As you are aware, beginning on January 31, 2024, the California Health and Human Services (CalHHS) enacted the Health and Human Services Data Exchange Framework (DxF), a first-ever, statewide data sharing agreement, which aims to accelerate and expand the exchange of health information among health plans, health systems and provider organizations, government agencies, and social service programs.

In addition to submitting the required Health Equity and Quality Measure Set (HEQMS) with Anthem as described in our communication dated May 16, 2024 (Health Equity and Quality Measure Set reporting - Provider News (anthem.com), Anthem will now be able to share clinical and claims data for your patients. In this new data exchange framework, unless a member has opted out of sharing their claims and clinical records with the providers, they receive care and treatment from, we can now provide you with pertinent patient data when requested to guide patient care. The goal of DxF is to ensure providers have access to the best information possible to deliver high-quality care and optimize treatment for your patients.

We invite you to participate and access the information to:

• Treat the patient quickly and safely.
• Connect health care, behavioral health, and social services agencies to deliver an integrated model to manage the health of Californians.
• Assess how the public health system can better address the needs of all communities.

How to Participate in DxF?

Providers may register as described below:

1. Effective September 4, 2024, providers can register with Anthem using the Availity Payer Space (Availity Essentials) tile Data Exchange Framework following the below steps:

1. Provider selects the Data Exchange Framework payer space tile.
2. Provider lands on the registration form and fills in certain information and submits the form. Details on how to register can be found in https://rebrand.ly/4025117.
3. A submitted form will go into a pending state, and the Interoperability operations team will review the form and approve it.
4. Once approved, the provider can go back to the registration website for Anthem and request the credentials to connect with Anthem and request the member’s clinical and claims data.

The registration approval as described above may take two to four weeks.

We have included a General and Technical Frequently Asked Questions section to reference in this communication.

If there are any questions related to the onboarding, please reach out to: InteroperabilityWorkgroup@anthem.com.

Additional information on DxF is available in the Frequently Asked Questions below and at the following link: cdii.ca.gov/committees-and-advisory-groups/data-exchange-framework/

General and Technical Frequently Asked Questions

General FAQ

Note: Please check the Technical FAQ section for all the technical and specification-related questions.

1. Where can I find more information on the California Data Exchange Framework (DxF)?
   All the relevant information related to CA DxF can be located on the below state website: cdii.ca.gov/committees-and-advisory-groups/data-exchange-framework/
2. What data can providers expect to receive?
   Anthem will share the clinical and claims data for our members that are being cared for by our provider partners. Please check out the Technical FAQ section for technical specifications used in the data exchange.
3. Do I need to get consent from members to receive the data?
   No, providers do not need to receive consent from members to access their data through DxF. All member information, except sensitive data, is automatically available in the data set available to providers. As per 42 CFR Part 2 and California state health data sharing guidelines, member consent would be required if the request includes access to sensitive data (for example, HIV, reproductive, behavioral, and substance use disorder).
4. Can the member opt out of the Data Exchange Framework?
   Yes, if a member opts out or refuses to share the data, Anthem will not provide the data for that specific member.
5. Can I test with Anthem before connecting in production?
   Yes, the entities can register and test on our sandbox environment using the instructions on: https://totalview.healthos.elevancehealth.com/fhir/documentation#overview-section

Technical FAQ

1. Is there a technical document that highlights the capabilities supported by Anthem?
   Our APIs and technical documentation can be accessed here:
   https://totalview.healthos.elevancehealth.com/fhir/documentation#overview-section
2. What standards does Anthem use to exchange the data?
   Anthem supports the FHIR 4.0.1 standard to enable the data exchange. 
3. What technical specifications does Anthem use for the data exchange?

• Inbound Request Format: For an inbound request, please use the Hrex Technical Specification. The structure of the inbound request is also provided in the API/technical documentation provided above.
• Consent Specification: For receiving the consent, Anthem will be using the Hrex-Consent profile. Consent is enabled using the policy field in the consent profile. The structure of the consent is also provided in the API/technical documentation provided above.
• Clinical Data Payload FHIR Specification: A payload containing claims and clinical data as defined in USCore 5.0.1(USCDI V2) will be returned to the requester.

