1. health and fitness
2. disease
3. cancer

November 2014
In this issue
Page
Health Care Reform Updates (Including Health Insurance Exchange)

Important information available online
3

Preventive care services covered with no member cost share
3
Announcements and General Updates

Clarification of CoramRx/CVS Caremark change

Specialty pharmacy updates

Certain self-administered specialty drugs not covered under
medical benefit

Free Apps help manage cancer symptoms and coordinate care

Program helps educate employers to support employees
with cancer

Reminder: WellPoint Cancer Care Program has launched

Interactive Care Reviewer (ICR) now accepts behavioral
health requests

Misrouted protected health information PHI
Billing
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Network

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
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CalPERS Health Plan – EFT/ERA processing and check
EOB/RA changes
Coding update modifiers: XE, XP, XS, and XU for professional
Claims, effective January 1, 2015
New National Drug Code (NDC) requirements on professional
claims
Changes to the file naming convention for activity logs and
response reports for electronic trading partners
Contracted provider claim escalation process
Moved your office?
2014 Fall seminars – contracted providers – last chance!
Web site changes you will like for your third party administrators,
self-funded and union trust fund patients!
More ACO providers in Northern California
Important information for contracting Groups/IPAs, regarding
contract compliance and access to care
Sign-up now for our Network eUPDATE today – it’s free!
Network leasing arrangements
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Network Relations:
855-238-0095
CANL (11/14)
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In this issue Continued
Page
Quality Programs and Guidelines

Update to the Blue Physician Recognition Program

HEDIS ® 2014 results are in

Clinical practice and preventive health guidelines available on
the web

Timely access regulations
Medicare Advantage Updates

Encourage exercise to prevent falls

Prior authorization required for members

Individual Medicare Advantage membership moves to new claims
processing system January 1, 2015

New for 2015: Anthem Blue Cross introduces new benefits, plans
for Medicare Advantage members

OrthoNet to conduct medical necessity reviews, professional
service coding reviews

Prior authorizations required for CMS-designated high-risk
medications

Clearinghouse helps ensure timely and accurate claims payment
for vaccine covered by Medicare Part D

New federally qualified health center billing guidelines in effect
for original Medicare

