Professional Documents
Culture Documents
Medi-Cal Managed Care, Healthy Families Program, Access for Infants and Mothers, and Major Risk Medical Insurance Program
Chapter 2: Important Contact Information Contact Information by Inquiry Type . . . . . . . . . . . . . . . . 1 Chapter 3: Covered and Noncovered Services Medi-Cal Californias Medicaid Program. . . . . . . . . . . . 1
What Is Medi-Cal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Medi-Cal (Californias Medicaid Program). . . . . . . . . . . . . . . . . . . 1 Who Is Eligible for Medi-Cal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Program Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
What Is MRMIP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Who Administers MRMIP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Who Pays for the Program? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Who Is Eligible for MRMIP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 What Happens After 36 Months With MRMIP? . . . . . . . . . . . . . 6 Want to Know More About MRMIP? . . . . . . . . . . . . . . . . . . . . . 6 Cross-Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Medicare Part D (Impact on Medi-Cal ONLY) . . . . . . . . . . . . . 17 Formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Prior Authorization of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Selective Serotonin Reuptake Inhibitors (SSRIs) Medi-Cal and Healthy Families Program Only . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Pharmacy Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Screening for Dental Problems . . . . . . . . . . . . . . . . . . . . . . . . . . 35
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Dental Referral Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Topical Fluoride Varnish . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Fluoride Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Cross-Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Non-Emergency Mental Health Services . . . . . . . . . . . . . . . . . . 37 Emergency Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . 37 Referral Criteria to Mental Health Specialists . . . . . . . . . . . . . . . 37 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Benefits Matrixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Healthy Families Program HMO Benefits Summary . . . . . . . . . 59 Healthy Families Program Exclusive Provider Organization (EPO) Benefits Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 AIM HMO and EPO Benefits Summary. . . . . . . . . . . . . . . . . . . 66 MRMIP Benefits Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Medi-Cal Managed Care Benefits Summary . . . . . . . . . . . . . . . . 71
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Chapter 5: Claims and Billing Guidelines Introduction and General Claims Guidelines . . . . . . . . . . 1
The Importance of a Correct Clean Claim. . . . . . . . . . . . . . . . . 1 Claim Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Claim Filing Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Questions about Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Submitting a Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Methods for Submitting Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Clinical Submissions Categories . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Coordination of Benefits (COB) . . . . . . . . . . . . . . . . . . . . . . . . . 11
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Outpatient CodingInstitutional . . . . . . . . . . . . . . . . . . . . . . . . 28 Sample Section from the CMS-1450 Form with Instructions . . 30 Recommended Fields for CMS-1450 . . . . . . . . . . . . . . . . . . . . . . 31
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Preservice Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
What to Have Ready When Calling UM . . . . . . . . . . . . . . . . . . . . 4 Preservice Review Time frame . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Emergency Medical Conditions and Services . . . . . . . . . . . . . . . . 6 Stabilization and Post-Stabilization . . . . . . . . . . . . . . . . . . . . . . . . 7 Referrals to Specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Concurrent Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Admission and Continued Stay Reviews . . . . . . . . . . . . . . . . . . . . 8 Inpatient Admission Notification. . . . . . . . . . . . . . . . . . . . . . . . . . 9 Clinical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Denial of Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Post-Service/Retrospective Review . . . . . . . . . . . . . . . . . . . . . . . 10
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Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Chapter 10: Member Rights and Responsibilities Member Rights and Responsibilities . . . . . . . . . . . . . . . . 1
Member Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Member Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Medi-Cal (L.A. Care Health Plan [L.A. Care]) . . . . . . . . . . . . . . . . 4 Healthy Families Program Member Rights and Responsibilities . 6 AIM Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . . 7 MRMIP Member Rights and Responsibilities . . . . . . . . . . . . . . . . 9
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Open Clinical Dialogue/Affirmative Statement . . . . . . . . . . . . . 13 Provider Terminations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Provider Terminations from Groups . . . . . . . . . . . . . . . . . . . . . . 13 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
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Chapter 14: Clinical Practice Guidelines Clinical Practice Guidelines . . . . . . . . . . . . . . . . . . . . . . . . 1 Chapter 15: Preventive Health Care Guidelines Preventive Health Care Guidelines . . . . . . . . . . . . . . . . . . 1 Chapter 16: Health Services and Programs Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Initial Health Assessment . . . . . . . . . . . . . . . . . . . . . . . . . 2
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
How to Schedule Health Education Classes . . . . . . . . . . . . . . . . . 7 Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 How to Get Health Education Materials for Your Office . . . . . . 7 Document Health Education Counseling and Referrals . . . . . . . . 8 Get Up and Get Moving! Family Workbook. . . . . . . . . . . . . . . . . 8 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Chapter 17: Provider Quality Improvement Quality Improvement (QI) Program Structure . . . . . . . . . 1
Quality Improvement (QI) Program Scope . . . . . . . . . . . . . . . . . . 1
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Quality Improvement (QI) Program Work Plan and Annual Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 What Providers Can Do to Support the Plans Quality Improvement (QI) Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Quality Improvement (QI) Studies and Projects . . . . . . . . . . . . . . 2
Disenrollment from the Plan: Medi-Cal and L.A. Care Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Who Can Initiate Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Member-Initiated Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The Plans Response to Member Disenrollment Calls . . . . . . . . . 4 Plan-Initiated Member Disenrollment . . . . . . . . . . . . . . . . . . . . . . 5 State Agency-Initiated Member Disenrollment . . . . . . . . . . . . . . . 6
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Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Chapter 22: Acronyms, Definitions and Maps Acronym List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Maps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
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CHAPTER 1: INTRODUCTION
Provider Operations Manual
PROPRIETARY INFORMATION
The information provided in this Provider Operations Manual is intended to be informative and assist you in navigating the various aspects of participation with the Anthem Blue Cross State Sponsored Businesses. Unless otherwise specified in your contract, the information contained in this manual is not binding upon Anthem Blue Cross and is subject to change. Please refer to the online manual for the most up-todate information. Anthem Blue Cross will make reasonable efforts to notify you of changes to the content of this material in advance. The information contained in this Provider Operations Manual for State Sponsored Business is the proprietary information of Anthem Blue Cross referenced in this manual. By accepting this manual, you agree not to disclose such information, to protect and hold the information confidential and to use this manual solely for the purposes of referencing information regarding the provision of medical services to Medi-Cal, the Healthy Families Program, Access for Infants and Mothers (AIM) and Major Risk Medical Insurance Program (MRMIP) members.
WELCOME
Using This Manual This manual is on the State Sponsored Business section of the Anthem Blue Cross website at www.anthem.com/ca. You may link to any section of this manual by clicking on the topic in the Table of Contents or in the Index. Each section also may contain links to other sections, definitions, and important phone numbers or to our website or outside websites containing additional information. Icons, bold type or boxes may draw attention to important information. Icons used are as follows:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
CHAPTER 1: INTRODUCTION
Provider Operations Manual
This manual and any further updates, revisions, and amendments are part of your applicable Anthem Blue Cross Participating Provider Agreement. In those instances when we determine that provisions in this manual, including any further updates, revisions and amendments, differ with provisions contained in your applicable Anthem Blue Cross Participating Provider Agreement, such provisions of the applicable Anthem Blue Cross Participating Provider Agreement shall govern and control over the provisions of this manual. The California Department of Health Care Services (DHCS) and the California Department of Public Health (DPH) contract with Anthem Blue Cross for the provision of Medi-Cal coverage in certain counties in California. Anthem Blue Cross provides coverage pursuant to the Managed Risk Medical Insurance Board for the Healthy Families Program (MRMIB), the Major Risk Medical Insurance Program (MRMIP), and the Access to Infants and Mothers (AIM) Program in the state of California. In Los Angeles County, Anthem Blue Cross also subcontracts with L.A. Care Health Plan for the provision of Medi-Cal coverage. Express Scripts, Inc. provides pharmacy benefit management services for all of these programs. Anthem Blue Cross Partnership Plan and Anthem Blue Cross are hereafter referenced jointly in this manual as Anthem Blue Cross or the Plan. This manual provides standards for services to members of the Medi-Cal, Healthy Families Program, MRMIP and AIM Programs only. It does NOT establish standards for services to any other members of the Plan or its affiliates. If a section of this manual only applies to a certain program, this is indicated in the applicable section. If there is no such indication, the information is applicable to all of the above programs. This manual does not obligate you to provide services to members enrolled in any of the above programs unless you are under contract with the Plan to provide services to members in one or more of these programs. You are only required to follow the standards in this manual that are applicable to the program in which the member is currently enrolled. There are instances throughout this manual where information is included as sample or example information. This information is intended to be for illustrative purposes only and is not intended to be used or relied upon.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
CHAPTER 1: INTRODUCTION
Provider Operations Manual
There are instances throughout this manual that refer to information on different websites. Any information on a website referred to in this manual, including, but not limited to, the information on the Anthem Blue Cross website, is being provided for informational purposes only and is expressly not incorporated into this manual by reference. However, as discussed in the Manual Updates section of this chapter, new materials or revisions to this version of the manual may be posted on the Anthem Blue Cross website and to the extent permitted by state laws, will be considered addenda to this manual. This manual and the Anthem Blue Cross website used by the Plan may provide links and pointers to internet sites maintained by third parties (Third Party Sites). From time to time, third party materials may be provided on the Anthem Blue Cross site used by the Plan. Neither the Plan nor its related, affiliated companies operate or control in any respect any information, products or services on the Third Party Sites. Third party material on the Anthem Blue Cross site used by the Plan and the Third Party Sites are provided without warranties of any kind either express or implied to the fullest extent permissible pursuant to applicable law. The Plan disclaims all warranties, express or implied, including, but not limited to, implied warranties of merchantability and fitness. The Plan does not warrant or make any representations regarding the use or results of the use of the third party materials on the Third Party Sites in terms of their correctness, accuracy, timeliness, reliability or otherwise. Please note that the members benefit agreement governs the members benefits, conditions, limitations and exclusions. In the event of any conflict between the terms outlined in this manual and the members benefit agreement, the terms of the members benefit agreement shall govern. Manual Updates If new material or revisions to existing material in this manual occur after this manual is published, we will provide updates through various means of distribution including, but not limited to, special mailings or newsletters, fax.or through our State Sponsored Business website at www.anthem.com/ca. As we improve our website, the content is subject to change. To the extent permitted by state laws, these updates are considered addenda to the manual. If you have questions about the content of this manual, contact our Customer Care Center or your provider network representative. This manual does not contain legal, tax or medical advice. Consult your own advisors for such advice.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
CHAPTER 1: INTRODUCTION
Provider Operations Manual
If we send you an e-mail or attachment containing PHI, you are notified that you
have a Secure eMail message.
By clicking on a link in this e-mail notification, you are directed to the Secure eMail
website at https://messages.wellpointsecureemail.com.
If you are using Secure eMail for the first time, you must register to create a
password-protected account.
Next, log in to Secure eMails Message Center to retrieve your e-mail and
attachment.
You can also use Secure eMail to send encrypted e-mails to us.
If you need technical assistance or have questions about Secure eMail, contact our eBusiness Help Desk at 1-866-755-2680. This service is available to you at no charge. We hope you understand the importance of taking these steps in protecting the personal information of your clients.
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https://provideraccess.co Monday: 12:30 a.m. to m midnight. Log in or follow instructions Tuesday to Friday: 1:30 a.m. in the Login box to create an to midnight. account. Saturday: 1:30 a.m. to 7 p.m. Holidays: 12:30 a.m. to midnight.
Medi-Cal Customer Care Center and IVR (outside L.A. County) Medi-Cal Customer Care Center and IVR (inside L.A. County) Healthy Families Program Customer Care Center and IVR
1-800-407-4627
Monday to Friday: 7 a.m. to 7 p.m. (Call 24/7 NurseLine for after-hours services.) Monday to Friday: 7 a.m. to 7 p.m. (Call 24/7 NurseLine for after-hours services.) Monday to Friday: 7 a.m. to 7 p.m. (Call 24/7 NurseLine for after-hours services.) Monday to Friday: 8:30 a.m. to 7 p.m. (Call 24/7 NurseLine for after-hours services.)
1-888-285-7801
1-800-845-3604
See above. 24 hours a day, 7 days a week. 24 hours a day, 7 days a week.
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https://provideraccess.co Monday: 12:30 a.m. to m midnight. Log in or follow instructions Tuesday to Friday: 1:30 a.m. in the Login box to create an to midnight. account. Saturday: 1:30 a.m. to 7 p.m. Holidays: 12:30 a.m. to midnight.
Claims Address: See CCC for Member P.O. Box 60007 eligibility. Los Angeles, CA 90060-0007
Fraud and Abuse Department See CCC phone numbers above. Fax: 1-805-384-3102
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Pharmacy
Resource Express Scripts Prior Authorization Customer Service Phone Number/Website 1-866-302-7166 Fax: 1-866-302-7167 1-800-227-3032 Hours of Availability Monday to Friday: 7 a.m. to 7 p.m. Monday to Friday: 5 a.m. to 10 p.m. Saturday and Sunday: 6 a.m. to 3 p.m.
Referrals
Resource California Childrens Service Referral Phone Number/Website Hours of Availability
Telemedicine
Resource Web portal Phone Number/Website 1-866-855-2271 www.anthem.com/ca/ telemedicine Hours of Availability Monday to Friday: 8 a.m. to 5 p.m. 24 hours a day, 7 days a week.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Is the second largest source of health care coverage in California, surpassed only
by employer-based coverage.
Provides health care coverage for low-income people who lack health insurance. Is a complex network of public and private health care providers who serve
Californias most vulnerable citizens. Who Is Eligible for Medi-Cal? While Medi-Cal is for low-income Californians, not everyone who is poor is eligible. There are 165 categories, or aid codes, under which an individual or a family may be eligible. Generally speaking, Medi-Cal covers:
Low-income children and their parents. Aged, blind or disabled persons. Low-income pregnant women. Individuals with refugee status. Qualified low-income Medicare recipients. People in special treatment programs (for example, tuberculosis and dialysis).
In Los Angeles County, we are subcontractors for the Medi-Cal Program for L.A. Care Health Plan.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
See Medi-Cal Managed Care Benefits Summary for Medi-Cal benefits information. Program Contacts Medi-Cal Customer Care Center: Medi-Cal, Health Care Options (HCO): L.A. Care Customer Care Center: Medi-Cal, L.A. Care (Los Angeles County): 1-800-407-4627 1-800-430-4263 1-800-285-7801 1-888-452-2273
Newborns up to 19th birthday. California residents. U.S. citizens or qualified immigrants. Ineligible for no-cost Medi-Cal. Not covered by employer health insurance for the past 90 days. Part of a family that meets Federal Income Guidelines.
See Healthy Families Program HMO Benefits Summary and Healthy Families Program Exclusive Provider Organization (EPO) Benefits Summary for Healthy Families Program benefits information.
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Program Contacts Customer Care Center: Healthy Families Program: 1-800-845-3604 1-800-880-5305
Makes her baby automatically eligible for enrollment in The Healthy Families
Program. AIM-linked Healthy Family infants are eligible for California Childrens Services (CCS). California Childrens Services is a state- and county-funded program that serves children under the age of 21 who have acute and chronic conditions that may benefit from specialty medical care and case management. State statutes and contracts required that CCS Program services be carved out of our Healthy Families Programs. As a result, upon suspicion or identification of a CCS-eligible condition, refer the child to the local CCS Program or contact us to assist with the referral. See California Childrens Services in this chapter for additional information about the CCS Program. AIM: Who Is Eligible? To qualify for AIM, a woman must be:
Pregnant, but not more than 30 weeks pregnant, as of the application date:
Application date: The date the application is sent to the AIM Program as shown by the U.S. postmark date on the application envelope or documentation from other delivery services. Weeks of pregnancy: Counting starts from the first day of the last menstrual period (applicants can also go to the AIM website to use a pregnancy calculator: www.aim.ca.gov).
A California resident: She has to have lived in California for the last six months.
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Not in other programs: She cannot be receiving no-cost Medi-Cal or Medicare Part
A and Part B benefits as of the application date.
Not covered by private insurance costing less than $500: She cannot have
maternity benefits through private insurance, unless coverage has a deductible or copayment specifically for maternity services that is more than $500 as of the application date.
