Anthem Blue Cross (Anthem) has network leasing arrangements with a variety of organizations, which we call Other Payors. Other payors and affiliates use the Anthem network.

Under the terms of your provider agreement, members of other payors and affiliates are treated like Anthem members. As such, they’re entitled to the same Anthem billing considerations, including discounts and freedom from balance billing. You can obtain the Other Payors list on the Availity web portal, at www.Availity.com. From the Availity site, select Home > Anthem California > Education and Reference Center, or email us at CAContractSupport@Anthem.com.

Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before with our Network eUPDATEs.

Network eUPDATE 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 Network eUPDATEs, so you can submit as many e-mail addresses as you like.

Effective October 14, 2018, Anthem Blue Cross will enforce the requirement to bill the correct modifier and HCPCS for services utilized.  Incorrect billing will be rejected and claims will be returned to the provider for correction and resubmissions.

Durable Medical Equipment (DME) may be purchased, rented or rented until the purchase price has been paid. 

Correct billing will allow member benefits to be applied correctly to include benefit accumulations for a member’s DME benefits.

This is an important reminder that any dispute regarding reimbursement, including non-payment of services, must comply with the Dispute Resolution terms of your Anthem Blue Cross (Anthem) Participating Agreement. 

Your contractual remedy is to contact Anthem for assistance and to initiate the dispute resolution process if necessary which requires binding arbitration if our Anthem Workers’ Compensation Customer Relations group cannot resolve your dispute. Please note the Workers’ Compensation Appeals Board (WCAB) does not have jurisdiction over Anthem participating provider agreement disputes specifically regarding amounts to be paid as defined in LC5304 below.

Labor Code 5304:

The appeals board has jurisdiction over any controversy relating to or arising out of Sections 4600 to 4605 inclusive, unless an express agreement fixing the amounts to be paid for medical, surgical or hospital treatment as such treatment is described in those sections has been made between the persons or institutions rendering such treatment and the employer or insurer.

Therefore, filing of liens against Other Payors at the WCAB is not consistent with this policy and will result in escalation of such lien filings to the contract compliance department.   Should you have questions regarding your Anthem contract reimbursement, please contact Anthem Workers’ Compensation’s Customer Relations team at (866) 700-2168 or email your questions to AWCCustomerRelations@anthem.com. All pricing inquiries require a copy of the bill and the Explanation of Review (EOR). Submissions may be returned if incomplete information is received.

Continuing to build on the initial launch of the new public provider pages, Anthem Blue Cross (Anthem) recently released a brand new, redesigned landing page for Provider Resources. The most recent release also includes a new Communications page with a clear and concise access point for Newsletters and eUpdates, as pictured below.

Beginning with dates of service on and after September 1, 2018, Anthem Blue Cross (Anthem) will reimburse appropriate and medically necessary care billed under HCPCS code A0998 (Ambulance response and treatment, no transport) by Emergency Medical Service (EMS) providers.

The HCPCS code is billed when care is provided in response to an emergency call to a member’s home or on a scene, whether or not transportation to the hospital was necessary and occurred. In the past, Anthem reimbursed EMS providers for treatment rendered only when the patient was transported to the hospital emergency room.  Anthem will apply medical necessity review to A0998 using coverage guideline CG-ANC-06.

Providers should only submit A0998 when:

1. The member consents to evaluation and treatment, AND
2. After evaluation, medic and patient agree there is not a medical emergency, AND
3. The member does not desire transport to an emergency department for evaluation, AND
4. The member is stable for referral to the patient’s physician or other community resource, AND
5. The member has the ability (mental capacity, transportation resources) to obtain assistance and medically indicated follow-up

For more information, please contact your contract representative.

Effective November 12, 2018, Anthem Blue Cross (Anthem) will integrate Community Health Workers utilized by Preferred Community Health Partners (PCHP) into our current care management program to provide enhanced care transition for Anthem members with complex needs.  Members will include, but are not limited to, those with the following:

• Hospital readmissions
• Frequent ER visits
• No engagement with PCP within three months or more
• Readmission risk score >24
• Multiple diagnoses
• Identified social determinants of health

PCHP does not replace Anthem Case Management, the care or the care management provided by PCPs and specialists. Instead provides an extra layer of support with Community Health Workers as an extension of care management to help our members navigate the complex health care system.

A PCHP Community Health Worker may reach out to your practice to introduce themselves and establish a relationship with the physician. They may also discuss developing a mechanism by which to share information regarding patients that have been identified for complex care services.

For questions regarding PCHP and complex care services, please contact 1-303-831-2405. 

