In conjunction with National Colorectal Cancer Awareness Month, Anthem Blue Cross (Anthem) would like to remind healthcare professionals to raise awareness to their patients about colorectal cancer screenings.

Encourage your patients to make time for regular colorectal cancer screenings. It’s one of the most valuable ways they can protect their health and peace of mind. Colorectal cancer is the third most common type of cancer among adults, but it often doesn’t show any symptoms especially at first.

The good news is that the survival rate for colorectal cancer is about 90% when it’s caught early, before it’s had the chance to spread. Regular screenings are the number one way to detect it, but many adults who need screenings don’t get them. Making these important tests a priority is about your patients staying healthy and strong for the ones they love.

The American Cancer Society[1] recommends that most adults have regular colorectal cancer screenings from age 45 to age 75. Talk to your patients about when and how often they should be tested and what kind of screening is right for them.

You and your Anthem patients have access to high-quality, low-cost colorectal cancer screening fecal immunochemical test (FIT) kits by Labcorp and Quest Diagnostics. If you have specific questions, contact the labs directly:

• Labcorp: FIT test, 888-LABCORP (888-522-2677) or labcorp.com/cancer/colorectal/providers
• Quest Diagnostics: InSure ONE^TM kit, 866-MY-QUEST (866-697-8378) or https://clinical.QuestDiagnostics.com/QuestInSureONE

To find Labcorp, Quest Diagnostics and other participating labs in your patient’s plan network, select Find Care from the Provider Resources menu at https://www.anthem.com/ca/provider.

[1] Colorectal Cancer Guideline | How Often to Have Screening Tests

New ID cards issued for our members effective January 1, 2023

Members and their dependents enrolled in the Screen Actors Guild – American Federation of Television and Radio Artists (SAG-AFTRA) Health Plan had a group number change effective January 1, 2023.  In the past, enrollees received their health insurance ID cards directly from SAG-AFTRA Health Plan.  

ID cards

Anthem Blue Cross (Anthem) issued new ID cards with the new group number L05927 to all Anthem members enrolled in the SAG-AFTRA Health Plan. New ID cards were provided digitally or mailed to all affected members. These ID cards carry the nationally recognized Anthem logo. 

It is important to note that any services requiring prior authorization, or any service being rendered on or after January 1, 2023, should be submitted under the new group number (L05927).  We suggest that you update your records with the new group number change. 

Tips to help ensure accurate claims processing and prompt payments  

When Anthem members arrive at the office or facility, ask to see their current member identification card at each visit. Many Anthem members no longer receive a paper card, so they will present their digital card on their mobile device. Asking this will help:

• Identify the member’s product.
• Obtain health plan contact information.
• Speed claims processing.

Note: Claims providers submit with an incorrect ID number may be unable to be processed and may be returned for correction and resubmission with the correct ID.

Use Availity to verify eligibility and benefits

Through our secure website Availity.com,* you can easily get answers to your questions about claim status, eligibility, and benefits. You can also retrieve electronic remittances, make provider demographic changes, and complete your prior authorization inquiries. 

If you are not an Availity user, visit www.availity.com to register today. It’s safe, secure, and easy to use. 

Contact us

To contact our Provider Service team, please call the Provider Service toll-free number located on the back of the member's new ID card.

Each year, Anthem performs a review of a sample of our members’ medical records as part of the HEDIS^® quality study. HEDIS is part of a nationally recognized quality improvement initiative and is used by Centers for Medicare and Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and several states to monitor the performance of managed care organizations.

For 2022, Anthem will begin requesting medical records in January 2023. No special authorization is needed for you to share member medical record information with us since quality assessment and improvement activities are a routine part of healthcare operations.

Ways to submit your records:

• Remote electronic medical records (EMR) access service: As we published in the Provider Newsletter, we now offer EMR access to providers to submit member medical record information to Anthem. If you are interested in more information, please contact us at Centralized_EMR_Team@anthem.com.
• Upload: Medical records can be uploaded to the Anthem secure website using the instructions in the request document.
• Fax: Medical records can be faxed to Anthem using the instructions in the request document.
• U.S. Postal Service: Medical records can be mailed to Anthem using the instructions in the request document.
• Onsite: Medical records can be pulled by an Anthem representative at your office where medical records are located.
• Secure File Transfer Protocol (SFTP): Medical records can be uploaded via secure website set up by Anthem.

HEDIS review is time sensitive, so please submit the requested medical records within the time frame indicated in the initial HEDIS request document.

