We are making temporary changes to health plan benefits to provide relief for members who must leave their homes due to the impact of the current wildfire emergency.

• For members who live in Tehama, Trinity, and Shasta counties, these changes are in effect from August 10, 2021, through September 8, 2021.
• For members who live in Nevada and Placer counties, these changes are in effect from August 5, 2021, through September 3, 2021.
• For members who live in Siskiyou County, these changes are in effect from August 5, 2021, through September 3, 2021. (Note: This is an extension for Siskiyou County. Its original effective dates were July 16, 2021, through August 14, 2021.)
• For members who live in Alpine, Butte, Lassen, and Plumas counties, these changes are in effect from July 23, 2021, through August 21, 2021. (Note: This is an extension for Lassen and Plumas counties. Their original effective dates were July 16, 2021, through August 14, 2021.)

If members need assistance during this emergency, we encouraged our members to please call us at 833-285-4030, weekdays between 8 a.m. and 5 p.m. We can help with finding available doctors, refilling prescription drugs, or other health plan questions.

If an Anthem member needs health care right away

• Members can receive emergency or urgent care from any doctor or hospital, even if they are not in their plan’s network. We will pay the claims as if they are in Anthem plan’s network.
• If a member doctor’s office or healthcare facility is closed because of the fires or extreme hot weather, or if they are unable to travel there, the member can easily contact us for support at 833-285-4030. We can help them find another doctor.
• If the member is in a care management program and needs to reach them the member can call 833-285-4030.

If an Anthem member needs prescription refills

• If the member’s Anthem plan covers their prescription medications, the member can receive up to a 30-day emergency refill at any pharmacy now, even if it’s not in their plan’s network.
• If a member uses Anthem’s mail-order pharmacy and their address changed, members may call us at 833-285-4030 so we can make sure to send their medicine to the right place.

If an Anthem member’s medical equipment is lost or damaged

• We can help members replace their equipment (also called durable medical equipment or DME). Members can call us at 833-285-4030.

If an Anthem member’s eyeglasses or contact lenses are lost or damaged

• We can help members replace their eyeglasses or contact lenses. Members can call us at 833-285-4030.

If an Anthem member needs preapprovals or referrals

• Members have more time to request them. There won’t be any late fees. Members can call 833-285-4030 if they need an extension.

If a Provider needs to file a claim

• Providers will have more time to file claims. Call us at 833-285-4030 if you need an extension.

If an Anthem member needs mental health or other additional support

• Anthem’s Employee Assistance Program (EAP) offers mental health support as well as resources on our website to help with legal/financial concerns and dependent-care needs. Call the EAP crisis line 24/7 at 877-208-8240 or go to com and use the log in: EAP Can Help.

If an Anthem member is unable to pay their health plan premium due to the emergency

• If a member receives a bill directly from Anthem for their monthly insurance premium and are experiencing financial difficulties as a result of the emergency, members have more time to pay their bill. Members can call us at 833-285-4030 to discuss options.

These relaxed guidelines are in effect for members who reside in Alpine, Butte, Lassen, Nevada, Placer, Plumas, Tehama, Trinity, Shasta, and Siskiyou counties in California and who must temporarily leave their home due to the wildfire emergency.

The time period for updated support and care may change based on the conditions. Please check here for updates: https://www.anthem.com/ca/blog/member-news/help-for-members-impacted-by-wildfires-in-california/

These changes are for members with Anthem group health plans through their employers, Anthem individual and family plans, and Medi-Cal. These changes are not for Federal Employee Health Benefit Plan, Medicare Advantage, or Medicare Part D plans. Those plans have their own guidelines.

If you have immediate questions in regards to member care and this notification, please contact the Provider Service phone number on the back of your patient’s ID card.  If your office has closed due to the fires please contact your Anthem representative.

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Join us in a Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving STARs ratings.

Program objectives:

• Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas.
• Apply the knowledge you gain from the webinars to improve your organization’s quality and STARs ratings.

Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.

