 Provider News CaliforniaMarch 2020 Anthem Blue Cross Provider News - CaliforniaEPO plans and network
For the 2020 benefit year, Anthem Blue Cross (Anthem) will continue to offer EPO individual on exchange and off exchange plans in Covered California.
We are pleased to announce the expansion of our individual EPO on and off exchange plans to the Central Coast areas of California. Below is a list of counties located in regions where Anthem will be offering 2020 EPO on and off exchange individual plans.
Counties
Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mariposa, Mendocino, Merced, Modoc, Monterey, Nevada, Plumas, San Benito, San Joaquin, San Luis Obispo, Santa Barbara, Santa Clara, Santa Cruz, Shasta, Sierra, Siskiyou, Stanislaus, Sutter, Tehama, Trinity, Tulare, Tuolumne, Ventura, Yuba
If you are an Anthem Behavioral Health Network provider, your agreement includes plans on and off the exchange. You will continue to provide services to Anthem members who have purchased coverage of a plan on or off the exchange as you currently do under your Anthem provider agreement.
The 2020 EPO plans do not have out-of-network benefits except for emergent/urgent or authorized services only.
HMO plans and network
Starting with 2020 benefit year, Anthem is excited to re-enter the counties listed below with our HMO individual on exchange and off exchange plans.
Counties
Fresno, Kings, Madera, Los Angeles, Riverside, San Bernardino
Anthem appreciates your continued network participation in our individual on and off exchange plans. If you have any questions regarding this information, email our Network Relations team at CAContractSupport@anthem.com. Anthem Blue Cross (Anthem) has network leasing arrangements with a variety of organizations, which we call Other Payors. Other payors and affiliates use the Anthem network.
Under the terms of your provider agreement, members of other payors and affiliates are treated like Anthem members. As such, they’re entitled to the same Anthem billing considerations, including discounts and freedom from balance billing. You can obtain the Other Payors list on the Availity web portal, at www.Availity.com. From the Availity site, select Home > Anthem California > Education and Reference Center, or email us at CAContractSupport@Anthem.com. Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before with our Provider News.
Provider News 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 Provider News, 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 Provider Maintenance Form landing page to review more.
The new online form can be found the redesigned provider site www.anthem.com/ca, select the Providers tab then select Provider Maintenance Form in the sub bullets. In addition, the Provider Maintenance Form can be accessed through the Availity Web Portal by selecting California> Payer Spaces-Anthem Blue Cross> Resources tab >Provider Maintenance Form.
Important information about updating your practice profile:
- Change request should be submitted using the online Provider Maintenance Form
- Submit the change request online. No need to print, complete and mail, fax or email demographic updates
- You will receive an auto-reply e-mail acknowledging receipt of your request and another email when your submission has been processed
- For change(s) that require submission of an updated IRS Form w-9 or other documentation, attach them to the form prior to submitting
- Change request should be submitted with advance notice
- Contractual agreement guidelines may supersede effective date of request
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, select the Providers tab, then select the Find A Doctor in the sub bullets) and review how you and your practice are being displayed. It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137), requires that Anthem Blue Cross (Anthem) provide our members accurate and up-to-date provider directory data. As a result, Anthem will be conducting ongoing outreaches to all practices to confirm the information we have on file is accurate. Without verification from you that our Provider Directory information is accurate, we will be required to remove your practice from the directories we make available to our members. We appreciate your attention to this matter. Blue Cross of California dba Anthem Blue Cross and Anthem Blue Cross Life & Health Insurance Company (collectively, Anthem”) are committed to keeping you, our network partners, updated on our activities related to our compliance with the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) Timely Access to Non-Emergency Health Care Services Regulations (the “Timely Access Regulations”), respectively. Anthem maintains policies, procedures, and systems necessary to ensure compliance with the Timely Access Regulations, including access to non-emergency health care services within prescribed timeframes (also referred to as the “time elapsed standards” or “appointment wait times”). Anthem can only achieve this compliance with the help of our provider network partners, you!
