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

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

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

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

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

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

Important information about updating your practice profile:

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

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

It is extremely important that we have accurate and up-to-date information about your practice in our directories. Senate Bill 137 (SB 137) 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.

Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before with our Provider News publication. 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, so you can submit as many email addresses as you like.

As a provider, we understand you are committed to providing the best care for our members, which may now include telehealth visits.  Telehealth visits are an acceptable form for seeing your patients, and assessing if they have risk adjustable conditions in support of the Anthem Blue Cross (Anthem) Commercial Risk Adjustment (CRA) prospective program. The prospective program is well under way for 2020, and focuses on member health assessments for patients with undocumented Hierarchical Condition Categories (HCC’s), in order to help close patients’ gaps in care.  We continue to provide updates regarding the prospective program to solicit your help getting patients in for a wellness visit before the calendar year ends, and we offer incentives to recognize your efforts (see details below.)

Inovalon Requests

Inovalon – an independent company that provides secure, clinical documentation services – helps us comply with the provisions of the Affordable Care Act (ACA) that require us to assess members’ relative health risk levels.  Please submit health assessments to Inovalon when completed and if you have questions, you can reach Inovalon directly at 1-877-448-8125.

Prospective Program ask of Providers:

Anthem network providers – usually PCPs – receive letters from Inovalon, requesting that they:

1. Schedule a comprehensive in person or telehealth visit  with patients identified by Inovalon to confirm or deny if previously coded or suspected diagnoses exists, and;
2. Submit a Health Assessment documenting the previously coded or suspected diagnoses (also called SOAP Notes - Subjective, Objective, Assessment and Plan).

Incentives offered for properly submitted Health Assessments:

• $100 for each Health Assessment properly submitted electronically via Inovalon’s ePASS® tool
• $50 for each Health Assessment properly submitted via fax

ePASS® is Training is available to ensure health assessment completion accuracy:

• Training Webinars every Wednesday - 12:00 - 1:00 PM PST
• Register by sending an email to ePASSProviderRelations@inovalon.com with your name, organization, contact information and the date of the webinar you wish to attend. Information will be provided on how to join the webinar.

Alternative Engagement

Inovalon’s ePASS® tool is our preferred method for submission. However, we offer alternate options to be flexible and meet your needs. If in 2019 your practice utilized these alternative options for prospective member outreach, we thank you for continuing to utilize these alternative forms of program participation in 2020.

For those providers not familiar with alternative options, they are listed here. Telehealth visits are also an acceptable form of a patient visit for these alternative engagement options.  Any questions can be directed to either your local Provider Representative, or the Anthem CRA Network Education Representative listed below.

• EPHC Providers using PCMS - Providers participating in our Enhanced Personal Health Care (EPHC) program can use member reports from our PCMS tool to schedule members for comprehensive visits. PCMS does have a link to take you directly to the Inovalon ePASS® tool where completed health assessments will result in a $100 incentive payment per submitted health assessment.
• List of Members to be scheduled - Anthem CRA provides member/patient reports for providers to schedule members for comprehensive visits. No health assessment needed. Not eligible for additional incentive because CRA will get the diagnosis for gap closure through claims submission.
• EPIC Patient Assessment Form (PAF) - Providers with EPIC as their electronic medical record (EMR) system can fax the EPIC PAF to Anthem CRA at 1-855-244-0926 with a coversheet indicating "see attached Anthem Progress Note,” which is eligible for a $50 incentive payment.
• Providers Existing Patient Assessment Form (PAF) - Utilizes providers’ existing EMR system and applicable PAF. Must be submitted to Anthem CRA at 1-855-244-0926 with coversheet indicating, "see attached Anthem Progress Note,’ which is eligible for a $50 incentive payment.

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

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

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

What’s new? 

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

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

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

First, you need to be assigned to the Patient360 Role which your Availity Administrators can locate within the Clinical Roles options.

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

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

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

• From Availity’s home page select Payer Spaces | Anthem payer tile| Applications | Custom Learning Center
• Select Resources from the menu located on the upper left corner of the page

(To use the catalog filter to narrow the results select Payer Spaces from the Category menu.)

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

Migrate Your EDI Transactions to Availity Today! We want to remind you, as the Availity migration continues full speed ahead, Anthem Blue Cross (Anthem) will guide you to make it an effortless transition without having to rush.

If you, your clearinghouse or vendor have already migrated over to Availity, thank you and you are a step ahead! If not, start the process today to make the transition before September 15, 2020.

Take Action Now! Availity setup is simple and at no cost for you!

Use this link to learn about Availity to get started today: 

All EDI transmissions currently sent or received today via the Anthem gateway are now available on the Availity EDI Gateway. 

• 837 Institutional and Professional
• 837 Dental
• 835 Electronic Remittance Advice
• 276/277 Claim Status
• 270/271 Eligibility Request
• 275 Medical Attachments
• 278 Prior Authorization/Referrals
• 278N Inpatient Admission and Discharge Notification

Below are the options you can choose from to exchange EDI transmissions with the Availity EDI Gateway:

• Transition your existing connection with Anthem and become a direct submitter with Availity.