Within AIM income guidelines: She must have a monthly household income (after
income deductions) within AIM Income Guidelines. Want to Know More About AIM? For questions about enrollment, please call: AIM Program: Available: Website: Cross-Reference 1-800-433-2611 Monday to Friday, 8 a.m. to 8 p.m. Saturday, 8 a.m. to 5 p.m. www.aim.ca.gov
Is a high-risk health insurance pool. Is for eligible people unable to secure private health coverage. Provides 36 months of access to health insurance.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Who Administers MRMIP? MRMIB, created in 1990, administers MRMIP. MRMIB began with a broad mandate to develop strategies for reducing the number of uninsured people in the state. MRMIB developed and launched MRMIP as its first program in 1991. The five-member Board has put together a comprehensive MRMIP benefits package. Subscribers may choose from any health plan participating in MRMIP. Who Pays for the Program? MRMIP is funded annually by $40 million from tobacco tax funds. With MRMIP, qualified members pay premiums. In turn, MRMIP supplements these premiums. Who Is Eligible for MRMIP? To be eligible for the program, applicants must meet four basic criteria:
A California resident Ineligible for Medicare, Part A and Part B, unless eligible solely because of
end-stage renal disease
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What Happens After 36 Months With MRMIP? To reduce the applicant waiting list and to serve more individuals with the limited funding available, MRMIP requires subscribers and enrolled dependents to leave MRMIP after 36 months and move into guaranteed coverage in the individual insurance market. Health plans are required to offer this guaranteed coverage. The State and health plans jointly subsidize the cost of guaranteed coverage. Approximately three months before the 36th month of enrollment, subscribers will receive additional information from MRMIP regarding that transition. Want to Know More About MRMIP? For questions on this program, please call: MRMIP Customer Service: Available: Website: Cross-Reference 1-877-687-0549 TDD: 1-888-757-6034 Monday to Friday, 8:30 a.m. to 7 p.m. www.mrmib.ca.gov
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The CCS program requires prior authorization through CCS for all services to be funded through CCS, per the California Code of Regulations. Services are generally authorized starting from the date of referral, with specific criteria for urgent and emergency referrals. A full description of the CCS program is available at http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx Sample Services and Benefits CCS provides funding for diagnosis, treatment and medical benefits (including medication and supplies) for eligible children. Care is delivered by CCS-paneled providers, CCS-approved facilities, Special Care Centers and other outpatient clinics. Additional services may be authorized by CCS based on a childs unique needs. This may include such necessary items as transportation to physician appointments, travel and lodging arrangements, special equipment and shift care. The state CCS program assesses the qualifications of each provider on its panel and maintains a list of specialists and hospitals that have been reviewed and found to meet CCS program standards. CCS also provides comprehensive medical case management services to all children enrolled in the program. Specialized Services Medical Therapy Program (MTP) Medical Therapy Program (MTP) provides physical and occupational therapy and comprehensive team services to children with specific physical disabilities, such as cerebral palsy, that require rehabilitation. The team physicians are specialists experienced in the treatment of chronically handicapped children. The team performs examinations and prescribes physical therapy (PT), occupational therapy (OT), durable medical equipment (DME) and other interventions to treat the childs eligible condition. Special Care Centers Children who need multi-disciplinary, multi-specialty care are required by CCS to receive their care at an approved special care center. Examples of conditions that benefit from treatment at special care centers are:
Craniofacial anomalies Complex congenital heart disease Chronic renal failure, including dialysis and transplant
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Sickle cell, hemophilia and other hemoglobinopathies Malignant neoplasms Certain endocrine disorders, including diabetes Inherited metabolic disorders Spina bifida Chronic lung disease HIV infection Cystic fibrosis Seriously ill neonates requiring hospitalization in the Neonatal Intensive Care Unit
(NICU) High-Risk Infant Follow-Up Program (HRIP) HRIP provides follow-up to infants up to three years of age who are discharged from an NICU without a CCS-eligible condition but who are at risk for developing a CCS-eligible condition such as cerebral palsy. Follow-up services include developmental assessment, neurology, ophthalmology and audiology evaluations. Program Eligibility To meet CCS program eligibility, children must:
Be under 21 years of age Have a CCS-eligible medical condition (refer to CCS Medical Eligibility) Meet certain other criteria (such as residential) Be cared for by CCS-paneled providers. Requirements for participation on the
CCS Provider Panel for specialists are listed on the back of the Panel Application, which may be obtained by contacting CCS. Anesthetists, assistant surgeons, certain other specialists and family practitioners who are not on the CCS panel may provide services as requested by a paneled physician. Contact your local CCS office if you want to become a CCS-paneled provider.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
For an application and requirements for CCS paneling go to http://www.dhcs.ca.gov/services/ccs/Pages/apply.aspx Find the telephone number and addresses for the local CCS offices at http://www.dhcs.ca.gov/Pages/Contacts.aspx Children who have Medi-Cal are financially eligible for the CCS program. For other criteria such as residential requirements, we can assist with this information. CCS Medical Eligibility This summary is not an authoritative statement of, and should not be cited as authority for, any decisions, determinations or interpretations under the CCS program. Refer to the California Code of Regulations for a full description or access CCS program medical eligibility information online at http://www.dhcs.ca.gov/individuals/Pages/qualify.aspx A brief overview of the applicable medical eligibility section is included with each category. Infectious Diseases (ICD-9-CM 001-139) (Section 41811) These are eligible when they involve bone, create visual problems leading to blindness, are congenitally acquired and require treatment or involve the central nervous system, and produce disabilities that require surgical or rehabilitative services. Neoplasms (ICD-9-CM 140-239) (Section 41815) These are eligible when they involve malignant neoplasms, including those of the blood and lymph systems. Benign neoplasms are included when they constitute a significant disability or visible deformity or significantly interfere with function. Endocrine, Nutritional and Metabolic Diseases and Immune Disorders (ICD-9-CM 240-279) (Section 41819) In general, these conditions are eligible. Eligible conditions include diseases of the pituitary, thyroid, parathyroid, adrenal, pancreas, ovaries and testes; growth hormone deficiency; diabetes mellitus; diseases due to congenital or acquired immunologic deficiency manifested by life-threatening complications; varied inborn errors of metabolism; cystic fibrosis. Nutritional disorders such as failure to thrive and exogenous obesity are not eligible.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Diseases of Blood and Blood-Forming Organs (ICD-9-CM 280-289) (Section 41823) In general, these conditions are eligible. Eligible conditions include sickle cell anemia, hemophilia and aplastic anemia. Iron or vitamin deficiency anemias are only eligible when there are life-threatening complications. Mental Disorders and Mental Retardation (ICD-9-CM 290-319) (Section 41827) Conditions of this nature are not eligible except when the disorder is associated with or complicates an existing CCS-eligible condition. Diseases of the Nervous System (ICD-9-CM 320-389) (Section 41831) Diseases of the nervous system are, in general, eligible when they produce physical disability (for example, paresis, paralysis, ataxia) that significantly impair daily function. Idiopathic epilepsy is eligible when the seizures are uncontrolled. (Generally, CCS requires the child to be on at least two medications to control seizures.) Treatment of seizures due to underlying organic disease (for example, brain tumor, cerebral palsy, inborn errors of metabolism) is based on the eligibility of the underlying disease. Specific conditions not eligible are those that are self-limiting and include acute neuritis and neuralgia and meningitis that does not produce sequelae or physical disability. Learning disabilities are not eligible. Disease of the Eye (ICD-9-CM 360-379) (Section 41835) Strabismus is eligible when surgery is required. Chronic infections or diseases of the eye are eligible when they may produce visual impairment or require complex management or surgery. Diseases of the Ear and Mastoid (ICD-9-CM 380-389) (Section 41839) Hearing loss, as defined per regulations and perforation of the tympanic membrane that requires tympanoplasty; mastoiditis, cholesteatoma, is eligible.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Disease of the Circulatory System (ICD-9-CM 390-459) (Section 41844) Conditions involving the heart, blood vessels and lymphatic system are usually eligible. Diseases of the Respiratory System (ICD-9-CM 460-519) (Section 41848) Some respiratory tract conditions may be eligible if they are chronic, such as chronic lung disease, respiratory failure requiring ventilatory support, and other chronic disorders of the lungs. Asthma may be eligible only if it results in chronic lung disease. Diseases of the Digestive System (ICD-9-CM 520-579) (Section 41852) Eligible conditions are diseases of the liver, chronic inflammatory disease of the gastrointestinal (GI) tract, most congenital abnormalities of the GI system and chronic intestinal failure. Malocclusion is eligible when there is severe impairment of occlusal function and is subject to CCS screening and acceptance of care. Diseases of the Genitourinary System (ICD-9-CM 580-629) (Section 41856) Chronic genitourinary conditions and renal failure are eligible. Acute conditions are eligible when complications are present. Diseases of the Skin and Subcutaneous Tissue (ICD-9-CM 680-709) (Section 41864) These conditions are eligible if they are disfiguring, disabling and require plastic or reconstructive surgery or prolonged and frequent multidisciplinary management. Disease of the Musculoskeletal System and Connective Tissue (ICD-9-CM 710-739) (Section 41866) Chronic diseases of the musculoskeletal system and connective tissue are eligible. Minor orthopedic conditions such as toeing-in, knock-knee and flat feet are not eligible. These conditions, however, may be eligible if extensive bracing, multiple casting or surgery is required.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Congenital Anomalies (ICD-9-CM 740-759) (Section 41868) Congenital anomalies of the various organ systems are eligible if the anomaly limits a body function, is disabling or disfiguring, amenable to cure, correction or amelioration, as per regulations. Certain Causes of Perinatal Morbidity and Mortality (ICD-9-CM 760-779) Neonates who have a CCS-eligible condition and require care in a CCS-approved Neonatal Intensive Care Unit (NICU) are eligible. Critically ill neonates who do not have an identified CCS-eligible condition but who are between 028 days and develop a disease or condition that requires certain services or combination of services in a CCS-approved NICU are eligible. Contact us to determine eligibility for these infants. Accidents, Poisonings, Violence and Reactions (ICD-9-CM 800-999) (Section 41872) Injuries of organ systems that, if left untreated, can result in permanent physical disability, permanent loss of function, disfigurement or death are eligible. Examples include fractures of the spine, pelvis or femur, some fractures of the skull, other fractures requiring open reduction, internal fixations or that involve joints or growth plates. Burns, foreign bodies, ingestion of drugs or poisons, lead poisoning and snake bites may be eligible depending on the severity of the injury and the need for continuing treatment. Medical Eligibility for Specific Conditions The CCS program requires sufficient medical documentation at the time of referral, and, in some cases, very specific documentation to provide evidence of strong suspicion that a CCS-eligible condition exists.
Cerebral Palsy: Detailed medical reports document the physical findings with a
complete musculoskeletal and neurological exam.
Hearing Loss: Refer after two separate audiometric evaluations, performed at least
six weeks apart, document hearing loss, if the child fails the Newborn Infant Hearing Screening Program or has documentation of risk factors associated with a sensorineural or conductive hearing loss.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
HIV Infection: If a positive PCR antigen or virus isolation results, refer children
with risk factors for HIV, including those less than 18 months of age with only a positive HIV antibody test to CCS for monitoring and follow-up.
Scoliosis: X-ray reports show a curvature of the spine greater than 20 degrees. Strabismus: Determination by an ophthalmologist that surgery is required to
correct the condition or that the strabismus is related to another CCS-eligible condition. Referral Process We can assist providers in making referrals to CCS. General guidelines follow for making referrals, including information that CCS requires to authorize services. The CCS program accepts referrals from any source such as health care providers, parents, legal guardians, school nurses, regional center counselors, health plans or other interested parties. Referrals to CCS may be made verbally or in writing. To consider a request, CCS requires the following information:
Date of referral Insurance information First and last name of child Home address of child Home and work numbers of parent/legal guardian Name and address of individual or agency requesting services Date of birth Client index number (CIN) Diagnosis
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP Version: 1.4 Revision Date: February 2010 Chapter 3: Page 13
Attending physician Name of hospital Admitting diagnosis Operative or diagnostic procedure (include CPT codes as appropriate) Estimated length of stay (LOS)
We can help you in making a request or referral to CCS for inpatient services.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
CCS Referral Procedures/Care Management Our staff works closely with the local CCS offices. The following procedures represent an overview of our referral and care management procedures for the Plans Medi-Cal Managed Care and Healthy Families Program members who are eligible for CCS.
Utilization Management refers the child to the Pediatric Care Management Unit
for CCS referral and continuity of care.
Our Care Management associates create a referral to CCS and obtain medical
records and additional information CCS requires to determine eligibility.
Our Care Management nursing staff work collaboratively with the local CCS office
to assure timely authorization of services and to coordinate care.
The PCP continues to provide care unrelated to the CCS-eligible condition. Once CCS authorizes services, the PCP office is notified in writing of the CCS
authorization for the members records.
Our claims associates assist with billing questions for children who have services
authorized by CCS. Provider Paneling Requirements for participation on the CCS provider panel for specialists are listed with the paneling application. Contact CCS or download the form online from the CCS website http://www.dhcs.ca.gov/formsandpubs/Pages/default.aspx Anesthetists, assistant surgeons and certain other specialists who are not on the CCS panel may provide services as requested by a paneled physician. Contact your local CCS office if you are interested in becoming a CCS-paneled provider. Find the telephone number and addresses for local CCS offices online at http://www.dhcs.ca.gov/ProvGovPart/Pages/Directories.aspx
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
PHARMACY BENEFITS
Members who are enrolled in Medi-Cal, Healthy Families Program, Major Risk Medical Insurance Program (MRMIP) or Access for Infants and Mothers (AIM) have pharmacy benefits. These benefits cover outpatient prescription drugs obtained through a retail pharmacy or mail order pharmacy, based on medical necessity and type of coverage. Licensed providers can prescribe medically necessary medication for a member. Copayments Plan members are responsible for the following pharmacy copayments:
Medi-Cal:
No copayment per generic prescription; limited to a 30-day supply at a retail pharmacy No copayment per brand name prescription; limited to a 30-day supply at a retail pharmacy No copayment per Attention Deficit Disorder (ADD) prescription for up to a 60-day supply at a retail pharmacy No copayment per oral contraceptive prescription for up to a 90-day supply at a retail pharmacy No copayment per prenatal vitamins prescription for up to a 90-day supply at a retail pharmacy No copayment per anti-tuberculosis prescription for up to a 90-day supply at a retail pharmacy
$5 copayment per generic prescription; limited to a 30-day supply at a retail pharmacy $5 copayment per brand name prescription; limited to a 30-day supply at a retail pharmacy $5 copayment per maintenance drug prescription; limited to a 90-day supply at our mail-order pharmacy (PrecisionRX) No copayment per prescription for contraceptive drugs/devices
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
MRMIP:
$5 copayment per generic prescription; limited to a 30-day supply at a retail pharmacy $15 copayment per brand name prescription; limited to a 30-day supply at retail pharmacy $5 copayment per generic prescription; limited to a 60-day supply at our mail-order pharmacy (PrecisionRX) $15 copayment per brand name prescription; limited to a 60-day supply at our mail-order pharmacy (PrecisionRX)
AIM:
No copayment per generic prescription; limited to a 30-day supply at a retail pharmacy No copayment per brand name prescription; limited to a 30-day supply at a retail pharmacy No copayment per maintenance drug prescription; limited to a 90-day supply at our mail-order pharmacy (PrecisionRX)
Medicare Part D (Impact on Medi-Cal ONLY) Medicare Part D, the new federal prescription drug benefit, pays for prescription drugs for Medicare/Medi-Cal dual-eligible recipients. This includes our dual-eligible Medi-Cal members with Anthem Blue Cross. We do not cover most prescription claims for these dual-eligible Medi-Cal members. Dispensing providers must submit most prescription claims to the dual-eligible members Prescription Drug Plan (PDP) or Medicare Advantage Prescription Drug Plan (MA-PDP).
Six categories of drugs and supplies listed below are covered by us for these
dual-eligible Medi-Cal members:
Weight loss medications (requires prior authorization submission for medical necessity) Cough/cold medications Over-the-counter medications (except for insulin and syringes, which are covered by PDP or MA-PDP) Barbiturates
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Prescription copayments are associated with PDP or MA-PDP for these dual-eligible Medi-Cal members. Dispensing providers may choose to waive these copayments or may not provide the prescriptions if the dual-eligible Medi-Cal member cannot pay these copayments. Formulary We use the Outpatient Prescription Drug Formulary to administer the pharmacy benefits for our members. The goal of the formulary is to ensure that our members receive therapeutically appropriate and cost-effective drug therapy. Since the formulary promotes rational, scientific care based on consideration of published clinical studies, Food and Drug Administration (FDA) data, community standards and cost-benefit evaluations, the formulary serves as a primary reference in the selection of medications for our members. Follow these steps to view the formulary:
Under Learn More, select Pharmacy to display the Pharmacy Web page.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
On the left side of the panel, select Anthem Blue Cross Formulary PDF
Format for a printable list of all Anthem Blue Cross formularies. Certain formulary medications and nonformulary medications may require a Prior Authorization of Benefits (PAB) depending on the members pharmacy benefit plan. Medi-Cal members: Certain formulary medications and all nonformulary medications require the prescribing provider to submit a written PAB to Express Scripts. Medi-Cal has a closed formulary, and do not substitute (DNS) or dispense as written (DAW) cannot be used as an override. Healthy Families Program, MRMIP and AIM members: Certain formulary medications and some nonformulary medications may require the prescriber to submit a written PAB to Express Scripts. Access to most nonformulary medications may be available when the prescribing provider indicates DNS or DAW on a written or verbal prescription. Use of this override is acceptable after a treatment failure, contra-indication to a formulary agent or agents or at the professional discretion of the prescribing provider. We will research excessive use of the override by prescribing providers and pharmacists for rationale. For medications requiring PAB, just fill out a PAB Form and submit it to Express Scripts for processing. Express Scripts administers the pharmacy program. Refer to Prior Authorization of Benefits in this section for more detailed information and a copy of the Prior Authorization of Benefits. For PAB assistance, call 1-866-302-7166. For specific quantity supply limits, refer to the Quantity Supply Limits for drugs. Branded Versus Generic Products The pharmacy benefit for our Medi-Cal and Healthy Families Program members is a mandatory generic program; however, branded products are available, if medically necessary, through the PAB process. MRMIP and AIM pharmacy benefits are driven by a copayment. Select medications are excluded from the mandatory generic program and include:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Lanoxin, Lanoxicap Synthroid, Levoxyl, Levothroid, Unithroid Dilantin, Phenytek Coumadin Sandimmune, Neoral, Gengraf Eskalith, Eskalith CR, Lithobid Uniphyl, Elixophyllin Depakene, Depakote, Depokote ER, Depakote Sprinkles Creon, Kutrase, Ku-Zyme HP, Pancrease, Pancrease MT, Ultrase, Ultrase MT, Viokase Clozaril Zarontin
For our MRMIP and AIM program members, generic prescriptions are dispensed by participating pharmacies unless the prescription specifies a brand name and states DNS or DAW. If the prescribing provider prefers not to use the DNS/DAW override, a prior authorization of benefits (PAB) request can be submitted to Express Scripts for processing an approval. Excluded Medications The pharmacy benefit for our members does not cover the following medications:
Fertility medications Cosmetic and hair medications Dietary supplements, except for treatment of phenylketonuria (PKU)
Over-the-Counter (OTC) Medications For all of our members, the pharmacy benefit does cover the following over-the-counter (OTC) medications when prescribed by a licensed practitioner for the treatment and monitoring of diabetes:
Blood glucose monitors (preferred brands are Accu-Check and One Touch)
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Blood glucose test strips (preferred brands are Accu-Check and One Touch) Ketone urine testing strips Lancets and lancet puncture devices Pen delivery systems for giving insulin Insulin products Insulin syringes
For our Medi-Cal members ONLY, select OTC medications are covered under the pharmacy benefit when prescribed by a licensed practitioner as a less expensive alternative to covered legend medications:
Analgesics Antacids Anti-diarrheals Anti-histamines (includes generic loratadine) Anti-inflammatories Anti-ulcer medications (includes Prilosec OTC) Benzyl peroxide for acne Contraceptive devices (spermicidal foams and creams, condoms) Cough and cold preparations Hematinics Hydrocortisone Laxatives/stool softeners Pediatric vitamins in established deficiencies Pediculicides Prenatal vitamins Smoking cessation products (generic nicotine patches and gums) Topical anti-fungal preparations
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Contraceptives The pharmacy benefit covers oral contraceptives, contraceptive devices and OTC contraceptives; however, injectable contraceptives and implantable devices, such as Norplant, are available through the medical benefit only. Cross-References
In the lower left side of the screen under Learn More, select Pharmacy to display
the Pharmacy page:
Find the subject matter list on the left side; then select to display information.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
PAB Guidelines Certain formulary medications and nonformulary medications may require PAB depending on the members pharmacy benefit plan. Medication utilization must meet FDA-approved indications and the guidelines for each particular medication. All PAB requests will be reviewed and decided upon within 24 hours or one business day. For a covered condition, we will not deny authorization for any FDA-approved drug that is approved for at least one indication and recognized for treatment of the covered indication in one of the standard reference compendia or in substantially accepted, peer-reviewed medical literature. For PAB questions, call the Express Scripts at 1-800-227-3032, Monday through Friday, 6 a.m. to 6 p.m. For a list of PAB drugs for Medi-Cal and Healthy Families Program, go online to http://pd.web.bluecrossca.com/wpf/forms/medicalpalist.pdf For Universal PAB Forms, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf All four programs follow the same prior authorization program. The PAB Forms are universal and can be used for all four programs. Nonformulary Prescriptions for Medi-Cal Members Only For Medi-Cal members, prescribing physicians must submit a written PAB request for all nonformulary medications. The DAW or DNS override has been permanently retired for our Medi-Cal members only. All nonformulary medication PAB requests require an internal review by Express Scripts on behalf of the Plan. Nonformulary medications may be approved if there are documented treatment failures, intolerance, contraindications or adverse effects to available formulary medications. Prior to being dispensed, nonformulary medications require an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For the Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
More-Than-Six-Prescriptions-Per-Month Review Program for Medi-Cal Members Only This Prescription Review Program requires a written PAB for all prescriptions that exceed the sixth prescription in a given month for Medi-Cal members only. The prescribing physician must submit a written PAB request for internal review by Express Scripts on behalf of the Plan. If additional prescriptions are medically necessary, Express Scripts will grant authorizations. This applies to both prescription and OTC medications. Prior to being dispensed, medications impacted by this program require an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For the Universal Medi-Cal PAB Forms, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf The most current PAB list can be found on the web at www.bluecrossca.com>Learn More>Pharmacy. Ophthalmic Antihistamines for Medi-Cal Members Only We promote the utilization of appropriate first-line therapies when medically appropriate. For a Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf Selective Serotonin Reuptake Inhibitors (SSRIs) Medi-Cal and Healthy Families Program Only We promote the utilization of generic citalopram, fluoxetine or paroxetine as first-line therapies when medically appropriate for depression. For a Selective Serotonin Reuptake Inhibitor (SSRI) Prior Authorization Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20SSP%20Brand%20Nam e%20SSRI%20PAB%20Form%209_7_05.pdf Statins For Medi-Cal and Healthy Families Program Only We promote the utilization of generic lovastatin as first-line therapy when medically appropriate for lowering high cholesterol. For a Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Onychomycosis (Lamisil, Sporanox, Intraconazole, Penlac) Anti-fungal medications are prescribed to treat systemic fungal infections. Prior to being dispensed, medications in this therapeutic class require an internal review by Express Scripts on behalf of the Plan to determine medical necessity. For a PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/onychomycosis.pdf Second Generation Antihistamines (Clarinex, Clarinex D, Allegra, Allegra D, Zyrtec, Zyrtec D) Prior to being dispensed, medications in this program require an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20NSA%20PAB%20Form %207_14_05.pdf Acne Agents (Isotretinoin: Accutane, Amnesteem, Claravis, Sotret) Prior to dispensing medication in this program, providers must request an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/isotretinoin.pdf Proton Pump Inhibitors (PPIs) (Prilosec, Prevacid, Aciphex, Protonix, Nexium, Zegerid, Omeprazole) Prior to being dispensed, medications in this program require an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form for initial therapy, go online to http://pd.web.bluecrossca.com/wpf/forms/initialppi.pdf For a PAB Form for maintenance therapy, go online to http://pd.web.bluecrossca.com/wpf/forms/maintenanceppi.pdf Growth Hormone (Humatrope, Genotropin, Serostim, Saizen, Nutropin, Nutropin AQ, Nutropin Depot, Norditropin, Protropin, Zorbitive) Prior to being dispensed, medications require an internal review by Express Scripts on behalf of the Plan to determine eligibility or medical necessity. For a PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/growthhormone.pdf
