This communication applies to the Commercial, Medicaid, and Medicare Advantage programs from Anthem Blue Cross (Anthem) in California.

 

We are making temporary changes to health plan benefits to provide relief for members who live in California and are impacted by the state’s current wildfire emergency. The changes are in effect for:

• Mariposa County from July 23 through August 21, 2022.
• Siskiyou County from July 30 through August 28, 2022.
• Emergency responders who have been activated by their state or local agency but who do not reside in the impacted area.

 

For assistance during this emergency, members can call 833-285-4030 Monday to Friday from
8 a.m. to 5 p.m. ET. We can help with finding available doctors, refilling prescription drugs, and other health plan questions.

 

Emergency or urgent care:

• 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 their plan’s network.
• If members doctor’s office or healthcare facility is closed because of the emergency, or if member is unable to travel there, they can call 833-285-4030. We can help members find another doctor.
• If members are in a care management program and need to reach the care management team, members can call 833-285-4030.

 

Prescription refills:

• If a member’s Anthem plan covers their prescription medications, they 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 the Anthem mail-order pharmacy and their address changed, they can call 833-285-4030 so we can make sure to send their medicine to the right place.  

 

Lost or damaged medical equipment:

We can help members replace their equipment (also called durable medical equipment [DME]) if they call 833-285-4030.

 

Lost or damages eyeglasses or contact lenses:

We can help members replace their eyeglasses or contact lenses if they call 833-285-4030.

Preapprovals or referrals:

Members have more time to request preapprovals or referrals without late fees. Members can call 833-285-4030 if they need an extension.

 

Filing a claim:

Members and their doctors have more time to file claims by calling 833-285-4030 to request an extension.

 

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 and financial concerns and dependent-care needs. You can call the EAP crisis line 24/7 at 877-208-8240 or go to anthemeap.com and use the log in EAP Can Help.

 

Health plan premiums:

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, they have more time to pay their bill. Members can call 833-285-4030 to discuss options.

 

The period for updated support and care may change based on the conditions. Please check back here for updates.

 

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

 

If members need additional support, please have them call 833-285-4030.

 

Additional resources

For additional support during the wildfires, check these state resources:

• California Department of Public Health Wildfire Information
• California Office of Emergency Services: Wildfire Recovery Health Information
• CAL FIRE: California Department of Forestry and Fire Protection
• California Office of Emergency Services: Resources for Californians impacted by wildfires

CABC-CDCRCM-005529-22

Keeping your provider directory information current is key for members and your healthcare partners to engage with you seamlessly. Please review your information regularly and let us know if any of your information we show in our online directory has changed.

 

To update your information, use our online Provider Maintenance Form. Online update options include:

• Add/change an address location
• Name change
• Tax ID changes
• Provider leaving a group or a single location
• Phone/fax number changes
• Closing a practice location

 

Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.

 

The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Help us keep our online provider directories current.

CABC-CM-004763-22-CPN4700

On June 14, 2022, the California Department of Managed Health Care (DMHC) issued All Plan Letter 22-017 to provide guidance on how commercial health plans are expected to comply with requirements to cover COVID-19 therapeutics.

 

This article is to inform network providers that at Anthem Blue Cross (Anthem), COVID-19 therapeutics are covered services when medically necessary to treat an enrollee.

 

Anthem follows guidance issued by the federal Department of Health and Human Services, the National Institutes of Health, and the CDC regarding COVID therapeutics that can be effective when administered within five to seven days of the onset of symptoms. Accordingly, Anthem considers access to COVID-19 therapeutics an urgently needed service. To ensure that enrollees for whom a COVID-19 therapeutic is medically necessary have access to these treatments and are given treatment as soon as possible, Anthem has waived any prior authorization requirements with respect to COVID-19 therapeutics.

 

Providers may visit Anthem’s Provider Communications site for updates on COVID-19.

 

More Information on COVID-19 therapeutics

The California Department of Public Health (CDPH) recently issued a COVID-19 Test-to-Treat Playbook. The playbook provides valuable information regarding COVID-19 therapeutics and outlines best practices for providers and others regarding prescribing, as well as provides resources for educating patients regarding therapeutics. You can find the playbook on the CDPH website.

 

CABC-CM-003633-22

The California Department of Managed Health Care has issued a number of All Plan Letters (APLs) to date addressing California legislation that went into effect in calendar years 2022 and 2021.  Anthem Blue Cross (Anthem) is summarizing certain key parts of the APLs.  To see the full APLs summarized below, please click here.

APL 22-017

In our August 2022 provider newsletter, we summarized APL 22‑017 which provided guidance on how commercial health plans are expected to comply with requirements to cover COVID-19 therapeutics.  Anthem’s notification was to inform network providers that at Anthem, COVID-19 therapeutics are covered services when medically necessary to treat an enrollee.

