 Provider News CaliforniaOctober 2023 Provider Newsletter Contents
CABC-CDCRCM-038795-23-CPN38706 As an Anthem Blue Cross (Anthem) participating care provider, you may have received our prior correspondence or read the articles in our Network Updates on Anthem cost transparency. Transparency tools such as Anthem’s Find Care tool and others are available to members at anthem.com and allow members to estimate their out-of-pocket impact and view the estimated costs for many procedures. In our prior correspondence, we also enclosed a summary of the methodology used to generate the cost information housed in the National Consumer Cost Tool (NCCT), the source data used to display costs in Find Care. The treatment categories for which costs are displayed and the methodology are defined by the Blue Cross Association. As indicated in their correspondence, Axis® (formerly NCCT), cost data is updated twice annually. The most recent update was completed in May 2023. The next update is scheduled for November 2023. Please look for more information in our provider newsletters posted to anthem.com. As a reminder, Anthem care provider costs are now available in a secure section of the Availity* provider portal. Authorized representatives of participating facilities and professional practices can log in to Availity at Availity.com and register to view the costs for their facility or practice. Costs will be made available to our participating care providers no less than 30 days before they become available to our members on anthem.com in the transparency tools such as Anthem Care Comparison. Should you wish to review the methodology, you may request a copy by sending an email request to your Provider Relationship Management representative. If you wish to provide an internet link on Anthem’s website where this cost information will be displayed, please provide us this link within 30 days of receiving the cost information from us. Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. CABC-CM-035716-23 The Consolidated Appropriations Act (CAA) of 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Maintaining your online provider directory information is essential for member and healthcare partners to connect with you when needed. Review your information frequently and let us know if any of your information we show in our online directory has changed. Submit updates and corrections to your directory information by following the instructions on our Provider Maintenance webpage. Online update options include: - Add/change an address location.
- Name change.
- Provider leaving a group or a single location.
- Phone/fax number changes.
- Closing a practice location.
Reviewing your information helps us ensure your online provider directory information is current. Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare. CABC-CM-038044-23-SRS38044 The 2023 Provider Satisfaction Survey is coming! Do you know what the Provider Satisfaction Survey is? Anthem Blue Cross (Anthem) conducts the Provider Satisfaction Survey annually to ensure compliance with various timely access requirements for California. We want to hear from youYour feedback helps us better serve you and your patients. Be prepared to act: - Mark your calendar. Starting in the fall of 2023, randomly selected providers will receive the annual Provider Satisfaction Survey.
- If selected, you will receive the survey by fax from our vendor, Sutherland Healthcare Solutions.*
- Respond within five business days of receiving the survey.
The questions ask that you rate your satisfaction on a scale of 1 to 4 on the areas below: - Your satisfaction with our referral and prior authorization process
- Your patients’ timely access to:
- Urgent care
- Non-urgent specialty services
- Non-urgent ancillary diagnostic and treatment services
- Non-urgent healthcare
- Your patients’ access to Anthem’s Language Assistance Program
- Your satisfaction with Anthem’s interpreter services
The survey should only take a couple of minutes to complete. Your responses help us measure your perspective and satisfaction with your patient’s ability to receive access to care within the timelines set forth under California law. Access the provider manual to learn more about Anthem’s timely access standards and language assistance program. We value your participation in advance of completing the survey. With your help, we can continually build towards a future of shared success. * Sutherland Healthcare Solutions is an independent company providing services on behalf of the health plan. CABC-CM-038502-23 A key goal of Anthem Blue Cross (Anthem) provider transparency is to improve quality while managing healthcare costs. Value-based program providersAnthem provides a wealth of various value-based programs (known as the Programs) including Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, and more. We help our value-based program care providers stay informed about quality, utilization and cost data, reports, and information about referrals for their patients covered under the Programs. Referral care providersIf a referral care provider is higher quality and/or lower cost, this component may result in getting more referrals from value-based program providers. However, if referral care providers are lower quality and/or higher cost, they may be referred to less. Making informed decisions and managing care costsProviding this type of data (including comparative cost information) to value-based program care providers helps them make more informed decisions about managing healthcare costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs. Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about value-based program care providers and referral care providers so that they can better understand how their healthcare dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost care providers. Anthem will share the data used to make these quality/cost/utilization evaluations upon request. We are also available to discuss any opportunities for improvement. For questions or support, please refer to your Provider Relationship Management representative. We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities. Transplant team at Anthem Blue Cross The Transplant team’s review of services includes solid organ (kidney, heart, lung, liver, pancreas, intestinal, multi-visceral, and combination organ) transplants, bone marrow and stem cell (autologous and allogeneic) transplants, chimeric antigen receptor (CAR)-T, and gene replacement. All delegated medical groups must notify the Anthem Blue Cross’ (Anthem) Centers of Medical Excellence (CME) Transplant and Special Therapy department when a member is referred for evaluation. The department requires an authorization for transplant and admitted for transplant within one business day. Send referrals to Anthem at the address or phone number provided in Section 2, Quick References, under CME Transplant and Special Therapy department. Select this link for contact information. Transplant medical necessity review is the responsibility of Anthem’s Transplant team. This includes initial evaluation, prior authorization, inpatient concurrent review, and discharge planning. The initial evaluation involves Anthem’s Transplant team reviewing member benefits and verification that the requested facility meets network requirements before consultation with the facility Transplant team. Transplant, CAR-T, and gene replacement therapy global period is outlined on the contract attachment provided upon approval of the service. During this global period, the Transplant team will review the transplant services for the member. Post global period, the UM review is the responsibility of the medical group. Financial responsibility for transplant and non-transplant related medically necessary covered services remain as described in the Division of Financial Responsibilities matrix in the Provider Agreement. Post-transplant, Anthem’s Transplant case manager works in conjunction with the member’s transplant team, PCP, and other clinicians to complete an assessment of the member’s healthcare needs, develop, implement, and monitor a care plan, coordinate services, and re-evaluate the care plan for the member. All care providers must obtain prior authorization for transplant evaluations and transplant surgery, regardless of financial risk. Transplant evaluations and surgery must be performed at one of Anthem’s Centers of Excellence or facilities approved by Anthem’s Transplant medical directors. Having reliable internet access is an important part of life. The internet helps us find information and connect with people, including finding and connecting with healthcare providers via virtual visits. However, not everyone can afford it. We share a health vision with our care provider partners that means real change for consumers. Making the internet more accessible is one way we can improve the whole health of our communities. The Affordable Connectivity Program can help. What is the Affordable Connectivity Program?The Affordable Connectivity Program is a government program that helps families who may need assistance pay for internet access. Qualified households can receive: Who is eligible for the program?A household is eligible for the Affordable Connectivity Program if: - Participates in certain government assistance programs such as the Supplemental Nutrition Assistance Program (SNAP), Medicaid, Social Security Income (SSI), the Free and Reduced-Price School Lunch Program or School Breakfast Program, or others.
- Participates in certain Tribal assistance programs, such as Head Start, Tribal Temporary Assistance for Needy Families (TANF), or others.
- Received a Federal Pell Grant during the current award year.
- Already receives a Lifeline benefit (another government program providing discounts on internet and phone service).
How do my patients apply?Your eligible patients can apply for the Affordable Connectivity Program online or by mail. They can also ask their current internet provider if they participate in the program. Please direct your patients to learn more at AffordableConnectivity.gov CABC-CDCRCM-036084-23-CPN34208 Background:We continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. Provider performance can vary widely in relation to efficiency, quality, and member experience. Our goal as your Medicare health plan partner is to ensure our members receive high-quality care that leads to improved member health outcomes across a wide range of variables. Beginning January 1, 2023, we added a new sorting option on the FindCare tool for members to leverage when they are searching for a primary care provider. This sorting option, called Personalized Match Phase 1, is based on each provider’s score relative to their peers in the patient’s preferred mileage search radius. Providers are listed in order of their total score, though no individual scores appear within the tool or be visible to Medicare covered patients. The Personalized Match Phase 1 algorithm is based on quality and efficiency criteria to assist members in making more informed choices about their medical care. Other sorting options are still available on FindCare for our members. Personalized Match Phase 1 highlights:- We strive to make healthcare simpler, more affordable, and more accessible, and one of the ways to help achieve that goal is to ensure that consumers are connected with care providers who have strong track records delivering quality care.
- Beginning on November 10, 2023, we will upgrade the online FindCare tool for Medicare members with a new sorting option called Personalized Match Phase 1, to match consumers with providers who perform well in efficiency and quality metrics within a certain geographical distance.
- The new sorting option, known as Personalized Match Phase 1, will be the default for consumers who search for Medicare non-primary specialty care providers in FindCare.