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Multiple Sclerosis Agents Medications require an internal review by Express Scripts on behalf of the Plan. For a Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf Leuprolide (Lupron) Medications in this program require an internal review by Express Scripts on behalf of the Plan. For a Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf Butorphanol Tartrate (Stadol NS) We promote the utilization of appropriate first-line therapies when medically appropriate. Medications require an internal review by Express Scripts on behalf of the Plan. For a Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf Topical Corticosteroids We promote the utilization of appropriate first-line therapies when medically appropriate. Medications in this program require an internal review by Express Scripts on behalf of the Plan. For a Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf Rheumatoid Arthritis Agents (Enbrel, Humira, Kineret) Prior to being dispensed, medications in this program require an internal review by Express Scripts. on behalf of the Plan to determine medical necessity. For a PAB Form for Enbrel, go online to http://pd.web.bluecrossca.com/wpf/forms/enbrel.pdf For a PAB Form for Humira, go online to http://pd.web.bluecrossca.com/wpf/forms/humira.pdf For a PAB Form for Kineret, go online to http://pd.web.bluecrossca.com/wpf/forms/kineret.pdf
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Psoriasis (Raptiva) Prior to being dispensed, Raptiva requires an internal review by Express Scripts on behalf of the Plan to determine medical necessity. For a PAB Form for Raptiva, go online to http://pd.web.bluecrossca.com/wpf/forms/raptiva.pdf Linezolid (Zyvox) Prior to being dispensed, Zyvox requires an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form for Zyvox, go online to http://pd.web.bluecrossca.com/wpf/forms/zyvox.pdf NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Irritable Bowel Syndrome (Lotronex, Zelnorm) Prior to being dispensed, medications require an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form for Lotronex, go online to http://pd.web.bluecrossca.com/wpf/forms/lotronex.pdf For a PAB Form for Zelnorm, go online to http://pd.web.bluecrossca.com/wpf/forms/zelnorm.pdf Forteo Prior to being dispensed, Forteo requires an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form for Forteo, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Forteo%20PAB%20For m%206_27_05.pdf Multi-Source Brand Medications (Brands with Generic Equivalents) Medications in this program require an internal review by Express Scripts on behalf of the Plan. For a Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf Narcolepsy (Provigil) Prior to being dispensed, Provigil requires an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form for Provigil, go online to http://pd.web.bluecrossca.com/wpf/forms/provigil.pdf Pulmonary Arterial Hypertension (PAH) For a PAB Form for PAH, go online to http://pd.web.bluecrossca.com/wpf/forms/pah.pdf
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Lyrica (Pregabalin) Prior to being dispensed, Lyrica requires an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form for Lyrica, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Lyrica%20PAB%20For m%208_16_05.pdf Somavert (Pegvisomant) Prior to being dispensed, Somavert requires an internal review by Express Scripts on behalf of the Plan to determine the medical necessity. For a PAB Form for Somavert, go online to http://pd.web.bluecrossca.com/wpf/forms/somavert.pdf Narcotic Pain Medication (Actiq) Prior to being dispensed, Actiq requires an internal review by Express Scripts on behalf of the Plan to determine medical necessity. For a PAB Form for Actiq, go online to http://pd.web.bluecrossca.com/wpf/forms/actiq.pdf Asthma (Xolair) Prior to being dispensed, Xolair requires an internal review by Express Scripts on behalf of the Plan to determine medical necessity. For a PAB Form for Xolair, go online to http://pd.web.bluecrossca.com/wpf/forms/xolair.pdf Angiotensin Receptor Blockers (ARBs) Medications in this program require an internal review by Express Scripts on behalf of the Plan. For a Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf Vfend (Voriconazole) Prior to being dispensed, Vfend requires an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form for Vfend, go online to http://pd.web.bluecrossca.com/wpf/forms/vfend.pdf
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Leukotriene Modifiers (Accolate, Singulair) Prior to being dispensed, medications in this program require an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form for leukotriene modifiers, go online to http://pd.web.bluecrossca.com/wpf/forms/leukotrienes.pdf Quantity Supply Limits Most pharmacy benefits allow up to a 30-day supply of medication in exchange for one copayment. This program defines a standard 30-day supply of medication for a select list of medications. If a medical condition warrants a greater quantity supply than the defined 30-day supply of medication, PAB ensures access to the prescribed quantity. Members should refer to their Evidence of Coverage (EOC) for benefit details, exclusions and limitations. For a PAB Form for quantity supply, go online to http;\\pd.web.bluecrossca.com/wpf/forms/qs.pdf For a PAB Form for narcotic quantity supply, go online to http://pd.web.bluecrossca.com/wpf/forms/qsnarcotics.pdf Dose Optimization The Dose Optimization Program, or dose consolidation, is an extension to the Quantity Supply Program that helps increase patient adherence with drug therapies. This program works with the member, the members physician or health care provider and the pharmacist to replace multiple doses of lower strength medications where clinically appropriate with a single dose of a higher-strength medication (only with the prescribing physicians approval). For a PAB Form for dose optimization, go online to http://pd.web.bluecrossca.com/wpf/forms/doseop.pdf Self-Injectables Newly approved injectable medications that are FDA-approved for self-administration will be covered through the outpatient prescription drug benefit but will be subject to written PAB until the agent is reviewed by the Pharmacy and Therapeutics Committee. For the Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Recombinant Erythropoietin Products (Procrit, Epogen, Aranesp) Prior to being dispensed, the medications in this program require an internal review by Express Scripts on behalf of the Plan. For the Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf Elidel and Protopic Prior to being dispensed, Elidel and Protopic require an internal review by Express Scripts on behalf of the Plan to determine medical necessity. For a PAB Form for Elidel or Protopic, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Elidel_Protopic%20PA B%20Form%20Draft%208_1_05.pdf Promethazine The FDA recently announced new safety information on the use of promethazine (Phenergan). Phenergan should not be used in pediatric patients less than 2 years of age because of potential for fatal respiratory depression. For the Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf Rozerem Prior to being dispensed, prescriptions for Rozerem require an internal review by Express Scripts on behalf of the Plan to determine medical necessity. For the Universal Medi-Cal PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf Ambien CR Prior to being dispensed, prescriptions for Ambien CR require an internal review by Express Scripts on behalf of the Plan to determine medical necessity. For the Universal Medi-Cal PAB Form, go to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Medi-Cal%20NF%20Br and%20Rx%20limit%20%20PA%20Form.pdf
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Lunesta Prior to being dispensed, medications in this program require an internal review by Express Scripts on behalf of the Plan to determine the appropriateness of the request. For a PAB Form for Lunesta, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Lunesta%20PAB%20Fo rm%207_29_05.pdf Zetia Prior to being dispensed, prescriptions for Zetia require an internal review by Express Scripts on behalf of the Plan to determine medical necessity. For a PAB Form for Zetia, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Zetia%20PAB%20Form %207_26_05.pdf Psychotropic Medication for Children Less than 6 Years Old Due to rising concerns about the use of various psychotropic medications in children less than six years old without the involvement of a specialist, particularly a child psychiatrist or pediatric neurologist, Anthem Blue Cross implemented a PAB Program to ensure that appropriate quality healthcare services are provided to our members. We require confirmation from either a child psychiatrist or neurologist for the prescribing and dispensing of anti-psychotic medications in children less than six years of age. In an effort to maintain the continuum of appropriate care, we encourage evaluation by a specialist for all children before initiating any psychiatric therapies. For a PAB Form, go online to http://pd.web.bluecrossca.com/wpf/forms/pageneric.pdf Pharmacy Contacts Express Scripts is a pharmacy benefit management company that administers all pharmacy benefits for the Plan. Contact Express Scripts for answers to pharmacy benefit questions, including eligibility, formulary status, PAB requests and benefit exclusions or inclusions, or call the following departments for pharmacy benefit issues:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Express Scripts Prior Authorization Center Telephone: Fax: Available: 1-866-302-7166 1-866-302-7167 Monday to Friday, 7 a.m. to 7 p.m.
Express Scripts Customer Care Center (Customer Service) Telephone: Available: 1-800-227-3032 Monday to Friday, 5 a.m. to 10 p.m. Saturday and Sunday, 6 a.m. to 3 p.m.
Request for Formulary Changes Formulary Addition Requests Anthem Prescription Management, LLC Attn: Formulary Department P.O. Box 746000 Cincinnati, OH 45274-6000 Epocrates website: www2.epocrates.com
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
DENTAL SERVICES
Proper dental care is essential to the overall health of our members. Lack of dental care and resulting oral diseases are among the most prevalent health problems in the United States. Lack of attention to dental issues can contribute to existing medical problems, reflect nutritional status, and create psychosocial problems. Our PCPs perform dental screening as part of the initial health assessments (IHA) for adults and children. This inspection follows guidelines established under the Child Health and Disability Prevention (CHDP), the Comprehensive Perinatal Services Program (CPSP) and the U.S. Preventive Task Force Guidelines. Dental services are not available for Medi-Cal members over age 21. Screening for Dental Problems PCPs conduct an inspection of the teeth, gums and mouth as part of an initial health assessment and make referrals to a dentist if appropriate. Dental Referral Procedures If needed, referrals to a dentist occur at a minimum during the initial health assessment and following each subsequent preventive care assessment. Members who have medical conditions or who are taking medication that affect the condition of the mouth or teeth are referred on an as-needed basis (for example, members who are immuno-compromised due to HIV or chemotherapy are at risk for developing mouth lesions that will require immediate care). The referral of children is a priority. An oral assessment is conducted during CHDP screenings; Medi-Cal eligible children over the age of three need to be linked to a dentist for preventive dental care, diagnosis, and treatment of existing problems. Parents needing assistance with scheduling a dentist appointment or obtaining transportation to the dentist are referred to the local CHDP office. Medi-Cal members can also call the toll-free Denti-Cal Dental Plan number at 1-800-423-0507 for dental plan information, referral to a dentist, or for information related to the members designated dental plan (if applicable). Healthy Families Program members are assigned to specific dental plans offered through MRMIB. The MRMIP and AIM programs do not cover dental services. Providers should document dental referrals on the members medical record.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Topical Fluoride Varnish Early childhood caries (ECC), more commonly known as tooth decay, is the most common chronic dental/medical problem in children. It is five times more prevalent than asthma and seven times more common than hay fever. It affects more the 50% of children by the time they are of kindergarten age. Physicians, nurses and medical personnel are legally permitted to apply fluoride varnish when the attending physician delegates the procedure and establishes protocol. When performing this procedure, it is necessary to document dental assessment and fluoride varnish application in the members medical record in a timely manner. Providers need to complete the Confidential Screening/Billing Report (Form PM 160). Go to http://files.medi-cal.ca.gov/pubsdoco/publications/Masters-Other/CHDP/ Forms/confPM160_c01.pdf for a sample report. Fluoride Application It takes less than three minutes to swab fluoride varnish directly onto the teeth. It sets within one minute of contact with saliva. No special dental equipment is needed. The provider may purchase fluoride varnish in tubes containing sufficient product for multiple applications; however, many providers find it easier and more convenient to use prepackaged single-use tubes that come with a small disposable applicator brush. HCPCS Code D1203 (topical application of fluoride [prophylaxis not included] child) is a Medi-Cal benefit for children younger than 6 years of age, available up to three times in a 12-month period. Topical Fluoride Varnish Training The First Smiles Program, funded by the California Children and Families Commission, conducts training for medical and dental professionals in various locations around the state. More information on oral health assessment, fluoride varnish application guidance as well as training dates and locations is available at http://www.first5oralhealth.org/. Information for ordering fluoride varnish can be found on the Kansas Department of Health and Environment at http://kdheks.gov/ohi/fluoride_varnish_ordering_info.html. Cross-Reference
Benefits Matrixes
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Medi-Cal: Call your local county mental health department. Healthy Families Program HMO: Call WellPoint Behavioral Health at
1-800-399-2421.
MRMIP and AIM HMO: Call the Customer Care Center at 1-877-687-0549.
Refer to the MRMIP Benefits Summary and AIM HMO and EPO Benefits Summary sections to determine which mental health benefits are available to your members. Emergency Mental Health Services PCPs refer any member in crisis, or who is a threat to himself, herself, or others, immediately for emergency care. An emergency referral for mental health services does not require a preservice review by us; however, PCP-initiated referrals allow for better coordination of care for the member. Referral Criteria to Mental Health Specialists PCPs refer members who are experiencing acute symptoms of a chronic mental health disorder, are exhibiting an acute onset of symptoms, or are in a crisis state. PCPs also make referrals for members the PCP currently treats for anxiety and mild depression and whose symptoms persist or become worse. Any member suspected of developing toxicities to medications that have been prescribed by a psychiatrist are referred back to the mental health system for observation and monitoring of his/her medications. PCPs refer any member with the following established diagnosis or suspected onset of symptoms indicative of these disorders to a mental health specialist:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Bipolar disorders Unipolar depression Eating disorders Adjustment disorder Behavioral disorders of children and adolescents
Criteria for Level of Care Selection Use the following criteria to determine which mental health provider or facility is appropriate for the level of care requested: Outpatient Visits
Goals require intensive, formal program with a minimum three hours per day and
at least three days per week.
Day treatment can reasonably be expected to abort an acute episode or reduce the
chances for relapse.
Member needs 24-hour skilled monitoring of medical or behavior conditions. Member needs 24-hour management of documented, measurable danger to self or
others.
Member exhibits severe disturbance of affect, behavior or thought. Member is unable to accomplish activities of daily living.
Intensive Inpatient
Member confined under involuntary legal commitment. Member needs 24-hour observation in secure environment. Member needs frequent/close medical monitoring of physiological or behavioral
reaction to treatment. Criteria for Provider Type Selection Psychiatrist Referrals
Problem is recurrent or greater than six months and member has prior treatment. Problem is recurrent or greater than six months and dysfunction severe or
disabling in any area of functioning.
Member is taking psychoactive medication. Member is referred by PCP or under PCP treatment for relevant problem. Problem is somatic and referral was not from PCP. Problem is somatic, member is under PCP care, and problem is severe or disabling
in some area of functioning.
Child member had prior treatment for same problem without medication and
problem is severe or disabling in some area of life.
Problem is cognitive and member has had previous inpatient or day treatment. Problem is cognitive and overall dysfunction is severe or disabling.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Problem is not recurrent or not greater than six months duration. Member is not taking psychoactives. Member is not referred by PCP or not under PCP treatment for relevant problem. Identifiable stressor is present. Problem is not severe or disabling in any area of functioning.
Cross-References
Utilization Management
VISION SERVICES
Medi-Cal members access basic vision care services through Vision Service Plan (VSP) providers. VSP is an independent entity not affiliated with us or our affiliates. Providers can contact the VSP Provider Service Support Line at 1-800-615-1883 for questions or visit the VSP website at www.vsp.com. Healthy Families Program members access the vision network contracted through MRMIB. Covered vision services for Medi-Cal and Healthy Families Program can be found in Benefits Matrixes. MRMIP and AIM do not cover vision services. Cross-References
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
This notification ensures that case manager nurses and social workers can follow up with members to coordinate their care and that members receive all necessary services while keeping the provider informed. Sample of Available State Services and Programs Content in the following table is a sample of State services; current information can be accessed on each respective program website.
Service or Program Description Services Provided Upon Referral Provides early intervention and related services Based on the assessed need of the child Delivered within the childs everyday routines, activities and places For infants and toddlers from birth to 36 months For children with significant developmental delays For children at high risk of having a substantial developmental disability
California Early Start A statewide inter-agency system of coordinated early intervention services for infants and toddlers with disabilities and their families. Website: Department of Developmental Services www.dds.cahwnet.gov
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Child Health and The CHDP Pr ogram is a Disability Prevention preventive health program (CHDP) Program serving Californias children and youth. CHDP makes early health care available to children and youth with health problems as well as to those who seem well. To be reimbursed, providers must be certified. Website: Department of Health Care Services, www.dhcs.ca.gov
Referral candidates:
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Precrisis and crisis services Rehabilitation and support services Comprehensive evaluation and assessment Vocational rehabilitation Residential services Medication education and management Services for homeless persons Case management Group services 24-hour treatment services Wraparound services Comprehensive medical knowledge, assistance and services relating to family planning community resources Contraception
Health education and certain medical services provided through community-based programs, including private nonprofit agencies and county health departments.
Website: Department of Public Referral candidates: Health http://www.cdph.ca.gov/pro Those seeking information about grams/OFP/Pages/default.as methods for planning family size, px deciding when to have children and preventing unwanted pregnancies
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Referral candidates: Individuals who may have engaged in behavior that places them at risk for contracting HIV
Immunization Services
Local immunizations coalitions and registries. Website: Department of Health Care Services, Immunizations Branch www.dhs.ca.gov
Also see Waiver Programs: AIDS Medi-Cal Waiver Program in this section Educate the community about childhood immunization
Recruit physicians to participate in the states immunization registry system Make referrals to provider for ongoing care and immunizations Maintain regional immunizations registries
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Support service to prevent Provides or arranges for management further transmission of infection of patients, including children and and to prevent development of adolescents: disease resistance. At risk for noncompliance with Website: Department of Health treatment of tuberculosis Care Services www.dhs.ca.gov On intermittent therapy or when treatment has failed
Who have relapsed after completing prior regimens With demonstrated drug resistance to Isoniazid or Rifampin Coordination of care with provider
Referral candidates:
Also, see Directly Observed Therapy (DOT) for Tuberculosis in this section.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
A supplemental nutrition Provides or arranges for: program that helps pregnant women, new mothers and young Supplemental food services, including special vouchers to buy children eat well and stay healthy. healthy foods such as milk, juice, Website: Department of Health eggs, cheese, cereal, dry beans and Care Services, WIC Branch peas and peanut butter. www.wicworks.ca.gov Beginning October 1, 2009, new WIC foods will support both the American Academy of Pediatrics feeding guidelines and Dietary Guidelines for Americans. A greater variety of foods, more incentives for breastfeeding women, and medical supervision for participants with medical conditions are featured. Fruits and vegetables will be available to WIC participants. Infants 6 to 11 months old will receive less formula and more baby food items. Infants will no longer receive juice. Allowances for milk, eggs, and juice have been reduced. Soy-based beverages and tofu can be substituted for milk and cheese.
Information about nutrition and health to help women and their families eat well and be healthy Support and information about breastfeeding. Beginning October 1, 2009, incentives for breastfeeding will include reducing the formula allowance for partially breastfed infants and expanding the amount of food for nursing mothers.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Help in finding health care and other community services. Beginning October 1, 2009, due to the greater number and variety of WIC food offerings, you must use the revised WIC Referral Form to document both the type and amount of WIC foods to infants and children with special needs. A qualifying condition is required for children to receive soy milk or tofu from WIC. You can find the new form at www.anthem.com/ca.
Referral candidates:
Eligible pregnant women and breastfeeding mothers Children under 5 years old (including foster children) Families with a low to medium income; working families may qualify
Services Provided Upon Referral Community-based prevention programs For arriving refugees: medical screening and initial medical treatment until enrolled in a health plan
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Comprehensive Perinatal Services Program (CPSP) Black Infant Health Adolescent Family Life Program Cal Learn Maternal, Child and Adolescent (MCAH) Outreach Sickle Cell Program Perinatal Substance Abuse Program Sweet Success California Diabetes and Pregnancy Program Infant Morbidity and Mortality Health Status Review Evaluation of amniotic fluid for genetic evaluation Genetic counseling Provision of preventive care services SBCs coordinate care with member/dependents provider, including notifying provider if child requires follow-up care
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Directly Observed Therapy (DOT) for Tuberculosis Tuberculosis (TB) has reemerged as an important public health problem, and drug resistance continues to increase. Poor compliance with medical regimens is a major reason for development of resistance. In Directly Observed Therapy (DOT), the patient is assisted in taking medications prescribed to treat TB. Members with TB with poor compliance are referred to the Local Health Department (LHD) for DOT services. Early Start Program Californias Early Start Program is for infants and toddlers up to 36 months with developmental disabilities. Federal and state laws mandate early intervention services to eligible children and families. In California, the Department of Developmental Services (DDS) administers and coordinates Early Start. Early intervention services are coordinated at a regional center or local education agency. What Children Are Served by Early Start Programs? Infants and toddlers from birth to 36 months may be eligible for Early Start if they:
Cognitive development Physical and motor development, including vision and hearing Emotional-social development Adaptive development (for example, feeding difficulties)
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Regional Centers: A Single Point of Entry Eligible children may receive services through one of Californias many community-based regional centers. These Regional Centers provide a single point of entry into the system that will:
Provide intake, evaluation and assessment Determine eligibility and service needs Provide service coordination
What Can the Family Expect from Early Start? The list of services is quite extensive and includes:
Assistive technology devices audiology services Family training and support Counseling and home visits Health services Medical services for diagnostic or evaluation purposes Nursing services Nutrition services Occupational services Physical therapy services Psychological services Social work services Special instruction Speech-language pathology services Transportation and related costs Vision services
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Early Intervention Begins with the Provider Identifying a child with disabilities at the earliest possible moment is critical to the intervention process. The provider has an immediate responsibility to refer a child for eligibility evaluation and assessment to identify the potential need for early intervention services. The provider assumes several levels of responsibility to a members child with developmental disabilities.