In our ongoing efforts to encourage medical and behavioral health integration, Anthem Blue Cross (Anthem) continues to promote early identification and intervention of behavioral health issues through primary care.  Anthem currently reimburses for screening and assessment for behavioral health and substance use through billing the following codes:

• G0396 /99408 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes
• G0397 / 99409 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention, greater than 30 minutes
• G0442 - Annual alcohol misuse screening, 15 minutes £ G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
• G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
• G0444 - Annual depression screening, 15 minutes

Anthem also supports behavioral counseling for specific chronic conditions while in the primary care office.  These services include:

• G0446 - Annual, face-to-face intensive behavioral therapy for cardiovascular disease, 15 minutes
• G0447 - Face-to-face behavioral counseling for obesity, 15 minutes
• G0473 - Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

In addition, Anthem reimburses for the psychiatric collaborative care codes; procedure codes 99492, 99493, 99494 are used to report these services.  These codes are reportable by primary care for their collaboration with a qualified behavioral health provider, such as a Psychiatrist, Licensed Clinical Social Worker, etc..  Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. These codes are intended to represent the care and management for patients with behavioral health conditions that often require extensive discussion, information-sharing, and planning between a primary care physician and a BH specialist.  The American Psychiatric Association (APA) has created a training program for primary care on the collaborative care model and the use of these codes.  It can be found at APA Training Module. 

Providers and facilities are required to review all member information received from Anthem Blue Cross (“Anthem”) to help ensure no misrouted PHI is included. Misrouted PHI includes information about members that a provider or facility is not currently treating. PHI can be misrouted to providers and facilities by mail, fax or e-mail. Providers and facilities are required to immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are providers or facilities permitted to misuse or re-disclose misrouted PHI. If providers or facilities cannot destroy or safeguard misrouted PHI, providers and facilities must contact Anthem’s provider services area to report receipt of misrouted PHI.

Effective January 1, 2019, the Anthem PERS Select PPO (non-Medicare) plan has been redesigned to include a value-based insurance design. The changes in design aim to improve quality and lower costs associated with health care by emphasizing primary care and introducing cost incentives to lower deductibles.

Each member of the plan will be assigned a primary care physician from our PERS Select network. Members who use their primary care doctor for routine services will have a reduced copayment of $10. Members may choose a Select PPO primary care physician by updating their profile or calling customer service.:

Members can reduce their deductible through completion of the following activities annually at no additional cost:

In addition, expecting Mothers will have their Inpatient covered in full when enrolled in the Anthem’s Future Moms program.

The 2019 PERS Select plan design continues to allow freedom of choice for Select PPO members, with the added benefit of lower copayments for office visits with the members’ primary care physician and lower deductible for engaging positively in their health.

For more information regarding the PERS Select PPO plan changes please visit www.anthem.com/ca/calpers.

The Special Investigations Unit (SIU) is tasked to conduct investigations involving allegations of fraud, waste and abuse, to work with our providers to resolve billing practice issues in order to reduce or eliminate future payment issues, and, where appropriate, to recover overpayments.

As part of Anthem’s role to safeguard our members and provide relevant information to providers we are relaying the following recent Food and Drug Administration (FDA) Warning Letters:  

Estring - On June 19, 2018, the Food and Drug Administration issued a letter of warning to Pfizer for "false or misleading" promotional materials related to ESTRING® (estradiol vaginal ring).  According to the FDA the posted “… video is especially concerning from a public health perspective because it fails to include any risk information about Estring, which is a drug that bears a boxed warning due to several serious, life-threatening risks, including endometrial cancer, breast cancer, and cardiovascular disorders, as well as numerous contraindications and warnings. The video thus creates a misleading impression about the safety and efficacy of Estring”.

Xtampza – On February 9, 2018, the Food and Drug Administration issued a letter of warning to Collegium Pharmaceuticals for publicly providing false or misleading representations regarding Xtampza (oxycodone) ER because it “fails to adequately communicate information about the serious risks associated with Xtampza ER use”.

Further details regarding these Warning Letters from the FDA can be obtained at:

• Estring
• Xtampza

For the 2019 benefit year, Anthem Blue Cross (Anthem) will continue to offer EPO Individual on-exchange and off-exchange plans in Covered California’s rating regions 1, 7, and 10. As in 2018, for all other regions, Anthem will not be offering Individual health plans in 2019*. Below is a table showing the counties located in the regions where Anthem will be offering 2019 “non-grandfathered” EPO Individual plans.

*There is no change for members covered under an Anthem Individual “grandfathered” plan.

Providers in Regions 1, 7 and 10

If you are participating in the on-exchange and off-exchange network located on one of these regions, you will continue to provide services to Anthem members who have purchased coverage on-exchange and off-exchange as you currently do under your provider agreement. Please ensure that if your Anthem patient from regions 1, 7 or 10 requires an authorization or referral, that it is to an Anthem on-exchange and off-exchange participating provider within regions 1, 7 or 10. The 2019 EPO plans do not have out-of-network benefits except for emergent/urgent authorized services only.

As a reminder, the “Medical Provider Network (MPN) applicant shall obtain from each physician participating in the MPN a written acknowledgment in which the physician affirmatively elects to be a member of the MPN.” 