• The 2024 Provider Satisfaction Survey is an opportunity to share insights to improve service delivery.
• The survey focuses on patient access to care, referral and authorization processes, and interpreter services.
• Participation is crucial as it aids in providing better healthcare services to communities.

An exciting opportunity is coming — we are gearing up for our annual Provider Satisfaction Survey. This activity is an essential part of our compliance with the timely access regulations in California. But more than that, it’s a chance for us to hear directly from you.

We’re genuinely eager to hear your thoughts. Your insights play a vital role in helping us deliver better service to you and your patients.

Stay tuned and prepare to participate:

• We’re kicking off the survey in Fall 2024.
• We’ll be randomly choosing providers to receive the annual Provider Satisfaction Survey.
• Our vendor, Sutherland Healthcare Solutions, will deliver the survey by way of fax.
• Share your insights within five business days upon receipt of the survey.

This brief survey, which only takes a few minutes, covers satisfaction ratings on a scale of 1-4 across several areas. It’s designed to gauge your experience and satisfaction with your patients’ ability to access care within California’s required timelines. This includes:

• Your satisfaction with our referral and authorization process.
• Your patients’ access to urgent care, non-urgent specialty services, non-urgent ancillary diagnostic and treatment services, and non-urgent healthcare.
• Your patients’ access to our Language Assistance Program.
• Your satisfaction with our interpreter services.

Want to know more about our Timely Access Standards and Language Assistance Program? Check out the Provider Manual online at Provider Manuals | Anthem.com.

We look forward to your participation and response in the survey. Thank you in advance for your valuable time and insights.

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.

Self-Insured Schools of California (SISC) covers several school districts in Butte County that have been using AmeriBen as their third-party plan administrator. Effective January 1, 2025, SISC will be moving the districts covered in Butte County back to Anthem as the plan administrator. Anthem will be responsible for the administration of benefits, including claims payment, benefit inquiries, and appeals for services with dates of service on or after January 1, 2025. Be sure to obtain a new member ID card to verify benefits and eligibility and for correct and updated information on claim submission.

In connection with this change, SISC plans use American Specialty Health and Carelon Medical Benefits Management, Inc. Therefore, for the newly effective Butte County schools, please ensure that any required prior authorizations for services on or after January 1, 2025, are obtained from the appropriate vendors. Contact Anthem customer service at 800-825-5541 if you have any questions.

Anthem updates the California Facility and Professional Provider Manual annually to provide the current information needed for care providers to work with us.

The provider manual incorporates information for both professional and hospital/facility providers. The current update is available on the website and is effective January 1, 2025.

To view and download the California Facility and Professional Provider Manual and the BlueCard and Medicare Advantage manuals, visit https://www.anthem.com/ca/provider/. Select the Provider Manuals page, where you can select Policies, Guidelines & Manuals, then scroll to Provider Manual, and select Download the Manual.

Enhanced Care Management (ECM) is a benefit for eligible Medi-Cal Managed Care (Medi-Cal) members with complex health and/or social needs. ECM provides a whole-person approach to care that addresses the clinical and non-clinical circumstances of a high-need Medi-Cal member and is a collaborative approach to providing intensive and comprehensive care management services to individuals.

Populations of focus

ECM is designed to assist the following populations of focus:

• Individuals experiencing homelessness
• Individuals at risk for hospitalization or emergency services
• Individuals with serious mental health and substance issues
• Adults at risk for long-term care
• Adult nursing facility residents transitioning to the community
• Individuals transitioning from incarceration
• Children and youth enrolled in California Children’s Services (CCS)

More information:

• For information about becoming an ECM provider, email CalAIMReferrals@anthem.com.
• To refer a member for ECM services:
• Review the CalAIM Enhanced Care Management Member Referral Form.
• Call the Medi-Cal Customer Care Center at 800-407-4627 (TTY 711) or 888-825-7801 (TTY 711) for members in Los Angeles County.
• For additional resources, visit the Community Resources Link.

