Anthem Blue Cross (Anthem) continues to look for ways to improve our processes and align with industry standards. With that in mind, it is also our goal to help providers receive their Anthem payments quickly and efficiently. Timely receipt of medical claims for your patients, our members, helps our chronic condition care management programs work most effectively, and also plays a crucial role in our ability to share information to help you coordinate patient care. In an effort to simplify processes, improve efficiencies, and better support coordination of care, we are changing all professional agreements to adopt a common time frame for the submission of claims to us. Notification was sent on June 21, 2019, to providers of applicable networks and contracts. 

Effective for all claims received by Anthem on or after October 1, 2019, all impacted contracts will require the submission of all professional claims within ninety (90) days of the date of service.  This means claims submitted on or after October 1, 2019 will be subject to a ninety (90) day timely filing requirement, and Anthem will refuse payment if submitted more than ninety (90) days after the date of service¹.

If you have any questions, email our Network Relations staff at CAContractSupport@anthem.com.

¹If Plan is the secondary payor, the ninety (90) day period will not begin until Provider receives notification of primary payor’s responsibility.

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

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

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

Provider News is our web tool for sharing vital information with you. It features short topic summaries and links that let you dig deeper into timely critical business information:

• Important website updates
• System changes
• Fee Schedules
• Medical policy updates
• Claims and billing updates

……and much more                                                                                                                          Registration is fast and easy. There is no limit to the number of subscribers who can register for Provider News (formerly Network eUPDATE), so you can submit as many e-mail addresses as you like.

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

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

The new online form can be found on www.anthem.com/ca/provider/ > Find Resources for California >  Answers@Anthem tab>Provider Forms bullet>Provider Change Forms> Provider Maintenance Form.  In addition, the Provider Maintenance Form can be found on the Availity Web Portal by selecting California> Payer Spaces-Anthem Blue Cross> Resources tab >Provider Maintenance Form.

Important information about updating your practice profile:

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

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

It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137), which went into effect on July 1, 2016, requires that Anthem Blue Cross (Anthem) provide our members accurate and up-to-date provider directory data. As a result, Anthem will be conducting ongoing outreaches to all practices to confirm the information we have on file is accurate. Without verification from you that our Provider Directory information is accurate, we will be required to remove your practice from the directories we make available to our members. We appreciate your attention to this matter.

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

Find Resources for California. From the Answers@Anthem page, select the link titled Provider Education Seminars and Webinars link.

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

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

As a reminder, the Workers’ Compensation Physicians Acknowledgments is required by California Code of Regulations §9767.5.1, “Medical Provider Networks” (MPN). The “MPN applicant shall obtain from each physician participating in the MPN a written acknowledgment in which the physician affirmatively elects to be a member of the MPN.”

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

Availity>Payer Spaces>Anthem Blue Cross>Resources>MPN Provider Affirmation Portal

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

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

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

• It’s easy, it’s free!
• No advance notice required
• All languages

For members whose primary language isn’t English, Anthem offers free language assistance services through interpreters. Members can call the Anthem Member Services number on their member’s ID card (TTY/TDD: 711) during regular business hours. After regular business hours, telephonic interpreter services are available through the 24/7 NurseLine. If you would like to access an interpreter on behalf of your member, please contact 1-800-677-6669. 

Please remember, in accordance with the California Language Assistance Program, you must notify Anthem members of the availability of the health plan interpreter services. You must also document a member’s refusal of any needed interpreter services in his or her patient chart.  Make sure to let your patients know that Anthem’s Customer Service Representatives are available to help coordinate appointment scheduling through the interpreter services.  Anthem does not delegate the provision of any Language Assistance services, below is what you can expect when accessing language services:

Telephone Interpreters

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

Face-to-Face Interpreters Including Sign Language

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

Written materials are translated upon request

• Materials who are Covered Individual-specific, for example, denial, delay, or claims letters are sent in English with the offer of translation when requested.
• Requested translated materials are sent to the Covered Individual no later than 21 days from the request date.
• Physicians and other health care professionals should advise their patients to contact Anthem Blue Cross by calling 1-888-254-2721 to request translated materials.
• Physicians and other health care professionals can call Anthem Blue Cross at 1-800-677-6669 to request translation on the Covered Individual’s behalf. Urgent requests are handled within one business day and non-urgent requests are handled within two business days. A copy of the document is required in order to complete the translation request. 

