Balance billing Medi-Cal Managed Care (Medi-Cal) beneficiaries is prohibited by federal and state law. 

Medi-Cal beneficiaries should not pay for physician visits and other medical care when they receive covered services from a provider in their provider network. This means beneficiaries cannot be charged for co-pays, co-insurance, or deductibles. This applies to both Medicare and Medi-Cal providers.

Billing Medi-Cal beneficiaries violates federal law as outlined in section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997. This section of the act is available at: http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. Protections are also found in California Welfare and Institutions Code section 14019.4.

Does your organization submit single claim submissions online to Availity Essentials? This feature is a no-cost option to submit your claims, but like all claim submissions, it’s important to review the response reports to ensure your claim has been accepted.

How do I view my response reports?

Your organization’s Availity administrator will need to assign the electronic data interchange (EDI) management role to users who submit online claim submissions. Even though the claims are submitted without using EDI software or a vendor, online claim submissions are still considered EDI transactions that will create response reports.

Once the role has been assigned, the user will have access to the EDI clearinghouse menu located under the Claims & Payments menu. The three tiles used are listed below:

• Send and receive EDI files — The response files will be in the receive folder.
• File restore — Availity will archive your response files after 60 days; use this option to restore your reports.
• EDI reporting preferences — Select text > Human readable format. The other formats are only used for EDI software.

What kind of response reports do I need to view?

• File acknowledgments — shows your claim has been received
• Immediate batch response — acknowledges accepted claim and identifies if rejected due to HIPAA and/or payer-specific edits
• Delayed payer reports — Certain policies will go through a second level of editing for the payer; This report will return if that is the case.

We are here to help

Availity Essentials offers on-demand recorded training and documentation to assist with reviewing your response reports:

• Log in to Availity Essentials and select Help & Training > Get Trained.
• Use the catalog filter and select EDI Clearinghouse; several courses will display for you to enroll in and view.
• Use the EDI Companion Document to view the Setup EDI Reporting Preferences Chapter.
• Contact Availity Client Services at 800-282-4548 Monday through Friday from 8 a.m. until 8 p.m.

Participating providers are responsible for offering members access to covered services 24/7. Access includes regular office hours on weekdays and the availability of a provider or designated agent by telephone after regular office hours, on weekends, and on holidays. When unavailable, providers must arrange for on-call coverage by another participating provider. Providers are also required to meet appointment access standards as described below.

After-hours calls:

• Providers must instruct their after-hours answering service to answer Anthem’s After Hours Survey questions. Non-compliant providers are subject to contractual enforcement actions, such as Corrective Action Plans (CAP) or escalated contractual sanctions for breach of contract.
• The answering service or after-hours personnel must ask the member if the call is an emergency. In the event of an emergency, the member must be immediately directed to dial 911 or to proceed directly to the nearest hospital emergency room.
• If staff or answering service is not immediately available, an answering machine may be used. The answering machine message must instruct members with emergency healthcare needs to dial 911 or go directly to the nearest hospital emergency room. The message must also give members an alternative contact number so they can reach the primary care physician (PCP) or on-call provider with medical concerns or questions.
• Non-English-speaking members who call their PCP after hours should expect to get
  language-appropriate messages. In the event of an emergency, these messages should direct the member to dial 911 or proceed directly to the nearest hospital emergency room.
• In a non-emergency situation, members should receive instruction on how to contact the on-call provider. If an answering service is used, the service should know where to contact a telephone interpreter. All calls taken by an answering service must be returned.

Appointment access

Note: The next available appointment date and time can be either in-person or by telehealth services.

Healthcare providers must make appointments for members from the time of request as follows:

SB221 — Effective since July 1, 2022, non-physician mental health/SUD appointments are subject to the timely access standards outlined in the chart above. This bill also requires that all health plans ensure that enrollees who are undergoing a course of treatment for an ongoing mental health or SUD condition can schedule a follow up appointment with their non-physicians mental healthcare or SUD provider within 10 business days of the prior appointment.

Specialists

The following guidelines are in place for our specialists:

• For urgent care, the specialist should see the member within 96 hours of receiving the request.
• For routine care, the specialist should see the member within 15 business days of receiving the request.
• A copy of the medical records and/or results of the visit should be sent to the PCP’s office to allow continuity of care.