As we stated, Anthem follows guidance issued by the federal Department of Health and Human Services, the National Institutes of Health, and the CDC regarding COVID-19 therapeutics that can be effective when administered within five to seven days of the onset of symptoms. Accordingly, Anthem considers access to COVID-19 therapeutics an urgently needed service. To ensure that enrollees for whom a COVID-19 therapeutic is medically necessary have access to these treatments and are given a treatment as soon as possible, Anthem has waived any prior authorization requirements with respect to COVID-19 therapeutics.

APL-21-025 (consolidates multiple new laws)

AB 342, Colorectal Cancer Screening and Testing, codified in Health and Safety Code § 1367.668, requires commercial health plans, on or after January 1, 2022, to cover, at zero cost-sharing, a ectal cancer screening test assigned either a grade A or B by the United States Preventative Services Task Force (USPSTF). The required colonoscopy for a positive result on a test or procedure, other than a colonoscopy, that is a ectal cancer screening examination or laboratory test identified assigned either a grade A or B by the USPSTF shall also be provided without any cost-sharing.  AB 342 allows plans that have coverage for out-of-network benefits to impose cost- sharing requirements for the items or services described in this law that are delivered by an out-of-network provider.

AB 347, Step Therapy, codified in Health and Safety Code §§ 1367.206, 1367.241 and 1367.244 requires commercial health plans, on or after January 1, 2022, to expeditiously grant a request for a step therapy exception within the applicable time limits required by Section 1367.241 if a prescribing provider (i) determines use of the prescription drug required under step therapy is inconsistent with good professional practice for the provision of medically necessary covered services, while taking into consideration the enrollee’s needs, medical history, and professional judgment and (ii) submits justification and clinical documentation supporting the provider’s determination to the plan.  This law (a) requires a plan to notify the prescribing provider within 72 hours of receipt, or within 24 hours of receipt if exigent circumstances exist, if a request for prior authorization or a step therapy exception is incomplete or additional clinical material information is necessary to make a coverage determination is needed. Once the requested information is received, the applicable time period to approve or deny a prior authorization or step therapy exception request, or to appeal, shall begin to elapse, and (b) allows enrollees to appeal to the plan through existing grievance procedures pursuant to Section 1368 and provider to appeal a denial as permitted under the plan’s existing utilization management procedures. The external exception request review process shall apply to a denial of a prior authorization or step therapy exception request.  The law also requires a plan contract delegating utilization review or utilization management functions to include terms that require the contracted entity to comply with Sections 1367.206 and 1367.241.

 

AB 457, Telehealth, codified in Health and Safety Code §§ 1374.14 and 1374.141, requires (i) commercial health plans that contract with third-party corporate telehealth providers to notify enrollees of their right to access their medical records and that the record of any services provided to the enrollee through a third-party corporate telehealth provider shall be shared with their primary care provider unless the enrollee objects, (ii) requires a plan contract delegating responsibility of the provisions of this new law to require the entity with whom the plan is contracting to comply with Section 1374.141 and (iii) requires plans to submit information regarding third-party corporate telehealth providers in the annual timely access and annual network submission.

 

AB 1184, Confidential Communication of Medical Information codified in Civil Code §§ 56.05, 56.35 and 56.107, requires health plans, on or after July 1, 2022, to protect the confidentiality of a subscriber or enrollee’s medical information, to not require a protected individual to obtain the primary subscriber or other enrollee’s authorization to receive sensitive services or submit a claim for sensitive services if the protected individual has the right to consent to care.  Also requires plans to direct certain communications regarding a protected individual’s receipt of sensitive services directly to the protected individual receiving care and requires plans to notify subscribers and enrollees that they may request a confidential communication in the following methods: (1) upon initial enrollment and annually thereafter upon renewal, (2) in the EOC, and (3) on the plan’s website.  The law also prohibits plans from disclosing medical information relating to sensitive health services provided to a protected individual to the primary subscriber or any plan enrollees other than the protected individual receiving care, absent an express written authorization of the protected individual receiving care.

 

SB 221, Timely Access, found in Health & Safety Code §§ 1367.03 and 1367.031, codifies some of the timely access standards adopted in regulation by the DMHC.  It requires, on or after July 1, 2022, that nonurgent follow-up appointments with a nonphysician mental health care or substance use disorder provider be offered within 10 business days of the prior appointment for those undergoing course of treatment for an ongoing mental health or substance use disorder condition. This language does not limit coverage for nonurgent follow-up appointments with a nonphysician mental health care or substance use disorder provider to once every 10 business days.  This law adds references to mental health and substance use disorder providers to other provisions in Section 1367.03 and requires plans to ensure they have sufficient numbers of contracted providers to maintain compliance with timely access and other requirements in Section 1367.03. This law also adds a requirement that a plan that uses a tiered network demonstrate compliance with the standards established by Section 1367.03 based on providers available at the lowest cost-sharing tier.  Importantly, this law provides that the obligation of a plan to comply with Section 1367.03 shall not be waived if the plan delegates to its medical groups, independent practice associations, or other contracting entities any services or activities that the plan is required to perform.

