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. Please review your demographic information in our online provider directories to ensure members and fellow providers can reach you.

 

Submit your updates by using our online Provider Maintenance Form. Update options include:

• add/change an address location
• name change
• tax ID changes
• provider leaving a group or a single location
• phone/fax number changes
• closing a practice location

 

You will receive an email to acknowledge your submitted Provider Maintenance Form. Visit the Provider Maintenance Form landing page for complete instructions.

 

Thank you for doing your part to help keep our online provider directories up to date.

2681-0622-PN-CA

Important program news for 2022

• The annual Provider Appointment Availability Surveys (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.
• Each year we communicate Anthem’s Timely Access Regulations and Language Assistance Program to our commercial Medical and Behavioral Health networks via an annual provider mailing.  The 2022 mailing was completed in February.
• SB 221, effective July 1, 2022 – Timely Access Requirements for Non-Physician Mental Health/Substance Use Disorder Appointments. More details follow the Access Standards for Medical Professionals table below.

 

Please take a moment to review and share with your staff the Access Standards tables for Medical Professionals and Behavioral Health that follow.

Access Standards for Medical Professionals

Type of Care	Standard
Non-urgent appointments for Primary Care (PCP)	Must offer the appointment within 10 business days of the request
Urgent Care (that does not require prior authorization)	Must offer the appointment within 48 hours of request
Non-urgent appointments with Specialist Physicians	Must offer the appointment within 15 business days of the request
Urgent Care (that requires prior authorization)	Must offer the appointment within 96 hours of request
Non-urgent appointment for ancillary services (for diagnosis or treatment of injury, illness, or other health condition)	Must offer the appointment within 15 business days of the request
After Hours Care	Available 24 hours/7 days. Member to reach a recorded message or live voice response providing emergency instructions; and for non-emergent (urgent) matters, a mechanism to reach a health professional and information as to when to expect a call back.
Emergency Care:  Anthem Blue Cross expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room. Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.	Members are directed to dial 911 or go to the nearest emergency room
Member Services by Telephone:  Access to Member Services to obtain information about how to access clinical care and how to resolve problems. (This is a Plan responsibility and not a physician responsibility; and this also applies to our Behavioral Health members.)	Reach a live person within 10 minutes during normal business hours (Plan standard: 45 seconds; Call abandonment rate <5%). The Member NurseLine is available 24/7 and the wait time is not to exceed 30 minutes.

 

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

For questions, please visit the Contact Us page on our provider website for up-to-date contact information. You can also email the Provider Experience team directly using the electronic form.

 

Changes are coming!  Effective July 1, 2022 – Timely Access Requirements for Non-Physician Mental Health/Substance Use Disorder Appointments

 

On October 8, 2021, the State Senate passed SB 221. This bill requires health care service and Managed Care Plans that fall under the jurisdiction of Department of Managed Health Care and the Department of Insurance, to ensure that appointments with Non-Physician Mental Health and Substance Use Disorder providers are subject to the Timely Access Requirements, as specified on the charts below, beginning July 1, 2022. This bill also requires that all health plans ensure that enrollees who are undergoing a course of treatment for an ongoing Mental Health or Substance Use Disorder condition can schedule a follow up appointment with their Non-physicians Mental Health Care or Substance use Disorder provider within 10 business days of the prior appointment.

 

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.

Type of Care	Standard
Routine Office Visit/Non-urgent Appointment	10 business days (Psychiatrists)* 10 business days (Non-Physician Mental Health Care      Providers) 5 business days (EAP)
Non-Life-Threatening Emergency Care	Must offer the appointment within 6 hours Members are directed to 911 or the nearest emergency room
Urgent Care (that does not require prior authorization)	Must offer the appointment within 48 hours
Urgent Care (that requires prior authorization)	Must offer the appointment within 96 hours
After-Hours Care	Available 24 hours/7 days. Member to reach a recorded message or live voice response providing emergency care instructions, and for non-emergent (urgent) matters, a mechanism to reach a Behavioral Health/EAP provider and information as to when to expect a call back
Emergency Care:  Anthem Blue Cross expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room. Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.	Members are directed to dial 911 or go to the nearest emergency room

* 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.

 

For questions, please visit the Contact Us page on our provider website for up-to-date contact information. You can also email the Provider Experience team directly using the electronic form.

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. The 2022 surveys are beginning soon.  The surveys 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 2022 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 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! 