A mother has a sick child and like all good mothers, wants comfort and care. And a prescription for antibiotics. BMJ Journals published a study that rated how many patients with upper respiratory infections (URI) prior to consultation with their physician expected a prescription for antibiotics[i]:

Evidence-based data does not support the use of antibiotics in the treatment of the common cold because they do not improve symptoms or shorten the course of the illness.[ii] Instead of putting away the prescription pad, use this one.

Offered by the CDC’s Be Antibiotics Aware campaign, the “Relief for common symptoms of colds and cough” prescription pad provides an alternative to unnecessary antibiotics. Get it through the CDC website here.

Measure up: HEDIS® guidelines for URI/Pharyngitis

URI measures the percentage of episodes for members 3 months of age and older with a URI diagnosis that did not result in an antibiotic dispensing event.

Appropriate Testing for Pharyngitis (CWP) evaluates members 3 years of age and older where the member was diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.

Records and Billing Codes

URI: In the patient’s medical records, document results of all strep tests or refusal for testing. If antibiotics are prescribed for another condition, take care to associate the antibiotic with the appropriate diagnosis.

CWI: In the patient’s medical records, document results of all strep tests or refusal for testing. If antibiotics are prescribed for another condition, take care to associate the antibiotic with the appropriate diagnosis.

ⁱBMJ Journals. Medical management of acute upper respiratory infections in an urban primary care out of hours facility: cross-sectional study of patient presentation and expectations. https:/bmjopen.bmj.com/content/9/2/e025396

ⁱⁱNCBI. Upper Respiratory Tract Infection. https//www.ncbi.nlm.nih.gov/books/NBK532961/

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Instead of faxing multiple pages of medical records for HEDIS® studies, use Anthem Blue Cross’ (Anthem) remote EMR access service we offer to providers that allows us to access your EMR system directly to pull the documentation we need. Our remote EMR access service helps reduce the time and costs associated with medical record retrieval while improving efficiency and lessening the impact on your office staff.

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 evidence related to the HEDIS® measures.
• We only view face sheets when there are demographic discrepancies.
• We exclude data related to hospice, long-term care, inpatient, and palliative care.

Let us help you! Getting started with remote EMR access is just one click away.

Download and complete this registration form and email it to us at Centralized_EMR_Team@anthem.com.

To learn more about our remote EMR access service, view the frequently asked questions (FAQ) below.

Q. How do you retrieve our medical records?

A. We access your EMR using a secure portal and retrieve only the necessary documentation by printing to an electronic file we store internally, on our secure network drives.

Q. What information do I need to submit to use your remote EMR access service?

A. Complete the registration form that requests the following information:
1. Practice/facility demographic information(e.g., address, National Provider ID, taxpayer identification numbers, etc.)
2. EMR system information (e.g., type of EMR system, required access forms, access type - web based or VPN-to-VPN connection, special requirements needed for access, etc.)
3. List of current providers/locations or a website for accessing this list. Also, if applicable, a list of providers affiliated  with the group that are not in the EMR System.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Did you know the cost Impact of medication non-adherence is $528 billion from non-optimized medication therapy?¹ That’s equivalent to 16% of U.S. total health expenditures and contributes to 275,689 deaths per year.²

As a healthcare provider, you can motivate your patients to adhere to their medication regimens, which can contribute to improved outcomes and increased STARS performance.

We developed this video to offer best practices in boosting medication adherence among your patient population.

Use the 6 SIMPLE strategies below to help improve medication adherence among your patient population.