Speaking the language of ICD-10

CMS mandated Opioid overutilization program

Hyaluronate agents require prior authorization

Important 2015 coverage changes for diabetic supplies

CuraScript moves to Accredo brand effective November 24, 2014

New D-SNP plans offered in 2015; D-SNP training available

Advanced notices of non-coverage for Medicare Advantage
members
Pharmacy Updates

Pharmacy information available on Anthem.com/ca
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Health Care Reform Updates (including Health Insurance
Exchange)
Important information available online
Also, we invite you to go to our website to learn about the many ways health care reform and health insurance exchange may impact you.
New information is added regularly. To view the latest articles on health care reform and/or health insurance exchange, and all archived
articles, go to anthem.com/ca, select the Provider link in the top center of the page, and click Enter. From the Provider Home page,
select the link titled Health Care Reform Updates and Notifications or Health Insurance Exchange Information.
Preventive care services covered with no member cost share
The Affordable Care Act (ACA, or health care reform law) requires Anthem Blue Cross to cover certain preventive care services with no
member cost-sharing (copayments, deductibles, or coinsurance).1 Cost-sharing requirements may still apply to preventive care services
received from out-of-network providers.
The list below shares an overview of services, drugs, and pharmacy items covered by Anthem Blue Cross under preventive care benefits.1
Services listed may not be appropriate for all members, as some may be covered based on member age and health condition(s). These
benefits may not apply to grandfathered health plans. Providers should continue to verify eligibility and benefits for all members
prior to providing services or receiving member copayments, deductibles, or coinsurance.
Child preventive care
•
Preventive physical exams
•
Screening tests
o Behavioral counseling to promote a healthy diet
o Blood pressure
o Cervical dysplasia screening
o Cholesterol and lipid level
o Depression screening
o Development and behavior screening
o Type 2 diabetes screening
o Hearing screening
o Height, weight and body mass index (BMI)
o Hemoglobin or hematocrit (blood count)
•
Immunizations
o Diphtheria, tetanus and pertussis (whooping cough)
o Haemophilus influenza type b (Hib)
o Hepatitis A and Hepatitis B
o Human papillomavirus (HPV)
o Influenza (flu)
November 2014
o
o
o
o
o
o
o
o
o
o
o
o
o
HPV screening (female)
Lead testing
Newborn screening
Screening and counseling for obesity
Oral (dental health) assessment when done as part of
a preventive care visit
Screening and counseling for sexually transmitted
infections
Vision screening2 when done as part of a preventive
care visit
Measles, mumps and rubella (MMR
Meningococcal (meningitis)
Pneumococcal (pneumonia)
Polio
Rotavirus
Varicella (chicken pox)
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Adult preventive care
•
Preventive physical exams
•
Screening tests
o Alcohol misuse: related screening and behavioral
counseling
o Aortic aneurysm screening (men who have smoked)
o Behavioral counseling to promote a healthy diet
o Blood pressure
o Bone density test to screen for osteoporosis
o Cholesterol and lipid (fat) level
o Colorectal cancer, including fecal occult blood test,
barium enema, flexible sigmoidoscopy, screening
colonoscopy and related prep kit, and CT
colonography (as appropriate)
o Depression screening
o Hepatitis C (HCV) screening for people at high risk
for infection and a one-time screening for adults born
between 1945 and 1965
•
o
o
o
o
o
o
o
o
o
o
Immunizations
o Diphtheria, tetanus and pertussis (whooping cough)
o Hepatitis A and Hepatitis B
o HPV
o Influenza (flu)
o
o
o
o
o
Type 2 diabetes screening
Eye chart test for vision2
Hearing screening
Height, weight and BMI
HIV screening and counseling
Obesity: related screening and counseling
Prostate cancer, including digital rectal exam and
PSA test
Sexually transmitted infections: related screening
and counseling
Tobacco use: related screening and behavioral
counseling
Violence, interpersonal and domestic: related
screening and counseling
Meningococcal (meningitis)
Measles, mumps and rubella (MMR)
Pneumococcal (pneumonia)
Varicella (chicken pox)
Zoster (shingles)
Women’s preventive care
•
•
•
•
•
•
Well-woman visits
Breast cancer, including exam, mammogram, and,
including genetic testing for BRCA 1 and BRCA 2 when
certain criteria are met6
Breast-feeding: primary care intervention to promote
including breast-feeding support, supplies and counseling
(female)3,4
Contraceptive (birth control) counseling
FDA-approved contraceptive medical services provided
by a doctor, including sterilization
Counseling related to chemoprevention for women with a
high risk of breast cancer
•
•
•
•
•
Counseling related to genetic testing for women with a
family history of ovarian or breast cancer
HPV screening4
Screening and counseling for interpersonal and domestic
violence
Pregnancy screenings: includes but is not limited to
gestational diabetes, hepatitis, asymptomatic bacteriuria,
Rh incompatibility, syphilis, iron deficiency anemia,
gonorrhea, chlamydia and HIV4
Pelvic exam and Pap test, including screening for cervical
cancer
Pharmacy items
Anthem Blue Cross covers certain OTC drugs and other pharmacy items at 100% when the member receiving the item meets certain age
and other specified criteria. Members must present a prescription from an in-network doctor or other health care provider to an in-network
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pharmacy in order for the item to be covered under preventive benefits with 100% coverage (even for items that do not require a
prescription to purchase). The preventive items listed below may not be appropriate for every person.
Child preventive drugs and other pharmacy items – age appropriate
•
Fluoride supplements for children from birth through 6 years
old
•
Iron supplements for children 0-12 months
Adult preventive drugs and other pharmacy items – age appropriate
•
•
Aspirin use for the prevention of cardiovascular disease
including aspirin for men ages 45-79 and women ages 55-79
Colonoscopy prep kit (generic or OTC only) when prescribed
for preventive colon screening
•
Tobacco cessation products including select generic
prescription drugs, select brand name drugs with no generic
alterative, and FDA-approved over-the-counter products, for
those 18 and older
Women’s preventive drugs and other pharmacy items – age appropriate
•
•
Contraceptives including generic prescription drugs, brandname drugs with no generic alternative, and over-the-counter
items like female condoms or spermicides 4, 5
Folic acid for women 55 years old or younger
•
•
Vitamin D for women over 65
Breast cancer risk-reducing medications following the U.S.
Preventive Services Task Force criteria (such as tamoxifen
and raloxifen)7
1. The range of preventive care services covered at no cost share when provided in-network are designed to meet the requirements of federal and state law. The Department of Health and Human Services has defined the
preventive services to be covered under federal law with no cost-share as those services described in the U.S. Preventive Services Task Force A and B recommendations, the Advisory Committee on Immunization Practices (ACIP)
of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents and women supported by the Health Resources and Services Administration (HRSA) Guidelines. Members may have
additional coverage under their health plan. Providers should verify eligibility and benefits for all members.
2. Some plans cover additional vision services. Please verify eligibility and benefits for all members.
3. Breast pumps and supplies must be purchased from an in-network medical/DME provider for 100% coverage.;
4. This benefit also applies to those younger than 19.
5. A cost-share may apply for other prescription contraceptives, based on member drug benefits.
6. Verify member eligibility and benefits for details.
7. Requires prior authorization. Coverage begins October 1, 2014.
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Announcements and General Updates
Clarification of CoramRx/CVS Caremark change
In the September 2014 issue of Network Update, the article, “CoramRx/CVS Caremark change for specialty drugs,” announced CVS
Caremark’s purchase of CoramRx. This it to clarify that information in that article only applies to CVS Caremark/Coram’s internal
processes when triaging medications for health plan members.
CVS Caremark’s purchase of Coram does not impact contracted home infusion/ambulatory infusion suite providers who supply specialty
medications and home infusion services for health plan members through the medical benefit.
Specialty pharmacy updates
In order to reduce unexpected post-service claim denials, Anthem Blue Cross will be adding specialty pharmacy drug codes to the
Specialty Pharmacy Prior Authorization list. The specialty pharmacy drug codes from new or current medical policies that are being added
to our existing pre-service review process are listed below.
All changes referenced in this notification only apply to Local Plan members. Please note that these recommendations do not apply
to: BlueCard (out-of-area), HMO, Medicare, Medicare Advantage (MA), the Federal Employee Program® (FEP®), or State Sponsored
Business (SSB).
The changes listed below will become effective on February 2, 2015.
Medical Policy or Clinical Guideline
Description
Codes
DRUG.00058
DRUG.00051
DRUG.00053
DRUG.00052
DRUG.00054
DRUG.00056
CG-DRUG-05
DRUG.00064
Ruconest
Zaltrap
Kyprolis
Perjeta
Jetrea
Kadcyla
Micera
Duopa
J3490
J9400
J9047
J9306
J7316
J9354
Q9972, Q9973
J3490
Note: If the service is not prior authorized/pre-certified, records will be requested for post service review based on the same criteria listed
in the medical policy or clinical guideline.
Certain self-administered specialty drugs not covered under medical benefit
Beginning January 1, 2015, self-administered specialty drugs on the list below will no longer be covered under the medical benefit for
Anthem Blue Cross members in some commercial Large Group health plan types. Plan types impacted by this change include PPO,
CDHP, and EPO plan types for California Large Group business. Members in California Large Group business with HMO, POS and
Medicare plans are not impacted
Coverage for these self-administered drugs should be submitted for review under the member’s pharmacy benefit.
In situations where provider administration may be medically necessary, please contact Provider Services at (800) 677-6669.
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MCI Indication
Brand
Generic
HCPC
BONE CONDITIONS
ENDOCRINE
DISORDERS
FORTEO
teriparatide
J3110
Route of
Administration
SUBCUTANEOUS
BRAVELLE
urofollitropin
J3355
INJECTION
CHORIONIC
GONADOTROPIN, NOVAREL,
PREGNYL
chorionic gonadotropin
J0725
INTRAMUSCULAR
FOLLISTIM AQ
follitropin beta
S0128
INJECTION
GONAL-F, GONAL-F RFF
follitropin alfa
S0126
SUBCUTANEOUS
REPRONEX, MENOPUR
menotropins
S0122
INJECTION
somatropin
J2941
INJECTION
J2170
J9212
SUBCUTANEOUS
SUBCUTANEOUS
S0145
SUBCUTANEOUS
PEGINTRON, PEGINTRON
REDIPEN
GANIRELIX ACETATE
mecasermin
interferon alfacon-1
pegylated interferon
alfa-2a
pegylated interferon
alfa-2b
ganirelix acetate
S0148
SUBCUTANEOUS
S0132
SUBCUTANEOUS
CIMZIA
certolizumab pegol
J0717
SUBCUTANEOUS
ENBREL
etanercept
J1438
SUBCUTANEOUS
HUMIRA
adalimumab
J0135
SUBCUTANEOUS
MULTIPLE SCLEROSIS
AVONEX
interferon beta-1a
MULTIPLE SCLEROSIS
MULTIPLE SCLEROSIS
BETASERON, EXTAVIA
COPAXONE
interferon beta-1b
glatiramer acetate
MULTIPLE SCLEROSIS
REBIF
interferon beta-1a
CANCER
CANCER
ACTIMMUNE
ALKERAN*
CYCLOPHOSPHAMIDE
ORAL*
ETOPOSIDE ORAL*
GLEEVEC
HYCAMTIN*
MATULANE
MYLERAN*
TEMODAR*
Interferon Gamma-1B
Melphalan
J1826,
Q3027
J1830
J1595
Q3028,
J1826
J9216
J8600
Cyclophosphamide Oral
J8530
ORAL
Etoposide Oral
Imatinib Mesylate
Topotecan HCl Oral
Procarbazine HCl
Busulfan Oral
Temozolomide Oral
J8560
S0088
J8705
S0182
J8510
J8700
ORAL
ORAL
ORAL
ORAL
ORAL
ORAL
ENDOCRINE
DISORDERS
ENDOCRINE
DISORDERS
ENDOCRINE
DISORDERS
ENDOCRINE
DISORDERS
GROWTH DEFICIENCY
HEPATITIS
GENOTROPIN, GENOTROPIN
MINIQUICK, HUMATROPE,
NORDITROPIN,
NORDITROPIN FLEXPRO,
NORDITROPIN NORDIFLEX,
NUTROPIN AQ NUSPIN,
OMNITROPE, SAIZEN,
SEROSTIM, ZORBTIVE
INCRELEX
INFERGEN
HEPATITIS
PEGASYS
GROWTH DEFICIENCY
HEPATITIS
INFERTILITY
INFLAMMATORY
CONDITIONS
INFLAMMATORY
CONDITIONS
INFLAMMATORY
CONDITIONS
CANCER
CANCER
CANCER
CANCER
CANCER
CANCER
CANCER
November 2014
INTRAMUSCULAR
SUBCUTANEOUS
SUBCUTANEOUS
SUBCUTANEOUS
SUBCUTANEOUS
ORAL
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CANCER
XELODA
CANCER /
TRANSPLANT
AFINITOR, AFINITOR
DISPERZ, ZORTRESS
BETHKIS,** TOBI,** TOBI
PODHALER**-inhalation
INFECTIONS
INFLAMMATORY
CONDITIONS
ORAL,
CHEMOTHERAPEUTIC,
NOS
PARKINSONS
DISEASE
RESPIRATORY
CONDITIONS
ARCALYST
Capecitabine
Everolimus
Tobramycin Inh
Rilonacept
J8520,
J8521
J8561,
J7527
J7682,
J7685
J2793
ORAL
ORAL
INHALATION
SUBCUTANEOUS
J8999
APOKYN
Apomorphine
Hydrochloride
J0364
SUBCUTANEOUS
PULMOZYME**-inhalation
Dornase Alfa
J7639
INHALATION
SKIN CONDITIONS
STELARA
Ustekinumab
TRANSPLANT
ASTAGRAF XL
GENGRAF, NEORAL,
SANDIMMUNE
HECORIA/PROGRAF
RAPAMUNE
FUZEON
Tacrolimus ER, Oral
TRANSPLANT
TRANSPLANT
TRANSPLANT
VIRAL INFECTIONS
Cyclosporine Oral
Tacrolimus Oral
Sirolimus
Enfuvirtide
J3357,
C9261
J7508
J7502,
J7515
J7507
J7520
J1324
SUBCUTANEOUS
ORAL
ORAL
ORAL
ORAL
SUBCUTANEOUS
*Only the oral formulation of the specified drug will not be covered under the medical benefit.
**Inhaled formulation of the specified drug will not be covered under the medical benefit.
Please note: This list is subject to change and may affect the member’s coverage. Additional drugs may be added to this list in the future.
Free Apps help manage cancer symptoms and coordinate care
New apps bring together national cancer organizations, to help improve the lives of individuals with cancer
Self-Care During Cancer Treatment and My Care Plan are two new free mobile apps that were designed to help people facing cancer to
better manage the disease by learning how to deal with certain symptoms, and coordinate their care after cancer treatment has ended.
o
o
Self-Care During Cancer Treatment is an app that provides strategies for managing symptoms of cancer treatment and the
disease itself – which can range from severe nausea to rashes and fatigue.
My Care Plan is an app that provides survivors with a tool to build a survivorship care plan they can finalize and share with their
providers. The app helps survivors know what to expect or look for when active treatment has ended, including the late- and
long-term effects of cancer treatment, and it provides a wellness plan to help survivors remain healthy.
“The purpose of creating these two apps is to help close gaps in cancer care by providing people with relevant, timely information they can
easily access,” said Jennifer Hausman, WellPoint public health program director.
Approximately 41 percent of men and women will be diagnosed with cancer at some point during their lifetime, based on 2008-2010 data,
according to the National Cancer Institutes. Today there are an estimated 14.5 million people living with all cancer types in the United
States.
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“We know that people who have cancer could benefit from easy-to-access self-care strategies tailored to the symptoms they are
experiencing during active treatment, as well as what to expect after treatment and guidance on when to connect with their health care
providers for follow up surveillance and care,” said Nina Wendling, NCCS chief operations officer.
About Self-Care During Cancer Treatment
This app is provided by Empowerment and Action for Cancer Care, an alliance between WellPoint and Genentech. The app’s content is
derived from the Michigan State University Symptom Management Guide and Automated Telephone Symptom Management intervention
tool.
It’s simple for the patient to use.
1. The app will prompt the patient to fill out a form on their mobile device
2. Score a list of symptoms on a scale of 0 – 10
a. If the individual scored “fatigue” with a high number, then the app would produce self-care strategies that match
accordingly.
3. The app then provides information on these options:
a. “What can I do about my fatigue?”
b. “When should I talk to my doctor or nurse about my fatigue?”
c. “Where can I get more information?”
4. The app can prompt people to schedule the next assessment, which triggers a reminder at the appropriate time.
“It’s very calming to have all the information in one place, right at my fingertips so I know how to manage my symptoms and when I should
contact my doctor,” said app user Joyce Johns. The app also helps me track how I’m doing between appointments so I can talk with my
doctor about my symptoms.”
About My Care Plan
Is an app version of the Journey Forward® program developed through a collaboration including the National Coalition for Cancer
Survivorship, UCLA Cancer Survivorship Center, the Oncology Nursing Society, WellPoint and Genentech.
1. Survivors can complete My Care Plan on their own and share it with their oncologist and health care team to review and finalize
the plan.
a. The plan includes a listing of care team members, a self-assessment tool to identify symptoms and concerns, a
summary of cancer treatment, a post-treatment care schedule, and a list of late- and long-term effects and other
symptoms to be aware of.
My Care Plan “I’ve taken a very active role in my care planning, and was very concerned I had left something out. The My Care Plan app
helps guide and inform the patient by managing what is needed for the care plan. It’s all in one place and easily accessed. This is an
excellent app,” said app user Doreen Rizopoulos.
These apps are not meant to replace the advice of the individual’s healthcare team or provide medical advice. Both apps are available in
the Apple App Store or the GooglePlay store.
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Program helps educate employers to support employees with cancer
Workplace Transitions for People Touched by Cancer is testing an actionable and interactive resource with six large businesses in an
effort to support employers and their employees’ healthy and productive return to work after a cancer diagnosis. The goal is to offer the
resource for free to all employers next year after it has been tested.
The Workplace Transitions for People Touched by Cancer program, a collaboration among the US Business Leadership Network, Cancer
and Careers, Pfizer, WellPoint, and SEDL, a nonprofit educational research firm, and is funded by a $250,000 grant from the WellPoint
Foundation. Six businesses – Ernst & Young, Merck, North American Mission Board, Northrop Grumman, Verizon and WellPoint – are
participating in the pilot.
“When we think of gaps in care for cancer, we traditionally think about gaps in treatment or gaps in the transition of the patient from one
doctor to another, or to the hospital and home,” Dr. Sam Nussbaum, WellPoint chief medical officer and executive vice president. “But
many people do go back to work and, as a society, there hasn’t been much thought until recently about other types of knowledge or
resource gaps that may exist at the workplace—which is where many people with cancer will spend a good deal of their wakeful time even
while they are in active treatment.”
Nearly 80 percent of people diagnosed with cancer say continuing work after diagnosis aids recovery, according to a 2013 survey from
Cancer and Careers and Harris Interactive. Still, just as many respondents said they struggle to find support navigating the work/life
balance of employment with cancer.
A recent survey of 188 employers conducted by WellPoint discovered that only 15 percent of managers believed they had the tools and
resources they needed to support employees in a cancer situation. Workplace Transitions for People Touched by Cancer gives managers
and their human resources staff members a web-enabled toolkit that provides useful information and guidance while empowering them to
manage situations that arise when someone on their team has been diagnosed with cancer, including how to talk to someone who has just
been diagnosed.
The main goals of the eToolkit are:
1. Ensure a supportive work environment
2. Support the employee’s quality of life
3. Increase employers awareness of the law regarding employee with disabilities (however, not all the laws apply to all employers
and not all people diagnosed with cancer are considered to have a disability)
4. To help employer’s understand their role in supporting their employee
As part of the project, researchers will survey employees from several large employers to determine if the eToolkit does what it
is intended to do.
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Reminder: WellPoint Cancer Care Program has launched
As a reminder, Anthem Blue Cross launched the WellPoint Cancer Care Quality Program ("Program"), a quality initiative, on
November 1, 2014. The Program provides participating physicians with evidence-based cancer treatment information that allows them to
compare planned cancer treatment regimens against evidence-based clinical criteria. The Program also identifies certain evidence-based
WellPoint Cancer Treatment Pathways ("Pathways"). Participating physicians who are in-network for the member's benefit plan are eligible
to participate in the Program and for enhanced reimbursement if an appropriate treatment regimen is ordered that is on Pathway. The
Program is administered by AIM Specialty Health® (AIM), a separate company.
For more information on the Program:




