Using our secure provider portal or EDI submissions (via Availity), administrative tasks can be reduced by more than fifty percent when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website or the secure provider portal via Availity.

Get payments faster

By eliminating paper checks, Electronic Funds Transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and you can receive payments faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance, which meets all HIPAA mandates - eliminating the need for paper remittances.

Member IDs go digital

Anthem Blue Cross (Anthem) members are transitioning to digital member identification cards making it easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member identification cards to EDI transactions, APIs to Direct Data Entry, we cover it all in our Provider Digital Engagement Supplement to the provider manual available here and on our secure provider portal through Availity. The Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits.

On September 1, 2020, we announced Site of Care medical necessity review for numerous surgical procedures beginning December 1, 2020, administered by AIM Specialty Health^® (AIM).

This review applies to local fully insured Anthem members and members covered under self-insured (ASO) benefit plans with services medically managed by AIM.  This does not apply to HMO, BlueCard^®, Medicare Advantage, Medicaid, Medicare Supplemental or Federal Employee Program^® (FEP^®).
 

AIM is offering the following training webinars on how to navigate the AIM ProviderPortal_SM to submit authorization requests: 

• November 9:           1:00pm Pacific
• November 10:         1:00pm Pacific
• November 13:         11:00am Pacific
• November 16:         11:00am Pacific
• December 14:         11:00am Pacific

To register for a webinar, go to aimproviders.com/surgical procedures. 

Starting November 16, 2020 ordering providers may submit prior authorization requests for Hospital Outpatient site of care for the applicable procedures for dates of service on or after December 1, 2020 to AIM in one of the following ways:

• Access AIM 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 AIM via the Availity Portal at availity.com
• Call the AIM Contact Center toll-free number: 1-877-291-0360, Monday–Friday, 7:00 a.m.–5:00 p.m. PT

The site of care review only applies to select procedures performed in an outpatient hospital setting.  The site of care review does not apply to procedures performed in a non-hospital setting or as part of an inpatient stay.  For inpatient admission, please contact the health plan at the number on the back of the member ID card.  Reviews also do not apply when Anthem Blue Cross is the secondary payer.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

Additional Resource Offerings

In addition, 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. Select Providers, under Communications go to Education and Training. Scroll down to view Training, Educational and Resource offerings.

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The purpose of this article is to provide additional information regarding submission of the CLIA number on claims for laboratory services that include QW or 90 modifiers. As a reminder, claims filed without the CLIA number are considered incomplete and will reject. 

Both paper and electronic claim formats accommodate the CLIA number. 

• On the CMS-1500 form, Box 23 (Prior Authorization) is reserved for the CLIA number.
• On the 837P, REF segments are available: REF (X4) in loops 2300 and 2400, and REF (F4) in loop 2400. 

Note: The CLIA number for the Referring Clinical Laboratory should be included in REF (F4) 

The following examples illustrate how the CLIA number as well as procedure code modifiers QW and 90 should be filed:

Additional information regarding CLIA is available on the CMS website:  https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/

If you have additional questions, please call the telephone number on the back of the member’s identification card.

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In this 60-minute webinar, you will learn how to use Availity's* Attachment tools to submit and track supporting documentation electronically to Anthem and affiliate payers.

We will explore key workflow options to fit your organization’s needs, including how to:

• Work a request in the inbox of your Attachments Dashboard.
• Enter and submit a web claim including supporting documentation.
• Use EDI batch options to trigger a request in your inbox.
• Track attachments you submitted using sent and history lists in your Attachments Dashboard.
• Get set up to use these tools.

As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.

Register for an upcoming webinar session:

1. In the Availity Portal, select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options:
   • In the Catalog, search by webinar title or keyword.
     1. To find this specific live session quickly, use keyword medattach.
   • Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you’ll receive emails with instructions to join the session.

Webinar Dates:

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 grievance forms, a description of grievance procedures, and assistance in filing grievances are readily available at each contracting provider’s office, contracting facility, or Plan facility.