Being familiar with services available for the child Referring the child to the appropriate service Determining if the service is meeting the childs needs
The Provider is the Crucial Link Between the Plan and Program Provider involvement is essential to coordinate continuity of care between us and DDS, including:
Making sure families understand the need to access these services Providing help with appointment scheduling Stressing the need for parents to make personal contact with their local
Community Resource Coordinator (CRC) for evaluation and a determination of eligibility for services
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Waiver Programs For some members in acute or Skilled Nursing Facilities (SNFs), waiver programs make it possible for them to leave the facility and receive health services at home. Members meeting criteria for waiver services will be referred to these programs. In-Home Medical Care Waiver Program (IHMC) Referrals to the In-Home Medical Care Waiver Program (IHMC) are considered for members currently receiving care in an acute hospital setting when an extended length of service for acute care is anticipated (for example, a patient who is stable but ventilator-dependent). In-home medical care can provide 20 hours of nursing care on a daily basis. For the remaining hours, the family assumes care. Skilled Nursing Facility (SNF) Waiver Program Members receiving care in an SNF may be eligible for:
In-home continuation of skilled care in the home Up to 26 hours of nursing care monthly
When nursing care staff is not present, an identified support person must be available in the home. MODEL Waiver Program Children receiving services at the acute and skilled nursing level may be eligible for up to 56 hours of home care a month. These children would include those needing:
Intravenous nutritional assistance Multiple procedures to maintain them physically (for example, suctioning,
aerosolized therapy, dressing changes, tube feedings and catheter care) Multipurpose Senior Service Program (MSSP) Waiver Program This waiver program provides social and health care management for frail elderly clients certifiable for nursing home placement who want to remain independent and in their community.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
To prevent or delay institutionalization of the frail member, the program arranges for and monitors the use of community services. Most members need assistance to carry out two or more of the five basic activities of daily living, such as bathing, transferring and dressing. They may also require assistance with instrumental activities such as transportation, meal preparation and housework. Most of the services required are for chore or personal care assistance. Some specific services that may be requested include:
Adult social day care Housing assistance In-home supportive services (IHSS), such as:
AIDS Medi-Cal Waiver Program The AIDS Medi-Cal Waiver Program (MCWP) provides home and community-based services to Medi-Cal recipients:
Diagnosed with AIDS or Symptomatic HIV Disease HIV-infected infants that meet specific program eligibility criteria
Program services are provided in lieu of placement in a nursing facility or hospital and in addition to other health care services available under the regular Medi-Cal Program. The program operates under a federal waiver of certain Medicaid requirements and contracts with agencies at the local level for nursing care management services (a hospital outpatient department, a county health department or a community-based agency). Services provided include:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Benefits counseling Psycho-social counseling Non-emergency medical transportation Nutritional supplements and counseling Home-delivered meals Medical equipment and supplies Day treatment or other partial hospitalization services
First Steps for Referral and Coordination of Care Our case manager contacts the Waiver Program to determine availability of services. The In-Home Operations Unit:
Administers waiver programs for In-Home Medical Care (IHMC), SNF and
MODEL
Northern Regional Office for Waiver Programs servicing Bakersfield and North to Eureka Southern California Regional Office (see Important Contact Information)
The Office of AIDS administers the AIDS and ARC Waiver Programs. The Department of Aging administers the Multipurpose Senior Service Program (MSSP) Waiver. The provider forwards complete medical records when submitting a request for services to the Waiver Program. Next Steps in the Transition
The Waiver Program staff is responsible for approving the move from facility to
home.
Following approval, a discharge date is set by the case manager, primary care
physician (provider) and hospital staff.
The member is enrolled with the Community-Based Care Section and the Waiver
Program is informed of enrollment.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Services begin on the day of discharge from the facility. We coordinate the members disenrollment from the managed care plan; medical
care and services continue until the effective date of disenrollment. The Waiver Program submits claims to EDS for services provided. We assume responsibility for reimbursement of claims for health care service delivery prior to acceptance in the Waiver Program. Members not meeting criteria for care in a Waiver Program or who are not accepted for other reasons (funding or space limitations) will continue to receive care in the facility which best meets their needs and as long as medically necessary. Home and Community-Based Services (HCBS) Waiver In general, members may qualify for the Medicaid HCBS Waiver Program if they:
Are developmentally disabled Currently live in the community Are at risk for institutional placement
Services provided include:
Home health aide Personal care Respite care Habilitation Skilled nursing Nonmedical transportation
HCBS Waiver Program: Referral and Coordination of Care Our case manager or provider identifies developmentally disabled members who may benefit from an in-home or adult day health center.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Determining availability of HCBS in the community Establishing what supportive services the member needs Initiating a request for services from the HCBS Waiver Program Forwarding (from the Plan and the provider) requested information to the HCBS
Waiver Program When submitting a request for services, the provider forwards complete medical records. Following approval, the Waiver Program staff, our case manager and the provider facilitate the members transition to the program. We and the provider are responsible for primary care and other medically necessary services. The Waiver Program bills EDS for services provided. We assume responsibility for reimbursement of claims for continuing primary health care service delivery. Referrals to Maternal, Child and Adolescent Health Program The Maternal, Child and Adolescent Health Program (MCAH) provides a wealth of direct patient services. The program is a mission of the Primary Care and Family Health Division, Maternal, Child and Adolescent Health (MCAH), Department of Health Care Services. The following descriptions demonstrate the breadth of programs available to meet members specific health care needs. For the Pregnant Member at Risk Services are available for the pregnant member at risk due to psychosocial, cultural, ethnic, nutritional and educational factors. When indicated for specific members, their physicians/providers and the case manager facilitate referrals to these programs. Some programs provide direct patient services; others provide only support services.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
For Pregnant and Parenting Teens: Adolescent Family Life Program This statewide program provides case management and counseling services to pregnant and parenting teens. It is designed to improve pregnancy outcome and to help teen parents complete educational or vocational programs, postpone subsequent pregnancies, become self-sufficient and prevent child abuse and neglect. Providers can make referrals to contractors within the county for case management services that include outreach services, comprehensive assessments, community referrals, counseling, follow-up and advocacy. To Reduce Infant Mortality: Black Infant Health This state program uses new and innovative approaches to reduce African American infant mortality rate. Black Infant Health provides outreach and education services to African American women who are pregnant or of child-bearing age. This demonstration project is offered to women living in one of the demonstration areas. For safer pregnancies: California Diabetes and Pregnancy Program (CDAPP). For women with pre-conception diabetes and pregnancy-related diabetes, CDAPP provides patient education along with nutritional, psychosocial assessments and interventions. County Health Departments Individual counties are funded to strengthen and develop local Maternal, Child and Adolescent Health (MCAH) Programs. We will refer individual members to those programs for education, and perinatal services. Perinatal Substance Abuse Pilot Project Program This program was developed jointly among the Maternal, Child and Adolescent Health (MCAH) Branch and the Department of Alcohol and Drug Abuse, Department of Social Services and Department of Developmental Services. It addresses the rapidly increasing numbers of drug-exposed women and infants. Five pilot projects are located in four counties. Each project provides drug treatment, case management and referral service. The MCAH Program is responsible for the case management portion of the pilot program. For pregnant and breastfeeding mothers: Women, Infants and Children (WIC) Program. Pregnant and breastfeeding mothers meet criteria for inclusion in the Women, Infants and Children (WIC) Program. Providers are to refer them to WIC for supplemental food services and nutrition education programs.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Supplemental Food Services WIC participants receive vouchers for purchasing food such as milk, eggs, cheese, iron-fortified cereal, vitamin C-enriched fruit juice, dried legumes and peanut butter. The member uses the food vouchers at the store or her choice. Beginning October 1, 2009, food benefits will change as follows:
Fruits and vegetables will be available. Formula allowances for partially breastfed infants will be reduced while more food
will be available for nursing mothers.
Infants 6 to 11 months old will receive less formula and more baby food items.
Infants will no longer receive juice. Other milk, egg, and juice allowances will be reduced.
Participants can substitute soy-based beverages and tofu for milk and cheese.
Nutrition Education Registered dietitians and trained nutrition paraprofessionals provide nutrition education to all participants and the parents or caretakers of infants and children. To Make a WIC Referral Provider responsibilities include:
Completing the WIC Referral Form or other form that documents the following:
Anthropometric data: height, current weight, pregravid weight Biochemical date: hemoglobin, hematocrit Expected date of delivery (EDD) Any current medical conditions
Providing member with the completed WIC Referral Form to be presented at the
local WIC agency Cross-Reference
Utilization Management
BENEFITS MATRIXES
The following matrixes summarize benefits for:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Healthy Families Program HMO Healthy Families Program EPO AIM HMO and EPO Available state services and programs MRMIP Medi-Cal Managed Care
Healthy Families Program HMO Benefits Summary This table lists all benefits provided for the Healthy Families Program HMO.
Healthy Families Program HMO Benefits
(Provided only for services that are medically necessary)
Services
Alcohol/Drug Abuse Services (Inpatient) Alcohol/Drug Abuse Services (Outpatient) Ambulance (Medical Transportation Services)1 Blood and Blood Products1 Cataract Spectacles and Lenses1 Clinical Cancer Trials
Hospitalization, as medically appropriate, to remove toxic substances from the system Crisis intervention and treatment of alcoholism or drug abuse Emergency ambulance transportation and non-emergency transportation to transfer a member from a hospital to another hospital or facility or facility to home Includes processing, storage and administration of blood and blood products in inpatient and outpatient settings Cataract spectacles and lenses, cataract contact lenses or intraocular lenses that replace the natural lens of the eye after cataract surgery Coverage for a members participation in a cancer clinical trial, Phases I through IV, when the members physician recommended participation in the trial and the member meets certain requirements Equipment and supplies for the management and treatment of insulin-using diabetes, noninsulin-using diabetes and gestational diabetes as a medically necessary, even if the items are available without prescription
Diabetic Care1
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Services
Laboratory services and diagnostic and therapeutic radiological services necessary to appropriately evaluate, diagnose, and treat members Medical equipment is appropriate for use in the home that primarily services a medical purpose, intended for repeated use, and is generally not useful to a person in the absence of illness or injury. Emergency services are covered both in and out of the Plans service area and in and out of the Plans participating facilities. Voluntary family planning services Includes education regarding personal health behavior and health care and recommendations regarding the optimal use of health care services Includes testing for hearing loss and hearing aids to correct hearing loss Services provided at the home by health care personnel For members who are diagnosed with a terminal illness and who elect hospice care instead of traditional health care services Room and board, nursing care and all medically necessary ancillary services Diagnostic, therapeutic and surgical services performed at a hospital or outpatient facility Professional and hospital services relating to maternity care Confinement in a participating hospital is covered. Care for members determined to have a serious emotional disturbance (SED) condition will be provided by the county mental health department. The member remains enrolled in the Plan and continues to receive medical care from Plan providers for services not related to the SED condition.
Hospital Services (Inpatient) Hospital Services (Outpatient) Maternity Care Mental Health Services (Inpatient)
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Services
Mental health care is covered when services are ordered and performed by a Plan mental health professional. Care for members determined to have a serious emotional disturbance (SED) condition are provided by the county mental health department. The member remains enrolled in the Plan and continues to receive medical care from Plan providers for services not related to the SED condition.
Organ Transplants1 Orthotics and Prosthetics1 Phenylketonuria (PKU)1 Physical, Occupational and Speech Therapy1 Prescription Drug Program1 Preventive Health Service
Coverage for organ transplants and bone marrow transplants that are not experimental or investigational Original and replacement devices as prescribed by a licensed practitioner Testing and treatment of PKU Therapy may be provided in a medical office or other appropriate outpatient setting. Drugs prescribed by a licensed practitioner Periodic health examinations, routine diagnostic testing and laboratory services, immunizations and services for the detection of asymptomatic diseases Services and consultations by a physician or other licensed health care provider Performed on abnormal structures of the body caused by congenital defects, developmental anomalies, trauma, infection, tumors or disease to improve function or create a normal appearance Services provided in a licensed skilled nursing facility
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Services
CCS is a California Medi-Cal Program that treats children who have certain physically handicapping conditions and who need specialized medical care. Services provided through the CCS Program are coordinated by the county CCS office. If a members condition is determined to be eligible for CCS services, the member remains enrolled in the Healthy Families Program and continues to receive medical care from Plan providers for services not related to the CCS-eligible condition. The member receives treatment for the CCS-eligible condition through the specialized network of CCS providers or CCS-approved specialty centers. No deductibles are charged for covered benefits No lifetime maximum limits on benefits apply under this Plan
These services may be covered and paid for by the California Childrens Services (CCS) program if the member is found to be eligible for CCS services.
Healthy Families Program Exclusive Provider Organization (EPO) Benefits Summary This table lists all benefits provided for the Healthy Families Program Exclusive Provider Organization (EPO):.
Healthy Families Program EPO Benefits
(Provided only for services that are medically necessary)
Services
Acupuncture Alcohol/Drug Abuse Services (Inpatient) Alcohol/Drug Abuse Services (Outpatient) Ambulance (Medical Transportation Services)1
Services must be obtained from a Plan provider. Hospitalization, as medically appropriate, may be required to remove toxic substances from the system. These services include crisis intervention and treatment of alcoholism or drug abuse. These include emergency ambulance transportation and nonemergency transportation to transfer a member from a hospital to another hospital or facility or facility to home.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Services
Biofeedback Blood and Blood Products1 Cataract Spectacles and Lenses1 Chiropractic Services Clinical Cancer Trials
These services must be obtained from a Plan provider. These include processing, storage and administration of blood and blood products in inpatient and outpatient settings. Cataract spectacles and lenses, cataract contact lenses, or intraocular lenses can be used ti replace the natural lens of the eye after cataract surgery. Services must be obtained from a Plan provider. These include coverage for a members participation in a cancer clinical trial, Phases I through IV, when the members physician recommended participation in the trial and the member meets certain requirements. This includes equipment and supplies for the management and treatment of insulin-using diabetes, noninsulin-using diabetes, and gestational diabetes as a medically necessary, even if the items are available without prescription. These are the laboratory services and diagnostic and therapeutic radiological services necessary to appropriately evaluate, diagnose and treat members. This is medical equipment appropriate for use in the home that primarily serves a medical purpose, is intended for repeated use, and is generally not useful to a person in the absence of illness or injury. Emergency services are covered both in and out of the Plans service area and in and out of the Plans participating facilities. These include voluntary family planning services. This includes education regarding personal health behavior and health care and recommendations regarding the optimal use of health care services. This includes testing for hearing loss and hearing aids to correct hearing loss. These are services provided at the home by health care personnel.
Diabetic Care1
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Services
Hospice
This is for members who are diagnosed with a terminal illness and who elect hospice care instead of traditional health care services. These include room and board, nursing care and all medically necessary ancillary services. These include diagnostic, therapeutic and surgical services performed at a hospital or outpatient facility. These include professional and hospital services relating to maternity care. Confinement in a participating hospital is covered. Care for members determined to have a serious emotional disturbance (SED) condition will be provided by the county mental health department. The member remains enrolled in the Plan and continues to receive medical care from Plan providers for services not related to the SED condition. Mental health care is covered when services are ordered and performed by a Plan mental health professional. Care for members determined to have a serious emotional disturbance (SED) condition are provided by the county mental health department. The member remains enrolled in the Plan and continues to receive medical care from Plan providers for services not related to the SED condition.
Hospital Services (Inpatient) Hospital Services (Outpatient) Maternity Care Mental Health Services (Inpatient)
Organ Transplants1 Orthotics and Prosthetics1 Phenylketonuria (PKU)1 Physical, Occupational and Speech Therapy1 Prescription Drug Program1
Organ transplants and bone marrow transplants that are not experimental or investigational are covered. Original and replacement devices as prescribed by a licensed practitioner are covered. This includes testing and treatment of PKU. Therapy may be provided in a medical office or other appropriate outpatient setting. Drugs prescribed by a licensed practitioner are included.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Services
This includes periodic health examinations, routine diagnostic testing and laboratory services, immunizations and services for the detection of asymptomatic diseases. Services and consultations by a physician or other licensed health care provider are included. This is performed on abnormal structures of the body caused by congenital defects, developmental anomalies, trauma, infection, tumors or disease to improve function or create a normal appearance. These are services provided in a licensed skilled nursing facility. CCS is a California Medi-Cal Program that treats children who have certain physically handicapping conditions and who need specialized medical care. Services provided through the CCS Program are coordinated by the county CCS office. If a members condition is determined to be eligible for CCS services, the member remains enrolled in the Healthy Families Program and continues to receive medical care from Plan providers for services not related to the CCS-eligible condition. The member receives treatment for the CCS-eligible condition through the specialized network of CCS providers or CCS-approved specialty centers. No deductibles are charged for covered benefits. No lifetime maximum limits on benefits apply under this Plan;
1. These services may be covered and paid for by the California Childrens Services (CCS) Program if the member is found to be eligible for CCS services.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
AIM HMO and EPO Benefits Summary This tables lists all benefits provided for the AIM HMO and EPO Programs.
AIM HMO and EPO Benefits Alcohol and Drug Abuse (Inpatient) Alcohol and Drug Abuse (Outpatient) Ambulance Services Blood and Blood Products Cataract Spectacles and Lenses Chiropractic Services Dental Injury Treatment Diabetes Treatment Diagnostic X-Ray and Lab Services Durable Medical Equipment and Supplies Emergency Health Care Family Planning Services Health Education Hearing Aids and Services Limited to one hearing aid replacement every 36 months MRIs and CTs of the spine require prior authorization Custom-made durable medical equipment requires prior authorization. Supplies also require prior authorization for EPO. Accidental injury to natural teeth or jaw Services Limited to the removal of toxic substances Limited to 20 visits per benefit year Non-emergency transportation when medically necessary and approved by Anthem Blue Cross
Medical evaluation All other services Limited to services prescribed by doctor Limited to terminally ill members
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Limited to 30 days per benefit year (except SMI and SED conditions) Limited to 20 visits per benefit year (except SMI and SED conditions)
Orthotics and Prosthetics Physical, Occupational and Speech Therapy Requires prior authorization and periodic evaluations as long as therapy is provided
Preventive Care
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Office visits for health problems or injuries Preventive services Immunizations Surgery, assistant surgery, anesthesia Radiation therapy, chemotherapy, dialysis treatment and blood transfusions EPO requires prior authorization for mastectomy-related services Limited to 100 days per benefit year and requires prior authorization Requires prior authorization
MRMIP Benefits Summary This tables lists all benefits provided for by the MRMIP Program.
MRMIP Benefits Ambulance Services Diagnostic X-Ray and Laboratory Services Durable Medical Equipment and Supplies Explanation Ground or air ambulance to or from a hospital for medically necessary services Outpatient diagnostic X-ray and laboratory services Must be certified by a physician and required for care of an illness or injury
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Initial treatment of an acute serious illness or accidental injury Includes hospital, professional services and supplies
Home Health Care Hospice Infusion Therapy1 Mental Health Services1 Physical, Occupational, Speech Therapy Physician Office Visits Pregnancy and Maternity Care Prescription Drugs
Home health services through a home health agency or visiting nurse association Hospice care for members who are not expected to live for more than 12 months Therapeutic use of drugs or other substances ordered by a physician and administered by a qualified provider Inpatient nervous and mental health services are limited to 10 days each calendar year Services of physical therapists, occupational therapists and speech therapists, as medically appropriate on an outpatient basis Services of a physician for medically necessary services Inpatient normal delivery and complications of pregnancy
Maximum 30-day supply per prescription when filled at a participating pharmacy Maximum 60-day supply for mail order
Skilled Nursing Facilities Copayments and Limits Calendar Year Deductible Copayment Yearly Maximum Copayment Limit Annual Benefit Maximum
Members amount due and payable to the provider of care Members annual maximum copayment limit when using participating providers is $2,500 per member; $4,000 per family Members must pay for all services received after the combined total of all benefits paid under the MRMIP reaches $750,000 in one calendar year
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
1. Refer to the Evidence of Coverage booklet for exact terms and conditions of coverage.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Medi-Cal Managed Care Benefits Summary This tables lists all benefits provided for by the Medi-Cal Managed Care Program.
