Anthem Blue Cross (Anthem) providers should now submit changes to their practice profile using our online Provider Maintenance Form.  

Online update options include: add an address location, name change, tax ID changes, provider leaving a group or a single location, phone/fax numbers, closing a practice location, etc. Visit the Provider Maintenance Form landing page to review more.

The new online form can be found the redesigned provider site www.anthem.com/ca, select the Providers tab then select Provider Maintenance Form in the sub bullets. In addition, the Provider Maintenance Form can be accessed through the Availity Web Portal by selecting California> Payer Spaces-Anthem Blue Cross> Resources tab >Provider Maintenance Form.

Important information about updating your practice profile:

• Change request should be submitted using the online Provider Maintenance Form
• Submit the change request online. No need to print, complete and mail, fax or email demographic updates
• You will receive an auto-reply e-mail acknowledging receipt of your request and another email when your submission has been processed
• For change(s) that require submission of an updated IRS Form w-9 or other documentation, attach them to the form prior to submitting
• Change request should be submitted with advance notice
• Contractual agreement guidelines may supersede effective date of request

You can check your directory listing on the Anthem Blue Cross: “Find a Doctor tool”. The Find a Doctor tool at Anthem is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans. To ensure Anthem has the most current and accurate information, please take a moment to access the Find A Doctor tool (www.anthem.com/ca, select the Providers tab, then select the Find A Doctor in the sub bullets) and review how you and your practice are being displayed.

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

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

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Our Provider Network Education team offers quality complimentary educational programs and materials specially designed for our providers. For a complete listing of our workshops, seminars, webinars and job aids, log on to the Anthem Blue Cross website: www.anthem.com/ca. Select Providers, under Communications go to Education and Training. Scroll down to view Training, Educational and other important Resource offerings.

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The National Accounts 2021 Pre-certification list has been published. Please note, providers should continue to verify member eligibility and benefits prior to rendering services.

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An online course for providers and office staff that addresses gaps in care and offers approaches to communication with patients.  This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians.

Self-Insured Schools of California (SISC) members are encouraged  to develop a relationship with a Primary Care Doctor (PCP). Effective October 1, 2020, Anthem Blue Cross members covered under a SISC self-funded PPO plan may be eligible for a $0 office copay with a PCP. The benefit will waive the first three office visits that are billed by a primary care physician (PCP) per calendar year. The copay waiver will apply to eligible claims based on the order they are received. This benefit is in addition to the $0 copay preventive/well exam benefit.

To confirm if a SISC PPO member is eligible for this benefit or that they have not used their three visits, please verify benefits through Availity.

Eligible SISC plans will consider the following provider specialties as primary care and eligible for this $0 copay benefit:  General Practitioners, Family Practitioners, Internists, Gynecologists, Obstetrics/Gynecology, Pediatricians and Nurse Practitioners.

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As employers host open enrollment periods for their employees, Anthem Blue Cross (Anthem) will offer a new option this fall; plans built around a new Anthem High Performance/Blue High Performance Network (Blue HPN®). Blue HPN plans strive to provide value to our members and clients. Anthem is launching Blue HPN in January 2021 to keep pace with the rapidly evolving nature of healthcare and to answer the call from our national employer groups to improve health outcomes and affordability of care for their organizations and employees.  Blue HPN is part of a national network of Blue High Performance networks being created in collaboration with the Blue Cross Blue Shield Association.

Anthem’s Blue HPN is available in six metropolitan service areas located in Northern and Southern California (Sacramento-Roseville-Arden-Arcade; San Francisco-Oakland-Hayward; San Jose-Sunnyvale-Santa Clara, Los Angeles-Long Beach-Anaheim, San Diego-Carlsbad; Riverside-San Bernardino-Ontario).  The Blue HPN will be offered to support some fully insured health benefit plans as well as certain self-funded plans. Select Anthem contracted physicians, hospitals and ambulatory surgery centers are included in Blue HPN. Participation status in the network will be communicated in writing by Anthem. 

