We ask that you review your online provider directory information on a regular basis to ensure it is correct. Access your information by visiting anthem.com/ca/provider, then under Provider Overview, choose Find Care. 

The Consolidated Appropriations Act (CAA) of 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. By reviewing your information regularly, you help us ensure your online provider directory information is current. 

Submit updates and corrections to your directory information by following the instructions on our Provider Maintenance webpage. We will send you an email acknowledging receipt of your request. Online update options include:

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

As part of our ongoing quality improvement efforts, we want you to know that some review requests may require documentation to substantiate the attestations that support the clinical appropriateness of the request. This documentation can be uploaded during the intake process.

When requested, providers must submit such documentation from the patient’s medical record. If medical necessity is not supported through documents submitted, the request may be denied as not medically necessary. Such documentation is limited to what has been asserted via the prior authorization (PA) review attestations. 

If the request would be denied as not medically necessary, providers can participate in a PA discussion with an Carelon Medical Benefits Management physician reviewer.

Please find the updated Non-Emergent Medical Transportation Physician Certification Statement (NEMT PCS) Form and instructions to submit the form at Provider Forms under For Providers.

During the COVID-19 public health emergency, Medicaid and Children’s Health Insurance Program (CHIP) members were able to stay enrolled in their current health coverage regardless of changes in eligibility or status. As Medicaid renewals begin again, your Medicaid and CHIP patients may have to take additional steps, which could include finding a new health plan. 

Patients who are receiving specialized care for medical conditions such as but not limited to pregnancy, chemotherapy, radiation therapy, or behavioral health therapy, may have additional concerns. They could be in the middle of treatment, scheduled for treatment, or on maintenance medications — and may be worried that they might lose access to their current care provider if they change health plans.

The need for continuity of care in this changing landscape

We’re committed to ensuring a smooth transition for your Medicaid and CHIP patients who are changing health plans. 

Our Continuity of Care/Transition of Care management team coordinates with you and your patients to ensure access to ongoing care. This includes a personalized evaluation of the member’s condition and network benefits to coordinate and minimize disruption of ongoing care: 

• Your patients can contact the number on the back of their member ID card and ask about our Transition of Care form. Once filled out, one of our dedicated nurse care managers will contact them to review their specialized care needs within 15 business days. 

• Download our provider manual to learn more about our Continuity of Care/Transition of Care Program. Refer to the table of contents and find Continuity of Care/Transition of Care Program under the Quality Improvement Program section.

A proactive approach to prior authorizations

For patients with CarelonRx, Inc.* as their pharmacy benefit manager and who are on maintenance medications or other medications for treatment, their existing, approved prior authorizations will automatically transfer to their new Anthem individual and family health plan, and there will be a one-time prior authorization applied for nonformulary medications. 

This will allow your patients to continue to fill their current medications and allow additional time to initiate the prior authorization process for any formulary differences. 

You and your patients can count on us for support

Your patients who are receiving specialized care may have concerns about continuing their care and staying with their current care providers. We want you to feel confident you have resources and answers to guide them.

Together, we can ease your patients’ potential concerns and ensure a smooth transition for those who choose an Anthem individual and family health plan. 

Register today for the youth mental health forum hosted by Anthem and Motivo* for Anthem providers on September 27, 2023.

Wednesday, September 27, 2023

3:30 to 5 p.m. Eastern time

This important event will address the critical need to engage young people in leading their mental health. By deepening the discussion on youth mental health, we can do our part to foster a culture of understanding and support for youth and young adults. 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 and young leaders as we explore the challenges experienced by today’s youth, amplify the experiences and ideas of young people, and equip attendees with practical tools and innovative approaches to create meaningful change.

Each forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, address, and deconstruct bias, have difficult and productive conversations, learn about valuable resources, increase inclusion, advance equity in healthcare.

Please register for this event by visiting this link.

On August 19, 2022, September 15, 2022, November 18, 2022, December 22, 2022, May 2, 2023, and May 19, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross (Anthem). These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email. Please see the explanation/definition for each category of Clinical Criteria below:

• New: Newly published criteria.
• Revised: Addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

Please share this notice with other providers in your practice and office staff.

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

On December 22, 2022, May 2, 2023, and May 19, 2023, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross (Anthem). These policies were developed, revised, or reviewed to support clinical coding edits. 

Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: Newly published criteria
• Revised: Addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

Please share this notice with other providers in your practice and office staff.