Please review and distribute the Anthem Blue Cross (Anthem) grievance form to all your participating offices. It is important to implement processes to provide grievance forms and assistance to Anthem members promptly upon request.

Your agreement with Anthem requires you to comply with all applicable laws and regulations and to cooperate with Anthem’s administration of its grievance program.

Information can be accessed on the process of submitting member grievances and appeals, grievance forms, definitions and appeal rights, on Anthem’s website at www.anthem.com/ca/forms. Go to View by Topic and click on the drop-down menu and select Grievance & Appeals, then select the desired resources link.

Also, grievance forms, grievance procedures and additional information about Anthem’s expedited grievance and appeals review process, can be found in your Provider Operations Manual.

Anthem has posted a required learning course via Availity Portal (login required) to ensure all contracted provider offices have implemented processes to provide grievance forms and assistance to enrollees. Please make sure to complete this course and the required attestation by December 31, 2020. We appreciate your cooperation and support.

To Register for the Course:

1. Log in to Availity Portal at availity.com.
2. At the top of Availity Portal, click Payer Spaces > Anthem Blue Cross.
3. On the payer spaces landing page, click Access Your Custom Learning Center from the Applications tab.
4. Search for the [Required Grievance Process/Form Course for Anthem Blue Cross Contracted Providers] using keyword grievance.
5. Enroll and complete the course, including the required attestation module.

Refer to this guide for more information.

Not registered for the Availity Portal?

Have your organization’s designated administrator register your organization for the Availity Portal.

1. Visit availity.com to register.
2. Click Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization. Refer to these PDF documents for complete registration instructions.

Getting Started

When you long in to Availity Portal for the first time, Availity prompts you to:

1. Accept privacy and security statements
2. Accept a confidentiality agreement
3. Choose three security questions and answers
4. Create a new password
5. Verify your email address

For questions regarding the Availity Portal, please contact Availity Client Services at 1-800-282-4548.

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If you have questions, you now have a new option to have them answered quickly and easily. With Anthem Blue Cross (Anthem) Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity.

• Faster access to provider services for all questions
• Real-time answers to your questions about PA and appeal status, claims, benefits, eligibility, and more
• A platform that is easy to use making it simpler to receive help
• The same high level of safety and security you have come to expect with Anthem

Chat is one example of how Anthem is using digital technology to improve the health care experience, with a goal to save you valuable time. To get started, please access the service through Payer Services on Availity.

Use Provider Chat: Select Payer Spaces, select Anthem, and from Applications select Chat.

Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before with our Provider News publication. 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 email addresses as you like.

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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.

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.

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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 are 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.

As previously communicated in the October 2017 Network Update, Anthem Blue Cross (Anthem) uses AIM to administer pre-service clinical reviews for services noted below.  AIM reviews requests in real time against evidence-based clinical guidelines and Anthem medical policies.  Providers are notified via letter or remit message when claims are submitted without the appropriate pre-service review by AIM.  If such a letter or message is received, providers will need to obtain a post-service clinical review for the service via the AIM ProviderPortal_SM.  If documentation/post–service review request is submitted to Anthem, Providers are notified via another letter or remit message to submit to AIM.

To help prevent delays in claim processing and post-service reviews, ordering providers submit pre-service request to AIM in one of the following ways:

• Access AIM ProviderPortal directly at providerportal.com available 24/7 to process orders in real-time
• Access AIM via the Availity web portal at availity.com
• Call the AIM Contact Center toll-free number: 1-877-291-0360, Monday–Friday, 7:00 a.m.–5:00 p.m. PT.

As a reminder, AIM reviews the following services for clinical appropriateness:

• Advanced diagnostic imaging
• Cardiology tests and procedures (e.g. MPI, echocardiography, PCI, cardiac catheterization)
• Medical oncology treatments through the Cancer Care Quality Program
• Radiation oncology treatments (e.g. IMRT, brachytherapy)
• Sleep testing, treatment and supplies
• Genetic testing
• Musculoskeletal (e.g., spine and joint surgeries, pain management)
• Surgical Site of Care (e.g., gastroenterology, other surgeries will be implemented which will be communicated via our provider newsletter) – effective December 1, 2020

Services performed in an emergency or inpatient setting are excluded from AIM programs.