Register for access to the AIM Provider Portal.
View the Cancer Care Quality Program website.
Get more information on WellPoint Cancer Treatment Pathways.
Access program FAQs.
For questions or if you need support, call the AIM Call Center at (877) 291-0360.
Interactive Care Reviewer (ICR) now accepts behavioral health requests
Our ICR tool continues to evolve, improving the precertification process. In the latest upgrade, Behavioral Health providers
as well as facilities can submit requests for behavioral health services.
If a Behavioral Health service requires pre-certification based on the member’s benefit, the request can be entered via the
ICR tool. This includes services such as:

Inpatient

Residential Treatment

Partial Hospitalization

Intensive Outpatient

Transcranial Magnetic Stimulation
Applied Behavioral AnalysisNew templates allow you to easily enter clinical detail previously provided via phone. In addition,
users can make an inquiry to view information on any precertification, which they are affiliated with, previously submitted via
phone, fax, ICR, or other online tool (for example, AIM, Behavioral Health, eReview, etc.) for any member covered by
Anthem Blue Cross and Blue Shield, Anthem Blue Cross (California), Blue Cross and Blue Shield of Georgia and Empire Blue
Cross and Blue Shield (NY).
Note: The above is not available at this time for members covered by Medicare Advantage, Medicaid, Federal Employee
Program ® (FEP), BlueCard ® and some National Account members. For these requests, follow the same precertification
process that you use today.
Furthermore, added functionality now offers you the ability to view a copy of the imaged letter within the case and save
multiple providers with the new “favorite” feature.
Watch future newsletters for details around ICR webinars for Behavioral Health Services.
You can access our ICR tool free of charge via the Availity ® Web Portal. If your organization has not yet registered for
access, go to www.availity.com and click on “Get Started” under Register Now for the Availity Web Portal. If your
organization already has access to the Availity Web Portal, your Primary Access Administrator can grant you access to
Authorizations and you can start using our tool right away.
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Please email our Behavioral Health Provider Relations team at [email protected] for general questions about ICR.
For questions related to accessing ICR, call Availity Client Services at 800-AVAILITY (800-282-4548) or email questions to
[email protected]. Availity Client Services is available Monday-Friday, 5 a.m. to 4 p.m. PT (excluding holidays) to
answer your registration questions.
Availity, an independent company, provides claims management services for Anthem Blue Cross.
Misrouted protected health information (PHI)
Providers and facilities are required to review all member information received from Anthem Blue Cross to help ensure no misrouted PHI is
included. Misrouted PHI includes information about members that a provider or facility is not currently treating. PHI can be misrouted to
providers and facilities by mail, fax or e-mail. Providers and facilities are required to immediately destroy any misrouted PHI or safeguard
the PHI for as long as it is retained. In no event are providers or facilities permitted to misuse or re-disclose misrouted PHI. If providers or
facilities cannot destroy or safeguard misrouted PHI, providers and facilities must contact Anthem Blue Cross’s provider services area to
report receipt of misrouted PHI.
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Billing
CalPERS Health Plan – EFT/ ERA processing and check EOB/ RA changes
The California State Controller’s Office (SCO) processes payments issued for the CalPERS PPO Benefit Plans administered by Anthem
Blue Cross. Effective December 2014, we will be implementing changes to claims payment and EOB processing for the CalPERS health
plans. Providers do not need to make any changes.
Currently, the SCO processes all provider check reimbursements, with a single check for each claim. After December 2014, claims
processed for the same payee ID at the same address will be bundled into a single payment, instead of being processed as separate
payments for each claim.
In addition, providers who are currently registered for Electronic Funds Transfer (EFT) with Anthem Blue Cross will begin receiving
payments via EFT, instead of receiving paper checks from the SCO. Provider’s that have also elected to receive their claim payment
details via an 835 ERA (Electronic Remittance Advice) will now receive those details electronically.
Paper checks with summary and separate Remittance Advice (RA)
Providers that have not elected EFT payments will continue to receive paper checks issued by the SCO. However, these checks will be
processed differently than they are today. If multiple claims are being paid to the same payee ID at the same address, the claims will be
combined into one payment, which will include a one-page summary remittance indicating the number of claims paid and the total dollar
amount of the payment. Detailed claims payment EOBs will be provided separately from Anthem Blue Cross either as a paper RA or 835
ERA. Participating providers will also be able to view the detailed EOBs on the provider portal at
https://provider2.anthem.com/wps/portal/ebpmybcc.
Questions?
If you have questions related to the changes to CalPERS Health Plan claims payments and EOBs, please contact our customer service
department at (877) 737-7776. Providers wanting to register for EFT should use the CAQH website and complete the online registration.
Coding update modifiers: XE, XP, XS and XU for professional claims, effective January 1, 2015
Effective January 1, 2015, CMS is adding four new HCPCS modifiers to selectively identify subsets of modifier 59 for Distinct Procedural
Services as follows:




XE Separate Encounter: a service that is distinct because it occurred during a separate encounter
XP Separate Practitioner: a service that is distinct because it was performed by a different practitioner
XS Separate Structure: a service that is distinct because it was performed on a separate organ/structure
XU Unusual Non-Overlapping Service: the use of a service that is distinct because it does not overlap usual components of
the main service
Beginning with claims for dates of service on or after January 1, 2015, the Health Plan will accept these new modifiers, collectively referred
to as -X{EPSU} modifiers. We will apply edits to the -X{EPSU} modifiers equivalent to our modifier 59 edits with our first quarter 2015
update scheduled for February 16, 2015. Prior to the February update, these modifiers will be considered informational and will not
be used to override an edit when a modifier 59 override would be appropriate.
Because these modifiers are more selective versions of modifier 59, they are not to be reported in conjunction with modifier 59. The -X
{EPSU} modifiers are to be used based on CPT instructions that state when another modifier is appropriate, it should be used rather than
November 2014
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modifier 59. Modifier 59 will still be considered a valid modifier in the absence of a more descriptive modifier. The -X {EPSU} modifiers are
not to be used with evaluation and management (E/M) services.
System Updates for 2015
As a reminder, our ClaimsXten editing software package will be updated quarterly in February, May, August and November of
2015, these upgrades will:





reflect the addition of new and revised CPT/HCPCS codes and their associated edits
include updates to National Correct Coding Initiative (NCCI) edits
include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
include assistant surgeon eligibility in accordance with the reimbursement policy
include edits associated with other reimbursement policies including, but not limited to, preoperative and postoperative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
New National Drug Code (NDC) requirements on professional claims
For any dates of service on or after January 1, 2015, all professional providers will be required to supply the 11-digit NDC for Not
Otherwise Classified or Miscellaneous drug HCPCS when billing for injections and other drug items on the CMS1500 claim forms as well
as on the 837 electronic transactions.
Note: These billing requirements will apply to Local Plan and BlueCard member claims only, and will exclude Coordination of
Benefits/ Secondary claims.
Line items will deny if Not Otherwise Classified or Miscellaneous Healthcare Common Procedure Coding System (HCPCS) codes are
billed for physician administered drugs AND do not include the following:



The valid 11-digit NDC, including the N4 qualifier
Unit of measure qualifier (F2, GR, ML, UN, ME)
NDC Units dispensed (must be greater than 0)
To ensure accurate and timely payment, it is important that you provide the above requested information. Anthem Blue Cross will deny
any line items on a claim regarding Not Otherwise Classified or Miscellaneous drug HCPCS’ that do not include the above
information.
Unit of Measurement Requirements
The units of measurement codes are also required to be submitted. The codes to be used for all claim forms are:





F2 – International unit
GR – Gram
ML – Milliliter
UN – Unit
ME - Milligram
Location of the NDC
The NDC is found on the label of a prescription drug item and must be included on the CMS-1500 claim form or in 837 electronic
transactions. The NDC is a universal number that identifies a drug or related drug item.
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NDC Number Section
1 (five digits)
2 (four digits)
3 (two digits)
Description
Vendor/distributor identification
Generic entity, strength and dosage information
Package code indicating the package size
Changes to the file naming convention for activity logs and response reports for electronic trading
partners
As of December 13, 2014, we will be implementing an expanded File Naming Convention for our activity logs and response reports you
may receive electronically. The file name will be changing from 12 characters to 15 characters to enable more efficient and faster
processing of inbound Electronic Data Interchange (EDI) transactions at our enterprise EDI gateway. There is not a change to how you
submit electronic transactions to us; however the activity logs and response reports picked up from our EDI gateway mailbox will have this
new naming convention beginning in December. If you use a clearinghouse or software vendor to pull these files into your system, they
have already been notified of this implementation. The notification to trading partners can be found on the Latest News section of our EDI
website.
We highly recommend that you consult with any clearinghouse or software vendor you use to ensure that they have made any needed
modifications to support your business processes. If you have questions, please contact E-Solutions by phone, Live Chat, or e-mail. Our
contact information can be found on anthem.com/edi.
Contracted provider claim escalation process
In an effort to better service our contracted providers right the first time, Anthem Blue Cross has improved our provider claim escalation
process. Just click, Provider Claim Escalation Process to read, print, download and share the improved process with your office staff.
Our Network Relations Team is available by e-mail at [email protected] to answer questions you have about the process,
if you need clarification.
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Network
Moved your office?
To ensure proper processing of all changes to addresses, tax ID numbers and provider profiles, please e-mail them to [email protected]. You can also send your changes by fax to 818-234-2836 or 866-243-3183. Keep in mind that all
changes must be submitted on the physicians or medical group's letterhead and signed by the physicians or authorized personnel.
Other convenient online options for updating practice information can be easily found on anthem.com/ca:



Physician/Physician Group Change Form
Behavioral Health/EAP Practice Profile
Institutional Provider Change Request Form
2014 Fall seminars – contracted providers – last chance!
Seminars
Our Fall ‘Provider Information Exchange’ seminars are interactive and offer tips, process improvements and best practices. Many
relevant Anthem Blue Cross business topics of interest are presented. In November, our seminars will be offered in four different
locations throughout California. Don’t miss this complimentary education opportunity!
JOIN US! Bring a Colleague!
This is your opportunity to engage in meaningful conversation and receive the most current provider operations updates taking place at
Anthem Blue Cross. The Provider Network Education Team will provide 2014 updates on:

BlueCard (Out-of-Area): updates and tips

Interactive Care Reviewer (ICR): inpatient, outpatient and behavioral health on-line prior authorization

Medicare Advantage: what’s new

ProviderAccess: proprietary content not on the Availity Web Portal, single sign-on tool

Contracted Provider Claim Escalation Process: getting it right the first time
November 2014
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
Provider Dispute Resolution Process: reminders

Secure Messaging: faster than phone or paper

The Availity Web Portal: troubleshooting tips

... and more!
Register On-Line: Click here to view the complete 2014 Fall Seminar schedule
Questions?
E-mail: [email protected]
Phone: 818-234-1016
Fax: 818-234-8959
Web site changes you will like for your third party administrators, self-funded and union trust fund
patients!
We are making it easier for you to find information for patients serviced by Managed Care Services (MCS):



Self-Administered Plans
Third Party Administrators (TPA)
Union Trust Funds
Anthem Blue Cross has network leasing arrangements with many of these organizations, and answers about these types of accounts can
be found in a few places.
Inquiries related to claim status, verification of eligibility and benefits should be addressed directly to the Payor. The contact information for
the Payor can be found on the back of the member’s Identification Card. We realize that it’s not always handy, and we are in the process
of making changes to the Availity Web Portal to make the search easier and more convenient.
On December 13, 2014, when a provider uses the new Payor drop down of MCS under the Eligibility and Benefits option on the Availity
Web Portal for an MCS member the following response will be returned for Eligibility and Benefit inquiries:
“Eligibility and Benefits are handled by a third party administrator”. The MCS contact information will also be displayed in the
response.
Use the above contact information to contact the group if you have any questions on benefits or eligibility.
In an effort to enhance your online service experience for MCS accounts, Anthem Blue Cross has some exciting changes on the Availity
Web Portal. Providers seeking claims information for MCS members will have access to a new Payor drop down menu on the Availity
Web Portal of MCS under the claims inquiry function. These changes on the Availity Web Portal will allow providers access to the
following:



Verify Anthem Blue Cross has received your claim
Anthem Blue Cross Claim Number
Anthem Blue Cross contracted rate or pricing
When are the changes coming?
We are targeting First Quarter 2015. Stay tuned for more details, in the next Network Update!
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More ACO providers in Northern California
Effective October 1, 2014, Hill Physicians Medical Group and several Sutter Health affiliated providers have joined Enhanced Personal
Health Care, Anthem Blue Cross’ Accountable Care Organization (ACO) program. This program helps members with two or more chronic
conditions improve their overall health through enhanced coordination of health care.
We are excited about the inclusion of Hill Physicians Medical Group, with multiple locations serving members from, San Francisco and the
East Bay to Sacramento and San Joaquin. While Sutter Health affiliated medical groups include East Bay Medical Foundation; Mills
Peninsula Medical Group; Palo Alto Medical Foundation; Sutter Pacific Medical Foundation.
Important information for contracting Groups/IPAs, regarding contract compliance and access to
care
Participating provider groups are required to comply with the terms of the California Care Medical Services Agreement (MSA). This
includes, but is not limited to, the obligation to provide reasonable access to services.
The MSA includes the following requirements to ensure reasonable access to care. In particular, the MSA requires the contracting group
to do the following:


To promptly provide or arrange for available and accessible services for each member assigned to the group.
To make all covered services available to members a minimum of forty (40) hours per week, except for weeks including
holidays. The foregoing services shall be available beyond normal business hours during additional hours to be scheduled by the
group.
Furthermore, the Anthem Blue Cross HMO and Senior Secure Provider Manual (April 2013), provides that “all Satellite PMGs and IPAs
must have at least one available physician available at all times during regular business hours of 9:00 am to 5:30 p.m. Monday through
Friday.”
Compliance monitoring is the key to success!
To ensure our contracting groups/IPAs are in compliance with these important access and availability requirements, the Plan has
developed a comprehensive system for monitoring accessibility to care. The Plan monitors compliance through the following methods
outlined in the Plan’s Provider Operations Manual.





Quarterly and annual reviews of grievances to identify trends of dissatisfaction related to access and availability;
Accessibility studies, such as the ICE Appointment Availability Survey, to assess the availability of the network and identify
possible gaps where additional providers may be needed;
Provider Satisfaction Surveys, to determine provider satisfaction with our networks;
Geographic Accessibility analysis of the adequacy of the network using geographic software; and
ICE After Hours Surveys to ensure appropriate directions are provided after normal business hours.
What can you do?
1. Become familiar with the requirements in the MSA and the Provider Operations Manual.
2. Ensure that your staffing and office hours are appropriate for your patient load.
3. Participate in provider surveys – we need your input!
4. Post your office hours where visible for members to see, including your after-hours availability.
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Sign-up now for our Network eUPDATE today – it’s free!
Connecting with Anthem Blue Cross and staying informed will be even easier, faster and more convenient than ever before
with our Network eUPDATEs.
Network eUPDATE is our web tool for sharing vital information with you. It features short topic summaries and links that let
you dig deeper into timely critical business information:
Important website updates
System changes

Fee Schedules

Medical policy updates

Claims and billing updates
……and much more
Registration is fast and easy. There is no limit to the number of subscribers who can register for Network eUPDATEs, so
you can submit as many e-mail addresses as you like.


Network leasing arrangements
Anthem Blue Cross has network leasing arrangements with a variety of organizations, which we call Other Payors. Other
payors and affiliates use the Anthem Blue Cross network.
Under the terms of your provider agreement, members of other payors and affiliates are treated like Anthem Blue Cross
members. As such, they’re entitled to the same Anthem Blue Cross billing considerations, including discounts and freedom
from balance billing. You can obtain the Other Payors list on ProviderAccess ® , which can be accessed through the Anthem
Blue Cross website at www.anthem.com/ca. If you don’t have internet access, please contact us at (855) 238-0095 for
assistance.
November 2014
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Quality Programs and Guidelines
Update to the Blue Physician Recognition Program
Anthem Blue Cross is committed to providing members with the tools they need to effectively partner with their doctors and make more
informed health care choices. As part of that effort, Anthem Blue Cross is pleased to participate in the Blue Cross and Blue Shield
Association’s consumer engagement initiative.
The Blue Physician Recognition (BPR) Program is designed to reinforce Blue Plans’ commitment to quality by providing more meaningful
and consistent information on physician quality improvement and recognition on the Blue National Doctor & Hospital Finder site and on
Anthem Blue Cross’ online provider directories. A BPR indicator is used to identify physicians, groups and/or practices who have
demonstrated their commitment to delivering quality and patient-centered care by participating in local, national, and/or regional quality
improvement programs as determined by the local Blue Plan.
Anthem Blue Cross recognizes primary care physicians practicing in the specialties of Family Practice, Internal Medicine and General
Practice with a BPR designation if they have achieved recognition from either the National Committee for Quality Assurance (NCQA) or
Bridges to Excellence (BTE) based on their successful completion of a care recognition program. Information regarding these recognition
programs can be found at http://www.ncqa.org or http://www.hci3.org .
At a minimum, we will update these recognitions annually to reflect the current status as identified by the Blue Cross and Blue Shield
Association’s Quality Recognition Extract.
If you have questions regarding the update, please contact your network contracting representative.
HEDIS ® 2014 results are in
Thank you for participating in the annual Healthcare Effectiveness Data and Information Set (HEDIS) data collection for 2014. You play a
central role in promoting the health of our members. By documenting services in a consistent manner, it is easy for you to track care that
was provided and identify any additional care that is needed to meet the recommended guidelines. Consistent documentation and
responding to our medical record requests in a timely manner eliminates follow up calls to your office and also helps improve HEDIS
scores, both by improving care itself and by improving our ability to report validated data regarding the care you provided.
Further information regarding documentation guidelines can be found on the HEDIS page of our Provider Portal. The Provider Portal can
be accessed by signing in to www.anthem.com/ and clicking on “Provider”, followed by “Health and Wellness”, “Quality”, and finally
“HEDIS”. You will find reference documents entitled “HEDIS 101 for Providers” and “HEDIS Documentation Guidelines”.
The table below shows comparison of some of our key measure rates to the Quality Compass® National Averages. [Bolded rates reflect
an improvement over 2013 HEDIS rates.]
Commercial HMO/POS Measures
Effectiveness of Care – Prevention and Screening
Adult BMI Assessment
Breast Cancer Screening
Childhood Immunization Status – DTAP
November 2014
HEDIS 2014 Rate
(Percent)
84.44
78.23
89.29
Comparison to National
Average
↑
↑
↑
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Childhood Immunization Status - HIB
Childhood Immunization Status - PCV
Childhood Immunization Status – HEP A
Childhood Immunization Status - ROTAVIRUS
Childhood Immunization Status - INFLUENZA
Colorectal Cancer Screening
Immunizations for Adolescents - MENINGITIS
Immunizations for Adolescents – TDAP/TD
Weight Assessment and Counseling – BMI TOTAL
Weight Assessment and Counseling – Nutritional Counseling TOTAL
Weight Assessment and Counseling – Physical ActivityTOTAL
Access / Availability of Care
Adults’ Access to Preventive/Ambulatory Health – TOTAL
Children & Adolescents’ Access to PCP (25 mos-6yrs)
Children & Adolescents’ Access to PCP (7-11 yrs)
Children & Adolescents’ Access to PCP (12-19 yrs)
Effectiveness of Care – Respiratory Conditions
Antibiotics for acute bronchitis
Appropriate Testing for Children w/ Pharyngitis
Appropriate Treatment Children w/ URI
Spirometry Testing for COPD
Utilization & Relative Resource Use - Utilization
Well-Child Visits in the first 15 Months of Life (6+ visits)
Adolescent Well-Care Visits
Effectiveness of Care - Cardiovascular
Cholesterol Management – LDL-C Control <100
Persistence of Beta-Blocker Treatment after AMI
Effectiveness of Care - Diabetes
Comprehensive Diabetes Care – Poor HbA1c Control (>9)*
Comprehensive Diabetes Care – Eye Exams
Comprehensive Diabetes Care – LDL-C Screening
Comprehensive Diabetes Care – LDL-C Controlled (LDLC<100 mg/dL)
Comprehensive Diabetes Care – Blood Pressure Control
<140/80
Comprehensive Diabetes Care – Blood Pressure Control
<140/90
Effectiveness of Care - Musculoskeletal
Use of Imaging Studies for Low Back Pain
Effectiveness of Care – Behavioral Health
Antidepressant Medication Mgmt – Acute
November 2014
96.84
89.78
89.78
83.94
63.26
67.12
72.78
89.44
60.74
↑
↑
↑
↑
↓
↑
↑
↑
↑
58.77
↑
59.51
↑
92.46
97.23
89.29
86.09
↓
↓
↓
↓
29.43
65.34
90.96
56.67
↑
↓
↑
↓
53.59
34.99
↓
↓
69.47
76.08
↑
↓
25.79
49.39
87.83
↑
↓
↑
50.85
↑
46.96
↑
73.48
↑
77.95
↑
57.11
↓
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Antidepressant Medication Mgmt – Continuation
Follow Up after Mental Health Hospitalization -7 days
Follow Up after Mental Health Hospitalization-30 days
FU Care Children’s ADHD Medication – Initiation
FU Care Children’s ADHD Medication - Continuation
*lower rate is better
42.09
55.52
73.00
36.59
42.72
↓
=
=
↓
↓
In California, many scores for commercial HMO/POS improved and exceeded the national average, especially those in ABA, WCC, most
childhood immunizations in CIS, IMA and CDC (good HbA1c control and BP<140/90). The largest rate increases were noted in adolescent
WCC – both BMI percentile and physical activity counseling/education. In the PPO line of business there were also many improved scores
that exceeded the national average, especially those in ABA, WCC, IMA and 6 or more well-child visits between birth and 15 months
(WC15), with the greatest improvement in adult BMI assessment (ABA) and adolescent physical activity counseling/education (within the
WCC measure).
Although many rates were above the national average this year, there were two measures that saw decreases in both HMO and PPO
plans: PBH (Persistence of Beta Blocker treatment following a heart attack) and FUH (follow up after a mental health hospitalization within
7 or 30 days). There are opportunities for improvement in these measures, as well as for AAB (avoidance of antibiotic medication for acute
bronchitis) in HMO plans, where an increase was observed in the number of adult patients with acute bronchitis prescribed antibiotics
(although the rate for avoidance of this practice remains above the national average).
Each year our goal is to improve our process for requesting and obtaining medical records for our HEDIS project, as well as to
demonstrate the exceptional care that you have provided to our members.
In an effort to improve our scores, you and your office staff can help facilitate the HEDIS process improvement by:




Responding to our requests for medical records within five days
Providing the appropriate care within the designated timeframes
Accurately coding all claims
Documenting all care in the patient’s medical record
Again, we thank you and your staff for demonstrating teamwork and partnership as we work together to improve the health of our members
and your patients. We look forward to working with you next HEDIS season.
The source for data contained in this publication is Quality Compass® 2014 and is used with the permission of the National Committee for
Quality Assurance (NCQA).Quality Compass 2014 includes certain CAHPS data. Any data display, analysis, interpretation, or conclusion
based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis,
interpretation, or conclusion. Quality Compass is a registered trademark of NCQA. CAHPS® is a registered trademark of the Agency for
Healthcare Research and Quality (AHRQ).
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA).
November 2014
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Clinical practice and preventive health guidelines available on the web
As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally
recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our website. The guidelines,
which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current
primary sources, the newest technological advances and recent medical research. All guidelines are reviewed annually, and updated as
needed. The current guidelines are available on our website. To access the guidelines, go to www.anthem.com/ca, select > Provider >
Enter > Home Page and then Health & Wellness>Practice Guidelines.
Timely access regulations
Anthem Blue Cross is committed to keeping you, our network partners, updated on our activities related to our compliance with the
Department of Managed Health Care (DMHC) Timely Access to Non-Emergency Health Care Services Regulations (the “Timely Access
Regulations”). Anthem Blue Cross maintains policies, procedures, and systems necessary to ensure compliance with the Timely Access
Regulations, including access to non-emergency health care services within prescribed timeframes (also referred to as the “time elapsed
standards” or “appointment wait times”). Anthem can only achieve this compliance with the help of our provider network partners, you!
There are many activities that are conducted to support compliance with the regulations and we need you, as well as members, to help us
attain the information that is needed. Some of these studies are sponsored by the Industry Collaborative Effort (ICE), allowing for
consistency across Health Plans. These studies allow our Plan to determine compliance with the regulations. The activities include, but
are not limited to the following:

ICE Provider Appointment Availability Survey

ICE Provider Satisfaction Survey

ICE Provider After - Hours Survey
These surveys are currently in process. Please make note of this with your office staff to ensure that they are prepared and that
they understand the importance of each provider’s participation in each of the surveys.
We appreciate that in certain circumstances the time-elapsed requirements may not be met. The Timely Access Regulations have
provided a few exceptions to the time-elapsed standards to address these situations:
Extending Appointment Wait Time: The applicable waiting time for a particular appointment may be extended if the referring or
treating licensed health care provider, or the health professional providing triage or screening services, as applicable,
acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has
determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the
patient.
Preventive Care Services and Periodic Follow Up Care: Preventive care services and periodic follow up care are not subject
to the appointment availability standards. These services may be scheduled in advance consistent with professionally
recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his
or her practice. Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions,
periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological
monitoring for recurrence of disease.
Advanced Access: The primary care appointment availability standard may be met if the primary care physician office provides
“advanced access.” “Advanced access” means offering an appointment to a patient with a primary care physician (or nurse
practitioner or physician’s assistant) within the same or next business day from the time an appointment is requested (or a
later date if the patient prefers not to accept the appointment offered within the same or next business day).
November 2014
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We hope this clarifies Anthem’s expectations and your obligations regarding compliance with the Timely Access Regulations. Our goal is to
partner with our providers to successfully meet the expectations for the requirements with the least amount of difficulty and member
abrasion. See below for a chart that outlines the Accessibility Standards for providers.
Access Standards for Medical Professionals
Access to
Standard
Non-urgent appointments for Primary Care (PCP)
Must offer the appointment within 10 business days of the
request
Urgent Care appointments not requiring prior
authorization
Must offer the appointment within 48 hours of request
Non-urgent appointments with Specialist Physicians
(SCP)
Must offer the appointment within 15 business days of the
request
Urgent Care (that requires prior authorization)
Must offer the appointment within 96 hours of request
Non-urgent appointment for ancillary services (for
diagnosis or treatment of inquiry, illness, or other health
condition)
In-office waiting room time
Must offer the appointment within 15 business days of the
request
After Hours Care
Member to reach a recorded message or live voice response
providing emergency instructions and foe non-emergent
(urgent) matters information when to expect to receive a call
back
Emergency Care (California law requires health plans
to follow the “prudent layperson” standard in providing
direction for emergency care and prohibits plans from
denying payment for emergency services, even if the
situation was discovered not to be emergent, if any
“prudent layperson” would have considered the situation
to be an emergency. Therefore, Anthem Blue Cross
expects every practitioner to instruct their after-hours
answering service staff that if the caller believes they are
experiencing an emergency, the caller should be
instructed to dial 911 or to go directly to the emergency
room. Answering machine instructions must also direct
the member to call 911 or go the emergency room if the
caller believes they are experiencing an emergency)
Member Services by Telephone. Access to Member
Service to obtain information about how to access clinical
care and how to resolve problems (this is a plan
responsibility and not a physician responsibility; and
this also applies to our Behavioral Health members)
Immediate Access to Emergency Care
November 2014
Usually members do not wait longer than 15 minutes to see a
physician or his/her designee
Reach a live person within 10 minutes during normal business
hours (Plan standard: 45 seconds; Call abandonment rate
<5%) Member Nurse line available 24/7
24 of 40
Access Standards for Behavioral Health and EAP Practitioners
Type of Care
Standard
Emergency Care Instructions (California law requires
health plans to follow the “prudent layperson” standard
in providing direction for emergency care and prohibits
plans from denying payment for emergency services,
even if the situation was discovered not to be emergent,
if any “prudent layperson” would have considered the
situation to be an emergency. Therefore, Anthem Blue
Cross expects every practitioner to instruct their afterhours answering service staff that if the caller believes
they are experiencing an emergency, the caller should be
instructed to dial 911 or to go directly to the emergency
room. Answering machine instructions must also direct
the member to call 911 or go to the emergency room if
the caller believes they are experiencing an emergency).
Members are directed to 911 or the nearest emergency room
Non-Life Threatening Emergency Care
6 hours
Urgent Care (that does not require prior authorization)
48 hours
Urgent Care (that requires prior authorization)
96 hours
Routine Office Visit/Non-urgent Appointment
15 Business days (Psychiatrists)
10 Business days (Non-Physician Mental Health Care
Providers)
5 Business days (EAP)
Access to After-hours Care
Available 24 hours / 7 days. Member to reach a recorded
message or live voice response providing emergency care
instructions, and for non-emergent (urgent) matters, a
mechanism to reach a Behavioral Health/EAP provider, and be
informed when the call will be returned.
In office waiting room time
Usually members do not have to wait longer than fifteen (15)
minutes after their scheduled appointment to see a Behavioral
Health/EAP provider.
Members also have access to Anthem Blue Cross’ 24/7 NurseLine. The phone number is located on the back of the
member’s health insurance ID card. In addition, Members and Providers have access to Anthem Blue Cross’ Customer
Service team at the telephone number listed on the back of the members’ ID card. A representative may be reached within
10 minutes during normal business hours.
If you have further questions, please contact Network Relations at 855 238-0095 or [email protected].
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Medicare Advantage Updates
Encourage exercise to prevent falls
Falls are the leading cause of injury in older adults. Each year, more than one-third of U.S. adults 65 and older experience a fall and, in
more than 20 percent of those cases, the falls lead to injuries like joint problems, bone fractures and brain trauma.1 Recovery can be
difficult and, in many cases, falls lead to a decline in independence and in overall health.2
Poor eyesight, dizziness caused by medication and tripping hazards in the home are common reasons for falls. Many times, however, falls
are simply caused by imbalance or a lack of strength. Some people who fall, even if they are not injured, develop a fear of falling, causing
them to limit their activities, which in turn increases their actual risk of falling. It’s just one more reason to emphasize the benefits of leading
an active, healthy lifestyle at any age.
Exercise can help reduce the risk of falling by

improving balance and strength

decreasing the need for medication that affects balance

increasing the confidence needed to live an active lifestyle, which reduces the risk of falling
As well, regular physical activity makes bones stronger so they’re less likely to break in the event of a fall, or heal faster if they do break.
Prescribe an exercise program to build strength, improve balance and increase confidence
The facts are decisive, but convincing older patients to adopt an exercise program can be challenging. Healthways SilverSneakers®
Fitness program, included as a benefit for your Anthem Blue Cross (“Anthem”) patients at no extra cost, makes it easier to turn a medical
recommendation into a reality. As you advise patients to “eat right and exercise,” you can direct them to a comprehensive program that
provides encouragement, direction and support every step of the way. With more than 2 million members, SilverSneakers is the nation’s
leading physical activity program designed exclusively for Medicare members.