Please note that all providers and facilities behavioral health-specific contracts, birthing centers, imaging providers, and all of the ancillary provider types listed below are included in Anthem’s Blue HPN:

• DME/O&P/Mail Order Disposable Supply (DMEPOS)
• Cardiac Event Monitoring (CEM)
• Home/Ambulatory Infusion/Immunization
• Skilled Nursing Facilities (Free Standing only)
• Reference Labs
• Therapies (PT,OT,ST)
• Audiologist
• Hearing Aid Providers
• Registered Dietitians
• Acupuncturists
• Home Health Agency (HHA)
• Hospice
• Dialysis Facilities
• Ground and Air Ambulance

. 

Blue HPN participation will be displayed in provider profiles in our provider directory on or prior to January 1, 2021. If you are not sure whether your practice will be part of Blue HPN as of January 1, 2021, contact your Anthem network representative. 

Member ID Cards

Blue HPN members will be issued a new ID card to identify and access Blue HPN providers. Virtual ID cards will also be available to members through the Sydney Health and Engage Wellbeing apps.

All Blue HPN plan ID cards will reflect Blue HPN in a suitcase on the front of the card and a disclaimer on the back of the ID card that reads “Services rendered by a non-Blue HPN provider will be limited to Urgent and Emergent care”.  Additionally:

• Anthem National Account (ANA) Blue HPN ID cards will always reflect the Blue High Performance Network name on the front of the ID card.
• Local LG and SG Blue HPN ID cards will always reflect both the Blue High Performance Network and the local Blue HPN Anthem state network on the front of the ID card.

Below is a sample ID card for a member from California enrolled in the national employer Blue HPN plan. Note the new “Blue High Performance Network” logo and “HPN” indicator in the suitcase icon.

We are excited about collaborating with providers in California to keep health care affordable. If you have any questions about this network, please use the following contact information below:

1. Behavioral Health for existing contracted providers: CABHNetworkRelations@Anthem.com
2. Commercial Medical Groups/IPAs & Facilities for existing contracted providers: CAContractSupport@Anthem.com
3. Enterprise Ancillary Networks (Acupuncturists, Cardiac Event Monitoring (CEM), Ground and Air Ambulance, Skilled Nursing, Lab, Hospice, Home Health, Home Infusion, Dialysis, DME, PT/OT/SP Therapy, Registered Dietitians, Audiology/Hearing Aid Suppliers): EnterpriseAncillary@Anthem.com

We are excited to announce our expansion of both EPO and HMO offerings to new regions. 

EPO Plans and Network

For the 2021 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, 9, 10 and 12.  We are also very pleased to announce the expansion of our Individual EPO on and off exchange plans into rating regions 13 and 14. 

Below is a list of counties located in those regions where Anthem will be offering 2021 EPO on and off exchange Individual plans.

Providers in Regions 1, 7, 9, 10 and 12

If you are already participating in the Pathway (on and off exchange) network located in one of these regions, you will continue to provide services to Anthem patients who have purchased coverage on and off exchange as you currently do under your Anthem provider agreement. 

Providers in Region 13 and 14

If you participated in the Pathway (on and off exchange) network in 2017, we have reinstated your participation in the Individual Pathway EPO network under your Anthem provider agreement.  We have further extended participation to providers who previously did not participate in the Anthem Individual Pathway EPO network.  A communication has been sent to both previously participating providers and new providers in the Pathway EPO network.

HMO Plans and Network 

Anthem Blue Cross (Anthem) is excited to re-enter rating region 18 with our HMO Individual on exchange and off exchange plans in addition to regions 11, 15, 16 and 17.  The Pathway HMO network providers have been selected and agreements executed.  Below is a list of counties located in the regions where Anthem will be offering 2021 Individual on and off exchange HMO plans.

These changes do not impact Anthem CA Individual “grandfathered” business. 

Anthem appreciates your partnership and continued participation in our Individual Pathway EPO and HMO networks. 

If you have any questions regarding this information please contact Anthem’s Network Relations Department via email at CAContractSupport@Anthem.com.

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As providers, you are committed to providing the best care for your patients – our members.  That care may now include telehealth visits.  Recognizing the continuing increased need for telephone and virtual services during the COVID-19 public health emergency, the U.S. Department of Health and Human Services (HHS) has given additional consideration to the treatment of telephone-only services in the HHS-operated Risk Adjustment Program.  HHS has clarified that telephone-only service CPT codes (98966-98968 and 99441-99443) are valid for the Risk Adjustment Program.  Telephone-only visits may benefit your patients who have not participated in, or felt comfortable using, a telehealth video visit.  Thank you for your continued commitment to assessing your patients’ health and closing possible gaps in care.

