At a glance:

• Care providers contracted with us need to verify and update their demographic data every 90 days using the provider data management (PDM) feature in Availity Essentials.
• Updating and attesting data are critical for maintaining accurate service directories for members and noncompliance with these requirements can result in removal from the online provider directory.
• Availity Essentials provides digital applications that enable users to monitor submitted demographic updates in real time, review the history of previously verified data, and manage multiple updates within one spreadsheet via the Upload Roster feature.

What are the requirements for the attestation of demographic data?

We require our contracted care provider partners to attest to their demographic data every 90 days. Maintaining your provider data is critical as it results in improved connection to members seeking care, supports the accuracy of claims processing, and allows for timely reimbursement, while aligning to a bold purpose of improving the health of humanity.

How do I update and attest to my data?

We require the use of the PDM capability available on Availity Essentials to update your provider or facility data. There are two options within Availity Essentials PDM that are available at no cost to care providers:

• Multipayer platform, which includes Directory Verification and Core PDM: allows care providers to make required updates using Directory Verification and changes using Core PDM
• Roster upload: allows care providers to submit multiple updates within one spreadsheet via the Upload Roster feature (The Upload Roster feature is currently only available and shared with the health plan.)

Both the multipayer platform and Roster Upload feature satisfy your 90‑day attestation requirement.

To attest to your provider data:

1. Log in to https://Availity.com.
2. Navigate to My Providers > Provider Data Management.
3. Select the action menu next to the business whose information you want to verify.
4. Select Verify Directory Listing.
5. Review each set of data for accuracy.
6. Once complete, select Submit Verified Profile.

Organizations with no changes since their last submission may see a Quick Verify button that allows for directory verification in one click.

Individuals registered for their TIN within the Availity Manage My Organization application on Availity Essentials will receive periodic automated emails and notifications in the Notification Center on Availity Essentials reminding them when their attestation is due or overdue.

How do I access Availity Essentials and the PDM application?

To access the PDM application, log on to https://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.

Within PDM you also have the ability to:

• Monitor submitted demographic updates in real time with a digital dashboard.
• Review the history of previously verified data.

Why is updating and attesting to my data important?

Our members use Find Care to make informed decisions about their healthcare and find quality doctors and hospitals. Keeping your data up to date ensures members have access to you when they need it the most.

Failure to complete the 90‑day attestation requirement puts your organization at risk of being classified as non‑compliant with the health plan’s policies and procedures and may result in removal from the online provider directory.

What if I’m not registered for Availity Essentials yet?

If you aren’t registered to use Availity Essentials, signing up is easy and secure. There is no cost to register or to use any of the digital applications. Start by going to https://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 TIN, 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 (282‑4548).

How do I get training on the Availity Essentials PDM tool?

You can learn about and attend one of our training opportunities by visiting here (apps.availity.com):

• For more information on PDM, check out the Quick Start Guide here (apps.availity.com) using your Availity Essentials user ID and password.
• For more information about the Roster Upload process:
  • See the Roster Submission Guide on https://Availity.com > Payer Spaces > Select Payer Tile > Resources > Roster Submission Guide using PDM.
  • Find training specifically for the Standard Template and Rules of Engagement by listening to our recorded webinar on our provider Learning Hub.
  • Take an on‑demand class hosted by Availity Essentials on the Learning Hub to learn about PDM.

What if I’m a behavioral health care provider?

If you are a behavioral health care provider and assigned to Carelon Behavioral Health of California, Inc., follow the Carelon Behavioral Health process for attestation. Council for Affordable Quality Healthcare (CAQH) care providers should attest, confirm, or update their data through the CAQH website. Non‑CAQH care providers and facilities should attest, confirm, or update their data directly with Carelon Behavioral Health.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

Join our on‑demand webinar on improving antibiotic use in the outpatient setting, led by Dr. Emily McDonald, MD, MPH, and Guillermo Sanchez, PA‑C, MPH, MSHS, from the CDC’s Office of Antibiotic Stewardship.

The webinar highlights key strategies such as proper diagnosis, adherence to clinical guidelines, and educational interventions. It will also address common misconceptions regarding patient satisfaction and prescribing practices. Additionally, the session will discuss tools and resources, such as HEDIS^® quality measures and communication training, available to help clinicians improve their antibiotic stewardship practices.

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

Program objectives:

• Review the epidemiology of outpatient antibiotic use in the U.S.
• Identify high‑priority conditions where antibiotic prescribing can be improved.
• Describe evidence‑based interventions that can improve antibiotic use.
• Address common myths related to antibiotic use.

