At a glance:

• Care providers contracted with us need to verify and update their demographic data every 90 days using the provider data management (PDM) feature in Availity Essentials.
• Updating and attesting data are critical for maintaining accurate service directories for members and noncompliance with these requirements can result in removal from the online provider directory.
• Availity Essentials provides digital applications that enable users to monitor submitted demographic updates in real time, review the history of previously verified data, and manage multiple updates within one spreadsheet via the Upload Roster feature.

What are the requirements for the attestation of demographic data?

We require our contracted care provider partners to attest to their demographic data every 90 days. Maintaining your provider data is critical as it results in improved connection to members seeking care, supports the accuracy of claims processing, and allows for timely reimbursement, while aligning to a bold purpose of improving the health of humanity.

How do I update and attest to my data?

We require the use of the PDM capability available on Availity Essentials to update your provider or facility data. There are two options within Availity Essentials PDM that are available at no cost to care providers:

• Multipayer platform, which includes Directory Verification and Core PDM: allows care providers to make required updates using Directory Verification and changes using Core PDM
• Roster upload: allows care providers to submit multiple updates within one spreadsheet via the Upload Roster feature (The Upload Roster feature is currently only available and shared with the health plan.)

Both the multipayer platform and Roster Upload feature satisfy your 90‑day attestation requirement.

To attest to your provider data:

1. Log in to https://Availity.com.
2. Navigate to My Providers > Provider Data Management.
3. Select the action menu next to the business whose information you want to verify.
4. Select Verify Directory Listing.
5. Review each set of data for accuracy.
6. Once complete, select Submit Verified Profile.

Organizations with no changes since their last submission may see a Quick Verify button that allows for directory verification in one click.

Individuals registered for their TIN within the Availity Manage My Organization application on Availity Essentials will receive periodic automated emails and notifications in the Notification Center on Availity Essentials reminding them when their attestation is due or overdue.

How do I access Availity Essentials and the PDM application?

To access the PDM application, log on to https://Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be 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.

Within PDM you also have the ability to:

• Monitor submitted demographic updates in real time with a digital dashboard.
• Review the history of previously verified data.

Why is updating and attesting to my data important?

Our members use Find Care to make informed decisions about their healthcare and find quality doctors and hospitals. Keeping your data up to date ensures members have access to you when they need it the most.

Failure to complete the 90‑day attestation requirement puts your organization at risk of being classified as non‑compliant with the health plan’s policies and procedures and may result in removal from the online provider directory.

What if I’m not registered for Availity Essentials yet?

If you aren’t registered to use Availity Essentials, signing up is easy and secure. There is no cost to register or to use any of the digital applications. Start by going to https://Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one TIN, ensure you have registered all TINs associated with your account.

If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY (282‑4548).

How do I get training on the Availity Essentials PDM tool?

You can learn about and attend one of our training opportunities by visiting here (apps.availity.com):

• For more information on PDM, check out the Quick Start Guide here (apps.availity.com) using your Availity Essentials user ID and password.
• For more information about the Roster Upload process:
  • See the Roster Submission Guide on https://Availity.com > Payer Spaces > Select Payer Tile > Resources > Roster Submission Guide using PDM.
  • Find training specifically for the Standard Template and Rules of Engagement by listening to our recorded webinar on our provider Learning Hub.
  • Take an on‑demand class hosted by Availity Essentials on the Learning Hub to learn about PDM.

What if I’m a behavioral health care provider?

If you are a behavioral health care provider and assigned to Carelon Behavioral Health, Inc., follow the Carelon Behavioral Health process for attestation. Council for Affordable Quality Healthcare (CAQH) care providers should attest, confirm, or update their data through the CAQH website. Non‑CAQH care providers and facilities should attest, confirm, or update their data directly with Carelon Behavioral Health.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

Anthem has a continued mission to leverage digital technology to provide enhanced services for both members and care providers. We encourage the support of care providers in accepting digital ID cards instead of a physical member ID card. As members increasingly use digital ID cards, care providers may need to implement changes in their processes to accept this format.