Learn more about Anthem programs on our website. Working together — we can make a difference!

• Members enrolled in Dual Eligible Special Needs Plan (D-SNP) can have free access to MyDirectives to manage advance directives digitally.
• Providers should discuss the importance of advance directives with patients during annual wellness visits.
• Members can access MyDirectives through their member website to easily create, upload, and share advance directives.

Anthem is providing all Medicare Advantage members enrolled in a Dual Eligible Special Needs Plan (D-SNP) with free access to MyDirectives, an advance directives creation tool.

What is MyDirectives?

MyDirectives is a digital tool that can be used to easily create, maintain, and share information on advance directives. It has an easy-to-use guide that takes members through a series of questions about their care preferences, the establishment of healthcare agents (medical powers of attorney), the sharing of information, and more.

Your role as a provider

To support the successful delivery of person-centered care, providers should speak to their patients about the value of establishing an advance directive during the annual wellness visit. The CMS recently revised its advance care planning (ACP) fact sheet, which includes important documentation and time requirements for this service.

How members access and use MyDirectives

To get started with the Advance Directives program, members can visit the Anthem member website and select the Benefits tab to access the link for the Advance Directives program. Selecting this link will take the member to the MyDirectives app, where they can create a free account or link an existing account:

• If they already have a written advance directive, MyDirectives allows members to upload copies of their current directives, making it easier to store and share when necessary.
• Members can create a contact list of individuals who can have access to their advance directives, including physicians. A member’s advance directive can also be retrieved through national data exchanges such as eHealth Exchange, Carequality, and CommonWell Health Alliance.

MyDirectives customer support:

• MyDirectives offers online customer support, which is the preferred contact method.
  Members can also call 888-884-3324 or email support@mydirectives.com.

We share a health vision with our care providers that means real change for consumers.

At a glance:

• Medi-Cal providers are required to conduct and document annual tobacco assessments.
• Prescribing FDA-approved quit aids and arranging counseling are part of the mandate.
• Implementation will be monitored by Anthem via health record and claims data reviews.

Primary care physicians (PCP) and their qualified staff are required to implement tobacco cessation interventions as outlined in the California Department of Health Care Services All Plan Letter 16-014 dated November 30, 2016. These interventions include:

• Conducting initial and annual assessments of all members, of any age, who use tobacco products or are exposed to tobacco smoke and documenting this information in the member’s medical record. Per the United States Preventive Services Task Force recommendations, this can be accomplished by instituting a tobacco user identification system by:
• Adding tobacco use as a vital sign in the chart or electronic health record, or by use of the ICD-10 codes in the medical record to record tobacco use. Refer to the Coding Guide for Tobacco. Use for codes that can be used.
• Prescribing FDA-approved tobacco cessation medications to nonpregnant adults of any age. Members enrolled in Medi-Cal will be covered for all FDA-approved tobacco cessation medications for adults who use tobacco products. This includes over the counter medications with a prescription from the provider.
• Referring tobacco users of any age to available individual, group, and telephone counseling. Anthem members qualify for four counseling sessions, each for a minimum of 10 minutes, for at least two separate quit attempts each year without prior authorization. Providers can:
  • Use the 5A’s model or other validated behavior change model when counseling members.
  • Refer a member to the EX Program here. The EX Program features:
    • A tailored quit plan based on their tobacco use type and stage in quitting.
    • Quit medication delivered right to the member’s home.
    • Live chat coaching with tobacco treatment experts, and more.
    • To learn more about the EX Program, a recording of the webinar can be found on the Provider Training Academy website.
• Refer a member to Kick It California at Kickitca.org or by calling 800-300-8086. Kick It California is available in various languages.
• California Center for Tobacco Cessation provides training and technical assistance to engage and build the capacity of organizations, clinicians, and community stakeholders to advocate for and put into effect tobacco-use assessments and cessation services within their communities and systems.
• Asking all pregnant women if they use tobacco or are exposed to tobacco smoke. If they smoke, offer at least one face-to-face counseling session per quit attempt and refer to a tobacco cessation quit line. Counseling services will be covered for 60 days post-delivery. Smoking cessation medications are not recommended during pregnancy.
• Providing education, including brief counseling, to school-age children and adolescents to prevent initiation of tobacco.

