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.

To help inform referrals and placements, we are asking all home health agencies to complete this survey, which will allow us to have the most up-to-date information about your facility and allow us to provide the best possible service to you and to our members.

With your help, we can continually build towards a future of shared success. Please complete the survey here. It should only take about 10 minutes of your time.

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.

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 HealthKeepers, Inc. 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 HealthKeepers, Inc. 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.

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

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

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

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

Patient care opportunities

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

What if I need assistance?

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

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

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

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

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

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

Patient care opportunities

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

What if I need assistance?

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

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

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

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

• Be proactive about asking if the patient requires interpretation services. No one wants to feel like a burden. By asking and preparing for an interpreter in advance, you are creating a welcoming atmosphere for the patient during their appointment. If you would like to request an interpreter, including sign language, on behalf of your Anthem HealthKeepers Plus 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 800-901-0020.

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