals Reference Guide located on the Availity Portal. Select: Payer Spaces | Applications | Education and Reference Center | Communication and Education. Find the link to the reference guide below the ICR menu.

Additional Training:

If you are new to ICR or want to get a refresher please attend our monthly ICR webinar.

Register Here for the next webinar.

An immediate authorization decision may be available to you when you use Interactive Care Reviewer (ICR) to initiate a request for precertification of some inpatient and outpatient procedures.  More services have been recently added to the list.

To find out the specific details on those services, go to the Availity Portal and select Payer Spaces and click on the Anthem Blue Cross logo. Scroll down and select Education and Reference Center l Communication & Education. From the Communication & Education drop down menu, select Interactive Care Reviewer l ICR Immediate Decision List.

Attend one of our upcoming webinars and learn about the features that will help you to optimize your ICR experience! Register here.

Continuing our 2019 CRA updates, Anthem Blue Cross (Anthem) requests your assistance with respect to our Commercial Risk Adjustment (CRA) reporting processes.

As a reminder, there are two approaches that we take (Retrospective and Prospective) to improve risk adjustment reporting accuracy.  This month we’d like to focus on the Retrospective approach, and the request to our providers.

Retrospective Program:

• Focus is on medical chart collection
• Medical chart collection will start soon (separated in three different time periods)
  • Period 1 (June 2019)
  • Period 2 (November 2019)
  • Period 3 (January 2020)
• Anthem’s medical chart collection is in compliance with the ACA provision to collect and report diagnosis code data for ACA members

Electronic options for chart collections:

• Remote/Direct Anthem Access
  • The most efficient option is to allow Anthem's medical coder team to have direct connection access to your EMR system for Anthem to retrieve member records. 
• EMR Interoperability. Options are in place for the following EMR systems
  • Allscripts (Opt in-signature required. Need to work directly with the CRA representative for your region)
  • NextGen (Opt out-auto enrolled)
  • Athenahealth (Opt out- auto enrolled)
  • MEDENT (Opt in-signature required. Need to work directly with the CRA representative for your region) 
• Inovalon virtual visit or onsite
  • Inovalon will work directly with your office to utilize electronic connectivity for a virtual visit, or they will have their staff go into the office for medical record retrieval based on a scheduled time that is convenient. 
• Secure FTP

• Set up directly with our vendors as a temporary secure FTP to transfer medical records. 

If you are interested in any of these electronic options, or would like to grant our Anthem medical coders with direct access to your EMR, please contact our CRA Representative: California, Colorado and Nevada -  Socorro.Carrasco@anthem.com

The Interactive Care Reviewer (ICR), our online authorization tool offers a real time authorization decision for some inpatient and outpatient authorization requests.  Recently we updated the list of services that may result in an immediate authorization decision.

To locate the Immediate Decision list* and review the specific details on those services, go to the Availity Portal and select Payer Spaces then choose the Anthem Blue Cross logo. Scroll down and select Education and Reference Center I Communication & Education. From the Communication & Education drop down menu, select Interactive Care Reviewer I ICR Immediate Decesion List.

Access ICR from the Availity Portal, select Patient Management | Authorizations & Referrals. To request an authorization you will need to have the Authorization Referral Request Role assigned to you by your Availity administrator.

Attend one of our upcoming webinars and learn about the features that will help you to optimize your ICR experience! Register here.

*Excludes: some Medicare Advantage, some Medicaid, Federal Employee Program® (FEP), BlueCard® and some National Account members

Requests involving transplant services

Services administered by vendors such as AIM Specialty Health

Services administered by OrthoNet LLC(Indiana ,Kentucky ,Missouri, Ohio, Wisconsin, California, Colorado and Nevada)

For the above requests, follow the same precertification process that you use today.

Continuing our 2019 CRA updates, Anthem Blue Cross (Anthem) requests your assistance with respect to our Commercial Risk Adjustment (CRA) reporting processes.

As a reminder, there are two approaches that we take (Retrospective and Prospective) to improve risk adjustment reporting accuracy.  This month we’d like to focus on the Retrospective approach, and the request to our providers.