This update applies to local fully-insured Anthem members and members who are covered under a self-insured (ASO) benefit plan, with services medically managed by AIM. It does not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®).

For more information please contact the phone number on the back of the member ID card.

Anthem Blue Cross (Anthem) is committed to creating innovative tools that help simplify health care. In pursuit of that commitment, we recently enhanced our digital tool that enables members to share their personal health data with physicians and hospitals. This tool, referred to as My Health Records, merges patient health records from providers who may have cared for an individual member and stores the data in one secure place that is accessible to the member via the Sydney Health mobile app and anthem.com/ca. My Health Records provides a new way for members to access their personal health information from multiple providers’ databases then view, download and share their health data and medical records with doctors via their smartphone or computer.

My Health Records allows members to share important health information with physicians, such as:

• Lab results and historical insights with visualizations
• Medications, Conditions, Immunizations, Vaccinations
• Health records
• Health records of dependents (14 years and under)
• Easy access to provider information
• Personalized health data tracking over time
• Integration for member authorization to more health record data

The enhanced digital tool gives physicians and hospitals a holistic view of a member’s up-to-date health data. This complete health data in one trusted place enables providers and members to feel more confident in making important life decisions easily and quickly.

This tool is now available to Anthem members in our Medicare, Individual, Small Group and Fully Insured Large Group business segments and will be available to members in our Large Group ASO and Anthem National Account business segments in early 2021.

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Click here for more information about how to Help prevent pre-eclampsia with prenatal aspirin.

Click here for more information about the New specialty pharmacy medical step therapy requirements.

This update is to inform you that there is now a separate and specific professional reimbursement policy to reference for Nurse Practitioner and Physician Assistant Services.

Anthem Blue Cross (Anthem) continues to allow reimbursement for services provided by nurse practitioner (NP) and physician assistant (PA) providers. Unless provider, state, federal or CMS contracts and/or requirements indicate otherwise, reimbursement is based upon all of the following:

• The service is considered a physician’s service.
• The service is within the scope of practice.
• Anthem does not allow direct reimbursement for NP and PA providers.

Services furnished by the NP or PA should be submitted by the supervising physician.

Need for coding compliance

Coding compliance refers to the process of ensuring that the coding of diagnosis, procedures and data complies with all coding rules, laws and guidelines.

All provider offices and health care facilities should have a compliance plan. Internal controls in the reimbursement, coding, and payment areas of claims and billing operations are often the source of fraud and abuse and have been the focus of government regulations.

Compliance plan benefits:

• More accurate payment of claims
• Fewer billing mistakes
• Improved documentation and more accurate coding
• Less chance of violating state and federal requirements including self-referral and anti-kickback statutes.

Compliance programs can show the provider practice is making an effort to submit claims appropriately and send a signal to employees that compliance is a priority.

Medical records documentation

All medical records entries should be complete and legible and should include the legible identity of the provider and date of service.

Each encounter in the medical record must include the patient’s full name and date of birth. Documentation integrity is at risk when there is wrong information on the wrong patient health record because it can affect clinical decision-making and patient safety.

Providers’ signatures and credentials are of the utmost importance in all documentation efforts. The signature is an attestation from the treating and documenting provider that certifies the written document as reflecting the provider’s intentions regarding the services performed during the encounter, and the reason(s).

Specific information is required to describe the patient encounter each time he or she presents for medical services.

Each encounter generally will need to contain the following:

• The chief complaint
• The history of present illness
• The physical examination
• Assessment and care plan.