There are many activities that are conducted to support compliance with the regulations and we need you, as well as covered individuals, to help us attain the information that is needed. These studies allow our Plan to determine compliance with the regulations.
The activities include, but are not limited to the following:
- Provider Appointment Availability Survey
- Provider Satisfaction Survey
- Provider After – Hours Survey
We appreciate that in certain circumstances time-elapsed requirements may not be met. The Timely Access Regulations have provided exceptions to the time-elapsed standards to address these situations:
Extending Appointment Wait Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.
Preventive Care Services and Periodic Follow-up Care: Preventive care services and periodic follow up care are not subject to the appointment availability standards. These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease.
Advanced Access: The primary care appointment availability standard may be met if the primary care physician office provides “advanced access.” “Advanced access” means offering an appointment to a patient with a primary care physician (or nurse practitioner or physician’s assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day).
We hope this clarifies Anthem’s expectations and your obligations regarding compliance with the Timely Access Regulations. Our goal is to work with our providers to successfully meet the expectations for the requirements with the least amount of difficulty and member abrasion.
Members also have access to Anthem’s 24/7 NurseLine. The NurseLine wait time is not to exceed 30 minutes. The phone number is located on the back of the member ID card. In addition, Members and Providers have access to Anthem’s Customer Service team at the telephone number listed on the back of the member ID card. A representative may be reached within 10 minutes during normal business hours.
Please contact the Anthem Member Services team at the telephone number listed on the back of the member ID card to obtain assistance if a patient is unable to obtain a timely referral to an appropriate provider.
If you have further questions, please contact Network Relations at CAContractSupport@anthem.com.
Click on the attachment to view Anthem's Access Standards.
For Patients (Members) with Department of Managed Health Care Regulated Health plans: If you or your patients are unable to obtain a timely referral to an appropriate provider or for additional information about the regulations, visit the Department of Managed Health Care’s website at www.dmhc.ca.gov/HealthCareinCalifornia/YourHealthCareRights/TimelyAccesstoCare.aspx or call toll-free 1-888-466-2219 for assistance.
For Patients (Members) with California Department of Insurance Regulated Health plans: If you or your patients are unable to obtain a timely referral to an appropriate provider or for additional information about the regulations, visit the Department of Insurance’s website at www.insurance.ca.gov or call toll-free 1-800-927-4357 for assistance.
Language Assistance Program
For members whose primary language is not English, Anthem offers free language assistance services through interpreters and other written languages. If you or the member is interested in these services, please call the Anthem Member Services number on the member’s ID card for help (TTY/TDD: 711). Anthem Blue Cross would like to share some recent enhancements to the online site for our monthly provider publication – Provider News.
- Article categories – such as “Administrative,” “Medicaid,” “Products and Programs” and so on – are now appearing directly under the article title on the website and in PDFs. (This will help differentiate between commercial and government business content.) Please see the illustration below.
- We have also enhanced the look and feel of PDFs for individual articles and publications. Within PDFs for publications, you’ll find:
- A table of contents
- A bold line separating each article
- The URL for each article is included so users can access online if desired
- Attachments will show if appropriate
We hope you find these changes helpful, as we continue to work to improve our provider communications vehicle and to make the tool easier to use.
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, Verscend, Ciox, Sharecare, and Episource 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.
We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2020). 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:
- EMR Interoperability
- Allscripts (Opt in -- signature required to allow for remote review)
- NextGen (Opt out -- auto-enrolled)
- Athenahealth (Opt out -- auto enrolled)
- 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 at Socorro.Carrasco@anthem.com.
Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests. Anthem Blue Cross (Anthem) relocated their Woodland Hills office.