To maintain and affirm your participation in all MPNs that you have been selected for and have subscribed to Anthem’s Provider Affirmation Portal, go to Availity and login. Once in, click on the Payer Spaces drop down menu in the top right hand corner, and select Anthem Blue Cross (Anthem) from the options available to you. On the next page click on “Resources” in the middle of the page and look for “MPN Provider Affirmation Portal.”

If you cannot go online, call Anthem Workers’ Compensation at 1-866-700-2168 and we can take action on your behalf in the Provider Affirmation Portal. Please also keep an eye out for email notifications from “Anthem MPN Admin.”

Please also be advised the Provider Affirmation Portal will also notify participating medical providers when an MPN is terminating its relationship with Anthem and/or the Division of Workers Compensation.

Great news! Anthem, Inc. and our affiliates now use Availity as our designated EDI service. If you currently use a clearinghouse, billing company, or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Anthem.

Check out this webinar for lots of great information to get you started. At the end of the training, you can participate in a live Q&A session. During this fast paced hour, learn how to:

• Understand Availity’s EDI Gateway and Clearinghouse workflow for 837, 270/271, 276/277, and 835 transactions.
• Use the Availity Portal to manage file transfers, set up EDI reporting preferences, manage your FTP account, and more.
• Enroll for and manage 835 ERA delivery with Availity.
• Access and navigate the Availity EDI Guide.
• and more…..

Upcoming Sessions

Currently scheduled upcoming sessions include:

• October 29, 2018, 10:00 a.m. – 11:00 a.m. PT
• November 7, 2018, 8:00 a.m. – 9:00 a.m. PT

Enroll

1. Log in to the Availity Portal.
2. Select Help and Training > Get Trained.
3. In the Availity Learning Center (ALC) Catalog, select Sessions.
4. Scroll Your Calendar to find and enroll for a live session.

Can’t make it?

We’ve got you covered with a recording of a previous live session. In the ALC, search the Catalog by keyword (song) and enroll for the on-demand option.

Need Help?

Email training@availity.com if you have issues enrolling for a live webinar.

Anthem has partnered with Availity to operate and service the entry point for all EDI submissions to Anthem, otherwise known as the EDI Gateway.

Most of you know Availity as web portal or claims clearinghouse, but they are much more.  Availity is also an intelligent EDI Gateway for multiple vendors and will be the EDI connection for all Anthem Inc. and its affiliates.

If you currently use a clearinghouse, billing company or if you submit directly, all your EDI transactions will flow through the Availity EDI Gateway to Anthem.

How are you submitting EDI transactions today?

• If you currently transmit your EDI Submissions using a clearinghouse or Billing Company, you should contact your clearinghouse to confirm your EDI submission path has not changed. If you are notified of any potential impacts with connectivity, workflow or financial, please know there is no cost alternate submission options available with Availity.

• If you currently submit directly to Anthem and already have an Availity login for the portal, you can use that same login for your EDI services.

• Please visit https://apps.availity.com/web/welcome/#/anthem to learn more.

How can you directly transmit EDI submission to Availity?

Below are the different ways you can submit direct EDI transactions to Availity:

• Submit transaction files through FTP - If you work with a practice management system, health information system, or other automated system that supports an FTP connection, you can securely upload EDI transactions to the Availity FTP site where they are automatically picked up by Availity and submitted to Anthem Blue Cross (Anthem)

• Submit transaction files through the Availity Portal - If you have batch files of EDI transactions that you need to process and you choose not to use the
  • o Availity FTP site, you can manually upload the batch files through the Availity Portal.

• Submit transactions through manual data entry in the Availity Portal – The Availity Portal makes it easy to submit transactions, such as eligibility and
  • o benefits inquiries or claims, by entering data into our user-friendly web forms.

What are your next steps?

• We recommend that you register with Availity for your EDI transmissions and begin migrating your volume by the end of 2018.

• Availity will be working directly with your Clearinghouse, Billing Companies and if you choose to submit directly- your organization.

We look forward to delivering a smooth transition to the Availity EDI Gateway. If you have any questions please contact Availity Client Services at 1-800-Availity (1-800-282-4548) Monday through Friday 5:00 a.m. to 4:30 p.m. Pacific Time. 

People are dying of opioid addiction. With the ECHO opioid addiction treatment, you can help save lives. Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website.

Benefits of participating include:

• Addiction treatment training.
• Free continuing education credits.
• Opportunity to receive expert input on your (de-identified) patient cases.
• Access to a virtual learning community for treatment guidelines, tools and patient resources.
• Opportunity to ask questions and get a variety of support from specialists.

Quality Medication-Assisted Therapy (MAT)

To help ensure members have access to comprehensive evidence-based care, Anthem Blue Cross is committed to helping its providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.

When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with buprenorphine or, in some plans, methadone maintenance treatment in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.

For more information

For more information about best practices for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use.

You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for more information about the ECHO and MAT programs.

The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) which prohibits member cost sharing for defined preventive services for non-grandfathered policies. The appropriate use of modifier 33 will reduce claim adjustments related to preventive services and your corresponding refunds to members.

Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.

Modifier 33 should be appended to codes represented for services described in the US Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.

The CPT® 2018 Professional Edition manual shares the following information regarding the billing of modifier 33, “When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”

Providers can access real-time, patient-specific prescription drug benefit information at the point of care. It is part of the e-prescribing process, and is located within a provider’s electronic medical record (EMR) system.

This functionality helps providers determine prescription coverage quicker by sharing information about patient drug cost, formulary, and coverage alerts such as prior authorization to sending a prescription to the pharmacy. This information can help providers proactively identify barriers to medication compliance. For example, if a medication is too costly for the member, alternatives can be discussed prior to the patient leaving the provider’s office.

Providers can find the following patient-specific prescription benefit information with their EMR:

• Formulary status of selected medication
• Pricing of medication at a retail and mail order pharmacy
• Formulary alternatives
• Coverage alerts, including prior authorization and step therapy

Providers should contact their IT department or EMR system with questions regarding access to real-time prescription drug benefit functionality. Upgrades to EMR software may be required.

The Education and Reference Center (ERC) offers the Communication & Education section where you can find training materials, important policy information, commonly used forms and reference guides on Anthem’s proprietary tools. When you visit the ERC, you can efficiently navigate to all available electronic resources using only the Availity Portal.

The Communication & Education section includes two new categories to help make it easier for you to find what you need:  Payer Spaces and Interactive Care Reviewer. 

With an Availity log in you can easily view any new content added to the ERC. There is no additional role assignment needed.  

Find the ERC on the Availity Portal under Payer Spaces > Anthem> Applications. If you are having trouble locating the Education and Reference Center, type Education and Reference Center in the Availity Search option located on the top navigation menu. Select the heart next to the application to save it to your Favorites.

In an effort to better service our contracted providers right the first time, Anthem Blue Cross has improved our provider claim escalation process. Just click, Provider Claim Escalation Process to read, print, download and share the improved process with your office staff.

Our Network Relations Team is available by email at CAContractSupport@anthem.com to answer questions you have about the process.

Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. For a complete listing of our workshops, seminars, webinars and job aids, log on to the Anthem Blue Cross website: www.anthem..com/ca. Scroll down the page to Partners in Health > Tools for Providers. In the middle of the page select the box  Find Resources for California. From the Answers@Anthem page, select the link titled Provider Education Seminars and Webinars link.

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 Anthem.com/ca form page to review more.

The new online form can be found on www.anthem.com/ca/provider/ > Find Resources for California >  Answers@Anthem tab>Provider Forms bullet>Provider Change Forms> Provider Maintenance Form.  In addition, the Provider Maintenance Form can be found on 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 online 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) and review how you and your practice are being displayed.

To report discrepancies please make correction by completing this Provider Maintenance Form online.

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our website. 

The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research. All guidelines are reviewed annually, and updated as needed.

The current guidelines are available on our website. To access the guidelines, go to https://www.anthem.com/ca/provider/. From there, scroll down and click on Read Polices. This will take you to Medical Policy, Clinical UM Guidelines (for Local Plan M, and Pre-Certification Requirements. Then click on the Practice Guidelines on the Health & Wellness tab.

No Interpreter? No Problem!

Anthem Blue Cross (Anthem) wants you to be able to communicate with your patients clearly and accurately.

— It’s easy                                  — It’s free

— No advance notice required   — All languages

For Anthem members whose primary language isn’t English, Anthem offers free language assistance services through interpreters. Members have access to interpreters over the phone or face to face during appointments. If the member is interested in these services, please have them call the Anthem Member Services number on their member’s ID card (TTY/TDD: 711) between 8:00 a.m. and 5:00 p.m. Monday through Friday. After regular business hours, telephonic interpreter services are available through the 24/7 NurseLine. If you would like to access an interpreter on behalf of your member, please contact  1-800-677—6999. 

Please remember, in accordance with the California Language Assistance Program, you must notify Anthem members of the availability of the health plan interpreter services. You must also document a member’s refusal of any needed interpreter services in his or her patient chart.  Make sure to let your patients know that Anthem’s Customer Service Representatives are available to help coordinate appointment scheduling through the interpreter services.

Here’s what to expect:

Telephone Interpreters

1. Give the customer care associate the member’s ID number.
2. Explain the need for an interpreter and state the language.
3. Wait on the line while the connection is made.
4. Once connected to the interpreter, the associate introduces the Anthem Blue Cross member, explains the reason for the call, and begins the dialogue.

Face-to-Face Interpreters Including Sign Language

Members can request to have an interpreter assist at a doctor’s office. This request may be made in advance, or when the member is in the office. Doctors may make these requests on behalf of members. Seventy-two business hours are required to schedule services, and 24 business hours are required to cancel

Make extra money on Anthem Blue Cross (Anthem) members that you already care for!  All we need is your “SOAP” note and the corresponding claim for a current year assessment.

