All participating commercial providers with Anthem are required, per the DMHC, to annually acknowledge that consumer grievance and appeals forms and a description of grievance procedures are readily available at each contracting provider’s office, contracting facility, or plan facility. The Department of Managed Health Care’s (DMHC) routine medical survey includes evaluation of a health plan’s compliance with California Health and Safety Code section 1368(a)(2); 28 CCR 1300.68(b)(6) and (7). These regulations require health plans to ensure that consumer grievance and appeals forms and a description of grievance procedures are readily available at each contracting provider’s office, contracting facility, or plan facility.

To ensure compliance, Anthem has issued a survey to allow participating providers to attest that consumer grievance and appeals forms and a description of grievance procedures are readily available at each contracting provider’s office. To date, our records indicate that your organization has not completed the 2024 Consumer Grievance and Appeals Attestation.

Please complete the survey by Friday, May 17, 2024.

For ease of completing the survey, we are providing the survey link to the Consumer Grievance and Appeals Attestation Survey: https://tinyurl.com/5ass6jbh

If you have any questions, please do not hesitate to contact me via email, gaattestationsurvey@anthem.com.

We thank you in advance for your participation.

Through our shared health vision, we can affect real change.

Providers must code their claims to the highest level of specificity in accordance with industry standard coding guidelines such as ICD-10-CM coding guidelines and reporting. When an ICD-10-CM diagnosis code has a specified laterality within the code description, the modifier that is appended to a CPT^® or HCPCS code must correspond to the laterality within the ICD-10-CM description.

On a CMS 1500 form, for professional submitted claims processed on or after June 1, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny claim lines that have a laterality diagnosis submitted with a CPT or HCPCS modifier that does not correspond to the diagnosis.

See examples below

Reported diagnosis: E11.3593 (Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral):

• Billed CPT code: 67228-RT Treatment of extensive or progressive retinopathy (for example, diabetic retinopathy), photocoagulation.
• Determination: It is not appropriate to report the RT modifier when the laterality of bilateral is identified in the ICD-10-CM diagnosis. Therefore, the claim line will be denied.

Reported diagnosis: S91.011A (Laceration without foreign body, right ankle, initial encounter):

• Billed CPT code: 27786-LT (Closed treatment of distal fibular fracture: lateral malleolus; without manipulation)
• Determination: It is not appropriate to report a LT modifier when the laterality of right is identified in the ICD-10-CM diagnosis. Therefore, the claim line will be denied.

Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT, HCPCS code(s), and/or modifiers billed.

Anthem will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

EOB message

Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex codes: v19 and 00V19

If you have questions about this communication or need assistance, contact your provider relationship account manager. We are committed to a future of shared success.

Our members depend on our directories to find in-network providers like you. Out-of-date information risks delays, frustration, and extra costs for our members. Current information leads to the better connection of new patients to the providers who best meet their needs.

Remember, we assume your practice is open and ready for new patients unless you tell us otherwise. In accordance with Timely Access Standards, you should only report being closed to new patients if staying open to them would pose a detriment to the care of new or current patients. If you are not currently accepting new patients, you will not be terminated; however, you must let us know.

We understand that updating your information can be tough when maintaining a busy practice, but it is essential. Anthem Blue Cross (Anthem) is required by state and federal laws to make sure our provider directories are accurate. This includes your availability or practice status. In simple terms, are you open or closed to new patients?

Keeping your Accepting New Patients data current is a requirement per your contract with Anthem. If this critical information is not updated regularly, it can lead to discrepancies and may lead to misunderstandings over your availability for new patients.

Anthem uses the provider data management (PDM) capability available on Availity Essentials (Availity) to update your provider data. Go to Availity today to tell us whether your practice is open or closed to new patients and update other information. Log on to Availity and select My Providers > Provider Data Management to begin using PDM. If you aren’t registered to use Availity, signing up is easy and 100% secure, and there is no cost to register. If you have technical questions call Availity Client Services toll-free at 800-AVAILITY (800-282-4548).

Note: California providers also have the option to submit updates via Symphony’s file-based data exchange (or via their premium service for a fee). Contact the Symphony team here.

To learn more about California timely access regulations and access to care responsibilities:

• Check out the Provider Manual at anthem.com/ca/provider/policies/manuals.
• Visit the California Department of Managed Health Care (DMHC) website or call 888-466-2219 toll-free.
• Visit the California Department of Insurance (CDI) website or call 800-927-4357 toll-free.

Successful healthcare starts with good communication. By keeping us updated, you make sure our Anthem members get the care they need without delays. Thank you for making healthcare better!

Effective June 1, 2024, County of Sonoma in California will offer a Medicare Preferred (PPO) plan with Anthem.