New Address: Old Address:
21215 Burbank Blvd. 21555 Oxnard Street
Woodland Hills, CA 91367 Woodland Hills, C 91367
Additional department contact information below:
Claims and correspondence via Federal Express, registered or certified mail, etc.:
Anthem Blue Cross / Name of Product
21215 Burbank Boulevard
Woodland Hills, CA 91367
Legal Department: Hospital Stop Loss
Anthem Blue Cross Anthem Blue Cross
Legal Department CA9303-R03B Attn: Hospital Stop Loss Unit
Attn: Meet and Confer Request 21215 Burbank Blvd.
21215 Burbank Blvd. Woodland Hills, CA 91367
Woodland Hills, CA 91367 Anthem Blue Cross (Anthem) will work to facilitate the Continuity of Care/Transition of Care (COC/TOC) when Members, or their covered dependents with qualifying conditions, need assistance in transitioning to in-network Providers or Facilities. The goal of this process is to minimize service interruption and to assist in coordinating a safe transition of care.
This program is for Members when their Provider or Facility terminates from the network and new Members (meeting certain criteria) who have been participating in active treatment with a provider not within Anthem’s network.
Anthem will work to facilitate the Continuity of Care/Transition of Care (COC/TOC) when Members, or their covered dependents with qualifying conditions, need assistance in transitioning to in-network Providers or Facilities. The goal of this process is to minimize service interruption and to assist in coordinating a safe transition of care.
Members can call Anthem’s Member Services to request continuity/transition of care or for help with completing the form.
For California members, fax the completed forms toll free:
- Medical requests 1-877-214-1781.
- Behavioral health requests - 1-877-521-4787
- Applied behavior analysis services 1-866-582-2287.
Access the Continuity of Care/Transition of Care Request Form online. The most current version includes an update to the definition of a maternal mental health condition - a mental health condition that can impact a woman during pregnancy, peri or postpartum, or that arises during pregnancy, in the peri or postpartum period, up to one year after delivery. For an individual who presents written documentation of being diagnosed with a maternal mental health condition from their treating health care provider, completion of covered services for the maternal mental health condition will be considered for a limited period of time, not to exceed 12 months from the diagnosis or from the end of the pregnancy, whichever occurs later.
Read about Anthem’s Continuity of Care/Transition of Care Program in the Facility and Professional Provider Manual. The Manual is available online at anthem.com/ca > Providers > Provider Overview: Policies, Guidelines & Manuals, scroll down to Provider Manual on the left-hand side of the webpage. Billing of patient treatment can be complex, particularly when determining whether modifiers are required for proper payment. Anthem Blue Cross (Anthem) reimbursement policy and correct coding guidelines establish the appropriate use of coding modifiers. We would like to highlight the appropriate use of some commonly used modifiers.
Things to remember…
- Review the “CPT Surgical Package Definition” found in the current year’s CPT Professional Edition. Use modifiers such as 25 and 59 only when the services are not included in the surgical package.
- Review the current year’s CPT Professional Edition Appendix A - Modifiers for the appropriate use of modifiers 25, 57 and 59.
- When an evaluation and management (E/M) code is reported on the same date of service as a procedure, the use of the modifier 25 should be limited to situations where the E/M service is “above and beyond” or “separate and significant” from any procedures performed the same day.
- When appropriate, assign anatomical modifiers (Level II HCPCS modifiers) to identify different areas of the body that were treated. Proper application of the anatomical modifiers helps ensure the highest level of specificity on the claim and can help show that different anatomic sites received treatment.
- Use modifier 59 to indicate that a procedure or service was distinct or independent of other “non E/M services” performed on the same date of service. The modifier 59 represents services not normally performed together but which may be reported together under the circumstances.
If you feel that you have received a denial after applying a modifier appropriately under correct coding guidelines, please follow the normal claims dispute process and include medical records that support the usage of the modifiers when submitting claims for consideration.
