Nationally, seven percent of all claims are denied because they weren’t filed within the timely filing limits. At Anthem, we want your claims to be received on time, so they get paid on time. One way to ensure your claim isn’t denied because it wasn’t received within timely filing limits is to follow-up with your clearinghouse on a regular basis.

When you send claims electronically through a clearinghouse, if errors are identified on the claims, they won’t get submitted for payment. Checking in regularly with your clearinghouse is key to identifying claims errors. This gives you the opportunity to correct claims quickly, avoiding delays in filing and running the risk of a claim denial because it wasn’t filed within the timely filing limit.

Have you confirmed the patient is an Anthem member?

Another reason claims are delayed is because the claim was filed with Anthem, but it should have been filed with another insurance company first. To make sure your claim is received on time, double check the member’s insurance information with each visit to your office confirming their primary insurance. To check the member’s eligibility or to get a digital copy of the member’s ID card, log onto Availity.com. From the Patient Registration tab use the Eligibility and Benefits Inquiry tool for a quick and easy search.

Checking your claims status.

It is easy to check your claim online to confirm we’ve received it. Log onto Availity.com and use the Claims & Payment tab for the Claims Status tool. You may also be able to check the claim to verify no adjustments are needed through the Claims Status Listing application located on the Payer Spaces home page.

The sooner you file the faster your claim is paid.

Filing your claim within the timely filing limits can eliminate claim denials. If your claim denies because it was filed late, Anthem will deny the claim as outlined in your contract with us. It is important to note that the member cannot be billed for denied claims that were not filed timely.

Use these helpful tips when filing your claims because Anthem understands that timely payments are as important as timely filing.

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The annual Provider Appointment Availability Survey (PAAS) will begin soon.  It is very important that you review this information with your office staff, so they are prepared and understand each provider’s responsibility to participate in the surveys. 

Here is what you need to do:  Educate your staff on the standards for appointment scheduling and after-hours care. 

Access Standards for Medical Professionals

Note: The next available appointment date and time can be either In-Person or by Telehealth.

Go to our Contact US page with questions.

Access Standards for Behavioral Health and EAP Providers.

* The DMHC Timely Access standard is 15 Business days for Psychiatrists; however, to comply with the NCQA accreditation standard of 10 Business Days, Anthem uses the more stringent standard.

Note:  The next available appointment date and time can be either In-Person or by Telehealth services.

Email any questions to Behavioral Health Provider Experience at CABHNetworkRelations@anthem.com.

WHY IS THIS IMPORTANT:   These are California state regulations.

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. 

To ensure compliance with these Timely Access Regulations, three (3) surveys are conducted annually.  These activities include, but are not limited to the following:

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

Each year we communicate Anthem’s Timely Access Regulations and Language Assistance Program to our commercial Medical and Behavioral Health networks.  The 2021 notice was mailed in February.  This information also includes access to non-emergency health care services within prescribed timeframes (also referred to as the “time elapsed standards” or “appointment wait times”). 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). Note: This exception does not apply to commercial Behavioral Health.

24/7 NurseLine Gives Peace of Mind

Anthem members have access to our 24/7 NurseLine. A convenient way to ask questions or get advice from a registered nurse anytime. Locate the toll-free phone number on the back of the Member ID card and the wait time is not to exceed 30 minutes.

Help is a Phone Call Away

Members and Providers have access to Anthem’s Member Services team for general questions or when having difficulty obtaining a referral to a provider. Call the toll-free phone number listed on the back of the member ID card for assistance. A representative may be reached within 10 minutes during normal business hours.

For Patients (Members) with DMHC Regulated Health Plans

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

For Patients (Members) with CDI Regulated Health Plans

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

Language Assistance Program

For members whose primary language is not English, Anthem offers, at no cost, 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).

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

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Chances are that one out of every four patients you see in your office has low back pain. The Centers for Disease Control and Prevention (CDC) reports that in the last three months, 25% of U.S. adults report having low back pain, making it second only to the common cold as a cause for lost work time and a primary reason for a doctor’s visit.¹  Back pain will usually go away on its own. About 90 percent of patients with low back pain recover within six weeks.² For this reason, the National Committee for Quality Assurance (NCQA) recommends avoiding imaging for patients when there is no indication of an underlying condition. In a study published by the CDC, Early imaging for acute low back pain, the findings indicated not only was early imaging not associated with better outcomes, it also indicated that certain early imaging (MRI) was associate with an increased likelihood of disability and its duration.³

Watch this video to learn more

Take advantage of the Recommendation for Treating Acute Low Back Pain video located on the CDC website or use this link. The video also offers communications strategies to share with patients for effectively treating their low back pain.

