The new name will reflect the company's exciting strategy for the future.

 

We are very excited to share the news that our parent company, Anthem, Inc., has filed a preliminary proxy statement to change its name. The new name, pending shareholder approval, will be Elevance Health.

 

Please know that if the name change is approved by shareholder vote, the following will not change:

• Your contract, reimbursement, or level of support
• Your patients’ plan or coverage

 

We will continue to do business as Anthem Blue Cross and Blue Shield.

 

Why the change?

The upcoming name change reflects the company’s strategy to elevate the importance of whole health and to advance health beyond healthcare for our customers, their families, and our communities.

 

Our path forward is clear

We are thrilled to share our journey with you as our parent company continues its evolution from a traditional health benefits organization to a health company that looks beyond the traditional scope of physical health and how to best support it.

 

For more information, please read the press release.

 

Thank you for being our trusted health partner.

 

Bryony Winn

President, Anthem Health Solutions

Anthem, Inc.

 

1811-0422-PN-NE

CMS requires that we ensure that the information in our provider directories is accurate; therefore, we conduct bi-annual verification of provider demographic and participation information. You may receive a fax, email or letter requesting that this information be confirmed. We appreciate your continued cooperation with this initiative.

 

Upon receipt of your verification form, please validate your demographic information for the specific location identified, indicate if changes are required, and fax back a revised form to the number indicated in your communication. If we need to verify information for your other locations or plans, we will contact you separately.

 

For reference, we will ask you to submit any changes to the information listed below. Upon receipt, we will include those changes in the provider directory within 30 days.

 

• Provider name
• Provider specialty
• Street address
• Phone number
• Accepting new patients
• NPI
• Fax number
• Email   
• Handicap accessibility

 

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The Consolidated Appropriations Act (CAA) effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. We are asking that you take a few minutes to review your online provider directory information to help ensure Anthem members can locate your most current information.

 

If changes are needed, please take the time to update your information by submitting updates and corrections to us on our online Provider Maintenance Form > select state. Online update options include:

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

 

Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.

 

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As a participating provider, please be reminded of your contractual obligation to help ensure our members have prompt access to services. Please visit anthem.com to access our Provider Manual for our guidelines for access to care for primary care practitioners (PCPs), specialty care practitioners (SCPs) and behavioral health practitioners (BHPs).

 

We use several methods to monitor adherence to these standards. Monitoring is accomplished by:

1. Assessing the availability of services via phone calls by our staff or designated vendor to the provider’s office
2. Analysis of member complaint data
3. Analysis of member satisfaction.

 

Providers are expected to make best efforts to meet these access standards for all members.

 

Here’s a quick reminder of our guidelines for PCPs:

• Preventive care – appointments for members scheduling periodic routine exams (well care/preventive visits) should be available within 45 calendar days of a member’s call. Care provided to prevent illness or injury; examples include, but are not limited to routine physical examinations, immunizations, mammograms and pap smears.
• Urgent care services with acute symptoms – appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, non-resolving headache.   
• Routine check-up – members must have access to care within 10 business days of their call. Care provided for non-symptomatic visits for health check.
• After-hours access – members must have access to care 24 hours a day, 7 days a week, 365 days a year. PCPs must arrange after-hours care to provide 24 hour coverage for our members by a network provider during non-business office hours. Members should have the ability to reach a recorded message or a live voice providing instructions on how to access care for emergencies and conditions requiring urgent attention.

 

Though it is important for members to have the continuity of receiving care from their PCPs, there are occasions when you may not be available at a time that meets their scheduling needs. As a reminder, we now contract with walk-in centers and urgent care facilities which are listed in our directory.

 

Here’s a quick reminder of our guidelines for SCP’s:

At this time these guidelines apply to certain specialties but could expand to other specialties in the future. To view those current impacted specialties, please view the access standards on anthem.com.

 

• Urgent care services with acute symptoms – appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, non-resolving headache.  
• Routine check-up – members must have access to care within 30 calendar days of their call. Care provided for non-symptomatic visits for health check.

