Provider News CaliforniaMarch 2019 Anthem Blue Cross Provider Newsletter - CaliforniaAnthem Blue Cross (Anthem) has network leasing arrangements with a variety of organizations, which we call Other Payors. Other payors and affiliates use the Anthem network.
Under the terms of your provider agreement, members of other payors and affiliates are treated like Anthem members. As such, they’re entitled to the same Anthem billing considerations, including discounts and freedom from balance billing. You can obtain the Other Payors list on the Availity web portal, at www.Availity.com. From the Availity site, select Home > Anthem California > Education and Reference Center, or email us at CAContractSupport@Anthem.com. Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before with our Network eUPDATEs.
Network eUPDATE is our web tool for sharing vital information with you. It features short topic summaries and links that let you dig deeper into timely critical business information:
- Important website updates
- System changes
- Fee Schedules
- Medical policy updates
- Claims and billing updates
……and much more
Registration is fast and easy. There is no limit to the number of subscribers who can register for Network eUPDATEs, so you can submit as many e-mail addresses as you like. Anthem Blue Cross (Anthem) providers should now submit changes to their practice profile using our online Provider Maintenance Form.
Online update options include: add an address location, name change, tax ID changes, provider leaving a group or a single location, phone/fax numbers, closing a practice location, etc. Visit the Anthem.com/ca form page to review more.
The new online form can be found on www.anthem.com/ca/provider/ > Find Resources for California > Answers@Anthem tab>Provider Forms bullet>Provider Change Forms> Provider Maintenance Form. In addition, the Provider Maintenance Form can be found on the Availity Web Portal by selecting California> Payer Spaces-Anthem Blue Cross> Resources tab >Provider Maintenance Form.
Important information about updating your practice profile:
- Change request should be submitted using the online Provider Maintenance Form
- Submit the change request online. No need to print, complete and mail, fax or email demographic updates
- You will receive an auto-reply e-mail acknowledging receipt of your request and another email when your submission has been processed
- For change(s) that require submission of an updated IRS Form w-9 or other documentation, attach them to the form online prior to submitting
- Change request should be submitted with advance notice
- Contractual agreement guidelines may supersede effective date of request
You can check your directory listing on the Anthem Blue Cross: “Find a Doctor tool”. The Find a Doctor tool at Anthem is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans. To ensure Anthem has the most current and accurate information, please take a moment to access the Find A Doctor tool (www.anthem.com/ca) and review how you and your practice are being displayed.
To report discrepancies please make correction by completing this Provider Maintenance Form online. It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137), which went into effect on July 1, 2016, requires that Anthem Blue Cross (Anthem) provide our members accurate and up-to-date provider directory data. As a result, Anthem will be conducting ongoing outreaches to all practices to confirm the information we have on file is accurate. Without verification from you that our Provider Directory information is accurate, we will be required to remove your practice from the directories we make available to our members. We appreciate your attention to this matter. Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. For a complete listing of our workshops, seminars, webinars and job aids, log on to the Anthem Blue Cross website: www.anthem..com/ca. Scroll down the page to Partners in Health > Tools for Providers. In the middle of the page select the box
Find Resources for California. From the Answers@Anthem page, select the link titled Provider Education Seminars and Webinars link. In an effort to better service our contracted providers right the first time, Anthem Blue Cross has improved our provider claim escalation process. Just click, Provider Claim Escalation Process to read, print, download and share the improved process with your office staff.
Our Network Relations Team is available by email at CAContractSupport@anthem.com to answer questions you have about the process. You want what’s best for your patients’ health. So, it's challenging when a patient doesn't follow your prescribed treatment plan. Why do approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed1? What can be done differently? The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg—the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline -- the Titanic-sized, often invisible, patient self-talk that may not get discussed -- can create a misalignment between patient and provider.
So we’ve created an online learning experience for the skills and techniques that may help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust, and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence—and you’ll earn CME credit along the way.
Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.
