The Department of Health & Human Services (HHS) requires health plans to report whether or not our in-network providers offer telehealth services.

If you provide telehealth services, please tell us by submitting your information to us through Availity.com. Updating your telehealth status will not affect your participation with us. We will add a telehealth indicator to your online provider directory profile, allowing our members to know you offer telehealth services.

If you have questions about submitting your information, please see the instructions below.

If your organization is not currently registered with Availity, you will need to create an account. The person(s) designated as your administrator(s) should go to Availity.com and select Get Started in the upper right corner of the webpage. You may also navigate directly to Availity’s registration website by selecting here.

Begin your application here. To update your application:

1. Log in to Availity Essentials.
2. Select My Providers.
3. Select Provider Data Management.

Please update your telehealth information at the service location.

Beginning with claims processing on or after December 1, 2024, we will update our outpatient facility claims editing process to deny claim lines when an add-on code is reported without a primary procedure code.

An add-on code is a specific type designated by the HCPCS or CPT^®. These codes describe additional procedures or services performed with a primary procedure.

According to CPT guidelines, add-on codes must be reported with a primary procedure code.

If you believe you have received a claim denial in error, please follow our claim dispute process.

With your help, we can continually build towards a future of shared success.

General Availability Standards

Members must be able to access their PCP 24 hours a day, 7 days a week. As the Member’s healthcare manager, the PCP is responsible for providing or arranging healthcare services on a 24/7 basis. (An answering machine does not suffice as access to the Provider.) The PCP must also have a method to inform his or her Anthem Members about regular office hours and how to obtain care after office hours.

When off-duty or otherwise unavailable, the PCP must arrange for back-up coverage by a network physician so that appropriate medical care is available to Members at all times. The PCP must have available the name, telephone number and address of the physician(s) responsible for providing back-up services to patients. The PCP should contact Anthem Physician Services at 800-552-6630, 8:30 a.m. to 5:00 p.m. ET, Monday to Friday or Provider Data Management via fax at 518-367-3103 if the designated back-up changes.

The designated back-up physician(s) must participate in the same network and be a comparably trained practitioner as noted below:

• Family Practice – can be backed up by a Provider with the following specialties:
  Family Practice; General Practice and/or a combination consisting of Internal Medicine – for adults and Pediatrics for Children.
• General Practice – can be backed up by a Provider with the following specialties:
  Family Practice; General Practice and/or a combination consisting of Internal Medicine –for adults and Pediatrics for Children.
• Internal Medicine – can be backed up by a Provider with the following specialties:
  Internal Medicine or Family Practice.
  Pediatrics – can be backed up by a Provider with the following specialties:
  Family Practice or Pediatrics

The back-up physician is responsible for communicating with the PCP about patient care he or she rendered. Documentation of all healthcare services provided by the back-up physician must be summarized in the patient’s medical record including all pertinent Facility services.

If a Member is out of the area and contacts Anthem with an urgent or emergent situation, the patient will be informed to call his or her PCP directly. If this is not possible, the patient will be told to contact the PCP’s back-up physician.

Annually, Anthem will conduct an audit of the after hour availability coverage for PCP network participation to ensure compliance.

Compliance will be met if:

• A live person is reached within two (2) phone calls.
• If an answering service is reached; compliance will be met if the service is cooperative in confirming their association with the physician and identifies how the physician can be reached (ex. pager; calls patched to physician)

In no event shall the messages refer the Member to the ER unless it is a true emergency or advise to call back during normal business hours.

Appointment Availability Standards

The following are considered minimums for patient accessibility. Obviously, excellent care and service will often require significantly better performance.

For HMO and POS Members, the PCPs must be in the office treating patients a minimum of 16 hours a week per office location.

Patients should not wait for more than 15 minutes past their appointment time without an explanation about the delay and if necessary, provided with an opportunity to reschedule the appointment.

