 Provider News CaliforniaNovember 2022 Anthem Blue Cross Provider News - CaliforniaProviders currently submit prior authorization (PA) requests to AIM Specialty Health®* (AIM) for outpatient diagnostic imaging services. These PA requests are often reviewed based on provider attestation of certain requirements.
As part of our ongoing quality improvement efforts, we want you to know that some review requests may require documentation to substantiate the attestations that support the clinical appropriateness of the request. This documentation can be uploaded during the intake process.
When requested, providers must submit such documentation from the patient’s medical record. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. Such documentation is limited to what has been asserted via the PA review attestations.
If the request would be denied as not medically necessary, providers can participate in a PA discussion with an AIM physician reviewer.
As you may be aware, California Health and Safety Code section 1368.01(b) requires health plan grievance systems to include the following:
(b) The grievance system shall include a requirement for expedited plan review of grievances for cases involving an imminent and serious threat to the health of the patient, including, but not limited to, severe pain, potential loss of life, limb, or major bodily function. When the plan has notice of a case requiring expedited review, the grievance system shall require the plan to immediately inform enrollees and subscribers in writing of their right to notify the department of the grievance.
In order to allow us to immediately inform members of their right to notify the regulator of the grievance:
For cases involving an imminent and serious threat to the health of an HMO patient (including but not limited to severe pain and potential loss of life, limb, or major bodily function), participating medical group/full-risk providers must inform Anthem within one hour if they receive a grievance from an Anthem HMO member.
Have you heard the news? The 2022 Provider Satisfaction Survey is coming!
Do you know what the Provider Satisfaction Survey is? Anthem Blue Cross (Anthem) conducts the Provider Satisfaction Survey annually to ensure compliance with various timely access requirements for California.
We want to hear from you!
Your feedback helps us better serve you and your patients.
Be prepared to act.
Mark your calendar — Starting in October 2022, randomly selected providers will receive the annual Provider Satisfaction Survey.
If selected, you will receive the survey by fax from our vendor, Sutherland Healthcare Solutions. * We ask that you respond quickly, within five business days of receiving the survey.
The survey questions ask that you rate your satisfaction on a scale of one of four on the areas listed below. The survey should only take a couple of minutes to complete, and your responses help us measure your perspective and satisfaction with your patient’s ability to receive access to care within the timelines set forth under California law.
Your satisfaction with our referral and prior authorization process
Your patients’ timely access to:
Urgent care
Non-urgent specialty services
Non-urgent ancillary diagnostic and treatment services
Non-urgent healthcare
Your patients’ access to Anthem’s Language Assistance Program
Your satisfaction with Anthem’s interpreter services
Access the Provider Manual online at anthem.com/ca to learn more about Anthem’s Timely Access Standards and Language Assistance Program.
We value your participation in advance of completing the survey.
As a partner in the care of our members, we ask that you review your online provider directory information regularly and provide updates as needed.
For any needed changes, please update your information by submitting them to us on our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request.
Online update options include:
- Add/change an address location
- Name change
- Tax ID changes
- Provider leaving a group or a single location
- Phone/fax number changes
- Closing a practice location
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Thank you for doing your part in keeping our provider directories current.
We’re phasing in clear, concise, and simplified denial descriptions when returning claims status inquiries. The denial descriptions will explain why the claim or claim line was denied and what to do next. We’ve even included details about how to provide us with information digitally to move the claim further along in the claims process.
Continuing to improve
The new denial descriptions will be phased in over the next few months. Based on your feedback, we’re starting with those claims or claim lines that have caused the most confusion. If new denial reasons are added, the descriptions will be expanded as well.
Accessing claim statuses
The Claims Status application on availity.com* enables you to check the status of your claim and submit attachments needed to process your claim, all in one place. To access the Claims Status app, log into availity.com and, from the Claims & Payments tab, select Claims Status. It’s just that fast and easy to check your claim status through Availity Essentials.
If you’re not enrolled in Availity Essentials, use this link for registration information: https://availity.com/Essentials-Portal-Registration. There is no cost for our providers to use the applications through Availity Essentials.
Working together to streamline processes through technology is a collaborative effort. We appreciate your feedback as we continue improving to meet your expectations. The enhancements we’ve made to the Availity Essentials* Authorization application make it faster, easier, and more efficient to submit digital authorizations for Anthem Blue Cross members.
View attachments for authorizations submitted — You can now view the attachments you’ve submitted to support your authorization in the Availity Essentials authorization application.
Servicing and rendering provider — We’ve enhanced the Availity Essentials Authorization Application to enable a group option when selecting the servicing and rendering provider.
View correspondence — Access status and decision letters right from the Authorization Application Dashboard. Letters can also be downloaded or printed if needed.