HEDIS® Measure: Use of Imaging Studies for Low Back Pain (LBP)

Description:  The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. The higher compliance score indicates appropriate treatment of low back pain.

Exclusions include cancer, recent trauma, IV drug abuse, neurologic impairment, HIV, spinal infection, major organ transplant and prolonged use of corticosteroids.

Coding Tips: This is a few of the approved codes for the diagnosis and services associated with the LBP measure. For a complete list, visit ncqa.org.

¹ https://www.cdc.gov/acute-pain/low-back-pain/index.html#:~:text=25%25%20of%20U.S.%20adults%20report,the%20most%20common%20pain%20reported.

² https://abcnews.go.com/Health/CommonPainProblems/story?id=4047737#:~:text=Answer%3A%20Back%20pain%20usually %20goes,people%20recover%20faster%20than%20others

³ http://dx.doi.org/10.1097/BRS.0b013e318251887b

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137) 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.

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Easily update demographic changes and much more, by simply submitting your updates through Anthem Blue Cross (Anthem) 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. Visit the Provider Maintenance Form landing page to review more.

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

You can check your directory listing on the Anthem “Find Care”. The Find Care tool at Anthem is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans. To ensure Anthem has the most current and accurate information, please take a moment to access Find Care. Go to anthem.com/ca, select Providers, under Provider Overview, choose Find Care. You can log in as a guest to view how you and your practice are being displayed.

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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 are 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 availity.com. From the Availity site, select Home > Anthem California > Education and Reference Center.

Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. Log on to the Anthem Blue Cross website: www.anthem.com/ca. Select Providers, under Communications go to Education and Training. Scroll down to view Training, Educational and Resource offerings.

Healthcare providers are often seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

• Address disparities for vaccine-preventable diseases
• Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine communications, providing vaccine education, and improving vaccine management and administration in your office;
• Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines; and
• Connect with your state immunization program, local immunization coalition or other vaccine advocates in your community to collaborate.

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

Let's Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.

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To provide you with better educational opportunities, we are collecting data to improve provider education offerings. We are also asking for preferences and topics of interest to ensure that we tailor the education experience to meet your needs.  We value our providers, and we want to deliver educational content that is most convenient for you. Please take a moment to complete a brief survey and remember. Your voice counts! 

Select the survey below to begin:

Provider education: Your Voice Counts

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

Effective September 1, 2021, Anthem will upgrade to the 25th edition of MCG* care guidelines for the following modules: inpatient and surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

Goal length of stay (GLOS) for inpatient and surgical care (ISC)

New Guidelines for Behavioral Health Care (BHC) and Recovery Facility Care (RFC)

Customizations to MCG care guidelines 25th edition

Effective September 1, 2021, the following MCG care guideline 25th edition customization will be implemented:

• Transcranial magnetic stimulation (TMS), W0174 (previously ORG: B-801-T) - Revised Clinical Indications for Procedure and added the following:

• Need for acute TMS treatment, up to six weeks
• Acute treatment course needed as indicated by (a) initial course of treatment for major depressive disorder (severe), or (b) relapse of symptoms after remission
• Continuation of acute treatment, up to six months
• TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
• Maintenance TMS treatment
• Continuation of acute TMS treatment for longer than 6 months
• TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, Anxiety disorders, Bipolar depression, Neurodevelopmental disorders, Obsessive-compulsive disorder, Peripartum depression, Post-traumatic stress disorder, Substance use disorders, Tourette's syndrome.     

To view a detailed summary of customizations, visit either this link for Medicaid or this link for Medicare Advantage, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.

For questions, please contact Provider Services:

• Medi-Cal Managed Care: 1-800-407-4627 (outside L.A. County)
• A. Care: 1-888-285-7801 (inside L.A. County)
• Cal MediConnect Plan: 1-855-817-5786

Medicare Advantage: Call the number on the back of the member ID card.

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Effective for dates of service on and after July 1, 2021, the following specialty pharmacy codes from current or new Clinical Criteria documents will require prior authorization.

Please note, inclusion of NDC code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below. 

If you have questions about this communication or need further assistance, please contact your local Provider Relations representative.