- We currently offer Personalized Match to Commercial consumer members. Personalized Match seeks to match consumers with documented health conditions with provider ranked based on cost effectively managing quality care. For example, if a consumer who has been given a diagnosis of diabetes conducts a search, they will be matched with providers whose patients are more likely to cost effectively manage similar patients with diabetes (for example, consistently receive recommended A1c tests A consumer who is a 60-year-old male would receive different Personalized Match provider rank order than a consumer who is a 30-year-old female). The goal is to move to this full Personalized Match solution in Medicare in the future. Personalized Match Phase 1 only analyzes providers’ quality and efficiency performance regardless of member characteristics for generating the sort order.
- You may review a copy of the new sorting methodology which has been posted on Availity.*
- If you have general questions regarding this new sorting option, please submit an inquiry via the web on Availity.
- If you would like information about your scoring used for this sorting option or if you would like to request reconsideration of your score, you may do so by submitting an inquiry via the web on Availity.
- This change is part of a greater effort to help improve access to high quality, affordable healthcare, which is essential to our customers.
FAQWhy are we reimagining the strategy for evaluating non-primary specialty care providers? There is variability in provider performance (efficiency, quality, experience), and we want to ensure all members receive high-quality care that leads to improved patient outcomes. The strategy aligns with the future direction of our specialty provider care strategy. This phase of the Medicare FindCare improvement utilizes measures related to appropriate practice (for example, overuse and underuse measures). We utilize a vendor, Motive Medical, to generate an overall Appropriate Practice Score at the NPI level, based on all CMS Fee-for-Service members. How will I know my inquiry went through successfully once I submit? An email will be sent to the inquirer acknowledging receipt of inquiry within two business days. What is the turnaround time from when I submit my question to receiving an answer? The goal is to have all questions answered within two business days. If further clarification is needed, or if detailed research is required, that time frame will be extended. How will I receive my response? An email will be sent with the required information back to the email address provided during the initial inquiry request. How do I submit an inquiry? Inquiries can be made at Availity site. There are three dropdown options for inquiry types. These are: 1) General Program Inquires, 2) Request a Copy of Your Provider Performance Scorecard, and 3) Provider Performance Scorecard Inquiries. An open text field is available to describe the nature of the inquiry in more detail. What type of inquiries can I submit? Any questions relating to Personalized Match Phase 1 that is not answered in this FAQ or by the Methodology document. Do providers have any recourse if they feel their Provider Performance Scorecard is inaccurate? If a provider disagrees with their Provider Performance Scorecard results, the provider can submit an inquiry at Availity site detailing their reasoning. We will determine the best course of action as needed, but potential outcomes could be a provider consultation, reanalysis, and potentially a rescoring of provider performance to be reflected in Personalized Match Phase 1 and the Provider Performance Scorecard. What provider specialties are included in Personalized Match Phase 1? For 2023, selected non-primary specialty care providers are included. We plan to potentially incorporate other provider specialties in future provider performance evaluations. What measures are included in quality scoring and why were they included? The quality measures selected for Personalized Match Phase 1 include underuse and overuse measures, within the appropriate practice domain. Measures vary by specialty and are available on request. How are measures weighted? Motive Medical considers three factors in weighting the importance of each measure as it impacts the overall NPI Appropriate Practice Score (APS): - Measure volume (for example, the number of instances a provider is eligible for measurement)
- Cost differential (for example, the difference in cost between the inappropriate service chosen versus the cost of the appropriate alternative), and
- Patient harm (for example, measures weigh more heavily if they have a stronger negative impact on the patient).
What measurement year and source are used in quality scoring? Motive Medical’s Fall 2022 Refresh was used for quality scoring with varying claim periods by measure including dates from January 1, 2019, to December 31, 2021. What are the inclusion criteria for quality scoring? A non-primary specialist care provider must have at least three appropriateness measures with at least ten members in each measure (a few measures require 20 members) for the APS score to be calculated. If the provider does not meet this threshold, the APS score is not available. The APS score can be described in the following steps: - Within each specialty, calculate the mean Motive Medical APS score to be used as the national-specialty benchmark.
- For each non-primary care specialty provider, calculate an APS Observed to Expected (O/E) ratio, comparing the provider to the benchmark for the same specialty:
- Provider’s APS / national-specialty benchmark.
- The quality score is the provider’s APS O/E percentile ranking at the national-specialty level.