Medi-Cal Managed Care Benefits/Services Abortion Acupuncture Yes GMC Yes (preauthorization required) Mainstream and Los Angeles Carved out to Fee For Service (FFS) Not covered effective July 1, 2009, for Medi-Cal members and for beneficiaries 21 and older outside of L.A. County. As of this same date, the Medi-Cal Program does not offer special services to L.A. County Health Plan members. Exceptions are covered through the L.A. County Health Plan. Yes Yes Yes Yes Yes Yes Yes (preauthorization required) Coverage
Air ambulance Dry runs Ground ambulance Nonemergent transport (from home to doctors office, dialysis, physical therapy)
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Biofeedback Blood and Blood Products Cancer Screening (refer to the EOC) Cataract Spectacles and lenses (limited) CHDP Services Chemical Dependency Rehabilitation Chemotherapy Drugs Chiropractic Services (limited)
Circumcision
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Dental Services
Detoxification (acute phase) Diabetic Services Diagnostic X-Ray and Lab Dialysis Directly Observed Therapy (DOT) Durable Medical Equipment
Outpatient Professional
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Yes (preauthorization required for elective surgeries) Yes (preauthorization required for elective surgeries) Notification on admission Yes Yes
Immediate Care
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Infant Apnea Monitor (outpatient) Infertility (diagnosis/treatment) Injectable Medications (outpatient) Inpatient Alcohol and Drug Abuse Interpreter Services Lab and Pathology Services Lithotripsy Major Organ Transplants (except kidneys and cornea) Mammography Mastectomy Maternity Care
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Inpatient mental health Outpatient mental health (including alcohol and drug abuse) Professional mental health services, evaluation crises intervention and treatment (short-term mental health conditions)
Carved out
Inpatient facility fees Inpatient professional fee Outpatient professional fee Professional fee Obstetrical CPSP services
Yes Yes Yes Yes Yes Yes Not covered effective July 1, 2009 for Medi-Cal members and for beneficiaries 21 and older outside of L.A. County. Medi-Cal will continue to cover ophthalmology services after this date. As an exception, Anthem Blue Cross will cover the benefits and services listed above if an emergency condition occurs and the benefit is required to treat the emergency condition. As of this same date, the Medi-Cal Program does not offer special services to L.A. County Health Plan members. Exceptions are covered through the L.A. County Health Plan.
Office Visit Supplies (splints, casts, bandages, dressing) Optometric and optician services
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Yes (preauthorization required) Yes (preauthorization required) Yes (preauthorization required) Yes Yes (preauthorization required) Not covered effective July 1, 2009 for Medi-Cal members and for beneficiaries 21 and older outside of L.A. County. Medi-Cal will continue to cover psychiatry services and all services through county mental health programs after this date. As an exception, Anthem Blue Cross will cover the benefits and services listed above if an emergency condition occurs and the benefit is required to treat the emergency condition. As of this same date, the Medi-Cal Program does not offer special services to L.A. County Health Plan members. Exceptions are covered through the L.A. County Health Plan.
Preadmission Testing Prosthetics and Orthotics (including artificial limbs and eye) Psychology services
Not covered effective July 1, 2009 for Medi-Cal members and for beneficiaries 21 and older outside of L.A. County. As an exception, Anthem Blue Cross will cover the benefits and services listed above if an emergency condition occurs and the benefit is required to treat the emergency condition. As of this same date, the Medi-Cal Program does not offer special services to L.A. County Health Plan members. Exceptions are covered through the L.A. County Health Plan. Yes
Radiation Therapy
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Reconstructive Surgery (not cosmetic) Rehabilitation Services Routine Physical Examinations Skilled Nursing Facility (SNF) Specialist Consultations Speech Therapy Services
Surgical Supplies TMJ Transfusions (blood and blood products) Urgent Care Center Vision Care
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
ELIGIBILITY VERIFICATION
We electronically update member eligibility each day following notification from the Department of Health Care Services (DHCS), the Department of Public Health (DPH), or contracted eligibility agents of changes in member eligibility in the Plan. Providers must verify the members eligibility before services are provided. Confirm Member Identity To prevent fraud and abuse, providers should confirm the identity of the person presenting the cards. Claims submitted for services rendered to noneligible members will not be eligible for payment. Ask to See Identification (ID) Cards Medi-Cal At each Medi-Cal member visit, before rendering services, providers must ask to see two separate ID cards to verify state and Plan eligibility: the state of California Beneficiary Identification Card and the Plans member ID card.
Beneficiary Identification Card (BIC): The state of California issues this plastic
card after approving the members eligibility. Providers can swipe this card in the Point of Service (POS) device to verify eligibility.
Member ID Card: This paper card, which we provide, contains member and
provider information on the front and back (see samples of Member Identification Cards at the end of this section). Healthy Families Program, Access for Infants and Mothers (AIM) and Major Risk Medical Insurance Program (MRMIP) There is no Beneficiary Identification Card (BIC) for these programs (only Medi-Cal uses that card). The member will only carry a Plan Member ID Card. Member ID Card: Each program (Medi-Cal, Healthy Families Program, AIM and MRMIP) has a unique member identification card. This card contains member and provider information (see samples of Member Identification Cards at the end of this section).
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Verify Member Eligibility Medi-Cal Providers can verify Medi-Cal eligibility in one of the following ways:
Swipe the Beneficiary Identification Card (BIC) through the Medi-Cal Point of
Service (POS) device.
Log on to the ProviderAccess website, the online tool for Plan providers. Select
ProviderAccess and type your User ID and password to enter this secure site.
Log on to the Medi-Cal website and use the medical web interface to perform
eligibility inquiry by going to www.medi-cal.ca.gov/Eligibility/Login.asp and then entering your User ID and Password. Next, click Submit, which will take you into the Real Time Internet Eligibility (RTIE) page, where you can select Single Subscriber and enter member information (subscriber ID, birth date, issue date and service date).
Call our Interactive Voice Response (IVR) automated telephone response system
at 1-800-407-4627 (all counties except Los Angeles County) or 1-888-285-7801 (Los Angeles County only) to verify member eligibility 24 hours a day, 7 days a week; you may also request a facsimile verification. Please note that the IVR accepts either your billing National Provider Identifier (NPI) or your Federal Tax Identification Number (TIN) for provider identification. Should the system not accept your billing NPI or Federal TIN, the system will route your call to a Customer Care Center representative, who will help you with your query. For purposes of assisting you, we may ask you for your TIN.
Log on to the ProviderAccess website, the online tool for Plan providers. Select
ProviderAccess; type your User ID and password to enter this secure site.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Major Risk Medical Insurance Program and Access for Infants and Mothers Providers can verify Major Risk Medical Insurance Program (MRMIP) and Access for Infants and Mothers (AIM) eligibility in one of the following ways:
Log on to the ProviderAccess website, the online tool for Plan providers. Select
ProviderAccess; type your User ID and password to enter this secure site.
Provider Roles and Responsibilities Claims and Billing Guidelines Important Contact Information
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Plastic Beneficiary Identification Card from the State of California The State-issued Beneficiary Identification Card (BIC) contains eligibility information, accessed by swiping the BIC in the Medi-Cal Point of Service (POS) device at each visit.
Healthy Families Program, AIM and MRMIP Member ID Cards Following enrollment in our Healthy Families Program, MRMIP, or AIM Program, the member receives a member identification card that he or she must present to a provider at each visit. Members in these programs do not have a Beneficiary Identification Card (BIC).
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Healthy Families Program HMO Member ID Card Sample The Healthy Families Program HMO Member Identification Card contains the following information:
Member Information PCP Assignment (includes PCP name, address, and phone number) Customer Service Number Pharmacy Information 24/7 NurseLine Number (24/7 NurseLine is our 24-hour nurse health
information line)
Mental Health Referral Number California Childrens Services (CCS) and Pregnancy Information
HMO Data Specic
DATE DOCTOR ADDRESS CITY, CA XXXXX (XXX) XXX-XXXX MEMBER FORD PREFECT ID CARD NO 123456789 Group No. Coverage Code Member Effective Date Plan Code 1270KA HIOPT 00/00/00 040 Plan Ofce Visit Prescriptions Annual Limit HMO or EPO $5 $5 $250
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Attention member: Carry this ID card with you at all times. Show it to your doctor or pharmacy when you go for covered services. See your Evidence of Coverage for a description of your benefits. In an emergency, call 911 or go to the nearest hospital emergency room for treatment. You do not need to get an OK ahead of time for emergency services. Member Services: TTY line: 24-hour nurse help line: 1-800-845-3604 1-888-757-6034 1-800-224-0336 Attention provider: This card is for identification purposes only and does not constitute proof of eligibility. For current eligibility, call 1-800-845-3604. Emergency services are covered without prior authorization. California Children Services (CCS) is the primary payor for CCS-eligible specialized medical care and rehabilitation services for children. Anthem Blue Cross is not responsible for coverage of CCS-eligible conditions. Hospitals: For all inpatient admissions, call 1-888-831-2246 within 48 hours or as soon as reasonably possible. Submit claims to: P.O. Box 60007 Los Angeles, CA 90060-0007 Pregnancy If the member is pregnant, call Blue Cross Member Services as soon as possible at 1-800-845-3604. The member may be eligible for other programs. Providers outside of California: For services provided outside of the state of California, the Healthy Families Program covers emergency services only. For current eligibility, call 1-800-676-BLUE. Please submit claims to your local Blue Cross and/or Blue Shield plan.
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Healthy Families Program EPO Member ID Card Sample The Healthy Families Program Prudent Buyer EPO Member Identification Card contains the following information:
Member Information Customer Service Number Pharmacy Information 24/7 NurseLine Number (24/7 NurseLine is our 24-hour nurse health
information line)
Mental Health Referral Number CCS and Pregnancy Information Preservice Review Information and Number
HMO Data Specic
DATE DOCTOR ADDRESS CITY, CA XXXXX (XXX) XXX-XXXX MEMBER FORD PREFECT ID CARD NO 123456789 Group No. Coverage Code Member Effective Date Plan Code 1270KA HIOPT 00/00/00 040 Plan Ofce Visit Prescriptions Annual Limit HMO or EPO $5 $5 $250
www.anthem.com/ca
Attention member: Carry this ID card with you at all times. Show it to your doctor or pharmacy when you go for covered services. See your Evidence of Coverage for a description of your benefits. In an emergency, call 911 or go to the nearest hospital emergency room for treatment. You do not need to get an OK ahead of time for emergency services. Member Services: TTY line: 24-hour nurse help line: 1-800-845-3604 1-888-757-6034 1-800-224-0336 Attention provider: This card is for identification purposes only and does not constitute proof of eligibility. For current eligibility, call 1-800-845-3604. Emergency services are covered without prior authorization. California Children Services (CCS) is the primary payor for CCS-eligible specialized medical care and rehabilitation services for children. Anthem Blue Cross is not responsible for coverage of CCS-eligible conditions. Hospitals: For all inpatient admissions, call 1-888-831-2246 within 48 hours or as soon as reasonably possible. Submit claims to: P.O. Box 60007 Los Angeles, CA 90060-0007 Pregnancy If the member is pregnant, call Blue Cross Member Services as soon as possible at 1-800-845-3604. The member may be eligible for other programs. Providers outside of California: For services provided outside of the state of California, the Healthy Families Program covers emergency services only. For current eligibility, call 1-800-676-BLUE. Please submit claims to your local Blue Cross and/or Blue Shield plan.
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
AIM Member ID Card Sample The AIM Member Identification Card contains the following information:
Member Information Customer Service Number Preadmission Review Information and Number (EPO only) PCP Assignment (includes PCP effective date, address and phone number) (HMO
only)
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
MRMIP Member ID Card The MRMIP Member Identification Card contains the following information:
Member Information Customer Service Number Preservice Review Information and Number Billing Address Pharmacy Information
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
We return claims submitted with incomplete or invalid information and request the claim be corrected and resubmitted. If you are using a clearinghouse for Electronic Data Interchange (EDI), the clearinghouse/gateway also rejects claims that are incomplete or invalid. Providers are responsible for working with their EDI vendor to ensure that claims that error out from the EDI gateway are corrected and resubmitted. If you are using EDI, you must include:
Billing Provider Name Rendering Provider Name Legal Name Federal Provider Tax ID Number Member Medi-Cal ID Number Plan Payor ID Number (professional or institutional) Provider Identifier Number License Number (if applicable) Medi-Cal Number (if applicable) National Provider Identifier (NPI)
You are required to include your unique Plan provider identifier number to speed up claims payment. Contact your vendor or billing service for instructions about how to ensure that the Plan provider ID is coded as an Anthem Blue Cross NPI. If you do not have a unique NPI, contact our Customer Care Center at 1-800-407-4627. You are also strongly encouraged to include your unique NPI to speed up claims payment. Contact your vendor or billing service for instructions about how to ensure that the Plan provider ID is coded as an Anthem Blue Cross NPI. If you do not have a unique NPI, contact our Customer Care Center at 1-800-407-4627. For more information, refer to National Provider Identifier (NPI) in this document.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Claim Forms Generally, there are two types of forms used for submitting claims for Plan reimbursement. They are:
The CMS-1500 Claim Form for professional services The CMS-1450 (UB-04) Claim Form for institutional services
A general description of how to complete each of these sample forms is available at the end of this chapter. Select the form name to link to a copy of the form and a description of each of the fields and the information required in each. These forms are available in both electronic and hard copy/paper format. Using the wrong form or not correctly or completely filling out the form causes the claim to be returned, resulting in processing and payment delays. Claim Filing Limits All claims must be submitted within the contracted filing limit to be considered for payment. We will deny claims that we receive past the filing limit. See the Claim Forms and Filing Limits charts for standard claim filing and processing time frames. Submit claims as soon as possible following delivery of service to avoid delays in processing. We are not responsible for a claim never received. Prolonged periods before resubmission may cause the provider to miss the filing limit. Determine filing limits as follows:
If the Plan is primary, use the length of time between the last date of service on the
claim and the Plans receipt date.
If the Plan is secondary, use the length of time between the other payors notice or
Remittance Advice (RA) date and the Plans receipt date.
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Claim Forms and Filing Limits If a member is retroactively enrolled, such action may alter the filing limits accordingly. Refer to the provider contract to confirm correct filing limits for claims.
Form CMS-1500 Claim Form Type of Service to be Billed Professional services (physician and other professional services). Time Limit to File For services provided to our HMO members, file a clean claim within 180 days from the date of service.
Specific ancillary services, including physical and occupational therapy, skilled nursing facilities (SNF), and speech therapy. Ancillary services, including: For services provided to our HMO members, file a clean claim within Audiologists, ambulance, ambulatory surgical center, dialysis, durable medical 365 days from the date of service. equipment (DME), diagnostic imaging centers, hearing aid dispensers, home infusion, home health, hospice, laboratories, prosthetics and orthotics, and free-standing SNFs. Some ancillary providers may use a CMS-1450 if they are ancillary institutional providers. Ancillary charges by a hospital are considered facility charges. CMS-1450 Hospitals and institutions For services provided to our HMO (UB-04) Claim members, file a clean claim within 180 days from the date of service. Form (If the member is in an extended inpatient stay for longer than 30 days, interim billing is required as described in the Anthem Blue Cross State Sponsored Business Participating Hospital Agreement).
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After 30 business days from the Plans receipt of a clean claim, submit a Claim Follow-Up Request Form. Provider must return requested information to the Plan within 90 calendar days from the date of the Plans request for correction.
The request for a claim reconsideration must be received within 365 days from the receipt of the Plans RA. The Plan sends acknowledgement within 15 calendar days of receipt of dispute. Determination made in 45 business days from the Plans receipt of dispute or amended dispute.
Claims and Correspondence Mailing Address Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007 If feasible, we will notify providers in writing of any changes in any claims submission address at least 30 days prior to the effective date of the change. If we are unable to provide 30 days notice, we will give providers a 30-day extension on their claims filing deadline to ensure claims are routed to the correct processing center.
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Questions about Claims Call the CCC with questions about claims, including completing the forms. You can link to the CCC phone numbers in the Important Contact Information section or ask your provider liaison for assistance.
SUBMITTING A CLAIM
Methods for Submitting Claims There are two methods for submitting a claim:
Billing Provider Name Rendering Provider Legal Name License Number (if applicable) Medicare Number (if applicable) Federal Provider Tax ID Number Medi-Cal ID Number National Provider Identifier (NPI)
You are strongly encouraged to include your unique National Provider Identifier (NPI) to speed up claims payment. Contact your vendor or billing service for instructions about how to ensure that the Plan Provider ID is coded as an Anthem Blue Cross NPI. You are also encouraged to include your unique NPI. Contact your vendor or billing service to determine how to submit.
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We cannot be responsible for claims never received. Providers must work with their vendors to ensure files are successfully submitted to us. Failure of a third party to submit a claim to us may risk the providers claim being denied for untimely filing if those claims are not successfully submitted during the filing limit. After submitting electronic claims, check the following:
Watch for (and confirm) Plan Batch Status Reports from your
vendor/clearing-house to ensure your claims have been accepted by us. You can correct and resubmit Batch Status Reports and error reports electronically.
Correct any errors and resubmit (electronically) immediately to prevent denials due
to untimely filing.
Include the Provider Tax ID Number on all claims regardless of who completed
the claim For Electronic Data Interchange (EDI) claims submissions that require attachments, contact your clearinghouse for guidelines. Contact our Electronic Data Interchange (EDI) unit at 1-800-227-3983 or send an e-mail to edi.bccenrollment@wellpoint.com:
To learn more about EDI and how to get connected For a current list of approved software vendors and clearing-houses To submit claims electronically if your system is compatible For technical assistance and support (for existing accounts, e-mail at
edi.operations@wellpoint.com) Electronic data transfers and claims must be HIPAA-compliant and meet federal requirements for EDI transactions, code sets, member confidentiality and privacy.
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National Provider Identifier (NPI) NPI is a 10-position, all-numeric identifier, issued only to providers of medical and health services and supplies. NPI is one provision of the Administrative Simplification portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). NPI improves the efficiency of the health care system and reduces fraud and abuse. NPI is used in all HIPAA transactions by all covered entities. There are several advantages to using your NPI for claims and billing, especially since it offers you the opportunity to bill with only one number. Other advantages include:
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NPI Online Submission Process Register your NPI with us by completing our online submission for at https://npi.wellpoint.com. If you are registering more than one NPI, complete one form for each NPI. Registration ensures our internal systems accurately reflect your NPI information. Online Resources for NPI Information The following websites offer additional NPI information: Anthem Blue Cross Centers for Medicare and Medicaid Services NPI National Plan and Provider Enumeration System (Enumerator) Workgroup for Electronic Data Interchange National Uniform Claims Committee www.anthem.com/ca www.cms.hhs.gov/NationalProvidentStand/ http://nppes.cms.hhs.gov/NPPES www.wedi.org www.nucc.org
National Uniform Billing Committee www.nubc.org Paper Claims Paper claims are scanned for optimal processing and recording of data provided; therefore, even paper claims must be legible and provided in the appropriate format to ensure scanning capabilities. The following paper claim submission requirements can speed claim processing and prevent delays:
Use the correct form type and be sure the form meets Centers for Medicare and
Medicaid Services standards (see http://www.cms.hhs.gov/).
Use black or blue ink; do not use red ink, as the scanner may not be able to read it. Use the Remarks field for messages. Do not stamp or write over boxes on the claim form. Send the original claim form to us and retain the copy for your records. Separate each individual claim form. Do not staple original claims together, as we
would consider the second claim an attachment and not an original claim to be processed separately.
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Remove all perforated sides from the form. Leave a -inch border on the left and
right side of the form after removing perforated sides; this helps our scanning equipment scan accurately.
Be sure the type falls completely within the text space and is properly aligned with corresponding information. If using a dot matrix printer, do not use draft mode since the characters generally do not have enough distinction and clarity for the optical character reader to accurately determine the contents.
Attachments to Paper Claims Some claims may require additional attachments. Be sure to include all supporting documentation when submitting your claim. Paper Claim Submission Mailing Addresses Mail paper claims for State Sponsored Business to: Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007 Clinical Submissions Categories The following is a list of claims categories where we may routinely require submission of clinical information before or after payment of a claim.
Claims pending for lack of pre-certification or prior authorization Claims involving medical necessity or experimental/investigative determinations Claims for pharmaceuticals requiring prior authorization
Claims involving certain modifiers, including, but not limited to. Modifier 22 Claims involving unlisted codes
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Claims for which we cannot determine from the face of the claim whether it
involves a covered service. Thus the benefit determination cannot be made without reviewing medical records (including, but not limited to, pre-existing condition issues, emergency service-prudent layperson reviews, or specific benefit exclusions. A prudent layperson is a person who possesses an average knowledge of health and medicine.)