Visit: Improving Antibiotic Use for Acute Respiratory Infections (This link works best with Chrome browser.)

Effective June 1, 2025, Anthem will upgrade to the 29th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive:

• Behavioral Health Care (BHG):
• The guidelines for substance‑related disorders have been updated to allow users to identify ASAM citations more easily within MCG content. Benchmarks have been added to the guidelines for Applied Behavioral Analysis, Neuropsychological Testing, Psychological Testing, and Urine Toxicology Testing.
• Inpatient & Surgical Care (ISC):
• Five new observation care guidelines have been added. Also, a new mean arterial pressure (MAP) calculator has been added.
• General Recovery Care (GRG):
• A new Hospital‑at-Home General Recovery Guideline has been added.
• Recovery Facility Care (RFC):
• The discharge planning section for Inpatient Rehabilitation Facility guidelines was expanded.
• Chronic Care (CCG):
• New guidelines have been added to self‑management and low‑intensity disease management pediatric guidelines.

If you have questions, please contact our Medi‑Cal Customer Care Center at 800‑407-4627 (TTY 711) outside L.A. County or 888‑285-7801 (TTY 711) inside L.A. County.

Effective June 1, 2025, Anthem will upgrade to the 29th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive:

• Behavioral Health Care (BHG):
• The guidelines for substance‑related disorders have been updated to allow users to identify ASAM citations more easily within MCG content. Benchmarks have been added to the guidelines for Applied Behavioral Analysis, Neuropsychological Testing, Psychological Testing, and Urine Toxicology Testing.
• Inpatient & Surgical Care (ISC):
• Five new observation care guidelines have been added. Also, a new mean arterial pressure (MAP) calculator has been added.
• General Recovery Care (GRG):
• A new Hospital‑at-Home General Recovery Guideline has been added.
• Chronic Care (CCG):
• New guidelines have been added to self‑management and low‑intensity disease management pediatric guidelines.

If you have questions, please contact Provider Services via the number on the back of our member ID card.

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 care 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 at https://providers.anthem.com/california‑provider/home > Resources > Provider Manuals, Policies and Guidelines > Select Clinical Practice Guidelines

What’s changing:

Effective January 1, 2025, postal employees began to participate in the Postal Service Health Benefits Program (PSHB), a health benefits program for those under the Federal Employee Program® (FEP).

What this means for you as the provider:

Postal employees in the PSHB program have a new ID card reflecting new enrollment codes. To ensure correct claim processing, the federal employee ID cards should be validated to confirm the provider has the correct enrollment information.

In 2025, federal and USPS employees in the FEP, along with their families, will have the same coverage and benefits as before. The plan options will remain Blue Standard, Blue Basic, and Blue Focus. Only the PSHB ID card and PSHB customer service number (on the back of the card) will be new.

Below is an example of the front of the new PSHB card. A stamp symbol in the upper right corner will identify the PSHB enrollment:

Once the PSHB member is enrolled, they will have a new ID card. The back of the ID card will reflect the toll-free Customer Service and prior authorization numbers for assistance.

Additional information for all federal employees can be found on the federal employee website at https://fepblue.org.

The CarelonRx, Inc. weight management program offers support and advocacy for patients throughout their weight loss journey. Individuals who are at least 18 years of age with a BMI of at least 27 have access to personalized weight management from CarelonRx through their partner, Lark. CarelonRx’s weight management program will provide access to digital coaching and wellness tools to help participants manage and monitor their weight goals. Patients benefit from 24/7 digital connectivity and access to personalized coaching support whenever needed. Patients design their own journey with goals and missions to inform personalized wellness plans to ensure a holistic experience.

What your patients can expect:

1. Engagement in lifestyle support through the Lark mobile app, which includes diet, exercise, and nutrition
2. Behavioral health support and ongoing social drivers of health (SDOH) monitoring
3. Injection, adherence, and side effect support for those on a GLP‑1 for weight loss
4. Ongoing weight maintenance support tailored to individual weight loss goals

Take action

If a preapproval is requested, you will be asked to confirm the member's enrollment in the Lark Weight Management Program.

For more information about the program, members can:

• Visit https://www.anthem.com/ca or the Sydney mobile app.
• Call the customer service number on the back of their identification card.

Effective for dates of service on or after June 1, 2025, the following medication codes will require prior authorization.

Please note, inclusion of a National Drug Code (NDC) on the medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.