 

Here’s a quick reminder of our guidelines for BHPs:

• Non-life threatening emergency services – must be seen, or have appropriate coverage directing the member, within six (6) hours. Emergent behavioral health care provided when a member is in crisis, experiencing acute distress and/or other symptoms and needs immediate attention; no risk of loss of life.
• Urgent services – must be seen, or have appropriate coverage directing the member, within 24 hours. Non-emergent behavioral health services that require immediate care; member is experiencing significant psychological distress with symptoms that impairs daily functioning; no risk of loss of life.  
• Initial routine services – must be seen within 10 business days. New patient non-urgent appointment scheduled after intake assessment or a direct referral from a treating practitioner.
• Follow-up routine services – must be seen within 30 calendar days. Non-urgent behavioral health care; member has been scheduled for a non-urgent consultation or requires services including, but not limited to, follow-up and existing medication management.
• BH follow-up appointment after discharge (inpatient psychiatric hospital release) – this standard is currently used for HEDIS ^® Members must be seen within 7 calendar days. Members can be seen in office by their practitioner or another practitioner in the practice within the same timeframe.
• After-hours access – members must have access to care 24 hours a day, 7 days a week, 365 days a year. Must have arrangement for after-hours care to provide 24-hour coverage for our members by a network provider during non-business office hours. Members should have the ability to reach a recorded message or a live voice providing instructions on how to access care for emergencies and conditions requiring urgent attention.

After-hours urgent access coverage

After-hours coverage, which is required by the Participating Provider Agreement, consists of an attendant or recording assisting the member in accessing urgent instructions outside of regular office hours. Note that telephone answering machines and voice mail are not acceptable means of providing urgent access for members if the answering machine or voice mail message only refers members to the emergency room or to call 911.

 

Compliance requires that a recording or live person directs callers to Urgent Care, 911, the ER, or connects the call to the caller’s doctor or the doctor on call.  In addition to these measures, but not in place of them, the messaging can give callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or an opportunity to ask for a call back for urgent questions or instructions.

Timely access to physicians is a major priority of our members and employer groups. The requirements adopted reflect not only their expectations, but market norms. We will be assessing physicians against these requirements through our customer satisfaction surveys and provider surveys as well as follow-up on any members’ complaints received. However, we are sensitive to problems related to seasonal services, the varying nature of practice specialties, and the challenges faced by busy practices. If your office routinely fails to meet these access and after-hours standards, it is important that you document, and we understand, the reasons that the requirements are not met.

 

1315-0422-PN-NH

This is a reminder that effective January 1, 2022, CVS Specialty Pharmacy and IngenioRx Specialty Pharmacy no longer dispense the brand name drug Botox®. However, Botox is still available to Anthem members through other vendors.

 

Please note:

• This is not a change in member benefits. This is a change in the Botox vendor only.
• If the member is not using IngenioRx Specialty Pharmacy or CVS Specialty Pharmacy to obtain Botox, no action is needed.
• This change does not affect any other specialty pharmacy coverage.

 

Medical specialty pharmacy benefits

Our members who obtained Botox through CVS Specialty Pharmacy using their medical specialty pharmacy benefits must move this prescription, as of January 1, 2022. Here are the options:

• Providers can purchase Botox for their patients, then supply it to Anthem members. Providers would then bill Anthem for the drug and administration of the drug. This will require a new prior authorization to notify Anthem of this change.
• If the Anthem member’s pharmacy benefit manager is IngenioRx, providers can transition the Botox prescription to receive the drug from any in-network pharmacy using their pharmacy benefits. Transferring the coverage will require a new prescription and new prior authorization.

 

For questions regarding a member’s medical specialty pharmacy benefits, call Provider Services using the information on the back of the member’s ID card.

 

Pharmacy benefits manager benefits

Effective January 1, 2022, members who obtained Botox through IngenioRx Specialty Pharmacy using their pharmacy benefits must move this prescription from IngenioRx Specialty Pharmacy to another in-network specialty pharmacy that dispenses Botox. If there are refills still available on the current prescription, members can transfer it to the new pharmacy. If not, members will need a new prescription.

 

For questions regarding a member’s pharmacy benefits, call Pharmacy Member Services using the information on the back of the member’s ID card.