Wait times

When a provider's office receives a call from an Anthem member during regular business hours — as well as after hours — for assistance and possible triage, the provider or another healthcare professional must either take the call or call the member back within 30 minutes of the initial call.

When an Anthem member arrives on time to an appointment, the member should be seen within 15 minutes of the scheduled appointment.

When Anthem members and/or prospective members call a physician’s office, they should not be placed on hold for longer than 10 minutes.

Interpretation services

When a provider’s office receives a call from an Anthem member, the provider’s office should know where to contact a telephone interpreter to communicate in the member’s preferred language.

Noncompliance

Ensure that you comply with the standards described; compliance with these standards is a contractual requirement. Anthem monitors compliance through a number of mechanisms, including annual telephonic surveys, to determine if participating provider offices meet the above standards.

For additional details, review the provider manuals at
https://providers.anthem.com/california-provider/resources/manuals-policies-guidelines.

Beginning in 2023, delegated network providers will be measured based on a compliance threshold of 70% as outlined in CCR 1300.67.2.2. Delegates scoring below 70% compliance for Non-Urgent and Urgent appointment availability will be subject to corrective action, up to and including, termination of the contract.

Required timely access training course — to be released in measurement year 2024

Rescheduling missed appointments — Los Angeles county providers only

This is a reminder that Los Angeles county providers are required to call to reschedule an appointment within 48 hours after a missed appointment. Ensure your office’s policies and procedures and training are updated to include this requirement. Providers may be surveyed on a random sample to ensure compliance with this standard.

Schedule of timely access surveys

Provider Appointment Availability Survey (PAAS):

• Survey subject(s): Appointment availability
• Managed Care Plan: Anthem
• Contractor conducting survey: Sutherland
• Regulatory agency: Department of Managed Health Care (DMHC)
• Schedule: July through November 2024

After Hours and Appointment Availability Survey:

• Survey subject(s): Emergency and urgent after-hours calls
• Managed Care Plan: Anthem
• Contractor conducting survey: TBD
• Regulatory agency: National Committee for Quality Assurance (NCQA); DMHC
• Schedule: October through November 2024

Primary Care and Specialty Care Appointment Availability Survey:

• Survey subject(s): Appointment availability, interpretation services
• Conducting/regulatory agency: Department of Health Care Services (DHCS)
• Schedule:
  • Q1: January through March
  • Q2: April through June
  • Q3: July through September
  • Q4: October through December

DHCS administers the surveys, and Anthem is provided the surveys after each quarter.

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

Per the Department of Managed Health Care (DMHC) All Plan Letter (APL) 22-028 — Health Equity and Quality Measure Set and Reporting Process, health plans including Anthem are required to meet the Health Equity and Quality Measure Set (HEQMS) and stratification of the HEQMS by race, language, and ethnicity as of January 1, 2023. Health plans are required to report on all HEQMS measures comprised of 12 Healthcare Effectiveness Data and Information Set^® (HEDIS) measures and one Consumer Assessment of Healthcare Providers and Systems^® (CAHPS) measure. The APL is linked below for your reference.

As a contracted Anthem healthcare provider, your organization is required to submit HEQMS and stratify such information to Anthem according to the APL.

The standardized set of health data elements contracted providers are required to submit must be in the most recent United States Core Data for Interoperability (USCDI) version. Here is a link to the detail list, including required code sets and terminology:

https://healthit.gov/isa/sites/isa/files/2021-07/USCDI-Version-2-July-2021-Final.pdf

We hope that in addition to directly providing this data to Anthem, you will consider joining a qualified health information organization (QHIO) available to providers seeking assistance in meeting the new data connectivity requirements under Assembly Bill 133. Some QHIO examples:

• Cozeva
• Health Gorilla, Inc.
• Long Health, Inc.
• Los Angeles Network for Enhanced Services (LANES)
• Manifest MedEx
• Orange County Partners in Health HIE
• SacValley MedShare
• San Diego Health Connect
• Serving Communities HIO

We invite you to work with such QHIOs not only to meet the requirements described in this communication (obtained from the DMHC All Plan Letter) but also to drive your own success and ensure that you are capturing data to support the high-quality care you deliver. QHIOs can support your work in driving improvements in HEDIS metrics, Medicare Stars, and risk adjustment.

