Managing illness can sometimes be a difficult thing to do. Knowing who to contact, what test results mean or how to get needed resources can be a bigger piece of a health care puzzle that for some, are frightening and complex issues to handle.

Anthem is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the number located in the grid below.  They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

How do you contact us?

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Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements starred (*) below.

• Prior authorization updates for specialty pharmacy are available*
  
  
• Medical Policy update*
  
  
• Updates to AIM Cardiology clinical appropriateness guidelines*
  
  
• Updates to AIM Advanced Imaging clinical appropriateness guidelines*
  
  
• Updates to AIM Radiation Oncology clinical appropriateness guidelines*
  
  
• Reimbursement policy update: Bundled services and supplies (Professional)*

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. Anthem Blue Cross and Blue Shield (Anthem)’s medical policies are available on Anthem’s website at anthem.com.

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below. 

UM criteria are also available on the web. Just go to anthem.com, then select the Providers tab at the top of the webpage > under Provider Resources select Policies, Guidelines & Manuals > select your state > scroll down and select View Medical Policies and Clinical UM Guidelines.

We work with providers to answer questions about the UM process and the authorization of care. Here’s how the process works:

• Call us toll free from 8:30 a.m. to 5:00 p.m. Eastern time, Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program hours are 8:00 a.m. to 7:00 p.m. Eastern time.
• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after 12 midnight will be returned the same business day. 
• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

Our UM associates identify themselves to all callers by first name, title and our company name when making or returning calls. They can inform you about specific UM requirements, operational review procedures, and discuss UM decisions with you.

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.

The following phone lines are for physicians and their staffs. Members should call the customer service number on their health plan ID card.

TTY Information

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The delivery of quality health care requires cooperation between patients, their providers and their health care benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement. It can be found on our website, under the FAQ question about “Laws and Rights that Protect You.” 

To access, go to anthem.com and select “Provider.” From there, select “Policies, Guidelines & Manuals” under Provider Resources.  Select your state, and scroll down to “Member Rights and Responsibilities” under More Resources. Click the “Read about member rights” link. 

Practitioners may access the FEP member portal at fepblue.org/memberrights to view the FEPDO Member Rights Statement.

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Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. Anthem Blue Cross and Blue Shield (Anthem) would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners.

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. Anthem urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other health care practitioners at the time treatment begins.

We expect all health care practitioners to:

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
   - Diagnosis
   - Treatment plan
   - Referrals
   - Psychopharmacological medication (as applicable)

In an effort to facilitate coordination of care, Anthem has several tools available on the provider website including a coordination of care form and coordination of care letter templates for both behavioral health and other medical practitioners.* Behavioral health tools are available, which includes forms, brochures, and screening tools for substance abuse, ADHD, and autism. Please refer to the website for a complete list.**

*Access to the forms and template letters are available at www.anthem.com/provider/forms/

**Access to the Behavioral Health tools are www.anthem.com/provider/forms/

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Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form, on anthem.com.

The impact of COVID-19 in 2020 prohibited Anthem from conducting the annual after-hours access studies to assess phone messaging for our members for perceived emergency or urgent situations after regular office hours.  We will resume the survey in the second quarter of 2021 and expect when your office is contacted, you will be able to accommodate a member’s urgent concerns after hours.

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

Emergency situations

The 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 doctor.

Urgent situations

The compliant response for urgent needs would direct the caller to urgent care or ER, to call 911 or connect the caller to their doctor or the doctor on call.

Messaging that only gives callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions is not complaint, as there is no direct connection to their health care practitioner. This prompt can be used in addition to, but not in place of the emergency and urgent instructions. 

Is your practice compliant?

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As of December 1, 2020, the providers listed below are participating air ambulance providers with Anthem Blue Cross and Blue Shield (Anthem). That means, for members picked up in Ohio, these participating providers have contractually agreed to accept the Anthem Rate as payment in full for approved and medically necessary transport, and will bill those members for cost-shares only.

