The Department of Health & Human Services (HHS) requires health plans to report whether or not our in-network providers offer telehealth services.

If you provide telehealth services, please tell us by submitting your information to us through Availity.com. Updating your telehealth status will not affect your participation with us. We will add a telehealth indicator to your online provider directory profile, allowing our members to know you offer telehealth services.

If you have questions about submitting your information, please see the instructions below.

If your organization is not currently registered with Availity, you will need to create an account. The person(s) designated as your administrator(s) should go to Availity.com and select Get Started in the upper right corner of the webpage. You may also navigate directly to Availity’s registration website by selecting here.

Begin your application here. To update your application:

1. Log in to Availity Essentials.
2. Select My Providers.
3. Select Provider Data Management.

Please update your telehealth information at the service location.

Balance billing Medi-Cal Managed Care beneficiaries is prohibited by federal and state law.

Medi-Cal beneficiaries should not pay physician visits and other medical care when they receive covered services from a provider in their provider network. This means beneficiaries cannot be charged for co-pays, co-insurance, or deductibles. This applies to both Medicare and Medi-Cal providers.

Billing Medi-Cal beneficiaries violates federal law as outlined in section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997. This section of the act is available at: http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. Protections are also found in California Welfare and Institutions Code section 14019.4.

Community Supports (CS) are a menu of services that, at the option of a managed care plan and a member, can substitute for covered Medi-Cal Managed Care services as medically appropriate and cost-effective alternatives. Anthem offers all 14 CS services the Department of Health Care Services (DHCS) has approved for individuals with complex physical behavior, developmental, and social needs.

A member who meets the criteria of any of the CS services below is eligible:

• Housing/homelessness:
  • Housing transition navigation services
  • Housing deposits
  • Housing tenancy and sustaining
  • Day habilitation
• Facilities:
  • Short-term post-hospitalization housing
  • Recuperative care (medical respite)
  • Sobering center
• In-home supports:
  • Respite services (can also be provided in a facility setting)
  • Personal care and homemaker services
• Nursing homes:
  • Nursing facility (NF) transition/diversion to assisted living facilities
  • Community transition services/NF transition to a home
• Construction (two services):
  • Environmental accessibility adaptations (home modifications)
  • Asthma remediation
• Meals:
  • Meals/medically tailored meals

We are committed to helping patients more easily access the care they need. For more information, visit our website.

We are pleased to announce our new Pathway HMO fee-for-service network design, Direct HMO. Direct HMO is a grouping of PPO physicians from which members can select a PCP. It applies only to the individual exchange network, Pathway HMO. Read on to learn more about Direct HMO:

• Direct HMO rolls out on January 1, 2025.
• Plan members receive an ID card with Pathway HMO at the bottom right and Direct HMO in the center. Members can also access these cards virtually through the Sydney^SM Health app.
• The network services the following California counties: Fresno, Kings, Los Angeles, Madera, Orange, Riverside, San Bernardino, and San Diego.
• You can access our online directory, Find Care, at anthem.com/ca to find providers in our Direct HMO network.
• Referrals are required for specialty care except for behavioral health services and other services specified in the member’s Pathway HMO health benefit plan, which members can access directly without a referral (for example, reproductive or sexual health care services and obstetrical/gynecological care consultations as described in the member’s Evidence of Coverage for complete benefit information). Make sure to refer only within the extensive network of Direct HMO specialists.
• For our members with an assigned PCP in Direct HMO, we require all participating plan care providers to follow specific Utilization Management (UM) requirements:

• Promptly notify us of all referral and authorization requests.
• Collaboration with our HMO Clinical Ops Team ensures timely and effective coordination of members’ care needs and guidance to the right in-network care providers.

Questions:

• For specific contract questions, email SpecialNetworkReq@anthem.com with Direct HMO in the subject line.
• For UM or medical management questions, contact our HMO Clinical Ops team. Call toll-free
  866-757-8211, fax to 866‑461‑2401, or email hmocomanagement@anthem.com. Please limit questions to medical management only.
• For general inquiries, contact our Provider Relations department. For more contact options, please visit anthem.com/ca > Contact Us.
• Our FAQ provides general information about Direct HMO and answers common questions. It will be updated as needed. Please refer to the attached FAQ for details.