Due to recent enhancements, care providers can bypass the request for cards by accessing Availity.com. If a copy of a physical member identification card is needed, a member can email, fax, or access card details saved in their digital wallet. As a reminder, care providers can also access eligibility and benefit information without the health care identification (HCID). This makes both check-ins and submitting claims easier and faster.

Anthem is dedicated to providing digital solutions that transform both care provider and payer interactions. Thank you in advance for your continued partnership and support in empowering our members to use their digital ID cards. With your help, we can continually build towards a future of shared success.

• Effective March 1, 2025, Carelon Medical Benefits Management will begin conducting clinical appropriateness reviews of cardiovascular, musculoskeletal, and surgical procedures.
• New outpatient utilization management also includes fertility procedures and other medical services for select insurance plans.

• Anthem will continue to perform reviews of transportation services.
• Providers are encouraged to use an online portal for service preauthorization, with resources and training available for guidance.

Carelon Medical Benefits Management will begin accepting prior authorization requests on February 24, 2025, for dates of service on or after March 1, 2025.

Members included in the new program

Updates to Carelon Medical Benefits Management programs apply to select local fully insured members and members covered under self‑insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard^®, Medicare Advantage, Medicaid, Medicare supplemental, or Federal Employee Program^® (FEP^®) plans. For more information, please call the phone number on the back of the member ID card.

Pre‑service review requirements

For procedures scheduled to begin on or after March 1, 2025, all care providers need to contact Carelon Medical Benefits Management to obtain a pre‑service review for the services, including, but not limited to, the following non‑emergency modalities. Please refer to the Clinical Guidelines at Anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.

Note: All codes will be reviewed for medical necessity for the requested service and not for site of care.

The tables below list our Clinical UM Guidelines and Medical Policies for medical necessity review.

To determine if prior authorization is needed for a member on or after March 1, 2025, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on http://Availity.com to pre‑certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Care providers should continue to submit pre‑service review requests to Carelon Medical Benefits Management using the convenient online service provided on the Carelon Medical Benefits Management provider website. The website is available 24 hours a day, seven days a week, and processes requests in real time using Clinical Criteria. To register, go to https://providerportal.com.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:

Cardiovascular Solution | Carelon Insights

Radiology Solution | Carelon Insights

Sleep Solution | Sleep Healthcare | Carelon Insights

Surgical Procedures Solution | Carelon Insights

Radiation Oncology Solution | Carelon Insights

Additional Outpatient Utilization Management

Sign up at provider training for provider training for the additional outpatient UM:

• Wednesday, February 5, 2025, at 12 p.m. ET/11 a.m. CT
• Wednesday, February 12, 2025, at 12 p.m. ET/11 a.m. CT
• Friday, February 21, 2025, at 11 a.m. ET/10 a.m. CT
• Wednesday, February 26, 2025, at 12 p.m. ET/11 a.m. CT
• Wednesday, March 5, 2025, at 12 p.m. ET/11 a.m. CT

Our website, Anthem.com, provides information and tools such as order entry checklists, Clinical Guidelines, and FAQ. You can also contact your provider relationship management representative with any questions.

Through genuine collaboration, we can simplify access to care and help you deliver high‑quality, equitable healthcare.

Join our on‑demand webinar on improving antibiotic use in the outpatient setting, led by Dr. Emily McDonald, MD, MPH, and Guillermo Sanchez, PA‑C, MPH, MSHS, from the CDC’s Office of Antibiotic Stewardship.

The webinar highlights key strategies such as proper diagnosis, adherence to clinical guidelines, and educational interventions. It will also address common misconceptions regarding patient satisfaction and prescribing practices. Additionally, the session will discuss tools and resources, such as HEDIS^® quality measures and communication training, available to help clinicians improve their antibiotic stewardship practices.

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

Program objectives:

• Review the epidemiology of outpatient antibiotic use in the U.S.
• Identify high‑priority conditions where antibiotic prescribing can be improved.
• Describe evidence‑based interventions that can improve antibiotic use.
• Address common myths related to antibiotic use.

Visit: Improving Antibiotic Use for Acute Respiratory Infections (This link works best with the Chrome browser.)