If you are interested in a coding training session specific to risk adjustable conditions, please contact the Commercial Risk Adjustment Network Education Representative: Socorro Carrasco at Socorro.Carrasco@anthem.com.

Thank you for your commitment to assessing your patient’s health and closing possible gaps in care.

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Blue Cross of California dba Anthem Blue Cross and Anthem Blue Cross Life & Health Insurance Company (collectively, Anthem”) are committed to keeping you, our network partners, updated on our activities related to our compliance with the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) Timely Access to Non-Emergency Health Care Services Regulations (the “Timely Access Regulations”), respectively. Anthem maintains policies, procedures, and systems necessary to ensure compliance with the Timely Access Regulations, including access to non-emergency health care services within prescribed timeframes (also referred to as the “time elapsed standards” or “appointment wait times”). Anthem can only achieve this compliance with the help of our provider network partners, you! 

There are many activities that are conducted to support compliance with the regulations, and we need you, as well as covered individuals, to help us attain the information that is needed. These studies allow our Plan to determine compliance with the regulations.

The activities include, but are not limited to the following:

• Provider Appointment Availability Survey
• Provider Satisfaction Survey
• Provider After – Hours Survey

These surveys are currently in progress; please review this information with your office staff so they are prepared and understand the importance of each provider’s participation in each of the surveys.

We appreciate that in certain circumstances time-elapsed requirements may not be met. The Timely Access Regulations have provided exceptions to the time-elapsed standards to address these situations:

Extending Appointment Wait Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.

Preventive Care Services and Periodic Follow-up Care: Preventive care services and periodic follow up care are not subject to the appointment availability standards. These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease.

Advanced Access: The primary care appointment availability standard may be met if the primary care physician office provides “advanced access.” “Advanced access” means offering an appointment to a patient with a primary care physician (or nurse practitioner or physician’s assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day).

We hope this clarifies Anthem’s expectations and your obligations regarding compliance with the Timely Access Regulations. Our goal is to work with our providers to successfully meet the expectations for the requirements with the least amount of difficulty and member abrasion.

Access Standards for Medical Professionals (see attachment)

Note: The next available appointment date and time can be either In-Person or by Telehealth (e.g. Phone Call or Video Call).

Members also have access to Anthem’s 24/7 NurseLine. The NurseLine wait time is not to exceed 30 minutes. The phone number is located on the back of the member ID card. In addition, Members and Providers have access to Anthem’s Customer Service team at the telephone number listed on the back of the member ID card. A representative may be reached within 10 minutes during normal business hours.

Please contact the Anthem Member Services team at the telephone number listed on the back of the member ID card to obtain assistance if a patient is unable to obtain a timely referral to an appropriate provider.

If you have further questions, please contact Network Relations at CAContractSupport@anthem.com.

For Patients (Members) with Department of Managed Health Care Regulated Health plans:

If you or your patients are unable to obtain a timely referral to an appropriate provider or for additional information about the regulations, visit the Department of Managed Health Care’s website at www.dmhc.ca.gov/HealthCareinCalifornia/YourHealthCareRights/TimelyAccesstoCare.aspx or call toll-free 1-888-466-2219 for assistance.

For Patients (Members) with California Department of Insurance Regulated Health plans:

If you or your patients are unable to obtain a timely referral to an appropriate provider or for additional information about the regulations, visit the Department of Insurance’s website at www.insurance.ca.gov or call toll-free 1-800-927-4357 for assistance.

Language Assistance Program

For members whose primary language is not English, Anthem offers, at no cost, language assistance services through interpreters and other written languages. If you or the member is interested in these services, please call the Anthem Member Services number on the member’s ID card for help (TTY/TDD: 711).

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Anthem Blue Cross (Anthem) offers you the ability to have a copy of the member’s ID card without having to physically handle the member’s card. This easy, low-touch access to view a member’s ID card is available from the Availity Portal.

