Doula services are aimed at preventing perinatal complications and improving health outcomes for birthing parents and infants. The Department of Health Care Services (DHCS) added doula services as a covered benefit in January 2023. Doula services require a recommendation or referral by a physician or other licensed practitioner.

Doulas are birth workers who provide health education, advocacy, and physical, emotional, and non-medical support for pregnant and postpartum persons before, during, and after childbirth, including support during miscarriage, stillbirth, and abortion. They are not licensed and do not require supervision.

Doulas:

• May provide services for up to 12 months from the end of pregnancy; beneficiaries are eligible to receive full-scope Medi-Cal Managed Care (Medi-Cal) coverage for at least 12 months after pregnancy.
• Provide person-centered, culturally competent care that supports the racial, ethnic, linguistic, and cultural diversity of members while adhering to evidence-based best practices.
• Offer various types of support, including health navigation, lactation support, development of a birth plan, and linkages to community-based resources.

Visit the California Advancing and Innovating Medi-Cal (CalAIM) page of our website for additional information about our Doula Program and doula resources, including a provider guide, provider manual, benefit recommendation form, and flyer.

We encourage you to share doula services information with your patients. Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

Effective December 1, 2024, Anthem is enhancing its claim edits system to ensure claims billed with pharmaceutical drug procedure codes are reported with the appropriate FDA-approved indicators for on- and off-label use.

These enhanced claim edits provide an opportunity for Anthem to evaluate submitted claims for drug quality, safety, and effectiveness. The enhancement is to have the claims deny if not billed with FDA indicator for on/off label use.

If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual and include medical records that clarify whether the indication was approved through the governing agencies. You will need to submit only the portion(s) of the medical record that is relevant to the drug provided.

If you have questions about this notification, contact your contract manager or provider relationship management account representative.

• Enhanced provisions in member eligibility such as verifying eligibility, children’s benefits, sensitive services, and telehealth
• Adjustments to special programs including managed long-term services, enhanced care management, street medicine, and palliative care
• Changes in multiple areas such as care provider procedures, administrative procedures, utilization management, care management, claims, state-directed payments, and regulatory requirements

The new Provider Operations Manual is now live on our provider website. This recently updated manual contains everything you need to know about our programs and how we work with you to provide quality care to our members. You can access the provider manual here.

Several important updates were made this year that we encourage you to review. These include the following:

• Member eligibility:
  • Verifying eligibility:
    • New language added reminding care providers they must review Medi-Cal eligibility for every member for the presence of Other Health Coverage (APL 22-027)
    • Updated member ID cards (for Los Angeles and non-Los Angeles) (new design
  • Children’s Benefits (new):
    • New subsection was added to incorporate different types of children’s benefits (California Children’s Services, Medi-Cal for Kids & Teens, and childhood lead exposure testing)
  • Sensitive services:
    • Abortion services are covered by the Medi-Cal program. Anthem will not deny or interfere with a member’s right to choose or obtain an abortion prior to viability of the fetus or when an abortion is necessary to protect the life or health of the pregnant individual. In addition, Anthem will not require a care provider to perform an abortion (APL 24-003).
    • New language added regarding care providers being prohibited from sharing, selling, marketing, or using any medical information about gender-affirming care, abortion, or any related services (AB 254 and AB 352)
  • Telehealth:
    • New language added for care providers who offer telehealth services requiring in-person care or to arrange for a referral to in-person care if member does not want to proceed with a telehealth visit (APL23-007 and AB 1241)
    • Doula, community health, and asthma preventive services can be conducted through telehealth (DHCS Telehealth Manual).
  • Transportation:
    • Members should schedule ride services at least five business days in advance, 10 business days in advance for long-distance appointments (exceptions apply: dialysis, chemotherapy, radiation therapy, urgent care, wound care, or facility discharges) (ModivCare).
• Special Programs:
  • Managed long-term services and supports:
    • Subdivision added to the topic of Intermediate Care Facilities for Developmentally Disabled (ICF/DD) (APL23-023)
  • Enhanced care management:
    • Removed the following population of focus: individuals with intellectual and developmental disabilities and pregnancy and postpartum individuals at risk of adverse perinatal outcomes
  • Street medicine:
    • New subsection added on street medicine (APL 24-001)
  • Palliative care program:
    • Hospice care providers may bill for medically necessary palliative care services for eligible Medi-Cal beneficiaries diagnosed with serious or life-threatening illnesses (DHCS Bulletin).
• Care provider procedures and responsibilities:
  • More language on balance billing added: care providers are prohibited from billing eligible members for covered services and billing dual-eligible beneficiaries for Medicare, and members may not pay for medical care (Cal Code of Regulation, 14019.4)
  • Access to care, appointment standards, and after-hours services:
    • To comply with AB1740, language was added regarding care providers posting a human trafficking notice (AB1740).
  • Required Assessments:
    • Removed CCS language and moved to children’s benefits
• Administrative procedures:
  • Updating provider directories:
    • New language added on updating delegate contact list (new DHCS contract requirement)
• Utilization management and prior authorization:
  • Authorization request and time frames:
    • New language added regarding the preferred method for digital submission of preauthorization requests (Availity Essentials authorization)
  • Transition and discharge planning:
    • New language added regarding ADT data (admission, discharge, transfer) (APL22-026)
• Care management and health programs:
  • Health services programs:
    • Updated language on New Baby, New Life