Attached is information on Commercial Risk Adjustment (“CRA”) and how to easily collect this incentive offer.  We have also included a schedule for a simple live on-line instruction on how to submit the SOAP note via the e-pass tool.

To get a list of the targeted patients in your practice, simply send an email to:

• Please contact Miriam Mondragon, Network Relations Consultant, Sr. at mondragon@anthem.com
• Please contact Gabriel Cortwright Network Relations Consultant at cortwright@anthem.com
• Please contact Socorro Carrasco Network Education Rep, Sr. at carrasco@anthem.com

Get started today!  Keep a look out for a packet mailed from our partner, INOVALON, for information on each target patient.

Please open attachments for more detail:
Commericial Risk Adjustment Overview
ePASS Webinar Schedule

For a practical overview of ePASS, please refer to Inovalon’s online document:

Frequently Asked Questions.

Effective December 1, 2018, prior authorization (PA) requirements will change for injectable/infusible drug Interferon beta-1a to be covered by Anthem Blue Cross for Medi-Cal Managed Care (Medi-Cal) members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Interferon beta-1a — injection, 30 mcg (J1826)

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-754-4708
• Phone:
  • o 1-888-831-2246 (Medi-Cal)
  • o 1-877-273-4193 (Medi-Cal Access Program and Major Risk Medical Insurance Program)

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at the following numbers for PA requirements:

• 1-888-831-2246 (Medi-Cal)
• 1-877-273-4193 (Medi-Cal Access Program and Major Risk Medical Insurance Program)

The AIM Genetic Testing program requires ordering providers to request medical necessity review of all genetic testing services for individual Medicare Advantage members.  Requesting this prior authorization will help ensure that the lab receives timely and accurate payment for these services.

Please submit genetic testing prior authorization requests to AIM through one of the following ways:

• Access AIM ProviderPortalSM 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 Web Portal at availity.com
• Call the AIM Contact Center toll-free number at 1-800-714-0040, Monday - Friday, 5:00 a.m. - 5:00 p.m. PT.

For further questions regarding prior authorization requirements, please contact the Provider Services number on the back of your patient’s ID card.

Effective January 1, 2019, Anthem will transition its Medicare back pain management and cardiology programs from OrthoNet LLC to AIM Specialty Health® (AIM), a specialty health benefits company. Anthem has an existing relationship with AIM in the administration of other medical management programs.  Additional information will be available at Important Medicare Advantage Updates at anthem.com/ca/medicareprovider.

The Centers for Medicare & Medicaid Services has increased its emphasis on the appropriate use of statins among Medicare Advantage beneficiaries diagnosed with diabetes and cardiovascular disease. Please evaluate whether your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

The 2013 American College of Cardiology and the American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults supports the use of moderate-intensity statin therapy in persons with diabetes 40 to 75 years of age to reduce the risks of atherosclerotic cardiovascular disease (ASCVD) events. High-intensity statin therapy is recommended if the patient has an estimated 10-year ASCVD risk ≥7.5 percent. For males 21-75 and females 40-75 years of age with clinical ASCVD, high-intensity statin therapy is recommended unless contraindicated.   These guidelines recommend statin therapy in these scenarios regardless of what patient LDL values are.  Please evaluate if your patients with diabetes and/or cardiovascular disease would be appropriate candidates for statin therapy.

Formulary agents are listed below:

**Available for a $0 co-pay for most plans in 2018
*Rosuvastatin (Crestor) is a preferred brand medication on the Medicare formulary. 

Per guidance established by the Comprehensive Addiction and Recovery Act of 2016, the Centers for Medicare & Medicaid Services has established provisions to develop a pharmacy and prescriber home program for opioid medications.  Beginning January 1, 2019 Anthem will work with beneficiaries and providers to help to reduce the risk of opioid dependency by streamlining access to opioid medications.  If a beneficiary is exhibiting at-risk opioid medication utilization, the plan sponsor will work with the beneficiary and provider to select a pharmacy home and prescriber home for the beneficiary’s opioid medications.   At risk is defined by CMS as:

1. Cumulative Morphine Milligram Equivalent (MME) > 90mg per day
2. Opioid prescribers > than three and opioid dispensing pharmacies > than three
3. Or Opioid prescribers > than five regardless the number of pharmacies

• Cancer, LTC and Hospice are exempt
• Beneficiaries will have the choice of which pharmacy or prescriber to select as their home.
• Plan sponsors will request agreement from the provider selected as the home.
• At this time, only opioid and benzodiazepine medications will be delegated to a home pharmacy or prescriber.
• Both beneficiaries and providers will receive letters to explain what is happening and how it will happen.
• Beneficiaries retain the right to request a coverage determination and may choose to change their Home pharmacy or prescriber at any time.

Effective January 1, 2019, members enrolled in a group-sponsored CalPERS PPO Medicare Advantage plan will receive new ID Cards.  Members will be assigned the new alpha prefix of MBL and a new group number.  New ID cards will be mailed to members in December 2018. 

