The Direct HMO fee‑for‑service network design was introduced on January 1, 2025, as part of the Pathway HMO (on and off exchange). This innovative service model groups PPO physicians together to create a network that operates similar to an HMO. We are committed to empowering our care providers with comprehensive education about this groundbreaking opportunity, ensuring sustained success for our members and care provider partners. To learn more about the Direct HMO network, review the information below.

About Direct HMO

Guidelines for care coordination and preapproval:

• Preapproval: Preapproval is required for laboratory tests, radiology, and diagnostic imaging services.
• Referrals: Referrals are required for specialty care so we can help care providers guide patients to appropriate specialists and ensure continuity of care. For complete benefit information, please refer to the member’s Evidence of Coverage.
• Exceptions include behavioral health and other specific services such as reproductive/sexual healthcare and obstetrical/gynecological care.
• Care coordination: Access to our HMO Clinical Operations team toll‑free at 866‑757‑8211 allows care providers to effortlessly coordinate care by streamlining the referral and approval processes, freeing up time to focus on patient care.

Benefits:

• Choosing care providers: Referring patients to contracted care provider partners for laboratory tests, radiology, and diagnostic imaging services ensures streamlined billing processes and minimizes administrative burdens, making it easier for care providers to focus on delivering quality care.
• Extensive specialist network: Referring patients to our extensive network of Direct HMO specialists offers providers access to a collaborative community, improving inter‑provider communication and enhancing patient outcomes. Use our online directory, Find Care, to locate providers in the Direct HMO network. Refer to the FAQ for specific navigational instructions to guide your search.
• Submitting requests: Our Referral and Prior Authorization Request Form ensures timely processing of your referral and authorization requests, reducing wait times and helping care providers maintain efficient practice operations.

A letter was sent to participating providers at the end of September 2024. To verify your participation status, please use the Find Care tool or contact us for more information using the appropriate option below.

For more information:

• Contracts: Email SpecialNetworkReq@anthem.com with Direct HMO in the subject line.
• Behavioral health utilization management: Call us toll‑free at 800‑274‑7767.
• Utilization and medical management: Call us toll‑free at 866‑757‑8211.
• General inquiries: Visit the Contact Us page on our provider website.

Expedited grievances and appeals are urgent pre‑service or concurrent requests to prevent an immediate and serious threat to a patient’s health. They apply to severe pain, risk of losing life or limb, primary bodily function, or delays in end‑of‑life care.

To ensure swift processing of your expedited grievances, please fax the appropriate department:

• For Medi‑Cal Managed Care members — 866‑387‑2968
• For Commercial plan members — 855‑211‑3699
• For Commercial behavioral health — 877‑487‑7394
• For dental or vision — 855‑273‑2689

We are committed to supporting you in providing the urgent care your patients need.

Annual wellness and well‑woman visits are covered with no member cost‑sharing when provided by in‑network providers for our members with Affordable Care Act (ACA)‑compliant plans. Individual and small group plan members are encouraged to schedule these visits within the first 90 days of their plan starting or renewing, so your practice may see an increase in requests, especially at the beginning of the second and fourth quarters.

Providers can perform the annual wellness or well‑woman visit, even if it has been less than one calendar year since the last wellness visit. We ask that your practice be flexible in accommodating members wanting to schedule their visits earlier than they may have previously. The wellness or well‑woman visit claim will be processed as a preventive care service covered with no member cost share.

Please note that this benefit may not apply to all health plans. You should continue to verify eligibility and benefits for all members in Availity Essentials (https://Availity.com) before providing services or receiving member copayments, deductibles, or coinsurance.

Take your success as a care provider to the next level by managing claims online with Availity Essentials

You can benefit from:

• Supercharged claim efficiency
• Swift payments
• Paperless ease
• Cost savings
• Comprehensive support for all your healthcare claims — medical, institutional, and dental

Navigate claims effortlessly with Claims & Payments

Submit and review with ease. Get prompt claim notifications and easily attach documents.

Elevate your expertise:

• Explore our Digital Solutions Learning Hub for trainings on Availity, claims, remittances, and more.
• Availity Essentials’ EDI Gateway features effortless 24/7 self‑service and 837 claims exchanges. Learn more here.

What if I’m not registered for Availity Essentials?

Signing up is easy and secure if you aren’t registered to use Availity Essentials. There is no cost to register or to use any of the digital applications.

To access the registration page, go to https://Availity.com and select New to Availity? Get Started at the top of the home screen. If you have more than one TIN, ensure you have registered all TINs associated with your account.

Assistance

For assistance, contact Availity Client Services online via Help & Training > Availity Support > Contact Support > Create a case, use Chat with Support, or call Monday through Friday from 8 a.m. to 8 p.m. Eastern time at 800‑AVAILITY (282‑4548).

We're dedicated to lightening your administrative load and securing timely payments because we value you, our care provider partners.

The Department of Managed Health Care (DMHC) and the California Health and Safety Code require care providers annually attest to the availability of member grievance and appeals forms, along with filing instructions, at patient facilities. These regulations ensure our members have the tools to feel heard and valued.

To facilitate compliance, we will reach out directly to organizations that have not confirmed adherence to these regulations. If you receive notice, please complete the Consumer Grievance and Appeals Attestation Survey acknowledging members have access to these grievance and appeals materials.

If you have any questions, email gaattestationsurvey@anthem.com.

On May 1, 2025, we will expand our innovative healthcare offering, the Anthem Full Dual Advantage (HMO D-SNP), to benefit Anthem Dual Special Needs Plan (D-SNP) members. In addition to our already robust network of provider medical groups, we’re looking to add more directly contracted care providers, ensuring a wider array of services and streamlined access for our D-SNP members.