Enhanced provider status — Out-of-network and in-network provider statuses are now enhanced to return fewer errors associated with provider status.
Expanded search — Search rendering and serving provider by NPI and ZIP code for quicker results.
Procedure code enhancement — Add the procedure code on an outpatient authorization for more accurate submission.
Case update features — You can now update your authorization right from your Authorization Application Dashboard.
Training sessions on the Availity Essentials authorization application are still available
Whether you prefer live training webcasts, on-demand webinar recordings, or a resource guide, we have everything you need to learn more about the Availity Essentials Authorization Application and how to make the most of it. Use this link to access the training option best for you.
The next live webcast is Wednesday, November 9, 2022, at 11 a.m. ET. Register here.
When submitting claims through the Electronic Data Interchange (EDI), a PWK segment indicator tells us you will be submitting supporting documentation for the claim and ensures the documents are attached correctly. The supporting documents are then sent through the Availity Essentials* Attachments Dashboard.
In November, the Attachments Dashboard will have a new look for Anthem Blue Cross claims
The sooner we receive your claim attachments, the faster your claim can be processed for payment. To meet this expectation, the Attachments Dashboard will begin a seven-calendar day countdown beginning in November. This means that claims will begin processing sooner for those claims with the PWK segment indicator.
If you are unable to meet the seven-calendar day submission deadline, the claim will move from your Attachments Dashboard inbox into your History folder and will be marked as expired. The claim will then deny for additional information based on the PWK segment indicator and move to Claims Status located under the Claims & Payments tab on availity.com. Upload your attachment from Claims Status by using the Submit Attachment button located on your claim.
To learn more about the new claims attachments workflow, visit our Provider Learning Hub or access the on-demand webinar recording, Learn about the new claims attachments workflow, using this link.
We incorrectly published this article in the November 2022 issue of Provider News. The digital dispute function is not currently available in California on Availity.com.
Submitting Anthem Blue Cross claims disputes through Availity Essentials* is the most efficient way to have a claim reconsidered. Easily accessible through the Claims & Payments application, select Claims Status to access the claim. Use the Dispute button to file the appeal and upload supporting document to finalize the submission.
Add multiple claims to one dispute submission
You can submit one dispute and add multiple claims — up to 25 claims — as long as the additional disputed claims are for the same member, provider, and dispute reason. For Commercial member claims, you can begin submitting multiple claims on one dispute beginning in November.
Access acknowledgement, update, and decision letters digitally, too
Access correspondence related to your disputes through the Appeals Dashboard. When you submit multiple claims on one dispute through Availity Essentials, you will receive correspondence related to each individual dispute, so expect a greater number of letters in your Appeals Dashboard. You can easily identify the correspondence related to your multiple dispute submission by looking for the
CI-COMM case number.
Availity Essentials appeals training
For detailed instructions about submitting disputes electronically, use this link to access appeals training from Availity Essentials.
New learnings added to the Provider Learning Hub.
Remittance Inquiry App: How to view, print, and save remittance advice
If you’re still using paper remittance to reconcile your claims, imagine the time you’ll save when you access remittance advice digitally through availity.com. This course shares information about how to view, print, and save electronic remittances.
Attachments: How to setup the Medical Attachment role
To submit attachments digitally (medical records, itemized bills, or other documents needed to process your claims), registering your organization in this training is step one. It will help you every step of the way.
Claim Submission: How to submit a claim using direct data entry
For providers who are not submitting their claims through Electronic Data Interchange (EDI), availity.com offers direct data entry for professional and facility claims. Take this course and walk through the process for submitting claims electronically.
Get started today
Access the Provider Learning Hub today using this link or from anthem.com under Important Announcements on the home page.
- All courses and webcasts are available 24/7 for your convenience.
- Use filtering options to quickly find courses and job aids.
- Use the Favorites folder to save items for easy access later.
- Once registered, no further registration is required.
- On future visits, your preferences are populated eliminating the need for any additional logon information.
Not registered on availity.com? Use this link for registration information or access registration information from the Provider Learning Hub. There is no cost for our providers to use availity.com.
This communication applies to the Commercial, Medicaid, and Medicare Advantage programs from Anthem Blue Cross (Anthem) in California.
HEDIS medical record submission made easier with our remote EMR access service
Let us take on the responsibility to retrieve medical records for the annual HEDIS® hybrid project by signing up for the remote electronic medical record (EMR) access service offered by Anthem.
We offer providers the ability to grant access to their EMR system directly to pull the required documentation to aid your office in reaching compliance while reducing the time and costs associated with medical record retrieval.
We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:
- We only access medical records of members pulled into the HEDIS sample using specific demographic data.
- We only retrieve the medical records that have claims evidence related to the HEDIS measures.