 

SB 242, Reimbursement For PPE, codified in Health & Safety Code § 1374.192, requires commercial health plans, on or after January 1, 2022, (i) to reimburse contracting providers for business expenses to prevent the spread of diseases causing public health emergencies, requires plans to reimburse these business expenses for each individual patient encounter, limited to one encounter per day per enrollee for the duration of the public health emergency. (ii) prohibits plan delegation of the financial risk to a contracted provider for the cost of enrollee services provided under this new law unless the parties have negotiated and agreed upon a new contract provision pursuant to Section 1375.7 and (iii) applies to public health emergencies declared on or after January 1, 2022. 

 

SB 306, Sexually Transmitted Disease: Home Testing Kits Coverage, is codified in Health and Safety Code § 1367.34.  As our reminder sent to you via email in July 2022, Senate Bill (SB) 306 requires health plans to provide coverage for home test kits for sexually transmitted diseases (STD), including the test kit and any laboratory costs of processing the kit that are deemed medically necessary or appropriate. The kit must be ordered directly by a clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs at zero-dollar cost share to Anthem Blue Cross members.

 

For purposes of this bill, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.

 

SB 368, Deductibles and Out-of-Pocket Maximums, codified in Health and Safety Code § 1367.0061, (i) requires plans, on or after July 1, 2022, to monitor an enrollee’s accrual towards their annual deductible and annual out-of-pocket maximum (OOPM) (ii) requires a plan to provide an enrollee with their accrual balance toward their annual deductible and annual OOPM for every month in which benefits were used and until the annual balance equals the full deductible amount or the full OOPM amount. In addition, a plan shall establish and maintain a system that allows an enrollee to request their most up-to-date accrual balance toward their annual deductible or annual OOPM from their plan at any time. (iii) requires accrual updates to be mailed to enrollees until the enrollee has elected to opt out of mailed notices and elected to receive the accrual update electronically, or unless the enrollee has previously opted out of mailed notices. Plans must notify enrollees of their rights pursuant to this new law, including how to request information and how to opt out of mailed notices and elect to instead receive their accrual update electronically, and (iv) requires a plan contract delegating claims payment functions to comply with the requirements of this new law with plan oversight of the delegated functions.

 

SB 428, Adverse Childhood Experiences Screenings, codified in Health and Safety Code § 1367.34, requires a plan, on or after January 1, 2022, that provides coverage for pediatric services and preventive care to additionally include coverage for adverse childhood experiences (ACEs) screenings, and allows a plan to apply cost-sharing requirements as authorized by law.

 

SB 510, COVID; Testing and Vaccination, codified in Health & Safety Code §§ 1342.2 and 1342.3, requires plans to cover the following costs without cost-sharing, prior authorization, or utilization management regardless of whether the services are provided by an in-network or out-of-network provider, (i) costs associated with diagnostic and screening testing for COVID-19; and, (ii) costs associated with the item, service or immunization that is intended to prevent or mitigate COVID-19, (ii) requires plans to cover COVID-19 diagnostic and screening tests and immunizations without cost-sharing when delivered by an out-of-network provider until the federal public health emergency expires. All other requirements remain in effect after the federal public health emergency expires. (iii) requires plans to reimburse an in-network provider, to the extent a provider would have been entitled to receive cost-sharing for these services, the amount of that lost cost-sharing through a negotiated rate or an out-of- network provider in an amount that is reasonable as set forth in this new law, and (iv) prohibits plan delegation of the financial risk to a contracted provider for diagnostic and screening testing related to the public health emergency unless the parties have negotiated and agreed upon a new contract provision pursuant to Section 1375.7.

 

SB 535, Biomarker Testing Mandate, codified in Health and Safety Code § 1367.665, prohibits plans, on or after July 1, 2022, from requiring prior authorization for biomarker testing for an enrollee with advanced or metastatic stage 3 or 4 cancer or biomarker testing for cancer progression or recurrence in the enrollee with advanced or metastatic stage 3 or 4 cancer.  This law allows a plan to require prior authorization for biomarker-testing that is not for an FDA-approved therapy for advanced or metastatic stage 3 or 4 cancer.

CABC-CM-005730-22

Register today for the Exploring the Intersection of Race and Disability forum hosted by
Anthem Blue Cross (Anthem) and Motivo* for Anthem providers on September 21, 2022.

 

Anthem is committed to making healthcare simpler and reducing health disparities. We believe that continuing the discussion we started at our June 2022 event to deepen the conversation about the disability experience for people is critically important. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve.

 

Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem about the intersection of disability and race. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address, and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.

 

Wednesday, September 21, 2022

1 p.m. to 2:30 p.m. PT (4 p.m. to 5:30 p.m. ET)

 

Please register for this event by visiting this link.

 

* Motivo is an independent company providing a virtual forum on behalf of Anthem Blue Cross.

 
CABC-CM-005458-22

The Health Resources & Services Administration (HRSA) Women’s Preventive Services Guidelines recommend women receive at least one preventive care visit per year.