 

1485-0422-PN-NE

 

The Centers for Disease Control and Prevention (CDC) public sector vaccine ordering data shows a 14% drop in 2020 and 2021 compared to 2019, and measles vaccine is down by more than 20%. Children need to get caught up now, so they are protected as they get back to regular schedules, play times and prepare for summer camps. Healthcare providers can identify families whose children have missed doses and contact them to schedule appointments.¹

 

Well-child visits

A well-child visit is an opportunity for parents to get regular updates about their child’s growth and development. For adolescents, it can be lifesaving, particularly when you discuss HPV, which isn’t always easy. The CDC has developed several resources for providers about how to recommend the HPV vaccine and how to talk to parents about the HPV vaccine. Get these resources from cdc.gov.

 

Adults need preventive care, too

Getting good medical care that finds problems early and treats them effectively is an essential part of staying healthy. That’s why it is important for your adult patients to get those annual check-ups. It’s an opportunity for you to provide essential health services such as blood pressure, cholesterol and diabetes screenings. It is the perfect time to talk to your patients about their physical activity, their diet, and their overall wellbeing. Scheduling annual visits with your adult patients can lead to better health outcomes.

 

Measure up

 

Adults’ Access to Preventive/ Ambulatory Health Services (AAP) HEDIS® measure includes members 20 years of age and older who have completed an ambulatory or preventive care visit during the measurement year.

 

Coding AAP

Ambulatory visit	CPT: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99483 HCPCS: G0402, G0438, G0439, G0463, T1015 ICD-10-CM: Z00.00, Z00.121, Z00.129, Z00.3, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9, Z76.1, Z76.2
Other ambulatory visits	CPT: 92002, 92004, 92012, 92014, 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337 HCPCS: S0620, S0621 UBREV: 0524, 0525
Telephone visits	CPT: 98966, 98967, 98968, 99441, 99442, 99443
Online assessments	CPT: 98969-98972, 99421-99423, 99444, 99457, 99458 HCPCS: G0071, G2010, G2012, G2061-G2063

 

Child and Adolescent Well Care Visits (WCV) measures the percentage of members 3 to 21 years of age who had a least one comprehensive well-care visit with a PCP or an OB/GYN during the measurement year.

 

Coding WCV

This is an abbreviated list of codes associated with the WCV measure.

Well-care	CPT: 99381-99385, 99391-99395, 99461
Encounter for routine child health check with abnormal findings	ICD-10: Z00.121
Encounter for routine child health check without abnormal findings	ICD-10: Z00.129
Encounter for examination for period of rapid growth in childhood	ICD-10: Z00.2

 

Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA.

 

1cdc.gov. https://www.cdc.gov/vaccines/partners/childhood/downloads/childVax-infographic.pdf

 

1489-0422-PN-NE

The National Committee for Quality Assurance (NCQA) has changed, revised, and retired HEDIS measures for measurement year 2022. Below is a summary of some of the key changes to be aware of:

 

Diabetes measures

NCQA has separated the Comprehensive Diabetes indicators into stand-alone measures:

• Hemoglobin A1c Control for Patients with Diabetes (HbA1c Control <8 and Poor Control HbA1c)
• Eye Exam Performed for Patients with Diabetes
• Blood Pressure for Patients with Diabetes
• Kidney Health Evaluation for Patients with Diabetes

 

The process measure Comprehensive Diabetes HbA1c testing was retired as the goal is to move towards more outcome measures.

 

Race/ethnicity stratification

To address health care disparities, the first step is reporting and measuring performance.  Given this, NCQA has added race and ethnicity stratifications to the following HEDIS measures:

• Colorectal Cancer Screening
• Controlling High Blood Pressure
• Hemoglobin A1c Control for patients with Diabetes
• Prenatal and Post-Partum Care
• Child and Adolescent Well Care Visits

 

NCQA plans to expand the race and ethnicity stratifications to additional HEDIS measures over several years to help reduce disparities in care among patient populations. This effort builds on NCQA’s existing work dedicated to the advancing health equity in data and quality measurement.

 

New measures

Antibiotic Utilization for Respiratory Conditions. Measures the percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event. This measure was added given antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse.

 

Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic use.  Given this new measure, the Antibiotic Utilization measure has been retired.

 

Deprescribing of Benzodiazepines in Older Adults. The percentage of Medicare members 65 years of age and older who were dispensed benzodiazepines and achieved a 20 percent decrease or greater in benzodiazepine dose during the measurement year. 

 

Guidelines recommend that benzodiazepines be avoided in older adults, and deprescribing benzodiazepines slowly and safely, rather than stopping use immediately. There is an opportunity to promote harm reduction by assessing progress in appropriately reducing benzodiazepine use in the older adult population.