We will be publishing additional articles on correct coding in upcoming newsletters. Some professional (837P / HCFA-1500) claims for services rendered to non-Anthem Blue plan members at retail health locations are being reported with a Place of Service that does not reflect a retail health clinic location. Specifically, for services rendered at a retail health location, some providers are submitting values for Office (11) or Urgent Care Facility (20) instead of the value of Walk-in Retail Health Clinic (17). Reporting Place of Service as 11 or 20 can cause claims to process incorrectly, and thus result in the need for claim adjustments and rework for providers.
If your practice is a Walk-in Retail Health Clinic, please remind your coding staff to report the most accurate Place of Service, Walk-in Retail Health Clinic (17), for professional claims when submitting claims for non-Anthem members. 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 anthem.com/pharmacyinformation. The commercial marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “Select Drug Lists.” 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. This communication applies to the Medicaid, Medicare Advantage and MMP programs for Anthem Blue Cross (Anthem).
Anthem provides benefits for covered services rendered by nurse practitioners (NPs) and physician assistants (PAs) when operating within the scope of their license. Our policy states that these mid-level practitioners are required to file claims using their specific NPI number — not that of the medical doctor.
We will continue to monitor this area of concern through medical chart review and data analysis. Billing noncompliance can be considered a contract breach.
Anthem recognizes the quality of care delivered to our members can be improved by the proper use of NPs and PAs. This notice is in no way intended to discourage their proper use, but rather to clearly define how services should be appropriately billed.
Thank you for your continued participation. Should you have any questions, please call one of our Provider Customer Care Centers:
- Medi-Cal (Outside L.A. County): 1-800-407-4627
- Medi-Cal (Inside L.A. County): 1-888-285-7801
- Cal MediConnect: 1-855-817-5786
- Medicare Advantage: Call the number on the back of members’ ID cards.
507411MUPENMUB This communication applies to the Medicaid, Medicare Advantage and MMP programs for Anthem Blue Cross (Anthem).
Anthem provides benefits for covered services rendered by nurse practitioners (NPs) and physician assistants (PAs) when operating within the scope of their license. Our policy states that these mid-level practitioners are required to file claims using their specific NPI number — not that of the medical doctor.
We will continue to monitor this area of concern through medical chart review and data analysis. Billing noncompliance can be considered a contract breach.
Anthem recognizes the quality of care delivered to our members can be improved by the proper use of NPs and PAs. This notice is in no way intended to discourage their proper use, but rather to clearly define how services should be appropriately billed.
Thank you for your continued participation. Should you have any questions, please call one of our Provider Customer Care Centers:
- Medi-Cal (Outside L.A. County): 1-800-407-4627
- Medi-Cal (Inside L.A. County): 1-888-285-7801
- Cal MediConnect: 1-855-817-5786
- Medicare Advantage: Call the number on the back of members’ ID cards.
Reminder: Mid-level practitioners are required to file using their NPI
Click here for more information about the Reimbursement Policy Update Child Health and Disability Program (CHDP).
507411MUPENMUB Code only confirmed cases
According to ICD-10-CM coding guidelines for Chapter One, code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H. In this context, ‘confirmation’ does not require documentation of positive serology or culture for HIV. The provider’s diagnostic statement that the patient is HIV positive or has an HIV-related illness is sufficient.
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Status
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ICD-10-CM code
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Asymptomatic HIV
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- Assign code Z21 — Asymptomatic human immunodeficiency virus [HIV] infection status when the patient without any documentation of symptoms is listed as being ‘HIV positive’, ‘known HIV’, ‘HIV test positive’ or similar terminology.
- Assign code B20 — Human immunodeficiency virus [HIV] disease on the claim when the term AIDS is used, when the patient is being treated for HIV-related illness or when the patient is described as having any active HIV-related condition.
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Patients with inconclusive HIV serology
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- Assign code R75 — Inconclusive laboratory evidence of human immunodeficiency virus [HIV] when the patient’s record is documented with inconclusive HIV serology, but there is no definitive diagnosis or manifestations of the illness.