Common coding and billing risk areas

The following billing risks are commonly subject to Office of Inspector General (OIG) investigations and audits:

• Billing for items or services not rendered or not provided as claimed
• Double billing, resulting in duplicate payment
• Submitting claims for equipment, medical supplies, and services that are not reasonable and necessary
• Billing for non-covered services
• Knowingly misusing provider identification numbers, which results in improper billing
• Unbundling
• Failure to properly use modifiers
• Upcoding the level of service.

Evaluation and Management (E&M) claims are typically denied for two reasons:

• Incorrect coding, such as the code not matching the documentation, and insufficient documentation, which can include a lack of a provider signature or no record of the extent and amount of time spent in counseling.
• Coordination of care when it is used to qualify for a particular level of E&M service.

There are several strategies on how to prevent E&M claims being denied:

• In addition to the individual requirements for billing a selected E&M code, providers should also consider whether the service is reasonable and necessary (for example, a level 5 office visit for a patient with a common cold and no comorbidities will not be reasonable and necessary).
• Remember the following when selecting codes for E&M services:
  • Patient type (new or established)
  • Setting/place of service
  • The level of service provided based on the extent of the history, the extent of the examination, and the complexity of the medical decision making (for example, the number and type of the key components performed).

Best practices to avoid common documentation mistakes

Providers need to formulate a complete and accurate description of the patient’s condition with a detailed plan of care for each encounter. Listing problems without a corresponding plan of care does not confirm physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (for example, diabetes management (DM), chronic kidney disease (CKD), congestive heart failure (CHF): Continue current treatment plan) equally diminishes the complexity and effort put forth by the physician.

The care plan needs to be documented clearly. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another provider is primarily managing the problem. For example, one provider can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD).

Pathology service, laboratory testing, radiology and medicine-based diagnostic testing contributes to diagnosing or managing patient problems.

Documentation tips:

• Specify tests ordered and document rationale in the medical record
• Document test review by including a description in the note (for example, elevated glucose levels)
• Indicate when images, tracings, or specimens are personally reviewed; be sure to include a comment on the findings
• Summarize any discussions of unexpected or contradictory test results with the provider performing the procedure or diagnostic study.

Patient risk in E&M is categorized as minimal, low, moderate or high based on the presenting problem, diagnostic procedures ordered, and management options selected. Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered less risky than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis. 

To determine the right complexity of the patient’s problems, providers should:

• Document the status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; do not assume that the auditor or coder can infer this from the documentation details.
• Document all diagnostic or therapeutic procedures considered.
• Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.

Frequent auditing is key to medical coding compliance

To ensure your organization’s E&M services are coded appropriately, it is important to periodically review your charts to check for insufficient documentation, miscoding, upcoding and downcoding. Conducting audits of your medical coding process and procedures can help give you an understanding of recurring risk areas and key improvement opportunities. Using these insights, you can then incorporate best practices and address any bad habits, lessening the chances of negative consequences.

Resources

1. CPT^® Professional Edition, 2020. AMA
2. Compliance Guidance. Office of Inspector General. https://oig.hhs.gov/compliance/compliance-guidance/index.asp
3. Risk Adjustment Documentation & Coding, 2^nd edition. American Medical Association

On February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (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 Clinical Criteria Web Posting June 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

Effective for dates of service on and after January 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation or renewal, in addition to the current medical necessity review of all drugs noted below.

The Clinical Criteria below will be updated to include the requirement of a preferred agent effective January 1, 2021.

Clinical Criteria is publicly available on our provider website at https://mediproviders.anthem.com/ca.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call one of our Medi-Cal Customer Care Centers at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County).

Your patient's health is closely related to their environment and experiences, and screening for these is now easy and billable. Adverse childhood experiences (ACEs) are circumstances that fit into 10 categories under the domains of abuse, neglect and household dysfunction and can result in toxic stress in patients.

Data shows that 62% of Californians have experienced at least one ACE and 16% have experienced four or more ACEs in their lives. Experiencing four or more ACEs has been clearly associated with 9 of the 10 leading causes of death in the United States, including chronic lower respiratory disease, stroke, cancer, heart disease and diabetes, along with a range of mental illnesses.

