Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com, then at the top of the webpage, select Find Care.

Submit updates and corrections to your directory information by following the instructions on the Provider Maintenance Form online. Update options include:

• add/change an address location
• name change
• phone/fax number change
• provider leaving a group or a single location
• closing a practice location

The Consolidated Appropriations Act (CAA) implemented in 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.

We share a health vision with our care providers that means real change for consumers.

Anthem wants to remind you of a training resource that’s available for all providers. It’s called Provider Pathways, an on-demand digital eLearning that’s comprised of a collection of topics called modules. Each module covers a different aspect of doing business with Anthem. Depending on what you need, you can take one or all the modules.

How to find Provider Pathways

Provider Pathways — Doing Business with eLearning for Anthem gives you the flexibility for scheduling training for yourself and your staff. You can find this training on the provider website:

• Go to https://providers.anthem.com/ky
• Select Training Academy under Resources in the top navigation.
• Once on the site, select Provider Pathways under Training Resources.

Summary

On September 21, 2023, and October 4, 2023, 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/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.

Effective June 1, 2024, Anthem will transition from CG-BEH-02 (Adaptive Behavioral Treatment) and MCG W0153 (Behavioral Health Care Applied Behavioral Analysis), to MCG B-806-T Behavioral Health Care Applied Behavioral Analysis (Original MCG Guideline), for medical necessity/clinical appropriateness reviews.

If you have questions, please contact the provider service number on the back of the member's ID card.

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross and Blue Shield patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes. Select here for our conversation guide for tips on how to engage patients who may be from a culture different from your own.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management associate or call Provider Services on the back of your patient’s member ID card.

Through our efforts, we can help deliver high quality, equitable healthcare.

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross and Blue Shield patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes. Select here for our conversation guide for tips on how to engage patients who may be from a culture different from your own.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management associate or call Provider Services on the back of your patient’s member ID card.

Through our efforts, we can help deliver high quality, equitable healthcare.

Hispanics are the largest ethnic minority group in the United States, making it vital that we recognize the unique health needs of the population. Take time in February to support American Heart Health Month and explore how your practice can help improve your Hispanic patients’ heart health.

What can your practice do to help improve health outcomes for Hispanic patients with heart disease?

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem Blue Cross and Blue Shield Medicaid patients, call Provider Services. Free interpreter services are also available to members by calling the Member's Services number on the back of their ID card (TTY/TTD 711) and through the 24/7 NurseLine.
• According to a study by the American Heart Association (link), Hispanic persons had similar rates of heart disease compared to Caucasian adults but lower rates of awareness and control. To help increase awareness of their condition, you can ask questions such as:
  • “Have you ever been told that you have high blood pressure or high cholesterol?”
  • “Has a healthcare provider ever discussed with you or prescribed you medication to control your blood pressure or cholesterol levels?”
• Once awareness of the condition is properly understood, educate the patient on any increased health risk factors they might have, especially if they have other conditions like diabetes or obesity.
• Use culturally appropriate examples when discussing lifestyle changes.
• Encourage scheduling follow-up appointments for blood pressure rechecks or lab work to check cholesterol levels before the patient leaves the office.
• Submit all blood pressure readings using Category II codes on claims or through your practice’s preferred supplemental data submission method. Blood pressure care gaps can open and close through the year and are based on the last recorded blood pressure reading of the year. The goal for every patient is a reading below 140/90 mmHg.
• Properly code statin therapy exclusions and prescribe low-cost medications to discourage the use of discount cards.

To learn more about our commitment to health equity, visit MyDiversePatients.com. Your patients can also learn more about the unique health needs of Hispanic persons by visiting takingactionforourhealth.org/.

Patient care opportunities

If you have questions on improving your quality scores, contact your care consultant or program manager to discuss your opportunities. You also can find patient care opportunities within the Patient360 application located on Availity Essentials Payer Spaces. To access the Patient360 application you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Choose the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are in the Active Alerts section of the Member Summary.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management associate or call Provider Services at 855-661-2028.

Through our efforts, we can help deliver high quality, equitable healthcare.