When conducting an eligibility and benefits inquiry for Anthem members, simply select View Member ID Card on the Eligibility and Benefits results page. Note: the Availity Portal requires you to enter the member’s ID number as well as a date of birth or the member’s first and last name into the search options in order to submit an E&B inquiry.

Images of both the front and back of the member ID card are available, allowing you to get all of the pertinent information without the need to make a phone call. The images can be saved directly to your practice management system as PDF files.

Another option available is to access the member’s digital version of their ID card as many members have transitioned to using a digital card instead of a paper card. Members are able to  fax or email a copy of the electronic ID card from their phone/app.

We encourage you to integrate these options into your workflow now.

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Anthem Blue Cross (Anthem) providers may now learn how to use Availity's attachment tools to submit and track supporting documentation electronically by attending one of the upcoming live webinars hosted by Availity. 

The attachments application is a multi-payer, multi-workflow feature. It allows inclusion of multiple records across a variety of workflows and request types to support different business processes for payers.

By attending one of the upcoming webinars, attendees will learn both the digital and electronic processes that include:

• How your organization gets set up
• Demonstrations of the tools used to submit attachments via Availity Portal
• Navigating the Attachments dashboard
• View electronic records of your submissions

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

Register for an upcoming webinar session

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

October/November Dates

Where can you find more help?

Select Help & Training > Find Help to display Availity Help in a new browser window.

Use Contents to display topics.

Depending on your needs, consider exploring these topics:

• Claim Submission
• Attachments (new)
• Medical Attachments (legacy)

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A central premise of Anthem’s Behavioral Health Case Management (BHCM) Program is to promote collaboration between all treating providers, ensuring coordination between medical care and behavioral health care. Once members are identified, Behavioral Health Care Managers outreach / consult with our community partners in medical and behavioral health practice settings. Our program supports the treatment planning needs of providers with respect to behavioral health services and often provides consultation/ suggestions for modifications in current care. This coordination is performed through various avenues including: notification letters to physicians informing them that their patients are engaged with the program, telephonic outreach calls, and the opportunity/option for physician peer-to-peer consultation when needed.

The essence of behavioral health management is ensuring that we direct our members to the right services at the right time. Our triage and tracking processes include specialized support during service level transitions, such as a discharge from inpatient to outpatient follow-up treatment to ensure that members are attending follow up appointments with community providers within 7 days of hospital discharge. In addition, we utilize a readmission risk algorithm, which identifies members most at risk for readmission to inpatient hospital care. Specialty services are also offered to members diagnosed with eating disorders, maternal mental health issues, families of children and adolescents with a recent inpatient psychiatric stay, and members referred from community providers affiliated with Enhanced Personal Health Care. Also, consenting members engaged in medical care management programs with a positive PHQ2 depression screen or any other BH condition impeding the member's ability to manage their medical condition are routed to BH for intervention.

Our clinicians work with the member and their family to:

1. Understand the options available for behavioral health treatment, utilize Anthem benefits for lowest possible out of pocket cost, and decrease unnecessary health care expenditures
2. Advocate for the coordination of all care, both medical and behavioral health
3. Educate on symptoms and condition management to prevent future inpatient hospitalization stays
4. Discuss and identify barriers to treatment compliance and offer resources and support to overcome them
5. Improve overall health outcomes for improved quality of life

Blue Cross of California dba Anthem Blue Cross and Anthem Blue Cross Life & Health Insurance Company (collectively, Anthem”) are committed to keeping you, our network partners, updated on our activities related to our compliance with the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) Timely Access to Non-Emergency Health Care Services Regulations (the “Timely Access Regulations”), respectively. Anthem maintains policies, procedures, and systems necessary to ensure compliance with the Timely Access Regulations, including access to non-emergency health care services within prescribed timeframes (also referred to as the “time elapsed standards” or “appointment wait times”). Anthem can only achieve this compliance with the help of our provider network partners, you!

There are many activities conducted to support compliance with the regulations and we need you, as well as Members, to help us attain the information that is needed. These studies allow our Plan to determine compliance with the regulations.

The activities include, but are not limited to the following:

• Provider Appointment Availability Survey
• Provider Satisfaction Survey
• Provider After – Hours Survey

These surveys are currently in progress; please review this information with your office staff so they are prepared and understand the importance of each provider’s participation in each of the surveys.