The provider services phone number is on the back of the member ID card. Providers should submit claims to their local Blue Cross and Blue Shield plan for processing.  

Please continue to check Important Medicare Advantage Updates at anthem.com/ca/medicareprovider for the latest Medicare Advantage information, including:

Prior authorization requirements for high-level definitive drug testing

Prior authorization requirements for Part B drugs: Moxetumomab Pasudotox, Cemiplimab and Fulphila  

July Medicare Advantage reimbursement policy  

Submit PA medication requests electronically; new phone number for MA prescription PAs 

MA members receive incentives for completing screenings

CMS issues regulatory changes for short- and long-acting narcotics; days’ supply limits effective Jan. 1, 2019  

Inpatient Readmissions   

Medical Policies update

On January 25, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross (Anthem). These policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the below listing.

The Medical Policies were made publicly available on our provider website on the effective date listed. To search for specific policies, visit https://www.anthem.com/ca/medicalpolicies/search.html.

Please note:

• Starting July 1, 2018, AIM Specialty Health® Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.
• For markets with carved-out pharmacy services, the applicable listings below are informational only.

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

Clinical Utilization Management Guidelines update

On January 25, 2018, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines applicable to Anthem. These clinical guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the following listing. This list represents the Clinical UM Guidelines adopted by the medical operations committee for the Government Business Division on March 2, 2018.

The clinical guidelines were made publicly available on our provider website on the effective date listed. To search for specific guidelines, visit https://www.anthem.com/ca/medicalpolicies/search.html.

Please note:

• Starting July 1, 2018, AIM Specialty Health® Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.
• For markets with carved-out pharmacy services, the applicable listings below are informational only.

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

Note:

• Effective November 1, 2018, MCG Health Care Guidelines® will be used for reviews, to include the use of customizations to certain guidelines and Behavioral Health Care Guidelines (NEW).
• Additionally, effective November 1, 2018, AIM Specialty HealthÒ Proton Beam Therapy will be used for clinical reviews.

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

To search for specific policies or guidelines, visit https://www.anthem.com/ca/medicalpolicies/search.html.

Medical Policies

On May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross (Anthem).

linical UM Guidelines

On May 3, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on March 24, 2018.

As part of our commitment to provide you with the latest clinical information and improve member outcomes, we have posted a vaginal birth after cesarean (VBAC) shared decision-making aid to our provider site. This tool has been reviewed and certified by the Washington Health Care Authority* and is available to aid in discussions with your patients regarding their treatment options.

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).

* The Washington Health Care Authority is recognized as a certifying body by NCQA.

Has your office received a request for additional information to process a claim for an Anthem Blue Cross (Anthem) member? Those records can now be submitted electronically using the medical attachments feature on the Availity Portal. The medical attachments feature makes submitting electronic documentation in support of a claim simple and streamlined. You can use your TIN or your NPI to register and submit solicited (requested by Anthem) medical record attachments.

Our solicited medical attachments feature supports an unlimited number of document attachments for each submission and can handle .tiff, .jpg and .pdf attachments. Once your office receives a letter requesting additional documentation, you can send up to 10 attachments through the portal for each claim. The maximum file size is 10 MB per attachment and file sizes larger than 10 MB can be split into smaller ones.

How to access solicited medical attachments for your office

Availity admin, complete these steps:

1. From My Account Dashboard, select Enrollments Center > Medical Attachments Setup, follow the prompts and complete the below sections.
2. Select Application, then choose Medical Attachments Registration.
3. Select Provider Management, then Organization from the drop-down list. Add NPIs and/or tax IDs. Multiples can be added separated by spaces or semicolons.
4. Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name.

Using medical attachments

Availity user, complete these steps:

1. Log in to the Availity Portal at https://www.availity.com.
2. Select Claims and Payments > Medical Attachments > Send Attachment.
3. Complete all required fields on the form.
4. Attach supporting documentation.
5. Select Submit.

Need training?

To access additional training for this Availity feature:

1. Log in to the Availity Portal at https://www.availity.com.
2. At the top of any Availity Portal page, choose Help and Training, then Get Trained. Make sure you do not have a pop-up blocker turned on or the next page may not open.
3. In the new window, a list of available topics will open. Locate and select Medical Attachments.
4. Under the Recordings section, select View Recording.

Extension for Community Health Care Outcomes (ECHO)

People are dying of opioid addiction. With the medication assisted treatment, you can help save lives! Join one of several video tele-consultative ECHO learning communities nationwide and participate with other clinicians learning about medication-assisted treatment for individuals with opioid disorders. For more information, visit the ECHO website at https://echo.unm.edu.

Benefits of participating include:

• Addiction treatment training.
• Free continuing education credits.
• Opportunity to receive expert input on your (de-identified) patient cases.
• Access to a virtual learning community for treatment guidelines, tools and patient resources.
• Opportunity to ask questions and get a variety of support from specialists.