- We access the least amount of information needed for use, disclosure, or for the specific medical records request.
- We only save to file and do not physically print any PHI.
Getting started with remote EMR access
Download and complete the registration form, then email it to us at: Centralized_EMR_Team@anthem.com.
FAQ
How does Anthem retrieve your medical records?
We access your EMRs using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.
Is printing access necessary?
Yes. The NCQA audit requires print-to-file access.
Is this process secure?
Yes. We only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives.
Why does Anthem need full access to the entire medical record?
There are several reasons we need to look at the entire medical record of a member:
- HEDIS measures can include up to a 10-year look back at a member’s information.
- Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
- Compliant data may be documented or housed in a nonstandard format, such as an in‑office lab slip scanned into miscellaneous documents.
What information do I need to submit to use the remote EMR access service?
Complete the registration form that requests the following information:
- Practice/facility demographic information (for example, address, NPI, TIN, etc.)
- EMR system information (for example, type of EMR system, required access forms, access type, etc.)
- List of current providers/locations or a website for accessing this list
Remote Access not an option? We are now offering onsite visits for HEDIS hybrid retrieval. Email us at Centralized_EMR_Team@anthem.com for more information.
This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross (Anthem) in California.
Effective November 6, 2022, Anthem will transition the Clinical Criteria for medical necessity review of perirectal hydrogel spacer to the AIM Specialty Health®* (AIM) Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline.
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at https://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 Availity* at availity.com.
For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com.
Additionally, you may access and download a copy of the current and upcoming guidelines here.
Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://www.anthem.com/ca/provider/policies.
You can request a free copy of our UM criteria from our Medical Management department. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at 888-831-2246, option 4. To access UM criteria online, go to https://www.anthem.com/ca/provider/policies.
We are staffed with clinical professionals who work with you to coordinate our members’ care. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues.
You can submit precertification requests 24/7 by:
- Calling: 888-831-2246, option 3 (includes both inside and outside L.A. County).
- Faxing a Pre-Service Review form to 800-754-4708 (includes both inside and outside L.A. County).
Have questions about utilization management?
Please call one of our Medi-Cal Customer Care Centers toll free at 800-407-4627 (TTY 711), or 888-285-7801 (TTY 711) for members in Los Angeles, Monday to Friday, 7 a.m. to 7 p.m.
Alcohol use disorders (AUD) often coexist with, contribute to, or result from many different psychiatric disorders. 1 Because AUD can mimic and complicate many mental health disorders, AUD leads to challenges in diagnoses for psychiatric complaints.
Heavy alcohol use directly affects brain function and may manifest as a broad range of psychiatric symptoms. Common mental health symptoms of AUD include depression and anxiety.
In addition, patients diagnosed with mental health disorders are more likely to use a high amount of mental health services, have difficulties decreasing alcohol consumption, and struggle with suicidal ideation or attempts.
Common co-occurring mental health conditions include depressive disorders, anxiety, schizophrenia, and bipolar disorders.
Depressive disorders:2
AUD and depressive disorders are among the most prevalent co-occuring disorders. Depressive disorders are the most common comorbid mental health conditions with AUD. People with AUD are 2 to 3 times more likely to have depression. People with alcohol dependence are more likely to have a depressive disorder than those with alcohol abuse.
Co-occurring AUD and depressive disorders disproportionately affect women, as these disorders are two times more likely to occur in women than in men. Racial and ethnic minorities also encounter systemic disadvantages. For instance, Black and Latino people are significantly less likely to receive integrated mental health and substance use treatment than other races and ethnicities.
Research suggests that AUD is equally as likely to precede depression as well as for depression to precede AUD. In addition, having one increases the risk of having the other. Though the etiology of these disorders is not fully known, studies have identified some evidence of genetic predisposition or dysfunction in reward and stress systems of the brain.
Anxiety:3
Up to half of patients receiving treatment for AUD meet the criteria for one or more anxiety disorders. Data shows that patients with anxiety disorders have poorer outcomes in treatment for alcohol use. Conventional treatment for anxiety (antidepressants and behavioral therapy) do not appear to reduce AUD. This suggests that co-occurring anxiety and AUD benefits from being treated separately but simultaneously.
In addition, patients with an anxiety disorder or AUD experience an increased risk in developing the other disorder. Trauma, chronic stress, and other inheritable traits are associated with the dysfunction in stress-response systems present in AUD and anxiety disorders.
Schizophrenia:4
The prevalence of schizophrenia is about 1% of the population; however, patients with schizophrenia are at a three times greater risk for AUD. Between 25% to 36% of patients with schizophrenia meet the criteria for AUD. Schizophrenia has a strong genetic risk factor, and a large genome-wide study revealed a significant genetic correlation between schizophrenia and AUD.