What factors go into your efficiency target? The factors going into our efficiency target are the episodes of the members are assigned to provider specialty who has the highest cost within the episode for Surgery and Evaluation costs. The observed cost of an episode is the sum of provider’s total allowed costs. The expected or peer benchmark cost of an episode is the average cost of treating the same condition or procedure with the same severity level for all specialists in the same line of business, specialty and geographic area multiplied by number of provider’s volume. For ETGs the measure is at the condition level (diabetes, asthma) and for PEGs it’s the procedure level (knee replacement, lumbar fusions): - Observed cost: Total provider cost
- Expected cost: Specialty average cost for same case mix * physician volume
- Efficiency index = observed / expected
How is your efficiency target set? Efficiency scores from the condition ETG and PEG procedure (observed/expected ratio scores) are blended into one final efficiency score by weighing the percentage of all the dollars that are tied to procedures vs conditions. This ensures that the efficiency scores for proceduralists (surgeons) are based more heavily on the procedure episodes. This is the final blended efficiency score for the provider: - A minimum of 20 episodes that have benchmarks are required to calculate a condition efficiency or procedure efficiency score for the provider.
- A 90% statistical confidence interval is computed around the provider’s final blended efficiency score to account for the level of statistical uncertainty around the point estimation. For example, a provider with a final blended efficiency score of 0.97 might have the following confidence interval: Upper confidence level (UCL) of 1.03, Lower Confidence level (LCL) of 0.91.
Cost ratings are then assigned to providers and provider groups using confidence intervals, as shown below. The provider group cost ratings are used for TIN Designation while individual provider cost ratings are used for the Provider composite score. 
For high-cost cases, how do you normalize which can occur across different groups? We exclude outlier episodes from the scoring, low cost and high-cost episodes are flagged by the software at Condition/Procedure, Severity, and Line of business level. Provider specialties with quality measures:- Cardiac electrophysiology
- Cardiac surgery
- Cardiology
- Colorectal surgery
- Endocrinology
- Gastroenterology
- General surgery
- Geriatric psychiatry
- Hand surgery
- Hematology
- Hematology/oncology
- Interventional cardiology
- Medical oncology
- Nephrology
| - Neurology
- Neurosurgery
- Obstetrics gynecology
- Ophthalmology
- Orthopedic surgery
- Otolaryngology
- Psychiatry
- Pulmonary disease
- Radiation oncology
- Rheumatology
- Surgical oncology
- Thoracic surgery
- Urology
- Vascular surgery
|
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan. CABC-CR-032316-23-CPN32306 As we continue our path to be your most valued partner in the industry, we’d like to share an update on how your organization should verify and initiate care provider demographic change requests for all professional and facility care providers.** Going forward, Availity Essentials* Provider Data Management (PDM) and Symphony* file-based data exchange are now the two options for care providers to submit demographic change requests, including submitting roster uploads. Availity PDM and Symphony will replace all current intake channels for demographic change requests and roster submissions as of January 1, 2024. While there are two options available, providers only need to use one. The Availity PDM option is available at no cost to providers, and the Symphony option is a premium service available for an additional cost if providers choose to sign up for it. If preferred, providers may continue to utilize the Provider Enrollment application in Availity Essentials to submit requests to add new practitioners under existing groups. Option 1: Availity PDM application via Availity Essentials (available at no cost to care providers)The Availity PDM application allows you to: - Update provider demographic information for all assigned payers in one location.
- Attest and manage current provider demographic information.
- Review the history of previously verified data.
Option 2: Symphony file-based data exchange (premium service available to care providers for a fee)As we communicated in February, Anthem is participating with Symphony, California’s centralized platform for provider directory data, led by the nonprofit organization, Integrated Healthcare Association. Providers can choose to work directly with Symphony for file-based data exchange and for multi-plan data submission, attestation, and reporting. Symphony benefits medical groups by reducing administrative burden, improving data quality, and supporting compliance. Contact the Symphony team here if you are interested in learning more. Benefits to our care providers using Availity PDMThe Availity PDM application will ensure the following: - Consistently updated data
- Decreased turnaround time for updates
- Compliance with federal and/or state mandates
- Improved data quality through standardization
- Increased provider directory accuracy
- Choice and flexibility to request data updates via the standard Availity PDM experience or by submitting a spreadsheet via a roster upload
Benefits to our care providers using Symphony: - Submit and attest to data for many health plans at one time with 17 health plans currently participating.
- Improve data quality through standardization and reports that highlight data discrepancies.
- Comply with federal and/or state mandates as well as with health plan requirements.
- Partner with Symphony Client Success team members who advocate for each Symphony participant’s unique needs.