We appreciate that in certain circumstances time-elapsed requirements may not be met. The Timely Access Regulations have provided exceptions to the time-elapsed standards to address these situations:

Extending Appointment Wait Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.

Preventive Care Services and Periodic Follow- up Care: Preventive care services and periodic follow up care are not subject to the appointment availability standards. These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease.

We hope this clarifies Anthem’s expectations and your obligations regarding compliance with the Timely Access Regulations. Our goal is to work successfully with our providers to meet the expectations for the requirements with the least amount of difficulty and member abrasion.

Access Standards for Behavioral Health and EAP Providers (open attachment to view table)

* The DMHC Timely Access standard is 15 Business days for Psychiatrists; however, to comply with the NCQA accreditation standard of 10 Business Days, Anthem uses the more stringent standard.

Note:  The next available appointment date and time can be either In-Person or by Telehealth services.

Email any questions to Behavioral Health Network Relations at CABHNetworkRelations@anthem.com.

Members also have access to Anthem’s 24/7 NurseLine. The NurseLine wait time is not to exceed 30 minutes. The
phone number is located on the back of the member ID card. In addition, Members and Providers have access to Anthem’s Customer Service team at the telephone number listed on the back of the member ID card. A representative may be reached within 10 minutes during normal business hours.

For Patients (Members) with Department of Managed Health Care Regulated Health plans:

If you or your patients are unable to obtain a timely referral to an appropriate provider or for additional information
about the regulations, visit the Department of Managed Health Care’s website at www.dmhc.ca.gov/HealthCareinCalifornia/YourHealthCareRights/TimelyAccesstoCare.aspx or call toll-free
1-888-466-2219 for assistance.

For Patients (Members) with California Department of Insurance Regulated Health plans:

If you or your patients are unable to obtain a timely referral to an appropriate provider or for additional information about the regulations, visit the Department of Insurance’s website at www.insurance.ca.gov or call toll-free 1-800-927-4357 for assistance.

Language Assistance Program

For members whose primary language is not English, Anthem offers at no-cost language assistance services through interpreters and other written languages. If you or the member is interested in these services, please call the toll-free Anthem Member Services number on the member’s ID card for help (TTY/TDD: 711).

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Anthem Blue Cross (Anthem) previously communicated in the June 2020 edition of Anthem's Provider News that AIM Specialty Health® (AIM), a separate company, would transition the clinical criteria for medical necessity review of certain rehabilitative services to AIM Rehabilitative Service Clinical Appropriateness Guidelines as part of the AIM Rehabilitation Program beginning October 1, 2020. Please be aware that this transition has been delayed. We anticipate that the new transition date will be in December 2020, and we will provide an update about the program in the December Network Update.

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As recently communicated in August 2020, AIM Specialty Health_® (AIM), a specialty health benefits company, will expand the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints for Anthem members effective November 1, 2020.  Replacement and revision surgeries for procedures such as total joint of ankle, correction of Hallux Valgus, hammertoe repair are included. 

The AIM  Musculoskeletal Program follows the Anthem Clinical Guidelines that state the services must be delivered by a qualified provider within the scope of their licensure. Qualified providers acting within the scope of their license, including podiatrists, who intend to perform certain elective surgeries of the small joints’ procedures should request prior authorization for those services through AIM. 

AIM will begin accepting prior authorization requests on October 26, 2020, for dates of service on and after November 1, 2020, and after. Prior authorization requests may be submitted via the AIM ProviderPortal or by calling the AIM Contract Center toll-free number: 1-877-291-0360, Monday – Friday, 7:00 a.m. – 5:00 p.m. PT.

We value your participation in our network and look forward to working with you to help improve the health of our members.

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To learn more information about evaluation and management services correct coding.

Effective November 1, 2020, prior authorization (PA) requirements will change for E0482. The Medical codes listed below will require PA by Anthem Blue Cross. 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:

• E0482 — Cough stimulating device, alternating positive and negative airway pressure

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

• Web: https://www.availity.com
• Fax: 1-800-754-4708
• Phone: 1-888-831-2246

Not all PA requirements are listed here. PA requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com at https://mediproviders.anthem.com/ca > Login. Contracted and noncontracted providers who are unable to access Availity* may call one of our Customer Care Centers for assistance with PA requirements:

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

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross.