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Well-child visits and vaccinations are essential services

In May 2020, the CDC released a report showing a drop in routine childhood vaccinations as a result of COVID-19; a result of stay-at-home orders and concerns about infection during well-child visits. Both the American Academy of Pediatrics and the CDC recommend the continuation of routine childhood vaccinations during the COVID-19 pandemic, noting they are essential services.

To encourage well-visits and vaccinations, here are some extra steps you can take to ensure visits are as safe as possible for both patients and staff. They include:

• Scheduling sick visits and well-child visits during different times of the day.
• Asking patients to remain outside until it’s time for their appointment to reduce the number of people in waiting rooms.
• Offering sick visits and well-child visits in different locations.

It is important to identify those children who have missed immunizations and well-child visits to schedule these essential in-person appointments. To help, the CDC has published vaccine catch-up guidance on their website.

Help your patients earn rewards

For additional encouragement, Anthem Blue Cross (Anthem) members can earn $25 or more in gift cards for completing vaccines and/or well visits through our Healthy Rewards program. Please encourage your patients to enroll in the program on the Anthem website so they can earn rewards for these activities.

Patients can enroll online at https://mss.anthem.com/ca or by calling 888-990-8681 (TTY 711).

Helpful information for keeping babies and children healthy:

Childhood Immunization Status (CIS) Combination 10 HEDIS^® measure requires that all children are immunized by their 2nd birthday:

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

Billing codes:

• MMR:
  • CPT^®: 90707, 90710
  • ICD-10-CM: B05.0-4, B05,81, B05.89, B05.9
• Mumps:
  • ICD-10-CM:0-3, B26.81-85, B26.89, B26.9
• Rubella:
  • ICD-10-CM:-00-02, B06.09, B06.81-82, B06.89, B06.9
• Rubella antibody:
  • CPT: 86762
• Hepatitis A:
  • CPT: 90633
  • ICD-10-CM:0, B15.9
• Influenza:
  • CPT: 90655, 90657, 90662, 90673, 90685, 90686-90689
  • HCPCS: G0008
• Rotavirus vaccine (RV):
  • CPT: 90681 (two-dose), 90680 (three-dose)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) Combination 2 HEDIS measure:

• One meningococcal vaccine (MCV) injection between 11 and 13 years of age
• One tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between 10 and 13 years of age
• Two or three HPV vaccines between 9 and 13 years of age

Billing codes:

• Meningococcal:
  • CPT: 90734
• Tdap:
  • CPT: 90715
• HVP:
  • CPT: 90649, 90650, 90651

Please refer to the Anthem HEDIS coding booklet for coding guidelines.

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Anthem Blue Cross has contracted with Aspire Health* to provide in-home and virtual palliative care services to our Medicaid members facing advanced illness.

The typical Aspire patient:

• Is usually in the most chronically ill sector of the physician’s patient population with high emergency room or hospitalization use.
• Confronts multiple illnesses, such as:
  • Chronic heart failure.
  • Chronic obstructive pulmonary disease.
  • Advanced cancers.
  • Dementia
  • Geriatric frailty.
  • Chronic or end-stage renal disease.
  • Chronic liver disease.
  • Cerebrovascular accidents.
  • Other neurologic illnesses.
• May see multiple providers, or frequently seek care in emergency rooms and hospitals.
• May have limited family support or have family caregivers with their own health concerns.
• Receives care that is both high-cost and low-value, often resulting in frequent hospitalizations for uncontrolled symptoms and/or exacerbations of chronic disease.

Aspire offers a solution to the fragmented and expensive care that patients so often experience during the last chapter of life. By working with community physicians to enroll and serve these vulnerable patients in their homes, Aspire helps patients to increase their overall comfort, increase their satisfaction with both their PCP and their health plan, and minimize the risk of unnecessary or unwanted hospitalizations.

The Aspire team works to align medical care with a patient’s goals and values. Through patient and caregiver support, education and expert symptom management with an interdisciplinary team accessible 24/7, Aspire enables patients to avoid unnecessary emergency department visits and hospitalizations.

Aspire’s model is built around a philosophy of co-management. After each Aspire visit, a patient’s PCP and pertinent specialists receive a clinical visit summary via secure eFax to facilitate coordination of care, and Aspire’s local clinical leadership is available to communicate with providers around the clock.

For more information or to refer one of your patients to the Aspire program, please call Aspire’s 24/7 Patient and Referral Hotline at 1-877-702-6863 or visit aspirehealthcare.com.

* Aspire Health is an independent company providing in-home health care services on behalf of Anthem Blue Cross.

