Medi-Cal Managed Care Major Risk Medical Insurance Program

Provider Manual Medi-Cal Managed Care Major Risk Medical Insurance Program

ACA-PM-0019-21 ANTHEM BLUE CROSS PROVIDER MANUAL

ANTHEM BLUE CROSS PR OVIDER MANUAL

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ACA-PM-0019-21 ANTHEM BLUE CROSS PROVIDER MANUAL

April 2021 TABLE OF CONTENTS ANTHEM BLUE CROSS PROVIDER MANUAL ...... 1 1 | INTRODUCTION ...... 4 WELCOME...... 4 USING THIS MANUAL ...... 4 2 | QUICK REFERENCE ...... 6 WEBSITES AND COMMUNITY RESOURCES ...... 6 ONLINE TOOLS FOR PROVIDERS...... 6 HEALTH EDUCATION AND CULTURAL AND LINGUISTIC NEEDS...... 7 MEDICAL APPOINTMENT STANDARDS ...... 7 CONTACT INFORMATION...... 9 COVERED SERVICES GRID...... 14 3 | MEMBER ELIGIBILITY...... 22 VERIFYING ELIGIBILITY...... 22 ENROLLMENT/DISENROLLMENT ...... 23 MEMBER-INITIATED PCP CHANGES ...... 24 MEMBER TRANSFERS TO OTHER PLANS ...... 25 MEMBER NONDISCRIMINATION ...... 25 4 | GENERAL BENEFITS ...... 27 BENEFIT PROGRAMS AND POPULATIONS ...... 27 BEHAVIORAL HEALTH AND SUBSTANCE ABUSE ...... 28 COMMUNITY-BASED ADULT SERVICES...... 33 SENSITIVE SERVICES...... 34 TELEHEALTH ...... 34 TRANSPORTATION...... 35 5 | MEMBER SERVICES, EDUCATION, WELLNESS...... 36 WELLNESS PROGRAMS...... 36 CULTURAL AND LINGUISTIC/ INTERPRETER SERVICES...... 40 MEMBER RIGHTS AND RESPONSIBILITIES ...... 43 6 | PHARMACY...... 46 COVERAGE AND LIMITATIONS ...... 46 PRIOR AUTHORIZATIONS ...... 49 PHARMACY BENEFIT MANAGER ...... 50 SPECIAL DRUG PROCEDURES...... 51 SPECIAL FILL PROCEDURES...... 52 PHARMACY PROGRAMS ...... 52 COORDINATION OF BENEFITS...... 53 ADMINISTRATIVE ...... 53 7 | SPECIAL PROGRAMS AND PILOTS ...... 55 MANAGED LONG-TERM SERVICES AND SUPPORTS ...... 55 HEALTH HOMES ...... 59 WHOLE PERSON CARE...... 61 PALLIATIVE CARE PROGRAM ...... 61 LIVEHEALTH ONLINE (LHO) ...... 63 8 | PROVIDER PROCEDURES AND RESPONSIBILITIES ...... 64 RESPONSIBILITIES APPLICABLE TO ALL PROVIDERS ...... 64 HOSPITAL SCOPE OF RESPONSIBILITIES ...... 66

ANTHEM BLUE CROSS PROVIDER MANUAL

ACCESS TO CARE, APPOINTMENT STANDARDS AND AFTER-HOURS SERVICES ...... 66 REQUIRED ASSESSMENTS ...... 71 CALIFORNIA CHILDREN’S SERVICES...... 72 PREGNANCY NOTIFICATION ...... 73 PREVENTIVE HEALTHCARE ...... 74 9 | ADMINISTRATIVE PROCEDURES ...... 78 PROVIDER TERMINATION, LOCATION, COVERED SERVICES AND OR POPULATION SERVED CHANGES 78 CONTRACT TERMINATION WITH HEALTH PLAN...... 78 TERMINATION OR AFFILIATION CHANGE WITH PROVIDER GROUPS ...... 79 UPDATING PROVIDER DIRECTORIES ...... 80 UPDATING PROVIDER INFORMATION ...... 80 10 | CREDENTIALING AND RECREDENTIALING ...... 81 CREDENTIALING SCOPE ...... 81 INITIAL CREDENTIALING ...... 82 HEALTH DELIVERY ORGANIZATIONS ...... 83 CREDENTIALING PROGRAM STANDARDS ...... 86 PARTICIPATION CRITERIA FOR BEHAVIORAL HEALTH PRACTITIONERS ...... 91 ADDITIONAL PARTICIPATION CRITERIA ...... 93 CREDENTIALS COMMITTEE ...... 97 SANCTION MONITORING ...... 98 APPEALS PROCESS ...... 99 11 | UTILIZATION MANAGEMENT AND PRIOR AUTHORIZATION...... 100 AUTHORIZATION REQUESTS AND TIME FRAMES ...... 100 EMERGENCY MEDICAL CONDITIONS AND SERVICES...... 104 CONTINUED STAY REVIEW ...... 105 POST-SERVICE CLINICAL CLAIMS REVIEW ...... 106 REFERRALS AND SECOND OPINIONS...... 106 TRANSITION AND DISCHARGE PLANNING...... 108 12 | CARE MANAGEMENT AND HEALTH PROGRAMS ...... 109 CARE MANAGEMENT ...... 109 CONTINUITY OF CARE ...... 111 DISEASE MANAGEMENT PROGRAMS...... 112 HEALTH SERVICE PROGRAMS ...... 113 13 | QUALITY MANAGEMENT ...... 116 PROVIDER PERFORMANCE DATA ...... 121 HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS)...... 121 FACILITY SITE REVIEW PROCESS ...... 123 MEDICAL RECORDS STANDARDS ...... 124 14 | CLAIMS AND ENCOUNTERS ...... 128 REIMBURSEMENT POLICIES ...... 128 CLAIM SUBMISSIONS ...... 129 CLAIMS CODING AND DOCUMENTATION ...... 149 CLAIM PROCESSING ...... 153 CLAIMS STATUS ...... 154 OVERPAYMENT AND RECOVERY ...... 155 ENCOUNTER DATA ...... 155 15 | GRIEVANCES, APPEALS, DISPUTES ...... 158 CLAIM PAYMENT DISPUTE ...... 158

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ANTHEM BLUE CROSS PROVIDER MANUAL

CLAIM INQUIRIES ...... 158 PROVIDER GRIEVANCES...... 160 ARBITRATION ...... 161 MEMBER APPEALS AND GRIEVANCES ...... 161 16 | COMPLIANCE AND REGULATORY REQUIREMENTS ...... 165 PROVIDER’S ROLE IN COMPLIANCE, ETHICS, PRIVACY AND HOTLINE REPORTING ...... 165 MARKETING RULES ...... 165 HIPAA PRIVACY, PHI, SECURITY...... 167 FRAUD, WASTE AND ABUSE ...... 168 DELEGATION OVERSIGHT...... 170 PROVIDER GROUP FINANCIAL OVERSIGHT ...... 171 HOSPITAL FINANCIAL REVIEW ...... 172

1 | INTRODUCTION

1 | I NTRODUCTION WELCOME USING THIS MANUAL Thank you for being part of the Anthem Blue Cross This Provider Manual is designed for Anthem family of healthcare services. Blue Cross contracted providers. Our goal is to create a useful reference guide for you and your Anthem Blue Cross has been selected by the office staff. California Department of Health Care Services (DHCS) to provide healthcare services for Medi-Cal Providers contracted with an independent physician Managed Care (Medi-Cal) members in the following association (IPA) or other provider organization counties: may have separate policies and procedures. Please contact the organization’s administrator for • Alameda • Mono details. • Alpine • Nevada We recognize that managing our members’ health • Amador • Placer can be a complex undertaking. It requires familiarity • Butte • Plumas with the rules and requirements of a system that encompasses a wide array of healthcare services • Calaveras • Sacramento and responsibilities. • Colusa • San Benito This includes everything from initial health • Contra Costa • San Francisco assessments to case management and from proper storage of medical records to billing for El Dorado Santa Clara • • emergencies. With that in mind, we’ve divided this • Fresno • Sierra manual into broad sections that reflect your questions, concerns and responsibilities before and • Glenn • Sutter after an Anthem Blue Cross member walks through • Inyo • Tehama your doors. This manual is available to you on our • Kings • Tulare website at: • Madera • Tuolumne  https://providers.anthem.com/CA. • Mariposa • Yuba Select any topic in the Table of Contents and you will be automatically redirected to that topic’s Anthem Blue Cross partners with L.A. Care Health location within the manual. Select any web address Plan to provide healthcare services for Medi-Cal and you will be redirected to that site. Each chapter members in the following county: may also contain cross-links to other chapters, • Los Angeles important phone numbers, and our website or outside websites containing additional information. Medi-Cal provides healthcare coverage for California's most vulnerable low-income citizens Throughout this manual, there are instances where who lack health insurance. information is provided as a sample or example. This information is meant for illustration purposes Medi-Cal is the second largest source of healthcare only and is not intended to be used or relied upon coverage in California. Anthem Blue Cross has a in any circumstance or instance. If you have any long-standing history of providing Medi-Cal services questions about the content of this manual, please to Californians. In fact, Anthem Blue Cross was one contact our Customer Care Center or your provider of the first Medi-Cal managed care organizations network representative. (MCOs).

1 | INTRODUCTION

DEFINITIONS By accepting this manual, Anthem Blue Cross Provider: Any individual or entity that is engaged in providers agree to use this manual solely for the purposes of referencing information regarding the the delivery of Medi-Cal services, or ordering or provision of medical services to Medi-Cal and referring for those services, and is legally MRMIP members who have chosen Anthem authorized to do so by DHCS. Blue Cross as their health plan. LEGAL AND ADMINISTRATIVE This manual does not obligate providers to provide REQUIREMENTS services to members enrolled in any of these programs unless the provider is under contract with Websites Anthem Blue Cross to provide services in one or The Anthem Blue Cross website and this manual more of these programs. Providers are only may contain links and references to internet sites required to follow the standards in this manual that owned and maintained by third parties. Neither are applicable to the program in which the member Anthem Blue Cross nor its related affiliated is currently enrolled. companies operate or control in any respect any information, products or services on third-party UPDATES AND CHANGES sites. Such information, products, services and The Provider Manual, as part of your Provider related materials are provided as is without Agreement and related Addendums, may be warranties of any kind, either expressed or implied, updated at any time and is subject to change. In the to the fullest extent permitted under applicable event of an inconsistency between information laws. contained in the manual and the Agreement Anthem Blue Cross disclaims all warranties, between you or your facility and Anthem expressed or implied, including but not limited to Blue Cross, the Agreement shall govern. implied warranties of merchantability and fitness. In the event of a material change to the Provider Anthem Blue Cross does not warrant or make any Manual, we will make all reasonable efforts to notify representations regarding the use or results of the you in advance of such change through web-posted use of third-party materials in terms of correctness, newsletters, fax communications and other accuracy, timeliness, reliability or otherwise. mailings. In such cases, the most recently The information contained in this manual will be published information should supersede all updated regularly and is subject to change. This previous information and be considered the current section provides specific information on the legal directive. obligations of being part of the Anthem Blue Cross The manual is not intended to be a complete network. statement of all Anthem Blue Cross policies or This manual provides standards for services to procedures. Other policies and procedures not members of the Medi-Cal and MRMIP programs. It included in this manual may be posted on our does not establish standards for services to any website or published in specially targeted other members of Anthem Blue Cross or its communications, including but not limited to letters, affiliates. If a section of the manual applies only to bulletins and newsletters. a specific program, that program will be indicated. If This manual does not contain legal, tax or medical there is no such indication, the information is advice. Please consult with your own advisors for applicable to all programs. such advice.

2 | QUICK REFERENCE

2 | QUI CK REFERENCE WEBSITES AND COMMUNITY 1. Select Register. RESOURCES 2. Select Get Started. A wide array of valuable tools, information and 3. Complete the online registration form. forms are available on our websites below:  If you have questions about registering for the  https://mss.anthem.com/CA Availity Portal, contact Availity Client Services  https://providers.anthem.com/CA at 1-800-282-4548. PATIENT360 ON AVAILITY ONLINE TOOLS FOR PROVIDERS Patient360 is real-time dashboard that gives you a The Availity Portal is a secure website for Anthem robust picture of a patient’s health and treatment Blue Cross eligibility, benefits and claim status history and will help you facilitate care coordination. inquiry functionality. All participating providers must You can drill down to specific items in a patient’s register for Availity to access these functions and medical record to retrieve demographic information, additional value-added features and services. care summaries, claims details, authorization Here are some of the other features and tools details, and pharmacy information. available on the Availity Portal: With this level of detail at your fingertips, you will be • Dispute a Claim able to: • Submit Medical Attachments • Spot utilization and pharmacy patterns. • Remittance Inquiry • Avoid service duplication. • Precertification Look up Tool • Identify care gaps and trends. • Clear Claims Connection • Coordinate care more effectively. • Claim Status Listing • Reduce the number of communications • Single or Batch Claim Submission needed between PCPs and case managers. • Custom Learning Center Patient360 is offered on the Availity Portal. This online application lets you quickly retrieve detailed • Provider Online Reporting (Eligibility & records about your Anthem Blue Cross patients. Roster Reports Patient360 replaces the Patient Care Summary that • Patient360 was previously accessed through Eligibility and Benefits on the Availity Portal. It will also replace Use of the Availity Portal will minimize time spent Member Medical History Plus (MMH Plus). on the telephone with Customer Service and allow more time for you to spend with your patients. In You must first be assigned the Patient360 role in fact, it may eliminate 80% of routine inquiries to the Availity Portal; administrators can make this Anthem Blue Cross. assignment within the Clinical Roles options. Then navigate to Patient360 using one of the methods Availity is available 24 hours a day, 7 days a week, outlined on the following page. except during scheduled maintenance and national holidays. Availity offers printer-friendly formats on all information screens.

THE AVAILITY PORTAL To gain access to the Availity Portal:  Go to www.availity.com.

2 | QUICK REFERENCE

Method 1  https://providers.anthem.com/california- Select Patient Registration from the top menu bar provider/resources/provider-training- in the Availity Portal. academy 1. Choose Eligibility and Benefits.  For after-hours telephone interpreter services, members can call the 24/7 NurseLine at 2. Complete the required fields on the 1-800-224-0336, TTY 1-800-368-4424. Eligibility and Benefits screen. 3. Select the Patient360 link on the member’s MEDICAL APPOINTMENT benefit screen. STANDARDS 4. Enter the member’s information in the Healthcare providers must make appointments for required fields. members from the time of request as follows:

Method 2 Emergency Immediate access 24 Select Payer Spaces from the top menu bar in the examination hours/7 days a week Availity Portal. Urgent (sick) Within 48 hours of 1. Choose the Anthem Blue Cross tile. examination request if authorization is not required or within Select Patient360 located on the 2. 96 hours of request if Applications page. authorization is required 3. Enter the member’s information in the or as clinically indicated required fields. Routine primary Within 10 business If you have other questions about Patient360, care examination days of request please contact your local network representative. (nonurgent) Nonurgent Within 15 business HEALTH EDUCATION AND consults/specialty days of request CULTURAL AND LINGUISTIC referrals NEEDS Nonurgent care Within 10 business Health education classes and cultural and linguistic with nonphysician days of request requests are available at no charge to Anthem Blue mental health Cross members enrolled in Medi-Cal and are providers accessible upon self-referral or referral by Anthem (where applicable) Blue Cross network providers. To refer a member, please use the Health Education and Cultural Nonurgent ancillary Within 15 business days of request Linguistic Needs Referral Form available on our website at the following address. Initial health Within 120 days of Providers can refer members to health education assessments enrollment classes using the Referral Form which can be Preventive care Within 14 days of accessed at the below link under the Patient Care visits request drop down: Routine physicals Within 30 days of  https://providers.anthem.com/california- request provider/resources/forms Additional information on interpreter services is available on the Interpreter Services section of our Provider Training Academy at:

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Initial health assessments (under age 21)

Children under the Within 120 days of age of 18 months enrollment or within American Academy of Pediatrics (AAP) guidelines, whichever is less

Children aged 19 Within 120 days of months to 20 years enrollment of age

Prenatal and postpartum visits

First prenatal visit Within 10 days of request

1st and 2nd Within 7 days of request trimester

3rd trimester Within 3 days of request

High-risk Within 3 days of pregnancy identification

Postpartum Between 21 and 56 days after delivery

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CONTACT INFORMATION The following resource grid is a consolidation of the most-used phone and fax numbers, websites and addresses found within the manual itself. We've also included other valuable contact information for you and your staff.

STATE OF CALIFORNIA Health services programs handled by the state: State services contacts Phone/fax numbers Other contact information

Automated Eligibility 1-800-456-2387 Verification System (AEVS)

California Children's Phone numbers are Referrals: Services (CCS) county-specific. www.dhcs.ca.gov/services/ccs/Pa Los Angeles County ges/default.aspx Phone: 1-800-288-4584 Fax: 1-800-924-1154 Community-Based Adult Services (CBAS) https://www.aging.ca.gov/ California Department of Programs/#CBAS Aging: Phone within California: 1-800-510-2020 Phone outside of California: 1-800-677-1116 Denti-Cal 1-800-423-0507 www.denti-cal.ca.gov 8 a.m. - 5 p.m., Monday through Friday Department of Health 1-800-452-8609 www.dhcs.ca.gov/services/medi- Care Services Medi-Cal cal/Pages/MMCDOfficeoftheOmbu Managed Care dsman.aspx Ombudsman Department of Health 1-800-942-1054 www.dhcs.ca.gov/services/ofp/Pa Care Services Office of ges/OfficeofFamilyPlanning.aspx Family Planning Department of Social 1-800-952-5253 Services Public Inquiry and Response Unit Department of Managed 1-877-525-1295 www.dmhc.ca.gov Health Care Indian Health Services 1-916-930-3927 www.ihs.gov/Calfornia

Medi-Cal Telephone 1-800-541-5555 Service Center

2 | QUICK REFERENCE

ANTHEM BLUE CROSS Contact information related to Anthem Blue Cross Medi-Cal programs:

Outside Los Inside Los Hours of Contact Angeles Angeles operation Address, email, fax and/or website County County (PT)

5 a.m. - 5 Availity 1-800-282-4548 p.m., www.availity.com Mon - Fri

Fax: 1-800-754-4708 Utilization 8 a.m. - Behavioral Health: Management: 1-888-831-2246 5 p.m., [email protected] Medi-Cal Mon - Fri Fax: 1-855-473-7902

Utilization 8 a.m. - Management: 1-877-273-4193 5 p.m., Fax: 1-800-754-4708 MRMIP Mon - Fri

Utilization Management: 1-888-831-2246 8 a.m. - Delegated 5 p.m., Fax: 1-888-232-0708

Groups to Mon - Fri Perform UM

8 a.m. - Case 1-888-334-0870 5 p.m., Fax: 1-866-333-4827 Management Mon - Fri

Claims: Anthem Blue Cross, P.O. Box 60007, Los Angeles, CA 90060-0007 Follow-Up

Overnight packages: Claims: Overpayment Recovery Overpayment Recovery Anthem Blue Cross Anthem Blue Cross Overpayment P. O. Box 92420 Lockbox 92420 Recovery Cleveland, OH 44135 4100 West 150th St. Cleveland, OH 44135

Availity Client Services at: 5 a.m. – 5 Claims: EDI 1-800-Availity (1-800-282- www.anthem.com/edi p.m., 4548) Mon-Fri

Claims: Paper Anthem Blue Cross, P.O. Box 60007, Los Angeles, CA 90060-0007

2 | QUICK REFERENCE

Outside Los Inside Los Hours of Contact Angeles Angeles operation Address, email, fax and/or website County County (PT)

Community- 8 a.m. - Based Adult https://www.aging.ca.gov/ 5 p.m., Services Programs/#CBAS 1-855-871-4899 Mon - Fri (CBAS) Fax: 855-336-4041

Central CA: 1-877-811- Network Los 3113 8 a.m. - Relations Angeles: 5 p.m., Department Northern 1-866-465- CA: Mon - Fri 2272 1-888-252- 6331

1-888-285- 1-800-407- 7801 7 a.m. - Customer Care 4627 For after-hours services, please call L.A. Care: 7 p.m., Center 1-888-757- 24/7 NurseLine (see below). 1-866-522- Mon to Fri 6034 (TTY) 2736

1-877-687- 1-877-687- www.dhcs.ca.gov 0549 0549 8:30 a.m. - MRMIP 7 p.m., For after-hours services, please call 1-888-757- 1-888-757- Mon - Fri 24/7 NurseLine (see below). 6034 (TTY) 6034 (TTY)

5 a.m. - Request for formulary changes: 10 p.m., IngenioRx Help Mon - Fri Anthem Prescription Mgt., LLC for Pharmacists 1-833-253- 1-833-253- Attn: Formulary Department 4454 4454 6 a.m. - P.O. Box 746000 3 p.m. Cincinnati, OH 45274-6000 Sat/Sun

Pharmacy Prior 7 a.m. - 1-844-410- 1- 1-844- Authorization 7 p.m., Fax: 1-844-474-3345 0746 410-0746 Center Mon - Fri

1-800-407- 4627 or Fraud and 7 a.m. - 1-888-231- 1-888-285- Abuse: 7 p.m., Fax: 1-866-454-3990 5044 (Blue 7801 Mon to Fri Medi-Cal Cross of California Fraud Hotline)

2 | QUICK REFERENCE

Outside Los Inside Los Hours of Contact Angeles Angeles operation Address, email, fax and/or website County County (PT)

Fraud and 7 a.m. - 1-877-687- 1-877-687- Abuse: 7 p.m., 0549 0549 MRMIP Mon - Fri

Grievance & Appeals Department Fax: Anthem Blue Cross Grievances & Physician/Provider P.O. Box 60007 1-888-387- Appeals Grievance Form Los Angeles, CA 90060-0007 2968 Fax: 1-866-387-2968

8 a.m. - Health Care 1-800-430-4263 5 p.m., Options Mon - Fri

8 a.m. - 8 p.m., Medi-Cal for 1-800-880- Mon - Fri Families 5305 Information Line 8 a.m. - 5 p.m., Sat

711 or Voice to TTY, English: Hearing 1-800-735-2922 24 hours a Impaired Spanish: For additional information, visit the day, 7 Services: 1-800-855-3000 California Relay Service webpage days a at: https://ddtp.cpuc.ca.gov California Relay TTY to voice, English: week Service 1-800-735-2929 Spanish: 1-800-855-3000

Medi-Cal: 1-800-407-4627

MRMIP: 1-877-687-0549 8 a.m. - Face-to-face interpreters can be Interpreter 5 p.m., requested via email at: Services Mon - Fri [email protected] After hours, use 24/7 NurseLine: 1-800-224-0336 1-800-368-4424 (TTY) L.A. Care 7 a.m. - Member 1-888-839-9909 7 p.m., Services Mon - Fri

2 | QUICK REFERENCE

Outside Los Inside Los Hours of Contact Angeles Angeles operation Address, email, fax and/or website County County (PT)

Long-Term 8 a.m. - https://www.aging.ca.gov/ Services and 1-855-871-4899 5 p.m., Programs/#CBAS Support Mon - Fri Fax: 855-336-4041

Interactive Voice Member (IVR) 24 hours a Response day, 7 Eligibility: (IVR) 1-888-285- days a Anthem 7801 1-800-407- week 4627

Member 24 hours a Automated Eligibility Voice Eligibility: day, 7 https://www.medi-cal.ca.gov/ System (AEVS): days a eligibility/login.asp State of 1-800-456-2387 California week

24 hours a Can be used for after-hours member 1-800-224-0336 day, 7 24/7 Nurseline eligibility verification and after-hours days a 1-800-368-4424 (TTY) requests for interpreter services week

https//www.availity.com Availity Portal

Provider Contracting: Relations [email protected] (Behavioral Network Relations: https://providers.anthem.com/CA Health BHMedi- Providers) [email protected]

Secure email: 1-866-755-2680 5 a.m. - eBusiness Help 5 p.m.,

Desk Mon - Fri

1-888-757-6034 8:30 a.m. - TTY 7 p.m., Mon - Fri

5 a.m. - 8 p.m., Vision Services: 1-800-615-1883 Mon - Fri Vision Service www.vsp.com 6 a.m. - Plan (VSP)* 5 p.m., Sat

2 | QUICK REFERENCE

COVERED SERVICES GRID The following table lists benefits covered by the Medi-Cal Managed Care program. This is not an all-inclusive list of benefits. For pharmacy benefit information, please see Chapter 6. For questions about services not listed, please contact the Customer Care Center or Provider Relations for assistance. Services received from an out-of-network provider without an authorization or referral are not covered, except in the case of medical emergencies. Covered by DHCS Fee-for-Service (FFS) Covered by Anthem Blue Cross or other state/county Benefits and services * Prior authorization (PA) is required. agencies PA* Abortion Covered Acupuncture Covered Allergy testing Covered • Antigen Ambulance services Covered • Air ambulance • Dry runs • Ground ambulance • Nonemergent transport Yes from home to doctor's office, dialysis or physical therapy Amniocentesis Covered Anesthetics (administration) Covered Artificial insemination Not covered Audiology services Outside Los Angeles County: Not covered for members 21 and older except in cases of emergency and where the benefit is required to treat the emergency Inside Los Angeles County: Covered Behavioral health Professional services covered; Inpatient and • Inpatient behavioral may require preauthorization outpatient services health (covered by FFS administered by the Medi-Cal) Note: Marriage and family therapy DHCS FFS Program, • Outpatient behavioral for relationship problems are not a specifically County health (including covered service. Mental Health alcohol and substance Departments use services, crisis intervention and treatment) • Professional behavioral health services for mild to moderate level of impairment • Professional applied behavioral analysis (ABA) for members under 21 years of age Biofeedback Not covered

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Covered by DHCS Fee-for-Service (FFS) Covered by Anthem Blue Cross or other state/county Benefits and services * Prior authorization (PA) is required. agencies Blood and blood products Covered Cancer screening (refer to Covered Member Handbook) Cataract spectacles and lenses Yes Covered when medically necessary

CHDP – Well Visit - services Covered Chemical dependency Administered by the rehabilitation DHCS FFS Program, specifically County Mental Health Departments Chemotherapy drugs Covered If under 21 years of age, services covered by California Children’s Services Circumcision Not covered unless medically necessary Colostomy supplies Covered • Inpatient facility • Outpatient dispensing • In conjunction with home health Community-based adult Covered services Dental services (medical) Not covered for members 21 years • Accidental injury — and older except in cases of inpatient facility or emergency and where the benefit emergency room is required to treat the emergency Professional component • Covered if within six months of (anesthesia) injury Covered for dental work given in an in-patient facility or surgical center to members who: • Are younger than 7 years of age • Have a developmental (growth) issue and are under 21 years of age • Require benefit due to medical necessity Dental services — preventive Not covered Covered by DHCS and restorative dental programs, Denti-Cal or dental managed care (county specific)

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Covered by DHCS Fee-for-Service (FFS) Covered by Anthem Blue Cross or other state/county Benefits and services * Prior authorization (PA) is required. agencies Detoxification (acute phase) Not covered Administered by the DHCS FFS Program, specifically County Mental Health Departments Diabetic services Covered for members 21 years of If under 21 years of age and older age, services covered by California Children’s Services Diagnostic X-ray Covered: • Must use contracted • Prior authorization required radiology provider for selected CT/MRI/MRA/PET/SPECT Dialysis Covered for members 21 years of If under 21 years of age and older age, services covered by California Children’s Services Directly observed therapy Not covered Covered by DHCS (DOT) for the treatment of FFS Program tuberculosis Durable medical equipment Yes Covered except the below: • Items used only for comfort or hygiene • Items used only for exercise • Air conditioners, filters or purifiers • Spas, swimming pools Early and Periodic Screening, Preventive care services are Diagnostic and Treatment covered including: (EPSDT) services • Health screenings • Applies to members • Physical exams under 21 years of age • Hearing screenings • Vision screenings • Dental screenings • Vaccines • Health education • Blood tests including lead screenings and lipids testing Emergency room Covered • In and outside of California • Outpatient facility services • Professional End of Life Services Not Covered Covered Endoscopic studies Covered Experimental procedures Not covered Not covered

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Covered by DHCS Fee-for-Service (FFS) Covered by Anthem Blue Cross or other state/county Benefits and services * Prior authorization (PA) is required. agencies Family planning services and Covered: supplies (in or out of network) • Birth control • Education and counseling • Pregnancy tests • Sexually transmitted disease screening • Sterilization Not covered: • Sterilization reversal • Hysterectomy for sterilization • Fertility treatments Fetal monitoring Covered Genetic testing Covered; administered by the State Genetic Disease Branch Health education Covered Hearing aids Covered Hemodialysis chronic renal Covered failure Hepatitis B vaccine/gamma Covered globulin Home health care services Yes Covered Hospice Yes Covered Hospital based physicians (in Covered lieu of acute inpatient or SNF) Hospitalization Covered • Inpatient services • Private room covered only if • Outpatient services medically necessary • Intensive care services Immunization administration Pediatric: Covered under • Pediatric vaccines Vaccines For Children (VFC) or • Adult vaccines CHDP under 22 years of age Obstetrical vaccines • Adult: Covered according to ACIP recommendations Obstetrical: Covered according to ACIP recommendations Infant apnea monitor Yes Covered (outpatient) Infertility diagnosis and Not covered treatment Injectable medications Covered (outpatient and self- administered)

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Covered by DHCS Fee-for-Service (FFS) Covered by Anthem Blue Cross or other state/county Benefits and services * Prior authorization (PA) is required. agencies Inpatient alcohol and drug Administered by the abuse DHCS FFS Program, specifically County Mental Health Departments Interpreter services Covered Lab and pathology services Covered Lithotripsy Yes Covered Major organ transplants Covered by DHCS (except kidneys and corneas) FFS Program Major organ transplants Yes Covered (kidneys and corneas) Mammography Covered Mastectomy Covered Maternity care Covered Alpha fetoprotein • Pre- and post-natal care (AFP) screening • Nurse/midwife services covered by the DHCS • Childbirth and cesarean FFS Program section • Newborn exam Nutritionist/dietician Yes Covered Obstetrical/gynecological Covered services • Inpatient facility fees • Inpatient professional fees • Outpatient professional fee • Professional fee • Obstetrical CPSP services • Vaccines per ACIP recommendations Office visit supplies including Covered splints, casts, bandages and dressings Ophthalmology services Covered Optometric and optician Outside Los Angeles County: services Not covered for member 21 and older

Inside Los Angeles County:

Covered Physical, occupational and Yes Covered speech therapy (for • Inpatient or SNF PT • Outpatient only) • Professional Physician office visits Covered

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Covered by DHCS Fee-for-Service (FFS) Covered by Anthem Blue Cross or other state/county Benefits and services * Prior authorization (PA) is required. agencies Podiatry services Covered if: • Provided by a physician • Outpatient setting • Clinic Preadmission testing Covered Prosthetics and orthotics Yes Covered (including artificial limbs and eyes) Psychology services Yes Covered (psychological testing when clinically indicated to evaluate a mental health condition) Radiation therapy Covered Radiology services Yes • Inpatient facility (for Covered component some OP • Outpatient facility svcs.) component • Professional component Reconstructive surgery (not Yes Covered cosmetic) Rehabilitation services Yes Covered Routine physical examinations Covered except when required by job, school, camp or sports program Skilled nursing facility (SNF) Yes Participating CCI counties — • Long-term care limited Sacramento and Los Angeles to month member enters facility plus month following Specialist consultations Covered

TMJ treatment Yes Covered

Transcranial magnetic Not covered stimulation (TMS) Transfusions (blood and blood Covered products) Transgender services Covered

Urgent care center Covered

Vision care Covered • Medically necessary • Frames • Lenses Vision screening (refraction) Covered

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Covered by DHCS Fee-for-Service (FFS) Covered by Anthem Blue Cross or other state/county Benefits and services * Prior authorization (PA) is required. agencies Well Visits – Adults Preventive care services are  Applies to adult covered including: members • Health screenings • Physical exams • Dental screenings • Testing as recommended by the USPSTF • Vaccines per ACIP recommendations • Health education

2 | QUICK REFERENCE

The following table lists benefits covered by the Major Risk Medical Insurance Program. This is not an all-inclusive list of benefits. For pharmacy benefit information, please see Chapter 6. For questions about services not listed, please contact the Customer Care Center or Provider Relations for assistance. Services received from an out-of-network provider without an authorization or referral are not covered except in the case of medical emergencies. Major Risk Medical Insurance Program Benefits and services PA Coverage Ambulance Ground or air ambulance to or from a hospital for medically necessary services Behavioral health services Inpatient behavioral health services; limited to 10 days each calendar year Diagnostic X-ray and lab Outpatient diagnostic X-ray and laboratory services services Durable medical equipment Must be certified by a physician and required for care of an illness and supplies or injury Emergency healthcare Initial treatment of acute illness or accidental injury; includes services hospital, professional services and supplies Home health care Yes Home health services through a home health agency or visiting nurse association Hospital Yes Services provided in an Anthem Blue Cross contracted hospital. Benefits are not covered when provided in a non-contracting hospital within California except in a medical emergency. Hospice Yes Hospice care for members not expected to live more than 12 months if the disease or illness follows its natural course Infusion therapy Yes Therapeutic use of drugs or other substances ordered by a physician and administered by a qualified provider Physical, occupational and Services of physical, occupational and speech therapists as speech therapies medically appropriate on an outpatient basis Pharmacy Maximum 30-day supply per prescription when filled at a participating pharmacy Maximum 60-day supply for mail order (MRMIP members only) Physician office visits Physician services for medical necessity Pregnancy and maternity care Inpatient normal delivery and complications of pregnancy Maternity care for a paid surrogate mother who enrolled in the program Skilled nursing facilities Yes Skilled nursing care Transgender services Covered Vision services MRMIP does not cover vision services (except for vision tests for children)

3 | MEMBER ELIGIBILITY

3 | M EM BER ELIGIBILI TY VERIFYING ELIGIBILITY ANTHEM BLUE CROSS MEMBER ID CARDS Anthem Blue Cross providers are required to verify Anthem Blue Cross provides members an ID card a person’s eligibility and identity before services are with plan and provider information on the front and rendered at each visit. Providers must ask to see back (sample below). two separate ID cards to verify state Medi-Cal and Front Anthem Blue Cross eligibility. Because eligibility can change, eligibility should be verified at every visit. Claims submitted for services rendered to a member that is not eligible are not reimbursable.

BENEFICIARY IDENTIFICATION CARD The state of California Department of Health Care Services (DHCS) issues the Beneficiary Identification Card (BIC) after approving the person's Medi-Cal eligibility. The BIC is composed of a nine-character Client Identification Number (CIN), a check digit and a four-digit date that matches the date of issue. Back Effective September 12, 2016, DHCS implemented a new BIC card design. New Medi-Cal ID cards will not be replaced all at once. Providers should accept both BIC designs.

Old BIC Card

Note: Los Angeles County members will have a slightly different looking card than non-Los Angeles County members.

New BIC Card Anthem Blue Cross electronically updates member eligibility each day following notification from the DHCS.

MAJOR RISK MEDICAL INSURANCE PROGRAM There is no state of California BIC for the Major Risk Medical Insurance Program (MRMIP) as MRMIP is not a Medicaid program. The member will have an Anthem Blue Cross ID card only.

3 | MEMBER ELIGIBILITY

INDIVIDUAL ELIGIBILITY Note: To be HIPAA Version 5010 compliant, To verify managed care Medi-Cal member providers are no longer able to conduct a name search. eligibility, choose one of the following four options: 1. Swipe the BIC in a POS device. ELIGIBILITY ROSTERS AND CAPITATION REPORTS 2. Use the Automatic Eligibility Verification System (AEVS) by calling: Log in to the Availity Porta:  AEVS: 1-800-456-2387 1. Select Payer Spaces > Provider Online Reporting once your Availity Administrator 3. Log on to the Medi-Cal website at: has granted you access to the Provider  https://www.medi- Online Reporting role. The following reports cal.ca.gov/eligibility/login.asp can be obtained: • Enter your user ID and password. • State Sponsored Eligibility Reports – Professional Medical • Select Submit, which will take you to the Real Time Internet Eligibility • State Sponsored Capitation Reports page. – Professional Medical • Enter member information including ENROLLMENT/DISENROLLMENT subscriber ID, birth date, issue date and service date.  Medi-Cal Enrollment: 1-800-430-4263 Hours of operation: Monday to Friday, 4. Log on to the secure Availity website at: 7 a.m. - 7 p.m.  www.availity.com  MRMIP Enrollment: 1-800-289-6574 or From top navigation bar: insurance agent/broker Hours of operation: Monday to Friday, • Select Patient Registration 8:30 a.m. - 5 p.m. Select Eligibility and Benefits Inquiry • The Medi-Cal managed care enrollment process is • Payer: Anthem-CA managed by Health Care Options (HCO). • Enter your National Provider Identifier (NPI) Individuals and families whose applications are approved for Medi-Cal receive a pre-enrollment • Complete Patient Information packet that includes a Medi-Cal Managed Care Note: Items with an asterisk (*) are Enrollment Form and the plan's provider directory. required. Members must return the signed enrollment form Required information on Availity includes: within 45 days including selection of a healthcare • Member ID and the alpha prefix plan and a primary care provider (PCP). If the member does not choose a healthcare plan within • Patient Date of Birth or Patient First and the given time frame, the state assigns the member Last Name to a Medi-Cal plan. • Date of Service (defaults to current date) To learn more about the enrollment process or to • Selection of defined HIPAA services types obtain the most current forms and information, visit the URL below. • An active member will show a term date of 12/31/9999  www.healthcareoptions.dhcs.ca.gov/HCOCS P/Home

3 | MEMBER ELIGIBILITY

Additional information is available via the following Members are instructed to call the Anthem resources: Blue Cross Customer Care Center below to request an alternate PCP. California DHCS Medi-Cal website: Customer Care Center (outside L.A. County)  www.medi-cal.ca.gov   1-800-407-4627 Health Care Options:  Customer Care Center (inside L.A. County): 1-800-430-4263  1-888-285-7801 Hours of operation: Monday to Friday, STATE AGENCY-INITIATED MEMBER 7 a.m. - 7 p.m. DISENROLLMENT  1-888-757-6034 (TTY) The DHCS informs Anthem Blue Cross of membership changes by sending daily and monthly Anthem Blue Cross accommodates member enrollment reports. These reports contain all active requests for PCP changes whenever possible. Our membership data and incremental changes to staff will work with the member to make the new eligibility records. PCP selection, focusing on special needs. Our Anthem Blue Cross disenrolls members who are policy is to maintain continued access to care and not listed on the monthly full replacement file continuity of care during the transfer process. effective as of the designated disenrollment date. When a member calls to request a PCP change: Reasons for disenrollment may include: • The Customer Care Center (CCC) • Admission to a long-term care or representative checks the availability of the intermediate care facility beyond the month member’s choice. If the member can be of admission and the following month assigned to the selected PCP, the CCC • Change in eligibility status representative will do so. • County or residence changes • If the PCP is not available, the CCC representative will assist the member in • Healthcare plan mergers or reorganizations finding an available PCP. • Incarceration • If the requested PCP is not available and • Loss of benefits the member indicates there is an established relationship with the PCP, the Permanent change of residence out of • CCC will contact the PCP to confirm the service area member has an established relationship • Voluntary disenrollments and whether the PCP will accept the assignment. MEMBER-INITIATED PCP • If the member advises the CCC that he or CHANGES she is hospitalized, the CCC will advise the Members have the right to change their PCP member to call us upon discharge so that monthly or more frequently under certain we can assist them with their PCP change. conditions. When beneficiaries enroll in a Medi-Cal • Anthem Blue Cross notifies PCPs of managed care program, they can choose a PCP members’ transfers to a new PCP through when selecting their managed care plan. If a monthly enrollment reports. PCPs can beneficiary does not select a PCP when selecting a access these reports by calling our managed care plan, Anthem Blue Cross will select Customer Care Center or by going to our a PCP for the member. secure Availity website at:

3 | MEMBER ELIGIBILITY

 https://provider2.anthem.com/wps/po MEMBER NONDISCRIMINATION rtal/ebpmybcc Anthem Blue Cross does not engage in, aid or • The effective date of a PCP transfer will be perpetuate discrimination against any person by the first day of the following month. Anthem providing significant assistance to any entity or Blue Cross may assign a member person that discriminates on the basis of race, color retroactively on a case-by-case basis. or national origin in providing aid, benefits or services to beneficiaries. Anthem Blue Cross does MEMBER TRANSFERS TO OTHER not utilize or administer criteria having the effect of PLANS discriminatory practices on the basis of gender or gender identity. Anthem Blue Cross does not select Members can voluntarily disenroll and choose site or facility locations that have the effect of another healthcare plan at any time, subject to a excluding individuals from, denying the benefits of restricted disenrollment period. or subjecting them to discrimination on the basis of Approved disenrollments become effective no later gender or gender identity. In addition, in than the first day of the second month following the compliance with the Age Act, Anthem Blue Cross month in which the member files the request. may not discriminate against any person on the Disenrollment may result in any of the following: basis of age, or aid or perpetuate age discrimination by providing significant assistance to • Enrollment with another healthcare plan any agency, organization or person that • Return to traditional or original fee-for- discriminates on the basis of age. Anthem service Medi-Cal for continuity of care if the Blue Cross provides health coverage to our member's benefits fall into a voluntary aid members on a nondiscriminatory basis, according code to state and federal law, regardless of gender, If a member asks a provider how to disenroll from gender identity, race, color, age, religion, national Anthem Blue Cross, the provider should direct the origin, physical or mental disability, or type of member to call the Customer Care Center in their illness or condition. area: Members who contact us with an allegation of  Medi-Cal Health Care Options (outside L.A. discrimination are informed immediately of their County): 1-800-430-4263 right to file a grievance. This also occurs when an Anthem Blue Cross representative working with a The member must complete a Request for member identifies a potential act of discrimination. Disenrollment Form and mail it to: The member is advised to submit a verbal or Health Care Options written account of the incident and is assisted in P.O. Box 989009 doing so, if the member requests assistance. We West Sacramento, CA 95798-9850 document, track and trend all alleged acts of discrimination.  Medi-Cal L.A. Care (Los Angeles County only): 1-888-452-2273 Members are also advised to file a civil rights complaint with the U.S. Department of Health and The member must complete a Plan Partner Human Services Office for Civil Rights (OCR): Change Form and mail it to: • Through the OCR complaint portal at L.A. Care Health Plan https://ocrportal.hhs.gov/ocr/portal/lobby 555 West Fifth Street .jsf Los Angeles, CA 90013 • By mail to: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, DC 20201

3 | MEMBER ELIGIBILITY

• By phone at: 1-800-368-1019 EQUAL PROGRAM ACCESS ON THE BASIS (TTY 1-800-537-7697) OF GENDER Complaint forms are available at Anthem Blue Cross provides individuals with equal www.hhs.gov/ocr/office/file/index.html. access to health programs and activities without discriminating on the basis of gender. Anthem Anthem Blue Cross provides free tools and Blue Cross must also treat individuals consistently services to people with disabilities to communicate with their gender identity, and is prohibited from effectively with us. Anthem Blue Cross also discriminating against any individual or entity on the provides free language services to people whose basis of a relationship with, or association with, a primary language isn’t English (for example, member of a protected class (in other words, race, qualified interpreters and information written in color, national origin, gender, gender identity, age other languages).These services can be obtained or disability). by calling the customer service number on their member ID card. Anthem Blue Cross may not deny or limit health services that are ordinarily or exclusively available If you or your patient believe that Anthem to individuals of one gender, to a transgender Blue Cross has failed to provide these services, or individual based on the fact that a different gender discriminated in any way on the basis of race, was assigned at birth, or because the gender color, national origin, age, disability, gender or identity or gender recorded is different from the one gender identity, you can file a grievance with our in which health services are ordinarily or grievance coordinator via: exclusively available. • Mail:

Attn: Grievance Coordinator Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007 • Phone: 1-805-557-6069

4 | GENERAL BENEFITS

4 | gener al benefits BENEFIT PROGRAMS AND members enrolled in Medi-Cal Managed Care do POPULATIONS not have deductibles or copays.