Claims that are the subject of an audit (internal or external) including high-dollar
claims
Claims for individuals involved in case management or disease management Claims that have been appealed (or that are otherwise the subject of a dispute,
including claims being mediated, arbitrated, or litigated
Requests relating to underwriting (including but not limited to member or physician misrepresentation/fraud reviews and stop loss coverage issues) Accreditation activities Quality improvement/assurance activities Credentialing Coordination of benefits (COB) Recovery/subrogation
Examples provided in each category are for illustrative purposes only and are not meant to represent an exhaustive list within the category. Coordination of Benefits (COB) When applicable, we coordinate benefits with any other carrier or program that the member may have for coverage, including Medicare. Indicate Other Coverage information on the appropriate claim form. If there is a need to coordinate benefits, include at least one of the following items from the other carrier or program when submitting a Coordination of Benefits (COB) claim:
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Third party provider Explanation of Benefits (EOB) Notice from third party explaining the denial of coverage or reimbursement
COB claims received without these items will be mailed back to you with a request to submit to the other carrier or program first. The filing limit for all COB claims is 180 days for hospitals and institutions and professional services providers and 365 days for ancillary service providers, as described above from the date on the other carriers or programs RA or Notice of Denial of Coverage or Reimbursement. When submitting claims as COB, indicate other coverage in:
Boxes 9a-d of the CMS-1500 Claim Form Boxes 58-62 of the CMS-1450 Claim Form
CLAIMS PROCESSING AND PAYMENT
Claims Processing A brief description of claims processing methods follows. All claims are assigned a unique Document Control Number (DCN). The DCN identifies and tracks claims as they move through the Claims Processing System. This number contains the Julian date, which indicates the date the claim was received. It monitors timely submission of a claim. DCNs are composed of 11 digits:
2-digit Plan year 3-digit Julian date 2-digit reel identification 4-digit sequential
Claims entering the system are processed on a line-by-line basis, except for inpatient claims. Inpatient claims are processed on an entire claim basis. Each claim is subjected to a comprehensive series of check points called edits. The edits verify and validate all claim information to determine if the claim should be paid, denied, or suspended for manual review.
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Providers are responsible for all claims submitted with their provider number, regardless of who completed the claim. Providers using billing services must ensure that their claims are handled properly. Entities submitting claims for services rendered by a health care provider are subject to Medi-Cal suspension if they submit claims for a provider who is suspended from Medi-Cal. Claim Return for Additional Information If a claim is returned to the provider for correction or additional information, we refer to this claim as a Mailback Form, which is our request for additional information from the provider that is necessary for us to process the claim. The provider has 90 days from the date on the Information Request/Mailback to submit the corrected claim information to us. If the provider does not resubmit within this time frame, the claim is denied. Refer to Claim Returned for Information. Claim Filing with Another Payor If a provider files a claim with the wrong payor and provides documentation verifying the initial timely claims filing to us (within the applicable claims filing time limits set forth above in this chapter from the date of the other carriers denial letter or RA Form), we process the providers claim without denying it for failure to file within our filing time limits. Claims Payment Upon receiving claims, we analyze the claims for covered services and the corresponding amount to be paid. We then generate an RA, summarizing services rendered and payor action taken, and send the appropriate payment amount to the provider. Providers should receive a response from us within 30 business days of the Plans receipt of a clean claim. If the claim contains all required information, we enter the claim into our Claims Processing System and send the Provider an RA at the time the claim is finalized. Electronic Funds Transfer We allow the Electronic Funds Transfer (EFT) option for claims payment transactions. This allows claims payments to be deposited directly into a previously selected bank account. You can enroll by calling EDI Services at 1-800-227-3983.
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Electronic Remittance Advice Electronic Remittance Advice (ERA) is available for providers contracted with us. ERAs are received through the SPC:MAILBOX. The SPC:MAILBOX is a mailbox set up between a provider or clearinghouse and us. Use the mailbox to send and receive ERA files, which are in an ANSI X12 835 file format. Implementation guides are available at no charge at www.wpc-edi.com/hipaa. There is no charge for the service but enrollment is required. Providers can enroll by calling EDI Services at 1-800-227-3983. Electronic data transfers and claims should be HIPAA-compliant and meet federal requirements for EDI transactions, code sets, member confidentiality, and privacy. Claims Overpayment Recovery Procedure We seek recovery of all excess claim payments from the payee to whom the benefit check is made payable. When an overpayment is discovered, we initiate the overpayment recovery process by sending written notification of the overpayment to a physician, hospital, facility, or other health care professional (provider). Return all overpayments to us upon the providers receipt of the notice of overpayment. Mail the check and a copy of the overpayment notification to: Anthem Blue Cross P.O. Box 4194 Woodland Hills, CA 91365 If the provider wants to contest the overpayment, the provider should contact us in writing. For a claims re-evaluation, send correspondence to the address indicated on the overpayment notification. If we do not hear from the provider or receive payment within 30 days, the overpayment amount is deducted from claims payments. In cases when we determine that recovery is not feasible, the overpayment is referred to a collection service.
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Claim Status Online Providers can confirm receipt of their claims through the provider website that features an online tool that confirms the Plans receipt of a claim. Providers can also view claim status and payment information. Access this site by selecting Providers from www.anthem.com/ca, then logging into the secure site with a provider number and password. Interactive Voice Response (IVR) Claim Status Providers can also confirm the Plans receipt of their claims through ProviderAccess or by calling the Customer Care Center (CCC). See Important Contact Information section. CCC hours are Monday through Friday, 7 a.m. to 7 p.m. (except certain holidays). Claim Follow-Up/Resubmission Providers can initiate follow-up action to determine claim status if there has been no response from us to a submitted claim within 30 business days from the date the claim was submitted. Participating physicians who provide professional services to EPO members enrolled in the Healthy Families Program or AIM or MRMIP Programs can initiate follow-up action to determine claim status if there has been no response from us to a submitted claim within 30 calendar days from the Plans receipt of the claim. To follow up on a claim, providers should:
Check ProviderAccess for disposition of the claim. Check the IVR for disposition of the claim. Contact the CCC. Provide a copy of the original claim submission and all supporting documentation
(such as records, reports) that the provider deems pertinent or that has been requested by us and mail the inquiry to: Claim Follow-Up Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007
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Reviewing Batch Status Reports Providers should receive and confirm the contents of the Batch Status Reports from the Electronic Vendor/Clearinghouse and correct any errors. Errors must be promptly corrected and resubmitted (electronically) to prevent denials due to untimely filing. Questions about Claim Status and Follow-Up Our CCC is available to answer any questions and provide further instructions regarding claim follow-up. A CCC representative can:
Research the status of claims Advise providers of necessary follow-up action, if any
CLAIM RETURNED FOR INFORMATION
We send a request for additional or corrected information to the provider when the claim cannot be processed due to incomplete, missing, or incorrect information in the original claim submission. The request for information includes a form that allows the provider to return the requested information in an easy-to-follow format. We call this a Mailback Form. This form must be returned with the requested information in order to process the claim. We may also request additional information retroactively for a claim that has already been paid. The same form is used for Plan requests for information. Time Frame for Returning Requested Information Upon receipt of this request for more information, the provider must provide the additional information within 90 days of the Plans request for information. See above section entitled Claim Return for Additional Information How to Submit Requested Additional Information To re-submit additional or corrected information on a claim, providers should send:
A copy of the Mailback requesting more information Any and all supporting documentation (such as records, reports) that the physician
or provider deems pertinent or that has been requested by us
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Many of the claims returned for further information are returned for common billing errors. Click Common Reasons for Rejected and Returned Claims to link to a list of examples. Common Reasons for Rejected and Returned Claims
Problem Explanation Member ID Number We provide ID cards to the member in Incomplete addition to our ID card. The members Plan ID number is called the CIN number. It includes a three-digit alpha prefix, followed by 10 to 14 numerical digits. Duplicate Claim Duplicate claims are submitted Submission before the applicable processing time frame has passed. Resolution Make sure to use the members CIN number from his/her paper ID card, not the number from the States card.
Wait to resubmit a claim until the appropriate time frame for processing has passed.
Then, look up claim status on Overlapping services dates for the the provider website or use the same services create a question IVR phone system to check claim status. about duplication. The Authorization Number is missing or Confirm that the Authorization the approved services do not match with Number is on the claim form the services described in the claim. (CMS-1500, Box 24 and CMS-1450, Box 63) and that the approved services match the provided services.
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A copy of the original/corrected CMS-1500 or CMS-1450 Claim Form Any and all supporting documentation (such as records, reports) which the
claimant deems pertinent or that we have requested Provider Dispute Address Mail the Provider Dispute Resolution Form and supporting documentation to: Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007 Plan Response to Provider Dispute Resolution (PDR) Request We send an acknowledgement of receipt to providers within 15 business days from the date of a provider dispute submitted by mail, fax, or in person. If the PDR results in reimbursement, we will send an Overturn Letter. The provider also receives a corrected RA within 45 business days of the Plans receipt of the provider dispute or the amended provider dispute. If no reimbursement is made, we will send an Uphold Letter to the provider within 45 days of the Plans receipt of the Provider Dispute Resolution Form or the Amended Provider Dispute Resolution Form.
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Questions about the Provider Dispute Process Direct questions regarding the provider dispute process to our CCC. See Important Contact Information in this manual. Cross-Reference
Level 2 consists of other codes that identify products, supplies and services not
included in the CPT codes, such as ambulance and durable medical equipment (DME). These are sometimes called the alpha-numeric codes because they consist of a single alphabetical letter followed by four numeric digits.
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Medi-Cal Local Codes and Modifiers In addition to the HCPCS, the California Department of Health Care Services (DHCS) created a set of additional codes for its Medi-Cal Program, sometimes called Local Codes. These codes identify services and products specific to Medi-Cal. Medi-Cal also provides for modifiers to HCPCS. To ensure accurate handling and prompt payment of claims, use the following national guidelines when coding claims:
Medi-Cal Local Only Codes (Local Only Codes): Use Local Only Codes until
the state remediates the codes; do not use Local Only Codes for dates of service after the remediation date; Local Only Codes billed after the remediation date will be denied for use of an invalid procedure code (Medi-Cal only).
Modifier Codes: Use modifier codes when appropriate with the corresponding
Local Only, HCPCS or CPT codes; for paper claims, all modifiers should be billed immediately following the procedure code in Box 24D of the CMS-1500 or in Box 44 of the CMS-1450 Claim Forms with no spaces. Use the Additional Code Tables: Medi-Cal & Healthy Families Program for commonly used codes for professional services. On-Call Services Insert On-Call for PCP in Box 23 of the CMS-1500 Claim Form when the rendering physician is not the PCP, but is covering for or has received permission from the PCP to provide services that day.
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Prior Authorization Number Indicate the prior authorization number or other authorization information in Box 23 of the CMS-1500 Claim Form. Member ID Number Use the members CIN (Client Index Number) when billing, whether submitting electronically or by paper. Use the members Plan ID card number, not the number on the Identification Card issued by the State. Physician License Number Indicate the rendering physicians state-issued license number in Box 24 of the CMS-1500 Form. Missing or invalid license numbers may result in nonpayment. Mid-level practitioners must submit claims with their name and license number in Box 19 of the CMS-1500 and the supervising physicians license number in Box 24 of the CMS-1500 Form. The following are defined as mid-level:
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MM DD Date of birth
Members sex M F
SEX Other
Self or Child
Married Full-Time Student
CITY
CITY
ZIP CODE
(
a. INSUREDS DATE OF BIRTH MM DD YY M b. EMPLOYERS NAME OR SCHOOL NAME
)
SEX F
a. EMPLOYMENT? (Current or Previous) YES b. AUTO ACCIDENT? F YES c. OTHER ACCIDENT? YES NO NO PLACE (State) NO
If member has other coverage complete b. THER INSUREDS DATE OF BIRTH SEX YY O MM fieldsDD 9a9d
M c. EMPLOYERS NAME OR SCHOOL NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. SIGNED
13. INSUREDS OR AUTHORIZED PERSONS SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.
Date
MM
File
SIGNED
File
Date of onset
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY FROM TO
Referring provider
17a. 17b. N
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? YES NO $ CHARGES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 1.
Primary diagnosis
3.
22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER
MM
YY
F. $ CHARGES
G.
DAYS OR UNITS
H.
I.
Procedure code(s)
Modifier code(s)
Line total
Units of occurrence
PI N
NPI
NPI
NPI
NPI
NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT? ( )
For govt. claims, see back
YES 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 32. SERVICE FACILITY LOCATION INFORMATION
NO
Providers$name, complete address, and $ INFO number & PH # 33. BILLING P ROVIDER ( ) telephone Medicaid provider number
a.
NPI
b.
NPI
b.
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2. 24. A.
Secondary diagnosis
4.
Authorization information
CARRIER
1500
CMS-1500 (08-05) Claim Form Fields If the claimant does not complete these fields on the CMS-1500 Form, the claim may be delayed or returned for additional information.
Field # Field 1 Title Medicaid/Medicare/Other ID Explanation If claim is for Medi-Cal, put an X in the Medicaid box. If the member has both Medi-Cal and Medicare, put an X in both boxes. Attach a copy of the form submitted to Medicare to the claim. Insureds ID Number From the Plan members ID Card. Make sure to use the members CIN number from the paper ID card, not the number from the States card. Patients Name Enter the last name first, then the first name and middle initial (if known). Do not use nicknames or full middle names. Patients Birth Date Write date of birth as MM/DD/YY (month, day, year) format. For example, write September 1, 1993 as 090193. If the full date of birth is not available, enter the year, preceded by 0101. Insureds Name Same is acceptable if the insured is the patient (not required for Medi-Cal). Patients Address/Telephone Enter complete address. Include any unit or Number apartment number. Include abbreviations for road, street, avenue, boulevard, place, or other common ending to the street name. Enter patients telephone number, including area code. Patient Relationship to The relationship to the member or subscriber, such Insured as self, spouse, child or other (not required by Medi-Cal). Insureds Same is acceptable if the insured is the patient (not required by Medi-Cal). Address/Telephone Number Patient Status Check patients status (single, married, other, employed, full-time student or part-time student). Check all that apply. Other Insureds Name If there is other insurance coverage in addition to the members coverage, enter the name of the insured. Name of the insurance with the group and policy Other Insureds Policy or Group Number number. Other Insureds Date of Enter date of birth in the MM/DD/YY (month, Birth day, year) format.
Field 1a
Field 2
Field 3
Field 4 Field 5
Field 6
Field 7
Field 8
Field 9
Field 9a Field 9b
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Field 14 Field 21
Field 24a
Field 24e Field 24f Field 24g Field 24H Field 25 Field 28 Field 31
Include any description of injury or accident, including whether it occurred at work. Y or N. If insurance is related to Workers Compensation, enter Y. Related to Auto Y or N. Enter the state where the accident Accident/Place? occurred. Related to Other Accident? Y or N. Reserved for Local Use Insureds Policy Group or Complete information about Insured, even if same FECA Number; Date of as Patient. Birth, Sex, Employer or School Name Date of Current Injury, Illness, or Pregnancy (if applicable) Diagnosis or Nature of Enter the appropriate diagnosis code or Illness or Injury nomenclature. Check the manual or with a coding expert if not sure. Date(s) of Service If dates of service cross over from one year to another, submit two separate claims (for example, one claim for services in 2006, one claim for services in 2007). Place of Service Procedure, Services or Enter the appropriate CPT codes or nomenclature. Supplies Indicate appropriate modifier when applicable. Do not use NOC Codes unless there is no specific CPT code available. If using an NOC Code, include a narrative description. Diagnosis Code Use the most specific ICD-9 code available. $Charges Charge for each single line item. Days or Units If applicable EPSDT Family Plan Enter Y for EPSDT or N for nonEPSDT. Federal Tax ID Number Enter this nine-digit number. Total Charge Total of line item charges Full Name and Title of Actual signature or typed/printed designation is Physician or Supplier acceptable.
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Field 33
Level 2 consists of other codes that identify products, supplies and services not
included in the CPT codes, such as ambulance and durable medical equipment (DME). These are sometimes called the alpha-numeric codes because they consist of a single alphabetical letter followed by four numeric digits. Medi-Cal Local Codes and Modifiers In addition to the HCPCS, the California Department of Health Care Services (DHCS) created a set of additional codes for its Medi-Cal Program, sometimes called Local Codes. These codes identify services and products specific to Medi-Cal. Medi-Cal also provides for Modifiers to HCPCS.
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Inpatient CodingInstitutional
Modifier Codes: Use modifier codes when appropriate; refer to the current
edition of the Physicians Current Procedural Terminology Manual published by the American Medical Association (AMA). Note: Bill surgical supply charges using the appropriate procedure code for the services rendered; they must be accompanied with a ZM (without anesthesia) or ZN (with anesthesia) modifier. Outpatient CodingInstitutional
HCPCS Codes: Refer to the current edition of CMS Common Procedure Coding
System published by the Centers for Medicare and Medicaid Services (CMS); to order, call 1-800-633-7467.
CPT Codes: Refer to the current edition of the Physicians Current Procedural
Terminology manual published by the American Medical Association (AMA); we require that when outpatient services are billed, they must have itemized CPT/HCPC/local use codes; use of Revenue Codes only on outpatient claims will result in a delay or denial of the claim for lack of information; to order, call 1-800-621-8335. Note: Medi-Cal and Healthy Families Program HMO Only-Use the appropriate HCPCS or CPT codes. The use of Revenue Codes only on outpatient claims may result in a delay or denial of the claim for lack of information. When billing Medicare/Medi-Cal claims, submit with HCPCS/CPT and corresponding Revenue Codes.
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Member ID Number Use the members CIN (Client Index Number) when billing, whether submitting electronically or by paper. Go to Recommended Fields for CMS-1450 for field descriptions or visit the Centers for Medicare and Medicaid Services website at www.cms.hhs.gov/forms.
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Provider's Tax ID
9 PATIENT ADDRESS b a
Member number
6 STATEMENT COVERS PERIOD FROM THR OUGH 7
TYPE OF BILL
Member Name
12 DATE ADMISSION 13 HR 14 TYPE 15 SRC
Member's Address
21 CONDITION CODES 22 23 24 25 26 27 OCCURRENCE SPAN FROM THROUGH 36 CODE
c 28
d 29 ACDT 30 STATE
11 SEX
16 DHR 17 STAT
18
19
20
Date of Birth
Sex
Admission Hour
35 CODE
37
38
39 CODE
40 CODE
41 CODE
a b c d
Value Codes
45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49
1 2 3 4 5 6 7 8
43 DESCRIPTION
Revenue Codes
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Description
9 10 11 12 13 14 15 16 17 18 19 20 21
PAGE
50 PAYER NAME
OF
51 HEALTH PLAN ID
CREATION DATE
52 REL. INFO
53 ASG. BEN.
TOTALS
Claim Total
56 NPI 57 OTHER PRV ID
22 23
54 PRIOR PAYMENTS
A B C
Amount Due
61 GROUP NAME
A B C
A B C
Insureds Name
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME
A B C
Authorization number/information
66 DX
Medicaid ID #
L M N F O
72 ECI 75 76 ATTENDING LAST NPI QUAL
B C
c.
Principal Procedure
OTHER PROCEDURE CODE DATE
d.
e.
NPI
Additional diagnosis
NPI
Prescriber ID
FIRST
FIRST
QUAL
THE CERT IFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
LIC9213257
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Recommended Fields for CMS-1450 The following guidelines will assist in completing the CMS-1450 Form (R indicates a required field). The PAGE OF and CREATION DATE fields on Line 23 should be reported on all pages of a multiple-page form.
.
# R blank blank
Box Title
Description Facility name, address, and telephone number. Members account number. Members record number, which can be up to 20 characters long. Enter the Type of Bill (TOB) Code. Enter the providers Federal Tax ID number FROM and THROUGH date(s) covered by the claim being submitted Leave blank. Members name. Complete address (number, street, city, state, zip code, telephone number). Members date of birth in MM/DD/YY (month, day, year) format. Members gender. Members admission date to the facility in MM/DD/YY (month, day, year) format. Members admission hour to the facility in military time (00 to 23) format. Type of admission. Source of admission. Members discharge hour from the facility in military time (00 to 23) format. Patient status. Enter Condition Code (81) X0 X9.
PAT. CNTL # MED. REC # R R TYPE OF BILL FED. TAX NO. STATEMENT COVERS PERIOD blank R R R R R R R R R R PATIENT NAME PATIENT ADDRESS BIRTHDATE SEX ADMISSION DATE ADMISSION HR ADMISSION TYPE ADMISSION SRC DHR STAT CONDITION CODES
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
37 38 3941 42 43 44
45 46 47 48 49 50 51
R R R
52 53 54 55 56 R R
REL. INFO ASG BEN. PRIOR PAYMENTS EST. AMOUNT DUE NPI
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
INSURANCE GROUP NO. Enter the Policy Number of any other health plan. TREATMENT AUTHORIZATION CODES DOCUMENT CONTROL NUMBER EMPLOYER NAME Authorization Number or authorization information must be entered on this field. The Control Number assigned to the original bill. Name of organization from which the insured obtained the other policy. Enter the diagnosis and procedure code qualifier (ICD version indicator). Principal Diagnosis Code. Enter the ICD-9 diagnostic code. Other Diagnosis Codes. Enter the ICD-9 diagnostic codes, if applicable. Leave blank. Admission Diagnosis Code enter the ICD-9 code. Enter the members reason for this visit, if applicable. Prospective Payment System (PPS) Code. Leave blank. External Cause of Injury Code. Leave blank.