Retrospective Program:

• Focus is on medical chart collection
• Medical chart collection will start soon (separated in three different time periods)
  • Period 1 (June 2019)
  • Period 2 (November 2019)
  • Period 3 (January 2020)
• Anthem’s medical chart collection is in compliance with the ACA provision to collect and report diagnosis code data for ACA members

Electronic options for chart collections:

• Remote/Direct Anthem Access
  • The most efficient option is to allow Anthem’s medical coder team to have direct connection access to your EMR system for Anthem to retrieve member records.
• EMR Interoperability. Options are in place for the following EMR systems
  • Allscripts (Opt in –signature required. Need to work directly with the CRA representative for your region)
  • NextGen (Opt out – auto-enrolled)
  • Athenahealth (Opt out – auto enrolled)
  • MEDENT (Opt in – signature required. Need to work directly with the CRA representative for your region)
• Inovalon virtual visit or onsite
  • Inovalon will work directly with your office to utilize electronic connectivity for a virtual visit, or they will have their staff go into the office for medical record retrieval based on a scheduled time that is convenient.
• Secure FTP

• Set up directly with our vendors as a temporary secure FTP to transfer medical records. 

If you are interested in any of these electronic options, or would like to grant our Anthem medical coders with direct access to your EMR, please contact our CRA Representative:

California, Colorado and Nevada -  Socorro.Carrasco@anthem.com

As we prepare for potential regulatory proposed standards for electronic attachments, Anthem Blue Cross (Anthem) will be implementing what is called the X12 275 5010 version of electronic attachments transactions for claims.

Standard electronic attachments will bring value to you by eliminating the need for mailing paper records and reduced processing time overall. 

Anthem and Availity will be piloting Electronic Data Interchange (EDI) batch electronic attachments with previously selected providers.  Both solicited and unsolicited attachments will be included in our pilots.

Solicited Attachment

Provider sends a claim, and the payer determines there is insufficient information to process the claim.  Payer then sends the provider a request for additional information (currently via letter).  Provider can then send the solicited attachment transaction with the documentation requested to process the claim.

Unsolicited Attachment

When the provider knows that the payer requires additional information to process the claim, the provider then sends the X12 837 claim with the “Paper Work Included” (PWK) segment tracking number.  Next, the provider sends the X12 275 attachment transaction with the additional information and includes the tracking number that was sent on the claim for matching purposes.

What you can do now

We encourage you to start having conversations with your Clearinghouse and/or Electronic Healthcare Records (EHR) vendor to determine their ability to set up the X12 275 attachment transaction capabilities. 

Look for more information about the general availability of this time-saving option later this summer and details on how to work with Anthem and Availity to send your attachments via electronic batch.

As a reminder, the Workers’ Compensation Physicians Acknowledgments is required by California Code of Regulations §9767.5.1, “Medical Provider Networks” (MPN). The “MPN applicant shall obtain from each physician participating in the MPN a written acknowledgment in which the physician affirmatively elects to be a member of the MPN.” 

To maintain and affirm your participation in all MPNs that you have been selected for and have subscribed to Anthem’s Provider Affirmation Portal, go to Availity and login. Once in, click on the Payer Spaces drop down menu in the top right hand corner, and select Anthem Blue Cross from the options available to you. On the next page click on “Resources” in the middle of the page and look for “MPN Provider Affirmation Portal.”

Availity>Payer Spaces>Anthem Blue Cross>Resources>MPN Provider Affirmation Portal

If you cannot go online, call Anthem Workers’ Compensation at 1-866-700-2168 and we can take action on your behalf in the Provider Affirmation Portal. Please also keep an eye out for email notifications from “Anthem MPN Admin.”

Please also be advised the Provider Affirmation Portal will also notify participating medical providers when an MPN is terminating its relationship with Anthem and/or the Division of Workers Compensation.

The Department Workers’ Compensation (DWC) posted an Order adopting updates to the California Medical Treatment Utilization Schedule (MTUS) that are applicable as of April 18, 2019.  These include:

• Ankle and Foot Disorders Guideline (ACOEM July 16, 2018)

• Cervical and Thoracic Spine Disorders Guideline (ACOEM October 17, 2018)
• Elbow Disorders Guideline (ACOEM August 23, 2018)
• Hand, Wrist, and Forearm Disorders Guideline (ACOEM January 7, 2019)
• Workplace Mental Health: Post-traumatic Stress Disorder and Acute Stress Disorder Guideline (ACOEM December 18, 2018)

These are most current evidence-based recommendations drawn from the current ACOEM Guidelines. 