Quality Medication-Assisted Therapy (MAT)

To help ensure members have access to comprehensive evidence-based care, Anthem is committed to helping its providers double the number of members who receive behavioral health services as part of MAT for opioid addiction.

When treating patients with opioid use disorder, it is considered best practice to offer and arrange evidence-based treatment. This usually consists of MAT with naltrexone, buprenorphine or, in some plans, methadone in combination with behavioral therapies. Behavioral therapies focused on medication adherence and relapse prevention can improve MAT outcomes and improve other social determinants of health, including development of an enhanced social support network in recovery.

For more information

For more information about what is considered best practice for medication-assisted treatment, please read the American Society of Addiction Medicine’s National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use.

You can also contact Jennifer Tripp by email at jennifer.tripp@anthem.com for more information about the ECHO and MAT programs.

Effective December 1, 2018, prior authorization (PA) requirements will change for injectable/infusible drug Somatrem to be covered by Anthem Blue Cross for Medi-Cal Managed Care (Medi-Cal) members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Somatrem — injection, 1 mg (J2940)

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-800-754-4708
• Phone:
  • o 1-888-831-2246 (Medi-Cal)
  • o 1-877-273-4193 (Medi-Cal Access Program and Major Risk Medical Insurance Program)

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us for PA requirements at:

• 1-888-831-2246 (Medi-Cal)
• 1-877-273-4193 (Medi-Cal Access Program and Major Risk Medical Insurance Program)

The Department of Health Care Services (DHCS) periodically communicates information regarding interpretations or changes in policy or procedures, federal or state law, and regulations that impact the delivery of Medi-Cal Managed Care (Medi-Cal) services. The information is communicated in the form of all-plan letters (APLs) and policy letters (PLs). Anthem Blue Cross has a responsibility to communicate the various changes to our contracted providers. Below are lists of the APLs and PLs that were published this year.

New APLs

To view copies of all active APLs and PLs issued during this and previous years, please refer to the DHCS website (www.dhcs.ca.gov > Forms, Laws & Publications > Bulletins, Information Notices, and Letters > Medi-Cal Managed Care All Plan and Policy Letters).

If you have questions about this communication or need assistance with any other item, contact your local Customer Care 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).

Anthem Blue Cross has partnered with Availity to become our designated EDI Gateway, effective January 1, 2019.

What does this mean to you as a provider?

All EDI submissions currently received are now available on Availity. Please note, there is no impact to provider participation statuses and no impact on how claims adjudicate.

Next steps

Contact your clearinghouse to validate their transition dates to Availity. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you — You can submit claims directly through Availity!

Register with Availity

If you wish to submit directly through Availity for your 837 (claim), 835 (electronic remittance advice) and 27X (claim status and eligibility) transactions, please visit https://www.availity.com to register.

We look forward to delivering a smooth transition to the Availity EDI Gateway.

If you have any questions please contact Availity Client Services at 1-800-282-4548, Monday to Friday, 8 a.m. to 7:30 p.m. Eastern time. 

In our efforts to improve pregnancy outcomes, including the prevention of preterm birth, Anthem Blue Cross previously communicated our endorsement of the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM) guidelines on cervical length (CL) screening and progesterone treatment.

We continue to encourage you to obtain a CL measurement with your patient’s routine prenatal anatomic evaluation ultrasound. For claims submitted on or after January 1, 2019, if a vaginal approach is necessary in addition to an abdominal scan to obtain this measurement, the transvaginal ultrasound will be considered for a multiple procedure reduction.

When a routine anatomic evaluation ultrasound (76801, 76802, 76805, 76810) and a transvaginal ultrasound (76817) are billed on the same day by the same provider, the transvaginal ultrasound is considered a part of the multiple procedure payment reduction policy and will be paid at 50% of the applicable fee schedule, and the complete procedure will be paid at the full applicable fee schedule.

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or c 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).

Thank you for being a valued provider.

Anthem Blue Cross (Anthem) is streamlining its pharmacy intake and prior authorization (PA) process for its Medi-Cal Managed Care (Medi-Cal) members. Effective November 4, 2018, please use the below fax number to submit all Anthem pharmacy PA requests for prescription drugs:

Prior Authorization number for prescription drugs: 1-844-474-3345

To ensure a seamless transition, please update your records immediately and discontinue the use of previous pharmacy PA fax numbers for prescription drugs.

In addition to the new PA fax number, effective November 4, 2018, there will also be a new Provider Services phone number that you can call for pharmacy PA-related questions: 1-844-410-0746.

For more information about this update, you can call one of our Medi-Cal Customer Care Centers at:

• 1-800-407-4627 (outside L.A. County)
• 1-888-285-7801 (inside L.A. County)

Anthem Blue Cross (Anthem) has partnered with CoverMyMeds to offer an electronic prior authorization (ePA) request tool that simplifies the process for requesting medications and checking the status of your submissions.