Want to submit a roster using Availity PDM?Now you can. Roster Automation is the new technology solution designed to streamline and automate provider data additions, changes, and terminations that are submitted using a standardized Microsoft Excel submission. Any provider, whether an individual provider/practitioner, group, or facility, can use Roster Automation today:*** - Utilize the Roster Automation Standard Template:
- For your convenience, there is a standard roster Excel document. Find it online here.
- Follow the Roster Automation Rules of Engagement:
- This reference document is available to ensure error-free submissions, driving accurate and more timely updates through automation. Find it online here.
- More detailed instructions on formatting and submission requirements can also be found on the first tab of the Roster Automation Standard Template (User Reference Guide).
- Upload your completed roster via the Availity PDM application.
What about the previous methods by which I have been submitting information?While we are in the process of sunsetting our legacy intake channels, we will continue to process submissions received through current intake channels until December 31, 2023. Effective January 1, 2024, all PDM requests, including rosters, must be submitted via Availity PDM or Symphony. As of this date, all provider demographic change requests, including rosters, will be rejected if submitted through any format/channel other than Availity PDM or Symphony. Again, if preferred, providers may continue to utilize the Provider Enrollment application in Availity Essentials to submit requests to add new practitioners under existing groups. How to access the Availity PDM applicationLog onto Availity.com and select My Providers > Provider Data Management to begin the attestation process. If submitting a roster, find the TIN/business name for which you want to verify and update information. Before you select the TIN/business name, select the three-bar menu option on the right side of the window, and select Upload Rosters (see screen shot below) and follow the prompts.  Availity administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. Training is available:- Availity PDM application specific training: (Availity account is required for accessing these training options. If not registered yet, see end of article for registration details.)
- Learn about and attend one of our live webinars by visiting here. (Note: You must log into Availity first. Then, select the link.)
- View the Availity PDM quick start guide here. (Note: You must log into Availity first. Then, select the link.)
Not registered for Availity yet?If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for your providers to register or to use any of our digital applications. Start by logging into Availity.com and selecting the Register icon at the top of the home screen, or you can use this link to access the registration page. If you have questions regarding registration, reach out to Availity Client Services at 800-AVAILITY. Start using Availity PDM today to improve your provider data management experience. ** Exclusions: - Behavioral Health providers assigned to Carelon Behavioral Health, Inc.* will continue to follow the process for demographic requests and/or roster submissions, as outlined by Carelon Behavioral Health.
*** If any roster data updates require credentialing, your submission will be routed appropriately for further action. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. Symphony is an independent company providing administrative support services on behalf of the health plan Carelon Behavioral Health, Inc. is an independent company providing utilization management services on behalf of the health plan. CABC-CDCR-036148-23-CPN34756 Find Care, the doctor finder and transparency tool in the Anthem Blue Cross (Anthem) online directory, provides Anthem members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options, such as sorting providers based on distance, alphabetical order, and provider name. Beginning in the second quarter of 2024 or later, an additional sorting option will be available for our Medicare Advantage members to search by provider performance called Personalized Match Phase 1. This sorting option is based on provider efficiency and quality outcomes, alongside member search radius. Providers with the highest overall ranking within the member’s search radius will be displayed first. Members will continue to have the ability to sort based on distance, alphabetical order, and provider name: - You may review a copy of the Personalized Match Phase 1 methodology that has been posted on Availity* – our secure Web-based provider tool – using the following navigation: Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Phase 1 Methodology.pdf.
- If you have general questions regarding this new sorting option, please submit an inquiry via the web at Availity.
- If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.
Anthem has expanded the scope of Personalized Match Phase 1 to include selected specialty providers and will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. * Availity, LLC is an independent company providing administrative support services on behalf ofthe health plan. CABC-CR-032108-23-CPN27574 We are committed to a future of shared success and therefore we are excited to announce improvements to Secure Messaging when checking claim status or when reaching out about a resolution to a previous inquiry. What’s new?In mid-October the process for Secure Messaging will change: - Through Claims Status:
- When you select Secure Messaging from the Claims Status application, the screens will be updated, creating a better navigation and accessibility experience.
- Through Payer Spaces:
- The process for submitting your secure message will stay the same through Payer Spaces. However, you will no longer use the Resources tab link to access your replies.
- You will send secure messages and receive your replies in one single location through Payer Spaces:
- Access Secure Messaging through the Payer Spaces under Applications tab.