MEDI-CAL MANAGED CARE MAJOR RISK MEDICAL INSURANCE PROGRAM (MRMIP) Medi-Cal Managed Care (Medi-Cal) is a complex network of public and private healthcare providers The Major Risk Medical Insurance Program (MRMIP) was designed to help insure the very who serve California's most vulnerable citizens: high-risk and those unable to secure private health low-income California residents who lack health insurance. Medi-Cal pinpoints 165 categories of coverage. The program is defined by the following: eligibility but generally covers the following • High-risk insurance pool populations: • Designed for those unable to secure private • Individuals in special treatment programs health coverage (including tuberculosis and dialysis) • Provides 36 months of access to health • Individuals with refugee status insurance • Low-income children and their parents • Requires an annual deductible • Low-income pregnant women • Requires copays for covered services • Qualified low-income Medicare recipients To qualify for MRMIP, applicants must meet the following criteria: • Seniors and persons with disabilities Anthem Blue Cross provides Medi-Cal services • The applicant must be a California resident. (Medicaid) for the California Department of Health • Denied individual coverage. Care Services and the Department of Public Health The following table lists all copays, deductibles and in the following counties: maximum benefits provided by the MRMIP. • Alameda • Madera • Alpine • Mariposa Copays/limits Explanation • Amador • Mono Calendar year $500 annual deductible • Butte • Nevada deductible per member • Calaveras • Placer $500 annual deductible per household • Colusa • Plumas • Contra Costa • Sacramento Copayment Payable to the provider at • El Dorado • San Benito the time of service • Fresno • San Yearly Member's annual • Glenn Francisco maximum maximum copay when copayment • Inyo • Santa Clara using participating providers: • Kings • Sierra $2,500 per member • Los Angeles (in • Sutter $4,000 per family partnership with • Tehama L.A. Care • Tulare Annual benefit Members must pay for Health Plan) • Tuolumne maximum services received after the combined total of all Yuba • benefits paid under MRMIP reaches $75,000 A covered services grid can be found in in a single calendar year Chapter 2: Quick Reference. Anthem Blue Cross

4 | GENERAL BENEFITS

Sexually transmitted diseases Copays/limits Explanation •

Lifetime benefit Members must pay for BEHAVIORAL HEALTH AND maximum services received after SUBSTANCE ABUSE the combined total of all benefits paid under OUTPATIENT (MEDI-CAL) MRMIP reaches $750,000 in the member's lifetime Behavioral healthcare services are covered when ordered by a participating provider for the diagnosis and treatment of a behavioral health condition. The STATE AND COUNTY-SPONSORED PROGRAMS conditions covered include the following: To ensure continuity and coordination of care for • Treatment for members who have our members, Anthem Blue Cross enters into experienced mild to moderate impairment related to a behavioral health diagnosis as agreements with locally-based state and county public health services and programs. Providers are identified by DSM-V. responsible for notifying Utilization Management Note: The treatment of severe mental illness or when a referral is made to any of the agencies or serious emotional disturbance remains the programs listed below. responsibility of the local county mental health plan. This notification ensures that case manager nurses At Anthem Blue Cross, our behavioral healthcare and social workers can follow up with members to benefit is fully integrated with the rest of our coordinate care. It also ensures that members healthcare programs. The provider roles include: receive all necessary services while keeping the • Ongoing communication and coordination provider informed. with physical health and other providers • Behavioral Health • Encouraging members to consent to the • California Children's Services (CCS) sharing of behavioral health treatment • California Early Start information • Child Health and Disability Prevention • Coordination with treating providers when Program members are hospitalized • Directly Observed Therapy for Tuberculosis • Ongoing coordination with Anthem Blue Cross Care Management (DOT) • End of Life Services (Contact the Medi-Cal MEMBER RECORDS AND TREATMENT and Provider Helpline at 1-800-541-5555. PLANNING Outside of CA, call 1-916-636-1980) Comprehensive Assessment • Family Planning Services Member records must meet the standards and • HIV Counseling and Testing contain the elements consistent with the licensure • Immunization Services of the provider. • Women, Infants and Children (WIC) Personalized Support and Care Plan • Waiver Programs A patient-centered support and care plan based • Targeted Case Management on the psychiatric, medical substance use and community functioning assessments found in the • Mental health initial comprehensive assessment must be • Alcohol and substance use disorder completed for any member who receives treatment services behavioral health services.

4 | GENERAL BENEFITS

There must be documentation in every case that signs and increased symptoms); active the member and, as appropriate, his or her family steps or self-help methods to prevent, de- members, caregivers or legal guardian participated escalate or defuse crisis situations; names in the development and subsequent reviews of the and phone numbers of contacts who can treatment plan. assist the member in resolving crisis; and the member’s preferred treatment options, The support and care plan must be completed to include psychopharmacology, in the within the first 14 days of admission to behavioral event of a mental health crisis health services and updated every 180 days or more frequently as necessary based on the • Actions agreed to be taken when progress member’s progress toward goals or a significant toward goals is less than originally planned change in psychiatric symptoms, medical condition by the member and provider and/or community functioning. • Signatures of the member, as well as family There must be a signed release of information to members, caregivers or legal guardian as provide information to the member’s PCP or appropriate evidence that the member refused to provide a signature. There must be documentation that PSYCHOTROPIC MEDICATIONS referral to appropriate medical or social support Prescribing providers must inform all members professionals have been made. considered for prescription of psychotropic or other A provider who discovers a gap in care is medications of the benefits, risks and side effects responsible to help the member get that gap in care of the medication, alternate medications and other fulfilled, and documentation should reflect the forms of treatment as consistent with their action taken in this regard. licensure. For providers of multiple services, one TIMELINESS OF DECISIONS ON comprehensive treatment/care/support plan is REQUESTS FOR AUTHORIZATION acceptable as long as at least one goal is written • Urgent, preservice requests: within 72 hours and updated as appropriate for each of the different of request services that are being provided to the member. • Urgent concurrent requests: within 72 hours The treatment/support/care plan must contain the of request following elements: • Routine, nonurgent requests: 5 business • Identified problem(s) for which the member days and up to 14 calendar days is seeking treatment • Retrospective review requests: within 30 • Member goals related to each problem(s) days of request identified, written in member-friendly language ACCESS TO CARE STANDARDS • Measurable objectives to address the goals Standards for timely and appropriate access to identified quality behavioral healthcare are outlined below: • Target dates for completion of objectives • Emergent: immediately • Responsible parties for each objective • Urgent: within 48 hours of referral/request • Specific measurable action steps to • Routine outpatient: within 10 days of accomplish each objective request • Individualized steps for prevention and/or • Outpatient following discharge from an resolution of crisis, which includes inpatient hospital: within 7 days of discharge identification of crisis triggers (situations,

4 | GENERAL BENEFITS

Definitions Psychological and neurological testing request Emergent: Treatment is considered to be an forms can also be mailed to: on-demand service and does not require Behavioral Health Department precertification. Members are asked to go directly Anthem Blue Cross to emergency rooms for services if they are either P.O. Box 60007 unsafe or their conditions are deteriorating. Los Angeles, CA 90060-0007 Urgent: A service need is not emergent and can be BEHAVIORAL HEALTH CLINICAL met by providing an assessment and services AUTHORIZATION AND PROTOCOLS within 48 hours of the initial contact. If the member is pregnant and has substance use problems, she The Anthem Blue Cross clinical authorization is to be placed in the urgent category. process is designed to be flexible, providing primary responsiveness to our members' needs Routine: A service need is not urgent and can be while simultaneously allowing The Anthem Blue met by receiving treatment within 10 calendar days Cross clinical team to gather information for of the assessment without resultant deterioration in appropriate medical necessity determinations. the individual's functioning or worsening of his or her condition. Authorization of medically necessary services within the required time frames is the responsibility HOW TO PROVIDE NOTIFICATION OR of The Anthem Blue Cross licensed behavioral REQUEST PREAUTHORIZATION health clinicians. Whenever a clinician questions You may request preauthorization for nonroutine the appropriateness of the requested level of care, outpatient mental health services that require prior the review is referred to an appropriate behavioral authorization via phone by calling: healthcare clinician. Our multidisciplinary team of behavioral healthcare clinicians can include:  1-888-831-2246 24 hours a day, seven days a week, 365 days a year • Licensed psychologists Licensed professional counselors Please be prepared to provide clinical information • in support of the request at the time of the call. • Licensed social workers You may request preauthorization via fax, email or • Registered psychiatric nurses the provider portal where available for certain levels • Board certified psychiatrist of care. These professionals conduct reviews of behavioral Fax forms are located on our website or via email health and substance abuse services to monitor at: and evaluate treatment requests and progress.  https://providers.anthem.com/CA They manage utilization, control behavioral healthcare costs and achieve optimal clinical Email: [email protected]  outcomes through a collaborative approach that The fax numbers to use when providing notification considers both utilization review data and nationally or requesting prior authorization for behavioral recognized clinical practice guidelines to determine health services are: the appropriate level of care.

 Outpatient requests: 1-888-831-2246 NECESSITY DETERMINATION AND PEER  Inpatient requests: contact the local county REVIEW department of mental health • When a provider requests initial or Note: All requests for precertification for continued precertification for a covered service, our Utilization Managers obtain psychological and neuropsychological testing necessary clinical information and review it should be submitted via fax to 1-855-473-7902.

4 | GENERAL BENEFITS

to determine if the request meets applicable error, please see the Grievances and Appeals medical necessity criteria. chapter of this manual for information and instructions on appeals, grievances and payment • If the information submitted does not appear disputes. to meet such criteria, the Utilization Manager submits the information for review If you did not receive a precertification for a by the Medical Director or other appropriate requested service and think that this decision was practitioner as part of the peer review in error, please see the Grievances and Appeals process. chapter of this manual for information and instructions on appeals, grievances and payment • The reviewer or the requesting provider disputes. may initiate a peer-to-peer conversation to discuss the relevant clinical information with AVOIDING AN ADVERSE DECISION the clinician working with the member. Most administrative adverse decisions result from If an adverse decision is made by the • non-adherence to or a misunderstanding of reviewer without such a peer-to-peer utilization management policies. Familiarizing conversation having taken place (as may yourself and your staff with notification and occur when the provider is unavailable for precertification policies and acting to meet those review), the provider may request such a policies can eliminate the majority of these conversation. In this case, we will make a decisions. Other administrative adverse decisions Medical Director or other appropriate result from misinformation about the member’s practitioner available to discuss the case status or benefits. with the requesting provider. This conversation may result in the decision Adverse decisions of a medical nature are rare. being upheld or changed. Such adverse decisions usually involve a failure of the clinical information to meet evidenced-based • Members, providers and applicable facilities national guidelines. We are committed to working are notified of any adverse decision within with all providers to ensure that such guidelines are notification time frames that are based on understood and easily identifiable for providers. the type of care requested and in Peer-to-peer conversations (between a Medical conformance with regulatory and Director and the provider clinicians) are one way to accreditation requirements. ensure the completeness and accuracy of the clinical information. Professional Billing Requirements Providers rendering covered behavioral health Medical record reviews are another way to services should bill Anthem Blue Cross using ensure that clinical information is complete and behavioral health CPT codes. All claims for accurate. Providers who can appropriately respond covered behavioral health services should be billed in a timely fashion to peer-peer and medical record to Anthem Blue Cross. For more information about requests are less likely to encounter dissatisfaction proper professional billing procedures, please refer with the utilization management process. We are to the Claims chapter of this manual or call the committed to ensuring a process that is quick and number below: easy and will work with participating providers to ensure a mutually satisfying process.  1-866-398-1922 BEHAVIORAL HEALTH CLINICAL NON-MEDICAL NECESSITY ADVERSE PRACTICE GUIDELINES DECISIONS (ADMINISTRATIVE ADVERSE All providers have access to evidence-based DECISION) clinical practice guidelines for a variety of If you received an administrative adverse behavioral health disorders commonly seen in determination and think that this decision was in

4 | GENERAL BENEFITS primary care. These clinical practice guidelines are • Voluntary inpatient detox located online at: For more detailed information on these programs,  https://providers.anthem.com/CA go to the state's Department of Mental Health website: CARVED-OUT BEHAVIORAL HEALTH  www.dhcs.ca.gov/services/Pages/MentalHea SERVICES lthPrograms-Svcs.aspx All facility-based behavioral health and substance abuse services are carved out to the local county INPATIENT department of mental health and the county alcohol In-patient mental health services are carved out to and other drug programs: the local County Mental Health department. Please • Inpatient admissions contact the County Mental Health Department for • Intensive Outpatient Program (IOP) any questions. • Partial Hospitalization Program (PHP) Major Risk Medical Insurance Program (MRMIP) Services for illnesses that do not meet the criteria Behavioral Health Self-Referrals for SMI or SED are limited to 15 visits per calendar Members may self-refer to any behavioral year. healthcare provider in the Anthem Blue Cross Inpatient mental healthcare services include network. If the member is unable or unwilling to access timely services through community treatment for SMI, which encompasses, but is not providers, call our Customer Care Center for limited to, the following: assistance. • Anorexia nervosa

BEHAVIORAL HEALTH, ALCOHOL AND • Bipolar disorder OTHER DRUG PROGRAM • Bulimia nervosa The following state and county behavioral health • Major depressive disorders services for those with severe level of impairment Obsessive compulsive disorder are available upon referral: • • Panic disorders • 24-hour treatment services Pervasive developmental disorder or autism • Case management • • Schizophrenia • Comprehensive evaluation and assessment • Schizoaffective disorder • Group services Inpatient mental healthcare services also include • Medication education and management treatment for SED including problems with eating, • Outpatient substance use disorders sleeping, or hurting oneself or others. services Note: For the treatment of SMI or SED, there is no • Pre-crisis and crisis services limitation on the number of treatment days. • Residential services STATE AND COUNTY SERVICES AND • Residential treatment services PROGRAMS • Services for homeless persons The following state and county behavioral health services are available upon referral: • Vocational rehabilitation • Wraparound services • 24-hour treatment services • Case management

4 | GENERAL BENEFITS

• Comprehensive evaluation and assessment Each CBAS center has a multidisciplinary team of health professionals who conduct a comprehensive • Pre-crisis and crisis services assessment of potential participants and work with • Group services the member to meet his or her specific health and • Medication education and management social needs. • Residential services CBAS ELIGIBILITY AND REFERRAL • Services for homeless persons PROCESS • Vocational rehabilitation CBAS services may be provided to members over 18 years of age who: For more detailed information on these programs, Meet nursing facility A or B requirements go to the state's Department of Mental Health • website: • Have organic/acquired or traumatic brain injury and/or chronic mental health  www.dhcs.ca.gov/services/Pages/MentalHea conditions lthPrograms-Svcs.aspx • Have Alzheimer’s disease or other COMMUNITY-BASED ADULT dementia SERVICES • Have mild cognitive impairment Community-Based Adult Services (CBAS) is a • Have a developmental disability facility-based outpatient program serving Referrals/requests for CBAS can be made by the individuals 18 years of age or older who have functional impairment that puts them at risk for member, caregiver, family member, nurse institutional care. practitioner or PCP. A preauthorization is required for all CBAS services. Referrals should be faxed to Enrolled members attend an Anthem Blue Cross- Anthem Blue Cross at: contracted adult day healthcare center several times a week where they can receive (among other  Los Angeles County: 1-877-279-2482 services):  Santa Clara County: 1-855-336-4041 • Skilled nursing  All other central region counties: • Social services 1-855-336-4041 • Physical, occupational and speech  All other northern region counties: therapies 1-855-336-4041 • Personal care Once the referral is received, the following steps are taken: • Family/caregiver training and support 1. An Anthem Blue Cross registered nurse will Hot meals and nutritional counseling • conduct an eligibility assessment of the • Behavioral health services member and assist in locating a CBAS facility if needed. • Transportation (to/from the center to residence) 2. Using an evaluation tool developed and provided by the state, Anthem Blue Cross The primary objective of CBAS is to prevent will approve or deny the request for inappropriate institutionalization in long-term care services. facilities. CBAS stresses partnership with the member, the family and/or caregiver, and the PCP 3. If approved, the member’s selected CBAS in working toward maintaining personal center will conduct a needs assessment, independence. develop a plan of care for the member, and

4 | GENERAL BENEFITS

determine the level of service that will be • There is a danger of serious provided at the center. physical or mental harm to the minor or others For more information on CBAS, call: • The children are the alleged  California Department of Aging: victims of incest or child 1-800-510-2020 abuse For a complete list of CBAS centers and contact numbers, please go to the California Department of TELEHEALTH Aging website at: Telehealth is a healthcare delivery method that  www.aging.ca.gov/ProgramsProviders/ADH applies high-speed telecommunications systems, C-CBAS computer technology and specialized medical cameras to examine, diagnose, treat and educate SENSITIVE SERVICES patients at a distance. Members do not need prior authorization and may For example, through a telehealth encounter, a self-refer for the following sensitive services patient at a telehealth clinic in a rural area may provided by qualified in-network or out of network seek medical treatment from a provider or providers: specialist in Los Angeles or San Francisco without incurring the expense of traveling to such distant Family planning services including: • locations. Contraceptive pills, devices and ◦ The advantages of communicating via telehealth supplies are the following: Diagnosis and treatment of sexually ◦ • Providers can choose from the Anthem transmitted disease Blue Cross network of specialists, no matter ◦ Health education and counseling where the member lives. ◦ Laboratory tests • The member does not have to wait long periods of time to schedule an appointment ◦ Limited history and physical with a specialist. examinations • Providers can electronically send the ◦ Pregnancy testing and counseling member's medical data to a specialist for ◦ Sterilization review. ◦ Annual examination with a network • Specialists can use the computers and obstetrician/gynecologist other equipment to send a recommendation ◦ HIV testing and counseling for care back to the providers and members from a distance. ◦ Sexual assault including rape Note: Utilizing telehealth does not require prior ◦ Drug or alcohol abuse for children authorization. 12 years of age or older Telehealth does not include services rendered by ◦ Outpatient mental healthcare for audio-only telephone, fax or email communication. children 12 years of age or older who are mature enough to Telehealth can connect a provider's office to a participate intelligently and when specialty center in one of the following ways: either: • Live video consult: The PCP and specialist meet at the same time using encrypted video conferencing equipment.

4 | GENERAL BENEFITS

• Store and forward: PCP sends images of It is a covered service when all of the following the patient's condition and medical history criteria have been met: as an encrypted email to the specialist for • Medical necessity review. • An Anthem Blue Cross provider requests Telehealth offers multiple benefits to providers and the service members: • The member is not able to use a bus, taxi, The member can continue to be cared for • car or van to get to their appointment by their local provider. • It is approved in advance by Anthem The member does not need to travel long • Blue Cross (when required) distances to receive specialist care. ModivCare* will help Anthem Blue Cross members • The PCP receives all records and test manage their rides to and from medically results from the encounter. necessary medical appointments including rides by • The PCP consults with the specialist livery, ambulette or mass transit. participating in the telehealth encounter to Routine transportation is an Anthem Blue Cross design any necessary course of treatment. value-added benefit, so there is no additional cost Telehealth can also be used for nonclinical consults for this service to these members. such as community services, continuing medical  Members can call to arrange for transportation education and other provider training sessions. through ModivCare. To find out more about telehealth, use the following contact information: EMERGENT TRANSPORTATION — AMBULANCE SERVICES  If you are located in Los Angeles, please call: 1-866-465-2272 Ambulance services must come from a licensed ambulance or air ambulance company and be used If you are located in central California and  only for emergencies. Coverage includes: surrounding rural counties, please call: 1-877-811-3113 • Base charge and mileage  If you located in northern California and • Cardiac defibrillation surrounding rural counties, please call: • CPR 1-888-252-6331 • EKGs  For contracting questions, please call Provider Solutions at: 1-877-496-0045 • IV solutions • Monitoring TRANSPORTATION • Oxygen NON-EMERGENCY MEDICAL • Supplies TRANSPORTATION

Non-emergency medical transportation (NEMT), which may require prior authorization, allows members to be transported to medical appointments for covered services, transferred from a hospital to another hospital, facility or home.

5 | MEMBER SERVICES, EDUCATION, WELLNESS

5 | M EM BER SERVI CES, EDUCATI ON, W ELLNES S  Customer Care Center (outside L.A. County): health information and options for any of the 1-800-407-4627 following: Hours of operation: Monday to Friday, • Emergency instructions 7 a.m. - 7 p.m. • Health concerns  Customer Care Center (inside L.A. County): 1-888-285-7801 • Local healthcare services Hours of operation: Monday to Friday, • Medical conditions 7 a.m. - 7 p.m. • Prescription drugs  MRMIP Customer Care Center: • Access to interpreter services 1-877-687-0549 Hours of operation: Monday to Friday, WELLNESS PROGRAMS 8:30 a.m. - 5 p.m.  https://mss.anthem.com/ca/pages/health- 24/7 NURSELINE wellness.aspx Questions about healthcare prevention and Anthem Blue Cross health services programs are management don’t always come up during office designed to improve our members' overall health hours. 24/7 NurseLine is a 24-hour-a-day, and well-being by informing, educating and 7-day-a-week phone line staffed by registered encouraging self-care in the early detection and nurses. treatment of existing conditions and chronic disease. 24/7 NurseLine allows members to closely monitor and manage their own health by giving them the These targeted programs are designed to ability to ask questions whenever they come up. supplement providers' treatment plans and include multiple categories such as:  24/7 NurseLine: 1-800-224-0336 • Preventive Care Programs for all  TTY: 1-800-368-4424 members including the Initial Health Members can call 24/7 NurseLine for: Assessment, the Staying Healthy Assessment (SHA) Tool and Well Woman • Self-care information including assistance programs and vaccines when with symptoms, medications and recommended by the ACIP side-effects, and reliable self-care home treatments • Wellness Programs that promote knowledge on self-care for targeted medical • Access to specialized nurses trained to conditions and chronic disease discuss health issues specific to our teenage members • Health Education including the 24/7 NurseLine for all health-related questions • Information on more than 630 healthcare topics through the 24/7 NurseLine audio • Emergency Room Initiative that instructs tape library members on the proper use of emergency room services • Assistance in finding an in-network provider We introduce new members to these programs Members can also call our 24/7 NurseLine anytime through a new member packet, which includes to speak to a registered nurse. Nurses provide preventive healthcare guidelines and a Member Services Guide that includes information on how to access health education services.

5 | MEMBER SERVICES, EDUCATION, WELLNESS

After that, we utilize a variety of methods and These interventions include conducting initial and informal settings to inform our members about annual assessments of all members of any age available health services including: who use tobacco products or are exposed to tobacco smoke and document this information in • Direct mailings the member’s medical record. This can be • Health education classes accomplished through instituting a tobacco user • Telephone calls identification system per USPSTF recommendations: • Health fairs and community events • Using the Staying Healthy Assessment or TOBACCO CESSATION PROGRAMS other IHEBA. Anthem Blue Cross supports smoking cessation for • Adding tobacco use as a vital sign in the members who want to become smoke-free by: chart or electronic health records or by use of the ICD-10 codes in the medical record to • Assisting members in improving their health record tobacco use. status and quality of life by becoming more actively involved in their own care. • Placing a chart stamp or sticker on the chart when the beneficiary indicates he/she uses • Encouraging members to quit using tobacco. tobacco. A recording on the Child Health and • Supporting members' tobacco cessation • Disability Prevention Program Confidential efforts with resources, referral programs Screening/Billing Report (PM160). and education. Prescribing Food and Drug Administration Tobacco cessation/information available to • (FDA) approved tobacco cessation members: medications to non-pregnant adults of any • California Smokers’ Helpline offers free age. telephonic counseling, self-help materials Note: Medi-Cal plans shall cover all FDA-approved and online help in six languages. tobacco cessation medications for adults who use  California Smokers' Helpline: 1-800-662-8887 tobacco products. This includes over-the-counter (1-800-NO-BUTTS) medications with a prescription from the provider.  www.nobutts.org A full set of ICD-10 codes to record tobacco use can be found at: American Lung Association Freedom from Smoking offers telephonic counseling, in-person  http://www.ctri.wisc.edu/documents/icd10.p group clinics and online resources. df  www.lung.org/stop-smoking/join-freedom- Anthem Blue Cross covers the following without from-smoking prior authorization:

Note: Enrollment in tobacco counseling is not • Nicotine patches required in order to obtain tobacco cessation • Nicotine gum materials. • Nicotine lozenges Provider Assessment of Tobacco Use: PCPs and their qualified staff need to implement • Bupropion SR (Zyban) the tobacco cessation interventions as outlined in the revised MMCD Policy Letter 16-014 dated November 30, 2016, from the California Department of Health Care Services.

5 | MEMBER SERVICES, EDUCATION, WELLNESS

Anthem Blue Cross covers the following with prior Providers can read the policy letter by going to the authorization: DHCS website at: • Nicotine nasal spray  www.dhcs.ca.gov/formsandpubs/Document • Nicotine inhaler s/MMCDAPLsandPolicyLetters/APL2016/AP L16-014.pdf • Varenicline (Chantix) The Smoking Cessation Leadership Center is a Referring tobacco users of any age to • national program that collaborates with health available individual, group and telephone professionals and institutions to increase their counseling. Anthem Blue Cross members competency in helping smokers quit. They provide qualify for four counseling sessions of at various types of resources including curriculums, least ten minutes for at least two separate presentations, online training, publications, toolkits quit attempts each year without prior and webinars for continuing education. authorization. If you are interested in tobacco cessation updates Providers can: through the aforementioned outlets, please visit: • Use the 5A’s Model or other validated  http://smokingcessationleadership.ucsf.edu behavior change model when counseling members. For additional information and provider training resources, visit The Anthem Blue Cross tobacco • Refer a member to the CA Smoker’s cessation webpage at: Helpline at 1-800-NO-BUTTS or another equivalent line.  https://providers.anthem.com/california- • Refer to available community programs. provider/resources/provider-training- academy • Ask all pregnant women if they use tobacco or are exposed to tobacco smoke. If they EMERGENCY ROOM ACTION CAMPAIGN smoke, offer at least one face-to-face The Anthem Blue Cross ER Action Campaign counseling session per quit attempt and identifies members who visit the emergency room refer to a tobacco cessation quit line. for non-emergency services that can be better Counseling services will be covered for 60 managed at their doctor’s office or an urgent care days after delivery. Smoking cessation center. medications are not recommended during pregnancy. With this campaign, we can help patients know that non-emergency, preventive and follow-up care • Provide education including brief counseling should always start with their doctor. to children and adolescents to prevent initiation of tobacco in school-aged children The ER Action Campaign teaches members about: and adolescents. • Seeking care for non-emergency events Anthem Blue Cross will monitor provider • Contacting their doctor first before going to performance in implementing these tobacco the ER cessation interventions through various processes comprising of medical record review, facility site • Alternatives to ER use review process, and review of medical or pharmacy • Importance of follow-up care by their PCPs claims data. Our ER Action Campaign relies on the support of providers like you, who remind patients that their doctor’s office and our 24/7 NurseLine should be their first call for non-emergency conditions.

5 | MEMBER SERVICES, EDUCATION, WELLNESS

Working together, we can help your patients get HEALTH EDUCATION REFERRAL appropriate care and avoid the long wait times and Providers can refer members to health education high costs often associated with ER visits and classes using the Health Education & Cultural encourage a strong relationship with you, their and Linguistic Referral Form on our provider primary doctor. website. HEALTH EDUCATION NO-COST CLASSES The form is located within the health education site at:  https://providers.anthem.com/CA  https://providers.anthem.com/california- Anthem Blue Cross offers health education provider/resources/forms services and programs to meet the specific health needs of our members, promote healthy lifestyles, To schedule a health education class, members and improve the health of those living with chronic should call our Customer Care Centers. diseases. If the member receives one-on-one counseling Health education classes take place at hospitals from an Anthem Blue Cross Health Educator, and/or community-based organizations. Classes Anthem Blue Cross sends a confirmation letter to are available at no charge to the member and are the member’s PCP with the following information: available upon self-referral or referral by Anthem • Member’s name Blue Cross providers. • Member's ID number Classes vary from county to county and include the following topics: • Topic discussed • Asthma management If the provider administers health education to the member, it must be documented in the member’s Breastfeeding education • medical record. Documentation must include the • Diabetes management following: • Exercise • Education topic • Family planning • Identification of person providing the education • HIV/STD control • Materials distributed to the member • Hypertension/heart disease education Notation of any follow-up or • Injury prevention • recommendations • Nutrition If a member is referred for one-on-one health • Obesity education counseling and the Health Educator is • Parenting unable to reach him/her after multiple attempts, Anthem Blue Cross sends an Unable to Reach • Perinatal education letter to the member’s PCP. • Smoking cessation/tobacco prevention Similarly, if the referred member declines health • Substance use education counseling, Anthem Blue Cross will send a letter notifying the provider. Members receive information about health education classes through enrollment materials, DIABETES PREVENTION PROGRAM member website, and information made available at their provider's office. Medi-Cal Managed Care (Medi-Cal) members at risk for type 2 diabetes have access to the Centers for Disease Control and Prevention (CDC)

5 | MEMBER SERVICES, EDUCATION, WELLNESS

Diabetes Prevention Program (DPP) through a new HEALTH EDUCATION MATERIALS FOR member benefit. DPP has been proven by the YOUR OFFICE National Institute of Health (NIH) in a randomized Health education materials including health topic- controlled trial to greatly reduce the progression of specific brochures such as Diabetes, Asthma, prediabetes to type 2 diabetes. Services are Smoking, Pregnancy and Baby’s Health, Exercise, delivered by trained lifestyle coaches and and Nutrition can be found on the Anthem organizations recognized by the CDC at no cost to Blue Cross provider website at the beginning of the member. this section. The DPP is a year-long program that consists of Under Provider Support, you will also find links to weekly sessions with a lifestyle coach for the first other valuable resources such as cultural and six months and monthly maintenance sessions for linguistic tools, perinatal education brochures, and the latter six months. Sessions can be held in a information regarding breastfeeding promotion. All group classroom setting or online. Participants will of these resources may be downloaded. You may learn realistic lifestyle changes emphasizing weight also request hard copies of these materials by loss through exercise, healthy eating and behavior calling the appropriate Customer Care Center at modification. the number(s) listed at the beginning of this Member eligibility criteria include: chapter. • At least 18 years of age CULTURAL AND LINGUISTIC/ • BMI of 25 or greater INTERPRETER SERVICES ◦ If member is of Asian descent, a At Anthem Blue Cross, we recognize that providing BMI of 23 or greater is required. healthcare services to a diverse population can • Blood screening (optional, if available): present challenges. We know it is important to continually increase your knowledge of, and ability ◦ Hemoglobin A1C: 5.7% to 6.4% to support, the values, beliefs, and needs of diverse ◦ Fasting plasma glucose: 100 to 125 patients. Differences in our members' ability to read mg/dL may add an extra dimension of difficulty when providers try to encourage follow-through on Oral Glucose Tolerance Test: 140 to ◦ treatment plans. 199 mg/dL Sometimes the solution is as simple as finding the Exclusions include no previous diagnosis • right interpreter for an office visit. Other times, a of end-stage renal disease or type 1 or type greater level of cultural awareness, like the 2 diabetes; not pregnant (previous examples, below can open the door to the kind of gestational diabetes is not an exclusion) interaction that makes treatment plans most Providers can refer members to the DPP by effective. completing the DPP Provider Referral Form located • Has the patient been raised in a culture that at: frowns upon direct eye contact or receiving  https://providers.anthem.com/california- medical treatment from a member of the provider/resources/forms opposite sex?

Providers can also direct members to take the • Is the patient self-conscious about his or her online risk assessment by visiting ability to read instructions?  https://solera4me.com/AnthemBC_MediCal Our Cultural Diversity and Linguistic Services Toolkit called Caring for Diverse Populations was or by calling 1-833-516-4483 to determine eligibility developed to give you specific tools for breaking and enroll in the DPP. through cultural and language barriers in an effort

5 | MEMBER SERVICES, EDUCATION, WELLNESS to better communicate with your patients. The • Resources to increase awareness on how toolkit can be downloaded by selecting the link cultural background impacts healthcare below: delivery  https://providers.anthem.com/california- ◦ Tips for talking with people across provider/resources/manuals-policies- cultures about a variety of culturally guidelines sensitive topics

This toolkit gives you the information you'll need to ◦ Information about healthcare beliefs continue building trust. It will enhance your ability to of different cultural backgrounds communicate with ease, talking to a wide range of • Regulations and standards for cultural and people about a variety of culturally sensitive topics. linguistic services And it offers cultural and linguistic training to your office staff so that all aspects of an office visit can ◦ Identifies important legislation impacting cultural and linguistic go smoothly. services including a summary of the The toolkit contents are organized into the following Culturally and Linguistically sections: Appropriate Services (CLAS) • Improving communications with a diverse standards, which serve as a guide patient base on how to meet these requirements ◦ Encounter tips for providers and • Resources for cultural and linguistic their clinical staff services ◦ A memory aid to assist with patient ◦ Cultural competency web-based interviews resources ◦ Help in identifying literacy problems The toolkit contains materials developed by and used with the permission of the Industry Tools and training for your office in caring • Collaboration Effort (ICE) Cultural and Linguistic for a diverse patient base Workgroup, a volunteer, multidisciplinary team of ◦ Interview guide for hiring clinical providers, health plans, associations, state and staff who have an awareness of federal agencies, and accrediting bodies working cultural competency issues collaboratively to improve healthcare regulatory compliance through public education. ◦ Americans with Disabilities Act (ADA) requirements  www.iceforhealth.org • Resources to communicate across In addition to the caring for diverse populations language barriers toolkit, Anthem offers additional resources to support provision of culturally and linguistically Tips for locating and working with ◦ appropriate services, including My Diverse interpreters Patients and a Cultural Competency Training, which can be accessed at: ◦ Common signs and common sentences in many languages  https://providers.anthem.com/california- ◦ Language identification flashcards provider/resources/provider-training- academy. ◦ Language skill self-assessment tools My Diverse Patients is a resource-rich, care provider website that covers topics relevant to providing culturally competent care and services for diverse individuals. The cultural competency

5 | MEMBER SERVICES, EDUCATION, WELLNESS training offers information on key components to  https://www11.anthem.com/ca/provider/f3/s1 the provision of culturally competent care. /t0/pw_b144192.pdf LANGUAGE CAPABILITY OF PROVIDERS This information will be reported in the Provider AND OFFICE STAFF Directory to help members find a provider and/or Anthem Blue Cross strives to have a provider office staff that speaks their preferred language. network that can meet the linguistic needs of our INTERPRETER SERVICES members. An important component of that is having network providers that are aware of the Providers must notify members of the availability of language capabilities of themselves and their office interpreter services and strongly discourage the staff. use of friends and family, particularly minors, to act as interpreters. It is important that you or your office Providers must notify members of the availability of staff document the member’s language, any refusal interpreter services and strongly discourage the of interpreter services and requests to use a family use of friends and family members, especially member or friend as an interpreter in the member’s children, acting as interpreters. Under the Federal medical record. guidance, published as section 1557 of the Affordable Care Act, providers are required to Face-to-face interpreters for members needing utilize qualified interpreters while interacting with language assistance including American Sign members with limited English proficiency. Language are available at no cost to the provider or member by placing a request at least 72 hours in As defined in Section 1557, a “qualified interpreter” advance. A 24-hour cancelation notice is required. for an individual with limited English proficiency means an interpreter who via a remote interpreting Over-the-phone interpreters are available 24 hours service or an onsite appearance. It requires that a a day, 7 days a week. qualified interpreter: To obtain free interpreting services, please call our 1. Adheres to generally accepted interpreter Customer Care centers. ethics principles including client  For after-hours telephone interpreter services, confidentiality. call the 24/7 NurseLine at 1-800-224-0336 2. Has demonstrated proficiency in speaking  TTY: 1-800-368-4424 and take the following and understanding both spoken English and steps. at least one other spoken language. 1. Give the customer care associate the 3. Is able to interpret effectively, accurately, member’s ID number. and impartially, both receptively and expressly, to and from such language(s) 2. Explain the need for an interpreter and state and English, using any necessary the language. specialized vocabulary, terminology, and 3. Wait on the line while the connection is phraseology. made. Multilingual staff should self-assess their non- 4. Once connected to the interpreter, the English language speaking and understanding associate or 24/7 NurseLine nurse skills prior to interpreting on the job. introduces the Medi-Cal member, explains Please be sure to provide annual updates on the language capabilities of your office staff and at least every three years for yourself by downloading the Provider Change Form by selecting the link below:

5 | MEMBER SERVICES, EDUCATION, WELLNESS

the reason for the call and begins the The form is located within the health education site dialogue. at: Request/Refusal of Interpreter Services forms are  https://providers.anthem.com/california- available in threshold languages on our provider provider/resources/forms > Patient Care. website below:  https://providers.anthem.com/california- MEMBER RIGHTS AND provider/resources/forms > Patient Care. RESPONSIBILITIES The members of The Anthem Blue Cross two HEARING LOSS, VISUAL AND/OR SPEECH healthcare programs, Medi-Cal and the Major Risk IMPAIRMENT SERVICES Medical Insurance Program, should be clearly During business hours, members with hearing loss informed about their rights and responsibilities in or speech impairment can call the following order to make the best healthcare decisions. That numbers: includes the right to ask questions about the way we conduct business as well as the responsibility to Voice to TTY (English): 711 or 1-800-735-2922  learn about their healthcare plan. Voice to TTY (Spanish): 1-800-855-3000  Members have certain rights and responsibilities  TTY to Voice (English): 1-800-735-2929 when receiving their healthcare. They also have a responsibility to take an active role in their care.  TTY to Voice (Spanish): 1-800-855-3000 As their healthcare partner, we are committed to  After regular business hours, members can call making sure their rights are respected while we the 24/7 NurseLine TTY number: 1-800-368-4424 provide their health benefits. This also means giving them access to our network providers and For additional information, visit the California Relay the information they need to make the best Service webpage at: decisions for their health and welfare.  http://ddtp.cpuc.ca.gov/ The following are our members' rights and default1.aspx?id=1482 responsibilities as stated in each of the member handbooks. They are also posted on our website Members with visual impairments can request at: verbal assistance or alternative formats for assistance with printed materials at no cost to the  https://mss.anthem.com/Documents/CACA_ member. CAID_MC_MemberHandbook_ENG.pdf

TRANSLATION OF MATERIALS ADVANCE DIRECTIVES Members can request translation of materials into Anthem Blue Cross recognizes a person's right to non-English languages and alternative formats at dignity and privacy. Our members have the right to no cost to them by contacting the designated execute an advance directive, also known as a Customer Call Center number in Chapter 2: living will, to identify their wishes concerning Contact Information. healthcare services in the event that they become incapacitated. Providers may be asked to assist CULTURAL AND/OR LINGUISTIC members in procuring and completing the REFERRAL necessary forms. Providers can make a cultural and /or linguistic Advance directive documents should be on hand in referral using the Health Education & Cultural the event a member requests this information. and Linguistic Referral Form on our provider Members, over the age of 18 years, will be asked website. by the provider if they are aware of advance

5 | MEMBER SERVICES, EDUCATION, WELLNESS directives or want more information. This • Do what they think is best for their information will be documented in the chart. healthcare without anyone stopping them. They may make health decisions without MEDI-CAL fear of retaliation from their doctor or health Our members have the right to: plan. • Be treated with respect, giving due • Make an advance directive (also known as consideration to the member’s right to a living will). privacy and the need to maintain • Get a range of covered services. confidentiality of the member’s medical information. • Get family planning services. Be treated for STIs. • Have access to, and where legally • appropriate, receive copies of, amend or • Access minor consent services if they are correct their medical record. under 18 years of age. • Be free to exercise these rights without • Obtain emergency care outside of the adversely affecting how they are treated by Anthem Blue Cross network as federal law Contractor, providers, or the State. allows. • Receive information about the health plan, • Have access to family planning services, its services, its practitioners and providers Federally Qualified Health Centers, and member rights and responsibilities American Indian Health Programs, sexually transmitted disease services and • Receive written information in alternative formats (including audio CD, large print and emergency services outside the contractor's braille) at no cost to them upon request and network pursuant to the federal law. in a timely way that is correct for the format • To receive oral interpretation services for that they asked for. their language at no cost to them. • Obtain member materials in a language • Tell us how they would like to change this other than English at no cost to them. health plan, including changes to the • Receive information on available treatment member’s rights and responsibilities. options and alternatives presented in a • To voice grievances or appeals, either manner appropriate to the member’s verbally or in writing, about the organization condition and ability to understand, or the care received. regardless of cost or benefit coverage. • To participate in decision making regarding • Expect us to keep private their personal their own healthcare including the right to health information. This is as long as it refuse treatment. Ask the Department of follows state and federal laws and our Social Services for a state fair hearing. privacy policies. • Ask the Department of Managed Health • Be free of any form of restraint or seclusion Care for an independent medical review. used as a means of coercion, discipline, • Choose to leave this health plan. convenience or retaliation. Members have the responsibility to: • Choose their PCP. • Give us, their doctors and other healthcare Refuse care or treatment from their PCP or • providers the information needed (to the other caregivers. best of their ability) to help them get the • Work with their doctors in making choices best possible care and all other benefits about their healthcare. they are entitled to.

5 | MEMBER SERVICES, EDUCATION, WELLNESS

• Understand their health problems as well as • Be treated with respect and with regard for they can and work with their doctors or their dignity in all situations. other healthcare providers to make a • Have their privacy protected by Anthem treatment plan they all agree on. Blue Cross, their doctors and all their other • Follow the care plan that they have agreed healthcare providers. on with their doctor and other healthcare • Know that information about them is kept providers. confidential and used only to treat them. Follow their doctor’s advice about taking • • Be in charge of their healthcare. good care of their selves. • Be actively involved in making decisions Use the right sources of care. • about their healthcare. Bring their health plan ID card with them • • Make an advance directive. when they visit their doctor. • Suggest changes in their health plan. • Treat their doctors and other caregivers with respect. • Complain about Anthem Blue Cross or the healthcare they receive. • Understand their health plan. • File a complaint or grievance if their cultural Know and follow the rules of their health • and linguistic needs are not met. plan. • Appeal a decision from Anthem Blue Cross Know that laws govern their health plan and • about the healthcare they receive. the types of service they get. • Make recommendations about our Rights Know we cannot discriminate against them • and Responsibilities Policy. because of their age, sex, race, national origin, culture, language needs, sexual Members have the responsibility to: orientation or health. • Give Anthem Blue Cross, their doctors and other healthcare providers the information MAJOR RISK MEDICAL INSURANCE needed to treat them to the best of their PROGRAM (MRMIP) ability. As an Anthem Blue Cross member, members have • Understand their condition and help their the right to: doctor set treatment goals you both agree • Be informed of their rights and on to the best of their ability. responsibilities. • Follow the plans they have agreed on with • Receive information about Anthem their doctors and their other healthcare Blue Cross services, doctors and providers. specialists. • Follow the guidelines for healthy living their • Receive information about all their other doctor and their other healthcare providers healthcare providers. suggest. • Talk honestly with their doctors about all the • Use the emergency room only in cases of appropriate treatments for their condition, emergency or as directed by their provider. no matter what the cost or whether their

benefits cover them. • Use interpreters who are not their family members or friends (interpreters will be provided at no charge to them).

6 | PHARMACY

6 | PHARMACY MEDI-CAL PHARMACY BENEFIT COVERAGE AND LIMITATIONS Anthem Blue Cross covers a maximum 30-day ELIGIBILITY supply. Providers may issue refills on the initial Prescription drugs without a copay or deductible prescription. Prescription refills will be allowed after are a covered Medi-Cal benefit if the following 90% of the previous prescription’s supply has been conditions are met: utilized according to the prescription directions. • The drug is prescribed by an appropriate MRMIP PHARMACY BENEFIT and licensed clinician. Prescription drugs are a MRMIP covered benefit. • The drug is used for the care and treatment Coverage guidelines are as follows: of an injury or illness. • $5 copay for generic drugs; limited to a 30- • The drug is pre-approved by Anthem day supply Blue Cross when it is not included on the • $5 copay for generic drugs; limited to a 60- Preferred Drug List (PDL). day supply through IngenioRx* Mail Service • The drug is approved for human use by the Pharmacy, the Anthem Blue Cross mail Food and Drug Administration (FDA). order pharmacy

PHARMACY NETWORK • $15 copay for brand name drugs; limited to a 30-day supply Members must have their prescriptions filled by drugstores within the Anthem Blue Cross pharmacy • $15 copay for brand name drugs; limited to network. Our pharmacy network provides coverage a 60-day supply through IngenioRx Mail in California and its bordering states: Arizona, Service Pharmacy, the Anthem Blue Cross Nevada and Oregon. mail order pharmacy Our Provider Directory lists drugstores that are in MRMIP benefits include but are not limited to the the Anthem Blue Cross pharmacy network. following drug categories: Prescriptions can be filled at more than 3,000 retail • Contraceptive drugs pharmacies in California and a listing of these can • Drugs for smoking cessation be found in our Provider Directory. • Formulas and special food products for  To verify pharmacy network participation or treatment of phenylketonuria (PKU) Anthem Blue Cross drug coverage, please call: • Glucagon 1-800-700-2533. • Insulin and insulin syringes PHARMACY MEMBER COST SHARING • Prescription prenatal vitamins Anthem Blue Cross members enrolled in Medi-Cal • Prescription fluoride supplements do not have a copay nor deductible for covered prescription drugs. See applicable sections regarding cost-sharing for the Major Risk Medical Insurance Program (MRMIP) prescription benefit.

