 Provider News CaliforniaNovember 2019 Anthem Blue Cross Provider News - CaliforniaIn response to the fires and evacuations in Northern and Southern California, Anthem Blue Cross Life and Health Insurance Company (Anthem) is revising its medical and pharmacy guidelines to help ensure our members and participating providers who have been impacted by these latest events have access to essential prescription medications and other health care related services and are able to provide needed care to our members.
- If your Anthem patient has an Anthem prescription drug plan they can get up to a 30-day emergency refill of their medications at any pharmacy now.
- If your Anthem patient uses Anthem’s mail-order pharmacy they can update their temporary mailing address information by calling us.
- Time limits for prior authorization, pre-certification or referral requirements will be relaxed — there will be no late penalties. Please call us for an extension if you need it.
- Anthem patients can get replacement medical equipment (also called Durable Medical Equipment or DME) if theirs was lost or damaged.
- Anthem patients and providers are being given more time to file claims, if needed. Please call us for an extension if you need it.
- Anthem patients can get emergency or urgent care services by doctors and hospitals, even if they’re not in their plan network — and claims will be paid as if they’re in the Anthem network.
- If the Anthem patient’s in-network provider is unavailable due to the disaster, or not available because the patient is out of the area due to a displacement as a result of the disaster, the patient can call us and we will help them find a new provider.
- If the Anthem patient is currently participating in a care management program, and need to reach them, the patient can contact Anthem toll-free at (833) 285-4030.
- If the Anthem patient received a bill directly from Anthem for their monthly insurance premium and are experiencing financial difficulties as a result of the disaster, they can call us to discuss options.
- Members with Anthem Blue View Vision can contact us at (833) 285-4030 to request the following:
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- Out of network coverage at in-network benefit levels for emergent and urgent claims only
- Replacement vision supplies if yours are lost or damaged (beyond frequency limits)
- More time to file claims, if needed
- Anthem’s Employee Assistance Program (EAP) provides support services to help with stressful situations and financial or legal concerns. EAP can be accessed at no cost. Call our 24/7 crisis line toll-free at (877) 208-8240.
These relaxed guidelines were previously effective from October 11, 2019 through November 10, 2019 for impacted members in Los Angeles and Sonoma counties. Effective October 25, 2019 through December 2, 2019 the relaxed guidelines are extended to impacted members who live in any part of California. They apply to members with Anthem group or individual and family health plans. They do not apply to Federal Employee Health Benefit Plan members, Medi-Cal, Medicare Advantage, and Medicare Part D plans - these programs have their own specific guidelines.
Anthem continues to monitor the fires and evacuations and may be taking additional steps to best serve its members and participating providers.
If your Anthem patient needs additional support, please have them call us toll-free at (833) 285-4030
If you have immediate questions in regards to member care and this notification, please contact the Provider Service phone number on the back of your patient’s ID card. If your office or location has closed due to the fires please contact CAContractSupport@Anthem.com. Anthem Blue Cross (Anthem) continues to look for ways to improve our processes and align with industry standards. With that in mind, it is also our goal to help providers receive their Anthem payments quickly and efficiently. Timely receipt of medical claims for your patients, our members, helps our chronic condition care management programs work most effectively, and also plays a crucial role in our ability to share information to help you coordinate patient care. In an effort to simplify processes, improve efficiencies, and better support coordination of care, we are changing all professional agreements to adopt a common time frame for the submission of claims to us. Notification was sent on June 21, 2019, to providers of applicable networks and contracts.
Effective for all claims received by Anthem on or after October 1, 2019, all impacted contracts will require the submission of all professional claims within ninety (90) days of the date of service. This means claims submitted on or after October 1, 2019 will be subject to a ninety (90) day timely filing requirement, and Anthem will refuse payment if submitted more than ninety (90) days after the date of service1.
If you have any questions, email our Network Relations staff at CAContractSupport@anthem.com.
1If Plan is the secondary payor, the ninety (90) day period will not begin until Provider receives notification of primary payor’s responsibility.
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) wants you to be able to communicate with your patients clearly and accurately.
- It’s easy, it’s free!
- No advance notice required
- All languages
For members whose primary language isn’t English, Anthem offers free language assistance services through interpreters. Members can call the Anthem Member Services number on their member’s ID card (TTY/TDD: 711) during regular business hours. After regular business hours, telephonic interpreter services are available through the 24/7 NurseLine. If you would like to access an interpreter on behalf of your member, please contact 1-800-677-6669.