64 65 66 67 67aq 68 69 70ac 71 72 73 74 R R R R
DX blank blank blank ADMIT DX PATIENT REASON DX PPS CODE ECI blank
PRINCIPAL PROCEDURE ICD-9 principal procedure code and dates, if (CODE/DATE) applicable.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Referring CCS eligible or potentially eligible conditions to CCS and Anthem Blue
Cross within 24 hours or the next business day.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Anthem State Sponsored Business will not reimburse claims for CCS-eligible conditions denied by CCS for noncompliance with CCS Program requirements. Providers may not seek additional payment or compensation from members for:
CCS-covered services CCS-denied claims due to failure to submit the application within time frames as
specified by CCS
PM-160 Form Completion Complete the CHDP PM-160 Information Only form and submit copies to:
The Plan with each claim for service The local county CHDP office Member or parent of member The members medical record
Make sure to include the providers original signature and the correct county-specific Prepaid Project Code on the PM-160 Form. The Prepaid Project Code prevents incorrect reporting of encounter data. For a Copy of the PM-160 Form, contact the claimants local CHDP office. They will sent the PM-160 form pre-printed with Provider of Service information.
By using the appropriate CHDP services codes, Anthem Blue Cross can capture accurate claims data which will make the HEDIS review process less intrusive for providers. Anthem Blue Cross follows AAP Prevention Care Guidelines.
CHDP Diagnosis Codes When billing for CHDP services, use the following ICD-9 codes as primary diagnosis: CPT Code V20.2 V70.0 Description For Children (newborn to 18 years of age) For adults (19 to 21 years of age)
Use the following table of codes for History and Physical Examination, Lab Services, and Childhood Immunizations and vaccines for children from age newborn to 21 years of age.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
History and Physical Examination Use the following codes for history and physical examinations performed by health assessment-only providers (includes school-based clinics and local health departments).
CHDP Service codes for History and Physical Examinations for Health Assessment-Only Providers
CPT Code 99385 99384 99383 99382 99381 99395 99394 99393 99392 99391
Description Adolescent (Ages 18-39) New Patient or Extended visit Adolescent (Ages 12-17) New Patient or Extended visit Late Childhood (Ages 5-11) New Patient or Extended visit Early Childhood (Ages 1-4) New Patient or Extended visit Infant (birth-11 months) New Patient or Extended visit Adolescent (Ages 17-39) Health assessment routine visit Adolescent (Ages 12-17) Health assessment routine visit Late Childhood (Ages 5-11) Established patient Early Childhood (Ages 1-4) Established patient Infant (birth-11 months) Established patient
School-Based Clinics CHDP Services Primary Care School-Based Clinics (SBC) follow the same claims and billing guidelines as PCP services. Non-PCP SBC Providers Health Assessment-only services, under CHDP guidelines, are provided to members. Notify us of the SBC status prior to submitting claims. SBCs must determine who the members PCP is and notify that PCP of the visit. The PCP is also responsible for Continued Access to Care/Continuity of Care for the member. Our case management staff can also work with providers to help members who need Care Management services.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
History and Physical Examinations Use the following codes for history and physical examinations performed by comprehensive care providers (PCPs). CHDP Service Codes for History and Physical Examinations for PCPs
CPT Code 99385 99384 99383 99382 99381 99395 99394 99393 99392 99391
Description Adolescent (Ages 18-39) New Patient or Extended visit Adolescent (Ages 12-17) New Patient or Extended visit Late Childhood (Ages 5-11) New Patient or Extended visit Early Childhood (Ages 1-4) New Patient or Extended visit Infant (birth-11 months) New Patient or Extended visit Adolescent (Ages 17-39) Health Assessment Routine visit Adolescent (Ages 12-17) Health Assessment Routine visit Late Childhood (Ages 5-11) Established patient Early Childhood (Ages 1-4) Established patient Infant (birth-11 months) Established patient
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Health Screening Procedures Use the following codes for health screening procedures performed by comprehensive care providers (PCPs). CHDP Service Codes for Health Screening Procedures for PCPs CHDP Codes 98998 98999 S0612 99173 Description Nutritional Counseling, Class or Group Setting Per (Half Hour) Individual Nutritional Counseling Per (Half Hour) Pelvic Exam- 19 years up to 22 years of age Snellen Eye Test Equivalent Visual Acuity Test age 7 through 18 years of age Snellen Eye Test Equivalent Visual Acuity Test age 3 through 7 years of age Bi-Anural Hearing Tests-Audiometric Pure Tone Audiometry PPD Screening-TB: Mantoux Test Dental Fluroide Wash
Clinical Laboratory Tests Use the following codes for clinical laboratory tests performed by comprehensive care providers (PCPs).
CHDP Codes 99830 81003 81007 85660 Hemoglobin or Hematocrit Urine Dipstick Urinalysis, routine, complete
Description
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
CHDP Codes 83655 (26/TC) 86592 87590 88150 84030 82947 82465 87110 87177 Z5220 Lead Blood Level VDRL, RPR, or ART Gonorrhea (GC) Test Pap Smear
Description
Phenylketonuria (PKU) blood test (under 1 month of age) Blood Glucose Assay Total Cholesterol Chlamydia Test Ova and/ or Parasites Lab collection and handling fee
Vaccines for Children All Medi-Cal providers who administer vaccines to children less than 19 years of age must be enrolled in the Vaccines for Children (VFC) Program. Billing for Immunizations Provided by the Vaccines for Children Program When billing immunizations provided to you by the VFC Program, the Medi-Cal local code SL modifier must be used with the appropriate CPT code on each line of Box 24D of the CMS-1500 Form. On another line of Box 24D, use the appropriate CPT code for administration fee code of the vaccine or immunization. Billing for Immunizations NOT Covered by the VFC Program When billing immunizations not covered by the VFC Program, use the appropriate CPT code on one line of Box 24D and the appropriate administration procedure code on the next line of Box 24D. Do not use the SL modifier. Immunizations and Vaccines Use the following codes for immunizations and vaccines performed by comprehensive care providers (PCPs). Use the appropriate CPT codes and corresponding administration fee codes for CHDP vaccines for members between the ages of 19 and 21. Both services are reimbursable. Enter the appropriate number of units in Box 24G of the CMS-1500 claim form or electronic claims transmission. Do not use the SL modifier.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP Version: 1.4 Revision Date: February 2010 Chapter 5: Page 40
90698
90700 90701
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Diphtheria and tetanus toxoids (DT) adsorbed for use in individuals younger than 7 years, for intramuscular use 90703 Tetanus toxoid absorbed, for intramuscular use 90705 not a benefit Measles virus vaccine, live, for subcutaneous use 90706 Rubella virus vaccine, live, for subcutaneous use Measles, mumps, and rubella virus vaccine (MMR), live, for 90707 subcutaneous use 90710 Measles, mumps, rubella and varicella (MMRV), live, for subcutaneous use (covered by Healthy Families Program only) 90712 Poliovirus vaccine, (any types [OPV], live, for oral use 90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous use 90714 Tetanus and diphtheria toxoids (Td) absorbed, preservative-free, for use in individuals seven years or older, for intramuscular use 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), for use in individuals 7 years or older, for intramuscular use 90716 Varicella virus vaccine, live, for subcutaneous use Tetanus and diphtheria toxoids (Td) absorbed for use in individuals 7 90718 years or older, for intramuscular use 90720 Diphtheria, tetanus toxoids and whole cell pertussis vaccine and Haemophilus influenza B vaccine (DTP-Hib), for intramuscular use 90721 Diphtheria, tetanus toxoids and acellular pertussis vaccine and Haemophilus influenza B vaccine (DtaP-Hib), for intramuscular use Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B and 90723 poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immuno-suppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use Meningococcal polysaccharide vaccine (any groups), for subcutaneous 90733 use 90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use 90743 Hepatitis B vaccine, adolescent (2-dose schedule), for intramuscular use 90744 Hepatitis B vaccine, pediatric/adolescent dosage (3-dose schedule), for intramuscular use 90746 Hepatitis B vaccine, adult dosage, for intramuscular use Hepatitis B and Haemophilus influenza b vaccine (HepB-Hib), for 90748 intramuscular use
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Description
Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component (List separately in addition to code for primary procedure) H1N1 flu vaccine administration fee effect. 9/2009 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)
90461
90470 90471
90472
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Description
Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid). Each additional vaccine (single or combination vaccine/toxoid) List separately in addition to code for primary procedure. Use 90474 in conjunction with 90471 or 90473
Comprehensive Perinatal Services Program Billing for CPSP Services Only Comprehensive Perinatal Services Program (CPSP)-certified providers can bill for CPSP services, and claims must contain CPSP-specific codes. CPSP Standards Refer to the DHCS CPSP manual. Procedure CodesCPSP Certified Medi-Cal Managed Care Providers lists codes for CPSP-certified providers, including nutrition and psychosocial and health education. Maternity Services All perinatal service providers must offer CPSP services to our members. If the Provider is not CPSP-certified and the member chooses to participate in CPSP services, the member must be referred to a CPSP Provider for those supplemental services.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Billing for Maternity Services Use the CMS-1500 Claim Form with the appropriate coding. For example: MRMIP 1921 AIM HMO 1922 AIM FFS PD02 AIM FFS T769 AIM EPO 1924 Healthy Families Program HMO Healthy Families Program EPO Medi-Cal Itemized1, global or antepartum codes2 (PBP Plan) Global only Itemized only Antepartum codes or partial global Itemized, global or antepartum codes (PBP Plan) Itemized only Global only Itemized only
1
2
Itemized: Evaluation and Management (E & M) Codes. Antepartem Codes: For example, 59425, 59426. See below for detailed instructions.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP Version: 1.4 Revision Date: February 2010 Chapter 5: Page 45
In the event that the entire OB care is not provided in the same practice, follow
Antepartum Care billing as described in the following section. Antepartum Codes If you see a pregnant woman from one to three times, report each visit using the appropriate level of Evaluation and Management (E and M) care (CPT 99201-99215). If you see a woman more than three times, but fewer than seven times, use code 59425; antepartum care only; four to six visits, and bill only one unit. If you allow seven or more visits, use code 59426; antepartum care only; seven or more visits, and bill only one unit. These codes are used to bill only the total number of times you see the member for all antepartum care during her pregnancy and may not be used to bill in combination with each other during the entire pregnancy period. Do not bill antepartum care-only codes in addition to any other procedure codes that include antepartum care (such as global OB codes). Global Codes Global codes are valid for AIM HMO, AIM Fee-for-Service (T760), AIM EPO, and MRMIP Programs, and Healthy Families Program EPO only. For all other claims that we receive with global codes, we will send you an Information Request/Mailback Letter, asking you to re-bill using itemized codes. You then have 90 days from the date of our information request letter to submit the corrected claim. The Healthy Families Program and AIM Fee-for-Service (PD02) Program should bill with regular E and M Codes, as appropriate. Refer to Maternity Procedure Codes for Medi-Cal Providers (below) for more maternity codes. Maternity Procedure Codes for Medi-Cal Providers Global billing is not accepted. All charges must be itemized.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Healthy Families Program and the AIM Program should bill with regular E and M Codes as appropriate.
.
Code Z1032
Service Definition Initial pregnancy-related office visit. OR Z1032 with Use if initial pregnancy-related ZL Modifier office visit within the 1st 16 weeks of gestation. Z1034 Antepartum follow-up visit (nonglobal), subsequent to the initial pregnancy-related office visit, per visit billing. Z1036 10th antepartum office visits (nonglobal). Any additional visits Z1038
2nd visit through 9th visit (bill each visit separately) Billed once per pregnancy.
Should be billed with regular Evaluation and Management codes as appropriate. Postpartum 1 follow-up office One time only. visit (nonglobal).
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Z6206
Z6208
Z6210
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Each subsequent 15 minutes Maximum of 1-1/2 hours or 6 units Z6304 Individual follow-up Maximum of 3 hours or 12 units. antepartum psychosocial assessment, treatment or intervention, 15 minutes each Z6306 Group, per patient, follow- Maximum of 4 hours or 16 units. up antepartum psychosocial assessment, treatment or intervention, 15 minutes each Z6308 Individual follow-up post Maximum of 1-1/2 hours or 6 units. partum psychosocial assessment, treatment or intervention including development of care plan, 15 minutes each. Health Education Z6400 Client orientation, health Maximum of 2 hours or 8 units. education, each 15 minutes. Individual initial health education assessment and development of care plan Z6402 Z6404 Z6406 First 30 minutes Each subsequent 15 minutes Individual, follow-up health education assessment treatment or intervention, 15 minutes. Group, per patient, follow-up health education assessment treatment or intervention, 15 minutes. Individual, perinatal education, each 15 minutes. May be billed once per pregnancy in lieu of Z6500. Maximum of 2 hours or 8 units. Maximum of 2 hours or 8 units.
Z6408
Z6410
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Sterilization Claims Sterilization is any procedure/treatment performed to permanently take away the ability to reproduce. Billing Sterilization Claims Use the CMS-1500 Claim Form and follow appropriate coding guidelines. Attach a copy of the completed Sterilization Consent Form PM330 to the claim for either gender receiving the sterilization. Refer to the California Code of Regulations, Title 22, Section 51305.4 for Consent Form PM330 guidelines. Dental Services Only bill emergency dental services to the Plan. Routine dental services are a carved-out benefit. Durable Medical Equipment (DME) See Ancillary Billing Requirements by Service Category.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Emergency Services Authorizations are not required for medically necessary emergency services. Emergency services are defined in the providers contract and by State and local law. Related professional services offered by physicians during an emergency visit are reimbursed according to the Providers contract. For emergency services billing, indicate the Injury Date in Box 14 on the CMS-1500 Claim Form. All members should be referred back to the Primary Care Provider (PCP) of record for follow-up care. Unless clinically required, follow-up care should never occur in the Emergency Department of a hospital. Initial Health Assessments (IHA) The PCP functions as the medical home or patient advocate and is responsible for member access to health care. Based on the members age, the PCP provides an Initial Health Assessment (IHA) consisting of a complete history and physical within 60 to 120 days from the members date of enrollment with us. Preventive services are to be rendered according to our Clinical Practice Guidelines. Billing Codes for Initial Health Assessment When billing for preventive services, use these ICD-9 diagnosis codes:
V20.2 for children (newborn to 18 years of age) V70.0 for adults (19 years and older)
Refer to the Adult Preventive Care Procedure Codes for CPT office visit codes for IHA and Adult Preventive Care. For details on correct billing procedures, refer to Submitting a Claim. You can also reference the Physicians Current Procedural Terminology (CPT) manual published by the American Medical Association (AMA).
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Initial comprehensive preventive medicine evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions and the ordering of appropriate immunizations, laboratory/diagnostic procedures, new patient 99381 99382 99383 99384 99385 99386 99387 Infant (age under 1 year) Early childhood (age 1 through 4 years) Late childhood (age 5 through 11 years) Adolescent (age 12 through 17 years) 1839 years 4064 years 65 years and over
Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions and the ordering of appropriate immunizations, laboratory/diagnostic procedures, established patient 99391 99392 99393 99394 99395 99396 99397 Infant (age under 1 year) Early childhood (age 1 through 4 years) Late childhood (age 5 through 11 years) Adolescent (age 12 through 17 years) 1839 years 4064 years 65 years and over
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Description TB Screening (PPD) Flu Shot Pneumovax Td-DiphtheriaTetanus Toxoid0.5 ml Pap Smear (lab procedure code only) Mammogram (specialty center) PSA (lab procedure code only)
Mental Health For Medi-Cal members only, certain Mental Health Services are carved out to the State. The PCP is expected to treat members with situational mental health problems, the most common of which are depression and anxiety disorders. For those Medi-Cal members whose mental health problems do not respond to treatment in a primary care setting, referrals must be made to the local county mental health system for assessment and ongoing services as indicated. Newborns Newborns of Medi-Cal members are covered under the mother, using the mothers CIN (Client Index Number), for the month of birth and the following month or until such time as the Department of Health Care Services issues a CIN for the newborn. Services rendered before the CIN is issued to the newborn should be billed using the CIN of the mother, and the name, date of birth, and other information about the newborn. Encourage Medi-Cal members to contact their social worker immediately and fill out all required paperwork to accurately enroll the newborn and prevent any lapse in coverage. For newborns of Healthy Families Program and Access for Infants and Mothers (AIM) Program members, the mother is sent a State ID card for the newborn and notifies the Plan. Providers should bill with the mothers Plan ID Number until the newborn receives a Plan ID card. AIM Program mothers are sent paperwork from MRMIB in order to enroll their newborns in the Healthy Families Program. Encourage these members to complete this paperwork and submit it to the program to obtain an ID card for the newborn. Hospitals should bill mothers and newborns separately, not together.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Self-Referable Services Members may access the following self-referable services at any time without preservice review requirements if their benefits allow. Members associated with capitated medical groups must self-refer to services within the group.
Diagnosis and treatment of Sexually Transmitted Diseases (STD) Testing for the Human Immunodeficiency Virus (HIV) Family Planning Servicesservices to prevent or delay pregnancy Abortions (in-network only) Annual Well Woman exam (ICD-9 Diagnosis V72.3) (in-network only) Prenatal services (in-network only) obstetric care
Self-referable services may (unless limited by state or federal regulation) be rendered by a willing provider, even those without a contract. We reimburse contracted providers according to the providers contract; we reimburse reasonable and customary rates for noncontracted providers. Sensitive Services Sensitive services are provided for family planning, including contraceptive management, sexually transmitted diseases, including AIDS/HIV, and other sensitive services, including abortion and alcohol/drug treatment for minors over age 12. Authorization requirements are waived when these services are billed. Members may receive these services from either in-network providers or out-of-network providers. Sterilization claims for either gender must include an attachment of the DHCS PM 330 consent form. Family Planning Services The following is a list of diagnosis codes specific to family planning services.
ICD-9 996.32 V15.7 V25.01 Description Due to intrauterine contraceptive device Contraception Prescription of oral contraceptives
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
ICD-9 V25.02 V25.09 V25.1 V25.2 V25.3 V25.40 V25.41 V25.42 V25.43 V25.49 V25.5 V25.8 V25.9 V26.0 V26.1 V26.22 ICD-9 V26.4 V26.51 V26.52 V26.8 V26.9 V45.51 V45.52 V45.59
Description Initiation of other contraceptive measures; fitting of diaphragm; prescription of foams, creams or other agents Other; family planning advice Insertion of IUD Sterilization; admission for interruption of fallopian tubes or vas deferens Menstrual extraction; menstrual regulation Contraceptive surveillance, unspecified Contraceptive pill Intrauterine contraceptive device; checking, reinsertion or removal of IUD Implantable subdermal contraceptive Other contraceptive method Insertion of implantable subdermal contraceptive Other specified contraceptive management; post-vasectomy sperm count Unspecified contraceptive management Tuboplasty or vasoplasty after previous sterilization Artificial insemination Aftercare following sterilization reversal Description General counseling and advice Tubal ligation status Vasectomy status Other specified procreative management Unspecified procreative management Intrauterine contraceptive device Subdermal contraceptive implant Other
The following is a list of procedure codes associated with family planning. They are payable without authorization requirements because they are self-referable.
HCPCS/CPT 11975 11976 11977 00840 00851 Description Norplant Implant Norplant Removal Removal with reinsertion, implantable contraceptive capsules Anesthesia for intraperitoneal procedures in lower abdomen, including laparoscopy Anesthesia for intraperitoneal procedures in lower abdomen, including laparoscopy, tubal ligation/transection
Version: 1.4 Revision Date: February 2010 Chapter 5: Page 55
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
X1512 X1514 X1520 X1522 HCPCS/CPT X1532 X6051 X7490 X7610 X7706 X7720 X7722 X7728 X7730 81025 84703 89320
Sexually Transmitted Diseases (STD) The following is a list of diagnosis codes specific to STDs. They are payable without authorization requirements because they are self-referable.
ICD-9 003.1003.9 010.00018.96 Description HIV-related HIV-related
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
The following is a list of procedure codes associated with STDs. They are payable without authorization requirements because they are self-referable.
HCPCS/CPT 54050 54055 54056 54057 54060 54065 Description Destruction of lesions, penis (for example, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical Destruction of lesions, penis (for example, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation Destruction of lesions, penis (for example, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery Destruction of lesions, penis (for example, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery Destruction of lesions, penis (for example, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision Destruction of lesions, penis (for example, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (for example, laser surgery, electrosurgery, cryosurgery, chemosurgery) Acute hepatitis panel. This panel must include the following: Hepatitis A antibody IgM antibody, Hepatitis B core antibody, IgM antibody Hepatitis B surface antigen Hepatitis C antibody Chlamydia (florescent antibody screen)
80074
86255
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
87340 87490 87491 87591 86592 86593 86631 86632 86692 86694 86696 86701 86702
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
87340
87341
87350
87380
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
87904
Other Sensitive Services The following is a list of procedure codes that include other sensitive services.