2748-0622-PN-CA

One in every 10 Americans have diabetes, but one in every five don’t know they have it. This makes annual testing important to those who have symptoms. For those patients who are diagnosed, testing is vitally important to reducing serious health complications and the costs associated with them. It isn’t always easy to help patients understand the need for annual testing. The Centers for Disease Control and Prevention has resources you can use in your practice to educate, inform, and hopefully motivate your patients. Visit their website cdc.gov and use their Health Care Providers section to access patient education programs, prevention toolkits and more.

Measure up

 

Comprehensive Diabetes Care (CDC): This HEDIS® measure evaluates Anthem Blue Cross members aged 18 to 75 years with type 1 or type 2 diabetes. Each year, members with type 1 or type 2 diabetes should have:

• Hemoglobin A1c (HbA1c) testing - HbA1c control (< 8%)
• Eye exam (retinal) performed
• Evaluation for kidney disease
• BP control (< 140/90 mm Hg)

 

Code type	Description	Code
ICD-10	Type 1 diabetes mellitus without complications	E10.9
ICD-10	Type 2 diabetes mellitus without complications	E11.9
ICD-10	Other specified diabetes mellitus without complications	E13.9

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
2765-0622-PN-CA

Anthem is committed to making healthcare simpler and reducing health disparities. We believe that open discussions about the disability experience for people of and reducing implicit bias, is critical to improving the health and wellbeing of all Americans and the communities in which we live and serve.

 

Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem about the intersection of disability and race on our health and wellbeing. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.    

 

Wednesday, June 22, 2022

1:00 p.m. to 2:30 p.m. PT

 

Please register for this event by June 22, 2022

Register today!

*Motivo is an independent company providing a virtual forum on behalf of Anthem Blue Cross.

CABC-COMM-000583-22

You have applied to join the Anthem Blue Cross (Anthem) network or submitted a request to add a provider to your existing group contract, what’s next?  Get application status every step of the review process via the Availity dashboard. You will need your application ID. An application ID is assigned to each provider once an application or request is submitted via the Anthem Digital Enrollment Process. Your dashboard makes it simple to check status, where your application or request is in our contracting process.

Our Digital Availity Enrollment Guide (Guide) helps you find your dashboard in Availity. Search the Guide by key word: application status. Access the Guide on anthem.com/ca > Providers > Forms and Guides > Filter to “Join Our Network” to find all currently updated guides.

Need an answer to a question other than application or request status?

• Questions about a new solo provider, new physician group or adding to your existing commercial physician group contract, email: CAPhysicianApp@anthem.com
• Questions about adding a provider to your existing commercial Behavioral Health (BH) or Applied Behavior Analysis (ABA) group contract, email: CABHContracting@anthem.com
• Questions about new commercial BH or ABA individual (solo) or group, email : CANetworkDevelopment@anthem.com

2766-0622-PN-CA

Beginning in June 2022, Anthem Blue Cross (Anthem) will implement new processes for providers to validate the information we have in our online provider directories.

 

Individual providers

 Anthem is partnering with CAQH to assist us in validation for individual providers. Providers will receive communications from CAQH asking them to register for CAQH ProView®, the online provider data-collection service, where providers can review and verify their information, as well as provide updates that may be needed.

 

Facilities and groups

Anthem is also partnering with First Source to assist us in validating information for facilities and groups. A file will be sent to providers with the information we have in our systems. We are asking that providers review this file, validate correct information, and provide updates as needed.

 

If you have questions, please contact Provider Services.

2781-0622-PN-CA

Submission of claims in overlapping Blue Plan service areas is dependent on what plan(s) the provider contracts within that state, the type of contract the provider has for example, PPO, Traditional, etc., and the type of contract the member has with their Home Plan.

 

In other states, a company may carry the Blue Cross and Blue Shield name together, as a single entity. In California, there are two separate and independent Blue Cross Blue Shield companies. One is Anthem Blue Cross, and the other is Blue Shield of California.
 

• If you contract with both Plans in California, you may file an out-of-area Blue Plan member’s claim with either Plan.
• If you contract with one Plan but not the other, file all out-of-area claims with your contracted Plan. 

Use the Anthem Blue Cross Payer ID number that was assigned to you, not the Blue Shield of California Payer ID number. If you submit an Anthem Blue Cross member claim with the Blue Shield of California Payer ID number instead of the Anthem Blue Cross Payer ID number, the claim will process as out-of-network.