• The physician must be able to schedule appointments within the following time frames:
• Type of Appointment Time Frame
• Routine baseline physical exam Within 4 weeks
• Routine follow-up care Within 2 weeks
• Urgent Care Within 24 hours
• Non-Urgent Care Within 5 days
• Emergency Care Within 2 hours or triage to emergency room
• Initial prenatal exam Within 3 weeks
• Initial newborn exam Within 2 weeks
• Availability standards will be monitored through:
  • On-site visits by Network Management Consultant,
  • Review of appointment books,
  • Member satisfaction surveys, and
  • Member complaints

PHYSICIAN RESPONSIBILITIES

All participating Providers are expected to comply with certain standards regardless of the networks in which they participate. These include:

• Following Anthem’s access/appointment availability standards
• Following Anthem’s managed care requirements (if applicable to the Member’s benefit plan). Adhering to Anthem’s standard practice guidelines
• Submitting Claims for Members, accepting program/network fee schedule and not balance billing Members for covered services
• Not prohibiting Members from completing Anthem surveys and/or otherwise expressing their opinion regarding services received from physicians or Providers
• Will not differentiate or discriminate against any Member as a result of his/her enrollment in a Plan, or because of race, color, creed, national origin, ancestry, religion, sex, marital status, age, disability, payment source, state of health, need for health services, status as a litigant, status as a Medicare or Medicaid beneficiary, sexual orientation, or any other basis prohibited by law. Provider shall not be required to provide any type, or kind of Health Service to Covered Members that it does not customarily provide to others.

HMO Physicians

Physicians participating in the HMO-based networks have certain additional responsibilities, based upon their roles as primary care physicians and/or referral specialists.

Primary Care Physicians

A Primary Care Physician (PCP) is a family physician/family practitioner, general practitioner, internist or pediatrician who is responsible for delivering and/or coordinating care. PCPs must:

• Be accessible 24 hours a day, 7 days a week, and provide back-up coverage
• Provide or arrange for all care delivered to HMO Members
• Provide written referrals to referral specialists, to the extent required by the Member’s benefit plan

To ensure continuous 24-hour coverage, primary care physicians (PCP) must maintain one of the following arrangements for their members to contact the PCP after normal business hours:

• Have the office telephones answered after-hours by an answering service, which can contact the PCP or another designated network medical practitioner.
• Have the office telephone answered after normal business hours by a recording in the language of each of the major population groups served by the PCP, directing the member to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider’s telephone; another recording is not acceptable.
• Have the office telephone transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP or a designated Anthem network medical practitioner.

In July, we announced an enhancement to the 277CA to notify you of submission errors discovered during claims processing.  

As of November 1, 2024, the 277CA will include additional corrective action types for your review. As communicated in July, these errors will still be sent through physical mailing.

With these added error types, there is no reduction to the services we already provide.

Through our efforts, we are committed to reducing administrative burden, improving communication, and ensuring timely payments because we value you, our care provider partners.

Find Care, the doctor finder and transparency tool in the Anthem online directory, provides Anthem members with the ability to search for in-network providers using the secure member website. This tool currently offers multiple sorting options such as sorting providers based on distance, alphabetical order, and provider name.

In our November 2022 newsletter, we provided an update regarding Personalized Match, an additional Find Care sorting option for Commercial members. We informed you that this provider sorting option was based on provider efficiency and quality outcomes described in a methodology document linked in the newsletter article, in addition to member search radius.

We want to inform you that, beginning in December 2024 or later, we will be enhancing Personalized Match. This will expand upon the existing program. Newer components of the provider personalization metrics will contain up to 10 times as many features as compared to existing metrics such as gaps in care and additional types of service cost and utilization. Personalized Match will continue to display providers with the highest overall ranking within the member’s search radius, first. Members will continue to have the ability to sort based on distance, alphabetical order, and provider name.

Helpful resources on Availity

You may review a copy of the Personalized Match methodology that has been posted on Availity, our secure web-based provider tool, using the following navigation:

• Go to Availity > Payer Spaces > Health Plan > Education & Reference Center > Administrative Support > Personalized Match Methodology.pdf.

