AdministrativeCommercialJune 1, 2025

Updated 2025 provider manual now available

We review and update our online provider manual annually. The latest updated manual is effective September 1, 2025, and is available now at provider website > Review Policies > Provider Manual section > Download the Manual > Looking for Our Upcoming Provider Manual section > Preview the upcoming manual.

Aside from minor formatting changes and changes to public provider website navigation, the following sections listed in alphabetical order were updated:

New content:

  • Email communications — directions to sign up for email notification when care provider news articles are published
  • Legal and Administrative Requirements:
    • Substance Use Disorder (SUD) Confidentiality Protections for Members
    • Patient Safety Standards Attestation Required by Hospitals
  • Claim Audit and Appeal Policy:
    • Chargemaster Audit Process

Updated content:

  • Availity Essentials:
    • Patient 360 changed to Total Member View under Payer Spaces for Anthem
  • Carelon Medical Benefits Management, Inc.:
    • Added information on the Provider Connections website for news, tips, and tools.
  • Centers of Medical Excellence:
    • Added Tecelra (afamitresgene autoleucel) under CAR‑T
    • Zynteglo, Skysona, Casgevy, Lyfgenia, and Lenmeldy added in the Gene Therapy section
  • Federal Employees Health Benefits Program and Postal Service Health Benefits Program:
    • Postal Health Benefits Program (PSHBP) content added
  • Fraud, Waste, and Abuse Detection:
    • Reinstated the Recoupment/Offset/Adjustment for Overpayments section, which had been removed from the previous manual.
  • Overpayments:
    • New Disputes/Inquiries through Availity Essentials
  • Provider enrollment through Availity Essentials:
    • Reference to Council for Affordable Quality Healthcare (CAQH) ProView changed to Provider Data Portal
  • Provider and Facility Digital Guidelines:
    • Additional content on provider enrollment, network management, and provider maintenance
    • Removed reference to Interactive Care Reviewer (ICR) under Availity Essentials authorizations
  • Quality Improvement Programs:
    • Updated for consistency with NCQA requirements
  • Reimbursement Requirements and Policies:
    • Expanded introductory section
    • Reimbursement Hierarchy, Review Schedule and Updates, Reimbursement Procedures for Effective Claims Management, and Reimbursement Audit and Review
    • Process sections added
  • Utilization Management:
    • Removed Observation Bed Policy section that referred to the Reimbursement Policies section
    • Removed separate bullet for Routine Maternity Admissions under Extenuating Circumstances Approval List as redundant
    • Replaced Submit Precertification Requests Digitally section with Prior Authorization Determinations and Submission section

The 2025 update is available now. The previous provider manual, 2024, will remain available until September 1, 2025.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWI), Compcare Health Services Insurance Corporation (Compcare), and Wisconsin Collaborative Insurance Company (WCIC). BCBSWI underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

WIBCBS-CM-084298-25

PUBLICATIONS: June 2025 Provider Newsletter