We appreciate the care you provide our members. Your assistance is crucial to ensuring our data is statistically valid, auditable, and accurately reflects quality performance.

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

Anthem wants to help our consumers access providers who will support their health and wellness needs. To facilitate this, we maintain an up-to-date, accurate, and complete provider directory.

We need your help! Center for the Study of Services (CSS) is an independent research firm that is helping us collect accurate information. Please take a moment to review and update the information we have on file for your practice.

To review your directory profile information, go to https://verify.cssresearch.org/CA.

Using your tax identification number, sign in and access the practice profile. You will be able to review your practice’s profile information and make any changes or updates, including:

• Network provider directory details.
• Office details (for example, practice office address, billing address, office hours, telephone number, email, etc.).
• Other provider details (for example, accepting new patients, hospital affiliations).

Please note, this link will be available for six weeks, beginning March 20, 2023, and ending May 1, 2023, to allow us to process any updates.

If you have any questions about this initiative, please contact your local Provider Relationship Management representative or email our Provider Services team at https://www.anthem.com/provider/contact-us/email-form/.

If you have problems accessing the website or entering information, please contact a CSS representative at provider_directory@cssresearch.org.

Thank you for your continued partnership in keeping provider records up to date for our consumers.

We previously communicated that Carelon Medical Benefits Management, Inc.,* a separate company, would expand the Musculoskeletal Program to perform medical necessity review of the requested site of service for certain joint and interventional pain procedures beginning September 1, 2022. The expansion was delayed and will now be effective April 1, 2023, for Anthem Blue Cross (Anthem) fully insured consumers, as further outlined below.

Carelon Medical Benefits Management, Inc. will continue to manage the Musculoskeletal Program and level of care review. The Level of Care Guideline for Musculoskeletal Surgery and Procedures is used for the level of care review. Prior authorization will now also be required for the clinical appropriateness of the site in which the procedure is performed (site of care). Carelon Medical Benefits Management, Inc. will use the following Anthem Clinical Utilization Management Guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services. The Clinical Criteria to be used for these reviews can be found on the Anthem Provider website Clinical UM Guidelines page. Note, this does not apply to procedures performed on an emergent basis.

A subset of the Musculoskeletal Program codes will be reviewed for site of care. A complete list of CPT^® codes requiring prior authorization for the Musculoskeletal Site of Care Program is available on the musculoskeletal microsite. To determine if prior authorization is needed for an Anthem consumer on or after April 1, 2023, contact the Provider Services phone number on the back of the consumer’s ID card for benefit information. If providers use the interactive care reviewer (ICR) tool on the Availity Essentials* website to pre-certify an outpatient musculoskeletal procedure, ICR will produce a message referring the provider to Carelon Medical Benefits Management, Inc.

Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management, Inc.

Consumers included in the new program

This program will be available to fully insured members that currently participate in the Carelon Medical Benefits Management, Inc. Musculoskeletal Program that have added the Musculoskeletal Site of Care Program to their consumers’ benefit package as of April 1, 2023.

Consumers of the following products are excluded from this program:

• Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program^® (FEP)

Pre-service review requirements

For services provided on or after April 1, 2023, ordering and servicing providers may begin contacting Carelon Medical Benefits Management, Inc. as early as March 15, 2023, for review. Providers may submit prior authorization requests to Carelon Medical Benefits Management, Inc. in one of several ways:

• Access the ProviderPortal_SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access Carelon Medical Benefits Management, Inc. via the Availity Essentials website at availity.com.
• Call the Carelon Medical Benefits Management, Inc. Contact Center toll-free number at 877‑430-2288, Monday through Friday, 8 a.m. to 6 p.m. Eastern time.

Training webinars

Carelon Medical Benefits Management, Inc. will be offering two Musculoskeletal Site of Care Program training sessions that providers are invited to attend:

• Thursday, March 9, 2023 – 11 a.m. CT
• Wednesday, March 15, 2023 – 11 a.m. CT

We value your participation in our network and look forward to working with you to help improve the health of our consumers.

Register today for the Advancing Mental Health Equity for Youth & Young Adults forum hosted by Anthem and Motivo* for Anthem providers on March 15, 2023.

Anthem is committed to making healthcare simpler and reducing health disparities for youth and young adults. We believe that advancing health equity for young people is critical to not only improving their experience, but also ensuring the mental health system is a safe and trusted resource. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve.

Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem as we discuss the intersection of mental health, race, sexual orientation, gender identity, disability, and supporting youth and young adults on their mental health journey.

Each quarterly forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase diversity equity and inclusion in healthcare. 

Wednesday, March 15, 2023

4 to 5:30 p.m. ET

 
Please register for this event by visiting this link.

We communicated in the June 2022 provider update letter that Carelon Medical Benefits Management, Inc.* (then, AIM Specialty Health_®) would expand the Musculoskeletal Program for Anthem Blue Cross (Anthem) local fully insured members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon beginning October 1, 2022. However, the initial program implementation was delayed. The confirmed new implementation date is April 1, 2023.

For services on or after April 1, 2023, prior authorization will be required for the clinical appropriateness of monitored anesthesia or conscious sedation (MAC) when requested in conjunction with interventional pain codes. Carelon will use the following Anthem Clinical UM Guideline: CGMED-78: Anesthesia Services for Interventional Pain Management Procedures. The Clinical Criteria to be used for these reviews can be found on the Anthem provider website at https://anthem.com/ca/provider/policies/clinical-guidelines. Clinical site of care review may also apply if these procedures are requested in a hospital outpatient department and could safely be done in an ambulatory surgery center. If you have a member in a current course of treatment for pain management where services were approved without reviewing the MAC, identify the member for us at the next request. Please note, this does not apply to procedures performed on an emergent basis.

The anesthesiologist may determine that a member requires monitored anesthesia on the day of service. A retrospective review may be requested, or a post service claim may be submitted with a clinical record including the pre-anesthesia assessment, the patient’s medical history documenting that patient meets criteria for MAC, and a detailed description of the procedure performed for Carelon to determine coverage for the service as medically necessary.   

At this time, the codes that will be reviewed are 01991, 01992, 01937, 01938, 01939, and 01940. See a complete list of codes requiring prior authorization for the Carelon Monitored 

Anesthesia Care for Interventional Pain program here. To determine if prior authorization is needed for a member on or after April 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the Interactive Care Reviewer (ICR) tool on the Availity Essentials* platform to pre-certify an outpatient musculoskeletal will receive a message referring the provider to Carelon. (Note: ICR cannot accept prior authorization requests for services administered by Carelon.)

Members of the following products are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program^® (FEP^®). 

Pre-service review requirements

For services provided on or after April 1, 2023, ordering and servicing providers may begin contacting Carelon as early as March 20, 2023, for review. Providers may submit prior authorization requests to Carelon in one of the following ways:

• Access Carelon’s ProviderPortal_SM directly at www.providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization. Initiating a request on Carelon’s ProviderPortal_SM and entering responses to all the requested clinical questions will allow you to receive an immediate determination.
• Access Carelon via Availity Essentials* at www.availity.com.

Call the Carelon Contact Center’s toll-free number at 877-291-0360, Monday through Friday, 8:00 a.m. to 5 p.m. PT.  

 Training webinars

Carelon will be offering two Monitored Anesthesia Care training sessions that providers are invited to attend:

• Thursday March 30, 2023 – 9 a.m. PT
  Register here.
• Thursday April 6, 2023 – 9 a.m. PT
  Register here.

We value your participation in our network and look forward to working with you to help improve the health of our members.

The provider payment option, Pay Doctor Bill, offered to consumers via InstaMed,* will be terminated effective March 31, 2023. Anthem contracted with InstaMed to deliver options for consumers to view their claims and pay their out-of-pocket responsibility to doctors from the Sydney Health mobile app or from https://www.anthem.com/ca/provider. This is not related to the payment of health insurance premiums.

Even though this option will no longer be available, consumers still have other ways of paying doctors:

• Through a Health Savings Account (HSA) or Flexible Spending Account (FSA) if they have this type of account
• Through their bank’s bill pay feature on a mobile app or website
• Directly through doctor’s secure payment website or at the doctor’s office with a debit or credit card

A month prior to the termination of Pay Doctor Bill from the Sydney Health mobile app and the Anthem website, we will notify consumers within these applications.

(Policy G-06003, effective 04/14/2023)

Beginning with dates of service on or after April 14, 2023, Anthem Blue Cross will update the Modifiers 25 and 57 policy to not allow reimbursement for CPT^® code 99211 when appended with Modifier 25.

Based on the descriptions of both Modifier 25 and CPT 99211, the Evaluation and Management must be separately identifiable, and CPT 99211 is not a separately identifiable service.