Effective May 1, 2025, Anthem will upgrade to the 29th edition of non‑customized MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive:

• Behavioral Health Care (BHG):
• The guidelines for substance‑related disorders have been updated to allow users to identify ASAM citations more easily within MCG content. Benchmarks have been added to the guidelines for Applied Behavioral Analysis, Neuropsychological Testing, Psychological Testing, and Urine Toxicology Testing.
• Inpatient & Surgical Care (ISC):
• Five new observation care guidelines have been added. Also, a new mean arterial pressure (MAP) calculator has been added.
• General Recovery Care (GRG):
• A new Hospital‑at-Home General Recovery Guideline has been added.
• Recovery Facility Care (RFC):
• The discharge planning section for Inpatient Rehabilitation Facility guidelines was expanded.
• Chronic Care (CCG):
• New guidelines have been added to self‑management and low‑intensity disease management pediatric guidelines.
• Ambulatory Care (AC):
• A new Gene and Cellular Therapy section was introduced. A new Specialty Medication guideline has also been added. In addition, new guidance for supporting requests for APAP machines has been added.
• Home Care (HC):
• Updates to Clinical Indications for admission were made.
• Multiple Condition Management (MCM):
• New and updated Readmission Risk Assessments have been added.
• Transitions of Care (TC)
• Patient Information (PIP)

If you have questions, please contact Provider Services at 866‑408-6132 (Hoosier Healthwise), 844‑533-1995 (Healthy Indiana Plan), 844‑284-1798 (Hoosier Care Connect), or 833‑569-4739 (Indiana PathWays for Aging).

Effective June 1, 2025, Anthem will upgrade to the 29th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive:

• Behavioral Health Care (BHG):
• The guidelines for substance‑related disorders have been updated to allow users to identify ASAM citations more easily within MCG content. Benchmarks have been added to the guidelines for Applied Behavioral Analysis, Neuropsychological Testing, Psychological Testing, and Urine Toxicology Testing.
• Inpatient & Surgical Care (ISC):
• Five new observation care guidelines have been added. Also, a new mean arterial pressure (MAP) calculator has been added.
• General Recovery Care (GRG):
• A new Hospital‑at-Home General Recovery Guideline has been added.
• Chronic Care (CCG):
• New guidelines have been added to self‑management and low‑intensity disease management pediatric guidelines.

If you have questions, please contact Provider Services via the number on the back of our member ID card.

Effective June 1, 2025, Anthem will upgrade to the 29th edition of MCG Care Guidelines for the following modules. Below is high level summary of the updates and is not intended to be all inclusive:

• Behavioral Health Care (BHG):
• The guidelines for substance‑related disorders have been updated to allow users to identify ASAM citations more easily within MCG content. Benchmarks have been added to the guidelines for Applied Behavioral Analysis, Neuropsychological Testing, Psychological Testing, and Urine Toxicology Testing.
• Inpatient & Surgical Care (ISC):
• Five new observation care guidelines have been added. Also, a new mean arterial pressure (MAP) calculator has been added.
• General Recovery Care (GRG):
• A new Hospital‑at-Home General Recovery Guideline has been added.
• Recovery Facility Care (RFC):
• The discharge planning section for Inpatient Rehabilitation Facility guidelines was expanded.
• Chronic Care (CCG):
• New guidelines have been added to self‑management and low‑intensity disease management pediatric guidelines.

If you have questions, please contact Provider Services via the number on the back of our member ID card.

At a glance:

• HHS finalizes rule allowing single consent for future uses and disclosures of substance use disorder (SUD) patient records.
• HIPAA-covered entities can now redisclose SUD records under new confidentiality regulations.

On February 8, 2024, the U.S. Department of Health & Human Services (HHS) through the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office for Civil Rights announced a final rule modifying the Confidentiality of Substance Use Disorder (SUD) Patient Records regulations at 42 CFR part 2 (“Part 2”).

The final rules allow for the following:

• A single consent for all future uses and disclosures for treatment, payment, and healthcare operations.
• HIPAA‑covered entities and business associates that receive records under this consent to redisclose the records in accordance with HIPAA regulations.

Required elements for written consent

A written consent to a use or disclosure under the regulations in this part may be paper or electronic and must include:

• The name of the patient.
• The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure.
• A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion.