SilverSneakers members have access to more than 11,000 fitness locations nationwide (including Alaska, Hawaii and Puerto
Rico), where they can use all basic amenities and take SilverSneakers group fitness classes led by certified instructors specially
trained in older-adult fitness. They can use any location any time they want, so even when traveling they can still work out.
In addition, SilverSneakers FLEX™ offers classes such as Latin dance, tai chi, walking groups and yoga in members’
neighborhoods – local parks, recreation centers, medical campuses and adult-living communities. FLEX participants can attend
their favorite SilverSneakers fitness location concurrently.
For members who can’t get to a SilverSneakers location or FLEX class, SilverSneakers Steps® offers a choice of four fitness
kits for at-home use – general fitness, strength, walking or yoga.
The SilverSneakers member website offers members tools to assess their health and track their activity, fitness advice, meal
plans and downloadable health recipes, and connection with the SilverSneakers online community for additional support.
SilverSneakers members have the tools and support they need to improve strength, balance and coordination, and the confidence to
continue being active. In fact, SilverSneakers members report experiencing fewer falls than older adults nationally. Among Anthem
members, 15 percent reported having a fall in 2013, compared to 26 percent of older adults nationally. And only 11 percent of members
reported having to be hospitalized compared to 17 percent of national older adults.3
Please encourage your patients to take advantage of this valuable benefit. To learn more, visit silversneakers.com or contact Stephanie
Williams at (678) 458-6371 ([email protected]). Staff trainings and SilverSneakers marketing materials are available for
your office.
November 2014
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1.
2.
3.
http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html
http://stopfalls.org/what-is-fall-prevention/fp-basics/
SilverSneakers Annual Member Survey, 2013.
Y0071_14_21645_I_001_09/17/2014
SilverSneakers® is a registered trademark of Healthways, Inc. © 2014 Healthways, Inc.
Prior authorization required for members
Anthem Blue Cross wants to remind providers that they are required to request a prior authorization for Medicare Advantage members for
services that require prior authorization. Failure to obtain a prior authorization will result in an administrative denial. The 2015 prior
authorization requirements were posted to the Provider Forms section of the Anthem Blue Cross Medicare Advantage Public Provider
Portal October 4, 2014.
Members cannot be balance billed for an administrative denial.
To obtain prior authorization or to verify member eligibility, benefits or account information, please call the telephone number listed on the
member’s plan membership card.
Please visit the Provider Forms section of the Anthem Medicare Advantage Public Provider Portal at
www.anthem.com/ca/medicareprovider to see the prior authorization list that is effective for 2015 as well as prior authorization
requirements for 2014.
Y0071_14_22046_I 10/14/2014
Individual Medicare Advantage membership moves to new claims processing system
January 1, 2015
Starting January 1, 2015, Anthem Blue Cross will move Individual (non-group) Medicare Advantage members to a new claims processing
system. Please review the following information so that you and your staff have the information you need to help ensure your claims are
processed accurately and efficiently. Group sponsored Medicare Advantage plan members are not affected by these changes: In
most cases, this information will not apply to Anthem Blue Cross group sponsored Medicare Advantage members unless separately noted.
As of January 1, 2015, members with the following prefixes on their member card will represent group sponsored Business only and will
remain on the current claims processing platform:
List of Alpha Prefixes
JQF
VZM
WGK
XDK
XGH
XKJ
XVL
YGJ
YLR
YRA
YRU
November 2014
JWM
VZP
WSP
XDT
XGK
XVJ
YCG
YGS
YLV
YRE
27 of 40


Pricing differences between individual and group sponsored Medicare Advantage members: Beginning January 1,
2015, providers may see differences in pricing between Medicare Advantage Individual and group sponsored member
claims. The reasons for the potential differences are based on the following:
Claims for Medicare Advantage individual and group sponsored members will be processed on different platforms
Timing of Original Medicare pricing software updates may vary by platform.
Administration of claims edits and sequestration.
Code editing enhancements: Effective January 1, 2015, we are updating our individual Medicare Advantage claims editing by
enhancing our code-editing technology to better align to existing payment guidelines. Individual Medicare Advantage claims will
be reviewed to:
-


Reinforce compliance with standard code edits and rules
Ensure correct coding and billing practices are being followed
Ensure all CMS required informational and reimbursement modifiers are billed
Determine the appropriate relationship between thousands of medical, surgical, radiology, laboratory, pathology and
anesthesia codes
Ensure compliance with industry standards
Reimbursement policy changes: Highlights of the changes to the reimbursement policies can be found here. These changes
are effective January 1, 2015. The complete set of policies is available here.
On-demand patient records: Patient 360 is a read-only dashboard available through Availity Web Portal to give you instant
access to detailed information about Anthem Blue Cross individual Medicare Advantage members. By clicking on each tab in the
dashboard, you can drill down to specific items in a patient’s medical record:
-
Demographic information – member eligibility, other health insurance, assigned PCP and assigned case managers
Care summaries – emergency department visit history, lab results, immunization history, and due or overdue
preventive care screenings
Claims details – status, assigned diagnoses and services rendered
Authorization details – status, assigned diagnoses and assigned services
Pharmacy information – prescription history, prescriber, pharmacy and quantity
Care management-related activities – assessment, care plans and care goals
Patient 360 will be available January 1, 2015. For more information call (866) 805-4589.

Changes to sequestration reduction: Beginning January 1, 2015, we will change how we administer the sequestration
reduction for Medicare Advantage claims processed on the new system.
-
Claims for individual members
-
-
We will continue the existing reduction for contracted providers paid according to Medicare reimbursement
methodologies.
We will begin reducing payments to non-contracted providers.
For both contracted and non-contracted providers, we will subtract the sequestration reduction from the final amount to
be paid to the provider after the Medicare Advantage member cost share has been applied. So, the final amount to be
paid to the provider is the plan allowance, minus any member cost-sharing, minus the sequestration reduction.
Claims for group members
-
We will continue the existing reduction for contracted providers paid according to Medicare reimbursement
methodologies.
Since group member claims are not migrating to the new claims processing system at this time, we will continue our
current methodology for applying the sequestration reduction to the plan allowance.
November 2014
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

Please file two separate claims for members who have both an Anthem Medicare Advantage plan and other Anthem
Blue Cross health benefits: If you treat an Anthem Blue Cross Medicare Advantage member who has Anthem Blue Cross
Medicare Advantage coverage in addition to health benefits with another Anthem plan, you will have to file the claim with both
plans separately. Please use the same electronic claims submission or address and P.O. Box you use today for Anthem Blue
Cross claims filing.
New Requirements effective January 1, 2015 For Individual Medicare Advantage Ambulance Anesthesia, Clinical
Laboratory and Mammography Claims: Effective January 1, 2015, Anthem Blue Cross individual Medicare Advantage frontend claims editing will return claims billed without CMS required criteria to the provider who submitted the claim. These new
front-end edits will include:
-
Ambulance Claims billed without the Ambulance Pickup Location – Reference Medicare Claims Processing Manual,
Chapter 15, Section 10.3 Point of Pickup
Anesthesia Claims billed without an appropriate modifier – Reference Medicare Claims Processing Manual, Chapter 12,
Section 50 K Anesthesia Claims Modifiers
Anesthesia Claims billed with a unit-of-measure of “units”
Clinical Laboratory claims billed without a Clinical Laboratory Improvement Amendment (CLIA) certification number in Box
23 on the CMS 1500
Mammography claims billed without a mammography certification number in Box 23 on the CMS 1500
Please ensure your billing staff is aware of this change. If you have any questions, please contact the Provider Services number
on the back of the member’s ID card.

Continue to use current phone number for 2015 precertifications: Individual Medicare Advantage members will be issued
new ID cards effective January 1, 2015. The new cards will have a new Provider Service phone number. The new number on the
ID cards will be used for all provider inquiries except precertification. For precertification, please continue to call the same
numbers currently in place – as listed below. If you call the number on the back of the member’s card for Precertification, you
will be directed back to the number below. To avoid this inconvenience, please note that the numbers below should be used for
precertification requests throughout 2015.
Phone: (866) 797-9884
Fax: (800) 959-1537
Submit all required clinical information at least three business days before the requested procedure to allow a thorough clinical
analysis. For Institutional Admissions, all facilities must notify us within 24 hours or the next business day (whichever is earlier) after
admission. In an urgent or emergent situation, the above time frames will be waived. Please provide notice to the plan as soon as
possible.