Data exchange via QHIO can assist with:

• Closing clinical care gaps and improving the quality of patient care.
• Reducing and/or eliminating the need for traditional medical chart-chase requests for HEDIS, Medicare Stars, and risk adjustment.
• Improving performance.
• Complying with DMHC’s regulatory requirements for all California healthcare entities.

Continue to check the Data Exchange Framework CDII (ca.gov) for any updates.

Contact us with questions or concerns: email a provider experience associate.

2024 PAAS Surveys

Each year, Anthem, along with other health plans in California, conducts Provider Appointment Availability (PAAS) and After-Hours Surveys. These surveys are administered to specific randomly selected network providers. The PAAS Survey assists in evaluating whether members can obtain care provider appointments within time frames mandated by the Department of Managed Health Care (DMHC) and California Department of Insurance (CDI). The After-Hours Survey measures care provider compliance with the standards relating to the availability of emergency and after-hours service.

2024 surveys coming soon

Anthem contracts with a vendor to administer the surveys. Sutherland Healthcare Solutions will conduct the 2024 PAAS and After-Hours Surveys from July through December 31, 2024.

Understanding how to comply

If Sutherland Healthcare Solutions contacts your office (via fax, email, or telephone), a surveyor will ask questions about urgent and non-urgent appointment availability. Refer to the charts that follow for specific standards:

• Compliant: Care provider offers an appointment within the required appointment time frames.
• Non-compliant: Care provider fails to offer an appointment within any of the required time frames or refuses to participate in the survey. Non-compliant care providers will receive a letter from Anthem requesting a Corrective Action Plan.
• Next available appointment date and time can be either in-person or by telehealth services.

Please take a moment to review and share with your staff the following access standards tables for medical and behavioral health professionals.

Access standards for medical professionals and ancillary care providers

Access standards for behavioral health and EAP care 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.

Access standards for after-hours

• Only appropriately qualified staff such as a physician, physician assistant, nurse practitioner, or registered nurse are allowed to provide triage or screening clinical advice.
• Interpreter services are coordinated by Anthem or its delegated network provider or other delegated entity with scheduled appointments for healthcare services in a manner that ensures the provision of interpreter services at the time of the appointment without imposing delay on the scheduling of the appointment. Anthem requires care providers and office staff to document members’ request, acceptance, or refusal of interpreter services in the medical record.
• Referrals to a specialist by a primary care provider or another specialist must meet applicable timely access standards.

As a reminder, in 2023, the DMHC expanded the list of physician and service type providers included in the PAAS. The table below identifies a current list of care providers included in the PAAS.

Keeping you informed

According to SB 221, effective January 1, 2023, a referral to a specialist by a primary care provider or another specialist should comply with the required time frame standards.

Why is this important?

Anthem is required by law to obtain appointment availability information from our network providers annually. We must ensure that our provider network can offer members an appointment within specific time frames. There are limits on how long members can wait to receive healthcare appointments and telephone advice.

The DMHC and CDI require that Anthem monitor its provider network and request a Corrective Action Plan if timely access to care standards are not met or if the provider refuses to participate in the survey.

Anthem recognizes 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 healthcare 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 can access our 24/7 NurseLine, to get advice from a registered nurse anytime. The toll-free phone number is listed on the back of the member ID card and the wait time cannot exceed 30 minutes.

Help is a phone call away

For general questions or difficulties in obtaining a referral, members and providers can call the toll-free phone number on the back of the member ID card to speak with the Member Services team for Anthem. Representatives are available 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 care provider or for more information about the regulations, visit the DMHC website at dmhc.ca.gov or call toll-free 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 care provider or for more information about the regulations, visit the CDI website at insurance.ca.gov or call toll-free 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 Member Services number listed on the Anthem member ID card for help (TTY/TDD: 711).

Questions

If you have any questions about this communication, contact your assigned provider relationship account manager or visit anthem.com/ca/provider/contact-us to view additional contact information.

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!

Please review your online provider directory information on a regular basis to ensure that it’s correct. Access your online provider directory information by visiting anthem.com/ca/provider, then at the top of the webpage, choose Find Care. Review your information and let us know if any of your directory information has changed.