In addition, the policy titled Modifiers 25 and 57: Evaluation and Management with Global Procedures will be renamed to Modifiers 25 and 57.

For additional information, please review the Modifiers 25 and 57 reimbursement policy at https://providers.anthem.com/ca.

Please continue to check for important Medi-Cal Managed Care updates at https://providers.anthem.com/california-provider/communications/news-and-announcements for the latest Medi-Cal Managed Care information, including:

• Clinical Criteria updates
• Prior authorization updates for medications billed under the medical benefit (Carvykti)
• Prior authorization updates for medications billed under the medical benefit (Aduhelm)

An annual planned visit (APV) can be a significant driver of positive health outcomes and engagement with a patient’s provider. There are three main types of important, but often underutilized, APVs: initial preventive physical exam (IPPE), annual wellness visit (AWV), and annual routine physical (ARP). By engaging your patient early in the year to schedule these visits, there is opportunity to increase your APVs in 2023, and, in turn, improve the health of your patients and increase your success in the value-based programs (VBPs) you may participate in.

The AWV is an important opportunity to address up to 20 Medicare Advantage Stars measures that encompass both clinical quality and patient experience. The development of a personalized prevention plan is a required component of the AWV and can be a useful tool in leading these conversations with patients.

(AMJC).

The terms AWV and ARP are often incorrectly used interchangeably, which can cause confusion as these services are vastly different. AWVs are visits that are focused on preventive care, screenings, and the development of a personalized prevention plan. While an AWV includes taking standard measurements such as blood pressure, height, and weight, no hands-on physical exam is performed. The ARP is more extensive than an AWV in that it consists of a comprehensive, multi-system physical exam and includes bloodwork and other lab tests that are all based on the patient’s age, gender, and identified risk factors.

Note: An AWV and ARP may be performed during the same visit and providers can submit one claim that includes codes for both.



While the AWV may seem to have many requirements, several components of this visit can be performed by care team members other than the provider. See the sample workflow below that highlights steps that office staff can complete.

It is essential for providers to complete an APV for each of their assigned Medicare members. These visits help keep patients healthy and can increase practice revenue. For more tools and resources, please visit https://www.anthem.com/ca/provider/medicare-advantage or reach out to your provider representative.

The Controlling High Blood Pressure (CBP) HEDIS^® measure can be challenging as it not only requires proof of a blood pressure reading, but also that the patient’s blood pressure is adequately controlled. CBP care gaps can open and close throughout the year depending on if the patient’s most recent BP reading is greater than 140/90 mmHG. As we approach the end of the year, it’s important that we have record of your patients’ blood pressure readings and that you schedule any members who have not had a BP reading during 2022, or who have had high readings recorded this year.

Tips when scheduling members to close CBP care gaps:

• When scheduling appointments, have staff ask patients to avoid caffeine and nicotine for at least an hour before their scheduled appointment time.
• If possible, update your scheduling app and/or your reminder text message campaigns to include reminders about abstaining from caffeine and nicotine prior to appointment time as well as a reminder to arrive early to avoid a sense of rushing.

Tips for lower BP readings during the appointment:

• Ask the patient if they tend to get nervous at appointments and have higher readings as a result. If they do, take their blood pressure at both the start and end of the appointment and document the lower reading.
• Readings can also vary arm to arm. If slightly elevated in one arm, try the other and document the lower reading.

Getting credit for adequately controlled blood pressure readings:

• Submit readings via Category II CPT^® codes on claims.

• Ensure readings are carefully and appropriately documented within your electronic medical record system.
• If you have questions on how to submit readings, speak to your care or practice consultant.
• Also, be sure to adequately code patients who meet the exclusion criteria:
  • Exclusions:
    • Palliative care
    • Enrolled in hospice
    • Frailty and/or advanced illness
    • Living in long-term care
  • Optional exclusions:
    • Dialysis (ESRD), kidney transplant, nephrectomy
    • Female members with a diagnosis of pregnancy
    • Non-acute inpatient admissions

Effective January 1, 2023, many Western Teamsters Welfare Trust retirees who are eligible for Medicare Parts A and B will be enrolled in an Medicare Preferred (PPO) plan for Anthem Blue Cross. The plan allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. In addition, Western Teamsters Welfare Trust retirees pay the same cost share for both in-network and out-of-network services. The MA 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, vision, LiveHealth Online*, and SilverSneakers^®.*

The prefix on Western Teamsters Welfare Trust member ID cards will be MBL. The ID cards will also show the Western Teamsters Welfare Trust logo.