If you have general questions regarding these upcoming changes, please submit an inquiry via the web at Availity.com. If you would like information about your quality or efficiency scoring used as part of this sorting option or if you would like to request reconsideration of those scores, you may do so by submitting an inquiry to Availity.com.

Anthem will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.

We are excited to announce the release of an Applied Behavior Analysis (ABA) Provider Resource Guide designed to assist with proper billing and documentation practices. This essential guide simplifies the complexities of ABA coding and requirements, ensuring that you can navigate these processes with ease. 

Refer to attached ABA Provider Resource Guides.

As respiratory syncytial virus (RSV) season approaches, we would like to remind providers about available RSV immunizations to help prevent severe RSV related disease in infants. According to a report from the CDC (March 2024), infant preventive antibodies showed 90% effectiveness against the need for hospitalization for RSV in babies. Two immunizations are available to prevent RSV lower respiratory tract infections in infants:

• Pfizer's Abrysvo, a maternal vaccine given during pregnancy
• Nirsevimab (Beyfortus), a monoclonal antibody administered to the baby

The maternal vaccine, Abrysvo, is recommended for those who are 32 to 36 weeks pregnant during RSV season, which generally falls between October and March. The vaccine can provide protection for infants up to six months if the mother receives it at least two weeks prior to delivery.

Nirsevimab (Beyfortus) provides up to five months of protection against RSV and is approved for infants under 8 months during their first RSV season, and certain children between 8 and 19 months at increased risk of severe RSV disease. In some cases where a mother received an RSV vaccine, Nirsevimab can still be considered for the child if there is a substantial risk for severe RSV disease or if the maternal immune response to the vaccination is inadequate.

Nirsevimab is covered under the Vaccines for Children Program. Additional information about RSV prevention and Nirsevimab (Beyfortus) can be found at cdc.gov/rsv.

We look forward to sharing resources and working with you to achieve improved outcomes for children in our communities.

As a contracted provider for a special needs plan (SNP) from Anthem, you are required to participate in an annual Model of Care training for providers, per CMS regulations. This training includes a detailed overview of Anthem special needs plans and program information, highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Please remember this training is specific to our plans and delivery of care for members, ensuring their specific care needs are met. Your participation is critical for improved quality and health outcomes.

Training for the SNP product is self-paced and available at Availity.com. The training must be completed by December 31, 2024.

How to access the Custom Learning Center:

1. Log in to the Availity website at Availity.com.
2. At the top of the Availity website, select Payer Spaces and select the appropriate payer.
3. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
4. In the Custom Learning Center, select Required Training.
5. Select Special Needs Plan and Model of Care Overview.
6. Select Enroll.
7. Select Start.
8. Once the course is completed, select Begin Attestation and complete.

Not registered for Availity Essentials?

Have your organization’s designated administrator register your organization for the Availity website:

1. Visit Availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

Refer to these PDF documents for complete registration instructions.

In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care, effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here.

Site of Care Guidelines:

• Site of Care for Advanced Imaging
• Rehabilitative Site of Care
• Surgical Site of Care

Please share this notice with other members of your practice and office staff.

In the July 2024 edition of Provider News, we announced the transition to the following Carelon Medical Benefits Management guidelines: Site of Care for Advanced Imaging, Rehabilitative Site of Care, and Surgical Site of Care effective September 1, 2024. To clarify, existing prior authorization requirements have not changed, and this does not equate to the presence of a site of care review requirement. In the event a site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such requirements.

You may access and download a copy of the current and upcoming guidelines here:

• Site of Care Guidelines:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

Please share this notice with other members of your practice and office staff.

Effective on November 17, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management, Inc. guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.

You may access and download a copy of the current and upcoming guidelines here:

• Musculoskeletal:
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

The above guideline updates have a publish date of November 17, 2024.

Please share this notice with other members of your practice and office staff.