Anthem will monitor provider performance in implementing these tobacco cessation interventions through various processes comprised of medical record review, facility site review, and review of medical or pharmacy claims data.

If your office would like tobacco education materials or more information about the revised policy letter, please email the regional health plan office:

• Northern California: northproviderrelationsmedicaid@anthem.com
• Central California: centralproviderrelationsmedicaid@anthem.com
• Southern California: southproviderrelationsmedicaid@anthem.com

Summary: On June 10, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or 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.

Please 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.

Summary: On June 10, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for 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 need 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.

Please note:

• The Clinical Criteria listed below apply 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 have been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

• Encourage patients to get flu and COVID-19 vaccines for overall health safety.
• Use resources from LetsVaccinate.org, the CDC, and the American Lung Association to raise vaccination rates.
• Research validates that vaccinations prevent severe COVID-19 outcomes and significantly lower the risk of intensive care unit (ICU) admission and death from flu.

You care about your patients and want to keep them healthy. That’s why it’s important that you and your care team remind your patients to stay up to date with their flu and COVID-19 vaccines. Physician recommendation is the greatest motivator for people to vaccinate themselves and their family members. Customized patient outreach can influence your patients’ decisions to get recommended vaccines.

The tools below were developed by clinical experts to support you and your care team in educating your patients on the health benefits of vaccines:

• Let's Vaccinate provides ready-to-use resources and strategies to help your care team increase vaccination rates.
• CDC’s vaccine information for healthcare professionals offers evidence-based immunization strategies and best practices critical to implementing a successful vaccination program.
• Fend Off Flu is the American Lung Association’s campaign to increase flu knowledge and vaccination rates.

Research shows:

• In a 2021 study among adults hospitalized with flu, vaccinated patients had a 26% lower risk of ICU admission and a 31% lower risk of death from flu compared with those who were unvaccinated.*
• COVID-19 vaccinations remain the safest strategy for avoiding hospitalizations, long-term health outcomes, and death from COVID-19.*

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.

* cdc.gov/covid/vaccines/benefits.html?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/vaccines/vaccine-benefits.html.

Instead of submitting medical records for the HEDIS^® hybrid project, use our Remote EMR Access service. We offer providers the ability to grant access to your electronic medical record (EMR) system directly to pull the required documentation to aid your office in reaching compliance. Granting our team remote access to your EMR helps reduce the time and costs associated with medical record retrieval while improving efficiency and allowing your office to focus on patient care.

We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:

• We only access medical records of members pulled into the HEDIS sample using specific demographic data.
• We only retrieve the medical records that have claims evidence related to the HEDIS measures.
• We only access the least amount of information needed for a use, disclosure, or a request.
• We only save to file and do not physically print any PHI.

Getting started with Remote EMR Access is just one email away. Email Centralized_EMR_Team@anthem.com today.

Frequently asked questions

Q. How do you retrieve our medical records?
A. We access your EMR using a secure website and retrieve only the necessary documentation by printing to an electronic file we store internally on our secure network drives.

Q. Is this process secure?
A. Yes, we only use secure internal resources to access your EMR systems. All retrieved records are stored on our secure network drives.

Q. Why does the health plan need full access to the entire medical record?
A. There are several reasons we need to look at the entire medical record of a member:

• HEDIS measures can include up to a six-year lookback of member’s information.
• Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
• Compliant data may be documented or housed in a non-standard format, such as an in-office lab slip scanned into miscellaneous documents.

Q. What information do I need to submit to use your Remote EMR Access service?
A. Email Centralized_EMR_Team@anthem.com with the following information:

• Practice/facility demographic information (for example, address, national provider ID, or taxpayer identification numbers)
• EMR system information (for example, type of EMR system, required access forms, or access type)
• List of current providers/locations or a website for accessing this list