Anthem will provide medical and prescription drug benefits for County of Sonoma retirees through the Preferred Provider Organization (PPO) product, which includes the National Access Plus benefit. The PPO plan allows members to receive services from any provider, as long as the provider is eligible to receive payments from Medicare.

County of Sonoma members’ copay or coinsurance percentage will be the same whether their provider is in or out-of-network. Locally or nationwide, doctors or hospitals, member share-of-cost (SOC) does not change.

Non-contracted providers may continue treating County of Sonoma members and will be reimbursed 100% of Medicare’s allowed amount for covered services.

The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers, while covering additional benefits that Medicare does not, such as LiveHealth Online and SilverSneakers.

The prefix on the Medicare Advantage ID cards is MBL.

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

Providers will follow their normal claim filing procedures for County of Sonoma member claims.

Providers may call Provider Services at 833-848-8730 for eligibility, prior authorization requirements, and any questions about the County of Sonoma member benefits or coverage.

We are excited for genuine collaboration with you, our care provider partners.

Maintaining your online provider directory information is essential for member and healthcare partners to connect with you when needed. Access your online provider directory information by visiting anthem.com/ca/provider, then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information we show in our online directory has changed.

Updating your information

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

PDM features include:

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

Accessing the PDM application

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

PDM training

PDM training is available:

• Learn about and attend one of our training opportunities by visiting here.
• View the Availity PDM quick start guide here.
• For Roster Automation Standard Template and Roster Automation Rules of Engagement specific training, listen to our recorded webinar here.

Not registered for Availity yet?

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

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

On April 1, 2024, Carelon Post Acute Solutions, LLC (formerly known as myNexus) began operating as Carelon Medical Benefits Management, Inc.

Provider materials that formerly included the Carelon Post Acute Solutions name, such as determination letters and provider forms, have adopted the new name. However, there will be no changes in the way you submit a case nor to the contact information you use for checking case status.

Please see below for a list of FAQ. Additional questions can be directed to our Health Care Networks team using the contact information below:

• Home health providers: HHprovider_relations@carelon.com
• Post-acute institutional management (PAC-IM) providers: PACprovider_relations@carelon.com
• Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers: DMEprovider_relations@carelon.com

Thank you for your continued partnership.

Carelon Medical Benefits Management transition FAQ

Q: Will there be any changes to the Carelon Post Acute Solutions provider website?

A: The name of our website has been updated to reflect Carelon Medical Benefits Management branding. Additionally, the web address you use today will automatically redirect to a new Carelon Medical Benefits Management site. There will be no changes to the case submission process.

Q: Are any phone number changes planned as part of this transition?

A: No, our inbound phone numbers will not change. The reference to Carelon Post Acute Solutions in recorded scripting will use the Carelon Medical Benefits Management name.

Q: How will third party websites, such as Availity, be impacted?

A: There will be no change to the way you access these websites. Within the sites, any reference to Carelon Post Acute Solutions will be replaced with the new name. This may take some time to fully complete.

Q: Will references to Carelon Post Acute Solutions on health plan websites and other materials be changed?

A: Yes, while you may continue to see the Carelon Post Acute Solutions company name on health plan websites for some time, these references will be updated over time through scheduled content update cycles. If your office includes the Carelon Post Acute Solutions name in any materials or web properties, we encourage you to update them to Carelon Medical Benefits Management during your next update cycle.

Q: Will information about Carelon Post Acute Solutions continue to be found on the corporate website?

A: Yes, post-acute care will be part of the Carelon Medical Benefits Management portfolio of solutions. You can learn more at careloninsights.com.

Q: Will provider resources, such as key documents and the provider finder, be impacted?

A: Our provider resources will continue to be available through our corporate website and our Provider Resources site.

Q: Does this impact provider agreements with Carelon Post Acute Solutions? Will I need to sign a new agreement?

A: No, there is no impact to provider agreements. You do not need to sign a new agreement regardless of whether your current contract is with MyNexus, Inc. or Carelon Post Acute Solutions.

Q: Do I need to complete credentialing again through Carelon Medical Benefits Management?

A: No, providers will not need to re-credential until their normal credentialing cycle.

Q: Will my claims be impacted?

A: No, claims are not impacted. Payer IDs will remain the same.

Q: Will I need to update my W-9?

A: Providers may need to update their W-9. If you need an updated W-9 from Carelon Medical Benefits Management, please contact the Carelon Provider Relations department at HHprovider_relations@carelon.com.

Limitation of outpatient hospital procedures

Self-Insured Schools of California (SISC) made a change to its benefit plan on October 1, 2018. The change may influence your patient’s choice of place of service for the following elective procedures.