Please note: 

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Your Dual-Eligible Special Needs Plan (DSNP) member’s Individualized Care Plan (ICP/CP) is available on Availity* at www.availity.com. We would like the opportunity to discuss identified problems/needs and collaborate on ways to assist the member in meeting their care plan goals. The member and/or caregiver are central to the process and are also invited to attend the Interdisciplinary Care Team (ICT) meeting.

Your participation is important. If you would like to participate in the ICT meeting, call us back as soon as possible at 844-408-6568. When contacting us, include the member’s name, date of birth, and Medicare identification number. The case manager will reach out to set up the meeting.

Any care plan changes made from the ICT meeting will be available for you to review on Availity one-to-two working days after the meeting. To access the care plan information, your Availity administrator must register you for access to Member Clinical Reports and complete the registration process using Payer Spaces > Preference Center. Once the registration piece is complete, log in to Availity, select Payer Spaces > Payer Tile > Alerts Hub to access the member’s ICP.

We are available Monday through Friday, 8 a.m. to 5 p.m., excluding holidays.

Purpose

The purpose of this bulletin is to provide guidance on the provision of an annual Medi-Cal cognitive health assessment for members 65 years of age or older.

Background

California Senate Bill (SB) 48 (Chapter 484, Statutes of 2021) expands the Medi-Cal schedule of benefits to include an annual cognitive assessment for Medi-Cal members who are 65 years of age and older if they are otherwise ineligible for a similar assessment as part of an annual wellness visit through the Medicare program, subject to an appropriation by the state legislature for this purpose as of July 1, 2022. The annual cognitive health assessment is intended to identify whether the patient has signs of Alzheimer’s disease or related dementias, consistent with the standards for detecting cognitive impairment under the Medicare annual wellness visit and the recommendations by the American Academy of Neurology.

Additionally, SB 48 outlines requirements that Medi-Cal providers must complete prior to being eligible to receive payment for conducting annual cognitive health assessments. Medi-Cal providers must complete training as specified and approved by the Department of Health Care Services (DHCS) and use validated tools recommended by the DHCS.

Policy

The annual cognitive health assessment is for members 65 years of age or older who do not have Medicare coverage. Trained providers who render the assessment will bill with CPT^® code 1494F. The code is allowable once per year as part of the member’s annual exam.

Provider billing requirements

To appropriately bill and receive reimbursement for conducting an annual cognitive health assessment, providers must do all of the following:

• Complete the DHCS Dementia Care Aware cognitive health assessment training (dementiacareaware.org) prior to conducting the brief cognitive health assessment:
  • Anthem Blue Cross (Anthem) will have access to a list of providers who have completed the training.
• Administer the annual cognitive health assessment as a component of an evaluation and management visit including but not limited to an office visit, consultation, or preventative medicine service (elements of the cognitive health assessment can be conducted by non-billing team members acting within their scope of practice and under the supervision of the billing provider).
• Document all the following in the member’s medical records and have such records available upon request:
  • The screening tool or tools that were used (at least one tool from the cognitive assessment tools section below is required)
  • Verification that screening results were viewed by the provider
  • The results of the screening
  • The interpretation of results
  • Details discussed with the member and/or authorized representative and any appropriate actions taken regarding screening results
• Use CPT code 1494F as outlined in the Medi-Cal Provider Manual. For further assistance, contact your Provider Relationship Management associate.

Cognitive assessment tools

At least one cognitive assessment tool listed below is also required. Cognitive assessment tools used to determine if a full dementia evaluation is needed include, but are not limited to:

• Patient assessment tools:
  • General Practitioner Assessment of Cognition (GPCOG)
  • Mini-Cog
• Informant tools (family members and close friends):
  • Eight-Item Informant Interview to Differentiate Aging and Dementia
  • GPCOG
  • Informant Questionnaire on Cognitive Decline in the Elderly

Medical record reviews

To ensure the provision of appropriate and necessary follow-up services based on assessment scores, including but not limited to additional assessment or specialist referrals, the plan may conduct random medical record reviews.

Members under 65 years of age

Anthem will cover medically necessary and appropriate coverage of assessments for members under 65 years of age who are reporting symptoms or showing signs of cognitive decline. This may include but is not limited to cognitive health assessments, appropriate treatment services, and necessary referrals billed through established practices.

Resources

Providers can view the required training at dementiacareaware.org.

Anthem Blue Cross (Anthem) reimburses providers for Medicare Advantage medication reconciliation.

Please see the FAQ to learn how to receive reimbursement for post inpatient discharge medication reconciliation.