We are committed to finding solutions that help our care provider partners offer quality services to our members.

Participating providers are responsible for offering members access to covered services 24/7. Access includes regular office hours on weekdays and the availability of a provider or designated agent by telephone after regular office hours, on weekends, and on holidays. When unavailable, providers must arrange for on-call coverage by another participating provider. Providers are also required to meet appointment access standards as described below.

After-hours calls:

• Providers must instruct their after-hours answering service to answer Anthem’s After Hours Survey questions. Non-compliant providers are subject to contractual enforcement actions, such as Corrective Action Plans (CAP) or escalated contractual sanctions for breach of contract.
• The answering service or after-hours personnel must ask the member if the call is an emergency. In the event of an emergency, the member must be immediately directed to dial 911 or to proceed directly to the nearest hospital emergency room.
• If staff or answering service is not immediately available, an answering machine may be used. The answering machine message must instruct members with emergency healthcare needs to dial 911 or go directly to the nearest hospital emergency room. The message must also give members an alternative contact number so they can reach the primary care physician (PCP) or on-call provider with medical concerns or questions.
• Non-English-speaking members who call their PCP after hours should expect to get
  language-appropriate messages. In the event of an emergency, these messages should direct the member to dial 911 or proceed directly to the nearest hospital emergency room.
• In a non-emergency situation, members should receive instruction on how to contact the on-call provider. If an answering service is used, the service should know where to contact a telephone interpreter. All calls taken by an answering service must be returned.

Appointment access

Note: The next available appointment date and time can be either in-person or by telehealth services.

Healthcare providers must make appointments for members from the time of request as follows:

SB221 — Effective since July 1, 2022, non-physician mental health/SUD appointments are subject to the timely access standards outlined in the chart above. This bill also requires that all health plans ensure that enrollees who are undergoing a course of treatment for an ongoing mental health or SUD condition can schedule a follow up appointment with their non-physicians mental healthcare or SUD provider within 10 business days of the prior appointment.

Specialists

The following guidelines are in place for our specialists:

• For urgent care, the specialist should see the member within 96 hours of receiving the request.
• For routine care, the specialist should see the member within 15 business days of receiving the request.
• A copy of the medical records and/or results of the visit should be sent to the PCP’s office to allow continuity of care.

Wait times

When a provider's office receives a call from an Anthem member during regular business hours — as well as after hours — for assistance and possible triage, the provider or another healthcare professional must either take the call or call the member back within 30 minutes of the initial call.

When an Anthem member arrives on time to an appointment, the member should be seen within 15 minutes of the scheduled appointment.

When Anthem members and/or prospective members call a physician’s office, they should not be placed on hold for longer than 10 minutes.

Interpretation services

When a provider’s office receives a call from an Anthem member, the provider’s office should know where to contact a telephone interpreter to communicate in the member’s preferred language.

Noncompliance

Ensure that you comply with the standards described; compliance with these standards is a contractual requirement. Anthem monitors compliance through a number of mechanisms, including annual telephonic surveys, to determine if participating provider offices meet the above standards.

For additional details, review the provider manuals at
https://providers.anthem.com/california-provider/resources/manuals-policies-guidelines.

Beginning in 2023, delegated network providers will be measured based on a compliance threshold of 70% as outlined in CCR 1300.67.2.2. Delegates scoring below 70% compliance for Non-Urgent and Urgent appointment availability will be subject to corrective action, up to and including, termination of the contract.

Required timely access training course — to be released in measurement year 2024

Rescheduling missed appointments — Los Angeles county providers only

This is a reminder that Los Angeles county providers are required to call to reschedule an appointment within 48 hours after a missed appointment. Ensure your office’s policies and procedures and training are updated to include this requirement. Providers may be surveyed on a random sample to ensure compliance with this standard.