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PHARMACY BENEFIT EXCLUSIONS Prior to dispensing of multiple doses of the lower The following medications are not covered by the strength medications, a written prior authorization needs to be submitted for an internal review by pharmacy benefit: Anthem Blue Cross to determine medical • Non-CMS OBRA rebateable drugs unless necessity. indicated by the state OUT OF AREA PHARMACY SERVICES • Medications used for cosmetic reasons (including hair growth) Anthem Blue Cross provides a maximum of 30 days of continuous out-of-service area coverage for • Medications used for infertility prescription drugs. If the member will be out of their • Medications used for weight loss service area for longer than 30 days, the • Drugs used for erectile dysfunction or prescribing physician must submit a prior sexual enhancement authorization request. The member will be referred to the health plan for eligibility review. If Drugs not approved by the FDA • out-of-service coverage is not approved, the • DESI drugs member will have to pay out of pocket for the prescription and submit a Prescription • Unit-dose (UD) and repackaged drugs Reimbursement Claim Form for reimbursement • Experimental or investigational drugs consideration if they fill a prescription outside of • Dietary supplements (except PKU their network. Anthem Blue Cross does not cover treatments) pharmacy services outside of the United States. • Dietary supplements (except PKU Note: If the member cannot find a pharmacy that treatments participates with the company, the member may pay for the medication and submit a reimbursement QUANTITY LIMITS request.

Certain medications are subject to quantity limits. A GENERIC MEDICAT IONS quantity limit establishes the maximum amount of medication that is covered within a defined period The Anthem Blue Cross pharmacy benefit has a of time. mandatory generic program. The appropriate use of generic drugs is one method of providing cost- Generally, the quantity limits are established based effective drug therapy. Multi-source brand name upon manufacturer or FDA dosing drugs are not covered and substitution of a generic recommendations. If a member has a medical is required when an FDA-approved generic condition that requires exceeding the limit, a prior equivalent exists. authorization request containing documentation of medical need for consideration will be required. This Multi-Source Brand Prior Authorization program promotes the utilization of appropriate DOSE CONSOLIDATION generic alternatives as first-line therapies when medically appropriate. Similar to quantity limits, certain medications may be subject to dose consolidation requirements. This Prior to prescribing any multi-source brand, program works with the member, the member's prescribers are encouraged to consider using its physician or healthcare provider, and the preferred generic alternative. Brands with a generic pharmacist to replace multiple doses of lower alternative will require a written prior authorization strength medications where clinically appropriate and an internal review by Anthem Blue Cross to with a single dose of a higher-strength medication determine medical necessity for benefit coverage. (only with the prescribing physician's approval).

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MAIL ORDER PHARMACY The PDL is posted on the website for members and Anthem Blue Cross does not offer a mail order providers. It is also made available in hard copy upon request. The PDL is updated periodically but benefit for Medi-Cal. Review the first page of this at a minimum quarterly. These changes are posted chapter for pharmacy mail order information on to the website upon their effective date and are MRMIP prescription benefits. faxed to participating providers. PHARMACY BENEFIT CARVEOUTS To request a drug be added to the PDL, please The following medications are administered by the contact Anthem Blue Cross through the website state and reimbursed by fee-for-service (FFS) below: Medi-Cal:  https://www11.anthem.com/ca/forms/pharm • Antipsychotic, mood stabilizer and acy/formulary_addition.html associated medications PHARMACY RESTRICTION PROGRAM • Erectile dysfunction drugs The Anthem Blue Cross Pharmacy Restriction Opiate and alcohol dependence treatment • process limits members to a single pharmacy to drugs obtain their medications. The need for restriction is • HIV drugs determined as a result of medication claims review. • Antihemophilic blood factors Members identified with uncoordinated care, excessive utilization or suspected patterns of fraud OVER-THE-COUNTER DRUG PHARMACY and abuse may also be referred to Case BENEFIT Management. Anthem Blue Cross follows the fee-for-service Using predefined queries, the Pharmacy Medi-Cal over-the-counter (OTC) drug list. The department identifies members that may meet the FFS OTC drug list is available online on the criteria for lock-in. Case managers review the California Medi-Cal Pharmacy webpage. clinical history of the member as well as attempt to contact the member for additional information. PREFERRED DRUG LIST After review with health plan medical directors the The Anthem Blue Cross Preferred Drug List (PDL) decision for lock-in is made. At the same time, any lists the preferred and/or nonpreferred drugs within recommendations for care coordination or case the most commonly prescribed therapeutic management become part of a total care plan for categories, identifying pharmaceutical preferences the member. The members are notified in advance based upon cost, value and evidence-based of the lock-in and provided 30 days to appeal or outcomes for member care. request additional information. All FDA-approved medications are eligible for All providers that have prescribed for this member coverage unless specified otherwise. The PDL in the previous 90 days will be notified of the identifies the preferred prescription medication and member’s lock-in status as well as receive a may include select OTC medications where six-month profile regarding the member’s applicable. utilization. OTC medications are generally less costly than The network pharmacy provider will also receive a prescription alternatives. Their use can contribute letter identifying the members that are restricted to to cost-effective therapy and are recommended as their pharmacy. first-line agents when appropriate. Medications that are not preferred and are not statutory benefit exclusions may be considered for coverage by means of the prior authorization process.

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PRIOR AUTHORIZATIONS The decision to approve or deny the request for PA is made within 24 hours of receipt of all necessary The Prior Authorization (PA) program is one of the information. If the prescriber has not responded to most widely used, cost-effective methods for the Pharmacy department’s request to obtain the managing inappropriate drug use and increasing information needed to make the decision within 72 drug costs. hours, the decision time frame will have expired, The PA programs are developed by the Clinical and notice will be provided to the prescriber and Pharmacy Service team and presented to the member. Pharmacy and Therapeutics (P&T) Committee for If the request is denied, the prescriber and member review and approval. are notified. In addition, a letter indicating the Drugs are selected for PA based on quality of care reason for the denial/noncertification is sent to the issues, cost and/or utilization trends. The PA member and prescriber within 24 hours of program complies with Section 1927 (d) of the rendering the decision, and the Social Security Act. PAs may be used under the denial/noncertification letter includes the appeals following conditions: procedure. A copy of the denial/noncertification • For prescribing and dispensing medically letter is maintained on file in the Pharmacy necessary non-formulary drugs department. • To limit drug coverage consistent with the All PA requests are processed and recorded using provisions of the Medicaid contract a web-based application maintained by Anthem. This database is used for reporting such requests, • To minimize potential drug over-utilization approvals and denials/noncertifications for monthly • To accommodate exceptions to Medicaid and quarterly reports as well as state required drug utilization review standards related to reports. proper maintenance drug therapy The Anthem Blue Cross PA process continuously • To ensure appropriate utilization of medical monitors the exception process and trends are injectable, specialty and oncology products reviewed by the P&T Committee. These reviews that are typically administered as a evaluate the consistency of management and component of the medical benefit timeliness of review and authorization. Clinical policies and procedures are developed by Anthem Blue Cross contracts with the pharmacy the Clinical Pharmacy Service team to define benefit manager (PBM) for the processing of PAs applicable criteria to allow coverage for drugs using the state’s required criteria as well as subject to one of the above conditions. These required turnaround times. policies and procedures are reviewed and approved by the P&T Committee. Where states PEER-TO-PEER REVIEW have specific requirements, their criteria and Providers may request a peer-to-peer conference management programs are implemented. with a Medical Director to discuss PA decisions by calling Anthem Peer-to-Peer at: If necessary, a 72-hour supply of medication may be dispensed by the retail pharmacy without PA 1-844-410-0746, option 3In this case, we will make through the use of an override code, while awaiting a Medical Director available to discuss the case a PA decision. with the requesting provider. This conversation may result in the decision being upheld or changed.

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PHARMACY BENEFIT MANAGER Pharmacy and Corporate Investigations departments. DESCRIPTION OF PBM SERVICES Pharmacies are required to return the All pharmacies contracted with our pharmacy overpayments, and Anthem Blue Cross may direct benefit manager (PBM), IngenioRx, are required to IngenioRx to take corrective action up to and provide traditional retail pharmacy products and including removal from the network. services following contract standards. CLAIMS PROCESSING Network development and management is the responsibility of the PBM and includes access and The PBM provides online transaction processing availability standards, contracting, provider (OLTP) systems and online operational reporting standards, compliance with formulary programs, systems. The PBM also provides the Pharmacy pricing and general contract management. PBM department with real-time access to the claim responsibilities include but are not limited to: adjudication system for review of member prescription history and entering of approved prior • Claim processing accuracy authorizations. • Eligibility processing Pharmacies submit claims using HIPAA-approved • Network access National Council for Prescription Drug Processing • Prompt payment (NCPDP) standard D.0 transactions along with the prescriber. • State or federal provider exclusions/sanctions The claims are priced according to the PBM pharmacy provider contract in place with that • Help desk performance pharmacy and an authorization of payment • Network audits message is returned to the pharmacy confirming coverage and payment. These transactions take on Fraud, waste and abuse activity • average less than three seconds. • Drug utilization review CLAIMS PROCESSING EDITS • Delegated functions such as drug recalls and prior authorization activity The Anthem Blue Cross Clinical Pharmacy Service team works with the delegated PBM’s clinical and PHARMACY NETWORK AUDITS technical staff to build all benefit design and utilization management system edits. Part of IngenioRx’s responsibility is to review the performance of the pharmacy network to ensure Hard, soft, contingent therapy and step therapy claims processing standards are followed. They do edits are effective methods for controlling costs and this by conducting periodic audits of pharmacies providing educational messaging to pharmacies identified as meeting certain thresholds. regarding the drug benefit. Edits and management practices are consistent with state and CMS The results of these audits are shared with the regulatory requirements. Pharmacy and Corporate Investigations departments. Pharmacies are required to return the These edits all occur at the time the prescription is overpayments and may be subject to other being filled through electronic communication with corrective actions by IngenioRx up to and including the claims system. The clinical pharmacists are removal from the network. responsible for developing edits related to formulary and benefit management activities. Anthem Blue Cross is contracted with a vendor to perform Anthem Blue Cross-specific pharmacy • Hard edits: These edits stop prescriptions at audits and to further identify potential fraud. The the point of sale (in the pharmacy), requiring results of these audits are shared with the the dispensing pharmacist to take action to

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ensure appropriate utilization of the injectable medications including but not limited to medication prior to the dispensing. This Humira, Enbrel, Copaxone, Stelara, Kineret, and action can include discussion with the Avonex. prescriber, which may result in a Members belonging to PMGs with this arrangement medication, dosage or quantity change or a will receive a hard edit claim reject at the contact to The Anthem Blue Cross pharmacy. The pharmacy should instruct the Pharmacy department for further member to obtain the self-injectable medication discussion. Examples of hard edits include through their medical provider. Typically, the eligibility verification, drug coverage limits, medical provider’s group has an arrangement with non-formulary drugs, quantity, days’ supply, a specialty pharmacy which can supply the PA, early refill and the highest potential risk patient’s medication. drug-drug interaction. Members belonging to PMGs without the Soft edits: These edits provide educational • self-injectable arrangement will be able to receive messaging to pharmacies designed to their self-injectable medications from The Anthem provide the pharmacist with additional Blue Cross pharmacy network (see Pharmacy information on certain drugs. These edits do Network). not stop the prescription from being filled. Examples of soft edits include lower PHYSICIAN-ADMINISTERED DRUGS potential risk drug-drug interactions or Physician-administered drugs are typically billed preferred formulary messaging. using HCPCS codes. Coverage policies must be • Contingent therapy edits: These edits are obtained by contacting Anthem Blue Cross designed to concurrently review the Utilization Management. electronic medication history of the member to determine if certain clinical criteria are COMPOUND DRUGS met. If the criteria are met, the prescription Compound drugs are prescriptions that are mixed, can be filled without requiring PA. If the combined or altered to create medication tailored to criteria are not met, the system provides the needs of an individual patient. Compounds can messaging regarding the preferred first-line be covered when all of the following conditions are agent or refers the pharmacy to contact The met: Anthem Blue Cross Pharmacy department. An example of a contingent therapy edit is • A commercial formulation of medication is the requirement that a member has not available previously tried other non-steroidal anti- • All active ingredients are FDA-approved inflammatory medication prior to receiving a All active ingredients require a prescription COX-II inhibitor. • to dispense SPECIAL DRUG PROCEDURES • The compound drug is not essentially the same as an FDA-approved product SPECIALTY MEDICATIONS marketed by a drug manufacturer Specialty medications such as Synagis, Makena, Compound drugs are not covered when: and Botox will require PA through Anthem Blue Cross. • A commercial formulation is available • Active ingredients are not FDA-approved SELF-INJECTABLE MEDICATIONS • Active ingredients are not CMS-rebateable Anthem Blue Cross has delegation arrangements (the manufacturer has not signed rebate with certain participating medical groups (PMGs) agreements with CMS) who agree to provide their assigned members’ self-

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• The compound includes proprietary • The member must provide detailed vehicles, bases and/or other pharmaceutical information regarding how the medication adjuvants was lost or stolen.

OPIATE PRESCRIBING • If the medication was stolen, a copy of the official police report will be required. To address the risk of opioid dependence, overdose and death, Anthem Blue Cross has • Based on clinical judgment of the reviewing instituted special limits on opioid prescriptions: clinical pharmacist, contact may be made with the prescriber to confirm his/her • Short-acting opiates are limited to two 7-day knowledge of the situation and the approval prescriptions per 30 days. Exceeding this for replacement medication. duration will require prescribers to submit a Habitual requests for replacement PA request detailing clinical rationale. • medications will be referred to the health • Long-acting opiates including formulary plan Medical Director and/or Medicaid agents now require PA for all new patient Special Investigations Unit. starts. • Replacement of narcotics or controlled SPECIAL FILL PROCEDURES substances is prohibited.

PHARMACY EMERGENCY SUPPLIES PHARMACY PROGRAMS

A pharmacist or hospital emergency room may PRESCRIPTION DRUG MONITORING dispense a 72-hour emergency supply to a member PROGRAM awaiting a PA decision as warranted. An Anthem Blue Cross does not routinely provide emergency is when lack of medical help could payment for replacement of lost, stolen or result in danger to a member’s health or, in the otherwise destroyed medications, even if a case of a pregnant member, the health of her physician writes a new prescription for the unborn child. medication. It is the responsibility of the member to All participating pharmacies will be reimbursed for replace these medications. the ingredient cost and dispensing fee of the Prescribers and dispensers are encouraged to 72-hour emergency supply of medication, whether register for CURES access as soon as possible in or not the PA request is ultimately approved or observance of mandates established by CA SB809 denied. and SB482.  The pharmacy must call IngenioRx Pharmacy California Health & Safety Code section 11165.1 Help Desk at IngenioRx Pharmacy Help Desk (a)(1)(A) states that healthcare practitioners  1-833-253-4454 for a prescription override to authorized to prescribe, order, administer, furnish, submit the 72-hour medication emergency or dispense Schedule II, Schedule III or Schedule supply for payment. IV controlled substances and pharmacists must submit an application for approval to access Excluded and carved-out medications/products are information online regarding the controlled not eligible for a 72-hour emergency supply. substance history of a patient. LOST OR STOLEN MEDICATIONS Providers should review six-month prescription PA may be considered in life-threatening situations profiles and/or California prescription drug and for maintenance medications only when the monitoring program (CURES) report with the following conditions are met: member, pointing out the importance of appropriate drug use and avoidance of drug interactions. SB482 requires providers to consult CURES in

6 | PHARMACY advance of prescribing certain controlled Value Assessment Committee (VAC): The role of substances. the VAC is to determine tier assignments, or coverage levels. In addition to the designations More information about CURES, including assigned by the CRC, the VAC may also look at registration information, may be found at: financial information (in other words, average  http://oag.ca.gov/cures-pdmp wholesale price, rebates, ingredient cost, cost of care, copayments, coinsurance), market factors COORDINATION OF BENEFITS and customer impact to determine tiers/levels. The VAC is responsible for creating tier assignments Medicaid is the payer of last resort. In order to that appropriately balance clinical, financial and properly adjudicate pharmacy claims, the pharmacy claims system also edits for coordination of benefits customer impact. (COB) using a COB flag that is sent on the member These designations are determined through a eligibility record. Following NCPDP standards, the rigorous review of clinical evidence, the product’s pharmacy enters certain codes indicating payment clinical attributes and clinical judgment. made by the primary insurer, and Anthem The CRC may assign one of four clinical Blue Cross covers the member’s remaining out-of- designations: pocket expense. For members with commercial primary coverage, Anthem Blue Cross can cover 1. Favorable member prescription deductibles and copays. 2. Comparable • For members with Medicare Part B, Anthem 3. Insufficient evidence Blue Cross can cover the member’s 20% cost share. 4. Unfavorable • For members with Medicare Part D, Anthem These designations are passed to a second Blue Cross covers select drugs which are committee known as the Value Assessment covered by Medicaid but not Medicare Part Committee (VAC). The CRC may also choose to D. provide the VAC with clinical comments about the products to assist in further defining their clinical • Anthem Blue Cross does not cover Part D rationale. deductibles, copays or catastrophic member cost share payments. The CRC may also provide clinical comments about any generics in that particular drug class as ADMINISTRATIVE well. To ensure that the clinical rationale is properly balanced with financial considerations, the VAC PHARMACY AND THERAPEUTICS must take into account the CRC’s clinical PROCESS designations and review the clinical comments The Pharmacy and Therapeutics (P&T) process when making decisions. The CRC always meets before the VAC. consists of two interdependent subcommittees: the Clinical Review Committee (CRC) and the Value CLINICAL POLICY DEVELOPMENT Assessment Committee (VAC). The development of clinical drug policies is critical Clinical Review Committee (CRC): The purpose of to the success of the PA program and to ensure the CRC is to clinically review drugs for safety, appropriateness and quality of care. The efficacy and clinical aspects in comparison to pharmacists and Medical Directors use the policies similar drugs within a therapeutic class or used to as a guideline in determining medical necessity of treat a particular condition. The committee’s main those drugs requiring PA. goal is assignment of clinical designations to each single-source brand product under review. The clinical pharmacists use several clinical resources to gather the most current information

6 | PHARMACY regarding FDA approved indications, dosing, • Medical device safety alert: issued in contraindications and other relevant information situations where a medical device may that would be required to determine medical present an unreasonable risk of substantial necessity. harm. In some cases, these situations are also considered recalls. These resources include but are not limited to: FDA-approved product labeling, peer-reviewed In the event of a drug recall either voluntarily by the literature, American Hospital Formulary Service manufacturer or as a result of an FDA requirement, Drug (AHDS) Information®, Truven Health Anthem Blue Cross ensures appropriate notification Analytics Inc. DrugPoints® or DrugDex®, National is provided to members and providers in Comprehensive Cancer Network (NCCN) ® Drug & compliance with NCQA guidelines. Biologicals Compendium®.

The policies are presented to the P&T Committee for review and approval. Clinical drug policies are updated at least annually so that the most current clinical information is being utilized in medical necessity determinations.

FDA DRUG RECALLS AN D PATIENT SAFETY Drug recalls are defined by the FDA and recognized by NCQA as follows: • Class I recall: a situation in which there is a reasonable probability that the use of or exposure to a volatile product will cause serious adverse health consequences or death. • Class II recall: a situation in which use of or exposure to a volatile product may cause temporary or medically reversible adverse health consequences or where the probability of serious adverse health consequences is remote. • Class III recall: a situation in which use of or exposure to a volatile product is not likely to cause adverse health consequences. • Market withdrawal: occurs when a product has a minor violation that would not be subject to FDA legal action. The firm removes the product from the market or corrects the violation. For example, a product removed from the market due to tampering without evidence of manufacturing or distribution problems would be a market withdrawal.

7 | SPECIAL PROGRAMS AND PILOTS

7 | Spec i al progr ams and pilots MANAGED LONG-TERM SERVICES Anthem Blue Cross maintains responsibility for AND SUPPORTS CBAS services in all of our California Medicaid counties through a separate program Managed Long-Term Services and Supports implementation rolled out by the state in 2012. (MLTSS) consists of a variety of state of California programs that provide services to help individuals CONSUMER DIRECTION remain living independently in the community or the MLTSS are provided under models that promote most appropriate setting of their choice. MLTSS are consumer direction. Members have a voice in how provided over an extended period, predominantly in eligible MLTSS services are provided, who the member’s home or community, but also in provides the services, and what goals they want facility-based settings such as nursing facilities. prioritized within their MLTSS plans of care. MLTSS consist of four distinct benefits: MLTSS SERVICE COORDINATION • Coordination of In-Home Support Services (IHSS) The Anthem Blue Cross MLTSS team works to support member choice and independence by Community-Based Adult Services (CBAS) • providing access to and coordination of services • Multipurpose Senior Services Program and supports. This allows members to live with (MSSP) dignity in their community or LTC facility, improving their quality of life. • Long-Term Care (LTC) To ensure members’ needs are being met, MLTSS Since the 2014 implementation of California’s staff work closely with our Case Management and Coordinated Care Initiative (CCI), Anthem Behavioral Health teams, PCPs, and MLTSS Blue Cross has taken responsibility for these providers to identify and connect with members programs in Santa Clara and Los Angeles who could benefit from MLTSS services. This Counties. In these two counties, most Medi-Cal includes: beneficiaries, including dual eligibles, must join a Medi-Cal managed care health plan like Anthem • Identification of needs through the review of Blue Cross to receive MLTSS and other Medi-Cal Health Risk Assessments and other benefits. member assessments By providing MLTSS and connecting members to • Review and processing of referrals from other home- and community-based services PCP, specialists and MLTSS providers (HCBS), Anthem Blue Cross works to ensure that • Coordination with members, family, members are getting the right care, in the right providers and case managers as needed to place, and at the right time. implement a plan of care With the exception of CBAS, MLTSS is not a part of • Review of MLTSS provider care plans and the Anthem Blue Cross benefit package outside of coordination with providers on additional Los Angeles and Santa Clara counties. However, support IHSS and MSSP are still available to members as carved-out benefits. Members requiring LTC are • Assistance in determining the right disenrolled from managed care so they may combination of MLTSS supports receive LTC services through FFS Medi-Cal. • Assistance in accessing MLTSS and other Anthem Blue Cross will refer to those programs for home- and community-based services members enrolled outside of Santa Clara and Los Angeles counties when applicable.

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• Assistance with caregiver issues, IHSS Eligibility and Referral Process community resource referrals, emergency To be eligible for IHSS, a member must: needs, financial assistance, housing arrangements, long-term care planning and • Reside in California, be a U.S. citizen/legal nursing home placement discussions resident and be living in his or her own home • Assistance with transitions from skilled nursing facilities back to the community • Be eligible to receive Medi-Cal benefits • Be 65 years of age or older, legally blind or IN-HOME SUPPORT SERVICES disabled by Social Security standards IHSS allows eligible seniors and persons with • Submit a healthcare certification form (SOC disabilities to hire a homecare worker to assist 873) signed by a licensed healthcare them with their activities of daily living, instrumental professional indicating that they need activities of daily living and other personal needs so assistance to stay living at home they can remain safely in their homes. Members receiving IHSS self-direct their own care by hiring, The IHSS program is administered by the county, managing and, if necessary, firing their homecare and county social workers are responsible for workers. Members can also elect to involve their assessing, approving and authorizing service hours IHSS homecare workers as members of their care based on the needs of the member. teams. The county (or delegated IHSS Public Authority) is also responsible for screening and enrolling IHSS Types of Services Provided by IHSS Homecare homecare workers, conducting criminal background Workers checks, conducting homecare worker orientations, Examples of services that can be provided by IHSS operating homecare worker registries and retaining homecare workers include: enrollment documentation. • Domestic and related services (in other Members who may benefit from IHSS or who need words, house cleaning/chores, meal assistance navigating the program can contact an preparation and clean-up, laundry, grocery Anthem Blue Cross MLTSS Service Coordinator at: shopping, heavy cleaning)  1-855-871-4899 • Personal care services (in other words, bathing and grooming, dressing, feeding) Members may also self-refer and apply directly with the county by calling the IHSS Application Hotline Paramedical services (in other words, • at: administration of medication, puncturing skin, range of motion exercises)  1-888-944-IHSS (Los Angeles County) • Other services (in other words,  1-408-792-1600 (Santa Clara County) accompaniment to medical appointments, yard hazard abatement, protective COMMUNITY BASED ADULT SERVICES supervision) CBAS is a facility-based outpatient program serving individuals 18 years of age or older who have functional impairment that puts them at risk for institutional care. For additional information on CBAS, see Chapter 4: General Benefits.

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MULTIPURPOSE SENIOR SERVICES In general, to be eligible for MSSP services a PROGRAM member must: MSSP is an intensive case management program • Be 65 years of age or older that coordinates social and healthcare services for • Live within an MSSP service area members who are eligible for nursing facility placement, but who wish to remain in the • Be eligible for Medi-Cal community. • Be certified for nursing home placement Contracted MSSP providers work with members to To begin the referral process for a member, please develop a care plan, assist the member in contact Anthem Blue Cross at: accessing services available in the community (in other words, MLTSS or HCBS), and pay for  1-855-871-4899 additional services to assist the member with other An MLTSS care coordinator will assist the member unmet needs. with locating an MSSP provider and navigating the Types of services provided by MSSP include: application process. For members who are placed on an MSSP’s waiting list, the coordinator will work • Care management (in other words, needs with the MSSP provider and other HCBS providers assessments, care plan development, to address the member’s needs until he or she can monitoring of care) be enrolled in the program. • Care management assistance (in other words, assistance accessing services, MSSP Payment Procedures personal advocacy) MSSP providers are paid a flat per member per • MSSP purchased services* (in other words, month (PMPM) rate that has been established by supplemental chore and personal care DHCS and must submit a monthly invoice to services, diet and nutrition, handyman Anthem Blue Cross no later than the tenth day of services, respite care, transportation, each month. The invoice shall include information appliance assistance, housing on each Anthem Blue Cross member enrolled in assistance/repair, personal emergency the program as of the first day of the month for response systems) which the report is submitted. The invoice must include the following information: * Approved purchased services are listed and defined in the MSSP Provider Site Manual located • The name of the Anthem Blue Cross on the California Department of Aging website at: member receiving the MSSP services  https://www.aging.ca.gov/ • The member’s Client Index Number (CIN) ProgramsProviders/MSSP • The MSSP provider’s ID number Other relevant information as identified by MSSP Eligibility and Referral Process • both Anthem Blue Cross and the MSSP The MSSP program currently operates under a California 1915c HCBS Waiver and there are a MSSP providers may not submit separate claims to limited number of slots available for members. different plans for the same MSSP recipient within Eligibility and authorization of services is the same invoice period. MSSP providers must determined by The Anthem Blue Cross contracted also submit zero-cost encounter data to Anthem MSSP providers based on criteria set by the state. Blue Cross within 60 days from the date of services for reporting purposes. Any questions related to MSSP billing and payments should be directed to the MLTSS Provider Relations Representative or to [email protected].

7 | SPECIAL PROGRAMS AND PILOTS

LONG-TERM CARE AND SKILLED LTC Claims and Reimbursement NURSING FACILITIES PAs are required for all LTC services. Providers Long-Term Care (LTC) is the provision of care in a rendering LTC services should submit claims to facility, such as a skilled nursing facility or Anthem Blue Cross using the appropriate CPT and sub-acute facility for an extended period (in other accommodation codes. words, longer than the month of admission plus There are several nuances specific to LTC that one month). should be taken into consideration when navigating LTC services are primarily for the purpose of the LTC billing and payment process. This includes assisting the member with their activities of daily retroactive eligibility, authorizations for LTC living or in meeting personal rather than medical absences, member share of cost, and the needs. LTC does not include specific therapy for an relationship between LTC and hospice. illness or injury, is not skilled care, and does not require the continuing attention or supervision of Retroactive Eligibility trained, medical or paramedical personnel. Anthem Blue Cross understands the unique requirements of LTC facilities to accept residents LTC Eligibility And Referral Process as Medi-Cal pending. As soon as the facility LTC services are available to Medi-Cal recipients receives notice from the state of the Medi-Cal who require 24-hour long or short-term care and approval, the facility should verify eligibility on the have a written order from their PCP requesting the Anthem Blue Cross website and then request an services. authorization back to the date of eligibility as established by the state. Requests for LTC authorizations should be submitted prior to the first day of service and no Note: It may take the state 24 to 48 hours to later than 30 days past the first day of service. transmit an updated eligibility file to Anthem General guidelines for obtaining a prior (PA) Blue Cross. authorization for LTC services are as follows: Authorized LTC Absences • Requests for authorizations must include a LTC facilities are allowed to request a bed hold for completed LTC authorization request form, a Medication Administration Record (MAR) up to seven days when an LTC member leaves a and the most recent Minimum Data Set facility and is admitted to an acute care facility or (MDS) for the member. hospital. To ensure accurate payment, the facility must bill hospital leave days consecutively • Facilities who have multiple members beginning with the date of admission. If a needing authorization for LTC services beneficiary goes to a hospital for observation should submit each request separately via purposes and is not admitted, the LTC facility fax. should bill for this as a normal day of service. PA requests should be faxed to: In the event of a nonmedical absence from an LTC  1-877-279-2482 (Los Angeles County) facility, providers must obtain an authorization and bill utilizing the appropriate end hold/leave of 1-844-285-1167 (Santa Clara County)  absence revenue code and accommodation code. An LTSS service coordinator will review the request A maximum of 18 home-leave days for LTC are and determine if the member qualifies for LTC allowed per calendar year (certain exceptions may placement following clinical guidelines established apply). by DHCS. Providers will not be reimbursed for days a bed is held for a resident beyond the limits set forth above and will not be reimbursed for any absences without preauthorization.

7 | SPECIAL PROGRAMS AND PILOTS

Member Financial Liability/Share of Cost Example 3: The member is approved for LTC as of For members who have a Medi-Cal share of cost the 1st of the month and has a $1,000 Medi-Cal (SOC), the LTC facility is responsible for collecting SOC. However, the member is discharged on the the SOC amount each month and must represent 6th day of the month. the liability in box 39 on each claim submitted. The • The state issues notice of action for the SOC should be indicated by billing value code 23 month for the amount of $1000 with amount collected on the claim. The payment The facility per diem is $150 and the facility remitted by Anthem Blue Cross will be reduced by • collects the $1000 patient liability on the first the member liability amount. of the month The following examples are provided to assist LTC The member is discharged on day 6: 6 x facilities with addressing member SOC. • $150 = $900 Example 1: The member is approved for LTC as of The facility refunds $100 to the the 1st of the month, remains in the facility for the • member/family or estate and submits a entire month, and has a $1,000 Medi-Cal SOC. claim to Anthem Blue Cross representing • The state issues a notice of action for the the $900 collected in box 39 month for the amount of $1,000 • Anthem Blue Cross will make a payment to • The facility per diem is $150: 150 x 30 = the facility in the amount of $0 $4,500 LTC and Hospice • The facility collects the $1,000 patient liability and submits a claim to Anthem When a member is admitted into an LTC facility Blue Cross representing the collected and is receiving hospice, the hospice provider is amount in box 39 responsible for obtaining an authorization for LTC services and is required to pay the facility for room Anthem Blue Cross will make a payment to • and board charges in accordance with CMS the facility in the amount of $3,500 methodology and at the current applicable Example 2: The member is approved for LTC as of Medi-Cal rate. Anthem Blue Cross is responsible the 15th of the month, remains in the facility for paying the hospice provider for all services through the end of the month, and has a $1,000 rendered but is not responsible for paying the LTC Medi-Cal SOC (of which, $400 has been met). facility directly for these services. • The state issues a notice of action for the month for the amount of $600 and for the HEALTH HOMES following month forward of $1,000 per Health Homes is a new program being designed month under ACA Section 2703 and California Assembly Bill 361 to provide an integrated (physical and • The facility per diem is $150: 150 x 15 = behavioral), person-centered service delivery $2,250 system for populations with complex/chronic • The facility collects the $600 patient liability conditions or serious mental illness. and submits a claim to Anthem Blue Cross Health Homes is intended to be an intensive set of representing the collected amount in box 39 services for a small subset of members who could • Anthem Blue Cross will make a payment to benefit from high-touch care coordination services. the facility in the amount of $1,650 Anthem Blue Cross has committed to implementing • The facility will collect $1,000 from the Health Home pilots in seven counties, beginning in patient in the following month July 2018 in San Francisco and Alameda. In July 2019, the program will launch in Santa Clara, Los Angeles, Tulare, and Sacramento.

7 | SPECIAL PROGRAMS AND PILOTS

The Health Homes program provides a unique experiencing homelessness, CBAS providers or group of services compared to other care other community-based organizations. coordination programs provided by Anthem Blue Cross and our partners. In its current design, ELIGIBILITY the program will place a stronger emphasis on: Eligible members for the Health Homes program • Addressing homelessness/unstable housing must meet the following criteria: for members Chronic Condition Criteria Improving HIT/HIE and other data-sharing • Has a chronic condition in at least one of the capabilities following categories: • Pushing care management/care • At least two of the following: chronic coordination to community-level providers obstructive pulmonary disease, diabetes, • Additional care management and care traumatic brain injury, chronic or congestive coordination services above currently heart failure, coronary artery disease, contracted services chronic liver disease, dementia, substance use disorders • More intense levels of outreach and engagement • Hypertension and one of the following: chronic obstructive pulmonary disease, • Development and sharing of a health action diabetes, coronary artery disease, chronic plan or congestive heart failure • Medication reconciliation services • One of the following: major depressive • Enhanced transitional care services disorders, bipolar disorder, psychotic In order to achieve the goals set forth under the disorders (including schizophrenia) Health Homes Program, Anthem Blue Cross will be • Asthma contracting with Community Based Care Management Entities (CB-CMEs) who will be Medical Acuity/Complexity Criteria responsible for Meets at least one of the following criteria: • Comprehensive care management • Has at least three of the eligible chronic • Care coordination (physical health, conditions behavioral health, community-based LTSS) • At least one inpatient stay in the last year • Health promotion • Three or more emergency department visits • Comprehensive transitional care services in the last year • Individual and family support • Chronic homelessness

• Referral to community and social support REFERRAL PROCESS services Providers can refer members they determine would Organizations who may act as CB-CMEs include benefit from Health Homes program services and FQHCs, community health centers, community must attest the member meets the eligibility criteria. mental health centers, local health departments, Referrals must be submitted to our Special primary care or specialist physician groups, SUD Programs department for review at treatment providers, providers serving individuals [email protected].

7 | SPECIAL PROGRAMS AND PILOTS

We’ll review all referrals to confirm members meet • Individual housing and tenancy sustaining the eligibility criteria. Members determined eligible services will be assigned a CB-CME for outreach and • Transition services engagement. • Flexible housing pools Additional information can also be found on the Anthem Blue Cross provider website at: Anthem Blue Cross has committed to partnering with nine counties who have received CMS and  https://providers.anthem.com/CA DHCS approval to implement WPC pilots. This includes Los Angeles, Santa Clara, Alameda, San WHOLE PERSON CARE Francisco, Sacramento (City), San Benito, Whole Person Care (WPC) pilots are five-year Mariposa, Kings and Placer counties. demonstration programs authorized under the state Additional information on WPC can be found on the of California’s Medi-Cal 2020 waiver to test locally DHCS website at: based initiatives that will coordinate physical health, behavioral health and social services for  www.dhcs.ca.gov/services/Pages/WholePer beneficiaries who are high users of multiple sonCarePilots.aspx healthcare systems. PALLIATIVE CARE PROGRAM WPC pilots are designed to address the needs of high utilizing Medi-Cal members who are not Anthem Palliative Care Program is a patient and currently receiving similar services through other family-centered care program that optimizes quality programs such as Health Homes or Cal of life for adult members with a terminal illness. MediConnect. Palliative Care includes coordination of services throughout the continuum of illness to address WPC places a strong emphasis on identifying physical, intellectual, emotional, social, and spiritual target populations, establishing strong needs, and to facilitate member autonomy, access infrastructures for data sharing and care to information, and choice. Unlike the hospice coordination, and on evaluating individual and benefit, members can receive palliative care population health progress. services concurrently with curative care. WPC pilots are led by county agencies, which fund 50% of the proposed WPC activities in order to TYPES OF SERVICES: draw down a 50% federal match. Each participating Anthem contracts with Palliative Care providers in county has the flexibility to design their own WPC the community to deliver services, such as: pilot following certain guidelines and must partner Advanced Care Planning with at least one local health plan. General • categories of service include establishing: • Care Coordination • Care coordination/management programs • Mental Health and Medical Social Services (may utilize filed-based care, such as case • Pain and Symptom Management managers, therapists or nurses delivering service on the street or in the home) • Care Plan Development • Recuperative care/medical respite • Palliative Care Assessment and programs Consultation

• Sobering centers PALLIATIVE CARE ELIGIBILITY AND • Transportation services REFERRAL PROCESS: • New IT and data sharing infrastructures In order to qualify for Anthem adult Palliative Care, members must meet all general eligibility criteria • Individual housing transition services

7 | SPECIAL PROGRAMS AND PILOTS and at least one of the disease-specific criteria services that align with the previous waiver listed below. including: General eligibility criteria: • All adult services (please see listed in Palliative Care Program) • Patient is likely or has started to use the hospital or emergency department to • Specialized services: manage their late-stage disease ◦ Expressive therapy (creative art, (“unanticipated decompensation”). music, massage, and child life) • Patient is in the late stage of illness. ◦ Family Bereavement counseling for • Patient’s death within a year would not be family and other primary caregivers unexpected. as applicable • Patient has received appropriate medical ◦ Respite care therapy. ◦ 24/7 nursing hotline Patient and designated support person • Children residing outside of the counties listed agree to attempt in-home, residential-based above are able to access our standard palliative or outpatient disease management and are care network and services. willing to participate in advanced care planning. In order to qualify for Palliative Care, members must have one of the eligible conditions: Disease-specific criteria: • Conditions for which curative treatment is Congestive heart failure (CHF) • possible, but may fail (e.g. advanced • Chronic obstructive pulmonary disease cancer) (COPD) • Conditions requiring intensive long-term • Advanced cancer treatment aimed at maintaining quality of life (e.g. HIV, cystic fibrosis) • Liver disease Progressive conditions for which treatment Referral Process: • is exclusively palliative after diagnosis (e.g. To initiate a referral for Palliative Care, please progressive metabolic disorders) contact the Palliative Care at Conditions involving severe, non- [email protected]. • progressive disability, or causing extreme Additional information on Palliative Care Services vulnerability to health complications (e.g. can also be found on the DHCS website at: extreme prematurity)  https://www.dhcs.ca.gov/provgovpart/Page/ Palliative-Care-and-SB-1004.aspx For more information on Pediatric Palliative Care PEDIATRIC PALLIATIVE CARE Program, including eligibility criteria, referral processes, and coordinating with providers, please Pediatric Palliative Care is a new benefit available contact Pediatric Palliative Care Program team at: to Anthem members as a part of DHCS’s Palliative [email protected]. Care Waiver transition, and is specialized care for Additional information can also be found on the children with serious, long-term health conditions. DHCS website at: Anthem Blue Cross contracted with providers in Alameda, San Francisco, Santa Clara, San Benito  https://www.dhcs.ca.gov/services/ppc/ and Los Angeles counties to provide Home-based Pages/default.aspx

7 | SPECIAL PROGRAMS AND PILOTS

LIVEHEALTH ONLINE (LHO) LiveHealth Online* (LHO) is a website and mobile application that gives patients 24/7 access to on- demand video visits (medical). It has an urgent care focus and provides convenient access anytime, anywhere in California (even at home!) via smartphone, tablet or computer. LHO connects patients with board-certified physicians supporting physical and behavioral health. Physicians can electronically prescribe to the member’s pharmacy. Note: Only noncontrolled substances can be prescribed. It is available at no cost for Anthem Blue Cross members enrolled in Medi-Cal Managed Care (Medi-Cal) beginning September 1, 2018. LHO does not provide: • Preventive or ongoing medical care.* • Lab orders. • Access to specialist care at this time. Access to translation services other than Spanish (doctor profiles indicate spoken languages). Members can get 24/7 help by calling: 1-888-548- 3432 | 1-888-LiveHealth For urgent prescription assistance after an online visit, members can call: 1-888-982-7956.

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

8 | PROVI DER PROCEDURES AND RESPONSI BI LI TI ES RESPONSIBILITIES APPLICABLE • Discriminating against Anthem Blue Cross TO ALL PROVIDERS members or Medicaid participants Our providers must fulfill their roles and Note: Services should always be provided without responsibilities with the highest integrity. We lean regard to race, religion, sex, color, national origin, on their extensive healthcare education, experience age or physical/behavioral health status. and dedication to our members. EMERGENCIES There are a number of responsibilities applicable to The answering service or after-hours personnel all Anthem Blue Cross providers. Responsibilities must ask the member if the call is an emergency. include the following: In the event of an emergency, the member must be • After-hours services immediately directed to dial 911 or to proceed • Eligibility verification directly to the nearest hospital emergency room. If the PCP’s staff or answering service is not • Collaboration immediately available, an answering machine may • Confidentiality be used. The answering machine message must • Continuity of care instruct members with emergency healthcare needs to dial 911 or go directly to the nearest Licenses and certifications • hospital emergency room. The message must also • Mandatory reporting of abuse give members an alternative contact number so they can reach the PCP or on-call provider with • Medical records standards and medical concerns or questions. documentation • Office hours NETWORK ON-CALL PROVIDERS • Open clinical dialog/affirmative statement Anthem Blue Cross prefers that our PCPs use network providers for on-call services. When that is • Oversight of non-physician practitioners not possible, the PCP must help ensure that the • Prohibited activities covering on-call physician or other professional • Provider contract terminations provider abides by the terms of our provider contract. • Termination of ancillary provider/patient relationship COLLABORATION • Updating provider information Providers share the responsibility of giving • Fully complying with all terms and respectful care and working collaboratively with conditions of the DHCS contract including Anthem Blue Cross specialists, hospitals, ancillary ownership and control disclosures, audits providers, and members and their families. and inspections of subcontractors, and Providers must permit members to participate actively in decisions regarding medical care monitoring activities related to care coordination, data reporting and other including, except as limited by law, their decision to functions refuse treatment.

PROHIBITED ACTIVITIES MANDATORY REPORTING OF CHILD ABUSE, ELDER ABUSE OR DOMESTIC • Billing eligible members for covered VIOLENCE services Providers must ensure that office personnel have • Segregating members in any way from specific knowledge of local reporting requirements other persons receiving similar services, and procedures to make telephone and written supplies or equipment reports of known or suspected cases of abuse.

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

All healthcare professionals must immediately advising a member or advocating on behalf of a report actual or suspected child abuse, elder abuse member for any of the following: or domestic violence to the local law enforcement • The member's health status, medical care agency by telephone. In addition, providers must or treatment options including any submit a follow-up written report to the local law alternative treatment that may be enforcement agency within the time frames as self-administered required by law. • Any information the member needs in order OPEN CLINICAL DIALOGUE/AFFIRMATIVE to decide among all relevant treatment STATEMENT options Nothing within the provider’s Provider Agreement • The risks, benefits and consequences of or this Provider Manual should be construed as treatment or nontreatment encouraging providers to restrict medically • The member's right to participate in necessary covered services or limit clinical decisions regarding his or her healthcare dialogue between providers and their patients. including the right to refuse treatment and to Providers can communicate freely with members express preferences about future treatment regarding the treatment options available to them decisions including medication treatment options regardless of benefit coverage limitations. • To receive information on the grievances and appeals and state fair hearing OVERSIGHT OF NONPHYSICIAN procedures PRACTITIONERS • To have access to policies and procedures All providers using nonphysician practitioners must covering authorization of services provide supervision and oversight of such To be notified of any decision to deny a nonphysician practitioners consistent with state and • federal laws. The supervising physician and the service authorization request or to authorize a service in an amount, duration or scope nonphysician practitioner must have written that is less than requested guidelines for adequate supervision, and all supervising providers must follow state licensing • To challenge, on behalf of our members, and certification requirements. the denial of coverage or payment for medical assistance Nonphysician practitioners include the following categories: • To be free from discrimination for the participation, reimbursement or • Advanced registered nurse practitioners indemnification of any provider who is • Certified nurse midwives acting within the scope of his/her license or • Physician assistants certification under applicable law solely based on that license or certification These nonphysician practitioners are licensed by the state and working under the supervision of a Anthem Blue Cross provider selection policies and licensed physician as mandated by state and procedures do not discriminate against particular federal regulations. providers who serve high-risk populations or specialize in conditions that require costly PROVIDER RIGHTS treatment. Anthem Blue Cross providers acting within the lawful scope of practice shall not be prohibited from

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

Note: Anthem Blue Cross members may select any Any admission or service that requires prior contracted PCP as their primary physician as long authorization and has not received the appropriate as that PCP is taking new patients. We furnish review may be subject to post-service review each PCP with a current list of assigned members denial. Generally, the provider is required to and from time to time provide medical information perform all prior authorization functions with about our members’ potential healthcare needs. In Anthem Blue Cross; however, the hospital may this way, providers can more effectively provide also ensure that prior authorization has been care and coordinate services. granted before services are rendered or risk post- service denial. HOSPITAL SCOPE OF RESPONSIBILITIES ANCILLARY SCOPE OF RESPONSIBILITIES PCPs refer members to contracted hospitals for PCPs and specialists refer members to contracted conditions beyond the PCP’s scope of practice that network ancillary providers for conditions beyond are medically necessary. the PCP’s or specialist’s scope of practice that are medically necessary. Hospital care is limited to Anthem Blue Cross benefits. Hospital professionals diagnose and treat Ancillary professionals diagnose and treat conditions specific to their area of expertise. conditions specific to their area of expertise. Hospital responsibilities include the following. Ancillary care is limited to Anthem Blue Cross benefits. SUPPLY MEDICATIONS We have a wide network of participating healthcare Hospital providers must provide members with an professionals and facilities. All services provided by adequate supply of medications upon discharge the healthcare professional and for which the from the emergency room or an inpatient setting to healthcare professional is responsible are listed in allow reasonable time for the member to access a the Ancillary Agreement. pharmacy to have prescriptions filled. ACCESS TO CARE, APPOINTMENT NOTIFICATION OF ADMISSION AND STANDARDS AND AFTER-HOURS SERVICES SERVICES The hospital must notify Anthem Blue Cross or the Anthem Blue Cross adheres to standards set by review organization of an admission or service at the following organizations: the time the member is admitted or service is rendered. • National Committee for Quality Assurance (NCQA) In the event that the emergency room visit results in the member’s admission to the hospital, • American College of Obstetricians and providers must contact Anthem Blue Cross within Gynecologists (ACOG) 24 hours or one business day if the member was • Department of Health Care Services admitted on a weekend or holiday. (DHCS)

NOTIFICATION OF PRIOR AUTHORIZATION • California Department of Managed Health DECISIONS Care (DMHC) If the hospital has not received notice of prior These guidelines help ensure that medical authorization at the time of a scheduled admission appointments, emergency services and continuity or service as required by the Utilization of care for new members are provided fairly, Management guidelines and the Hospital reasonably and within specific time frames. Agreement, the hospital should contact Anthem Anthem Blue Cross monitors provider compliance Blue Cross and request the status of the decision. with access to care standards on a regular basis.