Anthem Blue Cross (Anthem) is working to deliver a new digital ecosystem that better supports our members.  To that end, our new platform is designed to give our members a more personal, simplified experience.  Anthem is driving meaningful change through technology and Artificial Intelligence (AI) powered innovation to deliver an easier to use, more complete Web and mobile health care experience.

We’re excited to announce the launch of Sydney – our new mobile app that runs on intelligence – as part of our digital strategy. Launching September 1, 2019, the new app replaces Anthem Anywhere and provides the same services that members receive from Anthem Anywhere, plus we’ll phase in other features and new capabilities over time. In return, members will get a truly integrated mobile experience with even more personalized information to fit their unique needs. These changes will lead to a more personal experience, better engagement and improved health outcomes.

Beginning September 1, members enrolled in our commercial health benefit plans* (including those plans members purchase on or off the Health Insurance Marketplace) and Medicare health benefit plans will have with Sydney a personalized health assistant that connects questions to answers – and people to the right resources. It's all part of a more seamless digital experience, bringing together fully integrated benefit details, claims information, care finder tools, access to spending accounts and wellbeing programs.  Members can download Sydney at the app stores starting September 1. 

As part of our rollout efforts on September 1, Anthem will also launch – using a phased approach – a digital solution called My Family Health Record (MyFHR).  MyFHR offers several benefits for members and providers.  Members will be better able to manage their own health, address care gaps, and have the ability to download electronic medical records (EMR) from one or more providers. With MyFHR, members will also have the ability to share EMR information with family, caregivers, and providers.

Watch for information on future enhancements to Sydney and MyFHR in upcoming editions of Provider News. 

*Excludes Medicaid health benefit plans.

A key goal of Anthem Blue Cross’ (Anthem) provider transparency initiatives is to improve quality while managing health care costs. One of the ways this is done is by giving certain providers (“Payment Innovation Providers”) in Anthem’s various Payment Innovation Programs (e.g., Enhanced Personal Health Care, Bundled Payments, Medical Home programs, etc.) (the “Programs”) quality, utilization and/or cost information about the health care providers (“Referral Providers”) to whom the Payment Innovation Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in their getting more referrals from Payment Innovation Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

Providing this type of data, including comparative cost information, to Payment Innovation Providers helps them make more informed decisions about managing health care 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 Payment Innovation Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local Network Relations Representative. 

Beginning December 1, 2019, prior authorization (PA) requirements will change some codes covered by Anthem Blue Cross (Anthem) for Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) members. Federal and state law, state contract language and CMS guidelines (including definitions and specific contract provisions and exclusions) take precedence over these rules and must be considered first when determining coverage. Anthem will deny claims that are noncompliant with the new rules.

PA requirements will be added to the following:

• T1019 — Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)
• C9740 — Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants
• E0953 — Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware
• E1031 — Rollabout chair, any and all types with castors 5 inches or greater
• E1090 — High-strength lightweight wheelchair, detachable arms, desk or full-length,                    swing-away detachable footrests 
• E1130 — Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests 
• E1140 — Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests 
• E1260 — Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest 
• E1285 — Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest 
• E1290 — Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest
• E2207 — Wheelchair accessory, crutch and cane holder
• E2378 — Power wheelchair component, actuator, replacement only
• K0039 — Leg strap, H style

Not all PA requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com. Contracted and noncontracted providers who are unable to access the Availity Portal may call our Customer Care Center at 1‑855‑817‑5786 for PA requirements.

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Effective January 1, 2020, IngenioRx will become our new pharmacy benefit manager (PBM) and will start managing prescription coverage for your Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) individual and group retiree plan patients. IngenioRx PBM services will include handling your patients’ prescriptions for mail order and specialty pharmacy medications.