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Previously diagnosed HIV-related illness
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- Code B20 if you document a patient as having had any known prior diagnosis of an HIV-related illness — Z21 is no longer reported. If the patient develops an HIV-related illness, they should be assigned code B20 on every subsequent admission/encounter.
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HIV infection in pregnancy, childbirth and the puerperium
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- Assign code O98.7 — Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium first when a patient presents for treatment of an HIV-related illness during pregnancy, childbirth or the puerperium followed by code B20.
- Also assign additional code(s) for HIV-related illness(es). Keep in mind that codes from Chapter 16 take priority when sequencing codes on the claim.
- If a patient with asymptomatic HIV infection status presents for a routine visit during pregnancy, childbirth or the puerperium, the correct code assignment would be O98.7 followed by code Z21.
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Assign code B20 for all types of HIV infections, which may be described by a variety of terms including:
- AIDS.
- Acquired immune deficiency syndrome.
- Acquired immunodeficiency syndrome.
- AIDS-related complex (ARC).
- AIDS-related conditions.
- HIV infection, symptomatic.
Testing for HIV:
- Assign code Z11.4 — Encounter for screening for human immunodeficiency virus [HIV] when seeing a patient with no prior diagnosis of HIV infection or positive HIV-status to determine their HIV status.
- Code the signs and symptoms when seeing a patient with signs or symptoms for HIV testing. If you provide counseling during the encounter, assign additional code
Z71.7 — Human immunodeficiency virus [HIV] counseling.
- Assign code Z71.7 if a patient’s test results are negative for HIV.
- Assign code Z72.8 if a patient is known to be in a high-risk group for HIV infection. Other problems related to lifestyle can be assigned as an additional code.
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Major HIV-related conditions
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HIV-related condition
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ICD-10-CM code
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Pneumonia, unspecified organism
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J18.9
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Tuberculosis of other sites
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A18.89
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Sepsis, unspecified organism
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A41.9
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Candida stomatitis (thrush)
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B37.0
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Herpes zoster (any site)
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B02.9
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Encephalopathy, unspecified
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G93.40
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Other HIV-related conditions
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Tinea cruris
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B35.6
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Anemia, unspecified
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D64.9
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Underweight
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R63.6
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Acute lymphadenitis
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L04.9
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Arthropathy, unspecified
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M12.9
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Splenomegaly, not elsewhere classified
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R16.1
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Weakness
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R53.1
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HIV/AIDS prevention
The CDC works with other federal agencies, state and local health departments, national organizations, and other entities to reduce the spread of HIV in the United States. This work covers several components:
- Behavioral interventions — These interventions ensure people have the information, motivation and skills necessary to reduce the risk of infection.
- HIV testing — Testing is critical to prevent the spread of HIV.
- Treatment and care — Treatment and care enable individuals with HIV to live longer, healthier lives.
The CDC remains on the forefront of pursuing high-impact prevention. This approach is designed to maximize the impact of prevention efforts for all Americans at risk for HIV infections and the CDC is aligning its efforts with the first National HIV/AIDS Strategy for the United States (NHAS). The Division of HIV/AIDS Prevention has developed a strategic
three-year plan for 2017 to 2020 with the goal of one day achieving a future free of HIV.
Resources:
- ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2019.
- http://www.cdc.gov: HIV/AIDS.
ACA-NU-0209 Overuse of antibiotics is directly linked to the prevalence of antibiotic resistance. Promoting judicious use of antibiotics is important for reducing the emergence of harmful bacteria that is unresponsive to treatment. The following HEDIS® measures assess appropriate antibiotic dispensing for pharyngitis, upper respiratory infection and bronchitis/bronchiolitis. Changes for HEDIS 2020 include expanded age range and additional stratifications.
Appropriate Testing for Pharyngitis (CWP)
Pediatric Clinical Practice Guidelines recommend only children with lab‑confirmed group A strep or other bacteria-related ailments be treated with appropriate antibiotics. This measure reports the percentage of episodes for members 3 years of age and older where the member was diagnosed with pharyngitis, prescribed an antibiotic at an outpatient visit and received a group A strep test. A higher rate indicates better performance (in other words, appropriate testing).