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

Failure to comply with proper instructions, Nonurgent ancillary Within 15 business days standards or survey requests may result in of request corrective action. Initial health Within 120 days of AMERICANS WITH DISABILITIES ACT assessments enrollment REQUIREMENTS Preventive care visits Within 14 days of request Our policies and procedures are designed to promote compliance with the Americans with Routine physicals Within 30 days of request Disabilities Act (ADA) of 1990. Providers are Behavioral health required to take reasonable actions to remove an existing barrier and/or to accommodate the needs Standards for timely Emergent: immediately and appropriate of members who are qualified individuals with a Emergent, access to quality disability. This action plan includes: nonlife-threatening/crisis behavioral stabilization: within 24 hours healthcare • Street-level access of request • An elevator or accessible ramp into facilities Urgent: within 48 hours of referral/request • Access to a lavatory that accommodates a Initial visit for routine care wheelchair within 10 business days • Access to an examination room that accommodates a wheelchair Outpatient treatment 7 calendar days by a behavioral Routine outpatient: within health provider • Handicap parking clearly marked, unless 10 days of request post-inpatient there is street side parking discharge Outpatient following discharge from an APPOINTMENT STANDARDS inpatient hospital: within 7 days of discharge Healthcare providers must make appointments for members from the time of request as follows: Initial health assessments

Emergency Immediate access, Children under the Within 120 days of examination 24 hours/7 days a week age of 18 months enrollment or within American Academy of Urgent (sick) Within 48 hours of request Pediatrics (AAP) examination if authorization is not guidelines, whichever is required or within 96 less hours of request if authorization is required, Children aged 19 Within 120 days of or as clinically indicated months and over enrollment

Routine primary care Within 10 business days Prenatal and post-partum visits examination of request (nonurgent) First prenatal visit Within 10 days of request

Nonurgent Within 15 business days First and second Within 7 days of request consults/specialty of request trimester referrals Third trimester Within 3 days of request Nonurgent care with Within 10 business days nonphysician mental of request High-risk pregnancy Within 3 days of health providers identification (where applicable) Postpartum Between 21 and 56 days after delivery

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

MISSED APPOINTMENT TRACKING • The member has a disabling condition When members miss appointments, providers must • The member is a child with special do the following: healthcare needs Document the missed appointment in the • OFFICE HOURS member’s medical record. To maintain continuity of care, providers are Make at least three attempts to contact the • required to be available to provide services for a member to determine the reason for the minimum of 24 hours each week. Office hours missed appointment. must be clearly posted and members must be • Provide a reason in the member’s medical informed about the provider’s availability at each record for any delays in performing an site. There are strict guidelines for providing access examination including any refusals by the to healthcare 24 hours a day, 7 days a week: member. • Providers must be available 24 hours a day • Documentation of the attempts to schedule by telephone. an initial health assessment must be • During those times when a provider is not available to Anthem Blue Cross or state available, an on-call provider must be reviewers upon request. available to take calls.

SPECIALISTS WAIT TIMES The following guidelines are in place for our When a provider's office receives a call from an specialists: Anthem Blue Cross member during regular • For urgent care, the specialist should see business hours for assistance and possible triage, the member within 24 hours of receiving the the provider or another healthcare professional request. must either take the call or call the member back within 30 minutes of the initial call. • For routine care, the specialist should see the member within 15 business days of NONDISCRIMINATION STATEMENT receiving the request. Providers must post a statement in their offices that • A copy of the medical records and/or results details hours of operation that do not discriminate of the visit should be sent to PCP office also against Anthem Blue Cross members. This to allow continuity of care. includes wait times for the following: In some cases, a member may self-refer to a • Waiting times for appointments specialist. These cases include but are not limited to: • Waiting times for care at facilities • Family planning and evaluation • Languages spoken • Diagnosis, treatment and follow-up of AFTER-HOURS SERVICES sexually transmitted diseases (STDs) It is The Anthem Blue Cross policy and the state of Please note: Specialists are responsible for California's requirement that our members have ensuring that necessary pre-authorizations have access to quality healthcare services 24 hours a been obtained prior to providing services. day, 7 days a week. That kind of access means our For some medical conditions, it makes sense for PCPs must have a system in place to ensure that the specialist to be the PCP. Members may request members can call after hours with medical that the specialist be assigned as their PCP if: questions or concerns. • The member has a chronic illness

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

We monitor PCP compliance with after-hours phone or pager number]. You will receive a return access standards on a regular basis. It is call from the on-call physician within [time frame]." recommended that PCPs advise their answering Please note: Anthem Blue Cross prefers that services to participate in any after-hours PCPs use an in-network provider for on-call monitoring. Failure to comply may result in services. When that is not possible, PCPs must use corrective action. their best efforts to help ensure that the covering PCPs must adhere to the following after-hours on-call provider abides by the terms of the Anthem protocols: Blue Cross provider contract. Forward member calls directly to the PCP or • INTERACTIVE VOICE RESPONSE on-call provider or instruct the member that REQUIREMENTS OF PROVIDERS the provider will contact the member within 30 minutes. The following providers are required to have 24-hour service: • Ask the member if the call is an emergency. In the event of an emergency, they must • Assisted living facilities/services immediately direct the member to dial 911 • Emergency response systems or proceed directly to the nearest hospital Nursing homes/skilled nursing facilities emergency room. • Such providers will provide advice and assess care • Have the ability to contact a telephone as appropriate for each member’s medical interpreter for members with language condition. Emergent conditions will be referred to barriers. the nearest emergency room. • Return all calls. NETWORK ADEQUACY STANDARDS Answering machine messages: Below please find the Department of Health Care • May be used in the event that staff or an Services (DHCS) Network Adequacy Standards as answering service is not immediately outlined in All Plan Letter 20-003: available. • Must instruct members with emergency healthcare needs to dial 911 or proceed directly to the nearest hospital emergency room. • Must provide instructions on how to contact the PCP or on-call provider in a nonemergency situation. • Must provide instructions in English, Spanish and any other language appropriate to the PCP’s practice. We offer the following suggested text for answering machines: "Hello, you have reached [insert physician office name]. If this is an emergency, hang up and dial 911 or go to the nearest hospital emergency room. If this is not an emergency and you have a medical concern or question, please call [insert contact

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

Network Adequacy Standards Provider Type Timely Access Standard Time and Distance Standard by County Size Rural Small Medium Dense Primary Care Within 10 business days 10 miles or 30 minutes from the member’s residence (Adult and Pediatric) to appt. from request

60 miles or 90 45 miles or 75 30 miles or 60 15 miles or 30 Specialty Care Within 15 business days minutes from minutes from minutes from minutes from (Adult and Pediatric) to appt. from request the member’s the member’s the member’s the member’s residence residence residence residence

Obstetrics/Gynecology Within 10 business days (OB/GYN) 10 miles or 30 minutes from the member’s residence to appt. from request Primary Care

60 miles or 90 45 miles or 75 30 miles or 60 15 miles or 30 Obstetrics/Gynecology Within 15 business days minutes from minutes from minutes from minutes from (OB/GYN) to appt. from request the member’s the member’s the member’s the member’s Specialty Care residence residence residence residence

Hospitals Not Applicable 15 miles or 30 minutes from the member’s residence Dispensing of at least a 72-hour supply of Pharmacy covered outpatient drug 10 miles or 30 minutes from the member’s residence in an emergency situation Mental Health 60 miles or 90 45 miles or 75 30 miles or 60 15 miles or 30 (non-psychiatry) Within 10 business days minutes from minutes from minutes from minutes from Outpatient Services to apt. from request the member’s the member’s the member’s the member’s (Adult and Pediatric) residence residence residence residence Within 15 business days Ancillary Services Not Applicable to appt. from request. Time and distance standards are not established for Multipurpose Senior Services Program (MSSP), Skilled Long Term Services and Nursing Facilities (SNF), or Intermediate Care Facilities If applicable Supports (LTSS) (ICF) providers as these providers either travel to the member to provide services or the member resides at the facility for care.

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

REQUIRED ASSESSMENTS • If the new member is not an existing patient, transferred medical records can also meet The initial health assessment (IHA) is a complete the requirements for an IHA if a completed medical history, head-to-toe physical examination health history is included. and assessment of health behaviors. • If the new member refuses to schedule an The IHA should include but is not limited to the IHA. The refusal must be documented in the following specific screenings: member’s medical record. • A comprehensive history SENIORS AND PERSONS WITH Past medical history • DISABILITIES HEALTH RISK ASSESSMENT • Preventive services (SPD HRA) • Comprehensive physical exam We strongly encourage provider is assisting members in completing the health risk assessment • Diagnoses and plan of care for Senior and Persons with Disabilities. The • Individual Health Education Behavioral assessment is a ten-minute survey. The Assessment (IHEBA) such as the Staying assessment is state requirement. This information Healthy Assessment (SHA) is private. Information collected in the health survey • Developmental and behavioral assessment ensures members get the most out of their health plan. • Vaccines as recommended by the ACIP The SPD HRA assist with identifying care PCPs are strongly encouraged to review their coordination needs. For example, if member needs monthly eligibility list available on the Anthem Blue assistance with coordinating specialty services, we Cross provider portal and to proactively contact will help schedule an exam with a specialty their assigned members to make an appointment provider. Or, if you member has to refill a for an IHA within the following time frame: prescription, we can assist the member with • All new members must have an IHA within navigating their pharmacy benefits. These are just 120 days of enrollment. a few of many services Anthem can assist you with. We help our members stay connected to care and The PCP’s office is responsible for making and prevent unnecessary emergency room visits or documenting all attempts to contact assigned hospitalizations. members. Members’ medical records must reflect the reason for any delays in performing the IHA STAYING HEALTHY ASSESSMENT TOOL including any refusals by the member to have the (MEDI-CAL ONLY) exam. In addition to the initial health assessment, An initial health assessment is not necessary providers working with Medi-Cal members must under the following conditions: also fill out the Staying Healthy Assessment (SHA) • If the new member is an existing patient of Tool and periodically readminister it according to the PCP (but new to us) with an established the SHA periodicity chart. Annual reviews of medical record showing baseline health existing SHAs and counseling are required at status. This record must include a subsequent periodic exams. documented IHA within the past 12 months Note: This requirement does not apply to Major prior to the member's enrollment and Risk Medical Insurance Program members. sufficient information for the PCP to provide The California Department of Health Care Services treatment. (DHCS) recently updated the SHA and Individual Health Education Behavioral Assessment (IHEBA). It is now available in seven age-specific pediatric

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES questionnaires and two adult questionnaires To Obtain SHA Assessment Forms including one designed for seniors. It was The SHA assessment forms in all the age developed to achieve the following: categories and most Medi-Cal threshold languages • Identify and track high-risk behaviors are posted on the DHCS SHA webpage and are available to download at the following link: • Prioritize patient health education needs  www.dhcs.ca.gov/formsandpubs/forms/pag • Initiate discussion and counseling on es/stayinghealthy.aspx prioritized high-risk behaviors related to lifestyle, behavior, environment, cultural and To request hard copies of the SHA assessment language forms including electronic versions of the PCP responsibilities for the Staying Healthy assessment forms in Farsi or Khmer, please contact your local regional health plan. Assessment Program include: • Reviewing the completed SHA with the Electronic SHA Formats patient. With many offices now using electronic medical • Exploring patient responses to verify risk records (EMRs), providers have several options for factors and determining the extent to which using an electronic format of the SHA. they might harm the patient’s health. DHCS requires that providers must complete and • Based upon a patient’s behavioral risks and submit either the SHA Electronic or Other Format willingness to make lifestyle changes, PCPs Notification Form or Use of Bright Futures should provide tailored health education Notification Form at least one month prior to counseling, intervention, referral and implementation. Providers are advised to contact a follow-up. local regional health plan representative to request this form and initiate the process. • The PCP must document, initial and date all health education interventions and referrals USE OF ALTERNATIVE IHEBA TOOLS using the intervention codes listed on the Anthem Blue Cross strongly encourages the use of bottom of each SHA tool. the SHA. Should you prefer to use and administer Newly added PCP responsibilities for the Staying an alternative IHEBA, a request and justification to Healthy Assessment Program include: do so must be submitted to Anthem Blue Cross two months in advance of scheduled implementation to • Receive training on implementing and receive approval. administering the new SHA For more information about the SHA, please • Attest to receiving training on the contact your local Provider Relations team at the implementation, administration and state regulations regarding the use of the new appropriate phone numbers listed in the Quick Reference chapter of this manual. SHA assessment forms • Complete the DHCS-approved provider CALIFORNIA CHILDREN’S presentation training online at the following SERVICES link: California Children’s Services (CCS) is a state  http://tinyurl.com/StayingHealthy2014 program that treats children under 21 years of age (If the slideshow does not start when with certain health conditions, diseases or chronic health problems and who meet the CCS program opening the PowerPoint file, select the rules. If this health plan or your PCP believes a Slide Show tab and select the From child has a CCS condition, he or she will be Beginning” icon in the top left-hand corner referred to the CCS program. of your screen to start the narrated training.)

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

CCS program staff will decide if the child is eligible All providers, both in- and out-of-network, are for CCS services. If the child can get these types of obligated to follow CCS guidelines including the care, CCS providers will treat him or her for the following: CCS condition. This health plan will continue to • Refer CCS-eligible or potentially eligible cover types of service that do not have to do with conditions to CCS and Anthem Blue Cross the CCS condition such as physicals, vaccines and within 24 hours or the next business day. well-child checkups. • Use CCS network physicians and hospitals. Anthem Blue Cross does not cover care given by Non-CCS-paneled hospitals must contact the CCS program. For CCS to cover these CCS immediately for authorization of problems, CCS must approve the provider, inpatient members who are not stable for services and equipment. The state (not Anthem transfer to a CCS-paneled hospital. Blue Cross) pays for CCS services. Anthem Blue Cross will not reimburse claims for CCS does not cover all problems. CCS covers CCS-eligible conditions denied by CCS for most problems that physically disable or that need noncompliance with CCS program requirements. In to be treated with medicines, surgery or addition, providers may not seek additional rehabilitation (rehab). payment or compensation from members for any of CCS covers children with problems such as: the following: • Congenital • Spina bifida • CCS-covered services heart disease • Hearing loss • CCS-denied claims due to failure to submit Cancers the application within CCS time frames • • Cataracts • Tumors • CCS-denied claims due to failure to use • Cerebral palsy CCS network physicians or hospitals • Hemophilia • Seizures that Anthem Blue Cross will reimburse for all healthcare • Sickle cell are not services unrelated to the CCS-covered condition. anemia controlled We do not reimburse for services related to a • Thyroid • Rheumatoid potentially medically eligible condition or for care problems arthritis that is related to a condition that has been qualified • Diabetes • Muscular by the local CCS program. dystrophy • Serious chronic PREGNANCY NOTIFICATION kidney • AIDS problems  https://providers.anthem.com/CA > Forms. • Severe head, • Liver disease brain or spinal  Fax number: 1-855-410-4451 cord injuries • Intestinal The pregnancy notification process identifies disease • Severe burns Anthem Blue Cross members who are covered by • Cleft lip/palate • Severely Medi-Cal Managed Care (Medi-Cal) early in their crooked teeth pregnancy. Our goal is to identify women who may need additional health education, transportation Approved CCS providers must submit claims on assistance, case management (including high-risk the appropriate form to the local CCS program obstetrics), care coordination and any other needs according to the terms of their CCS agreement. related to women’s health. CCS is the primary payer for CCS-eligible The Pregnancy Notification Form provides diagnosis; Anthem Blue Cross does not provide important information to Anthem Blue Cross so that authorization for those conditions. we can ensure pregnant members access prenatal

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES care timely within their first trimester or within 42 representative consent if in compliance with law. days of enrollment as recommended by NCQA. Providers must be familiar with the security requirements of the Health Insurance Portability There is a revised Pregnancy Notification Form and Accountability Act of 1996 (HIPAA) and be in effective February 1, 2017, that replaces all prior compliance. versions. It can be found on the Anthem Blue Cross provider website located in the Prenatal Toolkit link In addition, providers must provide access to at the beginning of this section. medical records for the following: You should also complete the Maternity HEDIS® Form • Medical record reviews by Anthem accessible via the Availity Portal. Perform an Eligibility Blue Cross or the provider's contracted and Benefits request on an Anthem member and External Quality Review Organization choose one of the following benefit service types: (EQRO). Providers must have procedures Maternity, Obstetrical, Gynecological, Obstetrical/Gynecological. in place to provide timely access to medical records in the providers' absence. • Before you see the benefit results screen you will be asked if the member is pregnant • For public health communicable disease and given a Yes or No option. If you reporting, providers must provide all indicate “Yes” you will be asked what the medical records or information as requested estimated due date is and can fill that date and in the time frame established by state out if you have an estimate or leave it blank and federal laws. if you do not. PREVENTIVE HEALTHCARE • After you submit your answer you will be taken to the benefits page like normal. In Current educational materials and health the background a HEDIS Maternity form will management programs are located on the Quality have been generated for this patient in the Improvement Programs website below: Maternity application in the Payer Spaces  https://providers.anthem.com/california- for the Anthem Blue Cross plan. provider/resources/provider-training- academy MEDICAL RECORDS With respect to the issue of coverage, each Medical records must be maintained in a manner member should review his/her Evidence of that ensures effective and confidential member Coverage for details concerning benefits, care and quality review. At Anthem Blue Cross, we procedures and exclusions prior to receiving perform medical record reviews upon signing a treatment. provider contract and, at minimum, every three years thereafter to ensure providers are in The Evidence of Coverage supersedes the compliance with these standards. preventive health guideline recommendations. Medical records must be stored and retrieved in a Note: Our recommendation of these guidelines is manner that protects patient information according not an authorization, certification, explanation of to the Confidentiality of Medical Information Act. benefits or a contract. Actual member benefits and This act prohibits a provider of healthcare from eligibility are determined in accordance with the disclosing any individually identifiable information requirements set forth by the state of California. regarding a patient’s medical history, treatment, or With respect to the issue of coverage, each behavioral and physical condition without the member should review his/her Evidence of patient’s or legal representative’s consent or Coverage for details concerning benefits, specific legal authority. procedures and exclusions prior to receiving treatment. The Evidence of Coverage supersedes Records required through a legal instrument may the preventive health guideline recommendations. be released without patient or patient

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

PREVENTIVE HEALTHCARE GUIDELINES COMPREHENSIVE PERINATAL SERVICES The most up-to-date Preventive Healthcare PROGRAM Guidelines are located on our website at: The Comprehensive Perinatal Services Program (CPSP) is a Medi-Cal program that provides  https://providers.anthem.com/CA individualized perinatal services during pregnancy Anthem Blue Cross considers Preventive Health and 60 days following delivery by or under the Guidelines to be an important component of personal supervision of a physician approved by healthcare. Anthem Blue Cross develops CPSP. All members must be offered CPSP preventive health guidelines in accordance with services. recommendations made by nationally recognized The program emphasizes nutritional services, organizations and societies such as the American psychosocial support, health education and Academy of Family Physicians (AAFP), the postpartum treatment and intervention. American Academy of Pediatrics (AAP), the Advisory Committee on Immunizations Practices PCPs caring for pregnant women and (ACIP), the American College of Obstetrics and obstetrics/gynecology specialists are responsible Gynecology (ACOG) and the United States for assessing member needs and referring all Preventive Services Task Force (USPSTF). pregnant members to the following: The above organizations make recommendations • Community prenatal services based on reasonable medical evidence. We review • Women, Infants and Children Program the guidelines annually for content accuracy, (WIC) current primary sources, new technological Substance abuse programs advances and recent medical research and make • appropriate changes based on this review of the • Prenatal education classes recommendations and/or preventive health Women should be referred to a CPSP provider by mandates. We encourage physicians to utilize calling the appropriate Customer Care Center at these guidelines to improve the health of our the numbers listed at the beginning of this chapter. members. IMMUNIZATION PROGRAM CLINICAL PRACTICE GUIDELINES The Immunization Program was designed to Several national organizations produce guidelines increase both childhood immunization rates and the for asthma, diabetes, hypertension and other number of members who are fully immunized. conditions. The guidelines, which Anthem Blue Cross uses for quality and disease ACIP has recommended immunizations for all management programs, are based on reasonable children as well as adult members. medical evidence. We review the guidelines at All members should be notified by the PCP of the least every two years or when changes are made use of the California Immunization Registry (CAIR) to national guidelines for content accuracy, current to monitor immunizations administered to all primary sources, new technological advances and members. This program allows members to receive recent medical research. the appropriate immunization based on age at the Clinical Practice Guidelines can be downloaded at: appropriate timeframe.  https://www.anthem.com/ca/provider/ Providers should be working with the CAIR policies/clinical-guidelines program so all immunization information is obtained by CAIR whether by inputting data, upload or  You can also call Provider Services at transfer of information. 1-866-231-0847 to receive a copy.

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

When immunizations are given, the PCP must also infant feeding. Providers should encourage distribute the Vaccine Information Statement (VIS) breastfeeding for all pregnant women unless it is that educates on the vaccines administered. not medically appropriate.

ALL PEDIATRIC PROVIDERS MUST To support this goal, providers should do the PARTICIPATE IN THE VACCINES FOR following: CHILDREN (VFC) PROGRAM. WELL • Refer pregnant and postpartum women to WOMAN our Breastfeeding Support Line at The Well Woman Program was developed to 1-800-231-2999 for information, support remind and encourage women to have regular and referrals. cervical and breast cancer screenings. The Well • Refer pregnant women to community Woman Reminder Program sends a screening test resources that support breastfeeding such reminder mailer to women who are not up-to-date as La Leche League, WIC and with their recommended cervical and/or breast breastfeeding classes. cancer screenings. • Assess all pregnant women for health risks Providers are encouraged to refer members for that are contraindications to breastfeeding screenings and/or schedule the exams. PCP (for example, AIDS and active tuberculosis). responsibilities for the care of female members Provide breastfeeding counseling and include: • support to postpartum women immediately • Educating members on Preventive after delivery. Healthcare Guidelines for women • Assess postpartum women to determine the • Referring members for cervical and breast need for lactation durable medical cancer screenings equipment (DME) such as breast pumps • Scheduling screening exams for members and breast pump kits. • Document all referrals and treatments CHILDHOOD LEAD EXPOSURE related to breastfeeding in the patient’s TESTING/FREE BLOOD TEST KITS medical record (pediatricians should CMS requires that all children enrolled in Medicaid document frequency and duration of be tested for lead exposure at 1 and 2 years of breastfeeding in baby’s medical record). age. Children from 3 to 6 years of age who have • Refer members to breastfeeding classes not been tested also need screening regardless of prior to delivery by calling our Customer their risk factors. Care Center. PCP doing Point-of-Care testing must also notify • Support continued breastfeeding at the the California Department of Public Health (CDPH) postpartum visit. of the results of the test. If testing is in a laboratory, they also must report 100% of all results. Lactation management aids are a covered benefit for Medi-Cal members. Members can obtain Note: Completion of a lead risk assessment hand-held breast pumps through a prescription questionnaire does not fulfill this screening without prior authorization. In addition, the following requirement; a blood draw is also required. services are available: BREASTFEEDING • Electric breast pumps are available for The American Academy of Pediatrics, the members with medical necessity with a American College of Obstetrics and Gynecology, provider referral and prior authorization. and the American Public Health Association Contact Utilization Management for more recognize breastfeeding as the preferred method of information.

8 | PROVIDER PROCEDURES AND RESPONSIBILITIES

• Arrangement for the provision of human milk for newborns must be made if the mother is unable to breastfeed due to medical reasons and/or the infant cannot tolerate or has medical contraindications to the use of any formula including elemental formulas. The Mother’s Milk Bank of Santa Clara Valley Medical Center is the only human milk bank in the state of California. They can be contacted at:  1-408-998-4550

9 | ADMINISTRATIVE PROCEDURES

9 | ADM I NI STRATIVE P R OC E DU R E S Anthem Blue Cross lines of business and may PROVIDER TERMINATION, prevent the provider from participating with Anthem LOCATION, COVERED SERVICES Blue Cross in the future AND OR POPULATION SERVED It is imperative that these minimum timelines be CHANGES met to ensure members, the California Department of Managed Health Care, the California Department • If a provider who is part of a participating of Health Care Services and the health plan are medical group (PMG) and/or an notified as required, ensuring systems are updated independent practice association (IPA) in a timely manner. Future instances of untimely decides to terminate from the Anthem Blue notification will result in issuance of a corrective Cross network, changes location or action plan, including but not limited to financial changes their population served the sanctions and/or a breach of contract notice. following guidelines must be followed:

◦ The provider should notify all CONTRACT TERMINATION WITH affiliated PMGs/IPAs within a HEALTH PLAN minimum of 120 calendar days to ensure member notifications can be When a participating provider notifies Anthem sent timely. Blue Cross that the provider is terminating the contract with the network, we notify all members The PMGs/IPAs should notify ◦ that the provider will no longer be available. A Anthem Blue Cross. The provider's terminating provider who is actively treating termination and/or changes will members must continue to treat members until the become effective no less than 90 provider’s date of termination. calendar days after we receive notification. Impacted members are notified about the termination and provided the following information: ◦ The provider's decision to terminate from Anthem Blue Cross could • The impending termination date of their impact participation in other Anthem provider Blue Cross lines of business and • Their right to request continued access to may prevent the provider from care participating with us in the future. • Contact information to request a PCP • If a provider who is part of the Anthem Blue change Cross network terminates his/her contract, The DHCS Ombudsman phone number changes location, and or changes the • population they serve, the following • Referrals to Utilization Management for guidelines must be followed: continued access to care consideration ◦ The provider should notify Anthem • The opportunity to choose a new PCP or be Blue Cross within a minimum of 120 assigned to a new PCP with the option to calendar days to ensure timely change if the member does not choose a member notifications can be sent. PCP ◦ The provider's termination and/or • All other notification language required by changes will become effective no the H&S Code and the DHCS All Plan less than 120 calendar days after we Letter, Medi-Cal provider and subcontract receive notification. suspensions, terminations and The provider's decision to terminate from Anthem decertifications Blue Cross could impact participation in other

9 | ADMINISTRATIVE PROCEDURES

Members under the care of specialists can also For example: If the only pediatrician affiliated with submit requests for continued access to care the PMG terminates his employment or his including continued care after the transition period employment is terminated, Anthem Blue Cross will by calling the appropriate Medi-Cal Customer Care move members to an alternate PMG affiliation to Center below: ensure the affected members have access to appropriate pediatric care. If the PCP changes  1-800-407-4627 or 1-888-757-6034 (TTY) PMG affiliation and relocates his practice further Outside L.A. County than 10 miles, Anthem Blue Cross also has the  1-888-285-7801 or 1-888-757-6034 (TTY) right to select a new PCP for the affected Inside L.A. County membership. Network education representatives (NERs) are the TERMINATION OR AFFILIATION primary account managers for all provider services CHANGE WITH PROVIDER associated with an assigned PMG. The NERs also GROUPS serve as liaisons between Anthem and the provider Anthem Blue Cross PCPs may have multiple network for many providers who exist outside of the provider medical group (PMG) affiliations. To PMG including hospital, ancillary and individual ensure continuity of care, membership will remain providers. with an assigned PCP unless the PCP does not The NER is responsible for coordinating all have another Anthem Blue Cross PMG affiliation. additions, changes and terminations from the PCP A PCP can change PMG affiliations. Assigned and PMG. members will transfer to follow the PCP under the new affiliation. The following exceptions to this PROVIDER TERMINATIONS FROM GROUPS policy shall occur: When a provider who is part of a PMG and/or an independent practice association (IPA) decides to • If the PCP is an employee of the PMG terminate from the Anthem Blue Cross network, the (except Los Angeles), member affiliation will remain with the PMG. Members may elect following guidelines must be followed: to change this PMG affiliation to the PCP's • The provider should notify all affiliated new affiliation in order to facilitate continued PMGs/IPAs within a minimum of 120 days care under the established PCP. to ensure member notifications can be sent timely. ◦ If the PCP has an active PMG affiliation with Care 1st or LA Care • The PMGs/IPAs should notify Anthem outside of Anthem Blue Cross, Blue Cross. The provider's termination will members will be transitioned to the become effective 120 days after we receive active health plan. notification. • If a member is assigned to a safety net • The provider's decision to terminate from clinic, the member’s affiliation remains with Anthem Blue Cross could impact the clinic should a PCP terminate its participation in other Anthem Blue Cross affiliation. lines of business and may prevent the provider from participating with us in the CONTINUITY OF CARE PROVISION FOR A future. PMG-EMPLOYED PHYSICIAN Note: If we determine that the quality of care or If the PMG does not have the appropriate PCP services provided by a healthcare professional is specialty to serve members that were assigned to a not satisfactory as evidenced by member departing employed physician, Anthem Blue Cross satisfaction surveys, member complaints or has the right to move the affected member to the grievances, utilization management data, PCP's new PMG affiliation or an appropriate PMG.

9 | ADMINISTRATIVE PROCEDURES complaints or lawsuits alleging professional Failure to respond within the designated time frame negligence, or any other quality of care indicators, indicated on the outreach form will result in Anthem Blue Cross may terminate the Provider suppression from the provider directory. Agreement. Submissions provided voluntarily unrelated to the SB137 outreach do not satisfy this requirement. UPDATING PROVIDER There must be a response to the SB137 outreach DIRECTORIES form. Anthem providers are required to inform us of any material changes to their practice, either through UPDATING PROVIDER voluntarily effort or through mandatory response to INFORMATION Anthem Blue Cross provider outreach efforts in For voluntary updates separate from the SB137 compliance with Senate Bill 137 (SB137) including: outreach, use the new online Provider Maintenance • Change in professional business ownership Form (PMF) to notify Anthem Blue Cross of changes. The form is available in the Forms library • Change in business address or the location Provider Resources where services are provided on the page of our website at: • Change in federal 9-digit Tax Identification  https://providers.anthem.com/CA Number (TIN) For directions on how to access Availity, please • Change in specialty see Chapter 2 of this manual. • The age range of patients serviced by the provider • Languages spoken by both provider and mid-level staff • Change in demographic data (for example: phone numbers, fax numbers, email address, handicap or ADA accessibility and office hours) • Hospital admitting privileges • Legal or governmental action initiated against a healthcare professional including but not limited to: an action for professional negligence, for violation of the law, or against any license or accreditation which, if successful, would impair the ability of the healthcare professional to carry out the duties and obligations under the Provider Agreement • Other problems or situations that impair the ability of the healthcare professional to carry out the duties and obligations under the Provider Agreement care review and grievance resolution procedures • Notification that the provider is accepting new patients

10 | CREDENTIALING AND RECREDENTIALING

10 | CREDENTI ALING A ND RE C RE DE NTI AL ING CREDENTIALING SCOPE • Nurse practitioners who are licensed, certified or registered by the state to Anthem Blue Cross credentials the following practice independently healthcare practitioners: • Certified nurse midwives who are licensed, Medical doctors • certified or registered by the state to • Doctors of osteopathic medicine practice independently • Doctors of podiatry • Physician assistants (as required locally) • Chiropractors Anthem Blue Cross also certifies the following • Optometrists providing health services behavioral health practitioners (including verification of licensure by the applicable state covered under the health benefits plan licensing board to independently provide behavioral • Doctors of dentistry providing health health services): services covered under the health benefits Certified behavioral analysts plan including oral maxillofacial surgeons • • Psychologists who are state certified or • Certified addiction counselors licensed and have doctoral or master’s level • Substance abuse practitioners training Anthem Blue Cross credentials the following health • Clinical social workers who are state delivery organizations (HDOs): certified or state licensed and have master’s • Hospitals level training • Home health agencies • Psychiatric nurse practitioners who are nationally or state certified or state licensed • Skilled nursing facilities or behavioral nurse specialists with master’s • Nursing homes level training • Free-standing surgical centers • Other behavioral healthcare specialists who are licensed, certified or registered by the • Clinical laboratories state to practice independently • Birthing centers • Telemedicine practitioners who have an • Convenient care centers/retail health clinics independent relationship with Anthem Intermediate care facilities Blue Cross and who provide treatment • services under the health benefits plan • Urgent care centers • Medical therapists (for example, physical • Federally qualified health centers (FQHC) therapists, speech therapists and • Home infusion therapy agencies occupational therapists) • Rural health clinics • Licensed genetic counselors who are licensed by the state to practice • Behavioral health facilities providing mental independently health and/or substance abuse treatment in an inpatient, residential or ambulatory Audiologists who are licensed by the state • setting including: to practice independently ◦ Adult family care/foster care homes • Acupuncturists (non-medical doctors or doctors of osteopathic medicine) who are ◦ Ambulatory detox licensed, certified or registered by the state ◦ Community mental health centers to practice independently (CMHC)

10 | CREDENTIALING AND RECREDENTIALING

◦ Crisis stabilization units Anthem Blue Cross will verify those elements related to an applicants’ legal authority to practice, ◦ Intensive family intervention services relevant training, experience and competency from ◦ Intensive outpatient — mental health the primary source, where applicable, during the and/or substance abuse credentialing process. ◦ Methadone maintenance clinics All verifications must be current and verified within ◦ Outpatient mental health clinics the 180 calendar day period prior to the Credentials Committee (CC) making its credentialing Outpatient substance abuse clinics ◦ recommendation or as otherwise required by ◦ Partial hospitalization — mental applicable accreditation standards. health and/or substance abuse During the credentialing process, Anthem ◦ Residential treatment centers (RTC) Blue Cross will review verification of the — psychiatric and/or substance credentialing data as described in the following abuse tables unless otherwise required by regulatory or accrediting bodies. These tables represent The following HDOs are not subject to professional minimum requirements. conduct and competence review under the Anthem Blue Cross credentialing program but are subject to a certification requirement process: • Clinical laboratories (a CMS-issued CLIA certificate or a hospital-based exemption from CLIA) • End-stage renal disease (ESRD) service providers (dialysis facilities) • Portable X-ray suppliers INITIAL CREDENTIALING Each practitioner or HDO must complete a standard application form when applying for initial participation in one or more of The Anthem Blue Cross networks or plan programs. This application may be a state-mandated form or a standard form created by or deemed acceptable by Anthem Blue Cross. For practitioners, the Council for Affordable Quality Healthcare (CAQH), a universal credentialing datasource, is utilized. CAQH built the first national provider credentialing database system which is designed to eliminate the duplicate collection and updating of provider information for health plans, hospitals and practitioners.  To learn more about CAQH, visit their website at www.CAQH.org.

10 | CREDENTIALING AND RECREDENTIALING

Practitioners License to practice in the state(s) in which the practitioner will be treating covered individuals Hospital admitting privileges at a TJC-, NIAHO- or AOA-accredited hospital, or a network hospital previously approved by the committee DEA/CDS and state controlled substance registrations • The DEA/CDS registration must be valid in the state(s) in which the practitioner will be treating covered individuals. Practitioners who see covered individuals in more than one state must have a DEA/CDS registration for each state. Malpractice insurance Malpractice claims history Board certification or highest level of medical training or education Work history State or federal license sanctions or limitations Medicare, Medicaid or FEHBP sanctions National Practitioner Data Bank report State Medicaid Exclusion Listing if applicable

HDOs Accreditation if applicable License to practice if applicable Malpractice insurance Medicare certification if applicable Department of Health survey results or recognized accrediting organization certification License sanctions or limitations if applicable Medicare, Medicaid or FEHBP sanctions

RECREDENTIALING All applicable practitioners and HDOs in the network within the scope of Anthem Blue Cross The recredentialing process incorporates Credentialing Program are required to be re-verification and the identification of changes in the practitioner’s or HDO’s licensure, sanctions, recredentialed every three years unless otherwise certification, health status and/or performance required by contract or state regulations. information (including but not limited to malpractice experience, hospital privilege or other actions) that HEALTH DELIVERY may reflect on the practitioner’s or HDO’s ORGANIZATIONS professional conduct and competence. This New HDO applicants will submit a standardized information is reviewed in order to assess whether application to Anthem Blue Cross for review. If the practitioners and HDOs continue to meet Anthem candidate meets Anthem Blue Cross screening Blue Cross credentialing standards. criteria, the credentialing process will commence. During the recredentialing process, Anthem To assess whether network HDOs, within the Blue Cross will review verification of the scope of the Credentialing Program, meet credentialing data as described in the tables under appropriate standards of professional conduct and Initial Credentialing unless otherwise required by competence, they are subject to credentialing and regulatory or accrediting bodies. These tables recredentialing programs. represent minimum requirements.

10 | CREDENTIALING AND RECREDENTIALING

In addition to the licensure and other eligibility General Criteria for HDOs: criteria for HDOs as described in detail in Anthem 1. Valid, current and unrestricted license to Blue Cross Credentialing Program Standards, all operate in the state(s) in which it will network HDOs are required to maintain provide services to covered individuals. The accreditation by an appropriate, recognized license must be in good standing with no accrediting body or, in the absence of such sanctions. accreditation, Anthem Blue Cross may evaluate the most recent site survey by Medicare, the 2. Valid and current Medicare certification. appropriate state oversight agency, or a site survey 3. Must not be currently federally sanctioned, performed by a designated independent external debarred or excluded from participation in entity within the past 36 months for that HDO. any of the following programs: Medicare, Recredentialing of HDOs occurs every three years Medicaid or the FEHBP. unless otherwise required by regulatory or Note: If, once an HDO participates in The accrediting bodies. Each HDO applying for Anthem Blue Cross programs or provider continuing participation in networks or plan network(s), exclusion from Medicare, programs must submit all required supporting Medicaid or FEHBP occurs, at the time of documentation. identification, the HDO will become immediately ineligible for participation in the On request, HDOs will be provided with the status applicable government programs or of their credentialing application. Anthem provider network(s) as well as The Anthem Blue Cross may request and will accept additional Blue Cross other credentialed provider information from the HDO to correct incomplete, network(s). inaccurate or conflicting credentialing information. The CC will review this information and the 4. Liability insurance acceptable to Anthem rationale behind it as presented by the HDO and Blue Cross. determine if a material omission has occurred or if 5. If not appropriately accredited, HDO must other credentialing criteria are met. submit a copy of its CMS, state site or a designated independent external entity HDO ELIGIBILITY CRITERIA survey for review by the CC to determine if All HDOs must be accredited by an appropriate, The Anthem Blue Cross quality and recognized accrediting body or in the absence of certification criteria standards have been such accreditation, Anthem Blue Cross may met. evaluate the most recent site survey by Medicare, the appropriate state oversight agency, or site survey performed by a designated independent external entity within the past 36 months. Nonaccredited HDOs are subject to individual review by the CC and will be considered for covered individual access need only when the CC review indicates compliance with Anthem Blue Cross standards and there are no deficiencies noted on the Medicare or state oversight review which would adversely affect quality or care or patient safety. HDOs are recredentialed at least every three years to assess the HDO’s continued compliance with Anthem Blue Cross standards.

10 | CREDENTIALING AND RECREDENTIALING

ADDITIONAL PARTICIPATION CRITERIA FOR HDO BY PROVIDER TYPE

Facility Type — Medical Care Acceptable Accrediting Agencies Acute care hospital CIQH, CTEAM, HFAP, DNV/NIAHO, TJC Ambulatory surgical centers AAAASF, AAAHC, AAPSF, HFAP, IMQ, TJC Birthing center AAAHC, CABC Clinical laboratories COLA, CLIA - https://www.cms.gov/Regulations-and- Guidance/Legislation/CLIA/Downloads/AOList.pdf

Convenient care centers (CCCs)/retail DNV/NIAHO, UCAOA health clinics (RHC) Dialysis center TJC, CMS Federally qualified health center (FQHC) AAAHC Free-standing surgical centers AAAASF, AAPSF, HFAP, IMQ, TJC Home health care agencies (HHA) ACHC, CHAP, CTEAM , DNV/NIAHO, TJC Home infusion therapy (HIT) ACHC, CHAP, CTEAM, HQAA, TJC Hospice ACHC, CHAP, TJC Intermediate care facilities CTEAM Portable X-ray suppliers FDA certification Skilled nursing facilities/nursing homes BOC INT'L, CARF, TJC Rural health clinic (RHC) AAAASF, CTEAM, TJC Urgent care center (UCC) AAAHC, IMQ, TJC, UCAOA, NUCCA

Facility Type — Behavioral Healthcare Acceptable Accrediting Agencies Acute care hospital — psychiatric disorders CTEAM, DNV/NIAHO, TJC, HFAP Acute inpatient hospital — chemical HFAP, NIAHO, TJC dependency/detoxification and rehabilitation Adult family care homes (AFCH) ACHC, TJC Adult foster care ACHC, TJC Community mental health centers (CMHC) AAAHC, TJC Crisis stabilization unit TJC Intensive family intervention services CARF Intensive outpatient — mental health and/or ACHC, DNV/NIAHO, TJC, COA, CARF substance abuse Outpatient mental health clinic HFAP, TJC, CARF, COA Partial hospitalization/day treatment — CARF, DNV/NIAHO, HFAP, TJC, for programs psychiatric disorders and/or substance abuse associated with an acute care facility or residential treatment facilities Residential treatment centers (RTC) — DNV/NIAHO, TJC, HFAP, CARF, COA psychiatric disorders and/or substance abuse

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Facility Type — Rehabilitation Acceptable Accrediting Agencies Acute inpatient hospital — detoxification only DNV/NIAHO, HFAP, TJC facilities Behavioral health ambulatory detox CARF, TJC Methadone maintenance clinic CARF, TJC Outpatient substance abuse clinics CARF, COA, TJC

CREDENTIALING PROGRAM Physicians and Surgeons of Canada STANDARDS [RCPSC], College of Family Physicians of Canada [CFPC], American Board of ELIGIBILITY CRITERIA Podiatric Surgery [ABPS], American Board of Podiatric Medicine [ABPM], or American Initial applicants must meet the following criteria in Board of Oral and Maxillofacial Surgery order to be considered for participation: [ABOMS]) in the clinical discipline for which 1. Must not be currently federally sanctioned, they are applying. debarred or excluded from participation in Individuals will be granted five years or a any of the following programs: Medicare, 2. period of time consistent with ABMS board Medicaid or FEHBP eligibility time limits, whatever is greater, 2. Possess a current, valid, unencumbered, after completion of their residency or unrestricted and nonprobationary license in fellowship training program to meet the the state(s) where he/she provides services board certification requirement. to covered individuals 3. Individuals with board certification from the 3. Possess a current, valid and unrestricted American Board of Podiatric Medicine will Drug Enforcement Agency (DEA) and/or be granted five years after the completion of Controlled Dangerous Substances (CDS) their residency to meet this requirement. registration for prescribing controlled Individuals with board certification from the substances if applicable to his/her specialty American Board of Foot and Ankle Surgery in which he/she will treat covered will be granted seven years after completion individuals; the DEA/CDS registration must of their residency to meet this requirement. be valid in the state(s) in which the However, individuals no longer eligible for practitioner will be treating covered 4. board certification are not eligible for individuals; practitioners who see covered continued exception to this requirement. individuals in more than one state must have a DEA/CDS registration for each state As alternatives, MDs and DOs meeting any one of Initial applications should meet the following the following criteria will be viewed as meeting the education, training and certification requirement: criteria in order to be considered for participation with exceptions reviewed and approved by the CC: 1. Previous board certification (as defined by one of the following: ABMS, AOA, RCPSC, 1. For MDs, DOs, DPMs, and oral and CFPC) in the clinical specialty or maxillofacial surgeons, the applicant must subspecialty for which they are applying have current, in force board certification (as defined by the American Board of Medical Specialties [ABMS], American Osteopathic Association [AOA], Royal College of

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which has now expired and a minimum of referral arrangement with a network practitioner to 10 consecutive years of clinical practice provide inpatient care.