There are several theories as to why AUD is so highly prevalent in patients with schizophrenia:
- A combination of neurobiological vulnerability (genetic risk) and environmental vulnerability (poverty, homelessness, trauma, etc.)
- The concept of self-medication, suggesting people with schizophrenia turn to alcohol for relief from their psychiatric symptoms
- Similar to depressive disorders, the hypothesis that both schizophrenia and AUD are related to a dysregulation of the reward system in the brain
Bipolar disorder:5
Bipolar disorder is the most likely psychiatric disorder to have a co‑occurring condition with a substance use disorder (SUD). Estimates for a lifetime co‑occurring bipolar disorder and AUD is between 40% to 70%. These co-occurring disorders are most common in women.
Bipolar disorder occurs in between 1.5% to 5% of the population. Like schizophrenia, bipolar disorder has a shared genetic predisposition with AUD. Heavy alcohol use worsens symptoms of bipolar disorder and can trigger episodes of mania and depression. Conversely, these episodes can lead to increased alcohol consumption. Treatment for bipolar disorder often assists in treatment for co‑occurring AUD. Mood stabilizers used to treat bipolar disorder have been shown to reduce alcohol cravings in patients with bipolar disorder.
Alcohol (and other substances) are likely triggers for the onset of bipolar disorders. In one study, substance use preceded 60% of first manic episodes.6 In juvenile cases, bipolar onset early in life is correlated with AUD development as an adult.
What if I need assistance?
If you need assistance connecting your patients to mental health or AUD treatment, call one of our Medi-Cal Customer Care Centers at 800-407-4627 (outside L.A. County) or
888-285-7801 (inside L.A. County).
Anthem Blue Cross (Anthem) is implementing two new Medicare Advantage plans in 2023. With each plan, our goal is to deliver on our missing of improving the lives of our members. With the new plans, we are excited to continue to offer strong plans that meet our members’ needs. The plans will help connect Medicare Advantage members to the care, support, and resources they need to lead healthy lives. The two new plans are named Anthem MediBlue Prime (HMO) and Anthem MediBlue Full Dual Advantage (HMO D-SNP).
Anthem MediBlue Prime (HMO) will be offered in Fresno, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Mateo, and Ventura counties. Members who are currently enrolled in Anthem MediBlue Coordination Plus (HMO) and Anthem MediBlue Connect Plus (HMO) in these counties will be transitioned to the new Anthem MediBlue Prime (HMO). Members enrolled in the new plan will have $0 monthly premium as well as $0 copay for PCP visits, specialist visits, and inpatient hospital stays. Our goal is to improve the healthcare of our members and pursue a simpler, more effective healthcare experience.
Anthem MediBlue Full Dual Advantage (HMO D-SNP) will be offered in Los Angeles and Santa Clara counties. This plan is an exclusively aligned enrollment dual special needs plan (EAE D-SNP). The plan was created to support the state of California’s Advancing and Innovating (CalAIM) initiative. The plan offers an integrated approach to care and care coordination. The matching Medicare D-SNP and Medi-Cal plans will work together to deliver all covered benefits to their members. And as all members in the plan are also enrolled in the matching managed care plan, they can receive integrated member materials, such as one integrated member ID card. Current members enrolled in Anthem MediBlue Dual Advantage (HMO D-SNP) and Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan) will be transitioned to the new Anthem MediBlue Full Dual Advantage (HMO D-SNP) in 2023. The goal is to improve care coordination and person-centered care for beneficiaries that are eligible for both Medicare and Medi-Cal.
Anthem has pursued best efforts to keep all members with their current PCP with both plans. Anthem anticipates the provider networks will be the same or better in these plans for our members. Anthem strives to offer members a full comprehensive network to meet all their healthcare needs. Participating providers in the plans will receive a notification with additional information. If you have any questions about the plans, please contact us. Additional details regarding the plans can be found on our provider website at https://www.anthem.com/ca/medicareprovider.
Find Care, the doctor finder and transparency tool in the Anthem Blue Cross (Anthem) online directory, provides Anthem members with the ability to search for in-network providers using the secure member website at www.anthem.com/ca. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetic order, and provider name.
Beginning January 1, 2023, or later, an additional sorting option will be available for members to search by provider performance called Personalized Match. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Provider pairings with the highest overall ranking within the member’s search radius will be displayed first. Members will continue to have the ability to sort based on distance, alphabetic order, and provider name.
- You may review a copy of the Personalized Match methodology which has been posted on Availity* – our secure web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Anthem > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.
- If you have general questions regarding this new sorting option, please submit an inquiry via the web at www.availity.com.
- If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to www.availity.com.
Going forward, Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.
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