**Reminder**

Free Access to the California MTUS Available to Providers in California

Arrangements by the DIR/DWC and The Reed Group, publisher of the “ACOEM Guidelines”, allows for free access to the MTUS for Providers involved in the California Workers’ Compensation System by signing up with the Reed Group at: www.mdguidelines.com/mtus.  Additional tools are available, the Guidelines are clear, relatively concise, and expedites treatment requests and enhances knowledge of accepted evidence-based care. 

In an effort to better service our contracted providers right the first time, Anthem Blue Cross has improved our provider claim escalation process. Just click, Provider Claim Escalation Process to read, print, download and share the improved process with your office staff.

Our Network Relations Team is available by email at CAContractSupport@anthem.com to answer questions you have about the process.

Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. For a complete listing of our workshops, seminars, webinars and job aids, log on to the Anthem Blue Cross website: www.anthem.com/ca. Select Providers, then scroll down to Find Resources for California. From the Answers@Anthem page, select the link titled Provider Education Seminars and Webinars link.

It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137), which went into effect on July 1, 2016, requires that Anthem Blue Cross (Anthem) provide our members accurate and up-to-date provider directory data. As a result, Anthem will be conducting ongoing outreaches to all practices to confirm the information we have on file is accurate. Without verification from you that our Provider Directory information is accurate, we will be required to remove your practice from the directories we make available to our members. We appreciate your attention to this matter.

Anthem Blue Cross (Anthem) providers should now submit changes to their practice profile using our online Provider Maintenance Form.  

Online update options include: add an address location, name change, tax ID changes, provider leaving a group or a single location, phone/fax numbers, closing a practice location, etc. Visit the Provider Maintenance Form landing page to review more.

The new online form can be found on the redesigned provider site www.anthem.com/ca, select the Providers tab then select Provider Maintenance Form in the sub bullets. In addition, the Provider Maintenance Form can be accessed through the Availity Web Portal by selecting California> Payer Spaces-Anthem Blue Cross> Resources tab >Provider Maintenance Form.

Important information about updating your practice profile:

• Change request should be submitted using the online Provider Maintenance Form
• Submit the change request online. No need to print, complete and mail, fax or email demographic updates
• You will receive an auto-reply e-mail acknowledging receipt of your request and another email when your submission has been processed
• For change(s) that require submission of an updated IRS Form w-9 or other documentation, attach them to the form prior to submitting
• Change request should be submitted with advance notice
• Contractual agreement guidelines may supersede effective date of request

Anthem Blue Cross (Anthem) has network leasing arrangements with a variety of organizations, which we call Other Payors. Other payors and affiliates use the Anthem network.

Under the terms of your provider agreement, members of other payors and affiliates are treated like Anthem members. As such, they’re entitled to the same Anthem billing considerations, including discounts and freedom from balance billing. You can obtain the Other Payors list on the Availity web portal, at www.Availity.com. From the Availity site, select Home > Anthem California > Education and Reference Center, or email us at CAContractSupport@Anthem.com.

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our website.  The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website. To access the guidelines, go to https://www.anthem.com/ca/provider/.   From there, scroll down and click on Read Polices.  This will take you to Medical Policy, Clinical UM Guidelines (for Local Plan M, and Pre-Certification Requirements. Then click on the Practice Guidelines on the Health & Wellness tab.

Blue Cross of California dba Anthem Blue Cross and Anthem Blue Cross Life & Health Insurance Company (collectively, Anthem”) are committed to keeping you, our network partners, updated on our activities related to our compliance with the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) Timely Access to Non-Emergency Health Care Services Regulations (the “Timely Access Regulations”), respectively. Anthem maintains policies, procedures, and systems necessary to ensure compliance with the Timely Access Regulations, including access to non-emergency health care services within prescribed timeframes (also referred to as the “time elapsed standards” or “appointment wait times”). Anthem can only achieve this compliance with the help of our provider network partners, you! 

There are many activities that are conducted to support compliance with the regulations and we need you, as well as covered individuals, to help us attain the information that is needed. These studies allow our Plan to determine compliance with the regulations.