 

While many members may receive a standalone preventive care visit, well-women visits may also include prepregnancy, prenatal, postpartum, and interpregnancy visits. For members receiving prepregnancy, prenatal, postpartum, and/or interpregnancy care that is billed using a global maternity code (for example, CPT^® 59400, 59510, 59610, 59618) or antepartum/postpartum codes (for example, CPT 59425, 59426, 59430), it is appropriate to submit a claim for a wellness visit (for example, CPT 99385, 99386, 99387, 99395, 99396, 99397) when recommended preventive care has been rendered for a member who has not received a wellness visit in the last year. This will help ensure recognition that recommended preventive services have been provided for our members.

 

Please note, wellness evaluation and management (E/M) codes should not be billed on the same day as global maternity or antepartum/postpartum codes. Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 
CABC-CM-003953-22

As a reminder, when billing medical drug codes to Anthem Blue Cross, include these three components:

• National Drug Code (NDC) 
• Quantity
• Unit of measure

 

To prevent possible denial of the of the billed code, please ensure all three components are included in the claim.

 

CABC-CM-004458-22

Keeping you informed:

 

• The annual Provider Appointment Availability Surveys (PAAS) are currently in progress.  Review this information with your office staff so they are prepared and understand each provider’s responsibility to participate in the surveys.
• Each year, we communicate the Anthem Blue Cross (Anthem) Timely Access Regulations and Language Assistance Program to our commercial medical and behavioral health networks via an annual provider mailing. The 2022 mailing was completed in February.
• Effective July 1, 2022, Anthem implemented SB 221 — Timely Access Requirements for Non-Physician Mental Health/Substance Use Disorder Appointments.  For more details, review the Timely access regulations and language assistance program article in the March 2022 edition of Provider News.
• Effective January 1, 2023, SB 221 — A referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard.

 

Why is this important?

These are California state regulations.

 

Anthem is 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 (timely access regulations). 

 

To ensure compliance with these timely access regulations, three surveys are conducted annually. The surveys 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 2022 notice was mailed in February. This information also includes access to non-emergency healthcare 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 healthcare provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their 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 healthcare 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 California Department of Managed Health Care (DMHC) website at www.dmhc.ca.gov 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 Center for Diagnostic Imaging (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 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 help 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! If you have any questions, visit the Contact Us page on our provider website. 

 

Take a moment to review and share the following appointment wait times with your staff the access standards tables for medical professionals and behavioral health that follow. The clock starts when the request for the appointment is made.

 

Access standards for medical professionals

Type of care	Maximum wait time after appointment request
Non-urgent appointments for PCP	10 business days
Urgent care (that does not require prior authorization)	48 hours
Non-urgent appointments with specialist physicians	15 business days
Urgent care (that requires prior authorization)	96 hours
Non-urgent appointment for ancillary services (for diagnosis or treatment of injury, illness, or other health condition)	15 business days
After-hours care	Available 24 hours per day, 7 days per week. Member to reach a recorded message or live voice response providing emergency instructions; and for non-emergent (urgent) matters, a mechanism to reach a health professional and information as to when to expect a call back.
Emergency care: Anthem expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room. Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.	Members are directed to dial 911 or go to the nearest emergency room.
Member Services by telephone:  Access to Member Services to obtain information about how to access clinical care and how to resolve problems. (This is a plan responsibility and not a physician responsibility. This also applies to our behavioral health members.)	Reach a live person within 10 minutes during normal business hours (Plan standard: 45 seconds; Call abandonment rate < 5%). The Member NurseLine is available 24/7 and the wait time is not to exceed 30 minutes.

 

Access standards for behavioral health and employee assistance program providers

Type of care	Maximum wait time after appointment request
Routine office visit/non-urgent appointment	10 business days (Psychiatrists)*   10 business days (Non-physician mental healthcare/substance use disorder provider)   10 business days from the prior appointment for those undergoing a course of treatment (Non-physician mental healthcare/substance use disorder)   5 business days (employee assistance plan [EAP])
Non-life-threatening emergency care	6 hours Members are directed to 911 or the nearest emergency room.
Urgent care (that does not require prior authorization)	48 hours
Urgent care (that requires prior authorization)	96 hours
After-hours care	Available 24 hours/7 days. Member to reach a recorded message or live voice response providing emergency care instructions, and for non-emergent (urgent) matters, a mechanism to reach a behavioral health/EAP provider and information as to when to expect a call back.
Emergency care:  Anthem expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room.  Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.	Members are directed to dial 911 or go to the nearest emergency room.

 

* 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.
• Clinical advice may only be provided by appropriately qualified staff, a physician, physician assistant, nurse practitioner or registered nurse.

 

Questions

If you have any questions, contact your assigned Provider Experience associate, or visit the Contact Us page on our provider website. You can also email the Provider Experience team directly using the electronic form.

 

CABC-CM-004804-22

 

This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross (Anthem) in California.

 

Effective July 1, 2022, Anthem recognizes and accepts qualifying claims for acute Hospital in Home (HiH) services through the newly established revenue code 0161. We encourage hospitals or other entities that meet the HiH requirements to reach out to their Anthem contractor to get an appropriate participation agreement in place, which will ensure more streamlined processing of HiH claims. 