S - Simplify the regimen

• Limit the # of doses and frequency
• Encourage adherence aids such as a pill box
• Utilize generic prescriptions if clinically appropriate
• Implement real-time pharmacy benefit to understand patient cost-share at the point of care

I - Impart knowledge

• Assess patient’s knowledge of medication regimen
• Provide clear medication instructions (written and verbal)
• Patient-provider shared decision-making

M - Modify patient beliefs and behavior

• Ask open ended questions about impact of not taking medications
• Empower patients to self-manage their condition

P - Provide communication and trust

• Provide emotional support
• Allow adequate time for the patient to ask question

L - Leave the bias

• Understand patient’s health literacy and how it affects outcomes
• Develop a patient-centered communication style

E - Evaluate Adherence

• Utilize motivational interviewing to confirm adherence
• Review pharmacy refill records, Rx bottles, lab testing
• Identify barriers to adherence
• Determine interventions and follow-up
• When appropriate, prescribe 90 day fills for chronic conditions  

Watch this video to learn more best practices on helping improve medication adherence and your organization’s overall quality and STARS performance.

Reference:

1 Lloyd J et al. How much does medication nonadherence cost Medicare fee-for-service program? Med Care. 2019; 00:1-7.

2 Watannabe JE et al. Cost of prescription drug-related morbidity and mortality. Ann Pharmacother. 2018;52(9):829-837.DOI: 10.1177/060028018765159

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Adults 40–75 years of age with diabetes, who do or do not have clinical atherosclerotic cardiovascular disease (ASCVD), should be started on a statin for primary and secondary prevention of ASCVD regardless of lipid status.¹

Studies show that statin use reduces comorbidities and mortality from heart disease and non-adherence to statins may increase cardiovascular events and even death.²

Clinicians play a powerful role in ensuring their patients are adherent to their statin therapies. In fact, 90% of patients can be successfully adherent to statin therapy with a personalized approach.

CALL TO ACTION: We created this video to offer clinicians best practices in helping their patients remain adherent to their statin therapies.

The following 7 strategies can help increase adherence to statin therapy in your patients:

1. Initiate statin therapy for patients with diabetes or clinical ASCVD as appropriate
   • For diabetics without ASCVD, use MODERATE INTENSITY statin for primary prevention.²
   • For diabetics with ASCVD, use HIGH INTENSITY statin for secondary prevention.¹
   • Low Intensity statins are not recommended unless unable to tolerate moderate or high intensity.⁴

1. If a statin is not suitable for a patient, document exclusion criteria with the appropriate ICD-10 code
2. Educate patients about the long-term cardiovascular benefits of statin therapy and potential side effects 
3. Try a lower dose, different statin, or consider intermittent statin therapy if there were previous statin-associated side effects

5. Inform patients that a significant number of generic statin medications are available for $0 for a 90-day supply on most plans
6. Encourage patients to use their plan ID card to fill statin medications
7. Watch this video to learn best practices on helping improve statin therapy adherence and your organization’s overall quality and STARS performance.

References:

1 2013 ACC/AHA Prevention Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S1-S45, June 24, 2014. https://www.ahajournals.org/doi/pdf/10.1161/01.cir.0000437738.63853.7a

2 American College of Cardiology, The New 2017 American Diabetes Statement on Standards of Medical Care in Diabetes: Reducing Cardiovascular Risk in Patients with Diabetes, May 22, 2017. https://www.acc.org/latest-in-cardiology/articles/2017/05/22/11/00/new-2017-american-diabetes-statement-on-standards-of-medical-care-in-diabetes

3 CMS, 2019 Medicare-Medicaid Plan Performance Data Technical Notes. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination Office/FinancialAlignmentInitiative/Downloads/MMPPerformanceDataTechNotes.pdf

4. Cochrane Database Syst Rev. 2013: CD004816

The annual Provider Appointment Availability Survey (PAAS) is currently in progress.  It is very important that you review this information with your office staff, so they are prepared and understand each provider’s responsibility to participate in the surveys. 

Here is what you need to do:  Educate your staff on the standards for appointment scheduling and after-hours care.

Access Standards for Medical Professionals

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

For questions, please visit the Contact Us page on our provider website for up-to-date contact information.  Simply click on the link below and select the CA Contract Support - Provider Experience representative for your county. https://www.anthem.com/ca/provider/contact-us/

Access Standards for Behavioral Health and EAP Providers

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

Note:  The next available appointment date and time can be either in-person or by telehealth services.