1 Centers for Disease Control and Prevention. (2017, Feb 1). Overcoming Barriers to Medication Adherence for Chronic Conditions. Retrieved from https://www.cdc.gov/cdcgrandrounds/archives/2017/february2017.htm. As a reminder, the Workers’ Compensation Physicians Acknowledgments is required by California Code of Regulations §9767.5.1, “Medical Provider Networks” (MPN). The “MPN applicant shall obtain from each physician participating in the MPN a written acknowledgment in which the physician affirmatively elects to be a member of the MPN.”
To maintain and affirm your participation in all MPNs that you have been selected for and have subscribed to Anthem’s Provider Affirmation Portal, go to Availity and login. Once in, click on the Payer Spaces drop down menu in the top right hand corner, and select Anthem Blue Cross from the options available to you. On the next page click on “Resources” in the middle of the page and look for “MPN Provider Affirmation Portal.”
Availity>Payer Spaces>Anthem Blue Cross>Resources>MPN Provider Affirmation Portal
If you cannot go online, call Anthem Workers’ Compensation at 1-866-700-2168 and we can take action on your behalf in the Provider Affirmation Portal. Please also keep an eye out for email notifications from “Anthem MPN Admin.”
Please also be advised the Provider Affirmation Portal will also notify participating medical providers when an MPN is terminating its relationship with Anthem and/or the Division of Workers Compensation. LabCorp, a participating provider in California, now has several patient service centers (PSCs) located at Walgreens in the Inland Empire (see locations below). Information regarding PSC location information is subject to change. For a complete and accurate list of locations, visit LabCorp.com.
View a list of locations here. A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways this is done is by giving certain providers (“Payment Innovation Providers”) in Anthem’s various Payment Innovation Programs (e.g., Enhanced Personal Health Care, Bundled Payments, Medical Home programs, etc.) (the “Programs”) quality, utilization and/or cost information about the health care providers (“Referral Providers”) to whom the Payment Innovation Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in their getting more referrals from Payment Innovation Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.
Providing this type of data, including comparative cost information, to Payment Innovation Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.
Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Payment Innovation Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.
Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant. Anthem Blue Cross (Anthem) has designated Availity to operate and serve as your electronic data interchange (EDI) entry point or also called the EDI Gateway. The EDI Gateway is a no-cost option for our providers that choose to submit their own EDI claims to Anthem. If you prefer to use a clearinghouse or billing company, please work with them to ensure connectivity.
As a mandatory requirement, all trading partners who currently submit directly to the Anthem EDI Gateway must transition to the Availity EDI Gateway.
Do you already have an Availity User ID and Login? You can use the same login for your Anthem EDI transactions.
- Log in to the Availity Portal and select Help & Training | Get Trained. In the Availity Learning Center, search the Catalog by key word “SONG” for live and on-demand resources created especially for you.
If you wish to become a direct a trading partner with Availity, the setup is easy.
Need Assistance?
The Availity Quick Start Guide will assist you with any EDI connection questions you may have.
835 Electronic Remittance Advice (ERA)
Please use Availity to register and manage account changes for ERA.
If you were previously registered to receive ERA, you must register using Availity to manage account changes.
Log into the Availity Portal and select My Providers | Enrollments Center | ERA Enrollment to enroll for 835 ERA delivery.
Electronic Funds Transfer (EFT)
To register or manage account changes for EFT only, use the EnrollHub™, a CAQH Solutions™ enrollment tool, a secure electronic EFT registration platform. This tool eliminates the need for paper registration, reduces administrative time and costs, and allows you to register with multiple payers at one time.
If you have any questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday through Friday 5 a.m. to 4:30 p.m. Pacific Time. Each year, Anthem Blue Cross (Anthem) requests your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), in order to document and close the coding gaps.
The CRA Program is specific to our Affordable Care Act (ACA) Members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).
With our Retrospective Program we focus on medical chart collection. We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS). This particular effort is part of Anthem’s compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership. The members’ medical record documentation helps support this data requirement.
Analytics are performed internally on claims which do not have the ICD10 code for which we suspect a chronic condition. These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.