2770-0622-PN-CA

Important program news for 2022

• The annual Provider Appointment Availability Surveys (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.
• Each year we communicate Anthem’s Timely Access Regulations and Language Assistance Program to our commercial Medical and Behavioral Health networks via an annual provider mailing.  The 2022 mailing was completed in February.
• SB 221, effective July 1, 2022 – Timely Access Requirements for Non-Physician Mental Health/Substance Use Disorder Appointments. More details follow the Access Standards for Medical Professionals table below.

 

Please take a moment to review and share with your staff the Access Standards tables for Medical Professionals and Behavioral Health that follow.

 

Access Standards for Medical Professionals

Type of Care	Standard
Non-urgent appointments for Primary Care (PCP)	Must offer the appointment within 10 business days of the request
Urgent Care (that does not require prior authorization)	Must offer the appointment within 48 hours of request
Non-urgent appointments with Specialist Physicians	Must offer the appointment within 15 business days of the request
Urgent Care (that requires prior authorization)	Must offer the appointment within 96 hours of request
Non-urgent appointment for ancillary services (for diagnosis or treatment of injury, illness, or other health condition)	Must offer the appointment within 15 business days of the request
After Hours Care	Available 24 hours/7 days. Member to reach a recorded message or live voice response providing emergency instructions; and for non-emergent (urgent) matters, a mechanism to reach a health professional and information as to when to expect a call back.
Emergency Care:  Anthem Blue Cross expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room. Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.	Members are directed to dial 911 or go to the nearest emergency room
Member Services by Telephone:  Access to Member Services to obtain information about how to access clinical care and how to resolve problems. (This is a Plan responsibility and not a physician responsibility; and this also applies to our Behavioral Health members.)	Reach a live person within 10 minutes during normal business hours (Plan standard: 45 seconds; Call abandonment rate <5%). The Member NurseLine is available 24/7 and the wait time is not to exceed 30 minutes.

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

For questions, please visit the Contact Us page on our provider website for up-to-date contact information. You can also email the Provider Experience team directly using the electronic form.

 

Changes are coming!  Effective July 1, 2022 – Timely Access Requirements for Non-Physician Mental Health/Substance Use Disorder Appointments

 

On October 8, 2021, the State Senate passed SB 221. This bill requires health care service and Managed Care Plans that fall under the jurisdiction of Department of Managed Health Care and the Department of Insurance, to ensure that appointments with Non-Physician Mental Health and Substance Use Disorder providers are subject to the Timely Access Requirements, as specified on the charts below, beginning July 1, 2022. This bill also requires that all health plans ensure that enrollees who are undergoing a course of treatment for an ongoing Mental Health or Substance Use Disorder condition can schedule a follow up appointment with their Non-physicians Mental Health Care or Substance use Disorder provider within 10 business days of the prior appointment.

 

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.

Access Standards for Behavioral Health and EAP Providers

Type of Care	Standard
Routine Office Visit/Non-urgent Appointment	10 business days (Psychiatrists)* 10 business days (Non-Physician Mental Health Care      Providers) 5 business days (EAP)
Non-Life-Threatening Emergency Care	Must offer the appointment within 6 hours Members are directed to 911 or the nearest emergency room
Urgent Care (that does not require prior authorization)	Must offer the appointment within 48 hours
Urgent Care (that requires prior authorization)	Must offer the appointment within 96 hours
After-Hours Care	Available 24 hours/7 days. Member to reach a recorded message or live voice response providing emergency care instructions, and for non-emergent (urgent) matters, a mechanism to reach a Behavioral Health/EAP provider and information as to when to expect a call back
Emergency Care:  Anthem Blue Cross expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room. Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.	Members are directed to dial 911 or go to the nearest emergency room

* 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.

 

For questions, please visit the Contact Us page on our provider website for up-to-date contact information. You can also email the Provider Experience team directly using the electronic form.

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. The 2022 surveys are beginning soon.  The surveys 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 2022 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 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! 

2748-0662-PN-CA

Prompt written notice of a closed practice prevents member servicing delays. Are you accepting new patients? Your practice status - open or closed must be reflected accurately in our provider directories. California law requires that participating health care providers notify health plans within five days when their “Accepting New Patients” status changes.

 

Refer to the Anthem Blue Cross – California Facility and Professional Provider Manual for time frames and information about reporting your practice status and any related information about your practice.