Updating your information

Anthem uses the provider data management (PDM) capability available on Availity Essentials to update your provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate provider demographic data set by the Consolidated Appropriations Act (CAA).

PDM features include:

• Updating provider demographic information for all assigned payers in one location.
• Attesting to and managing current provider demographic information.
• Monitoring submitted demographic updates in real-time with a digital dashboard.
• Reviewing the history of previously verified data.

Accessing the PDM application

Log on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

PDM training

PDM training is available:

• Learn about and attend one of our training opportunities by visiting apps.availity.com/web/onboarding/availity-fr-ui/#/login.
• After logging in, view the Availity PDM quick start guide.
• Listen to the recording of our Roster Automation Template and Rules of Engagement Training at tinyurl.com/3xe5cayv.

Not registered for Availity yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account.

If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY.

We strive to advance health equity so everyone has a fair opportunity to be at their healthiest. As we reduce barriers to whole health — physical, behavioral, and social — and personalize the healthcare journey, we can more effectively advance health equity. While focusing on understanding member needs, we actively develop educational tools for providers.

In recognition of June as National LGBTQIA+ Pride Month, we are introducing three eLearning tools on LGBTQIA+ health, available on the My Diverse Patients site. This site offers a comprehensive repository of resources for providers to help support the needs of diverse patients and address healthcare disparities. Multiple free continuing medical education (CME) courses are available, with CME credits offered through the American Academy of Family Physicians (AAFP).

For the month of June, our featured eLearning experience and resources are:

• My Inclusive Practice — Improving Care for LGBTQIA+ Patients — a CME credit hour provider training. Course benefits:
  • Understand the fears and anxieties LGBTQIA+ patients often feel about seeking medical care.
  • Learn key health concerns of LGBTQIA+ patients.
  • Develop strategies for providing effective healthcare to LGBTQIA+ patients.
  • Review ideas for creating a welcoming office environment.
• National LGBTQIA+ Health Education Center — Resources & Tools:
  • The National LGBTQIA+ Health Education Center provides educational programs, resources, and consultation to healthcare organizations with the goal of optimizing quality, cost‑effective healthcare for lesbian, gay, bisexual, and transgender people.
• Pre-Exposure Prophylaxis (PrEP) Action Kit — Resources & Tools:
  • The PrEP Action Kit includes clinical resources to help providers incorporate PrEP into their practices. Including helpful resources such as tips on taking a comprehensive sexual history, frequently asked questions about PrEP, and a pocket card about PrEP prescribing and monitoring, this action kit is an essential resource for all providers treating LGBTQIA+ patients or patients at risk of HIV infection.

These courses are designed for doctors (CME credit provided), nurses, health professionals, and medical office staff.

Providers can view these courses on their smartphone, tablet, or computer.

We're pleased to offer these resources as we work together to deliver high-quality, equitable healthcare.

Join us to hear from a diverse panel of experienced professionals from Motivo and Anthem. During this interactive webinar, we will explore the recent research on the impact mental health has on providers and share insights into support services like counseling, stress management, and self-care resources.

Register today for the Thriving Not Just Surviving: Navigating Challenging Times as a Clinician forum hosted by Anthem and Motivo for Anthem providers.

Recognizing the emotional stress providers often experience, this forum aims to deepen the discussion on mental health and the importance of prioritizing clinician’s self-care.

Together, we will work to foster a culture of understanding and support not just for clients, but for providers. By doing so, we work collaboratively for the health and wellbeing of all Americans and the communities in which we live and serve.

Each forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, have difficult and productive conversations, learn about valuable resources, and improve the health and wellbeing of our communities.

Also, join us in November, National Family Caregivers Awareness Month, for a webinar dedicated to supporting caregivers.

We are committed to working together to achieve improved outcomes and foster genuine collaboration with our care provider partners.

We have enhanced functionality on the eLearning platform MyDiversePatients.com.

This new functionality identifies learners and supports our ongoing commitment to health equity and cultural competency.