As a reminder, to find your claims status fast, use the self-service Claim Status application on Availity.com.* Recent enhancements make it even easier and faster to get the information you are looking for. Access Claims Status from the Claims & Payments tab. For questions, contact your Provider Relationship Management representative or use Chat with Payer also available through Payer Spaces. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. CABC-CDCRCM-035674-23-CPN35463 Fifty-three million Americans (more than one in five) are family caregivers. According to a new study, Caregiving in the U.S. 2020, caregivers face health challenges of their own. Nearly a quarter of caregivers find it hard to take care of their own health and say that caregiving has made their own health worse. Now, helpforcancercaregivers.org is here to help caregivers care for themselves. This interactive website, available 24/7, provides the information and resources that caregivers need to care for their own health and well-being. The website walks users through a brief survey and then provides a personalized Self-Care Guide to help them improve their health. Studies show that family caregivers suffer from poorer physical health than those who do not have additional caregiving responsibilities. Studies have also found that: - Caregivers show higher levels of depression.
- Caregivers suffer from high levels of stress and frustration — which can lead to burnout.
- Stressful caregiving situations may lead to harmful behaviors, such as abusing drugs or alcohol.
- Caregivers have an increased risk of heart disease.
- Caregivers have lower levels of self-care.
- Chronic diseases of caregivers are often more difficult to manage.
- Caregivers have an increased risk of sickness and premature death.
Evidence has also shown that education and intervention reduce caregiver strain, uncertainty, and helplessness and that information helps normalize the caregiver experience and enhances a sense of control. Your patients can access Help for Cancer Caregivers at helpforcancercaregivers.org. CABC-CM-036947-23-CPN36922 As a contracted provider for Special Needs Plan (SNP) from Anthem Blue Cross (Anthem), you are required to participate in an annual training on Model of Care for Anthem. This training includes a detailed overview of SNPs and program information — highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Training for SNP product for Anthem is self-paced and available at availity.com.* The training must be completed by December 31, 2023. How to access the Custom Learning Center on the Availity website:- Log in to Availity website at availity.com.
- At the top of Availity website, select Payer Spaces and select the appropriate payer.
- On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
- In the Custom Learning Center, select Required Training.
- Select Special Needs Plan and Model of Care Overview.
- Select Enroll.
- Select Start.
- Once the course is completed, select Begin Attestation and complete.
Not registered for Availity Essentials?Have your organization’s designated administrator register your organization for the Availity website: - Visit availity.com to register.
- Select Register.
- Select your organization type.
- In the Registration wizard, follow the prompts to complete the registration for your organization.
Refer to these PDF documents: https://apps.availity.com/availity/Demos/Registration/index.htm for complete registration instructions. * Availity, LLC is an independent company providing administrative support services on behalf of the health plan. CABC-CR-022627-23, CPN22400, CABC-CR-039457-23-CPN39408 This forum has moved from the original date of September 27, 2023 to October 19, 2023.Register today for the youth mental health forum hosted by Anthem and Motivo* for Anthem providers on October 19, 2023 Thursday, October 19, 2023
3:30 to 5 p.m. Eastern time This important event will address the critical need to engage young people in leading their mental health. By deepening the discussion on youth mental health, we can do our part to foster a culture of understanding and support for youth and young adults. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve. Please join us to hear from a diverse panel of experienced professionals and young leaders as we explore the challenges experienced by today’s youth, amplify the experiences and ideas of young people, and equip attendees with practical tools and innovative approaches to create meaningful change. Each forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, address, and deconstruct bias, have difficult and productive conversations, learn about valuable resources, increase inclusion, advance equity in healthcare. Please register for this event by visiting this link * Motivo is an independent company providing a virtual forum on behalf of the health plan. CABC-CDCRCM-039375-23 OverviewWe’re committed to being actively involved with our care provider partners and going beyond the contract to create a real impact on the health of our communities. That’s why we offer care providers free continuing medical education (CME) sessions to learn best practices to overcoming barriers in achieving clinical quality goals and improved patient outcomes. Engagement Hub objectives:Learn strategies to help you and your care team improve your performance across a range of clinical areas.- Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
- Offer care providers a convenient way to earn CME credits at a time that works best for them.
- Each session in this series is approved for one American Academy of Family Physicians credit:
- Browse the listing of free CME webinars.