Appropriate Treatment for Upper Respiratory Infection (URI)
This measure calculates the percentage of episodes for members 3 months of age and older with a diagnosis of upper respiratory infection that did not result in an antibiotic dispensing event. Reducing unnecessary use of antibiotics is the goal of this measure. It is reported as an inverted rate. A higher rate indicates appropriate upper respiratory infection treatment (in other words, the proportion of episodes that did not result in an antibiotic dispensing event).
Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)
There is considerable evidence that prescribing antibiotics for uncomplicated acute bronchitis is not indicated unless it is associated with a comorbid diagnosis. This measure assesses the percentage of episodes for members ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event. It is reported as an inverted rate. A higher rate indicates appropriate acute bronchitis/bronchiolitis treatment (in other words, the proportion of episodes that did not result in an antibiotic dispensing event).
Helpful tips:
- When patients present with symptoms of pharyngitis, ensure proper testing (for strep) is performed to avoid the unnecessary prescribing of antibiotics. Record the results of the strep test.
- If prescribing an antibiotic to members with acute bronchitis, be sure to use the diagnosis code for the bacterial infection and/or comorbid condition.
- Educate members on the difference between bacterial and viral infections. Refer to the illness as a common cold, sore throat or chest cold. Parents and caregivers tend to associate these labels with a less frequent need for antibiotics.
- Write a prescription for symptom relief, such as rest, fluids, cool mist vaporizers and over‑the‑counter medicine.
- If a patient insists on an antibiotic, consider using delayed prescribing. Refer to the CDC handout for patients titled What is Delayed Prescribing? available at the link below.
Resources:
ACA-NU-0207 This communication applies to the Medicaid, Medicare Advantage and MMP programs for Anthem Blue Cross (Anthem).
Anthem provides benefits for covered services rendered by nurse practitioners (NPs) and physician assistants (PAs) when operating within the scope of their license. Our policy states that these mid-level practitioners are required to file claims using their specific NPI number — not that of the medical doctor.
We will continue to monitor this area of concern through medical chart review and data analysis. Billing noncompliance can be considered a contract breach.
Anthem recognizes the quality of care delivered to our members can be improved by the proper use of NPs and PAs. This notice is in no way intended to discourage their proper use, but rather to clearly define how services should be appropriately billed.
Thank you for your continued participation. Should you have any questions, please call one of our Provider Customer Care Centers:
- Medi-Cal (Outside L.A. County):........... 1-800-407-4627
- Medi-Cal (Inside L.A. County):.............. 1-888-285-7801
- Cal MediConnect:.................................. 1-855-817-5786
- Medicare Advantage:.... Call the number on the back of members’ ID cards.
507411MUPENMUB Beginning January 1, 2020, patients using nonpreferred products with a high patient cost share are now contacted about the availability of lower patient cost share preferred alternatives. If the patient is interested in switching, we will call or fax their provider who can determine whether the preferred alternative is clinically appropriate. This is strictly informational and not a substitute for physician‑directed medical evaluations or treatments.
Open the attachment to view the list of included nonpreferred products and corresponding preferred alternatives.
507643MUPENMUB
Your patient’s current supplemental benefit for Personal Home Helper has been reauthorized for 2020. For billing in 2020, use the new authorization number. For more information or to view the new authorization number, sign into the Availity Portal or call Provider Services at 1-800-499-9554.
Submit claims electronically through Availity
Availity is well known as a web portal and claims clearinghouse, but they are much more. Availity also functions as an electronic data interchange (EDI) gateway for multiple payers and is the single EDI connection for all of Anthem, Inc. It will allow you to submit claims electronically, verify pre-authorization and member information, check claims status, and much more.
To get started, go to https://www11.anthem.com/edi and select your state.
507288MUPENMUB |