Schedule of timely access surveys

Provider Appointment Availability Survey (PAAS):

• Survey subject(s): Appointment availability
• Managed Care Plan: Anthem
• Contractor conducting survey: Sutherland
• Regulatory agency: Department of Managed Health Care (DMHC)
• Schedule: July through November 2024

After Hours and Appointment Availability Survey:

• Survey subject(s): Emergency and urgent after-hours calls
• Managed Care Plan: Anthem
• Contractor conducting survey: TBD
• Regulatory agency: National Committee for Quality Assurance (NCQA); DMHC
• Schedule: October through November 2024

Primary Care and Specialty Care Appointment Availability Survey:

• Survey subject(s): Appointment availability, interpretation services
• Conducting/regulatory agency: Department of Health Care Services (DHCS)
• Schedule:
  • Q1: January through March
  • Q2: April through June
  • Q3: July through September
  • Q4: October through December

DHCS administers the surveys, and Anthem is provided the surveys after each quarter.

Non-compliant providers are subject to contractual enforcement actions, such as Corrective Action Plans (CAP) or escalated contractual sanctions for breach of contract.

In July, we announced an enhancement to the 277CA to notify you of submission errors discovered during claims processing (https://tinyurl.com/774zs7j7).

As of November 1, 2024, the 277CA will include additional corrective action types for your review. As communicated in July, these errors will still be sent through physical mailing.

With these added error types, there is no reduction to the services we already provide.

Through our efforts, we are committed to reducing administrative burden, improving communication, and ensuring timely payments because we value you, our care provider partners.

Find Care, the doctor finder and transparency tool in the Anthem online directory, provides Anthem members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options such as sorting providers based on distance, alphabetical order, and provider name.

In our November 2022 newsletter, we provided an update regarding Personalized Match, an additional Find Care sorting option for Commercial members. We informed you that this provider sorting option was based on provider efficiency and quality outcomes described in a methodology document linked in the newsletter article, in addition to member search radius.

We want to inform you that, beginning in December 2024 or later, we will be enhancing Personalized Match. This will expand upon the existing program. Newer components of the provider personalization metrics will contain up to 10 times as many features as compared to existing metrics such as gaps in care, and additional types of service cost and utilization. Personalized Match will continue to display providers with the highest overall ranking within the member’s search radius, first. Members will continue to have the ability to sort based on distance, alphabetical order, and provider name.

Helpful resources on Availity

You may review a copy of the Personalized Match methodology that has been posted on Availity, our secure web-based provider tool, using the following navigation:

• Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.

If you have general questions regarding these upcoming changes, please submit an inquiry via the web at 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 Availity.com.

This notice serves as a reminder of what to do if a provider who is part of the Anthem Blue Cross network terminates their contract, changes location, or changes the population they serve. This applies to both primary care physicians (PCPs) and all specialists.

Please adhere to the following guidelines:

• The provider should notify Anthem within a minimum of 120 calendar days to ensure timely member notifications can be sent.
• The provider's termination and/or changes will become effective no less than 120 calendar days after the notification is received.

The provider's decision to terminate from Anthem could impact participation in other Anthem lines of business and may prevent the provider from participating with Anthem in the future.

This is a contractual requirement. It is imperative that these minimum timelines are met to ensure members, the California Department of Health Care Services (DHCS), and the health plan are notified as required, ensuring systems are updated in a timely manner. Future instances of untimely notification may result in the issuance of a Corrective Action Plan, including but not limited to financial sanctions and/or a breach of contract notice.

Additional details and information can be found in the provider manual, available online at https://providers.anthem.com/ca > Resources > Provider Manuals, Policies & Guidelines > Medi-Cal Managed Care and Major Risk Medical Insurance Program Provider Manual.

As a contracted provider for a special needs plan (SNP) from Anthem, you are required to participate in an annual Model of Care training for providers, per CMS regulations. This training includes a detailed overview of Anthem special needs plans and program information, highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Please remember this training is specific to our plans and delivery of care for members, ensuring their specific care needs are met. Your participation is critical for improved quality and health outcomes.

Training for the SNP product is self-paced and available at Availity.com. The training must be completed by December 31, 2024.

How to access the Custom Learning Center:

1. Log in to the Availity website at Availity.com.
2. At the top of the Availity website, select Payer Spaces and select the appropriate payer.
3. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
4. In the Custom Learning Center, select Required Training.
5. Select Special Needs Plan and Model of Care Overview.
6. Select Enroll.
7. Select Start.
8. Once the course is completed, select Begin Attestation and complete.

Not registered for Availity Essentials?

