Introduction of the HPP designation program for individual member (Exchange) networks

In our February 2024 letter, Anthem informed you that we were implementing a new High Performing Provider (HPP) designation to care providers meeting certain cost and quality metrics as part of our expansion of consumer tools and programs. Additionally, we indicated the designation will initially focus on certain types of professional providers we categorize as primary care providers (PCPs), but it may be broadened to include other care provider types in the future.

Effective on or about November 15, 2024, Anthem will use a new HPP methodology (cost and quality metrics) to designate HPPs for PCPs participating in our individual member (Exchange) plan networks that service our Affordable Care Act plans (IND HPPs). The new IND HPP methodology will be tailored for our Exchange plans.

Anthem will continue to use the methodology we notified you about in our February 2024 letter (the methodology was included in that communication) for our non-Exchange commercial health plan networks.

As with the non-Exchange HPP designation, Anthem may highlight Exchange HPPs in various ways, including, but not limited to:

• Providing special opportunities to participate in product offerings.
• When members contact Anthem with requests for referral options.
• Placing a designation in the Care and Cost Finder. This would be in addition to Anthem’s existing tool in Care and Cost Finder called Personalized Match, which provides Anthem members with the option to search for in-network care providers through a specialized sorting tool that considers certain cost and quality metrics as well.
• Designating a factor in auto assignment PCP methodology for health benefit plans, which require a member to pick a PCP and the member fails to do so.

As shown in the IND HPP methodology, the IND HPP methodology for determining an IND HPP is virtually the same as the methodology for determining an HPP in general (which services the health plan’s large and small group commercial populations); however, certain metrics may solely apply to the individual member population. The IND HPP designation is solely for PCPs seeing an individual member population and not for specialists.

You can view the IND HPP designation methodology here. For more information on the individual member (Exchange) HPP designation or to know if your practice will receive the IND HPP designation, please contact your local provider relationship management representative.  

Review process

If you have questions or if you would like additional information or details about whether or not you will receive the designation or the designation methodology in general, please contact your local provider relationship management representative.

Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions. As always, thank you for participating in our networks, and we look forward to working collaboratively with you to provide our members with continued access to affordable and quality healthcare.

Process for requesting more information/reconsideration

If you would like more information on the methodology and/or data upon which a score is based or if you believe there is an error with your quality or cost results, you may request reconsideration and/or more information by contacting your local provider relationship management representative. Such requests must be made no later than November 15, 2024. To ensure that we properly address your concerns, please include in your email why you believe there is an error and/or the information you request. You may also submit via email any additional information or data you believe may be relevant to the determination.

You have the right to request a face-to-face meeting with those responsible for the appeal decision. To exercise this right, please indicate in your email your desire to have such a meeting. Upon receipt of such a request, we will schedule a time and date for the meeting, which will be held at a location reasonably convenient to you or by teleconference on or before December 1, 2024. Please note that you have the right to be assisted by a representative in any request for reconsideration.

Upon receipt of a request for reconsideration, one or more of the following will review your request and make a decision:

• Jonathan Sollender, MD, MBA, FACS Regional Vice President and Senior Clinical Officer
• Erica Kloehn, RVP, Provider Solutions
• Helene Coley, Staff Vice President, Provider Analytics

You will be notified of the decision and the basis for the decision in a letter on or before
January 1, 2025.

Updates to HPP designation program

Please continue to look for updates to our HPP designation program in this provider newsletter. If you do not currently subscribe to our provider newsletter, you can do so by going to https://providernews.anthem.com/colorado.