2. Training which met the requirements in CRITERIA FOR SELECTING place at the time it was completed in a PRACTITIONERS) specialty field prior to the availability of board certifications in that clinical specialty 1. Submission of a complete application and or subspecialty required attachments that must not contain intentional misrepresentations 3. Specialized practice expertise as evidenced by publication in nationally accepted peer 2. Application attestation signed date within review literature and/or recognized as a 180 calendar days of the date of submission leader in the science of their specialty and a to the CC for a vote faculty appointment of assistant professor 3. Primary source verifications within or higher at an academic medical center acceptable time frames of the date of and teaching facility in The Anthem Blue submission to the CC for a vote as deemed Cross network and the applicant’s by appropriate accrediting agencies professional activities are spent at that 4. No evidence of potential material institution at least 50% of the time. omission(s) on application Practitioners meeting one of these three above 5. Current, valid, unrestricted license to alternative criteria will be viewed as meeting all practice in each state in which the Anthem Blue Cross education, training and practitioner would provide care to covered certification criteria and will not be required to individuals undergo additional review or individual presentation to the CC. These alternatives are subject to 6. No current license action Anthem Blue Cross review and approval. Reports 7. No history of licensing board action in any submitted by delegate to Anthem Blue Cross must state contain sufficient documentation to support the above alternatives, as determined by Anthem 8. No current federal sanction and no history Blue Cross. of federal sanctions (per System for Award Management (SAM), OIG and OPM report For MDs and DOs, the applicant must have nor on NPDB report) unrestricted hospital privileges at a The Joint Commission (TJC), National Integrated 9. Possess a current, valid and unrestricted Accreditation for Healthcare Organizations DEA/CDS registration for prescribing (NIAHO), an AOA accredited hospital, or a network controlled substances if applicable to hospital previously approved by the committee. his/her specialty in which he/she will treat Some clinical disciplines may function exclusively covered individuals. The DEA/CDS in the outpatient setting, and the CC may at its registration must be valid in the state(s) in discretion deem hospital privileges not relevant to which the practitioner will be treating these specialties. Also, the organization of an covered individuals. Practitioners who treat increasing number of physician practice settings in covered individuals in more than one state selected fields is such that individual physicians must have a valid DEA/CDS registration for may practice solely in either an outpatient or an each applicable state. inpatient setting. The CC will evaluate applications from practitioners in such practices without regard DEA/CDS to hospital privileges. The expectation of these Initial applicants who have no DEA/CDS physicians would be that there is an appropriate registration will be viewed as not meeting criteria and the credentialing process will not proceed.

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However, if the applicant can provide evidence that failure to provide the appropriate DEA/CDS he/she has applied for a DEA/CDS registration, the registration within a 90 calendar day time credentialing process may proceed if all of the frame will result in termination from the following are met: network. 1. It can be verified that this application is 5. Must not be currently federally sanctioned, pending. debarred or excluded from participation in any of the following programs: Medicare, 2. The applicant has made an arrangement for Medicaid or FEHBP. an alternative practitioner to prescribe controlled substances until the additional 6. No current hospital membership or privilege DEA/CDS registration is obtained. restrictions and no history of hospital membership or privilege restrictions. 3. The applicant agrees to notify Anthem Blue Cross upon receipt of the required 7. No history of or current use of illegal drugs DEA/CDS registration. or history of or current alcoholism. 4. Anthem Blue Cross will verify the 8. No impairment or other condition which appropriate DEA/CDS registration via would negatively impact the ability to standard sources. perform the essential functions in their professional field. • The applicant agrees that failure to provide the appropriate DEA/CDS 9. No gap in work history greater than six registration within a 90 calendar day months in the past five years with the time frame will result in termination exception of those gaps related to parental from the network. leave or immigration where 12 month gaps will be acceptable. Other gaps in work DEA/CDS — OUT OF STATE history of 6 to 24 months will be reviewed Initial applicants who possess a DEA/CDS by the Chair of the CC and may be registration in a state other than the state in which presented to the CC if the gap raises they will be treating covered individuals will be concerns of future substandard professional notified of the need to obtain the additional conduct and competence. In the absence of DEA/CDS registration. this concern the Chair of the CC may approve work history gaps of up to two If the applicant has applied for additional DEA/CDS years. registration, the credentialing process may proceed if all of the following criteria are met: 10. No history of criminal/felony convictions or a plea of no contest. 1. It can be verified that this application is pending. 11. A minimum of the past 10 years of malpractice case history is reviewed. 2. The applicant has made an arrangement for an alternative practitioner to prescribe 12. Meets Credentialing Standards for controlled substances until the additional education/training for the specialty(ies) in DEA/CDS registration is obtained. which practitioner wants to be listed in The Anthem Blue Cross network directory as 3. The applicant agrees to notify Anthem designated on the application. This includes Blue Cross upon receipt of the required board certification requirements or DEA/CDS registration. alternative criteria for MDs and DOs and 4. Note: Anthem Blue Cross will verify the board certification criteria for DPMs, and appropriate DEA/CDS registration via oral and maxillofacial surgeons. standard sources; applicant agrees that

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13. No involuntary terminations from an HMO or department may be approved by the Chair of the PPO. CC after review of the applicable credentialing or recredentialing information. This information may 14. No "yes" answers to attestation/disclosure be in summary form and must include, at a questions on the application form with the minimum, practitioner’s name and specialty. exception of the following: 1. Submission of complete recredentialing • Investment or business interest in application and required attachments that ancillary services, equipment or must not contain intentional supplies misrepresentations • Voluntary resignation from a hospital 2. Recredentialing application signed date or organization related to practice relocation or facility utilization within 180 calendar days of the date of submission to the CC for a vote • Voluntary surrender of state license 3. Primary source verifications within related to relocation or nonuse of acceptable time frames of the date of said license submission to the CC for a vote as deemed • An NPDB report of a malpractice by appropriate accrediting agencies settlement or any report of a No evidence of potential material malpractice settlement that does not 4. omission(s) on recredentialing application meet the threshold criteria Currently participating providers must not • Non-renewal of malpractice 5. coverage or change in malpractice be currently federally sanctioned, debarred or excluded from participation in any of the carrier related to changes in the following programs, Medicare, Medicaid or carrier’s business practices (no FEHBP; if, once a practitioner participates longer offering coverage in a state or in the Anthem Blue Cross programs or no longer in business) provider network(s), federal sanction, • Previous failure of a certification debarment or exclusion from the Medicare, exam by a practitioner who is Medicaid or FEHBP programs occurs, at the currently board certified or who time of identification, the practitioner will remains in the five-year post become immediately ineligible for residency training window participation in the applicable government • Actions taken by a hospital against a programs or provider network(s) as well as practitioner’s privileges related solely The Anthem Blue Cross other credentialed to the failure to complete medical provider network(s); special consideration records in a timely fashion regarding the practitioner’s continued participation in The Anthem Blue Cross History of a licensing board, hospital • other credentialed practitioner network(s) or other professional entity may be requested by the Vice President investigation that was closed without (VP) responsible for that network(s) if, in the any action or sanction opinion of the requesting VP, the following Note: The CC will individually review any criteria are met: the federal sanction, practitioner that does not meet one or more of the debarment or exclusion is not reflective of criteria required for initial applicants. Practitioners significant issues of professional conduct who meet all participation criteria for initial or and competence, and participation of the continued participation and whose credentials have practitioner is important for network been satisfactorily verified by the Credentialing adequacy; the request with supporting

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information will be brought to The Anthem perform the essential functions in their Blue Cross geographic Credentials professional field Committee for consideration and final 15. No new (since previous credentialing determination, without practitioner appeal review) history of criminal/felony convictions rights related to the special consideration, including a plea of no contest regarding the practitioner’s continued participation in The Anthem Blue Cross 16. Malpractice case history reviewed since the other credentialed provider network(s), if last CC review; if no new cases are such participation would be permitted under identified since last review, malpractice applicable state regulation, rule or contract history will be reviewed as meeting criteria; requirements if new malpractice history is present, then a minimum of last five years of malpractice 6. Current, valid, unrestricted license to history is evaluated and criteria consistent practice in each state in which the with initial credentialing is used practitioner provides care to covered individuals 17. No new (since previous credentialing review) involuntary terminations from an 7. *No current license probation HMO or PPO 8. *License is unencumbered 18. No new (since previous credentialing 9. No new history of licensing board reprimand review) "yes" answers on since prior credentialing review attestation/disclosure questions with exceptions of the following: 10. *No current federal sanction and no new (since prior credentialing review) history of • Investment or business interest in federal sanctions (per SAM, OIG and OPM ancillary services, equipment or reports or on NPDB report) supplies 11. Current DEA/CDS registration and/or state • Voluntary resignation from a hospital controlled substance certification without or organization related to practice new (since prior credentialing review) relocation or facility utilization history of or current restrictions • Voluntary surrender of state license 12. No current hospital membership or privilege related to relocation or nonuse of restrictions and no new (since prior said license credentialing review) history of hospital • An NPDB report of a malpractice membership or privilege restrictions; or for settlement or any report of a practitioners in a specialty defined as malpractice settlement that does not requiring hospital privileges who practice meet the threshold criteria solely in the outpatient setting, there exists a defined referral relationship with a • Nonrenewal of malpractice coverage network practitioner of similar specialty at a or change in malpractice carrier network HDO who provides inpatient care to related to changes in the carrier’s covered individuals needing hospitalization business practices (no longer offering coverage in a state or no No new (since previous credentialing 13. longer in business) review) history of or current use of illegal drugs or alcoholism • Previous failure of a certification exam by a practitioner who is No impairment or other condition which 14. currently board certified or who would negatively impact the ability to

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remains in the five year post • Program must have been accredited within residency training window three years of the time the practitioner graduated • Actions taken by a hospital against a practitioner’s privileges related • Full accreditation is required; candidacy solely to the failure to complete programs will not be considered if master’s medical records in a timely fashion level degree does not meet criteria and practitioner obtained PhD training as a • History of a licensing board, hospital clinical psychologist but is not licensed as or other professional entity such, the practitioner can be reviewed. To investigation that was closed without meet the criteria, the doctoral program must any action or sanction be accredited by the American 19. No QI data or other performance data Psychological Association (APA) or be including complaints above the set regionally accredited by the Council for threshold Higher Education Accreditation (CHEA). In 20. Recredentialed at least every three years to addition, a doctor of social work from an assess the practitioner’s continued institution with at least regional accreditation compliance with Anthem Blue Cross from the CHEA will be viewed as standards acceptable. * It is expected that these findings will be LICENSED PROFESSIONAL COUNSELOR discovered for currently credentialed network (LPC) AND MARRIAGE AND FAMILY practitioners and HDOs through ongoing sanction THERAPIST (MFT) OR OTHER MASTER monitoring. Network practitioners and HDOs with LEVEL LICENSE TYPE: such findings will be individually reviewed and • Master’s or doctoral degree in counseling, considered by the CC at the time the findings are marital and family therapy, psychology, identified. counseling psychology, counseling with an Note: The CC will individually review any emphasis in marriage, family and child credentialed Network practitioners and HDOs that counseling or an allied mental field; master do not meet one or more of the criteria for or doctoral degrees in education are recredentialing. acceptable with one of the fields of study above PARTICIPATION CRITERIA FOR • Master or doctoral degrees in divinity do not BEHAVIORAL HEALTH meet criteria as a related field of study PRACTITIONERS • Graduate school must be accredited by one LICENSED CLINICAL SOCIAL WORKERS of the Regional Institutional Accrediting (LCSW) OR OTHER MASTER LEVEL Bodies and may be verified from the SOCIAL WORK LICENSE TYPE: Accredited Institutions of Post-Secondary Education, APA, Council for Accreditation of • Master or doctoral degree in social work Counseling and Related Educational with emphasis in clinical social work from a Programs (CACREP), or Commission on program accredited by the Council on Accreditation for Marriage and Family Social Work Education (CSWE) or the Therapy Education (COAMFTE) listings; the Canadian Association on Social Work institution must have been accredited within Education (CASWE) three years of the time the practitioner graduated

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• Practitioners with PhD training as a clinical CLINICAL PSYCHOLOGISTS: psychologist can be reviewed; to meet • Valid state clinical psychologist license criteria this doctoral program must either be accredited by the APA or be regionally • Doctoral degree in clinical or counseling, accredited by the CHEA; a practitioner with psychology or other applicable field of study a doctoral degree in one of the fields of from an institution accredited by the APA study noted will be viewed as acceptable if within three years of the time of the the institution granting the degree has practitioner’s graduation regional accreditation from the CHEA • Education/training considered as eligible for an exception is a practitioner whose CLINICAL NURSE doctoral degree is not from an APA SPECIALIST/PSYCHIATRIC AND MENTAL accredited institution, but who is listed in the HEALTH NURSE PRACTITIONER: National Register of Health Service • Master’s degree in nursing with Providers in Psychology or is a Diplomat of specialization in adult or child/adolescent the American Board of Professional psychiatric and mental health nursing; Psychology graduate school must be accredited from an Master’s level therapists in good standing in institution accredited by one of the Regional • the network who upgrade their license to Institutional Accrediting Bodies within three clinical psychologist as a result of further years of the time of the practitioner’s training will be allowed to continue in the graduation network and will not be subject to the above • Registered nurse license and any additional education criteria licensure as an advanced practice nurse/certified nurse specialist/adult CLINICAL NEUROPSYCHOLOGIST: psychiatric nursing or other license or • Must meet all the criteria for a clinical certification as dictated by the appropriate psychologist listed above and be board state(s) board of registered nursing if certified by either the American Board of applicable Professional Neuropsychology (ABPN) or • Certification by the American Nurses American Board of Clinical Association (ANA) in psychiatric nursing; Neuropsychology (ABCN). this may be any of the following types: • A practitioner credentialed by the National clinical nurse specialist in child or adult Register of Health Service Providers in psychiatric nursing, psychiatric and mental Psychology with an area of expertise in health nurse practitioner, or family neuropsychology may be considered. psychiatric and mental health nurse practitioner • Clinical neuropsychologists who are not board certified nor listed in the National • Valid, current, unrestricted DEA/CDS Register will require CC review. These registration where applicable with practitioners must have appropriate training appropriate supervision/consultation by a and/or experience in neuropsychology as network practitioner as applicable by the evidenced by one or more of the following: state licensing board; for those who possess a DEA registration, the appropriate ◦ Transcript of applicable pre-doctoral CDS registration is required; the DEA/CDS training registration must be valid in the state(s) in which the practitioner will be treating covered individuals

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◦ Documentation of applicable formal Note: A program located outside the United States one year post-doctoral training and its territories may be used to satisfy the (participation in CEU training alone psychoanalytic study requirement if the licensing would not be considered adequate) state determines the following: it prepares individuals for the professional practice of ◦ Letters from supervisors in clinical psychoanalysis; and is recognized by the neuropsychology (including number appropriate civil authorities of that jurisdiction; and of hours per week) can be appropriately verified; and is determined by ◦ Minimum of five years’ experience the licensing state to be the substantial equivalent practicing neuropsychology at least of an acceptable registered licensure qualifying or 10 hours per week accredited program. LICENSED PSYCHOANALYSTS: Must meet minimum supervised experience requirement for licensure as a psychoanalyst as Applies only to practitioners in states that • determined by the licensing state and examination license psychoanalysts. requirements for licensure as determined by the • Practitioners will be credentialed as a licensing state. licensed psychoanalyst if they are not otherwise credentialed as a practitioner type ADDITIONAL PARTICIPATION detailed in Credentialing Policy (e.g. CRITERIA psychiatrist, clinical psychologist, licensed clinical social worker). NURSE PRACTITIONERS: • Practitioner must possess a valid • The nurse practitioner applicant will submit psychoanalysis state license. the appropriate application and supporting documents as required of any other Practitioner shall possess a master’s ◦ practitioners with the exception of differing or higher degree from a program information regarding education/training and accredited by one of the Regional board certification. Institutional Accrediting Bodies and may be verified from the Accredited • The required education/training will be at a Institutions of Post-Secondary minimum the completion of an education Education, APA, CACREP or the program leading to licensure as a registered COAMFTE listings. The institution nurse and subsequent additional education must have been accredited within 3 leading to licensure as an NP. Verification years of the time the practitioner of this will occur either via verification of the graduates. licensure status from the state licensing agency provided that that agency verifies Completion of a program in ◦ the education or from the certification board psychoanalysis that is registered by if that board provides documentation that it the licensing state as licensure performs primary verification of the qualifying; or accredited by the professional education and training. If the American Board for Accreditation in licensing agency or certification board does Psychoanalysis (ABAP) or another not verify highest level of education, the acceptable accrediting agency; or education will be primary source verified in determined by the licensing state to accordance with policy. be the substantial equivalent of such a registered or accredited program.

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• The license status must be that of NP as Oncology Certified Nurse verified via primary source from the Practitioner (AOCNP) — only appropriate state licensing agency. (http://oncc.org) Additionally, this license must be active, Note: This certification must be active and primary unencumbered, unrestricted and not subject source verified. If the state licensing board primary to probation, terms or conditions. Any sources verifies this certification as a requirement applicants whose licensure status does not for licensure, additional verification by the company meet these criteria or who have in force is not required. If the applicant is not certified or if adverse actions regarding Medicare or his/her certification has expired, the application will Medicaid will be notified of this and the be submitted for individual review. applicant will be administratively denied. If the NP has hospital privileges, they must have If the NP has prescriptive authority which • hospital privileges at a CIHQ, TJC, NIAHO or allows the prescription of scheduled drugs, HFAP accredited hospital, or a network hospital their DEA and/or state certificate of previously approved by the committee. prescriptive authority information will be requested and primary source verified via Information regarding history of any actions taken normal company procedures. If there are in against any hospital privileges held by the NP will force adverse actions against the DEA, the be obtained. Any adverse action against any applicant will be notified of this and the hospital privileges will trigger a level II review. applicant will be administratively denied. The NP applicant will undergo the standard • All NP applicants will be certified in the area credentialing processes outlined in Credentialing which reflects their scope of practice by any Policies #4-17. NPs are subject to all the one of the following: requirements outlined in these Credentialing Policies including (but not limited to): the Certification program of the ◦ requirement for committee review of level II files for American Nurse Credentialing failure to meet predetermined criteria, Center recredentialing every three years, and continuous (www.nursecredentialing.org), a sanction and performance monitoring upon subsidiary of the American Nursing participation in the network. Association (www.nursingcertification.org/ Upon completion of the credentialing process, the exam_programs.htm) NP may be listed in the company provider directories. As with all providers, this listing will American Academy of Nurse ◦ accurately reflect their specific licensure Practitioners — Certification designation and these providers will be subject to Program the audit process. (www.aanpcertification.org) NPs will be clearly identified as such: ◦ National Certification Corporation (www.nccwebsite.org) 1. On the credentialing file ◦ Pediatric Nurse Certification Board 2. At presentation to the Credentialing (PNCB) Certified Pediatric Nurse Committee Practitioner (CPN) (Note: CPN is not 3. On notification to network services and to a nurse practitioner.) the provider database (www.pncb.org/ptistore/control/ex ams/ac/progs) CERTIFIED NURSE MIDWIVES: ◦ Oncology Nursing Certification • The certified nurse midwife (CNM) applicant Corporation (ONCC) — Advanced will submit the appropriate application and

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supporting documents as required of any ◦ The National Certification other practitioner with the exception of Corporation for OB/GYN and differing information regarding education, Neonatal Nursing training and board certification. ◦ The American Midwifery Certification • The required education/training will be at a Board, previously known as the minimum that required for licensure as a American College of Nurse Midwifes registered nurse with subsequent additional Note: This certification must be active and primary training for licensure as a certified nurse source verified. If the state licensing board primary midwife by the appropriate licensing body. source verifies one of these certifications as a Verification of this education and training requirement for licensure, additional verification by will occur either via primary source the company is not required. If the applicant is not verification of the license provided that state certified or if their certification has expired, the licensing agency performs verification of the application will be submitted for individual review by education or from the certification board if the geographic Credentialing Committee. that board provides documentation that it performs primary verification of the If the CNM has hospital privileges, they must have professional education and training. If the unrestricted hospital privileges at a CIHQ, TJC, state licensing agency or the certification NIAHO or HFAP accredited hospital, or a network board does not verify education, the hospital previously approved by the committee or in education will be primary source verified in the absence of such privileges, must not raise a accordance with policy. reasonable suspicion of future substandard professional conduct or competence. Information The license status must be that of CNM as • regarding history of any actions taken against any verified via primary source from the hospital privileges held by the CNM will be appropriate state licensing agency. obtained. Any history of any adverse action taken Additionally, this license must be active, by any hospital will trigger a level II review. Should unencumbered, unrestricted and not subject the CNM provide only outpatient care, an to probation, terms or conditions. Any acceptable admitting arrangement via the applicant whose licensure status does not collaborative practice agreement must be in place meet these criteria or who have in force with a participating OB/GYN. adverse actions regarding Medicare or Medicaid will be notified of this and the The CNM applicant will undergo the standard applicant will be administratively denied. credentialing process outlined in Credentialing Policies #4-16. CNMs are subject to all the If the CNM has prescriptive authority which • requirements of these Credentialing Policies allows the prescription of scheduled drugs, including (but not limited to): the requirement for their DEA and/or state certificate of committee review for level II applicants, prescriptive authority information will be recredentialing every three years, and continuous requested and primary source verified via sanction and performance monitoring upon normal company procedures. If there are in participation in the network. force adverse actions against the DEA, the applicant will be notified and the applicant Upon completion of the credentialing process, the will be administratively denied. CNM may be listed in the company provider directories. As with all providers, this listing will All CNM applicants will be certified by one • accurately reflect their specific licensure of the following: designation and these providers will be subject to the audit process. CNMs will be clearly identified as such:

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1. On the credentialing file must be active and primary source verified. If the state licensing board primary sources 2. At presentation to the Credentialing verifies this certification as a requirement for Committee licensure, additional verification by the 3. On notification to network services and to company is not required. If the applicant is the provider database not certified or if their certification has expired, the application will be classified as PHYSICIAN ASSISTANTS: a level II according to geographic • The PA applicant will submit the appropriate Credentialing Policy #8 and submitted for application and supporting documents as individual review by the Credentialing required of any other practitioners with the Committee. exception of differing information regarding • If the PA has hospital privileges, they must education/training and board certification. have hospital privileges at a CIHQ, TJC, • The required education/training will be, at a NIAHO or HFAP accredited hospital, or a minimum, the completion of an education network hospital previously approved by the program leading to licensure as a PA. committee. Information regarding history of Verification of this will occur via verification any actions taken against any hospital of the licensure status from the state privileges held by the PA will be obtained. licensing agency provided that that agency Any adverse action against any hospital verifies the education. If the state licensing privileges will trigger a level II review. agency does not verify education, the • The PA applicant will undergo the standard education will be primary source verified in credentialing process outlined in accordance with policy. Credentialing Policies #4-16. PAs are • The license status must be that of PA as subject to all the requirements described in verified via primary source from the these Credentialing Policies including (but appropriate state licensing agency. not limited to): committee review of level II Additionally, this license must be active, files failing to meet predetermined criteria, unencumbered, unrestricted and not subject recredentialing every three years, and to probation, terms or conditions. Any continuous sanction and performance applicants whose licensure status does not monitoring upon participation in the meet these criteria or who have in force network. adverse actions regarding Medicare or • Upon completion of the credentialing Medicaid will be notified of this and the process, the PA may be listed in the applicant will be administratively denied. company provider directories. As with all • If the PA has prescriptive authority which providers, this listing will accurately reflect allows the prescription of scheduled drugs, their specific licensure designation and their DEA and/or state certificate of these providers will be subject to the audit prescriptive authority information will be process. requested and primary source verified via • PA’s will be clearly identified such: normal company procedures. If there are in force adverse actions against the DEA, the applicant will be notified and the applicant will be administratively denied. • All PA applicants will be certified by the National Commission on Certification of Physician’s Assistants. This certification

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1. On the credentialing file commercial, Medicare and Medicaid) offered within the geographic purview of the CC. The Chair/Vice 2. At presentation to the Credentialing Chair will serve as a voting member(s) and provide Committee support to the credentialing/recredentialing process 3. On notification to network services as needed. and to the provider database The CC will access various specialists for CREDENTIALS COMMITTEE consultation as needed to complete the review of a practitioner’s credentials. A committee member will The decision to accept, retain, deny or terminate a disclose and abstain from voting on a practitioner if practitioner’s participation in a network or plan the committee member (i) believes there is a program is conducted by a peer review body, conflict of interest such as direct economic known as The Anthem Blue Cross Credentials competition with the practitioner; or (ii) feels his or Committee (CC). her judgment might otherwise be compromised. A The CC will meet at least once every 45 calendar committee member will also disclose if he or she days. The presence of a majority of voting CC has been professionally involved with the members constitutes a quorum. The chief medical practitioner. officer, or a designee appointed in consultation with Determinations to deny an applicant’s participation the Vice President of Medical and Credentialing or terminate a practitioner from participation in one Policy will designate a Chair of the CC as well as a or more networks or plan programs require a Vice Chair in states or regions where both majority vote of the voting members of the CC in commercial and Medicaid contracts exist. attendance, the majority of whom are network The Chair must be a state or regional lead medical practitioners. director, or an Anthem Blue Cross medical director During the credentialing process, all information designee and the Vice Chair must be a lead that is obtained is highly confidential. All CC medical officer or an Anthem Blue Cross medical meeting minutes and practitioner files are stored in director designee for that line of business not locked cabinets and can only be seen by represented by the chair. In states or regions where appropriate credentialing staff, medical directors only one line of business is represented, the Chair and CC members. Documents in these files may of the CC will designate a Vice Chair for that line of not be reproduced or distributed except for business also represented by the Chair. confidential peer review and credentialing The CC will include at least five but no more than purposes, and peer review protected information ten external physicians representing multiple will not be shared externally. medical specialties (in general, the following Practitioners and HDOs are notified that they have specialties or practice-types should be represented: the right to review information submitted to support pediatrics; obstetrics/gynecology; adult medicine their credentialing applications. This right includes [family medicine or internal medicine]; surgery; access to information obtained from any outside behavioral health; with the option of using other sources with the exception of references, specialties when needed as determined by the recommendations or other peer review protected Chair/Vice Chair). information. CC membership may also include one to two other Providers are given written notification of these types of credentialed health providers (for example, rights in communications from Anthem Blue Cross nurse practitioner, chiropractor, social worker, which initiates the credentialing process. In the podiatrist) to meet priorities of the geographic event that credentialing information cannot be region as per Chair/Vice Chair’s discretion. At least verified, or if there is a discrepancy in the two of the physician committee members must be credentialing information obtained, the credentialed for each line of business (for example,

10 | CREDENTIALING AND RECREDENTIALING

Credentialing staff will contact the practitioner or unlawful basis not specifically mentioned herein. HDO within 30 calendar days of the identification of Additionally, Anthem Blue Cross will not the issue. This communication will specifically discriminate against any applicant on the basis of notify the practitioner or HDO of the right to correct the risk of population they serve or against those erroneous information or provide additional details who specialize in the treatment of costly conditions. regarding the issue in question. This notification will Other than gender and language capabilities that also include the specific process for submission of are provided to the covered individuals to meet this additional information including where it should their needs and preferences, this information is not be sent. required in the credentialing and recredentialing process. Determinations as to which Depending on the nature of the issue in question, practitioners/HDOs require additional individual this communication may occur verbally or in writing. review by the CC are made according to If the communication is verbal, written confirmation predetermined criteria related to professional will be sent at a later date. All communication on conduct and competence as outlined in Anthem the issue(s) in question including copies of the Blue Cross Credentialing Program Standards. CC correspondence or a detailed record of phone calls decisions are based on issues of professional will be clearly documented in the practitioner’s conduct and competence as reported and verified credentials file. The practitioner or HDO will be through the credentialing process. given no less than 14 calendar days in which to provide additional information. Upon request, SANCTION MONITORING applicant will be provided with the status of his or her credentialing application. Written notification of To support certain credentialing standards between this right may be included in a variety of the recredentialing cycles, Anthem Blue Cross has communications from Anthem Blue Cross which established an ongoing monitoring program. includes the letter which initiates the credentialing Credentialing performs ongoing monitoring to help process, the provider website or Provider Manual. ensure continued compliance with credentialing When such requests are received, providers will be standards and to assess for occurrences that may notified whether the credentialing application has reflect issues of substandard professional conduct been received, how far in the process it has and competence. To achieve this, the credentialing progressed and a reasonable date for completion department will review periodic listings/reports and notification. All such requests will be within 30 calendar days of the time they are made responded to verbally unless the provider requests available from the various sources including, but a written response. not limited to, the following: Anthem Blue Cross may request and will accept 1. Office of the Inspector General (OIG) additional information from the applicant to correct 2. Federal Medicare/Medicaid reports or explain incomplete, inaccurate or conflicting credentialing information. The CC will review the 3. Office of Personnel Management (OPM) information and rationale presented by the 4. State licensing boards/agencies applicant to determine if a material omission has Covered Individual/Customer Services occurred or if other credentialing criteria are met. 5. Departments NONDISCRIMINATION POLICY 6. Clinical Quality Management Department Anthem Blue Cross will not discriminate against (including data regarding complaints of both any applicant for participation in its networks or a clinical and nonclinical nature, reports of plan programs on the basis of race, gender, color, creed, religion, national origin, ancestry, sexual orientation, age, veteran, or marital status or any

10 | CREDENTIALING AND RECREDENTIALING

adverse clinical events and outcomes, and were based on professional competence and satisfaction data, as available) conduct considerations. Immediate terminations may be imposed due to the practitioner’s or HDO’s 7. Other internal Anthem Blue Cross suspension or loss of licensure, criminal conviction, departments or The Anthem Blue Cross determination that the 8. Any other verified information received from practitioner’s or HDO’s continued participation appropriate sources poses an imminent risk of harm to covered When a practitioner or HDO within the scope of individuals. A practitioner/HDO whose license has credentialing has been identified by these sources, been suspended or revoked has no right to informal criteria will be used to assess the appropriate review/reconsideration or formal appeal. response including but not limited to: review by the REPORTING REQUIREMENTS Chair of Anthem Blue Cross CC, review by the Anthem Blue Cross Medical Director, referral to the When Anthem Blue Cross takes a professional CC, or termination. Anthem Blue Cross review action with respect to a practitioner’s or credentialing departments will report practitioners HDO’s participation in one or more of its networks or HDOs to the appropriate authorities as required or plan programs, Anthem Blue Cross may have an by law. obligation to report such to the NPDB. Once Anthem Blue Cross receives a verification of the APPEALS PROCESS NPDB report, the verification report will be sent to the state licensing board. The credentialing staff Anthem Blue Cross has established policies for will comply with all state and federal regulations in monitoring and recredentialing practitioners and regard to the reporting of adverse determinations HDOs who seek continued participation in one or relating to professional conduct and competence. more of The Anthem Blue Cross networks or plan These reports will be made to the appropriate programs. Information reviewed during this activity legally designated agencies. In the event that the may indicate that the professional conduct and procedures set forth for reporting reportable competence standards are no longer being met, adverse actions conflict with the process set forth in and Anthem Blue Cross may wish to terminate the current NPDB Guidebook, the process set forth practitioners or HDOs. Anthem Blue Cross also in the NPDB Guidebook will govern. seeks to treat network practitioners and HDOs as well as those applying for participation fairly and thus provides practitioners and HDOs with a process to appeal determinations terminating participation in The Anthem Blue Cross networks for professional competence and conduct reasons, or which would otherwise result in a report to the National Practitioner Data Bank (NPDB). Additionally, Anthem Blue Cross will permit practitioners and HDOs who have been refused initial participation the opportunity to correct any errors or omissions which may have led to such denial (informal/reconsideration only). It is the intent of Anthem Blue Cross to give practitioners and HDOs the opportunity to contest a termination of the practitioner’s or HDO’s participation in one or more of The Anthem Blue Cross networks or plan programs and those denials of request for initial participation which are reported to the NPDB that

11 | UTILIZATION MANAGEMENT AND PRIOR AUTHORIZATION

11 | UTI LI ZATI ON MAN AGE ME NT AND PRI OR AU THORI ZATION AUTHORIZATION REQUESTS AND Note: For an optimal experience with the ICR, use TIME FRAMES a browser that supports 128-bit encryption. This includes Internet Explorer, Chrome, Firefox or  Medi-Cal Utilization Management: Safari. 1-888-831-2246  To access ICR via the Availity Portal, visit:  MRMIP Utilization Management: www.availity.com. 1-877-273-4193  Access ICR under Authorizations and Referrals.  Hours of operation: Monday to Friday, 8 a.m. - 5 p.m.  To register for an ICR training webinar, select this link and register: ICR Webinar. ONLINE SUBMISSION PAPER FORMS The Anthem Blue Cross Interactive Care Reviewer (ICR) is the preferred method for the submission of Providers can also request prior authorization by preauthorization requests. Providers can use the completing, printing and faxing the appropriate ICR to request inpatient and outpatient medical or Request for Preservice Review forms found under behavioral health services for Anthem Blue Cross the Prior Authorization and Preservice Review members. Providers can also use the ICR for heading on the Provider Resources page of our inquiries on previously submitted requests website below: regardless of how they were sent (phone, fax, ICR  https://providers.anthem.com/CA/Pages/req or other online tools). uest-prior-authorization.aspx

The ICR features allow the provider to: Tips for filling out the forms and getting the fastest • Initiate preauthorization requests online, response to your authorization request: eliminating the need to fax. ICR allows • Fill out the form completely; unanswered detailed text, photo images and questions typically result in delays. attachments to be submitted along with your request. • Print and fax the form to the numbers above. • Submit a notification of admission and request for continued stay review. ICR • Do not store the form offline; access it allows submission of justification and online only. Anthem Blue Cross revises attachments along with your request. forms periodically, and outdated forms can delay your request. • Make inquiries on previously submitted requests via phone, fax, ICR or other online Note: We do not reward practitioners and other tool. individuals conducting utilization reviews for issuing denials of coverage or care. There are no financial • Have instant accessibility from almost incentives for UM decision-makers that encourage anywhere including after business hours. decisions resulting in underutilization. UM decision • Utilize the dashboard to provide a complete making is based only on appropriateness of care view of all UM requests with real-time status and service and existence of coverage. updates including email notifications if requested using a valid email address. SERVICES THAT DO NOT REQUIRE PRIOR AUTHORIZATION • Access real-time results for some common The following services do not require prior procedures with immediate decisions. authorization (PA) for in-network providers: • Emergency services

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• Post-stabilization services (if medically outside of an emergency room or urgent care necessary) setting. • Formulary enteral nutrition products when Some Anthem Blue Cross members are assigned provided by an in-network provider. to delegated medical groups or IPAs. Providers should contact the member’s assigned medical • Formulary glucometers and nebulizers group to confirm the need for authorization before • Family planning/well woman checkup — elective services. members may self-refer to any Medicaid Services requiring prior authorization include but provider for the following services: are not limited to: ◦ Pelvic and breast examinations • Air ambulance (nonemergent) ◦ Lab work • Behavioral health services (except ◦ Birth control psychiatric assessments and mental health ◦ Genetic counseling assessment by non-physician; for more information, see Chapter 5: Behavioral ◦ FDA-approved devices and supplies Health Services) related to family planning (such as IUD) • Cardiac and pulmonary rehabilitation ◦ HIV/STD screening • Cosmetic procedures • Obstetrical care — no authorization • Dental (medically necessary facility and required for in-network physician visits and anesthesia services) routine testing • Dialysis services • Members not affiliated with an IPA or • Durable medical equipment and disposable medical group do not require PA from supplies Anthem Blue Cross for physician referrals to Experimental and investigational services an in-network specialist for consultation or a • nonsurgical course of treatment • Genetic testing • Standard X-rays and ultrasounds • Home health care services • In-network speech therapy and • Hospice occupational therapy • Infusion therapies SERVICES THAT REQUIRE PRIOR • Chemotherapy AUTHORIZATION • Inpatient hospital services Prior authorization ensures that services are based Nonurgent inpatient admissions on medical necessity, are a covered benefit, and ◦ are provided by the appropriate providers. ◦ Long-term acute care facility (LTAC) Providers are responsible for verifying eligibility and ◦ Inpatient skilled nursing facility ensuring that our Utilization Management (UM) (SNF) department has conducted preservice reviews for ◦ Rehabilitation facility admissions elective nonemergency and scheduled services before rendering those services. ◦ Newborn stay beyond mother Prior authorization must be obtained for all • Laboratory tests (specific) out-of-network services or services rendered • Out-of-network referrals to specialists

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• Outpatient surgical services (delivered in an • Community standards of care ambulatory surgical center or outpatient The decision-making criteria used by the UM team hospital) is evidence-based and consensus-driven. We • Pharmacy and/or over-the-counter (OTC) periodically review criteria and update when products standards of practice or technology change. We involve practicing physicians in these updates and Certain preferred medications and all  notify providers of changes through our provider nonpreferred medications may require bulletins. PA; please call 1-844-410-0746 or fax CA DMHC standard PA form to 1-844- These criteria are available to members, physicians 474-3345. and other healthcare providers upon request by contacting the appropriate UM department using  Specialty injectable medications such as the contact numbers at the beginning of this Synagis and Botox require PA through chapter. Anthem Blue Cross. Contact the UM department at 1-888-831-2246 for more Based on sound clinical evidence, the UM team information. provides the following service reviews:

• Radiology services including MRA, MRI, • Prior authorizations PET and CT scans • Continued stay reviews • Spinal surgeries • Post-service clinical claims reviews ◦ Artificial disc placement Decisions affecting the coverage or payment for ◦ Artificial disc removal services are made in a fair, impartial, consistent and timely manner. The decision-making process Artificial disc replacement ◦ incorporates nationally recognized standards of ◦ Decompress spinal cord care and practice from sources including: ◦ Low back disc surgery • America Academy of Orthopedic Surgeons ◦ Lumbar spine fusion • American Academy of Pediatrics ◦ Remove spinal lamina • American College of Cardiology ◦ Vertebral corpectomy • American College of Obstetricians and Gynecologists • Kidney and cornea transplant services (excluding other major transplants-not • Cumulative professional expertise and covered by Anthem Blue Cross) experience  A more comprehensive list of services requiring Once a case is reviewed, decisions and notification prior authorization can be found under Prior time frames will be given for these services: Authorization and Preservice Review on the • Approval, modification, denial Provider Resources page of our website at https://providers.anthem.com/CA. If you disagree with a UM decision and want to discuss the decision with the physician reviewer, AUTHORIZATION CRITERIA please call: Authorizations are based on the following:  Peer-to-peer: 1-877-496-0071 • Benefit coverage • Established criteria

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REQUESTING AUTHORIZATION • Prognosis When authorization of a healthcare service is • Psychosocial status required, contact Anthem Blue Cross for questions • Exceptional or special needs issues or requests including: • Ability to perform activities of daily living • Routine, nonurgent care reviews • Discharge plans • Urgent or expedited preservice reviews Additional information to have ready for the clinical Urgent continued stay reviews • reviewer includes but is not limited to: Providers can also fax the UM team and include • Office and hospital records requests for: • History of the presenting problem  Preservice reviews: 1-800-754-4708 • Clinical exam  Nonurgent continued stay reviews: 1-866-333-4826 • Treatment plans and progress notes

Note: Faxes are accepted during and after normal • Information on consultations with the business hours. Faxes received after business treating practitioner hours will be processed the next business day. • Evaluations from other healthcare All providers including physicians, hospitals and practitioners and providers ancillary providers are required to provide • Photographs information to support their request to the UM • Operative and pathological reports department. Physicians are also encouraged to review their utilization and referral patterns. • Rehabilitative evaluations When contacting the Utilization Management • Printed copy of criteria related to the department to request a preservice review or report request a medical admission, please provide the following • Information regarding benefits for services information: or procedures • Member name and identification (ID) • Information regarding the local delivery number system • Diagnosis with the ICD-10 code • Patient characteristics and information Procedure with the CPT code • • Information from responsible family • Date of injury or hospital admission and members third party liability information (if applicable) REQUESTS WITH INSUFFICIENT CLINICAL • Facility name (if applicable) INFORMATION • Primary care provider (PCP) name When the UM team receives requests with • Specialist or attending physician name insufficient clinical information, we will contact the provider with a request for the information Clinical justification for the request • reasonably needed to determine medical necessity. Level of care • We will make at least one attempt to contact the • Lab tests, radiology and pathology results requesting provider to obtain additional information. If no response if received within the specified time • Medications frame of receipt of the request, we will send a • Treatment plan including time frames

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Notice of Action: Denial —– Requested Information EMERGENCY MEDICAL Not Received letter to the member and provider. CONDITIONS AND SERVICES PRESERVICE REVIEW TIME FRAME Anthem Blue Cross does not require a prior authorization (PA) for treatment of emergency For routine, nonurgent requests, the UM team will medical conditions. In the event of an emergency, complete preservice reviews within five business members can access emergency services 24 hours days from receipt of information reasonably a day, 7 days a week. necessary to make a decision, not to exceed 14 calendar days from the date of request. In the event that the emergency room visit results in the member’s admission to the hospital, Requests that do not meet medical policy criteria providers must contact Anthem Blue Cross within are sent to the physician advisor or medical director 24 hours or one business day if the member was for further review. admitted on a weekend or holiday. Providers will be notified of denials or deferrals by Members who call their PCP’s office reporting a phone or fax within one business day from the date medical emergency (whether during or after office of the decision. hours) are directed to dial 911 or go directly to the Providers and members will be sent a written nearest hospital emergency department. All notification of denials or deferrals within two nonemergent conditions should be triaged by the business days from the date of the decision. PCP or treating physician with appropriate care instructions given to the member. URGENT PRESERVICE REQUESTS For urgent preservice requests, the UM team will EMERGENCY STABILIZATION AND complete the preservice review within three POST-STABILIZATION calendar days from receipt of the request. The emergency department’s treating physician determines the services needed to stabilize the Providers are responsible for contacting Anthem member’s emergency medical condition. After the Blue Cross to request preservice reviews for both member is stabilized, the emergency department’s professional and institutional services. However, a physician must contact the member’s PCP or hospital or ancillary provider should always contact Anthem Blue Cross for authorization of further Anthem Blue Cross to verify preservice review services. status for all nonurgent care before rendering services. The member’s PCP and the phone number to report inpatient admissions is noted on the back of An urgent request is any request for medical care the ID card. If the authorizing entity you contacted or treatment that cannot be delayed because delay does not respond within 30 minutes, the needed would result in one of the following: services will be authorized. The attempt must be • Could seriously jeopardize the life or health documented in the member’s medical records and of the member or the member's ability to provided to Anthem Blue Cross UM in order to be regain maximum function based on a considered authorized. prudent layperson's judgment. All continued inpatient stays are reviewed to • In the opinion of a practitioner with determine whether the stay is medically necessary. knowledge of the member's medical The transfer process for out-of-network admissions condition, would subject the member to requiring transfer to an Anthem severe pain that cannot be adequately Blue Cross-contracted facility or to a higher level of managed without the care or treatment that care includes the following: is the subject of the request. • The attending physician determines whether the member is stable for transfer

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• The attending physician discusses the When a member’s hospital stay is expected to potential transfer with the PCP exceed the number of days authorized during preservice review or when the inpatient stay did not • To facilitate the transfer, the PCP is have preservice review, the hospital must contact required to contact the treating physician Anthem Blue Cross for continued stay review. within 30 minutes of the call Anthem Blue Cross requires clinical reviews on all • The attending physician must document members admitted as inpatients to: and sign orders stating that the member is stable for transfer • Acute care hospitals • Transfers of children require the signed • Intermediate care facilities permission of the parents except in cases of • Skilled nursing facilities transfer to a higher level of care We perform reviews to assess medical necessity The emergency department should send a copy of and determine whether the facility and level of care the emergency room record to the PCP’s office are appropriate. Anthem Blue Cross identifies within 24 hours. The PCP should: members admitted as inpatient by: Review the chart and file it in the member’s • • Facilities reporting admissions permanent medical record • Providers reporting admissions • Contact the member • Members or their representatives reporting Schedule a follow-up office visit or a • admissions specialist referral if appropriate • Claims submitted for services rendered However, as with all nonelective admissions, without authorization notification must be made within 24 hours or one business day if the member was admitted on a • Preservice authorization requests for weekend or holiday. The medical necessity of that inpatient care admission will be reviewed upon receipt of The Anthem UM team will complete continued-stay notification, and a determination of the medical inpatient reviews within 72 hours of the receipt of necessity will be rendered within 72 hours of that necessary clinical information to make a notification. determination consistent with the member’s All providers who are involved in the treatment of a medical condition. Anthem Blue Cross UM staff will member share responsibility in communicating request clinical information from the hospital on the clinical findings, treatment plans, prognosis and the same day Anthem Blue Cross is notified of the psychosocial condition of such member with the member’s admission and/or continued stay. member’s PCP to ensure effective coordination of care. CLINICAL INFORMATION FOR CONTINUED-STAY REVIEW CONTINUED STAY REVIEW If after notification of an inpatient admission, there is insufficient clinical information to determine HOSPITAL INPATIENT ADMISSIONS medical necessity, the provider is contacted with a Hospitals must notify the UM department of request for the clinical information reasonably inpatient medical admissions within 24 hours of necessary to determine medical necessity. admission or by the next business day. Behavioral Evidence-based criteria are used to determine health admissions are the responsibility of the medical necessity and the appropriate level of care. member’s county. If the information meets medical necessity review criteria, we will approve the request within 72 hours

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11 | UTILIZATION MANAGEMENT AND PRIOR AUTHORIZATION from the time the information is received. Requests REFERRALS AND SECOND that appear to not meet medical policy guidelines OPINIONS will be sent to the physician adviser or medical director for further review. REFERRALS TO SPECIALISTS Anthem Blue Cross will notify providers within 24 The UM team is available to assist providers in hours of the decision and send written notification accessing a network specialist. Review the of any denial or modification of the request to the following when referring members: member and requesting provider. • PA is not required if referring a member not DENIAL OF SERVICE affiliated with an IPA or medical group to an in-network specialist for consultation or a Only a medical or behavioral health provider who nonsurgical course of treatment. possesses an active professional license or PA is required when referring to an certification can deny services for lack of medical • out-of-network specialist. necessity including the denial of: Authorization from UM is not required for • Procedures • Medi-Cal members who self-refer for • Hospitalization sensitive services (see Chapter 4: General • Equipment Benefits), even if services are rendered out-of-network. When a request is determined to be not medically necessary, the requesting provider will be notified • Members with MRMIP may self-refer to of the following: in-network specialists. • The decision Provider responsibilities include documenting referrals in the member’s chart and requesting that The process for appeal • the specialist provide updates as to diagnosis and • How to reach the reviewing physician for treatment. peer-to-peer discussion of the case Note: Obtain a PA approval before referring Providers can contact the physician clinical members to an out-of-network provider. For out-of- reviewers to discuss any UM decision by calling the network providers, Anthem Blue Cross requires PA UM department. for the initial consultation and each subsequent service provided. POST-SERVICE CLINICAL CLAIMS REVIEW PCP REFERRALS Post-service clinical claims review determines the PCPs coordinate and make referrals to specialists, medical necessity and/or level of care for services ancillary providers and community services. that were provided without getting required Providers should refer members to network preservice or continued stay authorization. For facilities and providers. When this is not possible, inpatient admissions where no notification was providers should follow the appropriate process for received and no patient days were authorized, requesting out-of-network referrals. facilities are required to submit a copy of the Note: Specialty referrals to in-network providers do medical record with the claim. not require PA from Anthem Blue Cross; however, please check with the member’s medical group to confirm. All PCPs are expected or responsible to:

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• Help members schedule appointments with  Utilization Management fax: 1-866-333-4827 other providers and health education The Notification of Referral/Linked and Carved-Out programs. Services form can be found by selecting the URLs • Track and document appointments, clinical below: findings, treatment plans and care received Forms Library by members referred to specialists or other  healthcare providers to ensure continuity of  Provider Resources: care. https://providers.anthem.com/CA • Screen and evaluate procedures for OUT-OF-NETWORK REFERRALS detection and treatment of or referral for any known or suspected behavioral health Anthem Blue Cross recognizes that there may be problems and disorders. instances when an out-of-network referral is justified. Medi-Cal's Utilization Management team • Refer members to specialists or specialty will work with the PCP to determine medical care, behavioral health services, health necessity; after that, out-of-network referrals will be education classes and community resource authorized on a limited basis. The UM department agencies, when appropriate. may be contacted at: • Coordinate with the Woman, Infants and Medi-Cal Utilization Management: Children (WIC) program to provide medical  1-888-831-2246 information necessary for WIC eligibility determinations such as height, weight,  Medi-Cal Utilization Management fax: hematocrit or hemoglobin. 1-866-333-4827 • Coordinate with the local tuberculosis (TB)  Hours of operation: Monday to Friday, control program to ensure that all members 8 a.m. - 5 p.m. with confirmed or suspected TB have a contact investigation and receive Directly SELF-REFERABLE SERVICES Observed Therapy (DOT). Members may self-refer to any of the following • Refer members to specialists or specialty services without PA if their benefits allow. care, behavioral health services, health • Emergency services education classes and community resource agencies including the California • Abortion services (in-network only) Department of Developmental Services • Annual well-woman exam (in-network only) regional centers, which are responsible for • Diagnosis and treatment of sexually the Early Start Program (ESP) for children transmitted diseases (STD) up to 3 years of age with developmental disabilities. Community resources also • Family planning services (services to include the Child Health and Disability prevent or delay pregnancy) Prevention Program (CHDP), and California • Basic prenatal services (in-network only) Children's Services (CCS). • Testing and counseling for Human Note: Whenever a provider refers a member to any Immunodeficiency Virus (HIV) of these community-based agencies, complete and fax the Notification of Referral/Linked and Members associated with capitated medical groups Carved-Out Services form to Utilization must self-refer to services within the group. Management at:  Utilization Management: 1-888-334-0870

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Note: Self-referable services may be rendered by a willing provider, even a provider without a contract, unless limited by state of federal regulation. We reimburse contracted providers according to the provider's contract; noncontracted providers are reimbursed at reasonable and customary rates.