 

The new code enables hospitals to distinguish acute inpatient care in the home for qualifying patients. The code will follow the same guidelines and policies associated with any services performed in an inpatient setting, including but not limited to utilization management. Facilities must comply with all requests from Anthem for any information and data related to the HiH services and be an approved, active participant of the CMS Acute Hospital Care at Home Program for Medicare products. All services are subject to the Covered Individual Health Benefit Plan coverage and, if a covered benefit, the benefit will follow the inpatient hospital benefits that apply to services that are performed in a traditional hospital setting, which includes, but is not limited to, any applicable deductibles, copays, and coinsurance.

 

The following Anthem benefit plans are in scope for participation in HiH:

• Anthem Commercial
• Medicare Advantage (Individual and Group)
• Medicare Advantage Special Needs plans, including Dual-Eligible Special Needs (D-SNP)

 

The following Anthem plans are out of scope for participation in HiH:

• FEP
• Medicaid

 

Note:

• Be advised that while you may submit an electronic transaction to verify a Blue Plan member’s benefits and eligibility, Anthem suggests that you call the member’s Blue Plan to definitively determine whether the member has HiH benefits, since the electronic eligibility inquiry may not yield an answer specific to HiH eligibility. We suggest calling because if the member does not have this as a covered benefit, HiH services would then be the member’s financial responsibility.
• Covered individuals must express preference for and consent to treatment in the home setting for the HiH program and must be 18 years of age or older. This consent must be documented through a signed consent form. (Sample form available upon request.)
• Covered individuals may be admitted to the program from the emergency department (for a patient that needs the inpatient level of care) or transferred from the inpatient hospital setting.
• Facility shall not bill Anthem or the covered individual for any items or services provided by the facility in the home setting that typically would not be billed during an inpatient hospitalization.
• Notify Anthem immediately through the utilization management nurse assigned to the HiH case when:
  • An applicable member is admitted to the HiH program
  • A member in the program is transferred back to hospital inpatient care or has any other status change in their care plan
• As with other claims, participating facilities and/or providers may not bill the member for any denied HiH-related charges. Providers who disagree with the claim denial may request a review of the denial using the reconsideration and appeal process outlined in your Anthem Agreement and/or as outlined in the applicable Anthem provider manual.
• We will continue to update billing guidance as these programs evolve.

 

CABC-CRCM-003013-22-CPN2952

Summary of update

Effective October 1, 2022, Anthem Blue Cross (Anthem) and AIM Specialty Health_®* (AIM), a separate specialty benefits management company, will launch a new Back Pain Management Program for fully insured members, as further outlined below.

 

Who is AIM?

Anthem has an existing relationship with AIM in the administration of other programs. Anthem is excited to expand this relationship to include additional services. AIM works with leading insurers to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

 

What is the Back Pain Management Program?

In pursuit of the commitment to improve healthcare quality and costs, we have created a new voluntary Back Pain Management Program to help educate and support members navigate through their back pain journey to reduce risk of chronicity, minimize recurrences, and minimize complications.

 

The program will be utilizing predictive analytic models to identify members who are experiencing back pain or are at risk for complications related to back pain conditions. This early identification allows our program to target members who could experience an increase in back pain without the right education and support.

 

Our member engagement process includes:

• Predictive models for members likely to be referred for back surgery based on several risk factors.
• Risk stratification to ensure the appropriate level of support is provided.
• Targeted outreach to members through our digital engagement platform, email, and calls.
• Customized education and support of provider treatments based on member’s specific needs.
• Education and support of services such as behavioral health as appropriate.

 

Who is included in this new program?

All fully insured members currently participating in AIM and Anthem programs are included.

 

The following groups are excluded: Self-funded (ASO) groups, Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program^® (FEP). 

 

The AIM Back Pain Program microsite helps you learn more and access helpful information and tools such as program information and FAQs.

 

We value your participation in our network and look forward to working with you to help improve the health of our members.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross.

CABC-CM-005026-22

Keeping you informed:

 

• The annual Provider Appointment Availability Surveys (PAAS) are currently in progress.  Review this information with your office staff so they are prepared and understand each provider’s responsibility to participate in the surveys.
• Each year, we communicate the Anthem Blue Cross (Anthem) Timely Access Regulations and Language Assistance Program to our commercial medical and behavioral health networks via an annual provider mailing. The 2022 mailing was completed in February.
• Effective July 1, 2022, Anthem implemented SB 221 — Timely Access Requirements for Non-Physician Mental Health/Substance Use Disorder Appointments.  For more details, review the Timely access regulations and language assistance program article in the March 2022 edition of Provider News.
• Effective January 1, 2023, SB 221 — A referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard.

 

Why is this important?

These are California state regulations.

 

Anthem is 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 (timely access regulations). 

 

To ensure compliance with these timely access regulations, three surveys are conducted annually. The surveys 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 2022 notice was mailed in February. This information also includes access to non-emergency healthcare 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 healthcare provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their 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 healthcare 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 California Department of Managed Health Care (DMHC) website at www.dmhc.ca.gov 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 Center for Diagnostic Imaging (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 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 help 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! If you have any questions, visit the Contact Us page on our provider website. 