The Anthem Full Dual Advantage (HMO D-SNP) is part of California’s exclusively aligned enrollment (EAE) D-SNP model, which aims to deliver comprehensive and integrated healthcare services by unifying Medicare and MediCal benefits under one plan. This initiative aligns with our commitment to provide efficient, coordinated, and integrated care to our members.

Medi‑Cal care providers interested in joining this growing network, or who want more information, should contact Provider Services via the number on the back of our member ID card.

Anthem is happy to support the announcement of an exciting partnership between Premera Blue Cross, Amazon, and the American College of Lifestyle Medicine (ACLM) offering a free online Lifestyle Medicine & Food as Medicine Essentials Course for the entire provider community.

In this comprehensive online course, you will explore the six pillars of lifestyle medicine, emphasizing how food and nutrition can play a critical role in preventing and treating chronic diseases. The course is tailor‑made for healthcare providers looking to enrich their care approach with practical evidence‑based strategies. This course is available until September 14, 2025.

Benefits for providers:

• Free access: Participate in this valuable training at no cost.
• Earn credits: Completing the course awards, you earn 5.5 CME/CE credits.
• Enhance your practice: Acquire tools to transform care and effectively address chronic disease.

How to enroll:

1. Visit https://lifestylemedicine.org/essentials.
2. Log in or create an ACLM account.
3. Enter promo code ESS‑AMZNEDU at checkout to access the course for free.

Contact us

Please reach out to Dr. Jon Liu at jonliu@amazon.com with questions regarding the free course.

Manage your prior authorization requests with our digital tools — Availity Essentials and https://anthem.com/provider. These resources simplify requirement determination and request submissions, giving you more time to deliver effective and efficient care to our members. We encourage you to review the instructions below.

Determining prior authorization requirements

Availity Essentials:

1. Log in to https://Availity.com.
• If you do not already have access, select Get Started to create an account.
2. Go to the Payer Spaces tab.
3. Select the applicable plan.
4. Select Authorization Rules Lookup.
5. Enter the required provider information.
6. Select Next and enter the required member information.

Note: Final determination of prior authorization requirements is completed upon submission and may differ from search results.

Provider website:

1. Go to https://anthem.com/provider.
2. Scroll down and select the applicable state.
3. Scroll down to Commercial‑partnered programs and select Access the Commercial Provider site to access the Provider website homepage.
4. Under the Resources heading, select Prior Authorization.
5. Select the applicable state.
6. Select the appropriate link based on the member’s plan.

If the member’s home plan is not with Anthem, scroll to Helpful Links > Select Medical Policy and Prior Authorization for Blue Plans, then follow the prompts to determine the applicable home plan and prior authorization requirements.

Submitting prior authorization requests

Availity Essentials:

1. Log in to https://Availity.com.
2. Select the Patient Registration tab to access Authorizations and Referrals.
3. Select Authorization Request.

Note: Transplant prior authorization requests must be submitted by phone, fax, or secure email.

To verify eligibility for a point‑of‑service plan with HMO and PPO benefits, care providers encountering a “duplicate subscriber ID#” message should use the Patient Search Option from the dropdown menu. By manually entering the member’s patient ID, name, DOB, and group number, you can bypass the duplicate ID issue and confirm eligibility successfully, ensuring a smoother process for members and care providers.

Depending on the payer, various search options will appear, tailoring the experience to your needs. If the Patient Search Option field is unavailable, fill in all the required patient information fields under the Patient Information section.

Unlock new skills with our Digital Solutions Learning Hub

Access our training on this topic through the Digital Solutions Learning Hub.

Additional support

Our provider relations team is also ready to assist at 800‑676‑2583 if further guidance is needed.

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.

Provider Pathways supports the delivery of high‑quality services and value to our members by giving you instant access to premium learning tools and educational resources. The platform’s flexibility empowers you to choose the pace and topics that best suit your needs.

What does Provider Pathways offer?

• On‑demand training, available 24/7
• Microlearning modules — concise, convenient lessons on a variety of topics
• Specific information essential to our partnership

Recent enhancements:

• More topics and content to explore
• A new, user‑friendly menu and navigation experience
• Improved accessibility features:
• Closed captioning
• Voice actors
• Original transcriptions

Please visit the Training Academy to access Provider Pathways and review the modules available.

Summary: The Pharmacy and Therapeutics (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. For 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

Please share this notice with other members of your practice and office staff.

Please note:

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

Effective on July 10, 2025, Anthem will transition to the following Carelon Medical Benefits Management Clinical Appropriateness Guidelines. This article is to communicate the plan adoption of these guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

The following guidelines have a publish date of April 1, 2025:

• Cardiovascular:
• Ambulatory Cardiac Rhythm Monitoring
• Electrophysiological Studies
• Dialysis Access Evaluations
• Vascular Embolization and Occlusion Procedures

You may access and download a copy of the current and upcoming guidelines at https://guidelines.carelonmedicalbenefitsmanagement.com.

Please share this notice with other members of your practice and office staff.

The Medicaid medical advisory committee invites diverse specialty physicians to join us as voting members and external consultants to share their valuable insights. As a valued member of our Medicaid network, you are invited to explore this opportunity.

During our meetings, we:

• Present key metrics from the Quality Management program and satisfaction survey.
• Review peer cases and gather feedback on adopting Clinical Practice Guidelines.

Meetings are held virtually on the last Wednesday of February, May, August, and November, with additional sessions when necessary. Note that an honorarium for each meeting you attend is offered. 

For more information, contact Danielle Frouws at Danielle.Frouws@anthem.com.