To provide each PPO member with a choice of safe, quality services at a lower total cost for all PPO members, SISC has established a maximum benefit allowance as follows when services are not received at a PPO ambulatory surgery center.

If these routine services are provided in an outpatient hospital setting, without an approved exception form, the following maximums will apply to in-network hospital services:

• Colonoscopy services are limited to a maximum payment of $1,500 per procedure.
• Cataract surgery services are limited to a maximum payment of $2,000 per procedure.
• Arthroscopy services are limited to a maximum payment of $4,500 per procedure.
• Upper GI endoscopy services are limited to a maximum payment of $1,000 per procedure.
• Upper GI endoscopy with biopsy services are limited to a maximum payment of $1,250 per procedure.

Examples for an exception to the services listed above to be performed in an outpatient hospital include the following:

• If no appointment is available for the member at a participating ambulatory surgical center
• If there is no preferred ambulatory surgery center provider within a 30-mile radius of the member’s home
• If the provider can provide clinical documentation supporting the need for an outpatient setting (patient safety)

The member should consult their physician and contact Member Services for instructions on how to receive an exception.

It’s time for some of your patients to renew their Medi-Cal benefits. As states begin to recommence Medi-Cal renewals, we want to ensure you have the information needed to help your Medi-Cal patients renew their healthcare coverage. Some patients have never had to renew their coverage at all, while other patients may have forgotten the process entirely.

We’re here to help.

What steps do my patients need to take?

• Ready: Patient gets their documents ready.
• Set: Patient ensures their form is all set.
• Renew: Patient sends renewal form:
  • Via phone: Call your local county office.
  • Via mail: Send to your local county office.
  • Via in person: Patient can find their local county office by visiting https://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx.

What if I need assistance?

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 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 at the bottom of our provider website for the appropriate contact.

Use the information below to help complete required patient information on donor claims. Correct completion of the form is needed to process the claim.

Donor claims

There are two patients involved in an organ donation — the donor and the recipient. The insurance plan for the recipient is responsible for paying the donor claim. The recipient can be the subscriber or a dependent to the subscriber (Note: Plans are instructed to include living donor charges on the recipient claims).

When billing for services rendered to the transplant donor, the care provider enters the recipient’s name, date of birth, sex, and Anthem ID number.

Completing forms

Review the information outlined below for billing instructions needed to process donor claims.

CMS-1450 (UB-04 Uniform Bill):

• UB box 8b — recipient’s name*
• UB box 10 — recipient’s birthdate
• UB box 11 — recipient’s sex
• UB box 42 — donor ICD-10-CM codes and revenue codes
• UB box 58 — subscriber’s name
• UB box 59 — relationship code of 39 or 40
• UB box 60 — subscriber ID number
• UB box 66 — donor diagnosis codes
• UB box 80 — note this is a donor claim submission with donor’s name

CMS-1500 (Health Insurance Claim Form):

• HCFA box 1a — subscriber’s ID number
• HCFA box 2 — recipient’s name*
• HCFA box 3 — recipient’s date of birth and gender
• HCFA box 4 — subscriber’s name
• HCFA box 6 — relationship to subscriber, other (Complete with 39 or 40.)
• HCFA box 19 — note, this is a donor claim submission with donor’s name
• HCFA box 21 — donor diagnosis code
• HCFA box 53 (electronic claim) — will list the donor’s name:
• Example: Claim note ref code: ADD Claim note Text: 39-Jones, Sally

* The recommendation is that the recipient’s name be billed. However, the care provider can bill with the donor’s name. If the claim is billed with the recipient’s name, it has a better chance at adjudication upon initial submission.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

When determining transportation to an alternative hospital and to help avoid medical necessity denials for rotary wing air ambulance transports to another hospital, please remember the criteria below.

The use of air and water ambulance services is considered medically necessary when all the following criteria are met:

1. The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
2. The individual’s condition must be such that any form of transportation other than by ambulance would be medically contraindicated; and
3. The individual’s condition is such that the time needed to transport by land poses a threat to the individual’s survival or seriously endangers the individual’s health*; or the individual’s location is such that accessibility is only feasible by air or water transportation; and
4. There is a medical condition that is life threatening, or first responders deem to be life threatening, including, but not limited to, the following:

1. Intracranial bleeding; or
2. Cardiogenic shock; or
3. Major burns requiring immediate treatment in a burn center; or
4. Conditions requiring immediate treatment in a hyperbaric oxygen unit; or
5. Multiple severe injuries; or
6. Transplants; or
7. Limb-threatening trauma; or
8. High risk pregnancy; or
9. Acute myocardial infarction; if this would enable the individual to receive a more timely medically necessary intervention (such as percutaneous transluminal coronary angioplasty [PTCA] or fibrinolytic therapy).