Transferring prescriptions

We will automatically transfer prescriptions to IngenioRx Home Delivery Pharmacy for patients currently using Express Scripts Mail Order Pharmacy. Members will receive instructions for initializing IngenioRx Home Delivery Pharmacy later this year. For patients receiving specialty drugs from Accredo, we will automatically transfer prescriptions to IngenioRx Specialty Pharmacy. Most patients will be able to fill their prescriptions at their same retail pharmacy outlet. If your patient’s pharmacy will not be available, we will notify your patient by letter and include a list of three alternative pharmacies near his or her home.

Prescriptions for controlled substances currently being filled at Express Scripts Mail Order Pharmacy or Accredo cannot be transferred to another pharmacy under federal law. Patients currently receiving these medications will need a new prescription sent to IngenioRx Home Delivery Pharmacy or IngenioRx Specialty Pharmacy.

You can confirm whether your patient has transitioned to IngenioRx through the Availity Portal. Your patient’s PBM information can be located in the Patient Information section of their patient profile as part of the eligibility and benefits inquiry.

If you have immediate questions, call the Customer Care Center at 1-855-817-5786.

IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross.

Effective January 1, 2020, Anthem Blue Cross (Anthem) has updated the Modifier 62: Co‑Surgeons reimbursement policy to expand the current policy’s language, adding that Anthem does not consider surgeons performing different procedures during the same surgical session as co-surgeons, and Modifier 62 is not required.

Assistant surgeon and/or multiple procedures rules and fee reductions apply if a co-surgeon acts as an assistant in performing additional procedure(s) during the same surgical session.

Please note that assistant surgeon rules do not apply to procedures appropriately billed with Modifier 62.

Please visit https://mediproviders.anthem.com/ca to view the Modifier 62: Co-Surgeons reimbursement policy for additional information regarding percentages and reimbursement criteria.

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Check out additional information about the High-Risk OB Case Management Program.

On February 22, 2019, and March 14, 2019, the Pharmacy and Therapeutic (P&T) Committee approved changes to 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 website (https://mediproviders.anthem.com/ca), and the effective dates will be reflected in the Clinical Criteria Q1 web posting. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.

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

The upgrade to the 23rd edition of the MCG Care Guidelines for Anthem has changed from May 24, 2019, to November 5, 2019. In addition, Anthem has customized some of the MCG Criteria.

Customizations to the 23rd edition of the MCG Care Guidelines:

Effective November 5, 2019, the following customizations will be implemented:

• Left Atrial Appendage Closure, Percutaneous (W0157) — customized to refer to SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
• Spine, Scoliosis, Posterior Instrumentation, Pediatric (W0156) — customized to refer to Musculoskeletal Program Clinical Appropriateness Guidelines, Level of Care Guidelines and Preoperative Admission Guidelines

Effective November 1, 2019, customizations will be implemented for Chemotherapy and Inpatient & Surgical Care (W0162) for adult patients. The customizations provide specific criteria, guidance and/or examples for the following:

• Clinical indications for admission:
• Aggressive hydration needs that cannot be managed in an infusion center
• Prolonged marrow suppression
• Regimens that cannot be managed outpatient

Providers can view a summary of the 23rd edition of the MCG Care Guidelines customizations online by selecting Customizations to MCG Care Guidelines 23rd Edition (Publish date November 1, 2019).

For questions, contact our Customer Care Center:

• Medicaid:
  • o 1-800-407-4627 (Outside L.A. County)
  • o 1-888-285-7801 (Inside L.A. County)

• Medicare-Medicaid Plan: 1-855-817-5786

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Effective December 1, 2019, prior authorization (PA) requirements are changing for the codes listed below. The listed codes will require PA by Anthem Blue Cross for Medi-Cal Managed Care and L.A. Care members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements are being added to the following:

• Lower extremity prosthesis — shank foot system with vertical loading pylon (L5987)
• Gait trainer, pediatric size — anterior support, includes all accessories and components (E8002)
• Wheelchair, pediatric size — tilt-in-space, folding, adjustable, without seating system (E1234)
• Wheelchair, pediatric size — tilt-in-space, rigid, adjustable, without seating system (E1233)
• Transport chair, pediatric size (E1037)
• Multi-positional patient transfer system with integrated seat, operated by care giver (E1035)
• Wheelchair accessory — ventilator tray, gimbaled (E1030)
• Water circulating heat pad with pump (E0217)

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 through the Availity Portal (https://www.availity.com). Providers who are unable to access Availity may call us at 1-888-831-2246 for PA requirements.