SECOND OPINIONS Second opinions are covered services and offered at no cost to Anthem Blue Cross members. The following are important guidelines regarding second opinions: • The second opinion must be given by an appropriately qualified healthcare professional. • The second opinion must come from a provider of the same specialty. • The secondary specialist must be within the Anthem Blue Cross network and may be selected by the member. When there is no network provider who meets the specified qualifications, Anthem Blue Cross may authorize a second opinion by a qualified provider outside of the network upon request by the member or provider.

TRANSITION AND DISCHARGE PLANNING  Anthem Blue Cross assists with discharge planning as requested by the facility. For assistance with discharge planning, please call 1-805-713-0845.

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1 2 | CARE M ANAGEMENT AND HEAL TH PROGRAMS CARE MANAGEMENT and all related topics so that informed decisions can be made.  Care Management department: 1-888-334-0870 • Encourage appropriate use of medical facilities and services with the goal of  Care Management fax: 1-866-333-4827 improving quality of care.  Hours of operation: Monday to Friday, The Care Management team includes experienced 8 a.m. - 5 p.m. and credentialed registered nurses and Social Anthem Blue Cross care management is a process Workers, some of whom are certified case that emphasizes teamwork to assess, develop, managers (CCMs). The team also uses implement, and coordinate treatment plans in order Community Health Workers to reach members in to optimize our members’ healthcare benefits and the community or in their home. The Care promote quality outcomes. Management multidisciplinary team allows us to address not only our members’ medical needs, but Members referred to the Care Management team also their psychological, and social determinants of may be identified by disease, condition or high health. utilization of services. To support our diverse membership, the Care REFERRAL PROCESS Management team is able to provide culturally and linguistically appropriate community-based referrals Anyone may refer members to Care Management by phone or faxing a Care Management Referral as needed. Form to the Care Management office using the Interpreter services are also available to support numbers at beginning of this chapter. the care management process at no cost to the The Medi-Cal Case Management Referral Form member. is located in the General Forms Library on the PROVIDER RESPONSIBILITY Provider Resources page of our website at: Providers have the responsibility of participating in  https://providers.anthem.com/CA/pages/for care management, sharing information and ms.aspx facilitating the process by: A care manager will respond to a faxed request • Referring members who could benefit from within three business days. care management. ROLE OF THE CARE MANAGER • Sharing information as soon as possible including any complex healthcare needs The care manager, through discussions with the identified during the Initial Health member, the member’s representative and/or Assessment (IHA). providers, collects data and analyzes information about actual and potential healthcare needs for the • Collaborating with Care Management staff purpose of developing a treatment plan. The care on an ongoing basis. manager’s role also includes the responsibility to: • Recommending referrals to specialists as • Facilitate communication and coordination required. within the healthcare team, member or • Monitoring and updating the care plan to member representative. promote healthcare goals. • Educate the member and providers, on the • Notifying Care Management if members are healthcare team, about care management referred to services provided by the state or programs, community resources, benefits, some other institution not covered by the Anthem Blue Cross agreement.

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• Coordinating county or state-linked services provisions of all necessary and preventive medical such as public health, behavioral health, services. schools and waiver programs. The provider may call Care Management for additional POTENTIAL REFERRALS assistance. Providers, nurses, social workers, and members or their representatives may request care PROCEDURES management services. Examples of appropriate When a member has been identified as having a referrals include: condition that may require care management, the • Children or adults with special healthcare care manager contacts the referring provider and needs requiring coordination of care and member for an initial assessment. carved out services such as certain mental With the involvement of the member, the member’s health services representative and the provider, the care manager • HIV/AIDS develops an individualized care plan. That plan may involve coordinating services with public and • Chronic illnesses such as asthma, diabetes, behavioral health departments, schools and other heart failure or end-stage renal disease community health resources. • Complex or multiple care needs such as The care manager periodically reassesses the care multiple trauma or cancer plan to monitor the following: • Frequent hospitalizations or emergency • Progress toward goals room utilization • Necessary revisions • Hemophilia, sickle cell anemia, cystic fibrosis, cerebral palsy • New issues that need to be addressed to help ensure that the member receives the • High-risk pregnancies (in other words, teen support needed to achieve care plan goals pregnancies, history of pre-term birth, etc.) Once goals are met or Care Management can no • Potential transplants longer impact the case, the care manager closes • Seniors and persons with disabilities (SPD) the member’s case. • Individuals who may need or are receiving MEMBERS ELIGIBLE FOR SPECIALIZED services from out-of-network providers or SERVICES programs

The Care Management team works closely with TRANSITIONING DISENROLLEES providers to ensure continuity and coordination of care for our members who are eligible for linked The care manager is available to assist a member and state-administered services. These services that requests help to transition to another health may come from the following: plan. Providers may contact Care Management if assistance is needed. • California Children's Services (CCS) • County Mental Health care PROVIDER ASSESSMENT OF PREGNANCY RISK • Early Start/Early Intervention The PCP or prenatal care physician should assess • Regional Centers all pregnant members for high-risk indicators during Although these agencies provide specialized the initial prenatal care visit. For all pregnant services for our members, PCPs remain members, the provider needs to: responsible for providing or arranging for the

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• Complete a Pregnancy Notification Report • Newborns who are covered between the and submit it to our prenatal program ages of birth and 36 months coordinator at: • Pregnancy, regardless of trimester, through  1-877-848-0147 immediate postpartum care • Refer members to prenatal education, • Surgery that has been previously approved childbirth education and breastfeeding and scheduled to occur within 180 days of classes; members can register by calling the contract's termination or within 180 days our Customer Care Centers. of the effective date of coverage for a newly covered enrollee • Document all referrals in the member’s medical record. • Serious chronic conditions (in other words, hemophilia) • Schedule the member for a postpartum visit. • Terminal illness For additional information, visit the Prenatal States of transition may be any of the following: Resources page of our website at: • The member is newly enrolled.  https://providers.anthem.com/california- • The member is disenrolling to another provider/patient-care/pregnancy-and- health plan. maternal-child-services • The provider’s contract terminates. CONTINUITY OF CARE A terminated provider or provider group who actively treats members must continue to treat Anthem Blue Cross provides continuity of care for members until the provider's date of termination. members with qualifying conditions when Anthem Blue Cross makes every effort to notify healthcare services are not available within the members at least 30 days prior to termination. network or when the member or provider is in a state of transition. Providers help ensure continuity and coordination of care through collaboration. This includes the All new enrollees receive a Member Services confidential exchange of information between Guide/Evidence of Coverage (EOC) and PCPs and specialists as well as behavioral health membership information in their enrollment providers. In addition, Anthem Blue Cross helps packets. This provides information regarding coordinate care when a provider's contract has members’ rights to request continuity of care if the been discontinued to ensure a smooth transition to member transitions to another health plan. a new provider. Qualifying condition: A medical condition that Providers must maintain accurate and timely may qualify a member for continued access to care documentation in the member’s medical record and continuity of care. These conditions include but including but not limited to: are not limited to: • Consultations • Acute conditions (in other words, cancer) • Prior authorizations • Degenerative and disabling conditions, which includes conditions or diseases • Referrals to specialists caused by a congenital or acquired injury or • Treatment plans illness that require a specialized rehabilitation program or a high level of All providers share responsibility in communicating service, resources or coordination of care in clinical findings, treatment plans, prognosis and the the community member’s psychosocial condition as part of the coordination process. Utilization management

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12 | CARE MANAGEMENT AND HEALTH PROGRAMS nurses review member and provider requests for provider/CA_CAID_Forms_DiseaseManage continuity of care. These nurses facilitate mentReferralForm.pdf?v=202101090057 continuation with the current provider until a short-term regimen of care is completed or the DISEASE MANAGEMENT member transitions to a new practitioner. Disease Management/Population Health (DM) Note: Only Anthem Blue Cross can make adverse services are based on a system of coordinated determination decisions regarding continuity of care management interventions and care. communications designed to help physicians and other healthcare professionals manage members Adverse determination decisions are sent in writing with chronic conditions. to the member and provider within two business days of the decision. Members and providers can Our services include a holistic, member-centric appeal the decision by following the procedures in care management approach that allows care the Grievances and Appeals chapter of this managers to focus on multiple needs of members. manual. Reasons for continuity of care denials Our disease management programs include: include but are not limited to the following: • Asthma • Diabetes • Continuity of care is not available with the terminating provider. • Bipolar • HIV/AIDS disorder • Course of treatment is complete. • Hypertension Chronic • • Major depressive • Member is ineligible for coverage. obstructive disorder – adult pulmonary • Condition is not a qualifying condition. and disorder Request is for change of PCP only and not child/adolescent • (COPD) for continued access to care. • Schizophrenia • Congestive Requested services are not a covered • heart failure • Substance abuse benefit. (CHF) disorder • Services rendered are covered under a • Coronary global fee. artery disease • Treating provider is currently contracted (CAD) with our network. In addition to our 12 condition-specific disease DISEASE MANAGEMENT management programs, our member-centric, PROGRAMS holistic approach also allows us to assist members  Providers can refer a member to the program with managing their weight and/or smoking by calling DM at 1-888-830-4300. cessation education.  Hours of operation are 8:30 a.m. - 5:30 p.m. Program features: local time. Confidential voicemail is available 24 • Proactive identification process hours a day. • Evidence-based Clinical Practice Guidelines  DM program content is located at: from recognized sources https://providers.anthem.com/california- • Collaborative practice models that include provider/patient-care/disease-management the physician and support providers in  Referral Form: treatment planning https://providers.anthem.com/docs/gpp/ • Continuous self-management education california-

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• Ongoing process and outcomes • Know how to contact the case manager measurement, evaluation and management responsible for managing and communicating with their patients • Ongoing communication with primary and ancillary providers regarding patient status • Be supported by our organization when interacting with members to make decisions WHO IS ELIGIBLE? about their healthcare All members with the listed conditions are eligible. • Receive courteous and respectful treatment We identify them through: from our organization’s staff • Continuous case finding • Communicate complaints to the • Claims mining organization. • Referrals HOURS OF OPERATION As a valued provider, we welcome your referrals of Our DM case managers are registered nurses. patients who can benefit from additional education They are available: 8:30 a.m. to 5:30 p.m. local and disease management support. Our care time. managers will work collaboratively with you to Confidential voicemail is available 24 hours a day. obtain your input in the development of care plans. The NurseLine is available for our members 24 Members identified for participation in any of the hours a day, 7 days a week. programs are assessed and risk stratified based on the number of gaps in care/needs. Contact Information Members enrolled in Disease  You can call a DM team member at Management/Population Health programs receive 1-888-830-4300. education on self-management concepts, which include primary prevention, coaching related by  DM program content is located at healthy behaviors and compliance/monitoring as https://providers.anthem.com/CA. well as case/care management for high-risk Printed copies are available upon request. members. Providers are given telephonic and/or written updates regarding patient status and  Members can obtain information about DM progress. program by visiting: https://mss.anthem.com/CA DM Provider Rights and Responsibilities  or calling 1-888-8630-4300. You have the right to: ◦ Obtain information about our HEALTH SERVICE PROGRAMS organization’s services, staff qualifications and any contractual MATERNAL CHILD SERVICES: NEW BABY, NEW LIFE relations. • Decline to participate in or work with the  If you have an Anthem Blue Cross member in your care that would benefit from the New organzation’s programs and services on Baby, New Life program, please call us at behalf of their patients 1-888-334-0870. • Be informed of how the organization New Baby, New Life is a proactive care coordinates interventions with care plans for ℠ individual members management program for all expectant mothers and their newborns. It identifies pregnant women as early in their pregnancies as possible through review of state enrollment files, claims data,

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12 | CARE MANAGEMENT AND HEALTH PROGRAMS hospital census reports, and provider notification of The American College of Obstetricians and pregnancy and delivery notification forms and self- Gynecologists has outlined depression screening referrals. instruments to be used during the pregnancy and postpartum periods including: Once pregnant members are identified, we act quickly to assess obstetrical risk and ensure • The Edinburgh Postnatal Depression Scale appropriate levels of care and case management (EPDS). services to mitigate risk. Experienced case • Patient Health Questionnaire 9. managers work with members and providers to establish a care plan for our highest risk pregnant Providers are asked to document screening in the members. Case managers collaborate with medical record. community agencies to ensure mothers have  For referrals to care coordination for behavioral access to necessary services including health, please call 1-888-831-2246 and select 1 transportation, WIC, home-visitor programs, then option 2 to request care coordination. breastfeeding support and counseling. Maternal Outreach Program When it comes to our pregnant members, we are committed to keeping both mom and baby healthy. The Maternal Outreach Program is designed to That’s why we encourage all of our moms-to-be to identify mothers with prenatal and postpartum take part in our New Baby, New Life program — a support needs. Anthem Blue Cross will contact comprehensive case management and care pregnant women and new mothers by telephone to coordination program offering: identify any prenatal or postpartum needs, answer questions and share information about member Individualized, one-on-one case • resources. Anthem Blue Cross will also educate management support for women at the new mothers about well-child visits and highest risk. immunizations. Care coordination for moms who may need • We will also assist with appointment scheduling to a little extra support. encourage women to get their check-ups. Educational materials and information on • The program will allow Anthem Blue Cross and its community resources. providers to: Incentives to keep up with prenatal and • • Establish eligibility for care management postpartum checkups and well-child visits programs. after the baby is born. • Ensure mothers and babies receive For parents with infants admitted to the • appropriate medical care. neonatal intensive care unit (NICU), we offer the You and Your Baby in the NICU • Increase prenatal, postpartum and well- program. Parents receive education and child follow-up visits. support to be involved in the care of their • Enhance member engagement. babies, visit the NICU, interact with hospital Increase quality healthcare outcomes for care providers and prepare for discharge. • Parents are provided with an educational mothers and their babies. resource outlining successful strategies • Raise HEDIS® scores. they may deploy to collaborate with the care team. CLINICAL PRACTICE GUIDELINES Beginning July 1, 2019, obstetric providers are Several national organizations produce guidelines required to screen or offer to screen women for for asthma, diabetes, hypertension and other perinatal mood disorders. conditions. The guidelines, which Anthem

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Blue Cross uses for quality and disease management programs, are based on reasonable medical evidence. We review the guidelines at least every two years or when changes are made to national guidelines for content accuracy, current primary sources, new technological advances and recent medical research. Clinical Practice Guidelines can be downloaded at:  https://providers.anthem.com/california- provider/resources  Behavioral health: https://providers.anthem.com/california- provider/patient-care/behavioral-health  Matrix: https://providers.anthem.com/docs/gpp/ california-provider/ CA_CAID_MMP_ClinicalPracticeGuidelines Matrix.pdf?v=202009291618

 You can also call Provider Services at 1-866-231-0847 to receive a copy.

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13 | QUALI TY MANAGEM EN T The Anthem Blue Cross longstanding goal has perform at the least as well as 50% of all Medicaid been continuous, measurable improvement in our plans in the United States (50th percentile). delivery of quality healthcare. Following federal and This requirement is known as the Minimum state guidelines, we have a Quality Management Performance Level (MPL) and it applies to all (QM) program to: measures that are a part of the MCAS. When the • Objectively and systematically monitor and MPL is not met for any measure within the MCAS, evaluate the quality, safety and DHCS may impose the following actions on the appropriateness of medical care and MCP: service offered by the health network. • Corrective Action Plans • Identify and act upon opportunities for • Sanctions improvement. • PDSA/PIP Participation The QM program includes focused studies and reviews that measure quality of care in specific All applicable Anthem Blue Cross network clinical and service areas. All providers are providers, including safety net clinics, independent expected to participate in these studies as part of practitioners, Physician Medical Groups (PMGs), our mutual goal of providing responsive and Independent Physician Associations (IPAs), Public cost-effective healthcare that improves our Hospitals and other health systems are required to member’s lives. meet the MPL for all measures within the DHCS selected MCAS. Anthem Blue Cross reserves the QUALITY PERFORMANCE REQUIREMENTS right to and may impose sanctions on any provider that does not meet the MPL, including, but not Anthem Blue Cross participates in national and limited to: state evaluations that measure the quality performance of our plan and providers. The • Sending a quality performance notices that National Committee for Quality Assurance requires completion of specific QI (NCQA) provides a national annual report of their interventions Healthcare Effectiveness Data and Information • Suspending auto-assignment of members Set (HEDIS) rankings across health plans. that didn’t choose a provider This report is a tool used by more than 90% of • Freezing panels for assignment of any new America’s health plans to rate performance across members a wide spectrum of care and service areas including clinical performance and member • Withholding 5-15% of capitation payments satisfaction. The HEDIS results can also be used at Anthem discretion by anyone to make comparisons before choosing a • Terminating contracts for material breach or health plan. Anthem Blue Cross uses the HEDIS according to other termination provisions data to identify areas for improvement and shares For more information about the most updated the results with providers. Managed Care Accountability Set (MCAS) measures The California Department of Health Care please reference the link to the Department of Health Services (DHCS) has selected a set of quality Care Services (DHCS) All Plan Letters: measures that apply to all Medi-Cal Managed Care www.dhcs.ca.gov/formsandpubs/Pages/AllPlanLet ters.aspx. Plans (MCPs). These quality measures are known as the Managed Care Accountability Set (MCAS), formerly known as the External

Accountability Set (EAS). MCPs are required to

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REPORTING MEASURES FOR 2019 REPORTING MEASURES FOR 2019 2019 Managed Care Accountability Set (MCAS) 2019 Managed Care Accountability Set (MCAS) measures that must meet DHCS Minimum measures that must meet DHCS Minimum Performance Levels (MPL) Performance Levels (MPL) ACRYNOM NAME DESCRIPTION HYBRID Continuation ABA Adult BMI Members 18-74 Y Phase is for Assessment who had an members who outpatient visit remained on and whose the medication body mass 210 days and index was who, in addition documented to the initial during the visit, had at measurement least 2 follow- year, or the up visits within year prior. 9 months Please note: 1) AMM - Antidepress Members 18 N for ages 18-19 Behavioral ant years or older, medical record Health Medication who were must document (Acute) Management treated with the weight, antidepressant height, and BMI medication, percentile 2) for had a diagnosis ages 20-74 of major medical record depression and must document who remained the weight and on an BMI value antidepressant ADD - Follow-Up Children ages N medication for Behavioral Care for 6-12 newly at least 84 days Health Children prescribed (12 weeks) (Initiation Prescribed ADHD AMM - Antidepress Members 18 N Phase) ADHD medication and Behavioral ant years or older, Medications who had at Health Medication who were least 3 follow- (Continuat Management treated with up care within a ion) antidepressant 10 month medication, period. The 1st had a diagnosis visit has to be of major within 30 days depression and following the who remained Index on an Prescription antidepressant Start Date medication for (IPSD) and at least 180 must be with a days (6 practitioner with months) prescribing AMR Asthma Members 5–64 N authority Medication years of age ADD - Follow-Up Children ages N Ratio who were Behavioral Care for 6-12 newly identified as Health Children prescribed having (Continuat Prescribed ADHD persistent ion and ADHD medication and asthma and Maintenan Medications who had at had a ratio of ce) least 3 follow- controller up care within a medications to 10 months total asthma period. medications of

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REPORTING MEASURES FOR 2019 REPORTING MEASURES FOR 2019 2019 Managed Care Accountability Set (MCAS) 2019 Managed Care Accountability Set (MCAS) measures that must meet DHCS Minimum measures that must meet DHCS Minimum Performance Levels (MPL) Performance Levels (MPL) 0.50 or greater Care- A1c with diabetes during the Test (type 1 and measurement type 2) who year had AWC Adolescent Members 12– Y Hemoglobin Well Care 21 years of age A1c (HbA1c) who had at testing least one CDC- Comprehens Percentage of Y comprehensive A1C>9 ive Diabetes members 18– well-care visit Care-Poor 75 years of age with a PCP or Control >9 with diabetes an OB/GYN (type 1 and practitioner type 2) who during the had HbA1c measurement poor control year (>9.0%) BCS Breast Women 50–74 N CHL Chlamydia Women 16–24 N Cancer years of age Screening years of age Screening who had a who were mammogram to identified as screen for sexually active breast cancer and who had at CBP Controlling Members 18– Y least one test Blood 85 years of age for chlamydia Pressure who had a during the diagnosis of measurement hypertension year (HTN) and CIS – Childhood Children 2 Y whose BP was COMBO Immunizatio years of age adequately 10 ns Status- who had four controlled Combo 10 diphtheria, (<140/90 mm tetanus and Hg) during the acellular measurement pertussis year (DTaP); three CCS Cervical Women 21–64 Y polio (IPV); one Cancer years of age measles, Screening who had mumps and cervical rubella (MMR); cytology three performed haemophilus every 3 years, influenza type or women 30– B (HiB); three 64 years of age hepatitis B who had (HepB), one cervical chicken pox cytology/human (VZV); four papillomavirus pneumococcal (HPV) co- conjugate testing (PCV); one performed hepatitis A every 5 years (HepA); two or CDC-A1C Comprehens Percentage of Y three rotavirus ive Diabetic members 18– (RV); and two 75 years of age influenza (flu)

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REPORTING MEASURES FOR 2019 REPORTING MEASURES FOR 2019 2019 Managed Care Accountability Set (MCAS) 2019 Managed Care Accountability Set (MCAS) measures that must meet DHCS Minimum measures that must meet DHCS Minimum Performance Levels (MPL) Performance Levels (MPL) vaccines by within 42 days their second of enrollment birthday W15 Well Child The percentage Y IMA – Immunizatio Adolescents 13 Y Visits- 0-15 of members COMBO 2 ns For years of age months who turned 15 Adolescents who had one months old - Combo 2 dose of during the meningococcal measurement vaccine, one year and who tetanus, had 6+ well- diphtheria child visits with toxoids and a PCP during acellular their first 15 pertussis months of life (Tdap) vaccine, W34 Well Child The percentage Y and have Visits-3-6 of members 3– completed the years 6 years of age human who had one or papillomavirus more well-child (HPV) vaccine visits with a series by their PCP during the 13th birthday measurement PPC-POST Timeliness The percentage Y year for- of women who WCC - BMI Weight Members 3–17 Y Postpartum had a Assessment years of age Care postpartum visit & who had an on or between Counseling outpatient visit 21 and 56 days for Nutrition with a PCP or after delivery. and Physical OB/GYN and PPC-PRE Timeliness The percentage Y Activity who had for-Prenatal of pregnant evidence of Care women who BMI percentile received a documentation prenatal care (height, weight, visit in the first BMI percentile) trimester or

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QUALITY MANAGEMENT PROGRAM Providers support the activities of the QM program DOCUMENTATION by: The QM program focuses on developing and • Participating in the facility and medical implementing standards for clinical care and record audit process and completing service, measuring conformity to those standards, corrective action plans (CAPs) when and taking action to improve performance. The applicable. scope of the QM program includes but is not limited • Providing access to medical records for to the monitoring and evaluation of: quality improvement projects and studies • Care and service provided in all health and HEDIS review delivery settings • Responding in a timely manner to requests • Chronic disease management and for written information and documentation if prevention programs a quality of care or grievance issue has • Maternity management programs been filed • Coordination of medical care • Using Preventive Health and Clinical Practice Guidelines in member care • Community health • Sharing imperative data files, such as EMR • Service quality and lab files • Case management of members with • Using the immunization registry complex health conditions • Participating in performance improvement • Facility site review activities • Medical record review Information from these studies is actively shared • HEDIS medical record review with providers and we encourage constructive feedback. • Provider/member satisfaction • Member/patient safety COMMUNITY ADVISORY COMMITTEE • Utilization management Community Advisory Committees (CAC) provide input and recommendations to the Board of Behavioral health programs • Directors, Medical Advisory Committee and Quality • Pharmacy and therapeutics department on programs and issues. These advisory functions include providing input on topics • Clinical practice guidelines such as priorities for needs assessment, program • Over and under utilization development and provider network development. Anthem Blue Cross develops an annual work plan The CAC meets periodically in our California of quality improvement activities based on the counties with representatives from Quality results of the previous year’s QM program Management, Provider Relations, evaluation. QM program revisions are made based Community-Based Organizations and Anthem on outcomes, trends, accreditation, contractual and Blue Cross members enrolled in Medi-Cal in regulatory standards and requirements, and overall attendance. satisfaction with the effectiveness of the program. The responsibilities of the CAC are to: The QM program evaluation is the reporting Give input to Anthem Blue Cross on the method used to evaluate the progress of each • needs of the community. provider’s quality performance and results of planned activities toward established goals.

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• Provide suggestions on possible information available to consumers, approaches and strategies to address employers, peer practitioners and other issues raised by our members. healthcare stakeholders.

• Review and comment on group needs HEALTHCARE EFFECTIVENESS assessment results. DATA AND INFORMATION SET • Identify community resources to enhance (HEDIS) the services offered to Anthem Blue Cross members. HEDIS is a national evaluation and core set of performance measurements that gauge the • Be included and involved in policy decisions effectiveness of Anthem Blue Cross and its related to quality improvement, educational, providers in providing quality care. Anthem operational and cultural competency issues Blue Cross will provide the necessary education affecting groups who speak a primary and training you and your office staff need to language other than English. participate in required HEDIS evaluations. Providers can request consultations and training in PROVIDER PERFORMANCE DATA the following areas: Practitioners and providers must allow Medi-Cal • Information about the year’s selected and MRMIP to use performance data in HEDIS studies cooperation with our quality improvement program and activities. • How data for those measures will be collected Provider performance data refers to compliance rates, reports and other information related to the • Codes associated with each measure appropriateness, cost, efficiency and/or quality of • Tips for smooth coordination of medical care delivered by an individual healthcare record data collection practitioner such as a physician or a healthcare organization such as a hospital. Common Our QM staff will contact your office when we need to review or copy any medical records required for examples of performance data would include the HEDIS or QM studies. Requests to provider offices HEDIS quality of care measures maintained by the begin in early February. Anthem Blue Cross NCQA and the comprehensive set of measures requests the records be returned within five maintained by the National Quality Forum (NQF). business days to allow time to abstract the records Practitioner/provider performance data may be and request additional information from other used for multiple plan programs and initiatives providers if needed. Office staff must provide including but not limited to: access to medical records for review and copying • Reward programs: Pay for performance free of charge. (P4P), pay for value (PFV) and other results-based reimbursement programs that OVER/UNDER UTILIZATION tie provider or facility reimbursement to In accordance with NCQA standards, Anthem performance against a defined set of Blue Cross analyzes relevant utilization data compliance metrics. Reimbursement against established thresholds for each health plan models include but are not limited to shared to detect potential over or under utilization. savings programs, enhanced fee schedules If our findings fall outside specified target ranges and bundled payment arrangements. and indicate potential underutilization or • Recognition programs: Programs overutilization that may adversely affect our designed to transparently identify high-value members, further analyses will occur based upon providers and facilities and make that

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13 | QUALITY MANAGEMENT the recommendation of The Anthem Blue Cross Health topics may be targeted if significant gaps in Utilization Management Committee (UMC). care are identified by the QM team. QM staff is also available to support the network in closing gaps in The follow-up analyses may include gathering the care. following data from specific provider and practice sites: MEMBER SATISFACTION SURVEYS • Care management services needed by Member satisfaction with our healthcare services is members measured every year by the Consumer • Claims payments for covered services Assessment of Healthcare Providers and Systems (CAHPS®) survey. The survey is an • Coordination with other providers and NCQA requirement and is designed to measure agencies member satisfaction with services provided by • Focus studies Anthem Blue Cross and our network providers • Investigation and resolution of member and including: provider grievances and appeals within • Access to care established time frames • Physician care and communication with • Retrospective reviews of services provided patients without authorization • Anthem Blue Cross Customer Service GAPS IN CARE Anthem Blue Cross shares results of the CAHPS The QM Department regularly tracks member survey with our network providers upon request. utilization for nationally recognized standards of Providers can review the results, share them with care. When members are due for care or gaps in office staff, and incorporate appropriate changes to care are identified, QM outreach staff engages with their offices in an effort to improve scores. members directly. QM staff conducts outreach calls CAHPS is a registered trademark of the Agency for to the members, during which staff: Healthcare Research and Quality (AHRQ). • Educate members on the importance of PROVIDER SATISFACTION SURVEYS receiving their care. Anthem Blue Cross conducts provider surveys to • Identify barriers to care (for example, monitor and measure provider satisfaction with our transportation) and work with members to services and identify areas for improvement. overcome those barriers. Provider participation in these surveys is highly • Assist members with the scheduling of encouraged, and your feedback is very important. appointments. We inform providers of the results and plans for The main healthcare service delivery areas improvement through provider bulletins, targeted during member outreach include: newsletters, meetings or training sessions. • Prenatal and postpartum care MEDICAL RECORDS AND FACILITY SITE • Chronic disease management (for example, REVIEWS diabetes, asthma, hypertension) As required by California statute, all PCP sites participating in the Medi-Cal program must undergo • Childhood immunizations and well-child an initial site inspection and subsequent periodic visits • Routine preventive screenings (for example, breast cancer screening and pap smears)

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13 | QUALITY MANAGEMENT site inspections regardless of the status of other FACILITY SITE REVIEW PROCESS accreditation or certification. A facility site review (FSR) inspection is broken Anthem Blue Cross conducts subsequent down into the following six categories: inspections every three years in order to determine: • Access/safety • Provider compliance with standards for • Personnel providing and documenting healthcare. • Office management • Provider compliance with standards for documenting and storing medical records. • Clinical services • Provider compliance with processes that • Preventive services maintain safety standards and practices. • Infection control Provider involvement in the continuity and The Anthem Blue Cross Quality Management team coordination of member care. Note: DHCS, CMS, will call the provider’s office to schedule an Department of Health and Human Services (DHHS) appointment date and time before the FSR due Inspector General, the Comptroller General, date. The team will fax, email or mail a confirmation Department of Justice (DOJ), Department of letter with an explanation of the audit process and Managed Health Care (DMHC), or their designees required documentation. and Anthem Blue Cross have the right to enter into the premises of providers to inspect, monitor, audit During the FSR, our auditor will: or otherwise evaluate the work performed. We • Conduct a review of the facility and medical perform all inspections and evaluations in such a records manner as not to unduly delay work in accordance Develop a Corrective Action Plan if with the provider contract. • applicable. Medical records and facility site review tools are After the FSR is completed, our auditor will meet available under the Quality Improvement Program with the provider or office manager to: heading on the Provider Resources page of our website at: • Review and discuss the results of the facility site review and explain any required  https://providers.anthem.com/california- corrective actions. provider/resources • Provide a copy of the facility site review results and the CAP to the office manager or provider. • Educate the provider and office staff about our standards and policies. • Schedule a follow-up review for any corrective actions identified. Providers must obtain a score of 80% or greater in both the facility site review and the medical record review in order to pass.

FACILITY SITE REVIEW: CORRECTIVE ACTIONS If the facility site review or the medical record review results in a nonpassing or conditional score,

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Anthem Blue Cross will immediately notify Facilities must demonstrate 100% percent providers of the results as well as all cited compliance with these elements. deficiencies and corrective action requirements. Provider sites that score below 80% in the facility The provider office will develop and submit a CAP site review for two consecutive reviews must score as follows: a minimum of 80% in the next review. Correct critical deficiencies within 10 days • Sites that don’t score a minimum of 80% will be following the FSR removed from the network, and the provider’s • Develop and submit a CAP for all other members will be appropriately reassigned to other deficiencies within 45 days participating providers. • Sign an attestation when corrective actions are complete MEDICAL RECORDS STANDARDS Anthem Blue Cross requires providers to maintain If deficiencies (other than critical) are not closed medical records in a manner that is current, within 45 days from the date of the written CAP organized and permits effective and confidential request or the practitioner is otherwise member care and quality review. Anthem uncooperative with resolving outstanding issues Blue Cross performs medical record reviews of all with the facility site review, the provider will be PCPs and OB/GYNs (acting as PCPs) upon considered noncompliant. signing of a contract and, at a minimum, every Critical elements include: three years thereafter to ensure that network • Exit doors and aisles are unobstructed and providers are in compliance with these standards. escape accessible CONFIDENTIALITY Airway management equipment is available • Network providers shall agree to maintain the • Emergency medicine is available confidentiality of member information and • Only qualified/trained personnel retrieve, information contained in a member's medical prepare or administer medications. records according to the Health Information Privacy and Accountability Act (HIPAA) • Physicians review and follow-up standards. The Act prohibits a provider of referral/consultation reports and diagnostic healthcare from disclosing any individually test results identifiable information regarding a patient's • Only lawfully authorized persons dispense medical history, mental and physical condition, or drugs to patients treatment without the patient's or legal representative's consent or specific legal authority • Drugs and Vaccines are prepared and and will only release such information as permitted drawn only prior to administration. by applicable federal, state and local laws and that • Personal Protective Equipment for Standard is: Precautions is readily available for staff use. • Necessary to other providers and the health • Needles stick safety precautions are plan related to treatment, payment or practiced on site healthcare operations • Blood, other potentially infectious materials • Upon the member’s signed and written and regulated wastes are cared for and consent disposed of appropriately SECURITY • Spore testing of autoclaves completed monthly. The medical record must be secure and inaccessible to unauthorized access in order to

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13 | QUALITY MANAGEMENT prevent loss, tampering, disclosure of information, Providers must offer a copy of a member’s medical alteration or destruction of the record. Information record upon reasonable request by the member at must be accessible only to authorized personnel no charge, and the provider must facilitate the within the provider’s office, Anthem Blue Cross, transfer of the member’s medical record to another DHCS or to persons authorized through a legal provider at the member’s request. instrument. Confidentiality of and access to medical records Office personnel will ensure that individual patient must be provided in accordance with the standards conditions or information is not discussed in front of mandated in HIPAA and all other state and federal other patients or visitors, displayed, or left requirements. unattended in reception and/or patient flow areas. Providers must permit Anthem Blue Cross and STORAGE AND MAINTENANCE representatives of DHCS to review members’ medical records for the purposes of: Active medical records shall be secured and must Monitoring the provider’s compliance with be inaccessible to unauthorized persons. Medical • records are to be maintained in a manner that is medical record standards current, detailed and organized, and that permits • Capturing information for clinical studies or effective patient care and quality review while HEDIS maintaining confidentiality. Inactive records are to • Monitoring quality remain accessible for a period of time that meets state and federal guidelines. • Any other reason

Electronic recordkeeping system procedures shall MEDICAL RECORD DOCUMENTATION be in place to ensure patient confidentiality, prevent STANDARDS unauthorized access, authenticate electronic Every medical record is to include at a minimum: signatures and maintain upkeep of computer systems. • The patient’s name or ID number on each page in the record Security systems shall be in place to provide back- up storage and file recovery, to provide a • Personal biographical data including date of mechanism to copy documents, and to ensure that birth, home address, emergency contact recorded input is unalterable. name and telephone number, home and work telephone numbers, and marital status AVAILABILITY OF MEDICAL RECORDS • All entries dated with month, day and year The medical records system must allow for prompt retrieval of each record when the member comes in • All entries with the author’s identification (for for a visit. Providers must maintain members' example, handwritten signature, unique medical records in a detailed and comprehensive electronic identifier or initials) and title manner that accomplishes the following: • Identification of all providers participating in • Conforms to good professional medical the member’s care and information on practice services furnished by these providers • Facilitates an accurate system for follow-up • A problem list including significant illnesses treatment and medical and psychological conditions Presenting complaints, diagnoses and • Permits effective professional medical • review and medical audit processes treatment plans including the services to be delivered Medical records must be legible, signed and dated. • Physical findings relevant to the visit including vital signs, normal and abnormal

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findings, and appropriate subjective and • Evidence of preventive screening and objective information services in accordance with The Anthem Blue Cross Preventive Health Guidelines • Information on allergies and adverse reactions (or a notation that the patient has • Documentation of referrals, consultations, no known allergies or history of adverse diagnostic test results and inpatient records; reactions) evidence of the provider’s review may include the provider’s initials or signature • Information on advance directives and notation in the patient’s medical record • Past medical history including serious of the provider’s review and patient contact, accidents, operations, illnesses, and for follow-up treatment, instructions, return patients 14 years old and older, substance office visits, referrals, and other patient abuse (for children and adolescents, past information medical history relates to prenatal care, Notations of patient appointment birth, operation and childhood illnesses) • cancellations or “no shows” and the • Physical examinations, treatment necessary attempts to contact the patient to and possible risk factors for the member reschedule relevant to the particular treatment • No evidence that the patient is placed at • Prescribed medications including dosages inappropriate risk by a diagnostic test or and dates of initial or refill prescriptions therapeutic procedure • Instructions on follow-up care including date • Documentation on whether an interpreter of future preventive care visits must be was used and, if so, that the interpreter was documented on each visit also used in follow-up • For patients 14 years and older, appropriate • Documentation of the member’s preferred notations concerning the use of cigarettes, language alcohol and substance abuse (including anticipatory guidance and health education) MISROUTED PROTECTED HEALTH INFORMATION • Information on the individuals to be instructed in assisting the patient Providers and facilities are required to review all member information received from Anthem • Medical records must be legible, dated and Blue Cross to ensure no misrouted protected health signed by the physician, physician information (PHI) is included. Misrouted PHI assistant, nurse practitioner or nurse includes information about members that a provider midwife providing patient care or facility is not treating. PHI can be misrouted to • An immunization record for children that is providers and facilities by mail, fax, email or up-to-date or an appropriate history for electronic remittance advice. Providers and adults facilities are required to destroy immediately any • Documentation of attempts to provide misrouted PHI or safeguard the PHI for as long as it is retained. In no event are providers or facilities immunizations; if the member refuses immunization, proof of voluntary refusal of permitted to misuse or re-disclose misrouted PHI. the immunization in the form of a signed If providers or facilities cannot destroy or safeguard statement by the member or guardian shall misrouted PHI, please contact the appropriate be documented in the member’s medical Customer Care Center in Chapter 2: Quick record Reference.