 

Take a moment to review and share the following appointment wait times with your staff the access standards tables for medical professionals and behavioral health that follow. The clock starts when the request for the appointment is made.

 

Access standards for medical professionals

Type of care	Maximum wait time after appointment request
Non-urgent appointments for PCP	10 business days
Urgent care (that does not require prior authorization)	48 hours
Non-urgent appointments with specialist physicians	15 business days
Urgent care (that requires prior authorization)	96 hours
Non-urgent appointment for ancillary services (for diagnosis or treatment of injury, illness, or other health condition)	15 business days
After-hours care	Available 24 hours per day, 7 days per week. Member to reach a recorded message or live voice response providing emergency instructions; and for non-emergent (urgent) matters, a mechanism to reach a health professional and information as to when to expect a call back.
Emergency care: Anthem expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room. Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.	Members are directed to dial 911 or go to the nearest emergency room.
Member Services by telephone:  Access to Member Services to obtain information about how to access clinical care and how to resolve problems. (This is a plan responsibility and not a physician responsibility. This also applies to our behavioral health members.)	Reach a live person within 10 minutes during normal business hours (Plan standard: 45 seconds; Call abandonment rate < 5%). The Member NurseLine is available 24/7 and the wait time is not to exceed 30 minutes.

Access standards for behavioral health and employee assistance program providers

Type of care	Maximum wait time after appointment request
Routine office visit/non-urgent appointment	10 business days (Psychiatrists)*   10 business days (Non-physician mental healthcare/substance use disorder provider)   10 business days from the prior appointment for those undergoing a course of treatment (Non-physician mental healthcare/substance use disorder)   5 business days (employee assistance plan [EAP])
Non-life-threatening emergency care	6 hours Members are directed to 911 or the nearest emergency room.
Urgent care (that does not require prior authorization)	48 hours
Urgent care (that requires prior authorization)	96 hours
After-hours care	Available 24 hours/7 days. Member to reach a recorded message or live voice response providing emergency care instructions, and for non-emergent (urgent) matters, a mechanism to reach a behavioral health/EAP provider and information as to when to expect a call back.
Emergency care:  Anthem expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room.  Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.	Members are directed to dial 911 or go to the nearest emergency room.

* 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.
• Clinical advice may only be provided by appropriately qualified staff, a physician, physician assistant, nurse practitioner or registered nurse.

 

Questions

If you have any questions, contact your assigned Provider Experience associate, or visit the Contact Us page on our provider website. You can also email the Provider Experience team directly using the electronic form.

 

CABC-CM-004804-22

A number of chronic diseases, including heart disease, cancer, and type 2 diabetes, are linked to alcohol use disorders (AUD).

 

Heart disease:¹

 

Low alcohol consumption is associated with a reduced risk for cardiovascular disease (CVD), but higher amounts and binge drinking lead to a higher risk of CVD. Binge drinking and chronic heavy alcohol consumption is associated with a higher risk of hypertension. Alcohol leads to buildup of plaque in the arteries, disruptions in arterial function, oxidative stress throughout the body, and imbalances in hormones that control blood pressure regulation.

 

Heavy alcohol use is also associated with increased risk for coronary heart disease, stroke, peripheral arterial disease, and cardiomyopathy. It is suspected that the increase in blood pressure from heavy alcohol use plays a part in these increased risks. Alcohol also appears to contribute to arthrosclerosis and chronic inflammation, which follow the pathophysiologic process behind most CVD.

 

See Piano, 2017 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513687/) for a more

thorough examination of the increased risk of CVD from excess alcohol use; mechanisms of action; biomarkers; and considerations of genetic, socioeconomic, and racial factors.

Cancer:

 

An estimated 3.5% of cancer deaths in the United States are alcohol related. Alcohol is a known human carcinogen.² When consumed, ethanol breaks down into acetaldehyde, which is carcinogenic.

 

Alcohol consumption is linked to seven types of cancers.³ It raises the risk for cancer of the month, larynx, throat, and esophagus. Drinking and smoking together significantly increases this risk. Alcohol helps the harmful chemicals in tobacco to better infiltrate the cells and cause disease. Alcohol can also limit the cells’ ability to repair DNA damage from the chemicals in tobacco.

 

Regular, heavy alcohol use damages the liver and causes inflammation and scarring. This increases the risk of liver cancer. In addition, alcohol can raise estrogen levels, which is associated with a higher risk of breast cancer. Moderate drinkers have up to a one and a half times increased risk of ectal cancer. While the risk is increased for men and women, the evidence of this link is stronger in men.

 

Type 2 diabetes:

 

Chronic use of alcohol is considered to be a potential risk factor for the development of type 2 diabetes mellitus (T2D).⁴ Like heart disease, low alcohol consumption decreases the risk of T2D, but chronic heavy alcohol use increases the risk. Alcohol disrupts glucose homeostasis in the body and is associated with insulin resistance.