When a care provider (doctor, nurse, health professional, office staff) starts an online continuing medical education (CME) course, they now have the option to register a National Provider Identifier (NPI):

• Flexibility: Self-paced learning gives the learner the freedom to decide when and where to take the trainings.
• Multi-device accessibility: The course site is fully responsive and designed to work with multiple devices, including smartphone, tablet, and desktop. This means you can learn from the comfort of your home, while on the go, in the office, or any location of your choosing.
• Progress tracking: The NPI registration allows the platform to monitor and track learning progress and achievements, helping health professionals to meet their CME requirements efficiently.
• Credit management: Upon completion of a CME course and review of the recommended materials, the user has the opportunity to fill in a certificate of completion with the information they wish to appear on the document itself.
• Find Care provider search tool: If the eLearner chooses to register their NPI when they take a CME course, progress is tracked to completion. The NPI number allows for a cultural competency indicator to appear beside the provider’s name in directories (Find Care). This is designed to support referring practitioners and members by being able to identify providers who have received certificates in cultural competency.

Goals of My Diverse Patients:

• Offer a comprehensive repository of resources for care providers to help support the needs of diverse patients and address disparities.
• Provide cultural competency for relevant resources from external sources (such as, medical journals and medical/quality organizations.)

Benefits:

• Availability of multiple free CME resources — CME courses are offered through the American Academy of Family Physicians.
• Real life stories about diverse patients and the unique challenges they face.
• Tips for working with diverse patients to promote improvement in health outcomes.

New courses with CME credits and nursing continuing education units will be added in 2024. We look forward to working together to deliver equitable healthcare.

Effective September 1, 2024, Anthem will transition to the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for medical necessity/clinical appropriateness reviews for requested interventions. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. This does not equate to the presence of a prior authorization requirement. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

• Site of Care Guidelines:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

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

The anthem.com/provider portal and Provider News Quality Management page contains training opportunities, resources, updates, pharmacy and behavioral health information, forms, and policies, and Availity information for billing.

Refer to attachment to view full details

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 care providers or other individuals for issuing denials of coverage, service, or care. We do not 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 providers.anthem.com/ca > Resources > Medical Policies and Clinical UM Guidelines.

You can request a free copy of our UM criteria from our Medical Management department. Care providers can discuss a UM denial decision with a physician reviewer by calling us toll free at 888-831-2246, option 4. To access UM criteria online, go to providers.anthem.com/ca > Resources > Medical Policies and Clinical UM Guidelines.

We are staffed with clinical professionals who work with you to coordinate our members’ care. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues.

You can submit precertification requests 24/7 by:

• Calling: 888-831-2246, option 3 (includes both inside and outside L.A. County).
• Faxing a Pre-Service Review form to 800-754-4708 (includes both inside and outside L.A. County).

Have questions about utilization management?

Call one of our Medi-Cal Customer Care Centers Monday through Friday, from 7 a.m. to 7 p.m., at 800-407-4627 (TTY 711) (outside L.A. County) or 888-285-7801 (TTY 711) (inside L.A. County).

We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities.

In line with our commitment to participating practitioners and members, Anthem has a Members’ Rights and Responsibilities section located within the provider manual. The delivery of quality healthcare requires cooperation between patients, their care providers, and their healthcare benefit plans. One of the first steps is for patients and care providers to understand their rights and responsibilities. Review this section in your provider manual at providers.anthem.com/ca > Resources > Provider Manuals, Policies & Guidelines.

Beyond simply signing a contract, care providers are part of a genuine collaboration aimed at improving the lives of real people.

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 offers a Complex Case Management program to help make healthcare easier and less overwhelming for our members. Our care managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members and their caregivers to stay connected with their care team and follow their treatment plan. Care managers educate and empower our members to participate in their own care. The goal is to help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare. Care managers also support members and their caregivers with transitions between care settings.

Members or their caregivers can request case management by calling the Member Services number located on the back of their ID card.

Physicians can refer their patients by submitting a Case Management Referral Form via fax or email.

Have questions about case management?

Call one of our Medi-Cal Customer Care Centers Monday through Friday, from 7 a.m. to 7 p.m., at 800-407-4627 (TTY 711) (outside L.A. County) or 888-285-7801 (TTY 711) (inside L.A. County). 

We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities.