General requirement for designating recipients

The name(s) of the person(s), or class of persons, to which a disclosure is to be made (“recipient[s]”) is(are) required. For a single consent for all future uses and disclosures for treatment, payment, and healthcare operations, the recipient may be described as “my treating providers, health plans, third‑party payers, and people helping to operate this program” or a similar statement.

Special instructions when designating certain recipients

If the recipient is a covered entity or business associate to whom a record (or information contained in a record) is disclosed for purposes of treatment, payment, or healthcare operations, a written consent must include the statement that the patient's record (or information contained in the record) may be redisclosed in accordance with the permissions contained in the HIPAA regulations, except for uses and disclosures for civil, criminal, administrative, and legislative proceedings against the patient.

Healthcare operations involve activities listed in the definition at 45 CFR 164.501, including quality assessment, patient safety, population health, protocol development, case management, care coordination, and sharing treatment alternatives.

The final rule may be downloaded here.

What’s changing:

Effective January 1, 2025, postal employees began to participate in the Postal Service Health Benefits Program (PSHB), a health benefits program for those under the Federal Employee Program® (FEP).

What this means for you as the provider:

Postal employees in the PSHB program have a new ID card reflecting new enrollment codes. To ensure correct claim processing, the federal employee ID cards should be validated to confirm the provider has the correct enrollment information.

In 2025, federal and USPS employees in the FEP, along with their families, will have the same coverage and benefits as before. The plan options will remain Blue Standard, Blue Basic, and Blue Focus. Only the PSHB ID card and PSHB customer service number (on the back of the card) will be new.

Below is an example of the front of the new PSHB card. A stamp symbol in the upper right corner will identify the PSHB enrollment:

Once the PSHB member is enrolled, they will have a new ID card. The back of the ID card will reflect the toll-free Customer Service and prior authorization numbers for assistance.

Additional information for all federal employees can be found on the federal employee website at https://fepblue.org.

We would like to remind federally qualified health center (FQHC) providers of when to use the T1015 — clinic, visit/encounter, all‑inclusive code, to report valid medical encounter visits that would be eligible for wrap payments.

Ensure the claim includes a valid encounter code, which can be found on the Myers & Stauffer website: Medicaid and Medicare Auditing and Attest Services Provider Portal | Myers & Stauffer.

For members with Anthem as primary insurance or commercial primary coverage, follow these Indiana Health Coverage Programs (IHCP) billing guidelines:

• Use the CMS‑1500 claim form.
• Include place-of-service codes 02, 03, 04, 10, 11, 12, 31, 32, 50, or 72.
• Include the T1015 code if the encounter code is valid.

Secondary claims are claims that were first submitted to the commercial payer and are then submitted to Anthem. Secondary claims require the T1015. Anthem is required to pay any amount not paid by the commercial payer up to the IHCP fee schedule amount. Amounts paid by the commercial payer that exceed the IHCP fee schedule should be in a pay status at $0 so that wrap payment can be made.

Claims must include T1015 with a valid encounter code or they will not be processed for payment.

For Medicare or Medicare Advantage (crossover) claims (members eligible for both Medicare and Medicaid):

• No longer required to include T1015 for dates of service on or after July 1, 2021.
• Bill on the institutional UB‑04 form, as required by Medicare.
• Anthem accepts institutional claims that automatically cross over from Medicare but use the CMS‑1500 form for claims not automatically crossed over.
• Anthem is responsible for paying the co‑insurance/deductible amount for FQHC/rural health clinic (RHC) claims.

Medicare payments for FQHCs are applied to the FQHC Payment Code service line with revenue code 052X (medical visits) and revenue code 0900 (mental health visits). RHCs use revenue codes 052X (medical) and 0900 (mental health).

The Anthem payment applies only to the coinsurance, copayment, and deductible amounts for the FQHC Payment Code line, which are represented by specific G codes. There is no payment application to informational Qualifying Visit codes. Qualifying FQHC Payment Codes are listed in Table 1.

Table 1 — Qualifying Medicare FQHC/RHC payment codes and qualifying visit codes