Some air ambulance providers choose not to participate with Anthem. 

• These air ambulance providers may, and often do, charge members rates that are significantly higher than the Anthem contracted provider rates.
• These non-contracted air ambulance providers attempt to collect from Anthem members the difference between Anthem’s allowed amount and their billed amount.

To help Anthem members avoid the high costs of air transportation from non-contracted providers, we ask that, whenever possible, you choose a participating air ambulance provider for your patients who are Anthem members.

Utilizing participating providers:

• Protects the member from balance billing for what may be excessive amounts,
• Assures the most economical use of the member’s benefits, and
• Is consistent with your contractual obligations to refer to in-network providers where available.

To schedule fixed wing or rotary wing air ambulance services, please:

1. Contact Anthem for precertification for all non-emergent transports, using the number on the back of the member’s ID card, then
2. Call one of the phone numbers listed below.

Please have the following information ready when you call one of the contracted air ambulance providers:

• Basic medical information about the patient, including the patient’s name and date of birth or age.  If the service was not pre-certified with Anthem, the air ambulance provider will also need to receive a full medical report from the attending facility.
• Current location of the patient, the name of the hospital or facility caring for the patient and its address (city and state)
• Location where patient is to be transported, including the name of the destination hospital/facility and address
• Approximate transport date or timeframe
• Special equipment or care needs

Should you have questions regarding the air ambulance network, including providers contracted for air ambulance pickups outside of Ohio, please contact your Provider Network Manager.

Anthem contracted air ambulance providers for Ohio

First, call Anthem for precertification if required by the member’s policy.
Then call one of the following: 

Fixed Wing (Airplane) Providers (HCPCS codes: A0430 & A0435)

Rotary Wing (Helicopter) Providers (HCPCS Codes: A0431 & A0436)

To arrange air transport originating outside the U.S., U.S. Virgin Islands, and Puerto Rico: Call 800-810-BLUE for BCBS Global Core (formerly BlueCard Worldwide)

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The Provider Digital Engagement Supplement is another example of how Anthem Blue Cross and Blue Shield (Anthem) is using digital technology to improve the health care experience. The Supplement outlines Anthem provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits all in one comprehensive resource. We want providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.

Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:

• File claims
• Check statuses
• Verify eligibility and benefits
• Submit prior authorizations

Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit the Availity EDI website.

Get payments faster

Eliminate paper remittances

Member IDs go digital

Having a member email their ID card directly to you for file upload eliminates the need for you to scan or print, making it easier for you and the member. Member ID cards can also be accessed from the Availity. Save time by accepting the digital member ID cards when presented by the member via their App or email.

Read more about going digital with Anthem in the Provider Digital Engagement Supplement available online. Go to anthem.com, select Providers, under the Provider Resources heading select Forms and Guides. Pick your state if you haven’t done so already.  From the Category drop down, select Digital Tools, then Provider Digital Engagement Supplement.

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Are you looking for creative ways to talk to your patients about certain preventive care services such as breast cancer screening and adolescent vaccinations including the HPV vaccination?  As flu season approaches, do you want a way to educate your patients about the dangers of antibiotic resistance? Short educational videos, approximately two minutes in length, are available on anthem.com > Providers > Forms and Guides > under the Category heading, select Patient Care.

By providing education and addressing common fears and concerns, these brief videos offer an alternative approach to patient engagement on these important topics. Take a look today!

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We want to make you aware of upcoming changes to the BlueCard^® Provider Manual.

This updated BlueCard Provider Manual will replace the current BlueCard Provider Manual effective March 1, 2021.

The manual includes enhanced content and should be helpful in understanding the BlueCard Program that enables members of one Blue Plan to obtain health care service benefits while traveling or living in another Blue Plan’s service area.

We have posted the updated Provider Manual to the public provider website at anthem.com. To view the new manual, visit anthem.com, select Provider, and select the Policies, Guidelines & Manuals. Select Ohio followed by Provider Manual Download the Manual or click here.