Have your organization’s designated administrator register your organization for the Availity website:

1. Visit Availity.com to register.
2. Select 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.

As respiratory syncytial virus (RSV) season approaches, we would like to remind providers about available RSV immunizations to help prevent severe RSV related disease in infants. According to a report from the CDC (March 2024), infant preventive antibodies showed 90% effectiveness against the need for hospitalization for RSV in babies. Two immunizations are available to prevent RSV lower respiratory tract infections in infants:

• Pfizer's Abrysvo, a maternal vaccine given during pregnancy
• Nirsevimab (Beyfortus), a monoclonal antibody administered to the baby

The maternal vaccine, Abrysvo, is recommended for those who are 32 to 36 weeks pregnant during RSV season, which generally falls between October and March. The vaccine can provide protection for infants up to six months if the mother receives it at least two weeks prior to delivery.

Nirsevimab (Beyfortus) provides up to five months of protection against RSV and is approved for infants under 8 months during their first RSV season, and certain children between 8 and 19 months at increased risk of severe RSV disease. In some cases where a mother received an RSV vaccine, Nirsevimab can still be considered for the child if there is a substantial risk for severe RSV disease or if the maternal immune response to the vaccination is inadequate.

Nirsevimab is covered under the Vaccines for Children Program. Additional information about RSV prevention and Nirsevimab (Beyfortus) can be found at cdc.gov/rsv.

We look forward to sharing resources and working with you to achieve improved outcomes for children in our communities.

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

One of the ways this is done is by giving certain providers (value-based program providers, also known as payment innovation providers) in Anthem’s various value-based programs (for example, Enhanced Personal Health Care,) (the Programs) quality, utilization and/or cost data, reports, and information about the healthcare providers (referral providers) to whom the value-based program providers may be referring, or plan to refer, their patients covered under the programs. If a referral provider is higher quality and/or lower cost, this component of the programs may result in their getting more referrals from value-based program providers. The converse should be true if referral providers are lower quality and/or higher cost.

Providing this type of data, including comparative cost information, to value-based program providers helps them make more informed decisions about managing healthcare costs and maintaining and improving quality of care. It also helps them succeed under the terms of the programs.

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about value-based program providers and referral providers so that they can better understand how their healthcare dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request and will discuss it with referral providers — including any opportunities for improvement. If you have questions or support, please refer to your provider relationship management representative.

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

At a glance:

• The Child Health and Disability Prevention (CHDP) program has been phased out, and services were transitioned to other systems effective July 1, 2024.
• Medi-Cal will handle provider trainings and facility site reviews to ensure compliance with preventive care screenings.

Overview

The California Department of Health Care Services (DHCS) phased out the (CHDP) program and transitioned services to other delivery systems effective July 1, 2024. This transition simplified and streamlined the delivery of services to children and youth under the age of 21 in alignment with the goals of the CalAIM initiative.

Prior to July 1, 2024, the CHDP program included:

• Preventive health, vision and dental screening, and care coordination for fee-for-service (FFS) members eligible for Medi-Cal for Kids & Teens, federally known as the early and periodic screening, diagnostic, and treatment (EPSDT) benefit.
• CHDP Gateway, which serves as a presumptive eligibility (PE) entry point for children to receive temporary preventive, primary, and specialty healthcare coverage through the Medi-Cal fee-for-service (FFS) delivery system.
• Responsibility for provider trainings on well-child preventive care screenings that included anthropometric measurements, dental screenings/fluoride varnish application, and audiometric and vision screenings.
• Responsibility for facility and medical record reviews of CHDP program provider sites.

Effective July 1, 2024:

• The CHDP programs and EPSDT services are covered in both the FFS and managed care delivery systems.
• PE services will continue and expand under the new children’s presumptive eligibility (CPE) platform, and PE services for individuals over the age of 19 will continue under hospital presumptive eligibility (HPE).
• Managed care plans shall ensure that ongoing provider trainings on well-child preventive care screenings outlined above are conducted.
• Managed care plans shall conduct the facility site and medical record reviews (FSR/MRRs) of former CHDP program providers who are also primary care providers seeing Medi-Cal members during their periodic managed care FSR/MRRs.

Additional information about the CHDP program transition can be found here.