Email any questions to Behavioral Health Provider Experience at CABHNetworkRelations@anthem.com.

WHY IS THIS IMPORTANT:   These are California state regulations.

Blue Cross of California dba Anthem Blue Cross and Anthem Blue Cross Life & Health Insurance Company (collectively, Anthem”) are committed to keeping you, our network partners, updated on our activities related to our compliance with the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) Timely Access to Non-Emergency Health Care Services Regulations (the “Timely Access Regulations”), respectively. 

To ensure compliance with these Timely Access Regulations, three (3) surveys are conducted annually.  These activities include, but are not limited to the following:

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

Each year we communicate Anthem’s Timely Access Regulations and Language Assistance Program to our commercial Medical and Behavioral Health networks.  The 2021 notice was mailed in February.  This information also includes access to non-emergency health care services within prescribed timeframes (also referred to as the “time elapsed standards” or “appointment wait times”). We appreciate that in certain circumstances time-elapsed requirements may not be met. The Timely Access Regulations have provided exceptions to the time-elapsed standards to address these situations:

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

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

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

24/7 NurseLine Gives Peace of Mind

Anthem members have access to our 24/7 NurseLine. A convenient way to ask questions or get advice from a registered nurse anytime. Locate the toll-free phone number on the back of the Member ID card and the wait time is not to exceed 30 minutes.  

Help is a Phone Call Away

Members and Providers have access to Anthem’s Member Services team for general questions or when having difficulty obtaining a referral to a provider. Call the toll-free phone number listed on the back of the member ID card for assistance. A representative may be reached within 10 minutes during normal business hours.

For patients (members) with DMHC regulated health plans

If you or your patients are unable to obtain a timely referral to an appropriate provider or for more information about the regulations, visit the DMHC website at www.dmhc.ca.gov/HealthCareinCalifornia/YourHealthCareRights/TimelyAccesstoCare.aspx or call toll-free 888-466-2219 for assistance.

For patients (members) with CDI regulated health plans

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

Language Assistance Program

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

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

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The National accounts 2022 pre-certification list has been published. Please note, providers should continue to verify member eligibility and benefits prior to rendering services.

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Please continue to check for important Cal MediConnect updates at https://providers.anthem.com/california-provider/communications/news-and-announcements for the latest Cal MediConnect information, including:

• MMP clinical criteria updates notification May 2021

The best way to ensure you're submitting everything needed for a prior authorization is to use the prior authorization form on the Forms page. By filling out the form completely and with as much information as possible, you can be sure we have the information to process your request timely.

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Please continue to check for important Medicare Advantage updates at https://www.anthem.com/ca/provider/medicare-advantage/ for the latest Medicare Advantage information, including:

• Medicare Advantage clinical criteria updates notification May 2021

The best way to ensure you're submitting everything needed for a prior authorization is to use the prior authorization form on the Forms page. By filling out the form completely and with as much information as possible, you can be sure we have the information to process your request timely.

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On November 1, 2021, Anthem Blue Cross (Anthem) prior authorization (PA) requirements will change for L8702 covered by Anthem. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added for the following code:

• L8702 — Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://www.anthem.com/ca/provider/news/archives/?category=medicareadvantage > Login or by accessing Availity. Once logged in to Availity (http://availity.com), select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at the number on the back of your patients’ Anthem ID card for assistance with PA requirements.

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Effective November 30, 2021, Anthem Blue Cross claims for members who leave against medical advice and are admitted to another acute care facility on the same day are considered transfers and will follow the criteria detailed in the policy.

For additional information, please review the DRG Inpatient Facility Transfers reimbursement policy at http://www.anthem.com/ca/medicareprovider under the Facilities dropdown.

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Please continue to check for important Medi-Cal Managed Care updates at https://providers.anthem.com/california-provider/communications/news-and-announcements for the latest Medi-Cal Managed Care information, including:

• Prior authorization requirement changes effective October 1, 2021 – UM AROW 1576

• Clinical criteria updates notification May 2021