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

Patient360 is an interactive dashboard you can access through the Availity Portal* that gives you a full 360° view  of your Anthem patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.

What’s new: Medical providers now have the option to include feedback for Anthem patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.

Once you have completed all the required fields on the Availity Portal to access Patient360 you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

First, you need to be assigned to a Patient360 role, which your Availity administrators can locate within the Clinical Roles options.

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

Do you need a job aid to help you get started?

The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center.

1. From the Availity home page, select Payer Spaces > Anthem payer tile > Applications > Custom Learning Center
2. Select Resources from the menu located on the upper left corner of the page. (To use the catalog filter to narrow the results, select Payer Spaces from the Category menu.)
3. Select Download to view and/or print the reference guide

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Behavioral health disorders are classified in Chapter 5 of the ICD-10-CM

Behavioral health disorders are commonly underreported on claims. Many Anthem Blue Cross members may have behavioral health disorders that are not properly managed. Health care providers can assist by taking detailed histories and coding behavioral health issues properly on claims. Below are the ICD-10-CM coding guidelines for behavioral health conditions.

When documenting behavioral disorders, the following descriptors apply:

• Type: Depressive, manic, or bipolar disorder
• Episode: Single or recurrent
• Status: Partial or full remission; identify most recent episode as manic, depressed, or mixed
• Severity: Mild, moderate, severe, or with psychotic elements.

Schizophrenic related disorders

Schizophrenic related disorders are classified in category F20, with a fourth character indicating the type of schizophrenia as follows:

Major depressive disorder (MDD)

Major depressive disorder (MDD) is classified in ICD-10-CM to categories:

• Major depressive disorder, single episode
• Major depressive disorder, recurrent.

Categories F32 and F33 are further subdivided with fourth characters, and sometimes fifth characters, to provide information about the current severity of the disorders, as follows:

• 0 Mild
• 1 Moderate
• 2 Severe, without psychotic features
• 3 Severe with psychotic features
• 4 In remission
• 5 In full remission
• 8 Other
• 9 Unspecified.

Fourth characters 1 through 8 are assigned only when provider documentation of severity is included in the medical record.

Manic episodes and bipolar disorders

The table below outlines the ICD-10-CM classification for bipolar disorders. Manic/mania also falls within this code category. The codes in these categories require fourth and/or fifth digits to identify the severity of the current episode and whether or not psychotic symptoms are involved.

Anxiety disorders

Anxiety disorders are classified in ICD-10-CM under the following categories:

• F40 Phobic anxiety disorders
• F41 Other anxiety disorders
• F42 Obsessive-compulsive disorder.

Dissociative and conversion disorders

ICD-10-CM classifies dissociative and conversion disorders to category F44.

Dissociative disorders

Conversion disorders

Behavioral syndromes associated with physiological disturbances and physical factors

Categories F50 through F59 grouping includes the following conditions:

Disorders of adult personality and behavior

Categories F60 through F69 include disorders of adult personality and behavior:

Psychosocial circumstances and encounters

ICD-10-CM provides codes for behaviors that have not yet been classified to behavioral disorders, but that may contribute to the need for further treatment or study. The table below shows some examples:

For behavioral health disorders that resolve and do not require continued treatment, it is appropriate to report code Z86.59, Personal history of other mental and behavioral disorders.

Resources:

1. ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2019.
2. ICD-10-CM/PCS Coding. Theory and practice. 2019/2020 Edition. Elsevier.