Continue to reach provider customer service by calling the number on the back of the member’s ID card.
Continue to use Availty Web Portal: Availity Web Portal can be accessed in the same manner as before and will continue to
have information about both individual Medicare Advantage and group sponsored Medicare Advantage members.
Continue to use the same mailing address, Electronic Data Interchange gateway as you do today: Claims and
correspondence should continue to be submitted to same EDI gateway and the same Post Office Box address that you use
today.
November 2014
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New for 2015: Anthem Blue Cross introduces new benefits, plans for Medicare Advantage members
Anthem Blue Cross will introduce new benefits for our Medicare Advantage members and new types of Medicare Advantage plans. The
information below highlights what’s new for 2015. For more details now and throughout 2015, please refer to Important Medicare
Advantage Updates on your provider portal.
For a more detailed overview of 2015 changes in plan benefits, co-pays, service areas and more please see the 2015 Product Update
under Important Medicare Advantage Updates.
Dual Eligible Special Needs Plans New For 2015
Anthem Blue Cross will introduce Dual Eligible Special Needs Plans effective January 1, 2015. D-SNPs provide enhanced benefits to
people eligible for both Medicare and Medicaid. These plans are $0 premium plans. Many feature some transportation to doctor’s
appointments and some include over-the-counter drug costs.
Providers should understand that D-SNP members are protected from balance billing. Anthem Blue Cross D-SNPs are “zero cost
share” plans, meaning we only enroll dual-eligible beneficiaries (people eligible for both Medicare and Medicaid) who have Medicare cost
sharing protection under their Medicaid benefits. The provider may not seek payments for cost sharing from dual-eligible members for
health care service rendered to dual-eligible members. For any questions regarding how claims are paid, please contact Customer Service
at (888) 230-7338.
Dual Eligible Special Needs Plans, also known as D-SNPs, coordinate Medicaid and Medicare programs and provide enhanced member
benefits. Anthem Blue Cross will begin offering D-SNPs in 2015. Providers who treat Anthem Blue Cross DSNP members in will have to
file the claim twice to help ensure accurate reimbursement. Please use the same electronic claims submission or address and P.O. Box
you use today for Anthem claims filing.
Referrals
A referral may be required for Individual Medicare Advantage HMO members to see a specialist. In most situations, our individual
Medicare Advantage HMO members may need to receive a referral from their Primary Care Physician before they can use specialists in
the plan’s network. However, referrals from a PCP are not required for emergency care or urgently needed care. Certain routine care can
be obtained without having an approval in advance from their PCP, such as routine women’s health care (breast exams, screening
mammograms, Pap tests and pelvic exams) and routine dental and vision care. Providers are required to periodically review and comply
with the latest Medicare Advantage referral requirements found at www.anthem.com/ca/medicareprovider in the document
named: Medicare Advantage Referral Requirements.
Please visit our website for more detailed product information or contact Provider Services at the number on the back of the member’s ID
card. You can find Important Medicare Advantage Updates here. Contact your provider representative for participation details for our
contracted plans.
Precertification requirements updated for 2015
Please refer to your provider agreement, provider manual and the Medicare Advantage Precertification Guidelines found at the Medical
Policy, UM Guidelines and Precertification Requirements link on the Anthem provider home page at www.anthem.com/ca for further
information on existing precertification requirements and new precertification requirements for 2015.
Submit all required clinical information at least three business days before the requested procedure to allow a thorough clinical analysis.
For Institutional Admissions, all facilities must notify us within 24 hours or the next business day (whichever is earlier) after admission. In
an urgent or emergent situation, the above time frames will be waived. Please provide notice to the plan as soon as possible.
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Precertifications can be obtained at the following phone or fax numbers for individual and group-sponsored Medicare Advantage plans:
Phone: (866) 797-9884
Fax: (800) 959-1537
To verify member eligibility, benefits or account information, please call the telephone number listed on the back of the member’s
identification card.
For Individual Medicare Advantage Members Who Can’t Get To The Doctor’s Office, An Online Alternative
Live Health Online allows individual LPPO Medicare Advantage members to visit a board certified doctor of their choice, from a selected
group of independent doctors, on a secure connection over the Internet via a smart phone, tablet or computer. Members can see doctors
on their own schedule in non-emergency situations without having to leave their homes. If medically appropriate, doctors using LiveHealth
Online can send prescriptions directly to a nearby pharmacy. A summary of each visit is created and can be forwarded to the patient’s
primary care doctor with their permission, supporting continuity of care and collaboration among providers.
Advanced illness planning
The Vital Decisions program provides counseling by telephone to help individual Medicare Advantage members with advanced illness
identify their goals, share them with loved ones and take steps toward meeting them.
OrthoNet to conduct medical necessity reviews, professional service coding reviews
Anthem Blue Cross is collaborating with OrthoNet, LLC to conduct medical necessity reviews for physical therapy, occupational therapy
and spine and back pain management for our Medicare Advantage members.
What does this mean to you?
Effective January 1, 2015, the following services/treatment requests must be reviewed by OrthoNet for precertification.



Physical therapy
Occupational therapy
Spine and Back Pain Management procedures:
o Epidurals
o Facet Blocks
o Pain Pumps
o Neurostimulators
o Spinal Fusion
o Spinal Decompression
o Vertebro/Kyphoplasty
In addition, OrthoNet will conduct post service prepayment coding review of professional services, including:








Orthopedic Surgery
Plastic Surgery
Neurosurgery
Sports Medicine
Podiatry
Hand Surgery
Neurology
Pain Management
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






Psychiatry/ Physical Medicine and Rehabilitation (PM&R)
ENT
General Surgery
Dermatology
Cardiology
Urology
Percutaneous Coronary Intervention (PCI)
Please submit all required clinical information at least three business days before the requested procedure to allow a thorough clinical
analysis. For Institutional Admissions, all facilities must notify us within 24 hours or the next business day (whichever is earlier) after
admission. In an urgent or emergent situation, the above time frames will be waived. Please provide notice to the plan as soon as possible.
Precertifications can be obtained at the following phone or fax numbers:
Phone: (866) 797-9884
Fax: (800) 959-1537
A complete list of precertification requirements can be found at the Provider Forms section of the Anthem Blue Cross Medicare Advantage
Public Provider Portal www.anthem.com/ca/medicareprovider.
To verify member eligibility, benefits or account information, please call the telephone number listed on the back of the member’s
identification card. That number also may be used to obtain precertification.
Prior authorizations required for CMS-designated high-risk medications
The Centers for Medicare and Medicaid Services (CMS)/Medicare regulations require Medicare Prescription Drug plans to monitor the use
of drugs which pose a higher risk to individuals more than 64 years old. To help ensure patient safety, Anthem Blue Cross requires prior
authorization for certain high-risk medications. Please refer to your Medicare Advantage members’ List of Covered Medicare Prescription
Drugs (formulary) to see which drugs need prior approval.
To ensure providers are aware of any high-risk medications prescribed for our individual and group-sponsored Medicare Advantage
members, we also send a fax to providers when their patients fill a prescription for a high-risk medication.
Anthem Blue Cross also distributes a monthly report to prescribers detailing the number of members on high-risk medications and the
number of high-risk medications prescribed year-to-date. We also contact members who have filled prescriptions for high-risk medications
and suggest that they discuss the prescription with their physician and ask if there is a safer alternate drug.
If you receive a high-risk medication fax or report from us, please review it and help us support safe medication choices. Alternatives to
these high-risk medications are listed here.
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Clearinghouse helps ensure timely and accurate claims payment for vaccines covered by Medicare
Part D
Providers who have administered a shingles or tetanus vaccine to our individual and group-sponsored Medicare Advantage plan members
with pharmacy benefits may encounter a denial because the claim is covered under Medicare Part D only.
To streamline your claim processing and payment (as applicable) for these and other preventive vaccines covered under Part D, providers
may use TransactRX, a clearinghouse for claims submission.
To use TransactRX please contact the clearinghouse at the web site (http://www.transactrx.com) or call Customer Service at
(866) 522-3386. Physicians, facilities, health clinics and pharmacies may use this clearinghouse to process Part D claims. There is no
charge to providers who use electronic funds deposit to receive payment. There is a service fee of $2.50 for check payments on claims.
The Centers for Medicare & Medicaid Services provides more information on Part D vaccines here.
New federally qualified health center billing guidelines in effect for original Medicare
Medicare introduced a new Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) beginning October 1, 2014.
FQHCs that are non-contracted and those contracted to Medicare rates will be reimbursed the lesser of actual charges or the PPS rate,
less any cost sharing amounts. This will apply to Anthem individual and group-sponsored Medicare Advantage plans.


Federally Qualified Health Centers (FQHC) will be transitioned to the FQHC Prospective Payment System (PPS) based on their
cost reporting periods.
o
FQHCs whose cost reporting period began on or after October 1, 2014, will be reimbursed using the new PPS system.
o
FQHCs whose cost reporting period began before October 1, 2014, will be reimbursed using the current all-inclusive rate
until their new cost reporting period beings.
o
PPS and non-PPS dates of service cannot be billed on the same claim. This means two separate claims must be billed.
We would like to remind providers that CMS established five new HCPCS which are required for FQHC PPS billing.
o G0466 – FQHC visit, new patient (Revenue code 0519 or 052X)
o G0467 – FQHC visit, established patient (Revenue code 0519 or 052X)
o G0468 – FQHC visit, IPPE or AWV (Revenue code 0519 or 052X)
o G0469 – FQHC visit, mental health, new patient (Revenue code 0900 or 0519X)
o G0470 – FQHC visit, mental health, established patient (Revenue code 0900 or 0519X)
For more information, please refer to Medicare Learning Network (MLN) SE1039
November 2014
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Speaking the language of ICD-10
The Department of Health and Human Services has formally changed the compliance date for conversion to ICD-10 diagnostic and
procedure codes from October 1, 2014, to October 1, 2015. The delay provides us with an opportunity to continue our readiness efforts for
the transition to come. We encourage you to continue your ICD-10 readiness activities.
In our previous articles we shared with you some basic information and recommendations to help you begin your journey of learning to
speak the language of ICD-10. We realize that this journey will not be an easy one as the ICD-10 code sets include greater detail, changes
in terminology, and expanded concepts for injuries, laterality, and other related factors. As you make this journey, please be reminded that
complete and accurate medical record documentation and diagnosis coding plays a critical role in managing our Medicare Advantage
membership. Because your coding and record documentation efforts have a direct impact on accurate risk adjusted payment, we want to
share with you specific ICD-10 coding tips related to risk adjustment-related diagnosis codes (also referred to as hierarchical condition
categories, or HCCs).
For this article we will use diabetes mellitus as an example:
Type 2 Diabetes
Diabetes, no complication,
controlled
Diabetic Retinopathy with Macular
Edema
ICD-9 Code(s)
250.00- DM without complications, not
stated as uncontrolled
ICD-10 Code(s)
E11.9- DM without complications
250.50- DM with ophthalmic manifestations
E11.311- DM with unspecified diabetic
retinopathy with macular edema
362.01- Diabetic neuropathy NOS
*ICD-10 does not reference controlled vs
uncontrolled DM
362.07- Diabetic macular edema
Diabetic Neuropathy
Diabetic Peripheral Angiopathy
250.60- DM with neurological complications
357.2- Polyneuropathy in DM
250.70- DM with peripheral circulatory
disorders
E11.40- DM with diabetic neuropathy,
unspecified
E11.51- DM with diabetic peripheral angiopathy
without gangrene
443.81- Peripheral angiopathy in diseases
classified elsewhere
In future articles, we will continue to bring your helpful coding tips to assist you and your coding staff transition from ICD-9 to ICD-10.
Please note that CMS will not accept ICD-9 codes beginning October 1, 2015. This will be critical, as all encounters/claims submitted with
ICD-9 codes will reject beginning October 1, 2015 resulting in delay or denial of payment. We must all be prepared to meet CMS
guidelines. To further assist you in your preparation we are providing the following references, helpful links, and additional resources:
The one-page reference sheet produced by AAPC shows how the code sets are organized, with easy color coding to help you find what
you're looking for. It also has mnemonic tips (such as "C is for cancer" and "T is for toxicity") to help you remember where the new codes
are located.
American Medical Association physician resource page
Centers for Medicare & Medicaid Services (CMS) Provider Resources
AAPC ICD-10 Implementation and Training Opportunities
November 2014
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CMS mandated Opioid overutilization program
CMS expects Part D sponsors to have effective programs to address opioid overutilization to protect beneficiaries and to reduce fraud,
waste and abuse in the Part D program. CMS expects plans to continue to improve retrospective DUR programs and case management as
related to medication overutilization. As of March 12, 2012, the Food and Drug Administration (FDA) placed fentanyl-containing products
under a new Risk Evaluation and Mitigation Strategy (REMS), which is now called TIRF (Transmucosal Immediate Release Fentanyl)
REMS. The TIRF drugs include Abstral, Actiq, Fentanyl Citrate, Fentanyl Oralet, Fentora, Lazanda, Onsolis and Subsys. They are
approved for the management of breakthrough cancer pain in patients who are already receiving and who are tolerant to around-the-clock
opioid therapy for their underlying persistent cancer pain.
Anthem Blue Cross will mail and/or call providers upon identification of members with suspected patterns of opioid overutilization due to
multiple prescribers and multiple pharmacies. During the phone call, our pharmacists attempt to facilitate a conversation with providers
about the appropriate use, medical necessity and safety of the high opioid dosage for their patient.
Our goal is to work with providers to prevent overutilization and to determine the appropriate amount of opioids for our members.
For more information, please reference:
(1) GAO-11-699, http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/GAOInstancesofQuestionableAccesstoPrescriptionDrugs.pdf
(2) CMS Supplemental Guidance, http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/HPMSSupplementalGuidanceRelated-toImprovingDURcontrols.pdf
(3) HPMS Memo, Medication Part D Overutilization Monitoring System, http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/HPMSmemo_MedicarePartDOverutilizationMonitoringSystem011714.pdf
Hyaluronate agents require prior authorization
Effective immediately, the following drugs should not be billed under the members Part D benefit. Ordering physicians should call the
Specialty Pharmacy Part B department at (866) 797-9884 option 5 to obtain precertification for these drugs:

J7323 – Euflexxa, Monovisc

J7326 – Gel-One

J7324 – Orthovisc, Hyaluronan

J7325 – Synvisc, Synvisc One

J7321 – Supartz, Hyalgan
If these drugs are taken to a retail pharmacy and attempted to be billed to Part D benefits, the pharmacist will see a message that rejects
the claim and asks to have the prescribing physician call their Part B carrier for prior authorization.
Y0071_14_21633_I 09/24/2014
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Important 2015 coverage changes for diabetic supplies
Effective January 1, 2015, all of our individual Medicare Advantage plans will no longer cover certain diabetic supplies purchased from
Durable Medical Equipment (DME) providers.
HCPC codes no longer covered when purchased through a DME provider:

A4253 blood glucose test strips

E0607 home blood glucose monitor

E2100 blood glucose monitor with integrated voice synthesizer

E2101 blood glucose monitor with integrated lancing/blood sample
Members impacted by this change will be notified in October through their Annual Notice of Change and Evidence of Coverage plan
benefit materials. To be covered for a $0 copay, the members must purchase these supplies at an in-network retail or mail-order pharmacy
supplier.
Covered blood glucometers and blood glucose test strips in 2015:
 LifeScan, Inc., OneTouch®

Roche Diagnostics, ACCU-CHEK®

A limit of 100 blood glucose test strips per month
Other blood glucometer or blood glucose test strip brands or quantities of more than 100 test strips per month are not covered unless you
as the doctor or provider tell us another brand or a larger quantity is medically necessary for the member’s treatment, no other brand or
larger quantity limit will be covered.



If our member is currently using LifeScan, Inc., OneTouch® or Roche Diagnostics, ACCU-CHEK® blood test strips or glucometer
products and using an in-network retail or mail-order pharmacy supplier, you don’t need to do anything.
If our member is not using LifeScan, Inc., OneTouch® or Roche Diagnostics, ACCU-CHEK® blood test strips or glucometer
products or using an in-network retail or mail-order pharmacy supplier, then our member will need to get new prescriptions for
the supplies by January 1, 2015, for these claims to be covered by us.
You should discuss these coverage changes and possible new prescriptions with our member/your patient. If it is medically
necessary for them to continue using a different brand of blood test strips or glucometer and/or more than 100 blood test strips
per month, you will need to communicate this to us by requesting an exception.
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The benefit and brand limitations described above generally do not apply to our Group Sponsored Medicare Advantage Health
Benefit Plans. Please contact provider services for benefit information.
Individual Medicare Advantage Plans included in this coverage change:
Plan Name
State - Plan Type
Anthem Select Advantage (HMO)
CA-HMO
Blue Cross Senior Secure Plan I (HMO)
CA-HMO
Blue Cross Senior Secure Plan II (HMO)
CA-HMO
Anthem Dual Advantage (HMO SNP)
CA-HMO, D-SNP
Anthem Medicare Preferred Standard (PPO)
CA-LPPO
To determine whether or not a member is enrolled in one of our Individual Medicare Advantage plans versus a group sponsored plan,
check the lower right front of the ID card which reflects the contract and PBP number (example: H1234-001) and/or plan name.
Note: If the PBP (the last three digits of the contract-PBP number) is in the 800 series, that member is in a group sponsored plan and
these changes do not apply to their plans.
Please contact the plan’s Provider Service Department listed on the back of the member’s ID card if you have any questions about these
coverage changes.
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The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.
Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/co-insurance may change on January 1 of each year.]
Y0071_14_20940_I 07/31/2014
CuraScript moves to Accredo brand effective November 24, 2014
Express Scripts’ acquisition of Medco Health Solutions in 2012 resulted in the merger of ESI’s CuraScript Specialty Pharmacy and
Medco’s Accredo Specialty Pharmacy. Starting in 2014, unified pharmacy operations will be under the Accredo name and license.
Members of our Medicare Advantage Prescription Drug plans will transition to the Accredo brand on November 24, 2014.
Some of the limited changes members will experience:
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They will see the Accredo name and label on their medication shipments and pharmacy letters
Expanded pharmacy hours – Monday-Friday, 5 a.m. – 8 p.m. PT, Saturday, 5 a.m. – 2 p.m., PT.
Upgraded assessments to include therapy-specific questions for improved adherence
How providers will be impacted – frequently asked questions
Q. What changes will impact providers as a result of the brand transition to Accredo?
A. Referral forms will be updated to reflect the change to Accredo and will be available on the Accredo website. However, if providers
continue to use CuraScript-branded referral forms, Accredo can accept them and there will be no disruption in service.
Q. Will the fax number remain the same?
A. Yes, providers will continue to use the same fax number, (800) 824-2642.
Q. Will the provider contact number remain the same?
A. Yes, providers will continue to use the same phone number, (800) 870-6419.
Q. Will the pharmacy hours remain the same?
A. The Accredo Specialty Pharmacy will have expanded hours, Monday-Friday, 5 a.m. – 8 p.m. PT, Saturday, 5 a.m. – 2 p.m. PT.
Q. Will prior authorization phone numbers change?
A. No. Prior authorization phone numbers will stay the same.
Q. Will the process for ordering office-administered drugs change?
A. No, the process for ordering office-administered drugs will not change.
Q. If providers or their staffs have questions about the brand change to Accredo, who should they contact?
A. Providers and their staffs should contact the CuraScript provider help desk, just as they would today.
Q. How will providers be notified about the change?
A. In addition to this article, a letter will be faxed by CuraScript to prescribing providers prior to member notification, alerting providers to
the change.
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Pharmacy information available on online
Visit our website for more information on our Medicare Advantage Prescription Drug plans, including formularies, Part D conditions and
limitations and forms.
Y0071_14_21910_I 10/06/14
New D-SNP plans offered in 2015; D-SNP training available
In 2015, Anthem Blue Cross will provide Dual Eligible Special Needs Plans (D-SNPs) to people who are eligible for both Medicare and
Medicaid benefits or who are qualified Medicare beneficiaries (QMBs). D-SNPs coordinate Medicare and Medicaid programs and provide
enhanced member benefits.
Providers who see Anthem Blue Cross Medicare Advantage HMO members in California also are considered contractually eligible to see
Anthem D-SNP members effective January 1, 2015.
Anthem Blue Cross will offer an introduction to D-SNP plans, including claims submission, coding procedures and model of care
information. Upcoming training opportunities will be posted to Important Medicare Advantage Updates as soon as they are available.
Y0071_14_21954_I 10/08/2014
Advanced notices of non-coverage for Medicare Advantage members
The Centers for Medicare & Medicaid Services (CMS) issued recent guidance concerning Advance Notices of Non-Coverage. CMS
advised Medicare Advantage plans that contracted providers are required to provide a coverage determination for services that are not
covered by the member’s Medicare Advantage plan. This will ensure that the member will receive a denial of payment and accompanying
appeal rights. Please note that this guidance is not entirely consistent with Anthem Blue Cross’s provider agreements. The provider
agreements only require that you notify the member in writing in advance of providing non covered services and that you provide an
estimate of the member’s financial liability. Anthem Blue Cross asks that you follow the CMS requirements immediately. Anthem Blue
Cross will amend your provider agreement to reflect this change in guidance through a future communication. If you have any doubt about
whether a service is not covered, please seek a coverage determination from the plan.
A written coverage determination will help ensure that a claim for non-covered care from a contracted provider is paid accurately.
According to CMS, if the appropriate written notice of denial of payment is not given to the Medicare Advantage member regarding a noncovered service, the claim may be denied and the member cannot be held financially responsible. Therefore, your failure to provide an
appropriate coverage determination could result in a denial of payment for the non-covered service.
Contracted providers seeking a coverage determination for Anthem Medicare Advantage members should call the telephone number listed
on the back of the member’s identification card for assistance.
Y0071_14_22176_I_001_10/22/14
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Pharmacy
Pharmacy information available on anthem.com/ca
Visit http://www.anthem.com/pharmacyinformation for more information on copayment/coinsurance requirements and their applicable drug
classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or
other management methods subject to prescribing decisions, and any other requirements, restrictions or limitations that apply to certain
drugs. The commercial drug list is reviewed and updates are posted to the web site quarterly (the first of the month for January, April, July
and October).
To locate the “Marketplace Select Formulary” and pharmacy information for Health Plans offered on the Exchange Marketplace, go to
Customer Support, select your state, Download Forms and choose “Select Drug List”.
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