Anthem network providers -- may be PCPs, specialists, facilities, behavioral health, ancillary, etc. -- may receive letters from vendors such as Inovalon, Cotiviti, and CIOX requesting access to medical records for chart review. These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf. The vendors’ Web-based workflows help reduce time and improve efficiency and costs associated with record retrieval, coding and document management.
We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2019 at the latest). While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.
Electronic options that may make medical chart collection easier for providers:
- o Allscripts (Opt in -- signature required)
- o NextGen (Opt out -- auto-enrolled)
- o Athenahealth (Opt out -- auto-enrolled)
- o MEDENT
- Remote/Direct Anthem access
- Vendor virtual or onsite visit
- Secure FTP
The goal of these electronic options is to both improve the medical record data extraction and the experience for Anthem’s network-participating hospitals, clinics and physician offices. If you are interested in this type of set up or any other remote access options, please contact our Commercial Risk Adjustment Network Education Representative: Socorro.Carrasco@anthem.com.
Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests. This March, anthem.com/ca will be introducing exciting updates to the public provider site. Coming in the next wave of changes, providers can anticipate a new landing page for provider manuals, a redesign of Dental, Electronic Data Interchange (EDI) and Employee Assistance Program (EAP) pages, and the first version of a redesign of Provider Forms, as seen below.
This first version of the new Provider Forms will keep growing and evolving in the coming months.
We will continue to keep you informed of upcoming changes to the public provider site as we progress toward streamlining our Web platform and other business processes. As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website. To access the guidelines, go to https://www.anthem.com/ca/provider/. From there, scroll down and click on Read Polices. This will take you to Medical Policy, Clinical UM Guidelines (for Local Plan M, and Pre-Certification Requirements. Then click on the Practice Guidelines on the Health & Wellness tab. In January, Anthem, Inc. announced that it’s accelerating the launch of IngenioRx, its new pharmacy benefits manager (PBM), which will serve members of all Anthem’s affiliated health plans. We will begin moving some members to IngenioRx in Q2, and we will continue the transition, in waves, with the majority of members moving in the latter part of 2019 and Q1 2020.
As one of our contracted providers, we wanted to share a few details about what this means for you.
- If your patient has an active prior authorization, that will transfer to IngenioRx.
- If your patient currently fills home delivery or specialty prescriptions through Express Scripts, prescriptions with at least one refill will be transferred, with the exception of controlled substances and compound drugs, to IngenioRx Home Delivery Pharmacy and IngenioRx Specialty Pharmacy.
- As your patients transition, new home delivery and specialty prescriptions will need to be sent to IngenioRx.
- o For providers using ePrescribing there are no changes, simply select IngenioRx.
- o For providers who do not use ePrescribing, you should send your home delivery and specialty prescriptions to IngenioRx.
IngenioRx Home Delivery Pharmacy new prescriptions:
Phone Number: 1-833-203-1742
Fax number: 1-800-378-0323
IngenioRx Specialty Pharmacy:
Prescriber phone: 1-833-262-1726
Prescriber fax: 1-833-263-2871
- If you want to check whether or not a specific patient has moved to IngenioRx, Availity will display the member’s PBM information under the patient information section as part of the eligibility and benefits inquiry.
- If you have immediate questions, you can contact the Provider Service phone number on the back of your patient’s ID card or call the number you normally use for questions.
For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit https://www11.anthem.com/ca/pharmacyinformation/. The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To view the “Marketplace Select Formulary” and pharmacy information, scroll down to the end of the page, then click on “Select Drug List”. This drug list is also reviewed and updated regularly as needed. FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org. > Pharmacy Benefits.
AllianceRX Walgreens Prime is the specialty pharmacy program for the Federal Employee Program. You can view the Specialty Drug List or call us at 1-888-346-3731 for more information. Effective March 1, 2019, Laborers Health and Welfare Trust Fund for Northern California will offer an Anthem Blue Cross Medicare preferred PPO plan. Retirees with Medicare Parts A and B are eligible to enroll in the Medicare preferred PPO plan. The plan includes the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare.
Non-contracted providers may continue treating Laborers Health and Welfare Trust Fund for Northern California members and will be reimbursed 100% of Medicare’s allowed amount for covered services, less any member cost share.