2769-0622-PN-CA

 

The BlueCard® Program provides a valuable service that lets you file all claims for members from other Blue Plans with Anthem Blue Cross.

 

Here are some key points to remember:

• Always request a current ID card from the member and make a copy of the front and back of the member’s identification (ID) card.
• Look for the three-character prefix that precedes the member’s ID number on the ID card. It is critical for confirming membership and coverage.
• Call BlueCard Eligibility at 1-800-676-BLUE (2583) to verify the patient’s membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to Anthem Blue Cross.
• Submit the claim to Anthem Blue Cross. Always include the patient’s complete identification number, which includes the three-character prefix.
• For claims inquiries, contact Anthem Blue Cross.

2768-0622-PN-CA

Get help navigating the program and information about claim filing, eligibility, preauthorization, and contact information from the Blue Card® Program Provider Manual. Learn more online at our website, anthem.com/ca > Providers > Provider Resources | Policies, Guidelines & Manuals > scroll the page to Provider Manual > Access previous versions and other manuals.  Select this link to directly access the Provider Manual Library.

Also, you have access to online Supplemental Education Materials (SEM).  SEM#10 – BlueCard
(Out-of-Area) is available via the Anthem Blue Cross Provider Education and Training webpage and it   provides helpful tips to improve your claim experience, facts about ID cards and much more to explore.

2767-0622-PN-CA

In its efforts to improve the health of humanity, Anthem Blue Cross (Anthem) has made a long-term commitment to reducing morbidity and mortality associated with substance use disorder. In recent years, with a focus on primary and secondary prevention, we’ve seen significant reductions in the use of inappropriate opioid prescriptions for acute and chronic pain as well as the promotion of and increased use of safe alternatives for pain management. Similarly, Anthem has been a leader in increasing access to evidence-based treatment for substance use disorders including medication for addiction treatment (MAT).

 

Unfortunately, the COVID-19 pandemic has hindered the nation’s progress as evidenced by a 30% rise in deaths from overdose that the nation has experienced with the majority being from opioids (CDC). The impact on overdose rates from the pandemic requires that we also increase our efforts at preventing deaths from opioid overdose. Specifically, there is a need/opportunity to work collaboratively with our partners in the community to increase access to the opioid overdose reversal drug naloxone (aka “Narcan”). Anthem’s internal claims data from the second quarter of 2021 shows that approximately 20% of members experiencing a non-fatal opioid overdose are starting and continuing with medication for opioid use disorder (MOUD) which can include buprenorphine, methadone, or naltrexone. However, only 7% of these members have evidence of filling a prescription for naloxone. These rates have improved from a 2015 baseline of approximately 1%, but we have significant room for improvement.

 

What can we do to address this?

First, be an advocate for destigmatizing substance use disorders by supporting efforts to improve access to MOUD and harm reduction strategies including the use naloxone. We can learn more at www.Shatterproof.org, which is an organization that Anthem has historically supported.

                                                                           

Second, educate your patients about substance use disorders including how to spot them in a loved one, and how to support them when considering change. Visit https://www.samhsa.gov/find-help/recovery for more information.

 

Third, learn more about the life saving opioid overdose reversal drug naloxone including how to obtain it, and how to administer it. See www.getnaloxonenow.org for more information.  

2284-0622-PN-CA

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
• Medical drug benefit Clinical Criteria updates
• Anthem Blue Cross expands specialty pharmacy precertification list

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:

 

• Updates to AIM Specialty Health Musculoskeletal Clinical Appropriateness Guidelines
• Updates to AIM Specialty Health Sleep Disorder Management Clinical Appropriateness Guidelines
• New specialty pharmacy medical step therapy requirements
• Anthem Blue Cross expands specialty pharmacy precertification list

Evaluation and management services for COVID testing — professional

Effective with dates of service on or after September 1, 2022, Anthem Blue Cross (Anthem) will facilitate review of selected claims for COVID-19 visits reported with evaluation and management (E/M) services submitted by professional providers to align with CMS reporting guidelines. When the purpose of the visit is for COVID-19 testing only, reimbursement for CPT^® code 99211 (office or other outpatient visit) is allowed when billed with place of service office (11), mobile unit (15), walk-in retail health clinic (17), or urgent care facility (20). Claims for exposure only may be affected. Professional providers are encouraged to code their claims to the highest level of specificity in accordance with ICD-10 coding guidelines.