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To learn more information about the Medical drug benefit Clinical Criteria updates.

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

Anthem Blue Cross (Anthem) 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, PCPs, and caregivers. The complex case management process uses 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 healthcare.

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.

You can contact us by phone at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County). Case Management business hours are Monday through Friday from 8 a.m. to 5 p.m. Pacific time.

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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: 888-831-2246, options 3 (includes both inside and outside L.A. County).
• Faxing: 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 800-407-4627 (outside L.A. County) or 888-285-7801 (inside L.A. County) Monday through Friday from 8 a.m. to 5 p.m. Pacific time.

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The delivery of quality healthcare 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).

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As a reminder, Anthem Blue Cross (Anthem) Medicare Advantage does not allow separate reimbursement for claims that have been identified as a readmission to the same hospital for the same, similar or related condition unless provider, federal or CMS contracts and/or requirements indicate otherwise, as further described in the existing reimbursement policy located at: www.anthem.com/ca/medicareprovider.

If Anthem Medicare Advantage determines that this reimbursement policy has not been followed, Anthem Medicare Advantage may deny the claim prior to payment or recover any paid claim. Providers may dispute any claim denied under this policy consistent with applicable law, your agreement with Anthem Medicare Advantage and Anthem Medicare Advantage policies.

For more detailed information on the Inpatient Readmissions reimbursement policy, please visit https://www.anthem.com/ca/provider/policies/reimbursement.

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Learn more information about updates to the AIM Advanced Imaging Clinical Appropriateness Guidelines.

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Learn more information about Anthem Blue Cross working with Optum to collect medical records for risk adjustment.

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Learn more information about the Medical drug benefit Clinical Criteria updates.

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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 note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

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

To view a guideline, visit https://www.anthem.com/provider/news/archives/?category=medicareadvantage.

Notes/updates:

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

• *CG-LAB-17 - Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting
  • Outlines the medical necessity and not medically necessary criteria for multiplex PCR-based panel testing of gastrointestinal pathogens for infectious diarrhea in the outpatient setting
• *ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
  • Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as cosmetic and not medically necessary
• *CG-OR-PR-04 - Cranial Remodeling Bands and Helmets (Cranial Orthotics)
  • Removed condition requirement from reconstructive criteria and replaced current diagnostic reconstructive criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry
• *CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
  • Added TACE using immunoembolization (for example, using granulocyte-macrophage colony-stimulating factor [GM-CSF]) as not medically necessary for all liver-related indications
• *CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
  • Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
  • Added not medically necessary statement for when medical necessity criteria have not been met and clarified not medically necessary statement regarding replacement parts or upgrades
  • Added bone conduction hearing aids using an adhesive adapter behind the ear as not medically necessary for all indications
• CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment
  • A new Clinical Guideline was created from the content contained in GENE.00011. There are no changes to the guideline content and the publish date is April 7, 2021.
• CG-GENE-23 - Genetic Testing for Heritable Cardiac Conditions
  • A new Clinical Guideline was created from the content contained in GENE.00007 and GENE.00017. There are no changes to the guideline content and the publish date is April 7, 2021
• CG-SURG-110 - Lung Volume Reduction Surgery
  • A new Clinical Guideline was created from the content contained in SURG.00022. There are no changes to the guideline content and the publish date is June 25, 2021

AIM Specialty Health_®* Clinical Appropriateness Guideline updates. To view AIM guidelines, visit the AIM Specialty Health page.

• The Small Joint Surgery Guideline has been revised and will be effective on March 14, 2021.
• The following guidelines have been revised and will be effective on June 4, 2021.
• * Imaging of the Spine
• * Imaging of the Extremities
• * Vascular Imaging
• * Joint Surgery
• * Spine Surgery

Medical Policies

On February 11, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross (Anthem). These guidelines take effect June 4, 2021.

Clinical UM Guidelines

On February 11, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on February 25, 2021. These guidelines take effect June 4, 2021.

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The Group Retiree Medicare Advantage membership is experiencing a high volume of enrollment, and as we continue to grow, we wanted to send these reminders for our PPO plans for Anthem Blue Cross (Anthem). Group Retiree Medicare Advantage memberships may include the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare and accepts the member’s PPO plan. These PPO plans also offer benefits that original Medicare doesn’t cover, including an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online^* and SilverSneakers^®.^*

On February 19, 2021, and March 4, 2021, the Pharmacy and Therapeutics (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. If you have questions or would like 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 members of 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.

