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.

There may be times when a member requires a skilled home visit to assess their current status, instruct and reconcile medications, as well as instruct in early signs and symptoms of disease processes and complications to prevent hospitalization/re-hospitalization.

Skilled nursing (SN) and therapies such as physical therapy (PT), occupational therapy (OT), or speech therapy (ST) at home may be a needed option post a hospital or inpatient rehab stay. These service providers would keep you, the primary care provider, apprised of the member’s status.

We are working on two focus areas to assist members to get the care they need:

• Postpartum members
• Members with a sepsis diagnosis

Postpartum members

The State Department of Health has provided the guidance below regarding postpartum visits to Medicaid members as part of their benefit package. To attempt to improve New York State’s maternity morbidity and mortality rates, they provided the guidance below:¹

• All postpartum persons are eligible for one initial postpartum home visit after they give birth.
• Pregnant/postpartum persons are also eligible for home visits in pregnancy and/or additional postpartum visits if determined to be medically necessary by the principal maternal care provider.

Members with a sepsis diagnosis

Studies have shown that members with a sepsis diagnosis benefit from at least two post hospital home care skilled nursing visits:

• A National Institutes of Health (NIH) funded study showed that timely home health nursing visits and outpatient follow-up within seven days after hospital discharge, significantly reduced readmissions.
• 7 percentage point reduction in sepsis (41% relative reduction)².

We need your help

The first step in this process starts with you, the provider. We will need signed orders for the home health agency in the community to provide these home visits.

The process should begin while the member is still in the hospital as part of discharge planning. If the orders are not signed while the member is still in-patient, we will be reaching out to you to obtain the needed home health care orders.

Together, we can work towards improved outcomes.

Contact us

• Call the prior authorization at 212-563-5570, ext. 1062001261, option 3.

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.

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.

Background

In February 2022, updates to Clinical Utilization Management (UM) Guidelines were published with an August 1, 2022, effective date. These updates included changes to clinical coding edits for the lab test indicated below.

Update

The updated guidelines state that only medically necessary lab testing will be covered. Effective March 1, 2024, coverage for these labs will be denied unless medically necessary:

What if I have questions?

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 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 at the bottom of our provider's website for the appropriate contact.

Call to action

We need to rethink and refocus the way we care for people living with sickle cell disease (SCD). Anthem has created a comprehensive SCD care management program. The program partners with members and care providers to remove barriers to care, improve and facilitate treatment adherence, and increase the quality of life for people living with SCD. By focusing on the prevention of SCD complications and building strategies for effective pain management, we aim to reduce preventable emergency department (ED) utilization and hospital admissions.

Our goal is to ensure that members with SCD are receiving comprehensive whole person care that goes beyond treating SCD symptoms. We will provide disease education, medication adherence monitoring, care coordination, as well as connect members to community resources. By building trusting relationships between Anthem, members, care providers, and community resources, we empower our members to achieve the best quality of life possible.

To refer a Medicaid-enrolled member to the SCD Care Coordination program, call Provider Services at 800-450-8753.

Why this is important

SCD is a chronic condition and is the most common inherited red blood cell disorder in the United States affecting at least 100,000 Americans¹. The Center for Disease Control and Prevention (CDC) reports that SCD affects one out of every 365 Black and African American births and one out of every 16,300 Hispanic and Latin X births¹.

Most care providers are familiar with the unpredictable symptoms and long-term morbidities that individuals affected by SCD experience, including pain and vaso-occlusive crises, depression, and fatigue. Repeated vaso-occlusion, infarction, and chronic hemolytic anemia lead to organ dysfunction. More than half of people living with SCD have some organ disease and at least 24 percent have damage affecting multiple organs². Vaso-occlusive events can have devastating consequences across all age groups. For example, it is estimated that 50 percent of people with SCD will experience cerebral vasculopathy by age 14 and 25 percent of adults with SCD will experience a stroke by age 45.²

Care providers might lose sight of the high medical costs (estimated to be over $1 million per individual lifetime^6,1), barriers to care, and reduced quality of life people with SCD face. Despite medical advances in treatments such as medications and gene therapy, large discrepancies in both outcomes and mortality rates for people with SCD still remain. One startling national statistic shows that life expectancy for people with SCD is at least 22 years lower than that for people without SCD⁶. These gaps can be attributed to multiple factors including limited access to comprehensive care.