• Use your existing Clearinghouse or Billing Company for your EDI transmissions. (Work with them to ensure connectivity to the Availity EDI Gateway).

• Use Direct Single Claim entry through the Availity Portal with the new attachment function

Share with your team what you learn

Enroll in one of Availity’s free courses and training demos at your convenience. Making the switch to Availity's EDI Gateway is easy if you have all the resources that you need.

Follow these steps to register with Availity

1. Log in and select Help & Training | Get Trained to open the Availity Learning Center in a new tab Search Catalog field and choose. It is your dedicated ALC account.
2. Search by keyword (Medical Attachments/Attachments) to find on-demand and live training options.
3. Click Enroll to enroll for a course and then go to your Dashboard to access it any time.

For questions, contact Availity Client Services at 1-800-Availity (1-800-282-4548) for assistance Monday - Friday 5 a.m. - 4 p.m. PT.

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways this is done is by giving certain providers (“Value Based Program Providers” also known as “Payment Innovation Providers”) in Anthem’s various Value Based Programs (e.g., Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, etc.) (the “Programs”) quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value Based Program 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 may result in their getting more referrals from Value Based Program 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 Value Based Program 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 Value Based Program 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 Market Representative or Care Consultant.

As an Anthem Blue Cross (“Anthem”) participating 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 on 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 Blue Shield Association. As indicated in the correspondence, BCBS Axis (formerly NCCT) cost data is updated twice annually; the most recent update completed in May 2020, and the next update scheduled for November 2020. Please look for more information in our provider newsletters posted to anthem.com/ca.

As a reminder, Anthem provider costs are now available in a secure section of the Availity provider portal. Authorized representatives of participating facilities and professional practices can login to Availity at www.availity.com, and register to view the costs for their facility or practice. Costs will be made available to our participating providers no less than 30 days before they become available to our members on anthem.com/ca in the transparency tools such as Anthem Care Comparison.

Should you wish to review the methodology, you may request a copy by sending an e-mail request to the Anthem California contract support team at CAContractSupport@anthem.com.

Should you desire to provide an Internet Web site link on Anthem’s website where this cost information will be displayed, which provides a response to the cost information being displayed, please provide us this link within thirty (30) days of receiving the cost information from us.

We are offering providers that are using Change Healthcare for revenue cycle management an opportunity to have a streamlined in-workflow solution native to Relay Assurance application.

Starting September 1, 2020, Anthem Blue Cross (Anthem) will launch the use of Change Healthcare’s Medical Attachment functionality for electronic communications as an additional digital option. This new functionality allows providers to upload medical records and itemized bill documents electronically instead of through traditional paper communications. This functionality can improve communications and increase transparency for medical record requests and will not otherwise impact the audit program.

Important facts regarding this change:

• This change only affects providers who use Assurance Reimbursement Management™ from Change Healthcare and have opted in to using the Attach Assist functionality.
• The new functionality is only for medical record requests for post pay claims for the Payment Integrity Quality Claims Review (Provider Audit) department only.
• There will be no duplicate requests (either paper or electronic). If you opt to use this method, paper requests for medical records will not be sent.
• In Assurance Reimbursement Management™, requests for additional documentation will be displayed to the user on the History tab of the claim. Assurance will be configured such that these requests drive workflow to ensure they are brought to the user’s attention.
  • The original letter, historically sent via paper, is accessible as a PDF electronic copy in the provider’s downloads folder in Assurance for review. The letter content is exactly the same as it was in paper format.
  • Each request letter (first, second and final attempt) will have a timeframe for responding to the request. After the timeframe has passed for that letter, you will not be able to respond to that letter. If you wish to upload medical records after the response time has expired, please refer to the Change Healthcare training referenced below.
  • Providers can respond to the request by uploading records in Assurance Attach Assist. The attachments are received in almost real time and are delivered electronically to the payer’s systems through secure means. Records can be accessed through a hyperlink in Assurance Attach Assist for the particular claim the record is associated.
• The following is out of scope or not impacted:
  • Vendor requests for medical records on behalf of the payer
  • Providers who do not use Assurance Reimbursement Management™ Attach Assist from Change Healthcare or have not configured Attach Assist within  Assurance Reimbursement Management™
  • The request timing of request letter and the verbiage in the request letter
  • The Program Integrity Special Investigations Unit post pay review is not included at this time.

Resources

Training is available on the Change Healthcare Connect Center.  

Can I start using the functionality earlier?

Yes, you can. If you chose to opt in earlier, please ensure you are configured within Assurance Reimbursement Management™. Reach out to your Provider Solutions contact or request early access via email at dl-Prod-ChangeHealthcare-Provider-Support@anthem.com .

For additional information, see our [Change Healthcare Medical Attachment Functionality FAQ].

Anthem Blue Cross (Anthem) now offers a full suite of options to assist with medical record submissions

To ease your administrative burden and recognizing your staff may be working remotely, we have increased the intake channels for required medical records supporting claim submissions.