- Open the CME webinars in Google Chrome
CABC-CRCM-038420-23-CPN38131 Medical drug benefit Clinical Criteria updates On August 19, 2022, September 12, 2022, February 24, 2023, May 19, 2023, June 12, 2023, and July 11, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross (Anthem). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other providers in your practice and office staff. Note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Document number | Clinical Criteria title | New or revised | December 27, 2023 | *CC-0243 | Vyjuvek (beremagene geperpavec) | New | December 27, 2023 | *CC-0242 | Epkinly (epcoritamab-bysp) | New | December 27, 2023 | *CC-0241 | Elfabrio (pegunigalsidase alfa-iwxj) | New | December 27, 2023 | CC-0228 | Leqembi (lecanemab) | Revised | December 27, 2023 | *CC-0061 | Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications | Revised | December 27, 2023 | *CC-0015 | Infertility and HCG Agents | Revised | December 27, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised | December 27, 2023 | CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised | December 27, 2023 | *CC-0177 | Zilretta (triamcinolone acetonide extended-release) | Revised | December 27, 2023 | CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised | December 27, 2023 | CC-0032 | Botulinum Toxin | Revised | December 27, 2023 | *CC-0002 | Colony Stimulating Factor Agents | Revised | December 27, 2023 | *CC-0001 | Erythropoiesis Stimulating Agents | Revised | December 27, 2023 | *CC-0174 | Kesimpta (ofatumumab) | Revised | December 27, 2023 | *CC-0209 | Leqvio (inclisiran) | Revised | December 27, 2023 | *CC-0011 | Ocrevus (ocrelizumab) | Revised |
CABC-CD-036878-23-CPN36110 Medical drug benefit Clinical Criteria updates On August 19, 2022, September 12, 2022, November 18, 2022, February 24, 2023, May 19, 2023, June 12, 2023, and July 11, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross (Anthem). These policies were developed, revised, or reviewed to support clinical coding edits. Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below: - New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other providers in your practice and office staff. Note: - The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
- This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.
Effective date | Document number | Clinical Criteria title | New or revised | October 18, 2023 | *CC-0243 | Vyjuvek (beremagene geperpavec) | New | October 18, 2023 | *CC-0242 | Epkinly (epcoritamab-bysp) | New | October 18, 2023 | *CC-0241 | Elfabrio (pegunigalsidase alfa-iwxj) | New | October 18, 2023 | CC-0228 | Leqembi (lecanemab) | Revised | October 18, 2023 | *CC-0061 | Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications | Revised | October 18, 2023 | *CC-0015 | Infertility and HCG Agents | Revised | October 18, 2023 | *CC-0062 | Tumor Necrosis Factor Antagonists | Revised | October 18, 2023 | CC-0151 | Yescarta (axicabtagene ciloleucel) | Revised | October 18, 2023 | *CC-0177 | Zilretta (triamcinolone acetonide extended-release) | Revised | October 18, 2023 | CC-0149 | Select Clotting Agents for Bleeding Disorders | Revised | October 18, 2023 | CC-0032 | Botulinum Toxin | Revised | October 18, 2023 | *CC-0002 | Colony Stimulating Factor Agents | Revised | October 18, 2023 | *CC-0001 | Erythropoiesis Stimulating Agents | Revised | October 18, 2023 | *CC-0174 | Kesimpta (ofatumumab) | Revised | October 18, 2023 | *CC-0209 | Leqvio (inclisiran) | Revised | October 18, 2023 | *CC-0011 | Ocrevus (ocrelizumab) | Revised | October 18, 2023 | *CC-0005 | Hyaluronan Injections - Medicare Only | Revised |
CABC-CR-036933-23-CPN36113 New Reimbursement Policy
Genetic Tests: Once per Lifetime
(Policy G-23002, effective 01/01/2024) Beginning with dates of service on or after January 1, 2024, Anthem Blue Cross (Anthem) will implement a new reimbursement policy titled Genetic Tests: Once per Lifetime. This policy identifies specific genetic tests allowed once in a member’s lifetime. During the member’s lifetime, the germline genotype will not change. However, the interpretation of the gene sequence may change due to recategorization of variants, or other factors. Repeat sequencing is not required for future interpretation of germline genotype, or re-analysis of previously sequenced data. The Related Coding section includes a Once per Lifetime Genetic Test coding list, which describes the genetic procedures that are limited to once per lifetime sequencing. Reinterpretation of the original results are not separately reimbursable. For additional information, please review the Genetic Tests: Once per Lifetime reimbursement policy at https://www.anthem.com/ca/provider/medicare-advantage. CABC-CR-033752-23-CPN29184 Expanded specialty pharmacy precertification list Effective for dates of service on and after January 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process. 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. HCPCS or CPT® codes | Medicare Part B drugs | J3490, J3590 | Elfabrio (pegunigalsidase alfa-iwxj) | C9399, J3490, J3590, J9999 | Epkinly (epcoritamab-bysp) | J3490, J3590 | Qalsody (tofersen) | J3490, J3590 | Vyjuvek (beremagene geperpavec) | J9999 | Zynyz (retifanlimab-dlwr) |