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Through predictive analytics, health care teams can now receive real-time solutions to claim denials

Anthem is committed to providing digital first solutions. Our health care teams can now use self-service tools to reduce the amount of time spent following up on claim denials. Through the application of predictive analytics, Anthem has the answers before you ask the questions. With an initial focus on claim-level insights, Anthem has streamlined claim denial inquiries by making the reasons for the claim denial digitally available. In addition to the reason for the denial, we supply you with the next steps needed to move the claim to completion. This eliminates the need to call for updates and experience any unnecessary delays waiting for the EOB.

Access Claims Status Listing on Payer Space from our secure provider portal through anthem.com using the Log In button or through availity.com. We provide a complete list of claims, highlight those claims that have proactive insights, provide a reason for the denial, and the information needed to move the claim forward.

Claim resolution daily

Automated updates make it possible to refresh claims history daily. As you resolve claim denials, the claim status changes, other claims needing resolution are added, and claims are resolved faster.

Anthem has made it easier to update and supply additional information, too. While logged into the secure provider portal, you have the ability to revise your claim, add attachments, or eliminate it if filed in error. Even if you did not file the claim digitally, you can access the proactive insights. Predictive analytics supplies the needed claim denial information online – all in one place.

Predictive proactive issue resolution and near real-time digital claim denial information is another example of how Anthem is using digital technology to improve the health care experience.

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Anthem Inc. and Quest Diagnostics have entered into a strategic relationship by collaborating on a variety of outcomes-based programs designed to create an improved health care experience for consumers and providers beginning August 1, 2020.

Anthem and Quest will work together to improve efficiency in care delivery and reduce overall costs by leveraging a broad range of tools and programs to drive operational improvements, create pricing transparency, and enhance health care consumer engagement and outcomes.  The strategic relationship will focus on consumers in California, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, New York, Ohio, Virginia, and Wisconsin.

Please note that the joint press release may be accessed at https://newsroom.questdiagnostics.com/2020-08-17-Anthem-and-Quest-Diagnostics-Form-Strategic-Relationship.

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New health plans built around Anthem’s Blue High Performance Network will take effect January 1, 2021.

Blue HPN® plans offer access to providers with a record of delivering high-quality, efficient care. Blue HPN networks will go live January 1, 2021 in more than 50 cities across the country, including in the Cincinnati, Cleveland-Elyria and Columbus metro areas.

Blue HPN is a national network designed from our local market expertise, deep data and strong provider relationships, and aligned with local networks across the country. These local networks are then connected to the national chassis to form a national Blue HPN network.

If you are not sure whether your practice is part of the Blue HPN, ask your office manager or business office, or contact your Anthem Provider Relations Representative. Blue HPN participation will be displayed in provider profiles in our online provider directory January 1, 2021.

In Ohio, Anthem is offering large and small group employer plans with access to the HPN Network, calling the network for those plans Blue Connection.

Beginning January 1, you may see patients accessing this network through either a small group, large group, or national account plan. These will be HMO plans or HSA plans with an HMO network. Under these plans, out of network benefits are limited to emergency or urgent care. Members must select a primary care provider, but PCP referrals are not required for specialty care.

Large group Blue HPN health plans sold in Ohio will have a plan prefix of H8H, small group plans will have a prefix of H9H, and MEWA plans will have a prefix of H6Q.  Keep in mind that other prefixes may be part of HPN plan member IDs. The new “Blue High Performance Network” logo and “HPN” indicator in the suitcase icon are the most reliable indicators that a member is enrolled in an HPN plan.

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Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form, on anthem.com.

The impact of COVID-19 in 2020 prohibited Anthem Blue Cross and Blue Shield (Anthem) from conducting the annual appointment access studies to assess how well practices meet appointment access requirements for our members for behavioral health care (BH). We will resume the survey in second quarter 2021 and expect when your office is contacted, you will be able to accommodate a member’s needs in a timely manner.

To be compliant, per the Provider Manual, providers should meet the following access standards:

• Non-life-threatening emergency – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or a covering Practitioner within six hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate.
  