Features

With the new ePA tool you will be able to:

• Submit requests for general pharmacy medications (medications dispensed directly to a member from a retail pharmacy [or shipped from a specialty pharmacy]).
• Check PA status.
• Upload supporting documents and review appeal status.

Availability

The tool will be available beginning November 4, 2018.

Accessing the tool

• Visit https://www.covermymeds.com.
• Locate the existing link within your electronic medical records tool if available.

Support with ePA through CoverMyMeds

• For the Support Center, visit https://www.covermymeds.com/main/help.
• For support via chat, locate and activate the chat window in the bottom right of the webpage.
• For support via phone, call 1-866-452-5017.

Anthem is focused on providing new tools to help make your job a little easier. We appreciate the compassion and dedication with which you care for your patients and our members.

Effective November 1, 2018, prior authorization (PA) requirements will change for Part B injectable/infusible drugs Retacrit (epoetin alfa-epbx), Damoctocog and Ilumya (tildrakizumab) to be covered by Anthem Blue Cross for Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Retacrit (epoetin alfa-epbx) — for the treatment of anemia due to chronic kidney disease in patients on dialysis and not on dialysis, the effects of concomitant myelosuppressive chemotherapy or use of zidovudine in patients with HIV infection; also approved for the reduction of allogenic red blood cell transfusions in patients undergoing elective, noncardiac, nonvascular surgery (J3490, J3590)
• Damoctocog alpha pegol — for treatment of Hemophilia A (J3490, J3590)
• Ilumya (tildrakizumab-asmn) — for the treatment of adults with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy (J3490, J3590)

Please note, one or more of the drugs noted above are currently billed under the not otherwise classified (NOC) HCPCS J-codes J3490, J3590. Since these codes include all drugs that are NOC, if the authorization is denied for medical necessity, the plan’s denial will be for the drug and not the HCPCS codes.

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-866-959-1537
• Phone: 1-855-817-5786

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call our Customer Care Center at 1-855-817-5786 for PA requirements.

In an effort to identify clinically related readmissions to the same facility/network, licensed clinical staff with Anthem Blue Cross (Anthem) will review the clinical information submitted regarding the medical treatment and management of an Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) member admission that occurred within 2 to 30 days from a previous admission to the same facility/network. If the second admission is determined to be clinically related, Anthem will not reimburse for an additional admission as this is considered a continuation of the episode of care. This process was implemented June 2017.

Policy 13-001 update

Based on the information above, Anthem’s Inpatient Readmissions reimbursement policy has been updated. Anthem will utilize information indicating clinically related readmissions, clinical criteria and/or licensed clinical medical review for readmissions from day 2 to day 30 for the second admission determination. Please refer to the Inpatient Readmissions reimbursement policy at https://mediproviders.anthem.com/ca > Prior Authorization & Claims > MMP Reimbursement Policies for additional information.

In the Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter issued in April 2018, CMS included guidance related to opioid analgesics to help improve patient safety and reduce the misuse and abuse of opioid analgesics.

Beginning January 1, 2019, all short- and long-acting opioids will reject at the point of sale if they are prescribed for more than seven days. This edit applies to members who do not have a prescription in the previous 60 days. The edit excludes members with cancer and members in hospice.

The regulatory change and specific prescription drug edits are intended to:

• Lessen the risk of long-term use and addiction potential for those using the medication for acute pain.
• Promote regular review by prescribers to ensure therapy duration is appropriate for those using the medication for acute pain.
• Allow pain control for those with intractable pain in the case of cancer.
• Support and monitor access and remedy the unfortunate effects of overutilized opioids.

For more information, please read the CMS CY 2019 Final Call Letter.

Effective December 1, 2018, prior authorization (PA) requirements will change for Part B injectable/infusible drugs Moxetumomab Pasudotox, Cemiplimab and Fulphila (pegfilgrastim-jmbd) to be covered by Anthem Blue Cross for Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• Moxetumomab pasudotox — for treatment of relapsed or refractory hairy cell leukemia in patients who have received at least two prior lines of therapy (J3590, J9999)
• Cemiplimab — PD-1 inhibitor for the treatment of patients with metastatic cutaneous squamous cell carcinoma (CSCC) or patients with locally advanced CSCC who are not eligible for surgery (J3590, J9999)
• Fulphila (pegfilgrastim-jmbd) — a biosimilar to Neulasta approved for febrile neutropenia in patients with chemotherapy in certain types of cancer (J3490, J3590)

Please note, one or more of the drugs noted above are currently billed under the not otherwise classified (NOC) HCPCS J-codes J3490, J3590 and J9999. Since these codes include all drugs that are NOC, if the authorization is denied for medical necessity, the plan’s denial will be for the drug and not the HCPCS code.

To request PA, you may use one of the following methods:

• Web: https://www.availity.com
• Fax: 1-866-959-1537
• Phone: 1-855-817-5786

Not all PA requirements are listed here. PA requirements are available to contracted providers through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call the Customer Care Center at 1-855-817-5786 for PA requirements.