* Air transportation may be appropriate if the time between identification of the need for transportation until arrival at the intended destination for ground ambulance would be at least 30 minutes longer than air transport.

For additional details on Clinical UM Guideline CG-ANC-04 Ambulance Services: Air and Ground please visit the Anthem provider site.

Clinical UM guidelines are subject to change. Administrative services only (ASO) accounts may utilize alternate criteria. All terms and conditions of the member’s benefit plan apply.

For more information please refer to the number on the back of your patient’s member ID card for Provider Services.

Summary

On February 24, 2023, and November 17, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates (marked with an asterisk [*]): notate that the criteria may be perceived as more restrictive

Please share this notice with other providers in your practice and office staff.

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

As an Anthem participating provider, you may have received our prior correspondence, or read the articles in our Network Updates on Anthem cost transparency. Transparency tools such as Anthem’s Find Care tool and others are available to members on anthem.com and allow members to estimate their out-of-pocket impact and view the estimated costs for many procedures.

In our prior correspondence, we also enclosed a summary of the methodology used to generate the cost information housed in the National Consumer Cost Tool (NCCT), the source data used to display costs in Find Care. The treatment categories for which costs are displayed and the methodology are defined by the Blue Cross Blue Shield Association. As indicated in the correspondence Axis^® (formerly NCCT), cost data is updated twice annually. The most recent was update completed in March 2024, and the next update scheduled for November 2024. Please look for more information in our provider newsletters posted to anthem.com.

As a reminder, Anthem care provider costs are now available in a secure section of the Availity Essentials platform. Authorized representatives of participating facilities and professional practices can login to Availity at Availity.com, and register to view the costs for their facility or practice. Costs will be made available to our participating care providers no less than 30 days before they become available to our members on anthem.com in the transparency tools such as Anthem Care Comparison.

Should you wish to review the methodology, you may request a copy by sending an email request to your provider relationship management representative.

If you wish to provide an internet link on Anthem’s website where this cost information will be displayed, please provide us this link within 30 days of receiving the cost information from us.

We are committed to active involvement with care providers that leads to real change.

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing healthcare costs.

One of the ways this is done is by giving certain providers (value-based program providers, also known as payment innovation providers) in Anthem’s various value-based programs (for example, Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, etc.) (the Programs) quality, utilization and/or cost data, reports, and information about the healthcare providers (referral providers) to whom the value-based program providers may be referring, or plan to refer, their patients covered under the programs. If a referral provider is higher quality and/or lower cost, this component of the programs may result in their getting more referrals from value-based program 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 value-based program providers helps them make more informed decisions about managing healthcare 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 value-based program providers and referral providers so that they can better understand how their healthcare 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. If you have questions or support, please refer to your provider relationship management representative.

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

Estimates suggest that around 35 million American adolescents fail to receive at least one recommended vaccine.* The CDC and the American Academy of Pediatrics advise pre-teens between 10 and 12 years old receive three vaccines: (1) one dose for meningococcal; (2) one dose for tetanus, diphtheria, and pertussis (Tdap); and (3) two doses of human papillomavirus (HPV) given five months apart.

Encourage pre-teen immunizations

Take action to provide clear and specific guidance to your patients’ parents to get the recommended vaccines on time. Convey the importance by administering vaccines as part of routine visits and by offering vaccine clinics during non-traditional times when your patients and their parents might be more available. It is helpful to remind patients of their upcoming appointments, follow up to reschedule any missed appointments, and address any concerns or barriers. Although you should check your patients’ benefits, immunizations are generally a covered benefit.

Reporting and documenting for HEDIS

Take action to make sure that all vaccine doses given, including those administered in a pharmacy and an urgent care, are clearly documented in your electronic medical system, your patient’s medical record, and state Immunization Registry. Doses should be clearly reported on claim forms with the assistance of CPT^® codes to maximize data collection and to reduce the burden of HEDIS^® medical record review, especially since NCQA strongly encourages the electronic collection of Immunizations for Adolescents (IMA) HEDIS data. Contact your provider relationship management representative for additional information and assistance with establishing electronic data exchange.

Opportunities to learn more:

• An on-demand webinar about the importance of the HPV vaccine and starting the conversation early with parents of 9-year-olds can be found on the Clinical Quality Webinars Hub. One continuing education unit is provided upon completion.
• Mydiversepatients.com includes free resources and courses that might help you with your diverse patient population.
• Letsvaccinate.org provides ready-to-use resources and strategies to help your care team increase vaccination rates.

Through our shared health vision, we can affect real change.