  Explanation: These calls concern members in acute distress, whose ability to conduct themselves for their own safety, or the safety of others, may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. The situation has the potential to escalate into an emergency without clinical intervention.
  
  

• Urgent – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or by a covering Practitioner within 48 hours. 
  
  Explanation: These calls are non-emergent with significant psychological distress, when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
  
  

• Initial Routine office visit – A new patient must be seen in the office by a designated BH Practitioner or another equivalent Practitioner in the practice within 10 business days. It can be after the intake assessment or a direct referral from a treating Practitioner.
  
  Explanation: This is a routine call for a new patient defined as a patient with non-urgent symptoms, which present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
  
  

• Routine office visit – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or by a covering Practitioner within 30 calendar days.
  
  Explanation: These calls concern existing members, to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
  
  

• BH follow-up appointment after discharge – The patient must be seen in the office by their Practitioner or another Practitioner in the practice within 7 calendar days.
  
  Explanation: These calls concern members being released from inpatient psychiatric hospital care, requesting a follow-up appointment to evaluate what has taken place since release, including med management.

Methods used to monitor adherence to these standards consist of assessing the accessibility of appointments via phone calls from North American Testing Organization, a vendor working on Anthem’s behalf, and analysis of member complaint and member experience data.

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Introducing the Anthem Blue Cross and Blue Shield (Anthem) Provider Digital Engagement Supplement to the provider manual

Using our secure provider portal or EDI submissions (via Availity*), administrative tasks can be reduced by more than 50% when filing claims with or without attachments, checking statuses, verifying eligibility, benefits and when submitting prior authorizations electronically. In addition, it could not be easier. Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, please visit the Availity EDI website or the secure provider portal via Availity.

Get payments faster

By eliminating paper checks, electronic funds transfer (EFT) is a digital payment solution that deposits payments directly into your account. It is safe, secure and will deliver payments to you faster. Electronic remittance advice (ERA) is completely searchable and downloadable from the Availity Provider Portal or the EDI 835 remittance, which meets all HIPAA mandates — eliminating the need for paper remittances.

Member ID cards go digital

Members who are transitioning to digital member ID cards, will find it is easier for them and you. The ID card is easily emailed directly to you for file upload, eliminating the need to scan or print. In addition, the new digital member ID card can be directly accessed through the secure provider portal via Availity. Providers should begin accepting the digital member ID cards when presented by the member.

Anthem makes going digital easy with the Provider Digital Engagement Supplement

From our digital member ID cards, EDI transactions, application programming interfaces and direct data entry, we cover everything you need to know in the Provider Digital Engagement Supplement to the provider manual, available at https://www.anthem.com/medicareprovider > select your state > Providers > Policies, Guidelines & Manuals, and on the secure Availity Provider Portal. The supplement outlines our provider expectations, processes and self-service tools across all electronic channels Medicaid and Medicare, including medical, dental and vision benefits.

The Provider Digital Engagement Supplement to the provider manual is another example of how Anthem is using digital technology to improve the health care experience. We are asking providers to go digital with Anthem no later than January 1, 2021, so we can realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration. Read the Provider Digital Engagement Supplement now by going to https://www.anthem.com/medicareprovider > select your state > Providers > Policies, Guidelines & Manuals. Go digital with Anthem.

Go digital with Anthem.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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Click here for more information about the Policy Update — Emergency Department: Leveling of Evaluation and Management Services.

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

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

To view a guideline, visit https://www11.anthem.com/search.html.

Updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• 00134 – Noninvasive Heart Failure and Arrhythmia Management and Monitoring System:
  • Revised Investigational and Not Medically Necessary indications
• 00156 – Implanted Artificial Iris Devices:
  • Revised Investigational and Not Medically Necessary indications
• 00157 – Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis:
  • Revised Investigational and Not Medically Necessary indications
• CG-DME-07 – Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output:
  • Revised Medically Necessary and Not Medically Necessary indications
• 00052 – Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling:
  • Revised Medically Necessary indications
• 00077 – Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques:
  • Expanded scope and revised Investigational and Not Medically Necessary indications
• 00112 – Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures):
  • Revised scope, and Investigational and Not Medically Necessary indications
• CG-REHAB-12 – Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology:
  • A new clinical UM Guideline was created from content contained in CG-REHAB-04, CG-REHAB-05, CG-REHAB-06.
  • There are no changes to the guideline content.
  • Publish date is scheduled for December 8, 2020.
• The following AIM Specialty Health_®* Clinical Appropriateness Guidelines have been revised and will be effective on December 6, 2020. To view AIM guidelines, visit the AIM Specialty Health page:
  • Interventional Pain Management (See August 16, 2020, version.)*
  • Chest Imaging (See August 16, 2020, version.)*
  • Oncologic Imaging (See August 16, 2020, version.)*
  • Sleep Clinical Guidelines (See August 16, 2020, version.)*

Medical Policies

On August 13, 2020, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect December 6, 2020.

Clinical UM Guidelines

On August 13, 2020, the MPTAC approved the following Clinical UM Guidelines applicable to Anthem. These guidelines adopted by the medical operations committee for Medicare Advantage members on
September 24, 2020. These guidelines take effect December 6, 2020.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.

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Effective January 1, 2021, Pilkington North America, Inc. will offer an Anthem Blue Cross and Blue Shield (Anthem) PPO plan. Retirees with Medicare Parts A and B are eligible to enroll in the Local Preferred Provider Organization (LPPO) product. The plan includes the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. The Medicare Advantage plan offers the same hospital and medical benefits that Medicare covers and also covers additional benefits that Medicare does not, such as an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online* and SilverSneakers^®.*

The prefix on Pilkington North America, Inc. member ID cards will be ZVR. The cards will also show the Pilkington North America, Inc. name and National Access Plus icon.

Providers may submit claims electronically using the electronic payer ID for the Anthem plan in their state or submit a UB-04 or CMS-1500 form to the Anthem plan in their state. Claims should not be filed with Original Medicare. Contracted and non-contracted providers may call the provider services number on the back of the member ID card for benefit eligibility, prior authorization requirements and any questions about Pilkington North America, Inc. member benefits or coverage.

Detailed prior authorization requirements also are available to contracted providers by accessing the Availity* Provider Self-Service Tool at availity.com.

* LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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How do I check eligibility and benefits for these members?

Online — Eligibility, benefits, claims, links to secure messaging, commonly used forms and remit information are all available through the Availity* Portal at availity.com. For questions on access and registration, call Availity Client Services at 1-800-AVAILITY (1-800-282-4548). Availity Client Services is available Monday through Friday, 8 a.m. to 7 p.m. ET (excluding holidays) to answer your registration questions.

Phone — Call the Provider Service number on the back of the member’s ID card. You may also verify a member’s eligibility by calling the BlueCard Eligibility Line at 1‑800‑676‑BLUE (2583) and providing the member’s three-digit alpha prefix located on the ID card.

As new members enroll in Group Retiree Medicare Advantage plans under Anthem Blue Cross and Blue Shield, they will receive new ID cards. Additionally, existing members may receive new ID cards as a result of benefit changes. Please continue to check member ID cards to ensure you have the most up-to-date eligibility and benefit information.

Please note that we are experiencing an unusually high volume of changes for an effective date of January 1, 2021. Many of the changes do not affect member prefix, member ID or benefits, but some changes will. Because of this, we encourage providers to request a copy of the member’s ID card, particularly at the beginning of the year when members may have new ID cards.

What are the alpha prefixes for Group Retiree Medicare Advantage PPO members?

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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Anthem Blue Cross and Blue Shield (Anthem) and agilon health,* doing business in Ohio as CORE Care Select (CCS), have been partners in a value-based relationship providing Anthem members enrolled in Medicare Advantage with high-quality services to enable them to achieve their best health. The strong relationship between Anthem and CCS continues to grow, and in light of that growth, the time was right to re-evaluate our processes and make some revisions.