The activities include, but are not limited to the following:

• Provider Appointment Availability Survey
• Provider Satisfaction Survey
• Provider After – Hours Survey

These surveys will begin soon; please review this information with your office staff so they are prepared and understand the importance of each provider’s participation in each of the surveys.

We appreciate that in certain circumstances time-elapsed requirements may not be met. The Timely Access Regulations have provided exceptions to the time-elapsed standards to address these situations:

Extending Appointment Wait Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.

Preventive Care Services and Periodic Follow-up Care: Preventive care services and periodic follow up care are not subject to the appointment availability standards. These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease.

Advanced Access: The primary care appointment availability standard may be met if the primary care physician office provides “advanced access.” “Advanced access” means offering an appointment to a patient with a primary care physician (or nurse practitioner or physician’s assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day).

We hope this clarifies Anthem’s expectations and your obligations regarding compliance with the Timely Access Regulations. Our goal is to work with our providers to successfully meet the expectations for the requirements with the least amount of difficulty and member abrasion.

Open the attachment to view more information about Access Standards for Medical Professionals.

Members also have access to Anthem’s 24/7 NurseLine. The NurseLine wait time is not to exceed 30 minutes. The phone number is located on the back of the member ID card. In addition, Members and Providers have access to Anthem’s Customer Service team at the telephone number listed on the back of the member ID card. A representative may be reached within 10 minutes during normal business hours.

Please contact the Anthem Member Services team at the telephone number listed on the back of the member ID card to obtain assistance if a patient is unable to obtain a timely referral to an appropriate provider.

If you have further questions, please contact Network Relations at CAContractSupport@anthem.com.

For Patients (Members) with Department of Managed Health Care Regulated Health plans:

If you or your patients are unable to obtain a timely referral to an appropriate provider or for additional information about the regulations, visit the Department of Managed Health Care’s website at www.dmhc.ca.gov/HealthCareinCalifornia/YourHealthCareRights/TimelyAccesstoCare.aspx or call toll-free 1-888-466-2219 for assistance.

For Patients (Members) with California Department of Insurance Regulated Health plans:

If you or your patients are unable to obtain a timely referral to an appropriate provider or for additional information about the regulations, visit the Department of Insurance’s website at www.insurance.ca.gov or call toll-free 1-800-927-4357 for assistance.

Language Assistance Program

For members whose primary language isn’t English, Anthem offers free language assistance services through interpreters and other written languages. If you or the member is interested in these services, please call the Anthem Member Services number on the member’s ID card for help (TTY/TDD: 711).

You want what’s best for your patients’ health. When a patient doesn't follow your prescribed treatment plan, it can be a challenge. Approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed¹. What can be done differently?

The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg, that is, the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline — the giant, often invisible, patient self-talk that may not get discussed aloud — can create a misalignment between patient and provider.

We’ve created an online learning experience to teach the skills and techniques that can help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence — and you’ll earn continuing medical education credit along the way.

Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

Please continue to check Important Medicare Advantage Updates at anthem.com/ca/medicareprovider for the latest Medicare Advantage information, including:

2019 provider trainings

Submitting corrected claims

2019 Utilization management affirmative statement

You want what’s best for your patients’ health. When a patient doesn't follow your prescribed treatment plan, it can be a challenge. Approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed¹. What can be done differently?

The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg, that is, the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline — the giant, often invisible, patient self-talk that may not get discussed aloud — can create a misalignment between patient and provider.

We’ve created an online learning experience to teach the skills and techniques that can help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence — and you’ll earn continuing medical education credit along the way.

Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.

[1]   Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm.

Effective January 1, 2018, Anthem Blue Cross (Anthem) will update codes with a set rate per unit to the HIPAA-compliant, HCPCS “A” and “B” codes for medical supplies, which include enteral/parental products and formulas. Set rates for these codes will eliminate the need for an invoice, universal product number (UPN) or medical billing number (MBN) requirements.

Previous requirements entailed adding UPN on the claim line with “A” codes, adding MBN with “B” codes for enteral/parental product(s) on the claim line, or attaching an invoice or catalog page to the claim line to price. This is now eliminated.

New billing instructions

Do not attach an invoice or catalogue page to the claim line. Providers supplying members with medical supplies, including enteral/parenteral products and formulas, are not required to submit an invoice, UPN or MBN to receive payment.