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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 note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

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-17 - Molecular Gastrointestinal Pathogen Panel (GIPP) Testing for Infectious Diarrhea in the Outpatient Setting
  • Outlines the medical necessity and not medically necessary criteria for multiplex PCR-based panel testing of gastrointestinal pathogens for infectious diarrhea in the outpatient setting
• *GENE.00056 - Gene Expression Profiling for Bladder Cancer
  • Gene expression profiling for diagnosing, managing and monitoring bladder cancer is considered investigational and not medically necessary
• *LAB.00038 - Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
  • Cell-free DNA testing is considered investigational and not medically necessary as a non-invasive method of determining the risk of rejection in kidney transplant recipients
• *LAB.00039 - Pooled Antibiotic Sensitivity Testing
  • Pooled antibiotic sensitivity testing is considered investigational and not medically necessary in the outpatient setting for all indications
• *SURG.00159 - Focal Laser Ablation for the Treatment of Prostate Cancer
  • Focal laser ablation is considered investigational and not medically necessary for the treatment of prostate cancer
• *TRANS.00037 - Uterine Transplantation
  • Uterine transplantation is considered investigational and not medically necessary for all uses, including but not limited to the treatment of uterine factor infertility due to nonfunctioning or absent uterus
• *ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
  • Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as cosmetic and not medically necessary
• *CG-OR-PR-04 - Cranial Remodeling Bands and Helmets (Cranial Orthotics)
  • Removed condition requirement from reconstructive criteria and replaced current diagnostic reconstructive criteria with based on one of the following cephalometric measurement: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry
• *CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
  • Added TACE using immunoembolization (for example, using granulocyte-macrophage colony-stimulating factor GM-CSF) as not medically necessary for all liver-related indications
• *CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
  • Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
  • Added not medically necessary statement for when medical necessity criteria have not been met and clarified not medically necessary statement regarding replacement parts or upgrades
  • Added bone conduction hearing aids using an adhesive adapter behind the ear as not medically necessary for all indications
• CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment
  • A new Clinical Guideline was created from the content contained in GENE.00011. There are no changes to the guideline content and the publish date is April 7, 2021.
• CG-GENE-23 - Genetic Testing for Heritable Cardiac Conditions
  • A new Clinical Guideline was created from the content contained in GENE.00007 and GENE.00017. There are no changes to the guideline content and the publish date is April 7, 2021
• CG-SURG-110 - Lung Volume Reduction Surgery
  • A new Clinical Guideline was created from the content contained in SURG.00022. There are no changes to the guideline content and the publish date is June 25, 2021

Medical Policies

On February 11, 2021, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan). These guidelines take effect June 4, 2021.

Clinical UM Guidelines

On February 11, 2021, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem Blue Cross Cal MediConnect Plan. These guidelines were adopted by the medical operations committee for Anthem Blue Cross Cal MediConnect Plan members on February 25, 2021. These guidelines take effect June 4, 2021.

ACAD-NU-0157-21

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

Effective September 1, 2021, Anthem will upgrade to the 25th edition of MCG* care guidelines for the following modules: inpatient and surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

New Guidelines for Behavioral Health Care (BHC) and Recovery Facility Care (RFC)

Customizations to MCG care guidelines 25th edition

Effective September 1, 2021, the following MCG care guideline 25th edition customization will be implemented:

• Transcranial magnetic stimulation (TMS), W0174 (previously ORG: B-801-T) - Revised Clinical Indications for Procedure and added the following:
• Need for acute TMS treatment, up to six weeks
• Acute treatment course needed as indicated by (a) initial course of treatment for major depressive disorder (severe), or (b) relapse of symptoms after remission
• Continuation of acute treatment, up to six months
• TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
• Maintenance TMS treatment
• Continuation of acute TMS treatment for longer than 6 months
• TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, Anxiety disorders, Bipolar depression, Neurodevelopmental disorders, Obsessive-compulsive disorder, Peripartum depression, Post-traumatic stress disorder, Substance use disorders, Tourette's syndrome.     

To view a detailed summary of customizations, visit either this link for Medicaid or this link for Medicare Advantage, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.

For questions, please contact Provider Services:

• Medi-Cal Managed Care: 1-800-407-4627 (outside L.A. County)
• A. Care: 1-888-285-7801 (inside L.A. County)
• Cal MediConnect Plan: 1-855-817-5786
• Medicare Advantage: Call the number on the back of the member ID card.

ACA-NU-0325-21