 

Prior to payment, Anthem will review the selected claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is appropriate for the COVID-19 visit reported. If the visit is determined to be solely for the purpose of COVID-19 testing, Anthem will reimburse using CPT code 99211.

 

Professional providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the provider manual.

                                                              

If you have questions on this program, contact your Provider Solutions representative.

ABCCRNU-0242-22

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.

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.

 

Medical Policies

On February 17, 2022, 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, 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 adopted by the medical operations committee for our members on
March 24, 2022. These guidelines take effect June 4, 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

ABCCRNU-0243-22

On November 19, 2021, January 4, 2022, and February 25, 2022, 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.

 

Effective date	Document number	Clinical Criteria title	New or revised
June 9, 2022	*ING-CC-0211	Kimmtrak (tebentafusp-tebn)	New
June 9, 2022	*ING-CC-0210	Enjaymo (sutimlimab-jome)	New
June 9, 2022	*ING-CC-0213	Voxzogo (vosoritide)	New
June 9, 2022	*ING-CC-0212	Tezspire (tezepelumab-ekko)	New
June 9, 2022	*ING-CC-0086	Spravato (esketamine) Nasal Spray	Revised
June 9, 2022	ING-CC-0157	Padcev (enfortumab vedotin)	Revised
June 9, 2022	ING-CC-0125	Opdivo (nivolumab)	Revised
June 9, 2022	ING-CC-0119	Yervoy (ipilimumab)	Revised
June 9, 2022	*ING-CC-0099	Abraxane (paclitaxel, protein bound)	Revised
June 9, 2022	ING-CC-0120	Kyprolis (carfilzomib)	Revised
June 9, 2022	ING-CC-0126	Blincyto (blinatumomab)	Revised
June 9, 2022	ING-CC-0129	Bavencio (avelumab)	Revised
June 9, 2022	*ING-CC-0090	Ixempra (ixabepilone)	Revised
June 9, 2022	ING-CC-0110	Perjeta (pertuzumab)	Revised
June 9, 2022	ING-CC-0115	Kadcyla (ado-trastuzumab)	Revised
June 9, 2022	ING-CC-0108	Halaven (eribulin)	Revised
June 9, 2022	*ING-CC-0033	Xolair (omalizumab)	Revised
June 9, 2022	*ING-CC-0043	Monoclonal Antibodies to Interleukin-5	Revised
June 9, 2022	ING-CC-0038	Human Parathyroid Hormone Agents	Revised
June 9, 2022	*ING-CC-0186	Margenza (margetuximab-cmkb)	Revised
June 9, 2022	*ING-CC-0124	Keytruda (pembrolizumab)	Revised
June 9, 2022	*ING-CC-0078	Orencia (abatacept)	Revised
June 9, 2022	ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
June 9, 2022	ING-CC-0042	Monoclonal Antibodies to Interleukin-17	Revised
June 9, 2022	*ING-CC-0029	Dupixent (dupilumab)	Revised
June 9, 2022	*ING-CC-0208	Adbry (tralokinumab)	Revised
June 9, 2022	*ING-CC-0209	Leqvio (inclisiran)	Revised
June 9, 2022	*ING-CC-0166	Trastuzumab Agents	Revised
June 9, 2022	*ING-CC-0107	Bevacizumab for Non-ophthalmologic Indications	Revised

ABCCRNU-0241-22

For services beginning on September 1, 2022, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) will be reviewed by myNEXUS.* Through this program, myNEXUS clinicians will collaborate with caregivers and facility care managers/discharge planners to provide transition planning as well as the pre-service and concurrent review authorizations of post-acute care services. The goal of this program is to support members through their recovery process in the most appropriate, least restrictive environment.

 

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, myNEXUS will begin receiving requests on Tuesday, August 30, 2022, for members whose anticipated discharge date is September 1, 2022, or after.

 

Providers are encouraged to request authorization using NexLync. Go to https://portal.mynexuscare.com/home to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day.

 

If you are unable to use the link or website, you can call the myNEXUS Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to myNEXUS at
833-311-2986.

 

Please note: myNEXUS will not review authorization requests for durable medical equipment (DME), ambulance, and other related services that do not fall under Medicare-covered home healthcare services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras.

 

To learn more about myNEXUS and upcoming training webinars, visit www.myNEXUScare.com or email Provider_Network@myNEXUScare.com.

 

If you have additional questions, please call the myNEXUS Provider Call Center at 844-411-9622.

 

*Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to September 1, 2022, should be directed to the health plan.