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MEDICAL RECORDS REVIEW PROCESS received not only by our members but all patients The Anthem Blue Cross QM team will call the receiving care in these facilities. provider’s office to schedule a medical records Prevention of adverse events may require the review on a date and time. On the day of the disclosure of PHI. HIPAA specifies that PHI can be review, the QM staff will: disclosed for the purpose of healthcare operations in relation to quality assessment and improvement • Request the number and type of medical activities. Moreover, the information you share with records required. us is legally protected through the peer-review • Review the appropriate type and number of process. As such, it will be maintained in a strictly medical records per provider. confidential manner. If you receive a request for • Complete the medical record review. medical records, please provide them within 10 days from the date of request. • Meet with the provider or office manager to review and discuss the results of the We will continue to monitor activities related to the medical record review list of adverse events from federal, state and private payers including never events. • Schedule follow-up reviews for any corrective actions identified. Preventable adverse events should not occur. When they do, we firmly support the concept that a Providers must attain a score of 80% or greater in health plan and its members should not pay for order to pass the medical record review. A CAP will resultant services. be required if under 90% to improve future documentation. In the event that Anthem Blue Cross determines that the quality of care or services provided by a Provider sites that score below 80% in the medical healthcare professional is not satisfactory, as may record review for two consecutive reviews must be evidenced by member satisfaction surveys, score a minimum of 80% in the next review. Sites member complaints or grievances, medical that don’t score a minimum of 80% will be removed management data, complaints or lawsuits alleging from the network, and the provider’s members will professional negligence, or any other quality of be appropriately reassigned to other participating care indicator, Anthem Blue Cross may exercise providers. any appropriate rights to terminate the Provider PREVENTABLE ADVERSE EVENTS Agreement. The breadth and complexity of today’s healthcare Note: Medicaid is prohibited from paying for certain Healthcare Acquired Conditions (HCAC). This system means there are inherent risks, many of applies to all hospitals. which can be neither predicted nor prevented. However, when there are preventable adverse Never events: As defined by the National Quality events, they should be tracked and reduced with Forum (NQF), never events are adverse events the ultimate goal of eliminating them. that are serious but largely preventable and of concern to both the public and healthcare Providers and healthcare systems, as advocates for our members, are responsible for the providers. continuous monitoring, implementation and enforcement of applicable healthcare standards. Focusing on patient safety, we work collaboratively with network providers and hospitals to identify preventable adverse events and implement appropriate strategies and technologies to avoid them. Our goal is to enhance the quality of care

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14 | CLAI M S AND ENCO U NT E R S REIMBURSEMENT POLICIES REIMBURSEMENT HIERARCHY Reimbursement policies serve as a guide to assist Claims submitted for payments must meet all you in accurate claim submissions and to outline aspects of criteria for reimbursements. The the basis for reimbursement if the service is reimbursement hierarchy is the order of payment covered by a member’s Anthem Blue Cross benefit conditions that must be met for a claim to be plan. These policies can be accessed on our reimbursed. Conditions of payment could include website at: benefits coverage, medical necessity, authorization requirements or stipulations within a reimbursement  https://providers.anthem.com/california- policy. Neither payment rates nor methodology are provider/claims/reimbursement- considered to be conditions of payments. policies/medicaid-mmp. REVIEW SCHEDULES AND UPDATES The determination that a service, procedure, item, etc. is covered under a member's benefit plan is not Anthem Blue Cross reserves the right to review and a determination that you will be reimbursed. revise its policies periodically when necessary. Services must meet authorization and medical Reimbursement policies undergo reviews e for necessity guidelines appropriate to the procedure updates to state, federal or CMS contracts and/or and diagnosis as well as to the member’s state of requirements. residence. Additionally, updates may be made at any time if You must follow proper billing and submission we are notified of a mandate change or due to an guidelines. You are required to use industry Anthem Blue Cross business decision. When there standard, compliant codes on all claim is an update, the most current policy will be submissions. Services should be billed with Current published on the website provided at the beginning Procedure Terminology (CPT) codes, Healthcare of this section. Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote the REIMBURSEMENT BY CODE DEFINITION services and/or procedures performed. The billed Anthem Blue Cross allows reimbursement for code(s) are required to be fully supported in the covered services based on their procedure code medical record and/or office notes. definition, or descriptor, as opposed to their If appropriate coding/billing guidelines or current appearance under particular CPT categories or reimbursement policies are not followed, Anthem sections unless otherwise noted by state, federal or Blue Cross may: CMS contracts and/or requirements. There are • Reject or deny the claim. seven CPT sections: • Recover and/or recoup claim payment. 1. Evaluation and management Anthem Blue Cross reimbursement policies are 2. Anesthesia developed based on nationally accepted industry 3. Surgery standards and coding principles. These policies 4. Radiology (nuclear medicine and diagnostic may be superseded by provider or State contract imaging) language, or State, Federal requirements or mandates. System logic or setup may prevent the 5. Pathology and laboratory loading of policies into the claims platforms in the 6. Medicine same manner as described; however, Anthem Blue Cross strives to minimize these variations. 7. Category II codes: supplemental tracking codes that can be used for performance measurement

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8. Category III coeds: temporary codes for • If a provider has submitted a bill to a liable emerging technology, services or procedure third party, the provider has one year after the month of service to submit the bill for CLAIM SUBMISSIONS payment.

FILING LIMITS • If a legal proceeding has commenced in which the provider is attempting to obtain Claims must be submitted within the contracted payment from a third party, the provider has filing limit to be considered for payment. Claims one year to submit the bill after the month in submitted after that time period will be denied for which the services have been rendered. timely filing. The provider or hospital shall bill Anthem Blue Cross within 180 days from the date • If Anthem Blue Cross finds that the delay in of discharge for inpatient claims and 180 days from submission of the bill was caused by the date of service for outpatient and professional circumstances beyond the control of the claims or Anthem Blue Cross may refuse payment. provider. Filing limits should be determined as follows: CLEAN CLAIMS • If Anthem Blue Cross is the primary payer, Please use the following guidelines when use the length of time between the last date submitting a claim. of service on the claim and the Anthem • Submit clean claims, making sure that the Blue Cross receipt date. correct and complete information is • If Anthem Blue Cross is the secondary submitted on the correct form. A clean claim payer, use the length of time between the is a request for payment for a service other payer’s notice and remittance advice rendered by a provider that: date and the Anthem Blue Cross receipt ◦ Is submitted timely. date. ◦ Is accurate. • Note: Anthem Blue Cross is not responsible for a claim never received. If a claim is ◦ Is submitted in a HIPAA-compliant submitted inaccurately, prolonged periods format or using the standard claim before resubmission may cause you to miss form including a UB-04, CMS-1450 the filing deadline. To avoid missing or CMS-1500 (02-12), or successor deadlines, submit clean claims as soon as forms thereto, or the electronic possible after delivery of service. In the equivalent of such claim form. event of an inconsistency between ◦ Requires no further information, information contained in this Provider adjustment or alteration by the Manual and the Agreement between you provider or by a third party in order and Anthem Blue Cross, the Agreement to be processed and paid by us. shall govern. • Submit claims as soon as possible after • Pursuant to the California Welfare and providing service. Institutions Code (W&I) Section 14115, DHCS allows for the following four • Submit claims within the contract filing time exceptions to the 180-day filing limit: limit. • If the patient has failed to identify himself or If we do not adjudicate the clean claim within 30 herself as a Medi-Cal beneficiary within four business days, we will pay all applicable interest as months after the month of service. required by law. In the event that Anthem Blue Cross does not finalize a clean claim within 30 business days of receipt, interest will be due to the

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14 | CLAIMS AND ENCOUNTERS provider if the claim is payable. Providers are For EDI claims submissions that require notified of the disposition of a claim with either a attachments, contact Availity or your clearinghouse Remittance Advice (RA) or a Claims Disposition for guidelines. Notice (CDN) when the claim is finalized. For more information on EDI, providers and Paper claims that are determined to be unclean will vendors may call Availity Client Services at the be returned to the billing provider along with a letter following phone number-1-800-282-4548. You can stating the reason for the rejection. Electronic also contact this number if you are interested in claims that are determined to be unclean will be becoming a direct submitter. You can also email us rejected to the clearinghouse that submitted the at the following email address. claim. In the event you are a direct electronic EDI Solutions email: submitter to Anthem Blue Cross, the claim will be [email protected] returned to you directly. If you have any questions please contact Availity METHODS FOR SUBMISSION Client Services at 1-800-Availity (1-800-282-4548) There are two methods for submitting a claim: Monday through Friday 8:00 a.m. to 7:30 p.m. Eastern Time • Electronically through Electronic Data For additional information related to electronic Interchange (preferred) transactions, we have a website dedicated to • Paper or hard copy sharing billing information with providers and EDI ◦ CMS-1500 for Professional Services vendors including electronic clearinghouses. This information includes details on how to submit, UB-04 (CMS-1450) for Facility ◦ receive and troubleshoot electronic transactions. and/or Outpatient Ancillary Services To access all EDI manuals, forms and ELECTRONIC CLAIMS communications, go to: If the service is the responsibility of Anthem  http://www.anthem.com/edi Blue Cross, electronic filing methods are preferred The following are available online: for accuracy, convenience and speed. Electronic submitters will receive electronic acknowledgement • Availity* Quick Start Guide for EDI of the claim that has been submitted within 24 Submissions hours of receipt at Anthem Blue Cross. • EDI contacts and support information Electronic Data Interchange • EDI communications and electronic Anthem has a strategic relationship with Availity to submission tips serve as our Electronic Data Interchange (EDI) • Information on electronic filing benefits and partner for all electronic data and transactions. You cost savings can use your existing Clearinghouse or choose to send direct submissions to Availity. The website for • Filing instructions for EDI submission of more detail or to register is www.availity.com. eligibility, benefit and claim status inquiries (EDI) allows providers and facilities to submit and • Anthem Blue Cross HIPAA Companion receive electronic transactions. EDI is available for Guide and EDI User Guide with complete most common healthcare business transactions. information on submitting and receiving Please work with your software vendor, electronic transactions management service organization or your • Anthem Blue Cross report descriptions clearinghouse to enable electronic transactions. • FAQ about electronic transactions • Information and links to the HIPAA website

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PAPER CLAIMS • Don't highlight any fields on the claim forms If the service is the responsibility of Anthem or attachments; doing so makes it more difficult to create a clear electronic copy Blue Cross and you are unable to submit the claim when scanned. electronically, please mail paper claims to: If using a dot matrix printer, do not use draft Claims and Billing • mode since the characters generally do not Anthem Blue Cross have enough distinction and clarity for the P.O. Box 60007 Los Angeles, CA 90060-0007 optical scanner to read accurately. If you submit paper claims, you must include the If the service is the responsibility of one of our following provider information: delegated entities, please send the claim to the responsible entity. • Provider name Paper claims must be legible and submitted in the • Rendering provider group or billing provider proper format. Follow the guidelines below. • Federal provider tax identification number • Use the correct form and be sure the form (TIN) meets CMA standards. • National provider identifier (NPI) • Use black or blue ink (do not use red ink as • License number (if applicable) the scanner may not be able to read it). • Medicare number (if applicable) • Use the Remarks field for messages. Note: Some claims may require additional • Do not stamp or write over boxes on the attachments. Be sure to include all supporting claim form. documentation when submitting your claim. Send the original claim form to Anthem • A claim may be rejected or denied if it is submitted Blue Cross and retain a copy for your with incomplete or invalid information. It is the records. responsibility of the provider to submit accurate and • Separate each individual claim form. Do not timely information. staple original claims together; Anthem

Blue Cross will consider the second claim as an attachment and not an original claim to be processed separately. • Remove all perforated sides from the form; leave a ¼-inch border on the left and right side of the form after removing perforated sides. This helps our scanning equipment scan accurately. • Type information within the designated field. Be sure the type falls completely within the text space and is properly aligned. • Hand written claims need to use all capital letters and do not go outside of boxes into red areas. Use black ink and not markers.

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CMS-1500 CLAIM FORM FIELDS form for professional services and UB-04 (CMS-1450) for facility and/or some ancillary charges. Before submitting the claim to Anthem We encourage all providers to submit their professional claims to Blue Cross, please verify if Anthem Blue Cross is responsible for Anthem in an EDI format. In the event you need to submit a paper payment of the service. The service may be delegated to a provider claim, please submit the most current version of the CMS-1500 claim partner of Anthem Blue Cross.

# Title Explanation

1 Medicare, Indicate the type of health insurance coverage applicable to this claim by placing an X in the appropriate box. Only Medicaid, one box can be marked. TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other

1a Insured's ID Enter the insured’s ID number as shown on insured’s ID card for the payer to which the claim is being submitted. If Number the patient has a unique member identification number assigned by the payer, enter that number in this field.

2 Patient's Enter last name first, then first name and middle initial (if known). Do not use nicknames or full middle names. The Name ID card and the patient’s name must be identical.

3 Patient's Birth Enter the patient’s 8-digit date of birth as MM/DD/CCYY. Date

4 Insured's "Same" is acceptable if the insured is the patient. If the insurance is through a spouse or a parent, enter the Name insured’s name.

5 Patient's Enter complete address. Include any unit or apartment number. Include abbreviations for road, street, avenue, Address/Telep boulevard, place, etc. The NUCC recommends that the phone number not be reported. Phone extensions are not hone Number supported. Do not use punctuation in the address. Temporary addresses are not reported.

6 Patient The relationship to the member such as self, spouse, children or other. Relationship to Insured

7 Insured's "Same" is acceptable if the insured is the patient. It is not recommended to add the phone number as it is not Address/Phon transmitted over on the 837 file. e Number

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# Title Explanation

8 Reserved for Leave blank for NUCC use. NUCC Use

9 Other If there is other insurance coverage in addition to the member's coverage, enter the name of the insured. If the Insured's member has a Medigap policy different than that shown in item 2. Name

9a Other Enter the policy and/or group number of the secondary insurance (for example, Medigap insured preceded by Insured's MEDIGAP, MG or MGAP). Policy or Group Number

9b Other Enter date of birth in the MM/DD/YY format. If 9d is completed, leave blank. Insured's Date of Birth

9c Employer's Enter the claims processing address of the Medigap insurer If 9d is completed, leave blank. Name or School Name

9d Insurance Name of plan carrier. Plan Name or Program Name

10 Patient's Include any description of injury or accident including whether it occurred at work. Condition Related To

10a Related to Y or N. If insurance is related to workers compensation, enter Y. Employment?

10b Related to Y or N. Enter the state where the accident occurred. Auto Accident/Plac e?

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# Title Explanation

10c Related to Y or N. Other Accident?

10d Reserved for Condition codes: Approved for use in this item include codes for abortions, sterilization and codes for workman’s Local Use compensation claims. When required by payers to provide the subset of condition codes approved by the NUCC, enter the condition code in this field. The condition codes approved for use on the 1500 claim form are available at www.nucc.org under Code Sets.

11 Insured's Complete information about insured, even if same as patient. Medicare requires completion of these fields. Policy Group of FECA Number, Date of Birth, Sex, Employer or School Name

11a Insured’s Date Enter the insured’s 8-digit birth date (MM/DD/CCYY) and sex if different from item 3. If gender is unknown, leave of Birth blank.

11b Other Claim When submitting to property and casualty payers (e.g. automobile, homeowner’s, or workers’ compensation ID designated insurers and related entities), the following qualifier and accompanying identifier has been designated for use: Y4 by NUCC Agency Claim Number (Property Casualty Claim Number). Enter the qualifier to the left of the vertical, dotted line. Enter the identifier number to the right of the vertical, dotted line.

11c Insurance Enter the name of the insurance plan or program of the insured. Plan Name or Program Name

11d Is There This is marked to indicate if the patient has secondary insurance. If item is marked “YES,” items 9, 9a and 9d must Another also be completed. Health Benefit Plan?

12 Patient or The patient’s signature is required to authorize release of medical information to process the claim. Enter Authorized “Signature on File,” “SOF,” or legal signature. When legal signature, enter date signed in 6-digit (MM|DD|YY) or 8- Person’s digit (MM|DD|YYYY) format. If there is no signature on file, leave blank or enter “No Signature on File.” Use the Signature space available to enter signature/information and date.

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# Title Explanation

13 Insured or The patient’s signature authorizes payment of medical benefits to the physician or supplier. Authorized Person’s Signature

14 Date of Enter an 8-digit (MM/DD/CCYY) or 6-digit (MM/DD/YY) date of current illness, injury or pregnancy. For pregnancy, Current Injury, use the date of the last menstrual period (LMP) as the first date. Enter the applicable qualifier to identify which date Illness or is being reported. 431 Onset of Current Symptoms or Illness-484 Last Menstrual Period. Pregnancy

15 Other Date Enter another date related to the patient’s condition of treatment in either an 8-digit (MM/DD/CCYY) or 6-digit (MM/DD/YY) format. Enter the applicable qualifier to identify which date is being reported. Enter the applicable qualifier to identify which date is being reported.

16 Dates Patient If the patient is employed and unable to work in his/her current occupation, enter an 8-digit (MM/DD/CCYY) or 6- Unable to digit (MM/DD/YY) date when patient is unable to work. If the patient is treated for a work-related injury, the claim is Work in submitted to worker’s compensation and not the patient’s medical insurance. Current Occupation

17 Name of Enter the other ID number of the referring, ordering or supervising provider. Referring Provider or Other Source

17a Other ID# The other ID number of the referring, ordering or supervising provider is reported in 17a in the shaded area. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of 17a.The NUCC defines the following qualifiers used in 5010A1: 0B State License Number 1G Provider UPIN Number G2 Provider Commercial Number LU Location Number (This qualifier is used for supervising provider only.)

17b National Enter the NPI of the referring/ordering/supervising physician or nonphysician practitioner listed in item 17b. NPIs Provider are required. Number

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# Title Explanation

18 Hospitalizatio Enter the inpatient 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) hospital admission date followed by the n Dates discharge date (if discharge has occurred). If not discharged, leave discharge date blank. This date is when a Related to medical service is furnished as a result of, or subsequent to, a related hospitalization. Current Services

19 Additional Payers have different uses for this field. “Additional Claim Information” identifies additional information about the Claim patient’s condition or the claim. Information designated by NUCC

20 Outside Lab? Complete this item when billing for purchased services by entering an “X” in “YES” (for example, diagnostic tests $Charges subject to the antimarkup payment limitation). This is not used in an ASC. When “YES” is marked, charges are entered to the left of the vertical line. Enter number right justified to the left of the vertical line. Enter “00” for cents if the amount is a whole number. Do not use dollar signs, commas or a decimal point when reporting amounts. Negative dollar amounts are not allowed. Leave the right-hand field blank.

21 Diagnosis or The “ICD Indicator” identifies the version of the ICD code set being reported. The “Diagnosis or Nature of Illness or Nature of Injury” is the sign, symptom, complaint or condition of the patient relating to the service(s) on the claim. Enter the Illness or applicable ICD indicator to identify which version of ICD codes is being reported. Injury 9 ICD-9-CM 0 ICD-10-CM

22 Resubmission Enter the original reference number for resubmitted claims. When resubmitting a claim, enter the appropriate bill and/or frequency. 7 = replacement of prior claim; 8 = void/cancel of prior claim. Original Reference Number

23 Prior The “Prior Authorization Number” is the payer assigned number authorizing the service(s). Enter any of the Authorization following: prior authorization number, referral number, mammography precertification number, or Clinical Number Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service.

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# Title Explanation

24 Supplemental Supplemental information can only be entered with a corresponding, completed service line. The six service lines in Information section 24 have been divided horizontally to accommodate submission of both the NPI and another/proprietary identifier and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. The supplemental information is to be placed in the shaded section of 24a through 24g as defined in each item number. Providers must verify requirements for this supplemental information with the payer.

24a Date(s) of “Date(s) of Service” indicates the actual month, day and year the service(s) was provided. Grouping services refers Service to a charge for a series of identical services without listing each date of service.

24b Place of The “Place of Service” code identifies the location where the service was rendered. In 24b, enter the appropriate Service two-digit code from the Place of Service Code list for each item used or service performed. The Place of Service Codes are available at: https://www.cms.gov/Medicare/Coding/place-of-service- codes/Place_of_Service_Code_Set.html.

24c EMG “EMG” identifies if the service was an emergency. Check with payer to determine if this information (emergency indicator) is necessary. If required, enter Y for “YES” or leave blank if “NO” in the bottom, unshaded area of the field. The definition of emergency would be either defined by federal or state regulations or programs, payer contracts or as defined in 5010A1.

24d Procedure, “Procedures, Services or Supplies” identify the medical services and procedures provided to the patient. Enter the Services or CPT or HCPCS code(s) and modifier(s) (if applicable) from the appropriate code set in effect on the date of service. Supplies This field accommodates the entry of up to four two-digit modifiers. The specific procedure code(s) must be shown without a narrative description.

24e Diagnosis The “Diagnosis Pointer” is the line letter from item number 21 that relates to the reason the service(s) was Pointer performed. In 24e, enter the diagnosis code reference letter (pointer) as shown in item number 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. ICD-10-CM diagnosis codes must be entered in item number 21 only. Do not enter them in 24e.

24f $Charges “$Charges” is the total billed amount for each service line. Enter the charge for each listed service.

24g Days or Units “Days or Units” is the number of days corresponding to the dates entered in 24a or units as defined in CPT or HCPCS coding manual(s). Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. For anesthesia services based on time, the number of minutes must be reported as t units.

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# Title Explanation

24h EPSDT For Early and Periodic Screening, Diagnosis and Treatment-related services, enter the response in the shaded Family Plan portion of the field as follows: Enter “Y” for EPSDT or “N” for non-EPSDT. The following codes for EPSDT are used in 5010A1: AV Available – Not Used (Patient refused referral.) S2 Under Treatment (Patient is currently under treatment for referred diagnostic or corrective health problem.) ST New Service Requested (Referral to another provider for diagnostic or corrective treatment/scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service, not including dental referrals.) NU Not Used (Used when no EPSDT patient referral was given.)

24i ID Qualifier Enter in the shaded area of 24i the qualifier identifying if the number is a non-NPI. The other ID # of the rendering provider should be reported in 24j in the shaded area. If the provider does not have an NPI number, enter the appropriate qualifier and identifying number in the shaded area. There will always be providers who do not have an NPI and will need to report non-NPI identifiers on their claim forms. The qualifiers will indicate the non-NPI number being reported. The NUCC defines the following qualifiers used in 5010A1: 0B State License Number 1G Provider UPIN Number G2 Provider Commercial Number LU Location Number ZZ Provider Taxonomy (The qualifier in the 5010A1 for Provider Taxonomy is PXC, but ZZ will remain the qualifier for the 1500 claim form.)

24j Rendering The individual rendering the service should be reported in 24j. Enter the non-NPI ID number in the shaded area of Provider ID# the field. Enter the NPI number in the unshaded area of the field. The individual performing/rendering the service should be reported in 24j and the qualifier indicating if the number is a non-NPI is reported in 24i. The non-NPI ID number of the rendering provider refers to the payer assigned unique identifier of the professional.

25 Federal Tax Enter the “Federal Tax ID Number” (employer ID number or SSN) of the billing provider identified in item number ID Number 33. This is the tax ID number intended to be used for 1099 reporting purposes. Enter an “X” in the appropriate box to indicate which number is being reported. Only one box can be marked.

26 Patient’s Enter the patient’s account number assigned by the provider or service’s or supplier’s accounting system. This item Account No is optional to assist the provider in patient identification.

27 Accept Check the appropriate block to indicate whether the provider of service or supplier accepts assignment. Accepting Assignment? assignment means the provider agrees to the allowed amount (negotiated rate) for the charge.

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# Title Explanation

28 Total Charge Enter total charges for the services (for example, total of all charges in 24f). Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter “00” in the cents area if the amount is a whole number.

29 Amount Paid The “Amount Paid” is the payment received from the patient or other payers. Enter total amount the patient and/or other payers paid on the covered services only.

30 Reserved for This field is reserved for NUCC use. The NUCC will provide instructions for any use of this field. Leave blank. NUCC Use

31 Signature of The “Signature of the Physician or Supplier Including Degrees or Credentials” refers to the authorized or Physician or accountable person and the degree, credentials, or title. Enter the signature if provider of service or supplier, or Supplier his/her representative, and either an 8-digit (MM/DD/CCYY) or 6-digit (MM/DD/YY) date, or alpha-numeric date the Including form was signed. This can be completed as “Signature on File” or “SOF” or a computer generated signature. Degrees or Credentials

32 Service Enter the name, address, city, state and ZIP code of the location where the services were rendered. Providers of Facility service (namely physicians) must identify the supplier’s name, address, ZIP code and NPI number when billing for Location purchased diagnostic tests. When more than one supplier is used, a separate 1500 claim form should be used to Information bill for each supplier.

32a NPI# Enter the NPI number of the service facility location in 32a.Only report a service facility location NPI when the NPI is different from the billing provider NPI.

32b Other ID# The non-NPI ID number of the service facility is the payer assigned unique identifier of the facility. Enter the 2-digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen or other separator between the qualifier and number. The NUCC defines the following qualifiers used in 5010A1: 0B State License Number G2 Provider Commercial Number LU Location Number

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# Title Explanation

33 Billing Enter the provider’s or supplier’s billing name, address, ZIP code and phone number. The phone number is to be Provider Info entered in the area to the right of the field title. Enter the name and address information in the following format: & Ph # 1st Line – Name 2nd Line – Address 3rd Line – City, State and ZIP Code Item 33 identifies the provider that is requesting to be paid for the services rendered and should always be completed.

33a NPI of Billing The NPI number refers to the HIPAA national provider identifier number. Enter the NPI number of the billing Provider provider in 33a.

33b Other ID# The non-NPI ID number of the billing provider refers to the payer assigned unique identifier of the professional. Enter the 2-digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen or other separator between the qualifier and number. The NUCC defines the following qualifiers used in 5010A1: 0B State License Number G2 Provider Commercial Number ZZ Provider Taxonomy (The qualifier in the 5010A1 for provider taxonomy is PXC, but ZZ will remain the qualifier for the 1500 claim form.)

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UB-04/CMS-1450 CLAIM FORM FIELDS CMS-1500 claim form for professional services and UB-04 (CMS- We encourage all providers to submit their professional claims to 1450) for facility and/or ancillary charges. Before submitting the Anthem Blue Cross in an EDI format. In the event you need to claim to Anthem Blue Cross, please verify if Anthem Blue Cross is submit a paper claim, please submit the most current version of the responsible for payment of the service. The service may be delegated to a provider partner of Anthem Blue Cross.

# Title Explanation

1 Billing Provider The name and service location provider submitting the bill. The billing provider address must be a street address. Name, Address Use full nine-digit ZIP code XXXXX-XXXX. and Telephone Number

2 Billing The address that the provider submitting the bill intends payment to be sent if different than field 1. Address may Provider’s include P.O. Box or street name and number, city, state and ZIP. Use 5-digit ZIP code XXXXX. Designated Pay-to Address

3a Patient Control Patient’s unique number assigned by the provider to facilitate retrieval of the individual’s account of services Number containing the financial billing records and nay postings of payments.

3b Medical/Health The number assigned to the patient’s medical/health record by the provider. Record Number

4 Type of Bill A code indicating the specific type of bill (TOB) (for example, hospital inpatient, outpatient, replacements, voids, etc.). This is a four-digit code. First digit: leading zero/second digit: type of facility/third digit: bill classification/fourth digit: frequency of the bill

Federal Tax The number assigned to the provider by the federal government for tax reporting purpose, tax Identification Number number (TIN) or employer identification number (EIN).

Statement Covers Period The beginning and ending service dates of the period included on this bill. Format: MMDDYY. 6 (From- Through)

Reserved for Not used 7 Assignment

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# Title Explanation

8 Patient Last name, first name and middle initial of the patient and the patient identifier as assigned by the payer. Name/Identifier

Patient The mailing address of the patient. Enter the complete mailing address including street number and name or post 9 Address office box number or RFD; city name; state; ZIP code.

Patient Birth The date of birth of the patient. Format: MMDDYYYY 10 Date

11 Patient Sex The sex of the patient as recorded at admission, outpatient service or start of care. Format: M = male; F = female; U = unknown

Admission/Start The start date for this episode of care. For inpatient services, this is the date of admission. For other (home 12 of Care Date health) services, it is the date the episode of care began. Format: MMDDYYYY

13 Admission The code referring to the hour during which the patient was admitted for inpatient care. Enter the hour of Hour admission to the 24-hour (00-23) format. Do not include the minutes.

A code indicating the priority of this admission/visit.

Code Type Code Type

Priority (Type) 1 Emergency 4 Newborn-born 14 of Admission or outside hospital Visit 2 Urgent 5 Trauma

3 Elective

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# Title Explanation

A code indicating the point of patient origin for this admission or visit. UB-04: Required on all bill types except 014x.

Code Type Code Type

4 Transfer from a E Transfer from Hospital Ambulatory (Different Surgery Center Point of Origin Facility) (ASC) 15 for Admission or Visit 5 Transfer from a F Transfer from a Skilled Nursing Hospice Facility Facility (SNF)

6 Transfer from another Healthcare Facility

16 Discharge Hour The code referring to the hour during which the patient was admitted for inpatient care. Enter the hour of admission to the 24-hour (00-23) format. Do not include the minutes.

Patient A code indicating the disposition or discharge status of the patient at the end of service for the period covered on Discharge 17 this bill, as reported in FL6, Statement Covers Period. Status

18-28 Condition Condition codes are used to identify conditions related to the patient’s bill that may affect payer processing. These Codes codes should be entered from left to right in numeric-alpha sequence starting with the lowest value.

29 Accident State The accident state field contains the two-digit state abbreviation where the accident occurred.

30 Reserved for Not used. Assignment by the NUBC

31-34 Occurrence The code and associated date defining a significant event relating to this bill that may affect payer processing. Codes and Occurrence codes and dates should be entered from left to right, top to bottom in numeric-alpha order starting Dates with the lowest value.

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# Title Explanation

Occurrence A code and the related dates that identify an event that relates to the payment of the claim. These codes identify 35-36 Span Codes occurrences that happened over a span of time. Enter all dates as month, day and year (MMDDYY). and Dates

Reserved for 37 Assignment by Not used. the NUBC

Responsible The name and address of the party to whom the bill is being submitted. Address may include post office box or Party Name street name and number, city, state and ZIP code. Hospitals should abbreviate state in the address according to 38 and Address the post office standard abbreviations appearing in the instructions for Form Locator 01. The 9-digit ZIP code is (Claim used; it should be entered XXXXX-XXXX. Addressee)

A code structure to relate amounts or values to identify data elements necessary to process this claim as qualified by the payer organization. Enter value codes and amounts from left to right, top to bottom in numeric-alpha Value Codes sequence starting with the lowest value. Do not enter a decimal point (.), dollar sign ($), positive (+) or negative (-) 39-41 and Amounts sign. Enter full dollar amount and cents, even if the amount is even. Value codes and amounts are used to relate amounts to data elements necessary to process the claim. Value code information is required for Medicare/Medi- Cal crossover claims.

42 Revenue Codes that identify specific accommodation, ancillary service or unique billing calculations or arrangements. Codes (REV)

43 Revenue The facility can use this form locator to enter a narrative description or standard abbreviation for each revenue Description/IDE code shown in FL 42 on the adjacent line in FL 43. Number/Medic aid Drug Rebate

44 HCPCS/Accom 1. The Healthcare Common Procedure Coding System (HCPCS) applicable to ancillary service and outpatient modation bills. Rates/HIPPS 2. The accommodation rate for inpatient bills. Rate Codes 3. Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) on which payment determinations are made under several prospective payment systems.

45 Service Date Enter the date the service was rendered in six-digit format MMDDYY.

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# Title Explanation

46 Service Units Enter the actual number of times a single procedure or item was provided for the date of service. If billing for more than 99, divide the units on two or more lines. Inpatient Claims: Enter the number of days of care by revenue code.

47 Total Charges In full dollar amount, enter the usual and customary fee for the service billed. Do not enter a decimal point (.) or dollar sign ($). Enter full dollar amount and cents, even if the amount is even (for example, if billing for $100, enter “10000”not “100”).

48 Non-Covered The total noncovered charges pertaining to the related revenue code in FL 42 are entered here. Charges

49 Not used.

50 Payer Name Name of health plan that the provider might expect some payment for the bill.

51 Health Plan ID The number used to identify the payer or health plan.

Release of Information 52 Code indicates whether the provider has on file a signed statement (from the patient or the patient's legal Certification representative) permitting the provider to release data to another organization. Indicator

Assignment of Benefits 53 Code indicates provider has a signed form authorizing the third-party payer to remit payment directly to the Certification provider. Indicator

Prior Payments The amount the provider has received (to date) by the health plan toward payment of this bill. 54 - Payer

Estimated The amount estimated by the provider to be due from the indicated payer (estimated responsibility less prior Amount Due- 55 payments). Payer

National Provider The unique identification number assigned to the provider submitting the bill; NPI is the national provider identifier. 56 Identifier - Billing Provider

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# Title Explanation

Other (Billing) 57 Provider A unique identification number assigned to the provider submitting the bill by the health plan. Identifier

58 Insured's Name The name of the individual under whose name the insurance benefit is carried.

Patient's 59 Relationship to Code indicating the relationship of the patient to the identified insured. Insured

Insured's 60 Unique The unique number assigned by the health plan to the insured. Identifier

Insured's The group or plan name through which the insurance is provided to the insured. 61 Group Name

62 Insured's The identification number, control number, or code assigned by the carrier or administrator to identify the group Group Number under which the individual is covered.

Authorization An identifier that designates services on this bill have been authorized by the payer or indicates that a referral is Code/Referral 63 involved. Number

Document The control number assigned to the original bill by the health plan or the health plan's fiscal agent as part of their Control 64 internal control. Number (DCN)

Employer 65 Name (of the The name of the employer that provides healthcare coverage for the insured individual identified in FL 58. Insured)

Diagnosis and Procedure 66 Code Qualifier The qualifier that denotes the revision of International Classification of Diseases (ICD) reported. (ICD Version Indicator)

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# Title Explanation

Principal Diagnosis The lCD diagnosis code, appropriate to the lCD revision indicated in FL 66 describing the principal diagnosis (in Code and other words, the condition established after study to be chiefly responsible for occasioning the admission of the 67 Present on patient for care). Admission Indicator

68 Not used.

Admitting The ICD diagnosis code appropriate to the lCD revision indicated in field 66 describing the patient's diagnosis at 69 Diagnosis the time of admission. The reporting of the decimal between the third and fourth character is unnecessary Code because it is implied. ICD-10 is effective 10/1/2015.

Patient’s The lCD diagnosis codes appropriate to the lCD revision indicated in field 66 describing the patient's stated reason 70a-c Reason for for visit at the time of outpatient registration. The reporting of the decimal between the third and fourth character is Visit unnecessary because it is implied. ICD-10 effective 10/1/2015.

Prospective Payment 71 The PPS code assigned to the claim to identify the DRG based on the grouper software called for under contract System (PPS) with the primary payer. Code

External Cause of Injury (ECI) The lCD diagnosis codes appropriate to the lCD revision indicated in field 66 pertaining to the environmental Code and events, circumstances and conditions as the cause of injury, poisoning and other adverse effects. The reporting of 72a-c Present on the decimal between the third and fourth character is unnecessary because it is implied. ICD-10 effective Admission 10/1/2015. Indicator Element

73 Not used.

Principal Enter the appropriate ICD-10-PCS code identifying the primary medical or surgical procedure. Enter the ICD-10- 74 Procedure PCS code without periods or spaces between the numbers. In 6-digit format, enter the date the surgery or delivery Code and Date was performed.

Other Procedure Enter the appropriate ICD-10-PCS code identifying the secondary medical or surgical procedure without period or 74a-e Codes and spaces between the numbers. Dates

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# Title Explanation

75 Not used.

Attending Inpatient claim: The attending provider is the individual who has overall responsibility for the patient's medical care 76 Provider Name and treatment reported in this claim. and Identifiers Outpatient claim: Enter the referring or prescribing physician’s NPI in the first box.

Operating Inpatient claim: The name and identification number (NPI) of the individual with the primary responsibility for Physician 77 performing the surgical procedure(s). Do not enter a group provider number. Name and Identifiers Outpatient claim: Enter the rendering physicians name and identification number (NPI) in the first box.

Other Provider (Individual) 78-79 The name and ID number of the individual corresponding to the Provider Type category indicated in this section of Names and the claim. Inpatient claim: Enter the admitting physician’s name and individual identification number (NPI). Identifiers

80 Remarks Field If additional information cannot be completely entered in this field, attach the additional information to the claim on single-sided 8½ by 11-inch white paper.

Code-Code To report additional codes related to a field (overflow) or to report externally maintained codes approved by the 81 Field NUBC for inclusion in the institutional data set.

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CLAIMS PROCESSING: DOCUMENT Number (CIN) for the month of birth and the CONTROL NUMBER following month or until such time as the California All claims accepted by Anthem Blue Cross are Department of Health Care Services issues a assigned a unique document control number dedicated CIN for the newborn. (DCN). The DCN identifies and tracks claims that are accepted by Anthem Blue Cross. This number CLAIMS CODING AND contains the Julian date, which indicates the date DOCUMENTATION the claim was received. Claims submitted with incomplete or invalid Document control numbers are composed of 11 information will be rejected or denied and will need digits: to be resubmitted when applicable. Whether you submit a claim electronically or on paper, the claim • 2-digit plan year may be rejected/returned back to the submitter if it • 3-digit Julian date contains incomplete or invalid information and or is not deemed a clean claim. • 2-digit Anthem Blue Cross reel identification • 4-digit sequential number NATIONAL DRUG CODE CODING Medi-Cal billings for pharmaceuticals dispensed in CLAIMS PROCESSING: MCKESSON both professional and institutional settings should CLAIMSXTEN include the following information: For claims processing, Anthem Blue Cross uses National Drug Codes (NDCs) claims editing software from McKesson called • ClaimsXten. ClaimsXten incorporates McKesson • Healthcare Common Procedure Coding editing rules that apply plan payment policies. System (HCPCS) code The rules determine whether a claim should be • Unit of measurement paid, rejected or require manual processing. • Unit quantity The editing rules evaluate Current Procedural When billing for members enrolled in Medi-Cal, Terminology (CPT) and Healthcare Common providers are required to include a Universal Procedure Coding System (HCPCS) codes on Product Number (UPN), invoice submissions or the CMS-1500 form. A claim auditing action then for Enteral Medical Billing Number (MBN) for claims determines how the procedure codes and code involving medical supplies. combinations will be adjudicated. The auditing action recognizes historical claims related to INTERNATIONAL CLASSIFICATION OF current submissions and may result in adjustments DISEASES, 10TH REVISION DESCRIPTION to previously processed claims. Providers can refer As of October 1, 2015, ICD-10 became the code to McKesson ClaimsXtenTM rules by logging onto set for medical diagnoses and inpatient hospital Availity, our secure provider web portal at: procedures in compliance with HIPAA requirements  https://www.availity.com and in accordance with the rule issued by the U.S. Department of Health and Human Services (HHS). ClaimsXten may be updated periodically. Anthem Blue Cross will notify providers with advance notice ICD-10 is a diagnostic and procedure coding as per the Provider Agreement. system endorsed by the World Health Organization (WHO) in 1990. It replaces the International NEWBORNS Classification of Diseases, 9th Revision (ICD-9), Newborns of Medi-Cal members are covered under which was developed in the 1970s. Internationally, the mother using the mother's Client Index the codes are used to study health conditions and

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14 | CLAIMS AND ENCOUNTERS assess health management and clinical processes.  NPPES: 1-800-465-3203 In the United States, the codes are the foundation for documenting the diagnosis and associated CLINICAL SUBMISSION CATEGORIES services provided across healthcare settings. The following is a list of claims categories for which Although we often use the term ICD-10 alone, there we may routinely require submission of clinical are actually two parts to ICD-10: information before or after payment of a claim: • Clinical modification (CM): ICD-10-CM is • Claims involving precertification/prior used for diagnosis coding authorization/pre-determination (or some other form of utilization review) including but • Procedure coding system (PCS): not limited to: ICD-10-PCS is used for inpatient hospital procedure coding; this is a variation from ◦ Claims pending for lack of the WHO baseline and unique to the United precertification or prior authorization States. ◦ Claims involving medical necessity ICD-10-CM replaces the code sets ICD-9-CM, or experimental/investigative volumes one and two for diagnosis coding, and determinations ICD-10-PCS replaces ICD-9-CM, volume three for ◦ Claims for Injectables requiring prior inpatient hospital procedure coding. authorization NATIONAL PROVIDER IDENTIFIER • Claims requiring certain modifiers including local code (HCPCS Level III Interim codes if The National Provider Identifier (NPI) is a required) 10-digit, all numeric identifier. NPIs are only issued to providers of health services and supplies. As a • Claims involving unlisted codes provision of the Health Insurance Portability and • Claims for which we cannot determine from Accountability Act of 1996 (HIPAA), the NPI is the face of the claim whether it involves a intended to improve efficiency and reduce fraud covered service; thus, benefit determination and abuse. cannot be made without reviewing medical NPIs are divided into two types: records including but not limited to pre-existing condition issues, emergency • Type 1: individual providers, which includes service-prudent layperson reviews and but is not limited to physicians, dentists and specific benefit exclusions chiropractors Claims that we have reason to believe • Type 2: hospitals and medical groups, • involve inappropriate (including fraudulent) which includes but is not limited to hospitals, residential treatment centers, billing laboratories and group practices • Claims that are the subject of an audit (internal or external) including high-dollar For billing purposes, claims must be filed with the claims appropriate NPI for billing, rendering and referring providers. Providers may apply for an NPI online at • Claims for individuals involved in case the link below. management or disease management National Plan and Provider Enumeration • Claims that have been appealed (or that are System (NPPES) website: otherwise the subject of a dispute including claims being mediated, arbitrated or  https://nppes.cms.hhs.gov litigated) Or, you can get a paper application by calling NPPES at:

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Other situations in which clinical information might • Category II (HCPCS): These alphanumeric routinely be requested: tracking codes are used for execution measurement. • Accreditation activities Category III (interim/temporary codes): • Coordination of benefits • These are provisional codes for new and • Credentialing developing technology, procedures, and • Quality improvement/assurance efforts services. The codes were created for data collection and assessment of new services Recovery/subrogation • and procedures.* Examples provided in each category are for * In addition to the HIPAA-compliant codes, the illustrative purposes only and are not meant to California Department of Health Care Services represent an exhaustive list within the category. (DHCS) created a separate set of codes and modifiers for its Medi-Cal program, sometimes BILLING REQUIREMENTS FOR called Category III — Interim (local codes). These PROFESSIONAL, INSTITUTIONAL AND ANCILLARY CLAIMS codes and modifiers identify services and products specific to Medi-Cal. HIPAA compliant code sets must be used.* Mid-level practitioners: Indicate the name and HCPCS is an acronym for Healthcare Common license number in Box 19 of the CMS-1500 form; Procedure Coding System. Standardized code sets the supervising physician's license number should are necessary for Medicare and other health be entered in Box 24j. The following are defined as insurance providers to provide healthcare claims mid-level: that are managed consistently and in an orderly manner. HCPCS Level II coding system is one of • Physician assistants several code sets used by healthcare professionals • Nurse practitioners including medical coders and billers. The Level I • Certified nurse midwives HCPCS code set includes CPT codes. CPT is developed and owned by the American Medical • Licensed midwives Association (AMA). Prior Authorization Number: Indicate the prior CPT codes are the United States’ standard for how authorization number in Box 23 of the CMS-1500 medical professionals document and report form. medical, surgical, radiology, laboratory, There are certain exceptions to the prior anesthesiology, and evaluation and management authorization requirement. Professional and facility (E/M) services. All healthcare providers, payers claims for emergency services are not denied due and facilities use CPT codes. to lack of prior authorization. Emergency services HIPAA compliant codes fall into three categories: are determined by diagnosis codes and/or services billed. • Category I (CPT codes): These five-digit codes have descriptors which correspond to Member ID Number: Use the member's Client a procedure or service. Codes range from Index Number (CIN) when billing, whether 00100-99499. submitting electronically or on paper. It is important to use the member's plan ID card number, not the ◦ Modifier and/or revenue codes: number on the identification card issued by the Use modifier and revenue codes state. when appropriate with the corresponding HCPCS or CPT On-Call Services: Insert On-Call for PCP in Box codes. 23 of the CMS-1500 form when the rendering physician is not the PCP but is covering for or has

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14 | CLAIMS AND ENCOUNTERS received permission from the PCP to provide ◦ Crushing injuries services that day. ◦ Burns Note: When a provider/facility's reimbursement is ◦ Electric shock affected by a contract change during a course of treatment, the provider/facility is required to split • Manifestations of poor glycemic control the dates of service if you are a per-diem ◦ Diabetic ketoacidosis contracted provider/facility. This will allow your claim to be reimbursed at the appropriate rate. ◦ Nonketotic hyperosmolar coma ◦ Hypoglycemic coma REPORTING PROVIDER PREVENTABLE CONDITIONS ON PRESENT ON ADMISSION ◦ Secondary diabetes with CLAIMS ketoacidosis Medi-Cal providers are required to report ◦ Secondary diabetes with provider-preventable conditions (PPCs) with POA hyperosmolarity claims. This reporting is required for claims for • Catheter-associated urinary tract infection Medi-Cal payment or when treatment is given to a (UTI) Medi-Cal member for which payment would be Vascular catheter-associated infection available. • Surgical site infection following: Providers do not need to report PPCs that existed • before the provider initiated treatment for the Medi- ◦ Coronary artery bypass graft Cal member. The new federal regulations prevent (CABG) — mediastinitis Anthem Blue Cross from paying providers for the ◦ Bariatric surgery treatment of PPCs. To ensure compliance, DHCS will investigate all reports of PPCs to determine if • Laparoscopic gastric bypass payment adjustment is necessary. • Gastroenterostomy Please note: Reporting PPCs for a Medi-Cal • Laparoscopic gastric restrictive surgery member does not prevent or exclude the reporting of adverse events to the California Department of ◦ Orthopedic procedures Public Health pursuant to Health and Safety Code • Spine Section 1279.1. • Neck Scope of POA and PPC Claims • Shoulder The following is a list of preventable conditions • Elbow where payment is prohibited: • Deep vein thrombosis (DVT)/pulmonary • Foreign object retained after surgery embolism (PE) (not included for Medicaid • Air embolism for pediatric and obstetric populations) • Blood incompatibility ◦ Total knee replacement • Stage III and IV pressure ulcers ◦ Hip replacement • Falls and trauma Additionally, Anthem Blue Cross may not pay for the following events: ◦ Fractures • Surgery on the wrong patient ◦ Dislocations • Wrong surgery on a patient ◦ Intracranial injuries • Wrong site surgery

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The below Table of Indicator Codes for PPC forms These procedures are outlined in your Anthem Blue includes the codes to be used on the PPC form. Cross State Sponsored Business Group Using the codes correctly ensures you are Agreement. These procedures and disclosures reimbursed as appropriate. must comply with state/federal laws and regulations and our contractual standards and requirements. Indicator Description Reimbursable They must also be made available upon request by Y The condition Yes Anthem Blue Cross or a regulatory agency. was present on admission. Group claims processing systems must identify and track all claims activities including claims N The condition No was not present disputes and resolutions, and be able to deliver on admission. monthly reports. Groups must be able to identify and acknowledge the receipt of each claim, W The provider Yes determined that whether or not complete, and disclose the recorded it was not date of receipt in the same manner as the claim possible to was submitted. document if the If the claim was received electronically, the condition was • present on group must provide acknowledgement admission. within two business days of receipt of the claim. U The No documentation • If the claim was a paper claim, the group was insufficient must provide acknowledgement within 15 to determine if business days of receipt of the claim. he condition was present on Groups must pay a clean claim (or a portion admission. thereof) or contest or deny a claim (or a portion thereof) within 45 business days of receipt of the CLAIM PROCESSING claim (or within contractual time frames, which comply with the time frames set forth in this CLAIMS RETURNED FOR ADDITIONAL section). The group’s request for additional INFORMATION information must be sent to the provider of service Anthem Blue Cross may send you a request for with a due date for the requested information. additional or corrected information when the claim • Payment of a clean claim or notification of a cannot be processed due to incomplete, missing or denial must be sent, accompanied by a incorrect information. The request will indicate how remittance advice (RA), to the provider of long you have to return the information to Anthem service within 45 business days of the date Blue Cross. a claim is received.