 

In addition, alcohol affects excess caloric intake, pancreatitis, and impaired liver function. This affects blood glucose levels and causes hypoglycemia. Alcohol alters the brain’s ability to produce hunger hormones and increases food-seeking behaviors. Dysregulation of these hormones (specifically ghrelin and leptin) plays a part in T2D.

 

Heavy alcohol use can worsen symptoms in patients with TD2 and cause hyper-and hypoglycemia.⁵ Alcohol-induced hypoglycemia can lead to serious neurological complications in T2D patients, which may or may not be reversible. It can also cause life-threatening ketoacidosis and worsen diabetic neuropathy and retinopathy. Alcohol has serious interactions with some T2D medications including Chlorpropamide, Metformin, and Troglitazone.

 

If you need assistance connecting your patients to chronic disease or AUD treatment, please contact Anthem Blue Cross call centers at 800-407-4627 (outside L.A. County) or 888-285-7801 (inside L.A. County). For L.A. Care only: 888-285-7801.

 

1 Piano, 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513687/

2 National Cancer Institute, 2021 – https://www.cancer.gov/about-cancer/causes-prevention/risk/alcohol/alcohol-fact-sheet

3 American Cancer Society, 2020, https://www.cancer.org/cancer/cancer-causes/diet-physical-activityalcohol-use-and-cancer.html

4 Kim & Kim, 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3335891/

5 Emanuele et al. 1998, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761899/

CABC-CR-004568-22 (ACA-NU-0424-22)

The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for Anthem Blue Cross. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.

 

For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy at https://providers.anthem.com/ca.

CABC-CAID-002544-22-CPN2420

Managing illness can be a daunting task for our members. It is not always easy to understand test results, know how to obtain essential resources for treatment, or know who to contact with questions and concerns.

 

Anthem Blue Cross (Anthem) offers a Complex Case Management program to help make healthcare easier and less overwhelming for our members. Our care managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members and their caregivers to stay connected with their care team and follow their treatment plan. Care managers educate and empower our members to participate in their own care. The goal is to help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare. Care managers also support members and their caregivers with transitions between care settings.

 

Members or their caregivers can request Case Management by calling the Member Services number located on the back of their ID card.

 

Physicians can refer their patients by submitting a Case Management Referral Form via fax or email.

 

Have questions about case management?

Call the Customer Care Center toll-free, Monday through Friday, from 7 a.m. to 7 p.m., at 800-407-4627 (TTY 711) or at 888-285-7801 (TTY 711) for members in Los Angeles.

 

Email is the quickest and most direct way to receive important information from Anthem Blue Cross. To start receiving email from us (including some sent in lieu of fax or mail), submit your information via our online form (https://bit.ly/3lLgko8).

CABC-CD-003825-22-CPN3339

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

 

Submitting attachments electronically is the most efficient way for you to receive your claim payments faster. That’s why we’ve made submitting digital claims attachments easier, more intuitive and streamlined. You can now submit your claims attachments through the Claims Status Inquiry application on Availity.com.* Submitting attachments electronically is the most efficient way for you to receive your claim payments faster.

 

Submitting attachments electronically:

• Reduces costs associated with manual submission.
• Reduces errors associated with matching the claim when attachments are submitted manually.
• Reduces delays in payments.
• Saves time: no need to copy, fax, or mail.
• Reduces the exchange of unnecessary member information and too much personal health information sharing.

If your workflow for attachments is through electronic data interchange (EDI) submissions or directly through the Availity application, we have a solution for that.

Didn’t submit your attachment with your claim? No problem!

 

If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are [three] options for submitting attachments:

1. Through the attachments dashboard inbox:

• From com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox.

1. Through the 275 attachment:

• Important: you must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.

1. Through the Availity.com application:

• From com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.

If you submit your claim through the Availity application:

1. Simply submit your attachment with your claim.
2. If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:

• From com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.

 

For more information and educational webinars

In collaboration with Availity, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up today.

 

CABC-CDCR-002680-22

Effective for dates of service on and after November 1, 2022, the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization.

 

Please note, inclusion of a national drug code on your medical claim will help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

 

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below:

 

Clinical Criteria	HCPCS or CPT® code(s)	Drug name
ING-CC-0205	J9331	Fyarro (sirolimus albumin bound)
ING-CC-0206	J3490, J3590	BESREMi (ropeginterferon alfa-2b-njft)
ING-CC-0207	J9332	Vyvgart (efgartigimod alfa-fcab)
ING-CC-0208	J3490	Adbry (tralokinumab)
ING-CC-0209	J3490	Leqvio (inclisiran)

Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

Email is the quickest and most direct way to receive important information from Anthem Blue Cross. To start receiving email from us (including some sent in lieu of fax or mail), submit your information via our online form (https://bit.ly/3lLgko8).

CABC-CD-004131-22

Effective for dates of service on and after November 1, 2022, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon precertification initiation or renewal in addition to the current medical necessity review of all drugs noted in the chart.