The effects of SCD on quality of life are often unrecognized. Patients with SCD are more likely than people without SCD to have lost workdays and missed school days because of time spent in the hospital or ED⁶. The prevalence of depression and anxiety among people with SCD is five times greater than that of the general population.²

Patient experience is linked to their perceptions of quality of care.¹⁰ Many people living with SCD report dissatisfaction with the quality of care they receive. Contributing factors to this dissatisfaction include perceptions of racial discrimination, feelings of being stereotyped as drug seekers who do not have legitimate pain, barriers to accessing specialty care, and lack of clinician comfort with disease management – especially pain.¹⁰

The presence of implicit racial bias in healthcare and perceptions of discrimination are directly linked to negative health experiences.² One example comes from a published study that showed people with sickle cell crisis in the ED waited 50 percent longer for pain treatment than patients who arrived with long bone fractures.³ In another study of ED wait times, patients with SCD waited an average of two hours longer for initial pain treatment compared to patients without SCD.³

Negative healthcare experiences lead to feelings of mistrust, which result in poor health outcomes. Patients with SCD who report experiences of discrimination are 53 percent more likely to report nonadherence to physician treatment recommendations.¹⁰ The lack of trusting relationships with healthcare providers correlates to low patient self-efficacy. This is compounded by obstacles related to social determinants of health which disproportionately affect many individuals living with SCD.

Many primary care providers (PCPs) have few, if any, patients with SCD in their practices. Surveys show that care providers are often uncomfortable with SCD management especially when it comes to pain treatment. People living with SCD will benefit from closer partnerships with their PCPs.

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 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 800-300-8181.

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 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 Empire BlueCross BlueShield 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.

HEDIS^® 2023 documentation for Blood Pressure Control for Patients With Diabetes (BPD)

Measure description

The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose blood pressure (BP) was adequately controlled (< 140/90 mm Hg) during the measurement year.

What we are looking for in provider records:

• Last BP documented in 2023 regardless of reading
• Evidence of hospice or palliative services in 2023
• Evidence patient expired in 2023
• Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes

Helpful hints:

• Take a second BP at the end of the office visit if initial BP was > 140/90.
• Consider taking BP at every visit.
• Counsel on healthy habits for managing high blood pressure.
• Encourage medication adherence.
• Member-reported BPs during a telehealth visit are acceptable.
• Review diabetic services needed at each office visit.
• For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).

HEDIS 2023 documentation for Hemoglobin A1c Control for Patients With Diabetes (HBD)

Measure description

The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) whose hemoglobin A1c (HbA1c) was at the following levels during the measurement year:

• HbA1c control (< 8.0%)
• HbA1c poor control (> 9.0%)

What we are looking for in provider records:

• Last HbA1c documented in 2023 regardless of result
• Evidence of hospice or palliative services in 2023
• Evidence patient expired in 2023
• Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes

Helpful hints:

• Counsel on healthy habits for managing diabetes.
• If appropriate, set an HbA1c goal of less than 7%.
• Encourage timely HbA1c testing.
• Encourage medication adherence.
• Encourage continuous glucose monitoring.
• In progress notes when documenting HbA1c value include date the test was performed.
• Review diabetic services needed at each office visit.
• For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).

HEDIS 2023 documentation for Eye Exam for Patients With Diabetes (EED)

Measure description

The percentage of members 18 to 75 years of age with diabetes (types 1 and 2) who had a retinal eye exam.

What we are looking for in provider records:

• Evidence of a retinal eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or year prior with results
• Bilateral eye enucleation any time during the member’s history
• Evidence of hospice or palliative services in 2023
• Evidence patient expired in 2023
• Documentation of polycystic ovarian syndrome, gestational diabetes, or steroid induced diabetes

Helpful hints:

• Refer patients to an optometrist or ophthalmologist for a dilated or retinal eye exam annually.
• Fundus/retinal photography is considered imaging and is eligible for use; must be dated and interpreted by an eye care professional.
• Counsel on healthy habits for managing diabetes.
• In progress notes when documenting a retinal eye exam include the name of eye care provider or optometrist/ophthalmologist credentials, date performed, and result.
• Encourage medication adherence.
• Review diabetic services needed at each office visit.
• For members who have not been diagnosed with diabetes but take a diabetes medication for off-label use, document why they are taking medication (for example, weight loss, congestive heart failure, chronic kidney disease, etc.).