CAPITATED GROUP CLAIMS PROCESSING • The date of payment or notification of denial is the postmarked date of the payment. When claims processing is a delegated activity, Anthem Blue Cross oversees the processing and • The provider and member must be notified dispute resolution to ensure that both are if a claim is denied, adjusted or contested. conducted in a timely manner and in accordance The notification must include an with state/federal regulations and contractual understandable written explanation of the agreements. reasons for the denial, adjustment or contested elements. Groups must have written procedures for claims processing available for review.

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Groups must have a dispute resolution mechanism COORDINATION OF BENEFITS/ in place that allows providers to file a dispute within THIRD-PARTY LIABILITY 365 days of receipt of an RA. All disputes must be Anthem Blue Cross may coordinate benefits with resolved within 45 business days of the group’s any other healthcare program that covers our receipt of the dispute or as required by applicable members including Medicare. Indicate other state/federal law. Check out IPA contract language. coverage information on the appropriate claim If a group determines that a claim was overpaid, form. If there is a need to coordinate benefits, the group must notify the provider in writing of the include at least one of the following items from the overpayment. other healthcare program when submitting a Coordination of Benefits (COB) claim: • The written notice must identify the claim, the name of the member, the date of • Third-party Remittance Advice (RA) service and a clear explanation of the basis • Third-party provider Explanation of Benefits upon which the group believes the amount (EOB) paid was in excess of the amount due including interest and penalties. • Notice from third party explaining the denial of coverage or reimbursement • Providers have 30 days from the receipt of the notice of the overpayment to contest or COB claims received without at least one of these reimburse the overpayment. items will be mailed back to you with a request to submit to the other healthcare program first. Please The responsibility for claims payment as outlined make sure that the information you submit above continues until all claims have been paid or explains all coding listed on the other carrier’s RA denied for services rendered pursuant to your or letter. We cannot process the claim without this Anthem Blue Cross State Sponsored Business specific information. Group Agreement. The filing limits for COB claims are as follows: For questions related to delegation of claims processing activities, contact your group • 180 days: for hospitals, institutions and administrator. professional services providers • 365 days: for ancillary service providers ELECTRONIC REMITTANCE ADVICE • Claims follow-up resubmissions are subject Anthem Blue Cross offers secure electronic to the 90-day resubmission filling limit delivery of remittance advices, which explain claims in their final status. This service is offered through CLAIMS STATUS Electronic Data Interchange (EDI). For more information, providers and vendors may call the Claims status can be monitored by doing the EDI Solutions Helpdesk. following:  Availity Client Services :1-800-282-4548 • Monitor claim status online via Availity at  www.availity.com. ELECTRONIC FUNDS TRANSFER ◦ See Chapter 2 for login instructions Anthem Blue Cross allows Electronic Funds Transfer (EFT) for claims payment transactions. • Monitor claim status through the Customer This means that claims payments can be deposited Care Center's Interactive Voice directly into a previously selected bank account. Response (IVR) at the contact numbers Providers can enroll in this service by visiting listed at the beginning of this chapter. CAQH EnrollHub, or contacting them at 844- 815-9763

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Note: The Interactive Voice Response (IVR) accepts either your National Provider Identifier Anthem Blue Cross (NPI) or your Federal Tax Identification Number Overpayment Recovery (TIN) for provider ID. Should the system not accept P.O. Box 73651 those numbers, it will redirect your call to the Cleveland, OH 44193-1177 Customer Care Center. For purposes of assisting If Anthem Blue Cross does not hear from you or you, we may ask again for your TIN. receive payment within 30 days, the overpayment CLAIMS FOLLOW-UPS/RESUBMISSIONS amount is deducted from future claims payments. In cases where Anthem Blue Cross determines that Providers can initiate a follow-up to determine claim recovery is not feasible, the overpayment is status by going to the Availity Provider Portal From referred to a collection service. the Claims and Payments menu there are options to view the status of the claim and submit a ENCOUNTER DATA dispute, view the status of submitted disputes, submit a corrected claim electronically or submit a QUALITY MEASURES FOR ENCOUNTER medical record in support of a pended or denied DATA claim. On January 1, 2015, the California Department of When resubmitting a claim by paper, take the Health Care Services (DHCS) implemented a following steps: Quality Measures for Encounter Data (QMED) program for managed care organizations in the 1. Complete all required fields as originally state. As a result, Anthem Blue Cross implemented submitted and mark the change(s) clearly. new quality standards for encounter submissions 2. Write or stamp "Corrected Claim" across and medical records. These standards relate to: the top of the form. • Data completeness 3. Attach a copy of the RA/EOB and state the • Data accuracy reason for resubmission. • Data reasonability 4. Attach all supporting documentation. • Data timeliness 5. Send to: Note: These new standards do not supersede the Anthem Blue Cross current claims timely filing requirements for P.O. Box 60007 fee-for-service claim submissions. Los Angeles, CA 90060-0007 DATA COMPLETENESS AND DATA OVERPAYMENT AND RECOVERY ACCURACY Anthem Blue Cross seeks recovery of all excess Under the QMED program, the DHCS Audits and claims payments from the person or entity to whom Investigations Division (A&I) will draw a random the benefit check is made payable. When an sample from the encounters submitted and request overpayment is discovered, Anthem Blue Cross the corresponding medical records from the initiates the overpayment recovery process by provider to check for data completeness. In sending written notification. addition, DHCS will randomly select a second If you are notified by Anthem Blue Cross of an medical record for the same beneficiary (if overpayment or discover that you have been applicable) to verify if a corresponding encounter is overpaid, mail the check along with a copy of the in the DHCS data warehouse. This subsequent notification or other supporting documentation medical record will also be audited for data within 30 days to the following address: completeness.

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In an encounter data validation study date of service is null. Providers are expected to commissioned by DHCS, key data elements were submit encounter data no less than weekly to evaluated for data completeness. The study found Anthem Blue Cross, whether a provider utilizes a a lack of correlation between the medical records clearinghouse or submits encounter data directly to and corresponding encounter records. Providers Anthem Blue Cross. Do not delay, submit your are required to submit complete and accurate data encounter immediately following the service to elements, and Anthem Blue Cross will begin ensure timely handling of the data. auditing medical records to assess data Contracted providers are required to submit completeness and accuracy. encounter data to Anthem Blue Cross according to DATA COMPLETENESS the following guidelines: Encounter data is complete when it includes the • 65% of encounters submitted (and following: accepted) within 60 calendar days of DOS (lag time of 0-60 days). • Correct billing provider name • 80% of encounters submitted (and • Correct date of service accepted) within 150 calendar days of DOS • Complete beneficiary information (lag time of 0-150 days). • 95% of encounters submitted (and DATA ACCURACY accepted) within 335 calendar days of DOS Accurate encounter data means: (lag time of 0-335 days). • Correct rendering provider data Another timeliness measurement is timely handling of rejection reports. Anthem Blue Cross now • Correct diagnosis codes(s) requires contracted providers to respond to • Correct procedure code(s) rejection reports as soon as providers receive them • Correct procedure code modifier(s) and will measure this process as follows: • Correct NDC match for J3490/J3590 • 50% of denied encounters are corrected and submitted (and accepted) within seven DATA REASONABILITY calendar days of being denied. Encounter data is reasonable when both the • 80% of denied encounters are corrected individual data and the data as a whole include and submitted (and accepted) within 15 valid dates and accurate information. To ensure the calendar days of being denied. accuracy and acceptability of encounter data, • 95% of denied encounters are corrected providers must use valid national standard codes and submitted (and accepted) within 30 for procedure codes, revenue codes and diagnosis calendar days of being denied. codes. Providers must ensure a valid National Provider Identifier (NPI) is used for billing provider, COMPLETENESS THRESHOLD rendering provider, referring provider and prescribing provider. The QMED program includes an Encounter Completeness threshold by county for each aid DATA TIMELINESS code (ACA optional expansion, Adult, Child, and SPD) as well as category of service (combined The QMED program will also measure data outpatient and ER, inpatient, pharmacy, and timeliness, or the lag-time, in days, between the professional) for encounter submissions. These date of service (DOS) and the claims submission DHCS-required thresholds are based on data from date. The DOS refers to the last date of service at annualized encounters per thousand members and the claim level or the first date of service if the last are subject to change when DHCS revises each

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14 | CLAIMS AND ENCOUNTERS respective threshold. Providers are required to submit encounters in accordance with the thresholds. Anthem will notify providers as the thresholds are updated by DHCS. If you have any questions, please contact your regional health plan at:  Fresno/Madera: 1-559-353-3500  Los Angeles: 1-866-465-2272  Sacramento/Bay Area: 1-916-589-3030  Tulare/Kings: 1-559-623-0480

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15 | GRIEVANCES, APPEALS, DISPUTES

15 | GRI EVANCES, APPEALS , DI SPUTES Providers have the right to file a dispute with Claim Inquiry: A question about a claim or claim Anthem Blue Cross for denial, deferral or payment is called an inquiry. Inquiries do not result modification of a claim disposition or post-service in changes to claim payments, but the outcome of request. the claim inquiry may result in the initiation of the claim payment dispute. In other words, once you Providers also have the right to appeal on behalf of get the answer to your claim inquiry, you may opt to a member for denial, deferral or modification of a begin the claim payment dispute process. prior authorization or request for concurrent review. These appeals are treated as member appeals and Our Provider Experience program helps you with follow the member appeals process. claim inquiries. Just call: Note: Anthem Blue Cross does not discriminate  Medi-Cal Customer Care Center: against providers or members for filing a grievance 1-800-407-4627 (outside L.A. County) or an appeal. Providers are prohibited from  Medi-Cal Customer Care Center: penalizing a member in any way for filing a 1-888-285-7801 (inside L.A. County) grievance.  MRMIP Customer Care Center: Provider grievances and appeals are classified 1-877-687-0549 into the following two categories: and select the Claims prompt within our voice 1. Grievances relating to the operation of the portal. We connect you with a dedicated resource plan including benefit interpretation, claim team, called the Customer Care Center, to ensure: processing and reimbursement • Availability of helpful, knowledgeable 2. Provider appeals of claim determinations representatives to assist you. including medical reviews related to adverse benefit determinations • Increased first-contact, issue resolution rates. Member grievances and appeals can include but are not limited to the following: • Significantly improved turnaround time of inquiry resolution. • Access to healthcare services • Increased outreach communication to keep • Care and treatment by a provider you informed of your inquiry status. • Issues having to do with how we conduct The CCC is available to assist you in determining business the appropriate process to follow for resolving your CLAIM PAYMENT DISPUTE claim issue. Claim Correspondence: is different from a If you are not satisfied with the outcome of a claim payment dispute. Correspondence is when Anthem payment decision, you may begin the claim Blue Cross requires more information to finalize a payment dispute process. claim. Typically, Anthem makes the request for this The claim payment dispute process consists of the information through the EOP. The claim or part of following linear steps: the claim may, in fact, be denied, but it is only 1. Reconsideration because more information is required to process the claim. Once the information is received, 2. Claim payment appeal Anthem will use it to finalize the claim. Please be aware there are three common, claim- related issues that are not considered claim Medical Necessity Appeals: Medical necessity payment disputes. To avoid confusion with claim appeals refer to a situation in which an authorization payment disputes, we’ve defined them briefly here: for a service was denied prior to the service. Medical

CLAIM INQUI RIES necessity appeals/prior authorization appeals are

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CLAIM INQUIRIES different than claim payment disputes and should be The results will then be communicated to you in a submitted in accordance with the medical necessity determination letter within 45 business days of the appeal process. receipt of the reconsideration. If the outcome of the

reconsideration requires an adjustment to a claim A claim payment dispute may be submitted for payment, the adjustment will take place within 15 multiple reason(s), including: business days of the reconsideration decision. • Contractual payment issues. CLAIM PAYMENT APPEAL • Disagreements over reduced or zero-paid If you are unsatisfied with the outcome of the claims. reconsideration, you may submit a claim payment • Post-service authorization issues. appeal within 60 calendar days of the reconsideration outcome. Please submit your claim • Other health insurance denial issues. payment appeal in writing and please include as • Claim code editing issues. much information as is pertinent to help us better • Duplicate claim issues. understand why you are appealing the decision. • Retro-eligibility issues. A provider has 30 calendar days to resubmit the appeal when missing information is requested. • Experimental/investigational procedure issues. Note: Some providers may have additional time to submit an appeal based upon their contract with Claim data issues. • Anthem Blue Cross. Timely filing issues.* • Upon receipt of your claim payment appeal, an * We will consider reimbursement of a claim that acknowledgement letter will be sent to you within has been denied due to failure to meet timely filing 15 business days of our receipt. We will conduct an if you can: 1) provide documentation the claim was internal review that includes a thorough submitted within the timely filing requirements or 2) investigation of the appeal by a trained claims demonstrate good cause exists. appeal analyst utilizing all applicable statutory, regulatory, contractual and provider subcontract CLAIM PAYMENT RECONSIDERATIONS provisions, Anthem Blue Cross policies and Anthem Blue Cross encourages you to submit a procedures, and all pertinent facts submitted from claim reconsideration if you believe a claim was not all parties. processed correctly. Please submit your request for The results will then be communicated to you in a claim reconsideration in writing and include all determination letter within 45 business days of the pertinent information that will help us understand receipt of the claim payment appeal. If the outcome the issue. We must receive your request for of the claim payment appeal requires an reconsideration within 12 months of the last adjustment to a claim payment, the adjustment will action on a claim. take place within 15 business days of the Upon receipt of your reconsideration request, an reconsideration decision. acknowledgement letter will be sent to you within SUBMISSION OF DISPUTES 15 business days of our receipt. We will conduct an internal review that includes a thorough You may submit Reconsiderations and Claim investigation of the claim payment by a trained Payment Appeals electronically through analyst utilizing all applicable statutory, regulatory, the Availity Payment Appeal Tool at contractual and provider subcontract provisions,  https://www.availity.com. Anthem Blue Cross policies and procedures, and all pertinent facts submitted from all parties.

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Through Availity, you can upload supporting Provider grievances may be filed up to 180 documentation and will receive immediate calendar days from the date the provider became acknowledgement of your submission. aware of the issue. You may use the Provider Resolution Request If a provider or member has a grievance, Anthem Form on our website using the address below to Blue Cross would like to hear from them either by submit a reconsideration or claim payment appeal. phone or in writing. Grievances may be filed by calling the Customer Care Center or in writing and  https://providers.anthem.com/CA submitted to the Grievance and Appeal Please submit requests for reconsideration or claim department. Providers may file a written grievance payment appeals to: by using the Physician/Provider Grievance Form located on our website at the following address. Claims Payment Reconsideration Department Anthem Blue Cross  https://providers.anthem.com/CA P.O. Box 60007 To mail the form, use the following address: Los Angeles, CA 90060-0007 Grievance and Appeal Department REQUIRED DOCUMENTATION FOR CLAIMS Anthem Blue Cross PAYMENT DISPUTES P.O. Box 60007 Anthem Blue Cross requires the following Los Angeles, CA 90060-0007 information when submitting a claim payment Providers can also fax the form to: dispute (reconsideration or claim payment appeal):  1-866-387-2968 • Your name, address, phone number, email, and either your NPI or TIN Anthem Blue Cross will send a written acknowledgement to the provider within five The member’s name and his or her Anthem • calendar days of receiving a grievance. We may or Medicaid ID number request medical records or an explanation of the • A listing of disputed claims, which should issues raised in the grievance in the following include the Anthem claim number and the ways: date(s) of service(s) • By telephone All supporting statements and • • By fax with a signed and dated letter documentation • By mail with a signed and dated letter

The timeline for responding to the request for more PROVIDER GRIEVANCES information is as follows: A provider may be dissatisfied or concerned about • Standard grievances: Providers must another provider, a member or an operational issue comply with the request for additional including claims processing and reimbursement. information within 10 calendar days of the Provider grievances may be submitted orally or in date that appears on the request. writing and include the following: Providers are notified in writing of the resolution • Provider’s name including their right of appeal if any. According to state law, we may not be able to disclose the final • Date of the incident disposition of certain grievances due to peer review • Description of the incident confidentiality laws.

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Anthem Blue Cross sends a written resolution letter Members may request a grievance or an adverse to the provider within 30 calendar days of the benefit determination appeal by calling our receipt of the grievance. Customer Care Center at: Grievances are tracked and trended, resolved  Medi-Cal Customer Care Center: within established time frames, and referred to peer 1-800-407-4627 (outside L.A. County) review when necessary. The Anthem Blue Cross  Medi-Cal Customer Care Center: grievance and appeal process meets all 1-888-285-7801 (inside L.A. County) requirements of state law and accreditation agencies.  MRMIP Customer Care Center: 1-877-687-0549 Note: Anthem Blue Cross offers an expedited grievance and appeal process to members for If a member wants to file a grievance, the process decisions involving urgently needed care. Whether is to call the Customer Care Center, write a letter to standard or expedited, grievances and appeals are the Grievance and Appeal department, or fill out a reviewed by a person who is not subordinate to the Member Grievance Form and mail it to us, telling initial decision-maker. us about the problem. Grievance forms are available at the places where ARBITRATION members receive their healthcare, such as their If the provider is not satisfied with the outcome of a PCP’s office, as well as on our website at: review conducted through the provider appeal https://mss.anthem.com/ca/pages/medi-cal.aspx process, there are additional steps that can be  taken through arbitration in accordance with the 1. Select Other Resources (drop-down menu Anthem Blue Cross State Sponsored Business in the bottom right of the page). Provider Agreement. 2. Select the language of the Member For more information, please call the appropriate Grievances Form. Customer Care Center at the contact numbers The grievance form should be mailed to: listed in Chapter 2 of this manual. Grievance and Appeal Department MEMBER APPEALS AND Anthem Blue Cross GRIEVANCES P.O. Box 60007 Los Angeles, CA 90060-0007 We encourage Anthem Blue Cross members to seek resolution of issues through our grievance A person does not need to be a member to file a and appeal process. The issues may involve grievance or appeal. Other representatives may dissatisfaction or concern about a contracted include the following: provider or the plan. • Relative Note: Anthem Blue Cross does not discriminate • Guardian against members for filing a grievance or an appeal. Providers are prohibited from penalizing a • Conservator member in any way for filing a grievance. • Attorney To help ensure that our members' rights are • Member's provider protected, all Anthem Blue Cross members are entitled to a grievance and appeal process.

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The grievance submission must include the Filing Timelines for the Member Grievance and following information: Appeal Process:

• Who is part of the grievance Member Anytime grievance • What happened • When it happened Member appeal: 60 calendar days after Medi-Cal the date of the letter • Where it happened notifying the member of • Why the member was not happy with the a denial, deferral or modification of a healthcare services request for services • Attach documents that will help us look into the problem Member appeal: 180 calendar days after MRMIP the date on the letter If the member cannot mail the form or letter, we will notifying the member of assist the member by documenting a verbal a denial, deferral or request. modification of a request for services Note: If the member’s grievance is related to an adverse benefit determination already taken, it is Note: Anthem Blue Cross will resolve any considered an appeal. grievance or appeal, internal or external, at no cost Adverse benefit determinations may include the to the member. Interpreter services and translation following: of materials into non-English languages and alternative formats are available to support • Denial or limited authorization of a members with the grievance and appeal process at requested service including the type or level no cost to the member. of service • The reduction, suspension or termination of MEMBER GRIEVANCES AND APPEALS: a previously authorized service ACKNOWLEDGEMENT After we receive a member’s request, we will send • The denial, in whole or in part, of payment an acknowledgment letter within five calendar for service days from the date we receive it. • Failure to provide services in a timely If we receive a request for an expedited grievance manner as defined by the state or appeal, the Medical Director will review the • Failure of Anthem Blue Cross to act within request to determine if the request involves an required time frames imminent and/or serious threat to the health of the member including but not limited to severe pain and potential loss of life, limb or major bodily function. This determination is made within one working day of the receipt of the expedited request. When the Medical Director determines that a case meets the criteria to be handled as an expedited or standard request, attempts to notify the member of the decision are made by telephone. In addition, an acknowledgement letter is sent to the member

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CLAIM INQUIRIES indicating the decision to handle as expedited or OTHER OPTIONS FOR FILING standard. GRIEVANCES If a request is determined to be appropriate for Members may submit a request to the following expedited handling, the acknowledgement letter entities: includes the member’s right to immediately notify • Los Angeles County members only: L.A. the Department of Managed Health Care (DMHC) Care Health Plan of the expedited appeal and informs the member of the time available for providing information and that • Medi-Cal Managed Care Office of the limited time is available for expedited appeals. Ombudsman at the California Department of Health Care Services MEMBER GRIEVANCES AND APPEALS: RESOLUTION INDEPENDENT MEDICAL REVIEW Anthem Blue Cross may request additional After exhausting The Anthem Blue Cross grievance information from the involved providers by phone, and appeal process, if a member is still dissatisfied mail or fax. The requests may include a request for with a decision, the member has the right to additional medical records or an explanation from request an independent medical review (IMR) the provider(s) involved in the case. Providers are from the following entities: expected to comply with requests for additional • California Department of Managed Health information within 10 calendar days for standard Care: Members may request an IMR if grievances and appeals and within 24 hours for an eligible for an expedited review or an urgent expedited grievance or appeal. grievance or appeal. The member will receive a Grievance Resolution Note: If the member has requested a state fair Letter within 30 calendar days of the date we hearing, he or she cannot also request an IMR. received the grievance. Standard appeals are resolved within 30 calendar MEDI-CAL MEMBER APPEALS: STATE FAIR HEARING days from the date of receipt of the request. Members are notified in writing of the appeal The state fair hearing process is applicable to resolution including their right to further appeal if Medi-Cal enrollees only. Anthem Blue Cross any. The request for an appeal may be done orally members enrolled MRMIP may not request a state but must be followed up with a written request. fair hearing. However, they may request an IMR. Anthem Blue Cross resolves expedited appeals as Medi-Cal members may request a state fair hearing quickly as possible and within 72 hours. The with the California Department of Social Services member is notified by telephone of the resolution, if (CDSS) after exhausting The Anthem Blue Cross possible, and is also sent a written resolution letter appeal processes, or if Anthem Blue Cross fails to within 72 hours from receipt of the appeal request. resolve an appeal request within the required time frames. The state fair hearing must be filed within 120 days from the date of the Notice of Appeal Resolution. The request may be submitted by writing to the state of California at: Department of Social Services State Hearing Division P.O. Box 944243, MS19-37 Sacramento, CA 94244-2430 By calling the department toll free at:

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 1-800-952-5253. We document, track and trend all alleged acts of discrimination. A Grievance and Appeal associate Or submitting an online request will review and trend cultural and linguistic Request a Hearing Online grievances in collaboration with a cultural and linguistic specialist. Note: An IMR with the Department of Managed Health Care (DMHC) may not be requested if a MEDI-CAL MEMBER APPEALS: state fair hearing has already been requested for a CONTINUATION OF BENEFITS FOR Notice of Adverse Benefit Determination. ANTHEM BLUE CROSS MEMBERS DURING Once the state receives the member’s request, the AN APPEAL process is as follows: Medi-Cal members may continue benefits while • The state sends a notice of the hearing their appeal or state fair hearing is pending in request to Anthem Blue Cross. accordance with federal regulations when all of the following criteria are met: • Upon receipt of the request, all documents related to the request and are forwarded to • Member or his provider on the member’s the state. behalf must request the appeal within 10 days of our mail date of the adverse action The state notifies all parties of the date, • notification or prior to the effective date on time and place of the hearing. the written notice of the adverse action. Representatives from our administrative, medical and legal departments may attend • The appeal involves the termination, the hearing to present testimony and suspension or reduction of a previously arguments. Our representatives may authorized course of treatment. cross-examine the witnesses and offer • Services were ordered by an authorized rebutting evidence. provider. • An administrative law judge renders a • The original period covered by the initial decision in the hearing within 90 business authorization has not expired, and member days of the date the hearing request was requests extension of benefits. made.

• If the judge overturns The Anthem Blue Cross position, we must adhere to the judge’s decision and ensure that it is carried out.

MEMBER GRIEVANCES AND APPEALS: DISCRIMINATION Members who contact us with an allegation of discrimination are immediately informed of the right to file a grievance. This also occurs when one of our representatives working with a member identifies a potential act of discrimination. The member is advised to submit an oral or written account of the incident and is assisted in doing so if he or she requests assistance.

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16 | COM PLIANCE AND REGULATORY RE QUI REME N TS PROVIDER’S ROLE IN When there is a compliance violation, we require a COMPLIANCE, ETHICS, PRIVACY corrective action plan with management actions AND HOTLINE REPORTING that mitigate risks and prevent further occurrence. As part of any investigation, we require that STANDARDS OF ETHICAL BUSINESS providers cooperate with the investigation and CONDUCT provide access to pertinent member records. The Anthem Blue Cross values drive our ethics The Department of Health and Human Services, program, and we expect our providers to embody Office of Inspector General (OIG) has published a these same values as you interact with our notice to assist physician practices in developing a members. voluntary compliance program. The Anthem Blue Cross core values are:  OIG Compliance Program for Individual and Small Group Physician Practices: • Leadership – Redefine what’s possible. https://oig.hhs.gov/authorities/docs/ • Community – Committed, connected, physician.pdf invested. • Integrity – Do the right thing, with a spirit of SCREENING AND MONITORING EXCLUDED excellence. PARTIES In our role as a government healthcare program • Agility – Deliver today – transform contractor, Anthem Blue Cross may not employ or tomorrow. contract with individuals or companies that are • Diversity – Open your hearts and minds. barred from taking part in such programs or  You may call the Anthem Blue Cross Ethics and receiving funds from such programs. Compliance Help Line to report potential To meet this obligation, Anthem Blue Cross misconduct: 1-877-725-2702 screens our providers against exclusion lists kept by the OIG, General Services Administration (GSA) Anthem code of conduct is located at:  and the Department of Health Care Services http://anthem.cmpsystem.com/file.php/1/ (DHCS) Suspended and Ineligible Provider List. public/SOEBC.pdf We expect our providers to also screen and monitor their staff on a regular, periodic basis. ANTHEM BLUE CROSS COMPLIANCE PROGRAM Providers should notify Anthem within 10 working days of removing a suspended, excluded, or Compliant operations help our members receive terminated provider from its Provider Network. the care they need. We have robust processes and oversight of our operations and we expect the MARKETING RULES same from our providers. The delivery of quality healthcare poses numerous Anthem Blue Cross follows the 7 Elements of an challenges, not least of which is the commitment effective compliance program. One of those shared by Anthem Blue Cross and its providers to elements is auditing and monitoring. We routinely protect our members. monitor a variety of processes including grievances Anthem Blue Cross wants its members to make the and appeals to understand providers’ performance. best healthcare decisions possible for themselves We also use a risk assessment approach to and their families. And when they ask for our determine the actions of our compliance assistance, we want to help them make those associates. If our risk assessment or monitoring decisions without undue influence. indicates potential noncompliance, we will conduct an investigation.

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Anthem Blue Cross follows strict enrollment and • That a prospective member or medical marketing guidelines created by the California recipient will lose benefits under the DHCS. Medi-Cal program or other welfare benefits if the prospective member does not enroll ENROLLMENT POLICIES with a specific healthcare plan Anthem Blue Cross providers may not market These policies also prohibit network providers from directly to individuals or families. taking the following actions: An example of direct marketing that is not allowed • Making marketing presentations or allowing is mailing to individual patients any Anthem Anthem Blue Cross representatives to make Blue Cross or other health plan material in which marketing presentations to prospective they are told to join Anthem Blue Cross or another members. plan. • Offering or giving away any form of All information that prospective members receive compensation, reward or loan to a about our healthcare plan comes from the state or prospective member to induce or procure from marketing activities approved by the California member enrollment in a specific healthcare DHCS. The state must approve any marketing plan. materials we create. • Engaging in direct marketing to members Providers may distribute information about our that is designed to increase enrollment in a healthcare plan after receiving a specific member particular healthcare plan. The prohibition request for more information on our benefits and should not constrain providers from services. engaging in permissible marketing activities Note: As a network provider, you may not provide consistent with broad outreach objectives prospective members with an Enrollment Form; you and application assistance. may only assist Anthem Blue Cross members (who • Using any list of members obtained are patients) in completing the Enrollment Form. originally for enrollment purposes from confidential state or county data sources or MARKETING POLICIES from the data sources of other contractors. Anthem Blue Cross providers are prohibited from • Employing marketing practices that making marketing presentations and advising or discriminate against potential members recommending to an eligible individual that he or based on marital status, age, religion, sex, she select membership in a particular plan. gender identity, national origin, language, DHCS marketing practice policies prohibit network sexual orientation, ancestry, pre-existing providers from making the following false or psychiatric or medical conditions (such as misleading claims: pregnancy, disability or acquired immune deficiency syndrome), other than those • That the PCP’s office staff are employees or specifically excluded from coverage under representatives of the state, county or federal government our contract. Reproducing or signing an enrollment • That Anthem Blue Cross is recommended • application for the member. or endorsed by any state or county agency or any other organization • Displaying materials only from the provider’s contracted managed healthcare • That the state or county recommends that a organizations and excluding others. prospective member enroll with a specific healthcare plan • Engaging in any marketing activity on behalf of Anthem Blue Cross on state or county

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premises or at event locations such as  https://www.anthem.com/wps/portal/abc/ath/ health fairs and festivals, athletic events, bnfooter?content_path=shared/noapplicatio recreational activities and plan-sponsored n/f0/s0/t0/pw_a103877.htm&label=Privacy%2 events. 0Statement

Providers are permitted to: Anthem Blue Cross uses a secure email • Distribute copies of applications to potential encryption tool to ensure that member's protected members. health information (PHI) is kept private and secure and to help prevent identity theft. Secure • Assist members in finding out what email encrypts emails and attachments that it programs they qualify for and then direct identifies as potentially having PHI. Providers can them to call appropriate resources for more also use secure email to send encrypted email to information. Anthem Blue Cross when they respond to an • File a complaint with Anthem Blue Cross if a Anthem Blue Cross-encrypted email. provider or member objects to any form of Anthem Blue Cross expects that member PHI and marketing, either by other providers or by PII is assiduously guarded and under strict security Anthem Blue Cross representatives. in your offices. Security for hard copy records and (Please refer to the Grievances and files must adhere to stringent confidentiality Appeals chapter of this manual for more standards that meet or exceed the HIPAA information) regulations and California statutes related to Note: Providers are required to obtain approvals information security. As well, unauthorized parties prior to using patient-focused and Anthem must not be allowed to view Anthem members’ PHI Blue Cross-branded marketing materials created by or PII. your office. Before distributing materials to your When you travel from the Anthem Blue Cross Medi-Cal patients, submit your materials to Anthem website to another website, whether through links Blue Cross through your local Community provided by Anthem Blue Cross or otherwise, you Relations Representative. We will review and seek will be subject to the privacy policies (or lack approval from the following agencies as thereof) of the other sites. We caution you to appropriate: determine the privacy policy of such sites before • L.A. Care Health Plan providing any personal information. Department of Health Care Services • MISROUTED PROTECTED HEALTH (DHCS) INFORMATION • Department of Managed Health Care Providers and facilities are required to review all (DMHC) member information received from Anthem • Managed Risk Medical Insurance Board Blue Cross to ensure no misrouted PHI is included. (MRMIB) Misrouted PHI includes information about members that a provider or facility is not treating. PHI can be Other stakeholders as required • misrouted to providers and facilities by mail, fax, HIPAA PRIVACY, PHI, SECURITY email or electronic remittance advice. Providers and facilities are required to destroy The Anthem Health Insurance Portability and immediately any misrouted PHI or safeguard the Accountability Act of 1996 (HIPAA) Web Privacy PHI for as long as it is retained. In no event are Statement and additional information about privacy providers or facilities permitted to misuse or and security policies and procedures can be found redisclose misrouted PHI. on the Provider Resources page of our website at:

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If providers or facilities cannot destroy or safeguard EXAMPLES OF PROVIDER FRAUD, WASTE misrouted PHI, please contact the appropriate AND ABUSE Customer Care Center located in Chapter 2: • Altering medical records to misrepresent Quick Reference. actual services provided FRAUD, WASTE AND ABUSE • Billing for services not provided  Anthem Blue Cross Fraud, Waste and Abuse • Billing for medically unnecessary tests or Hotline: 1-888-231-5044 procedures • Billing professional services performed by UNDERSTANDING FRAUD, WASTE AND untrained or unqualified personnel ABUSE • Misrepresentation of diagnosis or services We are committed to protecting the integrity of our healthcare program and the efficiency of our • Soliciting, offering or receiving kickbacks or operations by preventing, detecting and bribes investigating fraud, waste and abuse. • Unbundling: when multiple procedure codes Combating fraud, waste and abuse begins with are billed individually for a group of knowledge and awareness. procedures which should be covered by a single comprehensive procedure code • Fraud: Any type of intentional deception or misrepresentation made with the knowledge • Upcoding: when a provider bills a health that the deception could result in some insurance payer using a procedure code for unauthorized benefit to the person a more expensive service than was actually committing it or any other person. The performed attempt itself is fraud regardless of whether EXAMPLES OF MEMBER FRAUD, WASTE or not it is successful. AND ABUSE • Waste: Generally defined as activities The following are examples of member fraud, involving careless, poor or inefficient billing, waste and abuse: or treatment methods causing unnecessary expenses and/or mismanagement of • Forging, altering or selling prescriptions resources. • Letting someone else use the member’s • Abuse: Any practice inconsistent with Medi-Cal identification card sound fiscal, business or medical practices • Obtaining controlled substances from that results in an unnecessary cost to the multiple providers Medicaid program including administrative costs from acts that adversely affect • Relocating to out-of-service plan area providers or members. • Using someone else’s Medi-Cal It should be noted that under federal law (in other identification card words, the False Claims Act (FCA), Title 31 U.S.C. • Violating the pain management contract 3729 et seq.), anyone who knowingly submits or Pain management contract: A written agreement causes another person or entity to submit false between a provider and member that the member claims for payment of government funds is liable for will not misrepresent his or her need for up to three times the damages or loss to the medication. If the contract is violated, the provider government plus civil penalties of $5,500 to has the right to drop the member from his or her $11,000 per false claim. practice.

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REPORTING PROVIDER OR RECIPIENT ANONYMOUS REPORTING OF SUSPECTED FRAUD, WASTE AND ABUSE FRAUD, WASTE AND ABUSE If you suspect a provider (for example, provider Any incident of fraud, waste or abuse may be group, hospital, doctor, dentist, counselor, medical reported to us anonymously; however, our ability to supply company, etc.) or an Anthem Blue Cross fully investigate an anonymously reported matter member has committed fraud, waste or abuse, you may be handicapped. As a result, we encourage have the right to report it. you to provide as much detailed information as The name of the person reporting the incident and possible. his or her callback number will be kept in INVESTIGATION PROCESS confidence by investigators to the extent possible by law. We investigate all reports of fraud, waste and abuse. Allegations and the investigative findings When reporting possible fraud, waste or abuse are reported to the California Department of Health involving a provider (a doctor, dentist, counselor, Care Services (DHCS), regulatory and law medical supply company, etc.), include: enforcement agencies. In addition to reporting, we • Name, address and phone number of take corrective action such as: provider • Written warning and/or education: We • Name and address of the facility (hospital, send certified letters to the provider or nursing home, home health agency, etc.) member that document the issues and the need for improvement or changes in billing • Medicaid number of the provider and facility activities or services rendered. Letters may if you have it include information of an educational • Type of provider (doctor, dentist, therapist, nature, requests for recoveries or advisories pharmacist, etc.) denoting further action. • Names and phone numbers of other • Medical record review: We may review witnesses who can help in the investigation medical records to substantiate or refute • Dates of events allegations or validate claims submissions. • Summary of what happened • Special claims review: A special claims review process places payment or When reporting possible fraud, waste or abuse electronic system edits on file to prevent involving a member include: automatic claim payment; this requires a • The member’s name certified medical reviewer evaluation. • The member’s date of birth, Social Security • Prepayment review: Through a variety of number or case number if you have it means, certain providers or certain claims submitted by providers may come to The The city where the member resides • Anthem Blue Cross attention for behavior • Specific details describing the fraud, waste that might be identified as unusual or for or abuse coding or billing or claims activity which indicates the provider is an outlier with respect to his/her/its peers. For example, Anthem Blue Cross uses computer software tools designed to identify providers whose billing practices indicate conduct that is unusual or outside the norm of the provider’s peers. Once a claim or a provider

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is identified as an outlier, further contract and other matters under the jurisdiction of investigation is conducted by the SIU to the federal government. determine the reason(s) for the outlier The Stark Law is an anti-referral statute that is status or any appropriate explanation for an directed specifically at physicians and prohibits unusual claim, coding or billing practice. If them from making referrals for designated health the investigation results in a determination services to an entity with which they or an that the provider’s actions may involve immediate family member have a financial fraud, waste or abuse, the provider is relationship. The definitions of referral, designated notified and given an opportunity to health service, entity and financial relationship are respond. all quite broad. Recoveries: We recover overpayments • All providers are advised to seek their own counsel directly from the provider. Failure of the to ensure no referral is made in violation of the provider to return the supported Stark Law. overpayment may be reflected in reduced payment of future claims, or other DELEGATION OVERSIGHT administrative steps, to include possible termination from our network for The Anthem Blue Cross Delegation program’s participating providers, or further legal intent is to assure quality of care and service from action. contracted entities with delegated functions prior to delegation of any function and to assure FALSE CLAIMS ACT, FALSE STATEMENTS compliance with all the federal, state, accreditation ACT, STARK LAW and organizational requirements (CMS, DMHC, NCQA, related to the delegated function. We are committed to complying with all applicable federal and state laws including the federal FCA. The Delegation Program describes the plan’s process for performing an objective and systematic The FCA is a federal law that allows the review of the delegated functions in a consistent government to recover money stolen through fraud manner for all contracted networks or entities with a by government contractors. Under the FCA, anyone who knowingly submits or causes another delegated function(s). person or entity to submit false claims for payment Anthem Blue Cross may delegate to a qualified of government funds is liable for three times the provider group/entity the authority to perform damages or loss to the government plus civil selected medical management and administrative penalties of $5,500 to $11,000 per false claim. functions on its behalf. The qualified contracted provider group/entity is expected to perform such The FCA also contains qui tam or whistleblower functions in a manner that is consistent with all provisions. A whistleblower is an individual who Anthem Blue Cross standards, state and federal reports in good faith an act of fraud or waste to the laws, rules, regulations and accreditation government or files a lawsuit on behalf of the organization standards. government. Whistleblowers are protected from retaliation from their employer under qui tam The qualified contracted provider group/entity is provisions in the FCA and may be entitled to a expected to comply with all requirements of percentage of the funds recovered by the network adequacy standards established in DHCS’ government. All Plan Letter for Network Certification Requirements (Attachment A: Network Adequacy The False Statements Accountability Act prohibits Standards). DHCS established requirements to anyone from making false statements or evaluate the ability to provide medically necessary representations (written or oral) or withholding services needed for anticipated membership and material information relating to a government utilization. The geographic requirements are

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16 | COMPLIANCE AND REGULATORY REQUIREMENTS provided for distance and time from a member’s required to submit to Anthem Blue Cross their residence to a contracted provider for primary care, quarterly and annual audited financial statements specialty care, obstetrics/gynecology primary care, pursuant to GAAP within the same time frame as obstetrics/gynecology specialty care, hospitals, mandated under Sec 1300.75.4 of Title 28 of the pharmacy, and mental health (non-psychiatry) California Code of Regulations. outpatient services. Anthem Blue Cross reviews financial data trends Additionally, the qualified contracted provider using The Anthem Blue Cross financial viability group/entity is expected to meet or exceed the standards noting in particular any material changes required full time equivalent (FTE) provider-to- in financial condition and unusual balances. Also, member ratio for PCPs of one primary care Anthem Blue Cross requires that soft copies of the provider to every 2,000 members and a total provider organization’s DMHC formatted quarterly network physician ratio of one FTE physician to and annual financial survey reports must also be every 1,200 members. provided to Anthem Blue Cross. Anthem Blue Cross shall be responsible and liable The depth of the analysis is based on the level of for all administrative and operational functions of financial risk of the provider organization as the plan described in The Anthem Blue Cross determined pursuant to The Anthem Blue Cross contract with the DHCS. The delegated Financial Oversight Policies and Procedures group/entity is additionally expected and required to submitted and acknowledged by DMHC. In the comply with all the requirements of the plan’s DHCS event the provider organization does not meet any contract. of the solvency regulations and The Anthem Blue Cross financial viability standards, the provider At all times the plan retains the accountability and organization shall within 30 days upon request by overall responsibility as well as the right to monitor Anthem Blue Cross provide a Standby Letter of and rescind the delegation function. Credit (SL/C) as a security reserve in an amount PROGRAM PHASES acceptable to Anthem Blue Cross to mitigate risk. The Anthem Blue Cross Delegation Program is The Anthem Blue Cross minimum financial viability divided into three phases as follows: standards include the following: • Phase 1: preassessment 1. Cash ratio of at least 90% (cash and/or equivalents plus marketable securities Phase 1a: preassessment ◦ divided by total current liabilities) documents 2. Total stockholders’ capital must equal to at Phase 1b: preassessment review ◦ least 6% of total revenue or 8% of total • Phase 2: oversight and monitoring medical expenses, whichever is higher ◦ Phase 2a: annual audit 3. Maintain a working capital ratio of at least 1.5:1 ◦ Phase 2b: ongoing monitoring and oversight 4. Maintain a debt to equity ratio of not more than 200% • Phase 3: de-delegation 5. Provision for incurred but not reported PROVIDER GROUP FINANCIAL (IBNR) claims liability of at least two months OVERSIGHT of average annual claims expenses or based on the actuarial estimate approved In accordance with The Anthem Blue Cross HMO per California regulation Finance Policies and Procedures, the Medical Services Agreement and the California Solvency 6. Days cash on hand (DCOH) must at least Regulations, capitated provider organizations are be 60 days

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Anthem Blue Cross reserves the right to amend the adversely impact their financial capacity to fulfill financial viability standards as indicated above. their contractual responsibilities. Hence, upon its discretion Anthem Blue Cross shall Please note that at the front-end or pre-contract add to, delete from and otherwise modify any part stage, Anthem Blue Cross may require the of the P&P at any time. applicant hospital to submit a Standby Letter of Credit (SL/C) amounting to a minimum of $300,000 HOSPITAL FINANCIAL REVIEW or as may be determined by Anthem Blue Cross Concurrent with The Anthem Blue Cross policy to Finance in order to mitigate the inherent financial mitigate the risk with capitated provider risk. Unlike the capitated provider organization, organizations, a set of hospital financial viability hospitals are not subject to California solvency standards are similarly used as analytical regulations. guideposts in the evaluation of the capitated hospital’s financial capacity as follows: 1. Minimum working capital ratio of 1.10:1 2. Minimum tangible net equity of $5 million (total assets less total liabilities less intangibles) 3. Hospital cash ratio of at least 0.9 (cash and equivalents plus marketable investments, net patient receivables and board designated funds divided by total current liabilities) 4. Days receivable equivalent to 70 days or less 5. Days cash on hand (DCOH) of at least 50 days 6. Positive operating margin Capitated hospitals are required to provide Anthem Blue Cross with quarterly and annual financial statements based on the same time frames applicable to capitated provider organizations. The timely review of hospital financials would alert Anthem to those experiencing financial difficulties or have emerging financial issues that could

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* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross. IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross. LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross. ModivCare is an independent company providing transportation services on behalf of Anthem Blue Cross. VSP is an independent company providing vision services on behalf of Anthem Blue Cross.

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County.