On January 1, 2021, Anthem Blue Cross prior authorization (PA) requirements changed for codes covered by Anthem. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following codes:

• 15771 — Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
• 15772 — Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
• 15773 — Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
• 15774 — Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
• 31574 — Laryngoscopy, flexible; with injection(s) for augmentation (for example, percutaneous, transoral), unilateral
• 0378T — Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional
• 0379T — Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional
• C9122 — Mometasone furoate sinus implant, 10 mcg (Sinuva)
• 11950 — Subcutaneous injection of filling material (for example, collagen); 1 cc or less
• 11951 — Subcutaneous injection of filling material (for example, collagen); 1.1 to 5.0 cc
• 11952 — Subcutaneous injection of filling material (for example, collagen); 5.1 to 10.0 cc
• 11954 — Subcutaneous injection of filling material (for example, collagen); over 10.0 cc
• 0565T — Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation
• 0566T — Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral
• C1878 — Material for vocal cord medialization, synthetic (implantable)
• G0429 — Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (for example, as a result of highly active antiretroviral therapy)
• L8607 — Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies
• Q2026 — Injection, Radiesse, 0.1 ml
• Q2028 — Injection, sculptra, 0.5 mg
• 0489T — Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells
• 0490T — Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands
• 0202U — Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
• 17999 — Unlisted procedure, skin, mucous membrane and subcutaneous tissue
• 46999 — Unlisted procedure, anus

Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.anthem.com/ca/medicareprovider > Login. Contracted and noncontracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.

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On February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the [Clinical Criteria Web Posting June 2020]. Visit Clinical Criteria to search for specific policies.

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

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Click here for more information about the May 2020 Medical Policies and Clinical Utilization Management Guidelines Update.

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

Patient360 is an interactive dashboard you can access through the Availity Portal* that gives you a full 360° view  of your Anthem patients’ health and treatment history and will help you facilitate care coordination. You can drill down to specific items in a patient’s medical record to retrieve demographic information, care summaries, claims details, authorization details, pharmacy information and care management-related activities.

What’s new: Medical providers now have the option to include feedback for Anthem patients who have gaps in care. Your practice can locate these care gaps in the Active Alerts section on the Member Care Summary page of the Patient360 application.

Once you have completed all the required fields on the Availity Portal to access Patient360 you will land on the Member Summary page of the application. To provide feedback, select the Clinical Rules Engine (CRE) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry window. You can choose the feedback menu option that applies to your patient’s care gap.

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

First, you need to be assigned to a Patient360 role, which your Availity administrators can locate within the Clinical Roles options.

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Anthem Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

Do you need a job aid to help you get started?

The Patient360 Navigation Overview illustrates the steps to access Patient360 through the Availity Portal and offers instructions on how to provide feedback for your patients who are displaying a Care Gap Alert. This reference is available for you to access online through the Custom Learning Center.

• From the Availity home page, select Payer Spaces > Anthem payer tile > Applications > Custom Learning Center
• Select Resources from the menu located on the upper left corner of the page. (To use the catalog filter to narrow the results, select Payer Spaces from the Category menu.)

• Select Download to view and/or print the reference guide

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On January 1, 2021, Anthem Blue Cross prior authorization (PA) requirements will change for codes below. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following codes:

• C1764 Event recorder, cardiac (implantable)
• E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED
• E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS,
• E0731 Conductive Garment For Tens
• G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other     preparatory procedures, administration and dressings, per treatment
• L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each
• L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength
• L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each
• L3224 Woman's Shoe Oxford Brace
• L3225 Man's Shoe Oxford Brace
• L3300 Shoe Lift Taper To Metatarsal
• L3310 Lift, elevation, heel and sole, neoprene, per in
• L3332 Lift, elevation, inside shoe, tapered, up to one-half in
• L3334 Lift, elevation, heel, per in
• L3340 Heel wedge, SACH
• L3350 Shoe Heel Wedge
• L3370 Shoe Sole Wedge Between Sole
• L3390 Shoe Outflare Wedge
• L3400 Shoe Metatarsal Bar Wedge Ro
• L3450 Shoe Heel Sach Cushion Type
• L3485 Shoe Heel Pad Removable For
• L3540 Ortho Shoe Add Full Sole
• L3580 O Shoe Add Instep Velcro Clo
• L3610 Transfer of an orthosis from one shoe to another, caliper plate, new
• L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing
• L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new
• L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified
• L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
• L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf
• L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf
• L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf
• L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
• L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type
• L3912 Hand-finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the-shelf
• L3913 HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
• L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
• L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated,

off-the-shelf

• L3925 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf
• L3927 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/spring, extension/flexion (for example, static or ring type), may include soft interface material, prefabricated,