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

• Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ
• Group Retiree members and National Access Plus
• Bill Medicare Part D for shingles or tetanus vaccination claims

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Effective January 1, 2020, IngenioRx will become our new pharmacy benefit manager (PBM) and will start managing prescription coverage for your Medicare Advantage individual and group retiree plan patients. IngenioRx PBM services will include handling your patients’ prescriptions for mail order and specialty pharmacy medications.

Transferring prescriptions

We will automatically transfer prescriptions to IngenioRx Home Delivery Pharmacy for patients currently using Express Scripts Mail Order Pharmacy. Members will receive instructions for initializing IngenioRx Home Delivery Pharmacy later this year. For patients receiving specialty drugs from Accredo, we will automatically transfer prescriptions to IngenioRx Specialty Pharmacy. Most patients will be able to fill their prescriptions at their same retail pharmacy outlet. If your patient’s pharmacy will not be available, we will notify your patient by letter and include a list of three alternative pharmacies near his or her home.

Prescriptions for controlled substances currently being filled at Express Scripts Mail Order Pharmacy or Accredo cannot be transferred to another pharmacy under federal law. Patients currently receiving these medications will need a new prescription sent to IngenioRx Home Delivery Pharmacy or IngenioRx Specialty Pharmacy.

You can confirm whether your patient has transitioned to IngenioRx through the Availity Portal.

Your patient’s PBM information can be located in the Patient Information section of their patient profile as part of the eligibility and benefits inquiry.

If you have immediate questions, you can contact the Provider Service phone number on the back of your patient’s ID card or call the number you normally use for questions.

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Effective November 5, 2019, customizations will be implemented for Chemotherapy and Inpatient & Surgical Care (W0162) for adult patients. The customizations provide specific criteria and guidance on the following:

• Clinical indications for admission; examples will also be added for:
• Aggressive hydration needs that cannot be managed in an infusion center.
• Prolonged marrow suppression.
• Regimens that cannot be managed outpatient; examples will also be added.

Providers can view a summary of the 23rd edition of the MCG Care Guidelines customizations online by selecting Customizations to MCG Care Guidelines 23rd Edition.

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On March 29, 2019, April 12, 2019 and May 1, 2019, the Pharmacy and Therapeutic (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 website (www.anthem.com/ca/medicareprovider), and the effective dates will be reflected in the Clinical Criteria Q2 update. Visit Clinical Criteria to search for specific policies.

For questions or additional information, use this email.

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As we prepare for the potential regulatory-proposed standards for electronic attachments, Anthem Blue Cross (Anthem) will be implementing X12 275 electronic attachment transactions (version 5010) for claims.

Standard electronic attachments will bring value to you by eliminating the need for mailing paper records and reducing processing time overall. 

Anthem and Availity will pilot electronic data interchange batch electronic attachments with previously selected providers. Both solicited and unsolicited attachments will be included in our pilots.

Attachment types

• Solicited attachments: The provider sends a claim and the payer determines there is not enough information to process the claim. The payer will then send the provider a request for additional information (currently done via letter). The provider can then send the solicited attachment transaction, with the documentation requested, to process the claim.
• Unsolicited attachment: When the provider knows that the payer requires additional information to process the claim, the provider will then send the X12 837 claim with the Paper Work Included segment tracking number. Then, the provider will send the X12 275 attachment transaction with the additional information and include the tracking number that was sent on the claim for matching.

What you can do

As we prepare for this change, you can help now by having conversations with your clearinghouse and/or electronic healthcare records vendor to determine their ability to set up the X12 275 attachment transaction capabilities.

In addition, you should be on the lookout for additional information and details about working with Anthem and Availity to send attachments via electronic batch.
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