 

The Clinical Criteria are publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.

Clinical Criteria	Status	Drug(s)	HCPCS codes
ING-CC-0166	Preferred	Kanjinti	Q5117
ING-CC-0166	Non-preferred	Herceptin	J9355
ING-CC-0166	Non-preferred	Herzuma	Q5113
ING-CC-0166	Non-preferred	Ogivri	Q5114
ING-CC-0166	Non-preferred	Ontruzant	Q5112
ING-CC-0166	Non-preferred	Trazimera	Q5116

CABC-CD-004446-22 (CABC-CD-002762-22)

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:

 

• Clinical criteria update

 

• Access to care standards

The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for Anthem Blue Cross. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.

 

For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy at https://www.anthem.com/ca/provider/medicare -advantage.

CABC-CARE-002545-22

AIM Specialty Health_®* (AIM) created new contact center phone numbers for Medicare providers to call for prior authorization requests. The new phone numbers are listed below.

 

Note: The old number is not available for requests after August 15, 2022, so please use this new number to submit new prior authorization AIM requests.

Health plan	Market	New number
Anthem Blue Cross	CA	833-404-1684

 

As always, the best way to reach AIM is to use the ProviderPortal^SM. It is:

• Self-service.
• Available 24/7.
• Customizable with physician information.
• Easy to use and allows real-time determinations.

 

The ProviderPortal is a fast and efficient way to start a case. It also allows your team to:

• Check order status and view order history. 
• Print/save PDF of order summary. 
• Use multiple staff members to enter/view the practice’s orders. 
• Increase payment certainty.
• Reference desk training and tutorials, including clinical criteria and CPT® lists.

 

If not already registered, your first step is to register your practice in the ProviderPortal at www.providerportal.com.

CABC-CR-004842-22

 

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

 

Submitting attachments electronically is the most efficient way for you to receive your claim payments faster. That’s why we’ve made submitting digital claims attachments easier, more intuitive and streamlined. You can now submit your claims attachments through the Claims Status Inquiry application on Availity.com.* Submitting attachments electronically is the most efficient way for you to receive your claim payments faster.

 

Submitting attachments electronically:

• Reduces costs associated with manual submission.
• Reduces errors associated with matching the claim when attachments are submitted manually.
• Reduces delays in payments.
• Saves time: no need to copy, fax, or mail.
• Reduces the exchange of unnecessary member information and too much personal health information sharing.

If your workflow for attachments is through electronic data interchange (EDI) submissions or directly through the Availity application, we have a solution for that.

Didn’t submit your attachment with your claim? No problem!

 

If you submitted your claim through EDI using the 837, and the PWK segment contains the attachment control number, there are [three] options for submitting attachments:

1. Through the attachments dashboard inbox:

• From com, select the Claims & Payments tab to access Attachments – New and your Attachments Dashboard Inbox.

1. Through the 275 attachment:

• Important: you must populate the PWK segment on the 837 with your document control number to ensure the claim can match to the attachment.

1. Through the Availity.com application:

• From com, select the Claims & Payments tab to run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.

If you submit your claim through the Availity application:

1. Simply submit your attachment with your claim.
2. If you need to add additional attachments, to add a forgotten attachment, or for claims adjustments:

• From com, select the Claims & Payments tab and run a Claims Status Inquiry to locate your claim. Find your claim and use the Send Attachments button.

 

For more information and educational webinars

In collaboration with Availity, we will hold a series of educational webinars that include a deep dive into EDI attachment submissions, as well as the new Claims Status Inquiry workflow. Sign up today.

CABC-CDCR-002680-22

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

 

Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.

 

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

HCPCS or CPT® codes	Medicare Part B drugs
J0172	Aduhelm (aducanumab-avwa)

CABC-CRMMP-004276-22-CPN365

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:

 

• Clinical Criteria Updates

 

• Medicare telehealth services during the Coronavirus (COVID-19) public health emergency (PHE) FAQ

 

• Anthem Blue Cross expands specialty pharmacy precertification list

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

 

On December 1, 2022, Anthem prior authorization (PA) requirements will change for the following code. 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. Non-compliance with new requirements may result in denied claims.

 

Prior authorization requirements will be added for the following code:

 

L6715 — Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement

 

Not all PA requirements are listed here. Detailed PA requirements are available to providers on the provider website at https://mediproviders.anthem.com/ca/pages/communications-updates.aspx or by accessing Availity* at https://availity.com.

 

Providers may also call Provider Services for assistance with PA requirements at 855-817-5786 for Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) or the number on the back of the patient’s member ID card for Medicare Advantage.

ACAD-NU-0380-22

The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for Anthem Blue Cross. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.

 

For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy at https://providers.anthem.com/ca.

CABC-CRMMP-002546-22

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

 

Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.

 

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

HCPCS or CPT® codes	Medicare Part B drugs
J0172	Aduhelm (aducanumab-avwa)

CABC-CRMMP-004276-22-CPN365

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:

 

• Anthem Blue Cross expands specialty pharmacy precertification list

 

• Clinical Criteria Updates