• Claims and encounters:
  • Claim submissions:
    • Language added regarding how much interest is paid if a clean claim is not processed promptly (APL23-020)
    • New subdivision added on electronic visit verification (APL 22-014)
  • Encounters:
    • Subsection title changed from encounters data to encounters
• State-directed payments:
  • Proposition 56:
    • Language changes made for state-directed payments
• Grievances, appeals, disputes:
  • Member appeals and grievances:
    • Removed Los Angeles County (for L.A. Care) regarding where to file grievances; all grievances must go to a Medi-Cal office now
    • New language added on Medi-Cal member appeals state hearings
• Compliance and regulatory requirements:
  
  • Marketing rules:
    • Anthem will no longer seek approval from Managed Risk Medical Insurance Board (MRMIB) on Anthem-branded marketing materials for Medi-Cal patients.

While we strive to keep our Provider Operations Manual current, please be sure to check our provider website for the most up-to-date plan policy information.

If you have questions about the provider manual or provider bulletins, contact your provider relationship management representative or call one of our Medi-Cal Customer Care Centers at 800‑407‑4627 (outside L.A. County) or 888-285-7801 (in L.A. County).

Beginning with claims processing on or after December 1, 2024, we are enhancing our claims edits system to ensure that claims billed with pharmaceutical drug procedure codes are reported with the appropriate Federal Drug Administration (FDA)-approved indicators for on- and off-label use.

What are the purposes of the enhanced claim edits?

These enhanced claim edits offer an opportunity for us to evaluate submitted claims for drug quality, safety, and effectiveness. The enhancement is designed to deny claims if they are not billed with the FDA indicator for on- and off-label use.

What steps should I take if I disagree with a claim reimbursement decision?

If you believe a claim reimbursement decision should be reviewed, follow the normal claims dispute process outlined in the provider manual and include medical records that clarify whether the indication was approved through the governing agencies. You will only need to submit the portion(s) of the medical record that is relevant to the drug provided.

With your help, we can continually build towards a future of shared success. If you have questions, contact your provider relationship management account representative.

Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) statute and regulations require additional information to be considered for payment. 

To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent for clinical laboratory services. The CLIA certificate identification number must be submitted in one of the following manners:

To be considered for reimbursement of reference laboratory services, the referring laboratory must be an independent clinical laboratory. Modifier 90 must be submitted to denote the referred laboratory procedure. Per the Centers for Medicare & Medicaid (CMS), an independent clinical laboratory that submits claims in paper format may not combine non-referred or self-performed and referred services on the same CMS-1500 claim form. Thus, when the referring laboratory bills for both non-referred and referred tests, it must submit two separate paper claims: one claim for non-referred tests and the other for referred tests. If submitted electronically, the reference laboratory must be represented in the 2300 or 2400 loop, REF02 element, with qualifier of F4 in REF01.

Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the QW modifier when any CLIA waived laboratory service is reported on a CMS-1500 claim form. 

Laboratory procedures must be rendered by an appropriately licensed or certified laboratory having the appropriate level of CLIA accreditation for the particular test performed. Thus, any claim that does not contain the CLIA ID, has an invalid ID, has a lab accreditation level that does not support the billed service code, does not have complete servicing provider demographic information and/or applicable reference laboratory provider demographic information, will be considered incomplete and rejected or denied. 

If you have questions, please contact your Provider Relationship Management representative. 