Research has also demonstrated that the effects of toxic stress show a pattern of intergenerational transmission, affecting multiple generations in a family. This is why the California Surgeon General has made it a priority to start screening for ACEs during regular doctor appointments and connect identified Californians with the proper resources to lower their level of risk. The ACEs screening tools and a comprehensive two-hour training is available to providers for free and provides 2 continuing medical education (CME) or Maintenance of Certification credits.

Once this training is completed, Medi-Cal Managed Care providers can be reimbursed for each screening completed and can help their patients live longer, healthier lives. For more information, go to https://www.acesaware.org.

ACE screening — good news for your office, better health for your patient and their family

This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

Introducing the Anthem Provider Digital Engagement Supplement to the provider manual

Using our secure provider portal or EDI submissions (via Availity*), administrative tasks can be reduced by more than 50% when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, just go here for EDI or here for the secure provider portal (Availity).

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and will deliver payments to you faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the Availity Provider Portal or the EDI 835 remittance, which meets all HIPAA mandates — eliminating the need for paper remittances.

Member ID cards go digital

Members who are transitioning to digital member ID cards, will find it is easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available by going to https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx > Manuals, Training & More > Resources > Provider Digital Engagement, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid, including medical, dental and vision benefits.

The Provider Digital Engagement Supplement to the provider manual is another example of how Anthem is using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now by going to https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx > Manuals, Training & More > Resources > Provider Digital Engagement, and go digital with Anthem.

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Click here for more information about the Prior authorization requirements for the below codes.

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Click here for more information about the AIM Musculoskeletal program expansion update.

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On January 1, 2020, Anthem Blue Cross (Anthem) implemented a preferred edit on Medicare Part B eligible continuous glucose monitors (CGMs). The preferred CGM is Freestyle Libre.

Preferred CGM edits do not apply to the following plans/plan types:

• Employer Group Waiver Plans (EGWP) Medicare Advantage Part D (MAPD) through Anthem
• Employer Group Waiver Plans (EGWP) Medicare Advantage (MA only) through Anthem
• Individual Medicare Advantage Plans (MA only) through Anthem

Delivery channels

Only members enrolled in a plan using preferred CGM edits will need to obtain their CGM systems from a retail or mail order pharmacy. Members on a plan without preferred CGM edits will be able to obtain their CGM systems through durable medical equipment (DME) providers in addition to retail and mail order pharmacies. Please check member and plan benefits to confirm the available delivery channels for accessing CGM products.

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You now have a new option to have questions answered quickly and easily. With Anthem Blue Cross (Anthem) Chat, providers can have a real-time, online discussion through a new digital service, available through Payer Spaces on Availity.* Provider Chat offers:

• Faster access to Provider Services for all questions.
• Real-time answers to your questions about prior authorization and appeals status, claims, benefits, eligibility, and more.
• An easy to use platform that makes it simple to receive help.
• The same high level of safety and security you have come to expect with Anthem.

Chat is one example of how Anthem is using digital technology to improve the health care experience, with the goal of saving valuable time. To get started, access the service through Payer Services on Availity.

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Anthem Blue Cross previously communicated that AIM Specialty Health_®* (AIM) would transition the clinical criteria for medical necessity review of certain rehabilitative services to AIM Rehabilitative Service Clinical Appropriateness Guidelines as part of the AIM Rehabilitation Program beginning October 1, 2020. Please be aware that this transition has been delayed. The new transition date will in December 1, 2020.

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This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

Introducing the Anthem Provider Digital Engagement Supplement to the provider manual

Using our secure provider portal or EDI submissions (via Availity*), administrative tasks can be reduced by more than 50% when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, just go here for EDI or here for the secure provider portal (Availity).

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and will deliver payments to you faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the Availity Provider Portal or the EDI 835 remittance, which meets all HIPAA mandates — eliminating the need for paper remittances.

Member ID cards go digital

Members who are transitioning to digital member ID cards, will find it is easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available by going to https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx > Manuals, Training & More > Resources > Provider Digital Engagement, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid, including medical, dental and vision benefits.