off-the-shelf

• L3999 Upper Limb Orthosis Nos
• L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system
• L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee
• L5620 Test Socket Below Knee
• L5645 Addition to lower extremity, below knee (BK), flexible inner socket, external frame
• L5649 Addition to lower extremity, ischial containment/narrow M-L socket
• L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
• 0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
• 0397T Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure.)
• 0421T Transurethral waterjet ablation of prostate, including control of post-operative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)
• 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure.)
• 0480T Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure.)
• 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation
• 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach
• 33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach
• 33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach
• 33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy)
• 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis
• 33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure)
• 33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed
• 33979 Insertion, Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle
• 33990 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only
• 36514 Therapeutic Apheresis; Plasma Pheresis
• 36522 Photopheresis, Extracorporeal
• 37215 Transcatheter Placement Of Intravascular Stent(S), Cervical Carotid Artery, Percutaneous; With Distal Embolic Protection
• 55874 Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed
• A4224 Supplies for maintenance of insulin infusion catheter, per week
• A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
• A5500 Diabetic Shoe for Density Insert
• A5501 Diabetic Custom Molded Shoe
• A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe
• A5504 Diabetic Shoe with Wedge
• A5505 Diabetic Shoe W/Metatarsal Bar
• A5507 Modification Diabetic Shoe
• A5512 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fah
• A5513 For diabetics only, multiple density inserts, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each
• A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries
• C1722 Cardioverter-defibrillator, single chamber (implantable)
• L5671 Addition to lower extremity, below knee (BK)/above knee (AK) suspension locking mechanism (shuttle, lanyard, or equal), excludes socket insert
• L5673 Addition to lower extremity, below knee/above knee, custom fabricated
• L5679 Addition to lower extremity, below knee/above knee, custom fabricated
• L5700 Replace Socket Below Knee
• L5701 Replace Socket Above Knee
• L5940 Endo Bk Ultra-Light Material
• L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature
• L5981 All lower extremity prostheses, flex-walk system or equal
• L5987 All lower extremity prostheses, shank foot system with vertical loading pylon
• L8699 Prosthetic implant, not otherwise specified
• L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code

Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.anthem.com/ca/medicareprovider > Login. Contracted and noncontracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.

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As you know, AIM Specialty Health_® (AIM)* administers the musculoskeletal program for Medicare Advantage members, which includes the medical necessity review of certain surgeries of the spine, joints and interventional pain treatment. For certain surgeries, the review also includes a consideration of the level of care.

Effective December 1, 2020, two joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM guideline, it is generally appropriate to perform these two procedures in a hospital outpatient setting. To avoid additional clinical review for these surgeries, providers requesting prior authorization should either choose hospital observation admission as the site of service or Hospital Outpatient Department (HOPD).

We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:

• Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
• Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.

On January 1, 2020, CMS removed total hip arthroplasty as well as six spine codes from the inpatient only (IPO) list making these procedures eligible for payment by Medicare in the hospital outpatient setting in addition to the hospital inpatient setting. The two-midnight rule should guide providers on the expected reimbursement. The codes that were removed from the inpatient only list and are also in the AIM Musculoskeletal program are 27130, 22633, 22634, 63265 and 63267. CMS has established a two year grace period (ending December 31, 2021) for site of service reviews of these codes in order to facilitate provider transition to compliance with the two-midnight rule. To this end, it is recommended that providers choose hospital observation or Hospital Outpatient Department (HOPD) during the prior authorization process when clinically appropriate to the respective patient. Choosing hospital observation still allows for the surgery to be performed and recovered in the main hospital, so long as discharge is planned for less than two midnights. Alternatively, the provider may choose to perform the procedure in the Hospital Outpatient Department (HOPD). However, the inpatient setting will still be approved should the provider decide it is the optimal setting for the member.

Providers should continue to submit prior authorization requests to AIM using one of the following ways:

• Access AIM ProviderPortal_SM directly at http://providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Portal* at http://www.availity.com.
• Call the AIM toll-free number at 1-800-714-0400, Monday through Friday 8 a.m. to 8 p.m. ET.

If you have questions, please contact the provider number on the back of the member’s ID card.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross.

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On May 15, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting May 2020. Visit Clinical Criteria to search for specific policies.

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