Provider trainings and medical record documentation

In an effort to ensure providers comply with required provider trainings and medical record documentation on well-child preventive care screenings, we developed/compiled the following provider resources:

Medi-Cal Managed Care for FSR and MRRs

DHCS requires managed care plans to conduct initial and subsequent facility and medical record reviews of primary care provider sites to ensure all contracted PCP sites have sufficient capacity to provide appropriate primary healthcare services and can maintain patient safety standards and practices. During the facility site reviews, reviewers shall assess staff competencies on well-child preventive care screenings as part of the CHDP program transition to ensure screenings are done appropriately. Please access the FSR MRR Preparation Checklist for more information on how your clinic can successfully complete managed care reviews.

In the June 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care, effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here.

Site of Care Guidelines:

• Site of Care for Advanced Imaging
• Rehabilitative Site of Care
• Surgical Site of Care

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

In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here:

• Site of Care Guidelines:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

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

Effective on November 17, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.     

You may access and download a copy of the current and upcoming guidelines here:

• Musculoskeletal:
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

The above guideline updates have a publish date of November 17, 2024.

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

Effective on January 30, 2025, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines updates will be adopted for Anthem. This article is to communicate the plan adoption of these Clinical Appropriateness Guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.

You may access and download a copy of the current and upcoming guidelines here.

• Cardiovascular:
  • Implantable Cardioverter Defibrillators
• Genetic Testing:
  • Cell-free DNA Testing for the Management of Cancer
  • Prenatal Testing using cell-free DNA
  • Somatic Tumor Testing
• Musculoskeletal:
  • Joint Surgery
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

The above guideline updates have a publish date of November 17, 2024.

The Medicaid Medical Advisory Committee is recruiting diverse specialty physicians to serve as voting members and external consultants, offering insights on various topics. In these roles, physicians will attend regular meetings to review key metrics from the plan's Quality Management Program and Satisfaction Survey and assess peer review cases. Additionally, feedback is solicited regarding the adoption of the plan's Clinical Practice Guidelines. Meetings are held virtually on the last Wednesday of the second month of each quarter, starting at noon, with additional ad-hoc meetings conducted as needed.

You are a valued member of our Medicaid network. If you are interested in learning more about this opportunity, please contact Danielle Frouws at Danielle.Frouws@elevancehealth.com. She will answer any questions for you and facilitate a discussion with Committee Chair Dr. Rafael Gonzalez-Amezcua, the plan’s medical director. In appreciation of your time and service, Anthem will provide an honorarium for each attended meeting.

At a glance:

• Care providers must prepare for HEDIS^® medical record reviews starting January 2025.
• Care providers will submit records through Remote Electronic Medical Record (EMR) Access Service, website upload, fax, secure file transfer protocol (SFTP), mail, or on-site.
  

Background

Each year, we perform a review of a sample of our members’ medical records as part of the HEDIS quality study. HEDIS is part of a nationally recognized quality improvement initiative and is used by the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and several states to monitor the performance of managed care organizations.

We will begin requesting medical records in January 2025. No special authorization is needed for you to share member medical record information with us since quality assessment and improvement activities are routine parts of healthcare operations.

Ways to submit your records in our preferred order:

• Remote EMR Access Service: We offer the Remote EMR Access Service to care providers to submit member medical record information to us. If you are interested in more information, contact us at Centralized_EMR_Team@anthem.com.
• Upload: Medical records can be uploaded to our secure website using the instructions in the request document.
• Fax: Medical records can be faxed to us using the instructions in the request document.
• SFTP: Medical records can be uploaded via a secure website.
• U. S. Postal Service: Medical records can be mailed to us using the instructions in the request document.
• On-site: Medical records can be pulled by a representative at your local office where medical records are located.

HEDIS review is time sensitive, so submit the requested medical records within the timeframe indicated in the initial HEDIS request document.

We appreciate the care you provide our members. Your assistance is crucial to ensuring our data is statistically valid, auditable, and accurately reflects quality performance.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

The Consumer Assessment of Healthcare Providers and Systems® (CAHPS) is an annual standardized survey conducted anonymously by a third-party vendor (Center for the Study of Services) to assess a random sample of consumers' experiences with their health plan, their personal provider, and healthcare services.

Refer to attachment to view full details.