Please remember, in accordance with the California Language Assistance Program, you must notify Anthem members of the availability of the health plan interpreter services. You must also document a member’s refusal of any needed interpreter services in his or her patient chart. Make sure to let your patients know that Anthem’s Customer Service Representatives are available to help coordinate appointment scheduling through the interpreter services. Anthem does not delegate the provision of any Language Assistance services, below is what you can expect when accessing language services:
Telephone Interpreters
- Give the customer care associate the member’s ID number.
- Explain the need for an interpreter and state the language.
- Wait on the line while the connection is made.
- Once connected to the interpreter, the associate introduces the Anthem member, explains the reason for the call, and begins the dialogue.
Face-to-Face Interpreters Including Sign Language
Members can request to have an interpreter assist at a doctor’s office. This request may be made in advance, or when the member is in the office. Doctors may make these requests on behalf of members. Seventy-two business hours are required to schedule services, and 24 business hours are required to cancel
Written materials are translated upon request
- Materials who are Covered Individual-specific, for example, denial, delay, or claims letters are sent in English with the offer of translation when requested.
- Requested translated materials are sent to the Covered Individual no later than 21 days from the request date.
- Physicians and other health care professionals should advise their patients to contact Anthem by calling 1-888-254-2721 to request translated materials.
- Physicians and other health care professionals can call Anthem at 1-800-677-6669 to request translation on the Covered Individual’s behalf. Urgent requests are handled within one business day and non-urgent requests are handled within two business days. A copy of the document is required in order to complete the translation request.
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. Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. For a complete listing of our workshops, seminars, webinars and job aids, log on to the Anthem Blue Cross website: www.anthem.com/ca. Scroll down the page to Partners in Health > Tools for Providers. In the middle of the page select the box Find Resources for California. From the Answers@Anthem page, select the link titled Provider Education Seminars and Webinars link. In an effort to better service our contracted providers right the first time, Anthem Blue Cross has improved our provider claim escalation process. Just click, Provider Claim Escalation Process to read, print, download and share the improved process with your office staff.
Our Network Relations Team is available by email at CAContractSupport@anthem.com to answer questions you have about the process. More exciting new changes are coming to the public provider site at anthem.com/ca. This next wave of updates includes a new, enhanced Medical Policies page. The page will have an improved and straightforward process for viewing policies that allows providers to easily scan, sort and filter. In addition, providers will now be able to access “Search” from the Medical Policies landing page. Take the opportunity to preview the streamlined page: As the physician of a member who has coverage under Affordable Care Act (ACA) compliant plans, you play a vital role in accurately documenting the health of the member to ensure compliance with ACA program reporting requirements. When members visit your practice, we encourage you to document ALL of the members’ health conditions, especially chronic diseases. Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.
Please ensure that all codes captured in your EMR system are also included on the claim(s), and are not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing 4. If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.
Reminder about ICD-10 coding
As you may be aware, the ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits. Additionally, Anthem uses ICD-10 codes submitted on claims to monitor health care trends and costs, disease management, and clinical effectiveness of management of medical conditions. The Centers for Medicare and Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a member’s health.
Using specific ICD diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.
- Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.
- Include any secondary diagnosis codes that are actively being managed.
- Include all chronic historical codes, as they must be documented each year pursuant to the ACA. (E.g.: An amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).
If you are interested in having a coding training session conducted by an Anthem coding auditor, please contact our Commercial Risk Adjustment Representative who supports your area: Socorro.Carrasco@anthem.com. Anthem Blue Cross' (Anthem) launch of our new pharmacy benefits manager (PBM) solution, IngenioRx, is nearly complete. IngenioRx serves members of all Anthem affiliated-health plans. We began transitioning members on May 1, 2019, and have continued throughout 2019, with all members completely transitioned to IngenioRx by January 1, 2020.
As a reminder, most day-to-day pharmacy experiences will not be affected:
- Members will continue to use their prescription drug benefits as they always have, getting their medications using a retail pharmacy, home delivery, or specialty pharmacy.
- Current home delivery and specialty pharmacy prescriptions and prior authorizations will transfer automatically to IngenioRx when a member transitions, with the exception of controlled substances and compound drugs (see more below).
- If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx after your patient has transitioned.
- If you do not use ePrescribing, send home delivery or specialty pharmacy prescriptions to IngenioRx after your patient has transitioned (see contact information below).
- Members will continue to use the same drug list.