Summary:

• The Consolidated Appropriations Act (CAA) obliges providers to validate their online directory details every 90 days to remain listed.
• Anthem's provider data management (PDM) on Availity Essentials enables providers to verify and update their information efficiently.
• Providers can submit data updates through the PDM's Roster Automation solution using a standard Microsoft Excel document.

The CAA of 2021 requires providers to review and verify the accuracy of the following information in the online provider directory every 90 days:

• Provider/facility name
• Address
• Specialty
• Phone number
• Digital contact information

Providers who fail to verify their information every 90 days may be removed from the online provider directory.

Providers will be reinstated to the online provider directory once verification is complete.

Review, verify, and update your directory information

To review, verify, and update your online directory information, Anthem uses the provider data management (PDM) capabilities of Availity Essentials to update provider or facility data. Using the Availity PDM application meets the verification requirement to validate provider demographic data set by the CAA.

PDM features include:

• Updating provider demographic information for all assigned payers in one location.
• Verifying and managing current provider demographic information.
• Monitoring submitted demographic updates in real-time with a digital dashboard.
• Reviewing the history of previously verified data.

To access the PDM application, log on to Availity and go to My Providers > Provider Data Management Administrators are automatically granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information. View the Availity PDM quick start guide here (PDF).

Use Roster Automation to submit provider demographic changes

Within the PDM application, providers also have the choice and flexibility to request data updates using our Roster Automation solution by submitting a spreadsheet via a roster upload.

Provider data additions, changes, and terminations are submitted on a standardized Microsoft Excel document. The resources for this process are available on our website. Visit anthem.com > For Providers > Forms and Guides. The following two resources appear under the Digital Tools category:

• Roster Automation Rules of Engagement: This is a reference document available to ensure error-free submissions for accurate and timely updates through automation.
• Roster Automation Standard Template: Use this template to submit your information. More detailed instructions on formatting and submission requirements can be found on the first tab of the template, the tab named User Reference Guide.

Beginning with dates of services on or after August 10, 2024, we will update our claims editing process for outpatient facility claims by applying the Medicare National Correct Coding Initiative (NCCI) medically unlikely edits (MUE). NCCI edits are Centers for Medicare & Medicaid Services (CMS) developed guidelines to promote national correct coding based on industry standards for current coding practices.

These edits provide an opportunity to shift certain existing back-end reviews to front-end adjudication for outpatient facility claims. While this may facilitate quicker claim adjudication, it may also cause claims to deny frequency unit limits tied to MUE if correct coding guidelines are not followed. For additional information, please visit CMS.gov and select the Medically Unlikely Edits page.

If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.

Fifty-three million, or more than one in five Americans, are family caregivers. Caregiving in the U.S. 2020 reports that caregivers face health challenges of their own, with nearly a quarter of caregivers finding it hard to take care of their own health and saying that caregiving has made their own health worse.

Now, we have made it easy for providers to help their patients who are family caregivers reduce their stress and improve their health. Help for Cancer Caregivers’ new healthcare provider landing page has an easy-to-download flyer that can be given to patients to encourage them to visit Help for Cancer Caregivers. This evidence-based, interactive website allows family caregivers to take a brief survey to create a personal self-care guide, access social services, and browse topics like dealing with feelings, keeping health, day-to-day needs, working together, and long-distance caregiving.

Studies show that family caregivers suffer from poorer physical health than those who do not have additional caregiving responsibilities. Studies have found that:

• Caregivers show higher levels of depression.
• Caregivers suffer from high levels of stress and frustration, which can lead to burnout.
• Stressful caregiving situations may lead to harmful behaviors, such as abusing drugs or alcohol.
• Caregivers have an increased risk of heart disease.
• Caregivers have lower levels of self-care.
• Chronic diseases of caregivers are often more difficult to manage.
• Caregivers have an increased risk of sickness and premature death.

Evidence has also shown that education and intervention reduce caregiver strain, uncertainty, and helplessness and that information helps normalize the caregiver experience and enhances a sense of control.

Access the healthcare provider landing page today. This website includes language and accessibility tools to support non-English speakers and people with accessibility needs.

Summary: On November 17, 2023, and March 21, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation or 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.

To help make it as easy as possible to keep up with annual changes to HEDIS documentation, Anthem created a library of HEDIS content for you. You’ll find tip sheets with coding information and more for many HEDIS measures and other documentation to help ensure accurate claims coding, which helps ensure accurate reimbursement.

Go to the Optimizing HEDIS & STARS category to view all the communications.