CABC-CR-037825-23-CPN37401 Anthem Blue Cross expands specialty pharmacy precertification list The previous effective date was previously listed in error as October 1, 2023, this correct effective date is December 1, 2023 Effective for dates of service on and after December 1, 2023, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process. 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. HCPCS or CPT® codes | Medicare Part B drugs | J9029 | Adstiladrin (nadofaragene firadenovec-vncg) | C9399, J7199 | Altuviiio (antihemophilic factor (recombinant) | C9399, J3490 | Lamzede (velmanase alfa-tycv) | J9350 | Lunsumio (mosunetuzumab-axgb) | J1440 | Rebyota (fecal microbiota, live – jslm) | J2502 | Signifor LAR (pasireotide) | C9151, C9399, J3490 | Syfovre (pegcetacoplan) | J9056 | Vivimusta (bendamustine) |
CABC-CR-023551-23-CPN23416 Effective December 1, 2023, the following medication codes will require prior authorization. Please note, inclusion of a national drug code on your medical claim is necessary for claims processing. Visit the Clinical Criteria website to search for the following Clinical Criteria: Clinical Criteria | HCPCS or CPT® code(s) | Drug name | CC-0072 | Q5129 | Vegzelma (bevacizumab-adcd) | CC-0107 | Q5129 | Vegzelma (bevacizumab-adcd) |
What if I need assistance?If you have questions about this communication or need assistance with any other item, contact your local Provider Relationship Management representative or call one of our Medi-Cal Customer Care Centers at 800-407-4627 (outside L.A. County) or 888-285-7801 (inside L.A. County). Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity. CABC-CD-026964-23-CPN25795 Managing illness can be a daunting task for our members. It is not always easy to understand test results, know how to obtain essential resources for treatment, or know who to contact with questions and concerns. Anthem Blue Cross offers a Complex Case Management program to help make healthcare easier and less overwhelming for our members. Our care managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members and their caregivers to stay connected with their care team and follow their treatment plan. Care managers educate and empower our members to participate in their own care. The goal is to help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare. Care managers also support members and their caregivers with transitions between care settings. Members or their caregivers can request Case Management by calling the Member Services number located on the back of their ID card. Physicians can refer their patients by submitting a Case Management Referral Form via fax or email. Have questions about case management?Call one of our Medi-Cal Customer Care Centers Monday through Friday, from 7 a.m. to 7 p.m., at 800-407-4627 (TTY 711) (outside L.A. County) or 888-285-7801 (TTY 711) (inside L.A. County). We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities. CABC-CD-036407-23-SRS36407 Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward care providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://providers.anthem.com/ca > Resources > Medical Policies and Clinical UM Guidelines. You can request a free copy of our UM criteria from our Medical Management department. Care providers can discuss a UM denial decision with a physician reviewer by calling us toll free at 888-831-2246, option 4. To access UM criteria online, go to https://providers.anthem.com/ca > Resources > Medical Policies and Clinical UM Guidelines. We are staffed with clinical professionals who work with you to coordinate our members’ care. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues. You can submit precertification requests 24/7 by: - Calling: 888-831-2246, option 3 (includes both inside and outside L.A. County).
- Faxing a Pre-Service Review form to 800-754-4708 (includes both inside and outside L.A. County).
Have questions about utilization management?Call one of our Medi-Cal Customer Care Centers Monday through Friday, from 7 a.m. to 7 p.m., at 800-407-4627 (TTY 711) (outside L.A. County) or 888-285-7801 (TTY 711) (inside L.A. County). We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities. CABC-CD-036672-23-SRS36407 In line with our commitment to participating practitioners and members, Anthem Blue Cross has a Members’ Rights and Responsibilities section located within the provider manual. The delivery of quality healthcare requires cooperation between patients, their care providers, and their healthcare benefit plans. One of the first steps is for patients and care providers to understand their rights and responsibilities. Review this section in your provider manual at https://providers.anthem.com/ca > Resources > Provider Manuals, Policies & Guidelines. Beyond simply signing a contract, care providers are part of a genuine collaboration aimed at improving the lives of real people. CABC-CD-036671-23-SRS36407 |