The Provider Digital Engagement Supplement to the provider manual is another example of how Anthem is using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now by going to https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx > Manuals, Training & More > Resources > Provider Digital Engagement, and go digital with Anthem.

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Anthem Blue Cross (Anthem) reviews the activities of the FDA’s approval of drugs and biologics on a regular basis to understand the potential effects for both our providers and members.

The FDA approves new drugs/biologics using various pathways of approval. Recent studies on the effectiveness of drugs/biologics going through these different FDA pathways illustrates the importance of clinicians being aware of the clinical data behind a drug or biologic approval in making informed decisions.

Here is a list of the approval pathways the FDA uses for drugs/biologics:

• Standard Review: The Standard Review process follows well-established paths to make sure drugs/biologics are safe and effective when they reach the public. From concept to approval and beyond, FDA performs these steps: reviews research data and information about drugs and biologics before they become available to the public, watches for problems once drugs and biologics are available to the public, monitors drug/biologic information and advertising, and protects drug/biologic quality. To learn more about the Standard Review process, go here.
• Fast Track: Fast Track is a process designed to facilitate the development and expedite the review of drugs/biologics to treat serious conditions and fill an unmet medical need. To learn more about the Fast Track process, go here.
• Priority Review: A Priority Review designation means FDA’s goal is to take action on an application within six months. To learn more about the Priority Review process, go here.
• Breakthrough Therapy: A process designed to expedite the development and review of drugs/biologics that may demonstrate substantial improvement over available therapy. To learn more about the Breakthrough Therapy process, click here.
• Orphan Review: Orphan Review is the evaluation and development of drugs/biologics that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. To learn more about the Orphan Review process, click here.
• Accelerated Approval: These regulations allowed drugs/biologics for serious conditions that filled an unmet medical need to be approved based on a surrogate endpoint. To learn more about the Accelerated Approval process, click here.

New molecular entities approvals — January to August 2020

Certain drugs/biologics are classified as new molecular entities (NMEs) for purposes of FDA review. Many of these products contain active ingredients that have not been approved by FDA previously, either as a single ingredient drug or as part of a combination product; these products frequently provide important new therapies for patients.

Source: www.fda.gov

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On February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (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  Clinical Criteria Web Posting May 2020 and  Clinical Criteria Web Posting June 2020. Visit Clinical Criteria to search for specific policies.

If you have questions or would like additional information, use this email.

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This update is to inform you that there is now a separate and specific professional reimbursement policy to reference for Nurse Practitioner and Physician Assistant Services.

Anthem Blue Cross continues to allow reimbursement for services provided by Nurse Practitioner (NP) and Physician Assistant (PA) providers. Unless provider, state, federal or CMS contracts and/or requirements indicate otherwise, reimbursement is based upon all of the following:

• Service is considered a physician’s service
• Service is within the scope of practice
• A payment reduction consistent with CMS reimbursement

Services furnished by the NP or PA should be submitted with their own NPI.

For additional information on the Nurse Practitioner and Physician Assistant Services professional policy, visit https://mediproviders.anthem.com/ca.

This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

Introducing the Anthem Provider Digital Engagement Supplement to the provider manual

Using our secure provider portal or EDI submissions (via Availity*), administrative tasks can be reduced by more than 50% when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, just go here for EDI or here for the secure provider portal (Availity).

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and will deliver payments to you faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the Availity Provider Portal or the EDI 835 remittance, which meets all HIPAA mandates — eliminating the need for paper remittances.

Member ID cards go digital

Members who are transitioning to digital member ID cards, will find it is easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available by going to https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx > Manuals, Training & More > Resources > Provider Digital Engagement, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid, including medical, dental and vision benefits.

The Provider Digital Engagement Supplement to the provider manual is another example of how Anthem is using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Digital Engagement Supplement now by going to https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx > Manuals, Training & More > Resources > Provider Digital Engagement, and go digital with Anthem.

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