Here are the options available to you

Leverage any of the following Availity-hosted channels for electronic claim attachment transmission:

• EDI Transaction: X12 275 Patient Information (version 5010)
  • Anthem supports the industry standard X12 275 transaction for electronic transmission of supporting claims documentation including medical records (pdf, jpeg, tif file types) Access your X12 275 companion guide for more details.
  • Electronic Integrated Submission – Submit the claim via EDI 837 batch file and supporting documentation via x12 275.
• Availity Secure Provider Portal Options–
  • Direct Data Entry (DDE) – The direct data entry claim application allows you to upload supporting documentation for a defined claim (unsolicited process).
  • Attachments-New tool - Submit solicited or unsolicited supporting documentation for your claims.

Attend an Availity hosted webinar to learn more about all capabilities

Start your transition today!

Start now to adopt these new processes and experience the many advantages to using an electronic option for claim attachment submission. You may find you are able to use these new processes to replace your more manual processes of submitting supporting documentation via fax or US Mail.

Advantages:

• Easy Submission of medical documentation to include but not limited to:
  • itemized bills
  • medical records
  • discharge summaries
• Less administrative burden - medical records submitted electronically save an average of 4 minutes per record for staff vs. faxing or mailing your records in
• Electronic acknowledgment with a transaction audit trail – confirm delivery/receipt
• Comprehensive history – view past medical record submissions by your organization
• Administrative Savings - reduce your mailing expense and/or fax related expenses

Want to learn more?

Register for an upcoming webinar session

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

September / October Dates

Anthem Blue Cross (Anthem) will begin publishing new indicators in our online provider directories to help members easily identify facilities and physicians designated as medication assisted treatment (MAT) providers for opioid use disorder.

These directory indicators fall into four categories related to MAT:

• Facility that provides MAT
• Physician who provides MAT
• Facility with a certified opioid treatment program
• Facility that provides counseling for opioid use disorders

We encourage facilities and individual providers who provide these services to update their demographic information so the above-mentioned MAT indicators can be added to our directories. To submit updated professional demographic information, please visit anthem.com and locate the Provider Maintenance form to submit changes to your information. For facility updates, please contact your provider network representative. Please contact Provider Services if you have any questions.

Anthem Blue Cross’ (Anthem) collaborative partnerships with oncology practices, which include sharing of relevant data, have helped drive improved outcomes. Our ‘Potentially Avoidable Admissions During Chemo’ model uses predictive analytics to equip oncologists with actionable, patient-level data to highlight those at greatest risk for complications during chemotherapy.

Since the launch of this model, early results indicate success, as observed by a 13% reduction in avoidable inpatient admissions.¹

Our oncology partners have recognized the value of this predictive modeling capability and routinely supplement their own information to proactively outreach to patients who may benefit from additional support during treatment.

Mary Scott, RN, from City of Hope says this data enables them make better decisions about patient care, “…best part [of this model] is having some data and some information and some specifics about patients that are deemed to be at risk and keeping them out of the hospital, which is a pretty critical part of our work. I think with the Anthem information we've been able to tackle that in a much better and more organized fashion because they provide us with a list of patients that are high risk, medium risk, and low risk for admission, people who are on chemotherapy, and these regimens can be pretty complicated, pretty toxic, and it helps us to make those better decisions for their care.”

Watch this video (use Chrome for viewing) to hear more about how our collaborative partnerships with oncology practices is leading to improved outcomes.

For more information on Anthem’s Cancer Care Solutions, email cancer.quality@anthem.com or contact your Anthem Oncology Provider Clinical Liaison.

Click here for more information about the Transition to AIM Specialty Health Rehabilitative Services Clinical Appropriateness Guidelines.

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

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

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

511673MUPENMUB

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

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

To view a guideline, visit https://www11.anthem.com/ca_search.html.

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• CG-DME-46 — Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
  • Expanded scope of document and revised Medically Necessary statement
• CG-DME-47 — Noninvasive Home Ventilator Therapy for Respiratory Failure
  • Revised Medically Necessary and Discussion/General Information sections
• CG-GENE-02 — Analysis of RAS Status
  • Clarified scope of document and revised the Not Medically Necessary and Coding sections
• CG-MED-64 — Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)
  • Revised the Medically Necessary statement
• CG-MED-68 — Therapeutic Apheresis
  • Revised Medically Necessary, Not Medically Necessary, Coding and Discussion/General Information sections
• 00011 — Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
  • Revised Investigational and Not Medically Necessary, Rationale and Coding sections
• 00004 — Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
  • Revised the Not Medically Necessary, Rationale and Coding sections

Medical Policies

On November 7, 2019, February 20, 2020 and May 14, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross (Anthem). 

Clinical UM Guidelines

On November 7, 2019, February 20, 2020 and May 14, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on November 28, 2019, April 23, 2020 and May 25, 2020.

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

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

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

The What Matters Most online training course for providers and office staff addresses gaps in care and offers approaches to communication with patients. The course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. The What Matters Most online training course can be accessed at www.patientexptraining.com.