Effective on November 30, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines updates will be adopted for Anthem. This article is to communicate the plan adoption of these Clinical Appropriateness Guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.

You may access and download a copy of the current and upcoming guidelines here.

• Musculoskeletal:
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

The above guideline updates have a publish date of November 17, 2024.

Please share this notice with other members of your practice and office staff.

At a glance:

• High Performing Providers will also be known as Anthem Diamond Providers.
• Providers receiving a designation based on the Blue National Physician Performance Dataset will also be known as Anthem Diamond Providers (National).

High Performing Provider program

Over the last several months, we have communicated with our providers about our High Performing Provider program. PCPs and specialists meeting certain criteria are designated High Performing Providers. High Performing Providers may also be referred to as Anthem Diamond Providers.

As a reminder, the following specialties may be designated High Performing Providers (aka Anthem Diamond Providers) from this program:

• PCP: family practice, general practice, geriatric medicine, internal medicine, pediatric medicine, and nurse practitioners
• Specialists: cardiology, endocrinology, nephrology, neurology, neurosurgery, obstetrics gynecology, orthopedic surgery, psychiatry, pulmonology, and rheumatology

If you have any questions about this program, contact Provider Services or your local provider relationship management representative.

Blue National Physician Performance Dataset

This is an Anthem designation program for providers in networks supporting Anthem national accounts and certain out-of-area providers.

As we previously communicated to you, effective January 1, 2025, Anthem may incorporate insights from the Blue National Physician Performance Dataset (Dataset) in various initiatives. For Anthem national accounts and certain out-of-area providers, Anthem will use data made available in the Dataset to assess individual physician’s performance at the NPI level. The individual physician’s performance is assessed across the three domains — cost of care/efficiency, quality of care, and appropriateness of care — for the following 16 primary care and specialty areas: cardiothoracic surgery, cardiovascular disease, endocrinology, neurology, ob/gyn, ophthalmology, orthopedics, pediatrics, primary care, pulmonology, surgery, urology, gastroenterology, otolaryngology, oncology, and radiation oncology.

The providers who qualify for the designation from this Dataset program will also be referred to as Anthem Diamond Providers (National).

If you have any questions regarding this, contact your local provider relationship management representative.

At a glance:

• Care providers must prepare for HEDIS^® medical record reviews starting January 2025.
• Care providers will submit records through Remote Electronic Medical Record (EMR) Access Service, website upload, fax, secure file transfer protocol (SFTP), mail, or on-site.

Background

Each year, we perform a review of a sample of our members’ medical records as part of the HEDIS quality study. HEDIS is part of a nationally recognized quality improvement initiative and is used by the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and several states to monitor the performance of managed care organizations.

We will begin requesting medical records in January 2025. No special authorization is needed for you to share member medical record information with us since quality assessment and improvement activities are routine parts of healthcare operations.

Ways to submit your records in our preferred order:

• Remote EMR Access Service: We offer the Remote EMR Access Service to care providers to submit member medical record information to us. If you are interested in more information, contact us at Centralized_EMR_Team@anthem.com.
• Upload: Medical records can be uploaded to our secure website using the instructions in the request document.
• Fax: Medical records can be faxed to us using the instructions in the request document.
• SFTP: Medical records can be uploaded via a secure website.
• U. S. Postal Service: Medical records can be mailed to us using the instructions in the request document.
• On-site: Medical records can be pulled by a representative at your local office where medical records are located.

HEDIS review is time sensitive, so submit the requested medical records within the timeframe indicated in the initial HEDIS request document.

We appreciate the care you provide our members. Your assistance is crucial to ensuring our data is statistically valid, auditable, and accurately reflects quality performance.

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.

The Consumer Assessment of Healthcare Providers and Systems^® (CAHPS) is an annual standardized survey conducted anonymously by a third-party vendor (Center for the Study of Services) to assess a random sample of consumers' experiences with their health plan, their personal provider, and healthcare services.

Refer to attachment to view full details.