Frequently Asked QuestionsQ. When can I expect my patient to transition to IngenioRx?A. Most Anthem members have already transitioned to IngenioRx. The remaining members will be transitioned on January 1, 2020. Q. Do providers need to take any action?A. Federal law does not allow prescriptions for controlled substances or compound drugs to be automatically transferred to another pharmacy, so providers with patients using these medications will need to send a new prescription to IngenioRx after they've transitioned. Q. Will my patients be notified of this change?A. Anthem will notify members before they transition to IngenioRx. Members currently filling home delivery and specialty pharmacy medications will be notified by mail. Q. How will a provider know if an Anthem member has moved to IngenioRx?A. Availity displays member PBM information under the patient information section as part of the eligibility and benefits inquiry. We have enhanced this section of Availity to indicate when a member has moved to IngenioRx. Availity includes the name of the PBM and date the member moved to IngenioRx, or the date the member is scheduled to move to IngenioRx. Q. How will specialty drugs be transitioned?A. Specialty pharmacy prescriptions and prior authorizations will automatically transfer to IngenioRx. In addition, the IngenioRx Care Team will call members to introduce them to IngenioRx and discuss the medications they take, Q. How do I submit prescriptions to IngenioRx?A. If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx in your ePrescribing system. If you do not use ePrescribing, you can submit prescriptions using the following information. IngenioRx Home Delivery Pharmacy New Prescriptions:Phone Number: 1-833-203-1742 Fax Number: 1-800-378-0323 IngenioRx Specialty Pharmacy:Prescriber Phone: 1-833-262-1726 Prescriber Fax: 1-833-263-2871 Q. What phone number should I call with questions?A. For questions, contact the Provider Service phone number on the back of your patient's ID card. Category: Cal MediConnect
On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutic (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in MMP Clinical Criteria Web Posting Q1 2019. Visit Clinical Criteria to search for specific policies.
For questions or additional information, use this email.
503277MUPENMUB Category: Cal MediConnect
On August 17, 2018, October 9, 2018, and November 16, 2018, the Pharmacy and Therapeutic (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the MMP Clinical Criteria Updates. Visit Clinical Criteria to search for specific policies.
For questions or additional information, use this email.
503274MUPENMUB Category: Cal MediConnect
On March 29, 2019, April 12, 2019, and May 1, 2019, the Pharmacy and Therapeutic (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider website, and the effective dates will be reflected in the MMP Clinical Criteria Web Posting Q2 2019. Visit Clinical Criteria to search for specific policies.
For questions or additional information, use this email.
503264MUPENMUB Category: Cal MediConnect
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. The online process is faster and easier to complete, and the response is automatic, which helps patients get their medications sooner. You can complete this process through your current electronic health record/electronic medical record (EHR/EMR) system or via the following ePA sites:
Creating an account is free and takes just a few minutes. If you are experiencing any issues or have a question about how the systems operate:
- For questions or issues with accessing the Surescripts portal, call 1-866-797-3239.
- For questions or issues with accessing the CoverMyMeds portal, call 1-866-452-5017.
For questions regarding pharmacy benefits, please contact your Provider Customer Care Center at one of the numbers listed below:
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
504120MUPENMUB Category: Medi-Cal Managed Care
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. The online process is faster and easier to complete, and the response is automatic, which helps patients get their medications sooner. You can complete this process through your current electronic health record/electronic medical record (EHR/EMR) system or via the following ePA sites:
Creating an account is free and takes just a few minutes. If you are experiencing any issues or have a question about how the systems operate:
- For questions or issues with accessing the Surescripts portal, call 1-866-797-3239.
- For questions or issues with accessing the CoverMyMeds portal, call 1-866-452-5017.
For questions regarding pharmacy benefits, please contact your Provider Customer Care Center at one of the numbers listed below:
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 Category: Medicare
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. The online process is faster and easier to complete, and the response is automatic, which helps patients get their medications sooner. You can complete this process through your current electronic health record/electronic medical record (EHR/EMR) system or via the following ePA sites:
Creating an account is free and takes just a few minutes. If you are experiencing any issues or have a question about how the systems operate:
- For questions or issues with accessing the Surescripts portal, call 1-866-797-3239.
- For questions or issues with accessing the CoverMyMeds portal, call 1-866-452-5017.
For questions regarding pharmacy benefits, please contact your Provider Customer Care Center at one of the numbers listed below:
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
504120MUPENMUB Category: Medicare
The Blue Cross and Blue Shield Association issued a mandate requiring a change in the way we process Host and Home plan HEDIS® STARS Care Gaps, risk adjustment (RADV) and medical records requests. The goal of this mandate is to improve health outcomes and care management for Medicare Advantage out-of-area members.
More information about this mandate will be published in the December 2019 newsletter.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
504427MUPENMUB
Category: Medicare
CMS defines an expedited/urgent request as ‘an expedited/urgent request for a determination is a request in which waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in seriously jeopardy.’ Contracted providers should submit requests in accordance with CMS guidelines to allow for organization determinations within the standard turnaround time, unless the member urgently needs care based on the CMS definition of an expedited/urgent request.
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