 

Advanced Care Planning. Measures the percentage of adults 65 to 80 years of age, with advanced illness, an indication of frailty or who are receiving palliative care, and adults 81 years of age and older, who had advance care planning during the measurement year. 

 

Advance care planning is associated with improved quality of life, this measure will allow an understanding if it is provided to those who are most likely to benefit from it. Given this new measure, the Care for Older Adults measure has been retired.

 

Measure changes

Use of Imaging Studies for Low Back Pain. This measure was expanded to the Medicare line of business and the upper age limit for this measure was expanded to age 75. Additional exclusions to the measure were also added.

 

A complete summary of 2022 HEDIS changes and more information, can be found at NCQA HEDIS 2022.

 

Source: NCQA.org

 

1232-0422-PN-NE

The Provider Manual which incorporates information for both professional and hospital/facility providers, will be updated for an effective date of July 1, 2022. To view the updated manual, please visit anthem.com. Select Providers, then Policies, Guidelines & Manuals. Select your state, scroll to Provider Manual and select Download the Manual to view and/or download the provider manual as well as BlueCard and Medicare Advantage manuals.

 

Archived copies of the professional and hospital/facility manual will remain available at the same location.

 

1312-0422-PN-NH

The annual after-hours access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate phone messaging for our members with perceived emergency or urgent situations after regular office hours. Unfortunately, most of the Anthem plans assessed fell short of the expectation of having a live person or a directive in place after hours.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to an inability to reach the provider and/or the lack of after-hours messaging altogether. They include:

• inaccurate provider information in Anthem’s demographic database to allow assessment of the after-hours messaging
• no voicemail or messaging at all
• voicemail not reflecting the practitioner’s name
• calls being auto forwarded with no identification, no voicemail or messaging

 

Update your office information

To help both your patients’ and Anthem’s ability to reach your practice, we ask that you update your office information using the online Provider Maintenance Form. Also, review your after-hours messaging regarding connectivity for patients’ urgent accessibility.

 

What this means for our members and your patients

The annual member experience survey of Anthem enrollees indicated that of those needing advice, a sizable number sometimes, or never, reached the provider’s office for urgent instructions. To improve upon these instances of failing to meet our member’s needs, implement these steps:

1. Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
2. Be sure to turn on the messaging mechanism when you leave the office.
3. Be sure you are using the acceptable messaging for compliance with your contract.
4. A live person or recording must express if there are prior arrangements with patients for after hour needs, to be compliant.

 

Be compliant

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:

• Emergency situations: Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects the caller directly to the practitioner.
• Emergent/urgent situations: Compliant responses for urgent needs after hours:
  • Live person, via a service, advises their practitioner or on call practitioner is available and connects.
  • Live person or recording directs or directly connects caller/patient to Urgent Care, 24-hour crisis services, 911 or ER.
  • Mechanism connects the caller to their practitioner or the practitioner on call. (Must directly connect.)

 

Non-compliant responses for urgent needs after hours include:

• No provisions for after hour accessibility.
• Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. These scenarios are non-compliant because there is no direct connection to their practitioner. This prompt can be used in addition to, but not in place of instructions.

 

Is your practice compliant?

 

1311-0422-PN-CTNH

 

Please continue to check Important Medicare Advantage Updates for the latest Medicare Advantage information, including:

• Medical Policies and Clinical Utilization Management Guidelines update
• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list
• AIM Specialty Health Outpatient Rehabilitative and Habilitative Services Clinical Appropriateness Guidelines updates

 

 

As a provider, every patient encounter is an opportunity to demonstrate how well you can listen and understand their needs and concerns. Likewise, to ensure your patients can implement your plan of care, you want to be sure that your patients are truly listening and understanding the advice you are giving.

 

Strategies to improve your communication to patients

One way to figure out if your communication with patients is effective is by asking them to repeat back the plan of care you discuss with them. You will be able to identify gaps in their understanding and clarify by asking a patient to repeat the next steps back to you.

 

If you have just shared information with your patient, ask them to repeat back what you told them.  For example, you could say, “I just shared a lot of information with you about the new medication I think you should try. Can you please repeat it back to me so we can make sure you remember all of the important points?”. 