 

* myNEXUS is an independent company providing post-acute benefits management services on behalf of Anthem Blue Cross.

ABCCRNU-0238-22

Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health_®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

 

Updates by Guideline

Imaging of the spine

• Perioperative and periprocedural imaging – Added requirement for initial evaluation with radiographs

 

Imaging of the extremities

• Trauma – Added computerized tomography (CT) scan as an alternative to magnetic resonance imaging (MRI) for tibial plateau fracture; added indication for evaluation of supracondylar fracture
• Rotator cuff tear – Combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks
• Shoulder arthroplasty – Modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty
• Perioperative imaging – Excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty

 

Vascular imaging

• Stenosis or occlusion, extracranial carotid arteries – New indications for post neck irradiation, incidental carotid calcification scenarios
• Stroke/Transient ischemic attack (TIA), extracranial evaluation – Subacute stroke/TIA; computed tomography angiography (CTA)/magnetic resonance angiography (MRA) neck allowed without prerequisite ultrasound (US), in alignment with 2021 American Heart Association (AHA)/American Stroke Association (ASA) guidelines
• Chronic stroke/TIA – New indication; modality approach by circulation presentation
• Pulmonary embolism – Removal of nondiagnostic chest radiograph (CXR) requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID-19 infection, etc.)
• Imaging study modality and/or site expansion – Pulsatile tinnitus, acute aortic syndrome, abdominal venous thrombosis
• Stenosis or occlusion, extracranial carotid arteries – post-revascularization scenario aligned with the Society for Vascular Surgery (SVS) guidelines to allow annual surveillance regardless of residual stenosis.
• Aneurysm of the abdominal aorta or iliac arteries – Management/surveillance scenarios aligned with SVS guidelines.
• Upper or lower extremity peripheral arterial disease (PAD):
• Suspected PAD without physiologic testing (including exercise testing) not indicated
• New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)

 

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

• Access AIM’s ProviderPortal_℠ directly at https://www.providerportal.com
• Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization
• Access AIM via the Availity Portal* at https://www.availity.com  
• Call the AIM Contact Center toll-free number: 833-404-1684 Monday through Friday from 5 a.m. to 5 p.m. PT

 

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

ABCCRNU-0235-22

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:

 

• Prior authorization updates for medications billed under the medical benefit
• Provider notification process
• Provider coding education: Webinars and on-demand trainings are now available!

Anthem Blue Cross (Anthem) is required to submit the Annual Network Certification (ANC) documentation to the California Department of Health Care Services (DHCS) to demonstrate compliance with network adequacy requirements, in accordance with the DHCS All Plan Letter (APL) 21-006 Network Certification Requirements. Below are specific mandates that subcontractors must comply with. The full APL and Attachment A are also attached for your reference. Network adequacy compliance includes mandatory provider types according to your contract agreement with Anthem. In addition, subcontractors may use nonphysician medical practitioners to meet network expectations; however, a licensed physician must supervise all nonphysician medical practitioners. The associated medical practitioner-to-supervisor and member-to-supervisor ratios are outlined in Attachment A.

 

Subcontractor oversight

Anthem is required to have processes in place to ensure subcontractors comply with network adequacy requirements. If a subcontractor has a network adequacy deficiency, DHCS requires that Anthem impose a Corrective Action Plan (CAP) until all deficiencies are corrected.

 

Subcontractors are required to maintain evidence of contracting efforts within their contracted service areas where network deficiencies are identified. DHCS requires Anthem to maintain documentation including, but not limited to:

• All correspondence related to provider offers via email/letter.
• Scheduled phone calls.
• Evidence of good faith negotiations.
• Marketing materials and advertisements.

 

As a delegated entity, Anthem may request the above-listed documentation from you. In addition, relevant policies and procedures must be maintained and provided to Anthem upon request.

 

If you have any questions regarding network adequacy, please reach out to the Provider Performance Management team at canoc@anthem.com.