Taking the time to help your patients boost their health and digital literacies can enhance trust and can lead to improved health outcomes and patient experience.

Refer to attachment to view full details

Vaccines are important in reducing the incidence of morbidity and mortality due to serious preventable diseases. Except for the annual flu and COVID vaccines, most childhood vaccines are administered before six years of age. Once children enter their pre-teen years, it is time for them to get a few more vaccines. The Center for Disease Control (CDC) and the American Academy of Pediatrics recommend pre-teens 11 and 12 years old get three vaccines to prevent diseases: 1) tetanus, diphtheria, and pertussis (Tdap); 2) meningococcal disease; and, 3) cancers caused by the human papillomavirus (HPV).

Refer to attachment to view full details

Measure details

Eligibility criteria:

Did you know?

Certain adverse reactions to a statin medication may exclude the patient from the measure denominator if properly documented. See required exclusions below.

Required exclusions:

• Diagnosis of myalgia, myositis, myopathy, or rhabdomyolysis during 2024:
  • Important note: The above exclusionary diagnoses must be documented each year. A diagnosis from a prior year will not carry over to the current year. These exclusionary diagnoses can come from claims or medical record data. Medical record documentation must contain two patient identifiers.
• Diagnosis of pregnancy during 2024
• Diagnosis of in-vitro fertilization in 2023 or 2024
• Dispensed at least one prescription for clomiphene during 2023 or 2024
• 66 years of age and older who are enrolled in an Institutional Special Needs Plan (I-SNP) or living long term in an institution during 2024
• 66 years of age and older with advanced illness during 2023 and/or 2024 and frailty during 2024
• 66 years of age and older with advanced illness during 2023 and/or 2024 and dispensed dementia medication during 2024:
  • Note: Exclusions for advanced illness, frailty, and dispensed dementia medications must come from claims.
  • The advanced illness exclusion can include telephone visits, e-visits, and virtual check-ins to meet the two visits with an advanced illness diagnosis criterion.
• Diagnosis of end-stage renal disease (ESRD) or dialysis during 2023 or 2024
• Diagnosis of cirrhosis during 2023 or 2024
• Hospice and palliative care:
  • Death

Closing the gap

Documentation needed:

• Only dispensed medication on a pharmacy claim is used to identify and close this gap.
• Patient must use their member ID card when filling a statin prescription at the pharmacy.
• Exclusions for advanced illness, frailty, and dispensed dementia medications must come from claims.
• Exclusions for myalgia, myositis, myopathy, or rhabdomyolysis can come from claims or medical record data. Medical record documentation must include two patient identifiers.

Moderate- to high-intensity statin medications

Best practices

Prescribe low-cost generics to eliminate cost as a barrier:

• Atorvastatin, lovastatin, pravastatin, simvastatin, and rosuvastatin are available for $0 for extended days’ supply prescriptions. These medications are free using the Medicare Advantage prescription drug plan benefit for Anthem even if the patient reaches the coverage gap.
• Encourage patients to fill their statin medication at a preferred pharmacy using their benefit.
• Discourage the use of discount cards.
• Let Anthem know of any patients filling outside of the benefit. Anthem can reach out to the pharmacy and/or patient regarding the $0 benefit cost.
• Short trial fills of a statin medication with $0 cost may help hesitant patients be more willing to try or re-try a statin medication.

Help patients manage potential side effects:

• Educate patients about the long-term cardiovascular benefits and potential side effects of a statin medication.
• If a patient experienced statin intolerance previously, a trial of a lower dose or different statin medication may help reduce risk or side effects.

Note: Patient history of statin-induced myalgia, myositis, myopathy, or rhabdomyolysis in a prior year must be documented each year for patient to be excluded from this measure. A diagnosis from a prior year will not carry over to the current year.

The Provider Quality and Health Equity team at Anthem has been hard at work creating and identifying resources to help improve quality rates and the overall experiences of your patients. Be sure to check the Quality Management section of this Provider Newsletter site periodically for resources and new content, including provider toolkits and HEDIS-related materials to help optimize your quality rates. New content, resources, webinars, and training opportunities are also available on the Clinical Quality Webinars Hub. Mydiversepatients.com is a great resource for training and resources to help you learn about and serve your diverse population.

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