Measure description

The percentage of discharges for members 18 years of age and older who had each of the following:

• Notification of inpatient admission (can only be captured through medical record review)
• Receipt of discharge information (can only be captured through medical record review)
• Patient engagement after inpatient discharge
• Medication reconciliation post-discharge

What we are looking for in care provider records:

• Notification of inpatient admission — Documentation in the outpatient medical record must include evidence of receipt for notification of inpatient admission on the day of admission through two days after the admission (three total days) with evidence of the date when the documentation was received. Any of the following examples meet criteria:
  • Communication about admission between inpatient care inpatient providers, staff, or ER, and the member’s PCP or ongoing care provider (for example, phone call, e-mail, fax, information exchange, automated alert system, shared electronic medical record, or from the member’s health plan)
  • Indication that the PCP or ongoing care provider admitted the member to the hospital
  • Indication that a specialist admitted the member to the hospital and notified the member’s PCP or ongoing care provider
  • Indication that the PCP or ongoing care provider placed orders for tests and treatments any time during the member’s inpatient stay
  • Documentation that the PCP or ongoing care provider performed a preadmission exam or received communication about a planned inpatient admission. The time frame that the preadmission exam or planned inpatient admission must be communicated is not limited to the day of admission through two days after the admission (three total days)
• Receipt of discharge information — Documentation in the outpatient medical record must include evidence of receipt of discharge information on the day of discharge through two days after the discharge (three total days) with evidence of the date when the documentation was received. Discharge information may be included in, but not limited to, a discharge summary or summary of care record, or in the structured fields in an electronic health record. At a minimum, the discharge information must include the following:
  • The practitioner responsible for the member’s care during the inpatient stay
  • Procedures or treatments provided
  • Diagnoses at discharge
  • Current medication list
  • Testing results, or documentation of pending tests or no tests pending
  • Instructions for patient care post-discharge
• Patient engagement after inpatient discharge — Documentation in the outpatient medical record must include evidence of patient engagement within 30 days after discharge. Any of the following meet criteria:
  • An outpatient visit, including office visits and home visits
  • A telephone visit
  • A synchronous telehealth visit where real-time interaction occurred between the member and care provider using audio and video communication
  • An e-visit or virtual check-in (asynchronous telehealth where two-way interaction, which was not real-time, occurred between the member and care provider)
• Medication reconciliation post-discharge — Documentation in the outpatient medical record must include evidence of medication reconciliation and the date when it was performed. Medication reconciliation must be conducted by a prescribing practitioner, clinical pharmacist, physician assistant, or registered nurse. Any of the following meet criteria:
  • Documentation of the current medications with a notation that the care provider reconciled the current and discharge medications
  • Documentation of the current medications with a notation that references the discharge medications (for example, no changes in medications since discharge, same medication at discharge, discontinue all discharge medications)
  • Documentation of the member’s current medications with a notation that the discharge medications were reviewed
  • Documentation of a current medication list, a discharge medication list and notation that both lists were reviewed on the same date of service
  • Documentation of the current medications with evidence that the member was seen for post-discharge hospital follow-up with evidence of medication reconciliation or review:
    • Evidence that the member was seen for post-discharge follow-up requires documentation that indicates the care provider was aware of the member’s hospitalization or discharge
  • Documentation in the discharge summary that the discharge medications were reconciled with the most recent medication list in the outpatient medical record. There must be evidence the discharge summary was filed in the outpatient chart on the date of discharge through 30 days after discharge (31 total days).
  • Notation that no medications were prescribed or ordered upon discharge
• Exclusions:
  • Evidence of hospice or palliative services in 2023
  • Evidence patient expired in 2023

Helpful hints:

• Documentation of a procedure/surgery that is typically performed inpatient (such as, aortic bypass) does not indicate that the care provider is aware of the hospitalization. Documentation of post-op/surgery follow-up alone does not indicate the care provider was aware of the hospitalization or discharge. Make sure documentation references the hospitalization, admission, or inpatient stay.
• If performing a pre-admission exam, document that it is a pre-admission exam.
• If performing a pre-surgical, pre-operative, or surgical clearance exam, the date of the admission must be documented.
• Implement process to receive automated alerts when a member is admitted or discharged from an inpatient facility.
• Review discharge medications with the member.
• Schedule post-hospital discharge following appointments and have the office call the member to remind them.
• Document a received date for discharge summaries and notification of inpatient admissions.
• Use the appropriate billing codes for Medication Reconciliation Post-Discharge and Patient Engagement After Inpatient Discharge.