Authorization and claim submission

• For Medi-Cal Managed Care (Medi-Cal) members, medical supplies may be a capitated service from independent practice associations (IPAs) or primary medical groups (PMGs). A member’s ID card will indicate which IPA/PMG to contact for possible authorization, claim submission and reimbursement criteria. If there is no IPA contact information, contact Anthem using the phone number on the back of the member’s ID card for possible authorization and claim submission information.

• For Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) members, Anthem is responsible for medical supplies. This is a traditional Part B service. Possible authorizations and benefits should be coordinated directly with Medicare as applicable. Contact Utilization Management using the phone number on the back of the back of the member’s ID card for possible authorization criteria and claim submission addresses.

Managing illness can be a daunting task for our members. It is not always easy to understand test results or know how to obtain essential resources for treatment or who to contact with questions and concerns.

Anthem Blue Cross is available to offer assistance in these difficult moments with our Complex Case Management program. Our care managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members, families, primary care physicians and caregivers. The Complex Case Management process utilizes the experience and expertise of the Case Coordination team to educate and empower our members by increasing self-management skills. The Complex Case Management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the Member Services number located on the back of their ID card. They will be transferred to a team member based on the immediate need. Physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about health care decisions and goals.

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://www.anthem.com/ca/provider/policies.

You can request a free copy of our UM criteria from our Medical Management department. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below. To access UM criteria online, go to https://www.anthem.com/ca/provider/policies.

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title and organization name when initiating or returning calls regarding UM issues.

You can submit precertification requests by:

• Calling 1-888-831-2246, options 3 (includes both inside and outside L.A. County).
• Faxing 1-800-754-4708 (includes both inside and outside L.A. County).

Have questions about utilization decisions or the UM process?

Call our Clinical team at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County) Monday through Friday from 8 a.m. to 5 p.m. Pacific time.

The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross has adopted a Members’ Rights and Responsibilities Statement. You may locate it in the provider manual.

If you need a physical copy of the statement, call us at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County).

Check out additional information about the 2019 Utilization Management Affirmative Statement.

All associates who make utilization management decisions are required to adhere to the following principles:

• Utilization management decision making is based only on appropriateness of care and service and existence of coverage.
• We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support or tend to support denials of benefits.
• Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization or create barriers to care and service.

70926MUPENMUB

Anthem Blue Cross (Anthem) allows reimbursement of anesthesia services rendered by professional providers for covered members. Reimbursement is based upon:

• The reimbursement formula for the allowance and time increments in accordance with CMS.
• Proper use of applicable modifiers.

Effective September 1, 2019, Anthem will recognize the following anesthesia modifier:

• Modifier 99: This denotes multiple modifiers under certain circumstances; two or more modifiers may be necessary to completely delineate a service. In such situations, Modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.

Anthem does not recognize Modifier AD or Modifier 23 as anesthesia modifiers. Anesthesia modifiers are appended to the applicable procedure code to indicate the specific anesthesia service or who performed the service. Modifiers identifying who performed the anesthesia service must be billed in the primary modifier field to receive appropriate reimbursement. Claims submitted for anesthesiology services without the appropriate modifier will be denied.

Anthem will continue to recognize the following anesthesia modifiers as well as physical status modifiers P3, P4 and P5:

• Modifier AA: anesthesiology service performed personally by an anesthesiologist — reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate

• Modifier QK: medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals — reimbursement is based on 50% of the applicable fee schedule or contracted/negotiated amount

• Modifier QX: qualified nonphysician anesthetist with medical direction by a physician — reimbursement is based on 50% of the applicable fee schedule or contracted/negotiated amount

• Modifier QY: anesthesiologist medically directs one certified registered nurse anesthetist (CRNA) — reimbursement is based on 50% of the applicable fee schedule or contracted/negotiated amount

• Modifier QZ: CRNA service without medical direction by a physician —reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated amount

• Modifier 47: denotes regional or general anesthesia services provided by the surgeon performing the medical procedure; we do not allow reimbursement of anesthesia services by the provider performing the medical procedure (other than obstetrical — see Obstetrical Anesthesia section of this policy); therefore, it is not appropriate to bill Modifier 47 with anesthesia services

For additional information, please review the Professional Anesthesia Services reimbursement policy at https://mediproviders.anthem.com/ca.

Check out additional information online about the Partial hospitalization services.