 

How do your patients know you are listening to them?

To make sure your patients know you are listening, repeat back to them what you have heard. A quick summary helps assure you heard correctly. For example, you might say, “I want to make sure that I understand all of the important information you just shared. Let me repeat back what I heard so you can verify I didn’t miss anything.” This will help your patients know you are understanding their needs.

 

ABSCRNU-0312-22

 

Effective July 1, 2022, when a member is readmitted within 30 days as part of a planned readmission and placed on a leave of absence, the admissions are considered to be one admission, and only one diagnosis-related group (DRG) will be reimbursed.

 

For additional information, please review the Inpatient Readmission reimbursement policy at https://www.anthem.com/medicareprovider.

 

ABSCRNU-0301-21

 

On November 19, 2021, December 13, 2021, and January 10, 2022, the Pharmacy and Therapeutics (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 members of 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.

 

Effective date	Document number	Clinical Criteria Title	New or revised
April 8, 2022	*ING-CC-0205	Fyarro (sirolimus albumin bound)	New
April 8, 2022	*ING-CC-0206	Besremi (ropeginterferon alfa-2b-njft)	New
April 8, 2022	*ING-CC-0207	Vyvgart (efgartigimod alfa-fcab)	New
April 8, 2022	*ING-CC-0208	Adbry (tralokinumab)	New
April 8, 2022	*ING-CC-0209	Leqvio (inclisiran)	New
April 8, 2022	ING-CC-0124	Keytruda (pembrolizumab)	Revised
April 8, 2022	ING-CC-0079	Strensiq (Asfotase Alfa)	Revised
April 8, 2022	ING-CC-0015	Infertility and HCG Agents	Revised
April 8, 2022	ING-CC-0102	Gonadotropin releasing hormone (GNRH)  Analogs for Oncologic Indications	Revised
April 8, 2022	ING-CC-0168	Tecartus (brexucabtagene autoleucel)	Revised
April 8, 2022	ING-CC-0029	Dupixent (dupilumab)	Revised
April 8, 2022	*ING-CC-0004	Repository Corticotropin Injection	Revised
April 8, 2022	ING-CC-0072	Selective Vascular Endothelial Growth Factor (VEGF) Antagonists	Revised

 

ABSCRNU-0315-22

 

We want to provide you with an update regarding the offering for City of New York retirees – the NYC Medicare Advantage Plus plan, an alliance between Empire BlueCross BlueShield and EmblemHealth.

 

The NYC Medicare Advantage Plus plan is not being implemented on April 1, 2022. All retirees will remain in their current plans until further notice.

 

What does this mean?

City of New York retirees will remain in their current plan until further notice and will not transition to the NYC Medicare Advantage Plus plan on April 1, 2022. At this time, City of New York retirees do not need to opt out of the NYC Medicare Advantage Plus plan in order to remain in senior care or their current plan.

 

Where should I submit claims?

Please continue to follow your current processes for claims submission for the City of New York retirees under your care. Those processes will not change on April 1, 2022, as City of New York retirees will remain in their current plan.

 

When will City of New York retirees transition to the NYC Medicare Advantage Plus plan?

A new effective date has not yet been determined. Detailed information will be made available regarding the new effective date once it has been established.

 

Thank you for your continued care for City of New York retirees.

 

ABSCRNU-0324-22

The new name will reflect the company's exciting strategy for the future.

 

We are very excited to share the news that our parent company, Anthem, Inc., has filed a preliminary proxy statement to change its name. The new name, pending shareholder approval, will be Elevance Health.

 

Please know that if the name change is approved by shareholder vote, the following will not change:

• Your contract, reimbursement, or level of support
• Your patients’ plan or coverage

 

We will continue to do business as Anthem Blue Cross and Blue Shield.

 

Why the change?

The upcoming name change reflects the company’s strategy to elevate the importance of whole health and to advance health beyond healthcare for our customers, their families, and our communities.

 

Our path forward is clear

We are thrilled to share our journey with you as our parent company continues its evolution from a traditional health benefits organization to a health company that looks beyond the traditional scope of physical health and how to best support it.

 

For more information, please read the press release.

 

Thank you for being our trusted health partner.

 

Bryony Winn

President, Anthem Health Solutions

Anthem, Inc.

 

ABSCARE-1421-22