 

Network adequacy resources

Your partnership is critical to ensuring adequate network access for our members. Below, you will find a listing of resources that you can use to help solve any gaps identified in your network:

• DHCS Managed Care Plan Provider Network File: https://data.chhs.ca.gov/dataset/managed-care-provider-network
• Fee-for-service open data portal: https://data.chhs.ca.gov
• Health Care Options: https://www.healthcareoptions.dhcs.ca.gov
• Health Care Access and Information (formerly known as Office of Statewide Health Planning and Development): https://hcai.ca.gov/data-and-reports/
• Health Professional Shortage Areas (HPSA): https://data.hrsa.gov/topics/health-workforce/shortage-areas

 

Out-of-network (OON) requirements:
                          

• In cases where a subcontractor is unable to meet time or distance standards to a core specialist, delegated entities are required to assist any requesting member in obtaining an appointment with an appropriate OON primary and core specialty provider, in accordance with APL 21-006 Attachment A, in person or via telehealth, when contracted for those services.
• When assisting the member, the subcontractor must make their best effort to establish a member‑specific case agreement with an OON core specialist at the Medi-Cal Managed Care fee-for-service rate or a mutually agreed upon rate, unless the subcontractor has already attempted to establish a member‑specific case agreement with the OON core specialist in the most recent fiscal year, and the core specialist has refused to enter into an agreement.
• If this cannot be arranged, the subcontractor must arrange for an appointment with an in‑network provider.
• The OON primary and core specialty provider must be able to provide services to a member within the applicable time or distance and timely access standards and, in cases where the OON primary and core specialty provider are not able to provide services to a member under these standards, the subcontractor must arrange for nonemergency medical transportation or nonmedical transportation.
• Subcontractors are responsible to authorize OON access to medically necessary providers within timely access standards and applicable time or distance standards, regardless of associated transportation or provider costs until the CAP is completed by the subcontractor and closed by Anthem.

 

DHCS also requires Anthem to ensure providers and subcontractors are trained on the right for members to request OON access for medically necessary services and transportation to providers when ANC requirements are not met.

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-0439-22

On November 19, 2021, January 4, 2022, and February 25, 2022, 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.

 

Effective date	Document number	Clinical Criteria title	New or revised
August 8, 2022	*ING-CC-0211	Kimmtrak (tebentafusp-tebn)	New
August 8, 2022	*ING-CC-0210	Enjaymo (sutimlimab-jome)	New
August 8, 2022	*ING-CC-0213	Voxzogo (vosoritide)	New
August 8, 2022	*ING-CC-0212	Tezspire (tezepelumab-ekko)	New
August 8, 2022	*ING-CC-0086	Spravato (esketamine) Nasal Spray	Revised
August 8, 2022	ING-CC-0157	Padcev (enfortumab vedotin)	Revised
August 8, 2022	ING-CC-0125	Opdivo (nivolumab)	Revised
August 8, 2022	ING-CC-0119	Yervoy (ipilimumab)	Revised
August 8, 2022	*ING-CC-0099	Abraxane (paclitaxel, protein bound)	Revised
August 8, 2022	ING-CC-0120	Kyprolis (carfilzomib)	Revised
August 8, 2022	ING-CC-0126	Blincyto (blinatumomab)	Revised
August 8, 2022	ING-CC-0129	Bavencio (avelumab)	Revised
August 8, 2022	*ING-CC-0090	Ixempra (ixabepilone)	Revised
August 8, 2022	ING-CC-0110	Perjeta (pertuzumab)	Revised
August 8, 2022	ING-CC-0115	Kadcyla (ado-trastuzumab)	Revised
August 8, 2022	ING-CC-0108	Halaven (eribulin)	Revised
August 8, 2022	*ING-CC-0033	Xolair (omalizumab)	Revised
August 8, 2022	*ING-CC-0043	Monoclonal Antibodies to Interleukin-5	Revised
August 8, 2022	ING-CC-0038	Human Parathyroid Hormone Agents	Revised
August 8, 2022	*ING-CC-0186	Margenza (margetuximab-cmkb)	Revised
August 8, 2022	*ING-CC-0124	Keytruda (pembrolizumab)	Revised
August 8, 2022	*ING-CC-0078	Orencia (abatacept)	Revised
August 8, 2022	ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Revised
August 8, 2022	ING-CC-0042	Monoclonal Antibodies to Interleukin-17	Revised
August 8, 2022	*ING-CC-0029	Dupixent (dupilumab)	Revised
August 8, 2022	*ING-CC-0208	Adbry (tralokinumab)	Revised
August 8, 2022	*ING-CC-0209	Leqvio (inclisiran)	Revised
August 8, 2022	*ING-CC-0166	Trastuzumab Agents	Revised
August 8, 2022	*ING-CC-0107	Bevacizumab for Non-ophthalmologic Indications	Revised

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-0437-22