In addition, Laborers Health and Welfare Trust Fund for Northern California retirees pay the same cost share for both in-network and out-of-network services. Locally or nationwide, doctors or hospitals, in- or out-of-network — the member’s cost share doesn’t change.
The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers, and also covers additional benefits that Medicare does not, such as an annual routine physical exam, hearing, LiveHealth Online and SilverSneakers®.
The prefix on Laborers Health and Welfare Trust Fund for Northern California member ID cards will be MBL. The cards will also show the Laborers Health and Welfare Trust Fund for Northern California name and National Access Plus icon.
Providers may submit claims electronically using the electronic payer ID for the Blue Cross Blue Shield plan in their state or submit a UB-04 or CMS-1500 form to the Blue Cross Blue Shield plan in their state. Claims should not be filed with Original Medicare. Contracted and noncontracted providers may call the provider services number on the back of the member ID card for benefit eligibility, prior authorization (PA) requirements and any questions about Laborers Health and Welfare Trust Fund for Northern California member benefits or coverage.
Detailed PA requirements also are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com. Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.
This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.
Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.
If you have questions or feedback, please use this email link. The following revised clinical criteria will be effective May 1, 2019. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria. Please share this notice with other members of your practice and office staff.
Clinical criteria effective date
|
Clinical criteria number
|
Clinical criteria
|
Clinical criteria (new/revised)
|
May 1, 2019
|
ING-CC-0001
|
Erythropoiesis Stimulating Agents
|
Revised
|
May 1, 2019
|
ING-CC-0004
|
H.P. Acthar Gel®
(repository corticotropin injection)
|
Revised
|
May 1, 2019
|
ING-CC-0072
|
Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
|
Revised
|
75743MUPENMUB 01/24/2019 Anthem updated the 835 electronic remittance advice (ERA) for individual Medicare Advantage members enrolled in dual special needs plans (D-SNPs). These members have Medicare and Medicaid coverage. This change was made per the Centers for Medicare & Medicaid Services Change Request CR10433. The following changes have been implemented for the cost share and should be filed with the state Medicaid agency:
- Group code patient responsibility (PR) will be assigned.
- Claim adjustment reason codes (CARCs) will include the following:
- o 1 — deductible amount (professional claim)
- o 2 — coinsurance amount (professional claim)
- o 3 — copay amount (professional and facility claim)
- o 247 — deductible for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
- o 248 — coinsurance for professional service rendered in an institutional setting and billed on an institutional claim (facility claim)
- Remittance advice remark codes (RARCs) will include the following:
- o N781 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
- o N782 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
- o N783 — Patient is a Medicaid/qualified Medicare beneficiary. Review your records for any wrongfully collected copay. This amount may be billed to a subsequent payer.
Please be sure to ask Medicare Advantage members for their Medicaid identification number to assist with billing for the cost share. This number will be different from their Medicare Advantage identification number.
75743MUPENMUB 01/24/2019 In 2019, Anthem is offering Dual Eligible Special Needs Plans (D-SNPs) to people who are eligible for both Medicare and Medicaid benefits or who are qualified Medicare beneficiaries (QMBs). D-SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These plans are $0 premium plans. Some include a combination of supplemental benefits such as hearing, dental, vision as well as transportation to doctors’ appointments. Some D-SNP plans may also include a card or catalog for purchasing over-the-counter items.
Providers who are contracted for D-SNP plans are required to complete annual training to keep up-to-date on plan benefits and requirements, including coordination of care and Model of Care elements. Providers contracted for our D-SNP plans will receive notices in Q1 2019 that contain information for online training through self-paced training through our training site, hosted by SkillSoft. Every provider contracted for our D-SNP plans is required to complete this annual training and click the attestation within the training site stating that they have completed the training. These attestations can be completed by individual providers or at the group level with one signature.
Centers for Medicare & Medicaid Services regulations protect D-SNP members from balance billing.
For any questions regarding how claims are paid, please contact Provider Services by calling the number on the back of the member’s ID card.
75743MUPENMUB 01/24/2019 |