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 non-contracted providers may call the Provider Services number on the back of the member ID card for benefit eligibility, prior authorization requirements and any questions about Western Teamsters Welfare Trust member benefits or coverage.

Detailed prior authorization requirements also are available to contracted providers by accessing the Provider Self-Service Tool at Availity.com.*

(Policy G-06006)

The Modifier Usage policy is aligning with Medicare modifier requirements by adding the following to our Related Coding section:

• Modifier CO — Outpatient occupational therapy assistant services
• Modifier CQ — Outpatient physical therapy assistant services

Additionally, Modifier FB (Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples) was expanded to facility providers.

For additional information, please review the Modifier Usage reimbursement policy at https://www.anthem.com/ca/provider/medicare-advantage.

Anthem Blue Cross is actively seeking to promote CMS’s transition care management (TCM) program for its Medicare members.

The goal is to ensure comprehensive physician follow-up and management of patients within seven and/or 14 days of discharge from hospital, skilled nursing facility (SNF), inpatient rehabilitation hospital (IRF), or long-term acute care hospitals (LTAC). And thus, to minimize clinical relapses, that often result in acute hospital readmissions, within 30-days of discharge.

CPT^® codes for these visits are:

• 99496 (post-discharge comprehensive follow-up within seven days): pays between $250 to $350, depending on region, and;
• 99495 (post-discharge follow-up within 14 days): pays between $190 to $260, depending on region. 

The primary intent for these visits is close post-discharge patient follow up with comprehensive physician/provider management of ongoing chronic comorbidities. So, visits should include:

• Review of the discharge information
• Medication reconciliation
• Treatment of acute exacerbations and/or fluctuations in the physician office as appropriate
• Active management of and attention to chronic renal, lung, cardiac, skeletal, social, caregiver, etc. conditions, and providers should:
  • Review the need for pending diagnostics, and/or follow up of said diagnostics.
  • Interact with other healthcare professionals who may assume care of any system-specific problems.
  • Educate the patient, family, and caregiver.
  • Establish referrals, arrange needed community resources, address/assist/advise the member/family with relevant caregiver needs.
  • Help schedule required community providers and services follow-up.
  • Comprehensively and holistically manage common chronic/acute medical conditions seen after hospital discharge, such as (but not limited to): Heart failure, COPD, DM, AFIB, DVT, cellulitis, pneumonia, dehydration, AMS, encephalopathy, AKI, polypharmacy/medication reconciliation, and even custodial/social needs impacting/resulting in admission(s).

CMS encourages TCM for Medicare members. CMS has detailed fact sheets explaining the program, and billing, see resources below:

• https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/transitional-care-management-services-fact-sheet-icn908628.pdf
• https://edit.cms.gov/files/document/billing-faqs-transitional-care-management-2016.pdf

Appendix

CPT 99496 coding requirements:

1. Attestation that the initial communication between patient/practitioner began within two business days of discharge:
   1. Geared to patients with conditions requiring medium or high-level decision-making
   2. Direct contact: telephone/electronic
2. Face-to-face visit within seven days of DC. Cannot be virtual
3. Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
4. Includes DC from hospitals, SNFs, IRFs, and LTACs
5. Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living
   
   CPT 99495 coding requirements:
6. Attestation that the initial communication between patient/practitioner began within two business days of DC
   1. Geared to patients with conditions requiring at least moderate complexity decision-making
   2. Direct contact: telephone/electronic
7. Face-to-face visit within 14 days of discharge. Cannot be virtual
8. Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
9. Includes DC from hospitals, SNFs, IRFs, and LTACs
10. Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living

Please continue to check for important Medicare Advantageupdates at https://www.anthem.com/ca/provider/medicare-advantage/for the latest Medicare Advantage information, including:

 Carelon Medical Benefits Management, Inc. Genetic Testing Clinical Appropriateness Guidelines CPT code list update

• Updates to Carelon Medical Benefits Management, Inc. Cardiac Clinical Appropriateness Guidelines
• Carelon Medical Benefits Management, Inc. Cardiology Clinical Appropriateness Guidelines CPT Code List update
• Clinical Criteria updates
• Update: Carelon Medical Benefits Management, Inc. Cardiology Clinical Appropriateness Guidelines CPT Code List
• New specialty pharmacy medical step therapy requirements (Neulasta, Neulasta OnPro, Udenyca)