The current agreement between Anthem and CCS included delegation of certain Anthem functions to CCS (utilization management, claims payment, provider services, etc.) for members attributed to providers affiliated with CCS (listed below). Anthem and CCS have mutually decided to discontinue the delegation components of our agreement at the end of 2020:

• COPC Senior Care Advantage — a partnership with Central Ohio Primary Care Physicians
• Paradigm Senior Care Advantage — a partnership with Pioneer Physicians Network
• Greater Dayton Senior Care Advantage — a partnership with Premier Integrated Medical Associates (PriMed Physicians)
• Trusted Senior Care Advantage — a partnership with the Physicians Group of Southeastern Ohio

This change will become effective on January 1, 2021, for dates of service on that date and beyond. CCS will continue to manage all runout for service dates that occurred in 2020.

Effective January 1, 2021, member ID cards will no longer include the Senior Care Advantage names identified above, but will continue to include the name of the member’s designated primary care provider.

This decision was arrived at jointly and will mark an end to the three-year period of delegation. Steve Sells, agilon’s CEO, stated that it was time to focus on areas where the company could create the greatest positive impact for their partners and the patients they serve. Anthem’s Kelly Owen, Regional Vice President, Ohio Provider Collaboration, acknowledged that this chosen path plays to both parties’ respective strengths and reiterated that the partnership between Anthem and agilon health remains strong.

Q&A:

1. When will this change become effective?
   Delegation of certain services granted by Anthem to CCS will end as of midnight on December 31, 2020.
   
   
2. What are the specific services affected?
   Utilization management, claims payment services, credentialing, provider services and care management.
   
   
3. What impact will this change have on Anthem members enrolled in Medicare Advantage in 2021?
   Members will receive new ID cards, which will no longer show the name of the Senior Care Advantage program on their face. Otherwise, the members should experience no other changes.
   
   
4. Will members be asked to change their primary care physician as a result of this?
   No, members may continue with their designated primary care physician as they have in the past. As always, members may change their PCP at any time by contacting Anthem Member Services at the number on the back of their ID card.
   
   
5. What happens if my claim is sent to CCS for a service received in 2021?
   The claim will be denied back to the provider with instructions to file the claim to the local Anthem location.
   
   
6. What happens to an authorization I had approved by CCS in 2020 for a service that won’t occur until 2021?
   CCS will send Anthem a file of all approved, open authorizations for dates of service in 2021 so that Anthem can apply them appropriately as claims are received.
   
   
7. Will members be able to track their claims on Anthem’s Member Portal?
   Yes, all claims with dates of service in 2021 will be displayed on this portal.
   
   
8. Where do I call next year if I have a question on how a claim was paid in 2020?
   CCS will continue to support the Provider Services line (1-833-440-5652) well into 2021 to address any questions on claims incurred in 2020.
   
   
9. What if I had a contract with CCS but not with Anthem’s Medicare Advantage network? Must I stop seeing Anthem patients enrolled in Medicare Advantage in 2021?
   These members will only have in-network benefits when covered services are rendered by a provider contracted with Anthem for the member’s plan.
   
   
10. What if a patient is admitted to a facility in late December 2020 and is not discharged until January 2021? Where is this claim sent for processing?
    CCS will be responsible for any admissions that begin prior to January 1, 2021, even when the member remains inpatient after January 1, 2021. CCS will also continue to provide concurrent review services for members admitted prior to January 1, 2021, until the member is discharged.

* agilon health is an independent company providing physician support services on behalf of Anthem Blue Cross and Blue Shield.

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Summary of benefits, evidence of coverage and formularies for 2021 individual Medicare Advantage plans will be available at anthem.com/medicareprovider. An overview of notable 2021 benefit changes will be available at anthem.com/medicareprovider> Read News and Updates. Please continue to check anthem.com/medicareprovider for the latest Medicare Advantage information.

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