HCPCS/CPT 99170 46608 57415 59840 59841 X1516 X1518 Description Anogenital examination with colposcopic magnification in childhood for suspected trauma Anoscopy; with removal of foreign body Removal of impacted vaginal foreign body (separate procedure) under anesthesia Dilation and Curettageused to induce a first trimester abortion, for termination of a pregnancy in the first 1214 weeks of gestation Dilation and Curettageused to induce a second trimester abortion, for termination of a pregnancy after 1214 weeks of gestation Natural (laminaria) hygroscopic sticks used in the cervical dilation process Synthetic hygroscopic sticks used in the cervical dilation process
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
The following is a list of procedure codes that include other sensitive services for minors over the age of 12 and through age 18 (plus 364 days).
HCPCS/CPT 80100 80101 80102 80103 80154 80173 80184 82055 82075 82101 82120 82145 82205 82520 82646 82649 82654 82742 83840 83992 Description Drug screen, qualitative; multiple-drug classes chromatographic method, each procedure Drug screen, qualitative; single-drug class method (for example, immunoassay, enzyme assay), each drug class Drug confirmation, each procedure Tissue preparation for drug analysis Benzodiazepines Haloperidol Phenobarbital Alcohol (ethanol); any specimen except breath Alcohol (ethanol); breath Alkaloids, urine, quantitative Amines, vaginal fluid, qualitative Amphetamine or methamphetamine Barbiturates, not elsewhere specified Cocaine or metabolite Dihydrocodeinone Dihydromorphinone Dimethadione Flurazepam Methadone Phencyclidine (PCP)
Vision Services (Routine) Some State Sponsored Business Programs cover vision services. Medi-Cal and Healthy Families Program members with vision coverage can access vision care services through Vision Service Plan (VSP) providers. The member can self-refer to any VSP Provider listed in the members Ancillary Services Directory under the Vision Service Plan Network. Refer to Covered and Noncovered Services in this manual for program vision services. Routine vision services are provided by and reimbursed by VSP.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Additional Billing Resources This Provider Operations Manual and information from the following references, provide detailed instructions on uniform billing requirements.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
CCS Referrals Newborns of Medi-Cal and Healthy Families Program members who have a CCS-eligible condition must be referred to CCS in a timely manner and as directed by the local CCS field office or our Utilization Management Department. Do not assume because the professional services are authorized by CCS that the facility component will automatically be granted authorization. Facilities must ensure they are paneled and approved for the procedure or service they are rendering on a CCS-eligible condition to ensure compensation for services rendered. Therapeutic abortions are excluded for payment under this rate, as well as treatment for ectopic and molar pregnancies or similar conditions. The maternity care rate covers the entire admission except for admissions that are approved for extension beyond what is contractually indicated on the continuous inpatient days. In such cases, the inpatient acute care requirements apply for each approved and medically necessary service day for the entire admission unless otherwise indicated. The Boarder Baby requirements are specific only to the days that the baby remains in the hospital nursery after the mother is discharged but do not apply to accommodations in the Neonatal Intensive Care Unit. Prior authorization is required for this extended boarder baby service period. A separate billing must be submitted for the period after the mother is discharged. Special billing instructions and requirements:
No additional requirements Utilization Management approval is required for all admissions Include ICD-9-CM procedure codes for the delivery in form Locators 80 (principal
procedure) through 81 (other procedures); applicable maternity procedure codes are 720 to 74.99, 75.50 to 75.52, 75.61 to 75.62, and 75.69; applicable Boarder Baby Revenue Codes are 0170 to 0173, 0179, unless otherwise indicated
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Inpatient Acute Care The billing requirements for inpatient acute care apply to each approved and medically necessary service day in a licensed bed (not covered under another category in this section) and include, but are not limited to, room and board (including all nursing care), emergency room (if connected with admission), urgent care (if connected with admission), surgery and recovery suites, equipment, supplies, laboratory, radiology, pharmaceuticals and other services incidental to the admission. Special billing instructions and requirements include:
A discharge plan and options that are individually customized and identified from
the admission date and carried forward from the admission date
Required weekly summaries for each discipline; bi-weekly team conference reports
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Defining Levels of Care Level 1 Level 1 represents the most basic level of care (room and board, nursing care, ancillary services, supplies, medication equipment and so on) required by a patient who does not need general acute care, as provided in an inpatient acute care setting, but who requires documented, continuous skilled nursing care. Care must be medically necessary and the services must be authorized. Special billing instructions and requirements include:
Utilization Management approval is required for admission. A revenue code must be included for the approved sub-acute care level; the
appropriate revenue code for Level 1 is 0191. Level 2 To meet Level 2 requirements, in addition to meeting all requirements for Level 1, the patient must need one or more of the following services:
Wound care Inhalation therapy by a licensed respiratory therapist, consisting of four or more
treatments per day for skilled therapeutic intervention, which is not routine or a self-administered treatment or self-administered pharmaceuticals
Continuous IV therapy through a peripheral or central line (other than solely for
hydration) or through Heparin lock
Colony-stimulating factors Ostomy care Tracheostomy care Special beds (for example, KinAir, Clinetron)
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP Version: 1.4 Revision Date: February 2010 Chapter 5: Page 67
Must have Utilization Management approval for admission Must include a Revenue Code for the approved sub-acute care level; the
appropriate revenue code for Level 2 is 0192 Level 3 To qualify for Level 3 care, the patient must meet criteria for either C-1 or C-2, as described below: C-1: In addition to meeting all the requirements for Level 1, the patient requires one or more of services listed below.
Hemodialysis Ventilator care Expanded spectrum IV antibiotics for sub-acute and skilled nursing facilities Rehabilitation residential transitional living centers for post-acute rehabilitation
services; such programs must meet the patient treatment and discharge plan requirements and must include four to six hours per day of skilled physical, occupational, speech, or neuropsychological therapy C-2: To qualify for Level 2 care, in addition to meeting all requirements for Level 1, the patient requires three or more services from items described in Level 2. Special Billing Instructions and Requirements include:
Must have Utilization Management approval for admission. Must include a Revenue Code for the approved sub-acute care level; the
appropriate Revenue Code for Level 3 is 0193 or 0194.
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Emergency Visits The billing requirements for an Emergency Room visit apply to all emergency cases treated in the hospital Emergency Room (for patients who do not remain overnight) and cover all diagnostic and therapeutic services provided, including, but not limited to, facility use (including all nursing care), equipment, laboratory, radiology, supplies, pharmaceuticals and other services incidental to the Emergency Room visit. Reimbursement for Emergency Room services relates to the emergency diagnosis and can be based on urgent care rates, depending on the diagnosis. Emergency services are services provided in connection with the initial treatment of a medical or psychiatric emergency. Special billing instructions and requirements include:
ICD-9-CM principal diagnosis codes are required for all services provided in an
Emergency Room setting.
Each service date must be billed as a separate line item. For Healthy Families Program HMORevenue Codes are 0450 to 0452 and 0459 .Medi-Cal Local Codes are Z7502 or Z7500 (Note: Z7500 must be billed with
Revenue Code 450 to be considered ER). Refer all members back to the Primary Care Provider of record for follow-up care. Unless clinically required, follow-up care should never occur in the Emergency Department of a hospital. Urgent Care Visits The billing requirements for urgent care visits apply to all urgent care cases treated and discharged from the hospital Outpatient Department/Emergency Room and include all diagnostic and therapeutic services provided, including, but not limited to, facility use (including all nursing care), equipment, laboratory, radiology, supplies, pharmaceuticals and other services incidental to the visit. Urgent care refers to nonscheduled, non-emergency hospital services required to prevent serious deterioration of a patients health status as a result of an unforeseen illness or injury. Urgent care visits do not apply to those cases that are admitted and treated for inpatient care following urgent care treatment.
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Required use of ICD-9-CM principle diagnosis codes for all services provided in
an urgent care setting or designated facility.
Billing each service date as a separate line item. Using the required Revenue Code 0456 for Healthy Families HMO. Using the Medi-Cal Local Codes for Medi-Cal Z7502 or Z7500 (Note: Z7500
must be billed with Revenue Code 456 to be considered urgent care). Outpatient Laboratory, Radiology and Diagnostic Services The billing requirements for outpatient laboratory, radiology and diagnostic services (not included elsewhere) refer to services that include, but are not limited to, clinical laboratory, pathology, radiology and other diagnostic tests. These billing requirements include services rendered in relation to an outpatient visit for laboratory, radiology or other diagnostic services, including, but not limited to, facility use, nursing care (including incremental nursing), equipment, professional services (if applicable), specified supplies and all other services incidental to the outpatient visit. See the fee schedule to view outpatient laboratory, radiology, and other diagnostic services fee schedules (technical component only). Outpatient radiation therapy is excluded from this service category and should be billed under the requirements of the Other Services category. Outpatient Surgical Services The billing requirements for outpatient surgical services apply to each outpatient hospital visit for outpatient surgery services, including, but not limited to, facility use (includes nursing care), equipment, supplies, pharmaceuticals, blood, laboratory, radiology, imaging services, implantable prostheses and all other services incidental to the outpatient surgery visit. Even though a service is classified by the hospital as an outpatient service, if the member is receiving that service in the hospital as of 12 a.m., the hospital is reimbursed at the inpatient per diem rate. Billing requirements are based on the highest grouping submitted. See the fee schedule for details. For surgery services that are not defined in the surgery grouping, medical records might be requested by us for review and determination of surgery grouping.
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Billing Medi-Cal Only with appropriate Local code when applicable. Giving service dates (both principal and other) must accompany each procedure.
Outpatient facility services for a CCS-eligible condition must also be referred in accordance with CCS guidelines. Billing instructions and requirements for outpatient care include:
Using the required CPT4/HCPCS Codes for each service; the technical
component (TC) modifier is required when appropriate. The following CPT4/ HCPCS Codes are not valid with a TC modifier:
8004985097 9513087999 8905089399 91100 9300093018 9304093237 9372093799 9398093990 94690 9476094762 9585195857 958950
Billing each service as a separate line item Using the following Revenue Codes with the appropriate CPT4/HCPCS Code:
03000302 03050309 031X 032X 0330 0339 03400341 0349 035X 040X 0482 0483 061X 0636 073X 074X 092X 09710972
Following the billing requirements outlined in the service category when the
Respiratory Therapy Department performs ECG, EEG or EKGs. Do not apply the Outpatient Therapy billing requirements.
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Outpatient Therapies Outpatient therapy services include physical therapy, occupational therapy, speech therapy, and respiratory therapy. An outpatient therapy visit means a single service date. Outpatient therapy visits include, but are not limited to, facility use (includes all nursing care), therapist/professional services, supplies, equipment, pharmaceuticals and other services incidental to the outpatient therapy visit. Special billing instructions and requirements include:
Billing each service date as a separate line item Using the required Revenue Codes:
Physical therapy042X or 0977 Occupational therapy043X or 0978 Speech therapy044X or 0979 Respiratory therapy044X or 0976, or Using the applicable HCPCS/CPT4 codes or Medical Local Only Codes
Outpatient Infusion Therapy Visit and Pharmaceuticals The outpatient infusion therapy visit billing requirements apply to each outpatient hospital visit for infusion therapy services, including, but not limited to, facility use (including all nursing care), equipment, professional services, laboratory, radiology, supplies (for example, syringes, tubing, line insertion kits and so on), intravenous solutions (excluding pharmaceuticals), kinetic dosing and other services incidental to the outpatient infusion therapy visit. An outpatient infusion therapy visit means a single service date. The outpatient infusion therapy pharmaceuticals billing requirements apply to the drugs (for example, chemotherapy, hydration and antibiotics) used during each outpatient visit for infusion therapy services, except for blood and blood products, which are considered other services. Refer to Home Infusion Therapy for HIT Billing instructions. Other Services This category is meant for those rare service types that do not reasonably fall under any other specific reimbursement rate. Other services rendered by the hospital that are not covered under the specific payment rates in the fee schedule are reimbursed at a percentage as specified in the hospital contract.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
We may require medical necessity review and prior approval for these services, pursuant to the agreement between us and the hospital. Stop Loss Claims Stop loss is a provision only in certain Anthem Blue Cross State Sponsored Business Participating Provider Agreements. Check your agreement to confirm if this section applies to you. Submit claims eligible for stop loss payment to us according the following guidelines. Provider Responsibility
Identify claims that meet our stop loss criteria. Submit notice to us within 90 days from the date of discharge. (Provider should
not wait for per-diem payment to submit stop loss claims.) The hospital must allow us, or its authorized agent, free access to the medical records upon written request from us. Failure to provide all necessary supporting documentation may result in the hospital waiving its rights to the additional stop loss payments. Any request for additional information must be provided within 10 working days of the date requested. Qualifications
We must be the primary payer. The Plan is secondary to Medicare and the member has Part B benefits but does
not qualify for Part A, or the member is eligible for Part A but the Part A benefits are exhausted.
Entire length of stay must be approved. The level of care billed must be the same as the approved level of care, or changes
to the covered billed charges may be reduced.
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Contract Changes During Hospitalization Determination of stop loss eligibility is based on the contract in force at the time of admission. Submission Procedure To qualify for stop loss consideration, the hospital must comply with all of the following procedures:
A stop loss requires two separate submissions. Per diem claims should be submitted in the usual fashion (paper or electronic). Stop loss claims must be submitted and received within 90 days of the patients
discharge and in the format described in these guidelines. Stop Loss Claim Submission Requirements Submit stop loss claims as hard copy and include the following items:
Original hard-copy Claim Form CMS-1450 Claim Form for the entire Length of
Stay (LOS)
Complete itemized bill Complete medical records including, but not limited to:
Physician orders Physician progress notes History and physical Laboratory results Diagnostic, radiological, or surgical procedure results
Stop Loss Claims Address Mail all stop loss claims by certified mail to: Attn: Stop Loss Department Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007
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Stop Loss Payment A Provider is paid a stop loss provision once the criteria listed in the contract are met. Stop Loss Application Stop loss only applies to the per-diem rates for the entire inpatient acute admission and does not apply to other rates, including, but not limited to:
Case rates Negotiated rates by Case Management for specific admissions Per visit rates Global fee payments Percentage of charges payments
Noncovered Charges Items not covered in the total covered billed charges include, but are not limited to:
Member comfort items Technical support charges Take-home drugs UR service charges Incremental and other nursing charges Charges not meeting medical necessity Charges not supported by the medical records as actual charges for services that
occur after the member leaves the hospital CCS Services Not Eligible for Stop Loss All services deemed eligible for CCS shall not be eligible for stop loss payment, even if the CCS payment is less than stop loss payment would have been.
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Audits
We perform audits on all paid claims wherever stop loss provision applies. We retain the right to use an authorized agent in the performance of the audit. Hospital agrees to provide complete medical records with the notice of stop loss
and to provide access to the information relative to the claim if requested by us or a third party auditing on our behalf.
Late charges are not eligible for the stop loss provisions if identified or submitted
after 90 days of discharge.
Undercharges and overcharges identified during an audit are not subject to the
90-calendar day filing limit.
Charges used to determine the stop loss threshold are limited to basic room and
board charges. Stop Loss Reconsideration/Appeal
The Provider has 365 days from the date of stop loss payment to request a
reconsideration by us (see Provider Dispute Resolution section for more details)
Laboratory and Diagnostic Imaging on a CMS-1500 Form Durable Medical Equipment on a CMS-1500 Form
Other types of services are also described. Laboratory and Diagnostic Imaging Note: To submit Laboratory and Diagnostic Imaging claims, refer to the guidelines below. (Use the CMS-1500 Form.)
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Billing requirements per contract: Our billing requirements apply to all member
claims, except some services administered through Medi-Cal and other state contract programs.
System edits: Edits are in place for both electronic and paper claims; therefore,
claims not submitted in accordance with requirements cannot be readily processed and most likely will be returned.
Valid coding: For claims submitted to us, valid HCPCS, CPT or Revenue Codes
are required for all line items billed, whether sent on paper or electronically. Refer to the specific service category for special coding requirements.
Split-year claims: For services that begin before December 2006 but extend
beyond December 2007, split claims at calendar-year end. This is necessary to accurately track calendar-year deductibles and co-payment maximums.
Medical records: Medical records for certain procedures might be requested for
determination of medical necessity.
Modifiers: Use modifiers in accordance with your specific billing instructions. Unlisted procedures: Services or procedures may be performed by physicians
that are not found in CPT; therefore, specific code numbers for reporting unlisted procedures have been designated. When an unlisted procedure code is used, we need a description of the service to calculate the appropriate reimbursement and may request medical records.
If it is determined a valid Local or National Code exists for an unlisted code, then the claim will not be paid.
CPT Code 99070: This code (supplies and materials provided by the Provider
over and above those usually included with the office visit or other services) is not accepted by us. Health care professionals are to use HCPCS Level II codes, which give a detailed description of the service provided. We will pay for surgical trays only for specific surgical procedures. Surgical trays billed with all other services will be considered incidental and will not be payable separately.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Disposable and Incontinence Medical Supplies The Department of Health Care Services (DHCS) has implemented Health Insurance Portability and Accountability Act (HIPAA)-mandated changes to Medi-Cal Managed Care billing requirements for disposable and incontinence medical supplies. Below is a reminder of billing criteria required for these claims:
You are required to bill disposable incontinence and medical supplies with HCPCS
Level II Codes for contracted items using either ASC X12N 4010A1P electronic format or CMS-1500 Form for paper claims.
You may not use Local 99 Codes for disposable incontinence and medical
supplies.
The state requires the use of the Universal Product Number (UPN) information
for contracted incontinence and medical supplies; however, we do not require the use of UPN information at this time. Durable Medical Equipment Durable Medical Equipment (DME) is covered when prescribed to preserve bodily functions or prevent disability. DME Preservice Review All custom-made DME requires preservice review; also, some other DME services may require preservice review. Prior to dispensing, contact our Utilization Management (UM) Department to determine if the DME services require preservice review. Services that require preservice review will be denied if approval is not obtained from UM. The UM Department reviews for medical necessity for all requested services requiring preservice review. The presence of a HCPCS code does not necessarily indicate benefit coverage or payment for a particular service. Some DME codes may be By Report and therefore require additional information for preservice review as well as for processing at point of claim.
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DME Billing DME providers should bill with the appropriate modifier to identify rentals versus purchases (new or used). Claims that lack the appropriate modifier will be reimbursed at rental price or rejected for corrected billing. NU is the modifier to designate New. UE is the modifier to designate Used. RR is the modifier to designate Rental. Follow these general guidelines for DME billing:
For Medi-Cal, use Local or HCPCS Codes for DME or supplies. For Healthy Families Program, use HCPCS Codes for DME or supplies. Use miscellaneous codes (such as E1399) when a HCPCS Code does not exist for
that particular item of equipment; use of an unlisted code like E1399 cannot be used to describe an expensive or difficult to order item when an adequate code exists for that item; E1399 is By Report.
The invoice must be from the manufacturer, not the office making a purchase. Unlisted codes will not be accepted if valid HCPCS Codes exist for the DME and
supplies being billed.
Catalog pages are not acceptable as manufacturers invoices. Procedure Code L9999 is obsolete. Many Local Codes have been remediated and are no longer acceptable for
submission. The correct way to bill for sales tax for DME/supplies is to
Bill the code for the service with the appropriate modifier for rental or purchased
for the amount charged, less the sales tax.
Bill the S9999 code on a different line with charges only for the sales tax.
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For example:
Procedure Modifier E0570 Applicable modifier code to designate a rental is RR. S9999 Sales tax will be paid as billed Amount 100.00 8.00
DME Rental Medical documentation from the prescribing doctor is required for DME rentals. Most DME is dispensed on a rental basis only, such as oxygen tanks or concentrators. Rented items remain the property of the DME Provider until the purchase price is reached.
DME providers may use normal equipment collection guidelines. We are not
responsible for equipment not returned by members.
Charges for rentals exceeding the reasonable charge for a purchase will be rejected,
and rental extensions may be obtained only on approved items. DME Purchase DME may be reimbursed on a rent-to-purchase basis over a period of ten months unless specified otherwise at the time of review by our UM Department. Wheelchairs/Scooters All Medi-Cal and Healthy Families Program HMO wheelchair claims are examined by claims examiners. The examiners follow Medi-Cal guidelines when calculating payments for By Report (customized) wheelchair claims. By report claims on CMS-1500 Claim Forms must be accompanied by either:
Manufacturers purchase invoice, or Manufacturers suggested retail price (MSRP) from a catalog dated before August
1, 2003.
If the item was not available before August 1, 2003, claims must be submitted with a manufacturers purchase invoice, the catalog page that initially published the item, and the MSRP. The initial date of availability must be documented in the Reserved for Local Use field (Box 19) of the claim. Documentation must include:
- Item Description
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- Manufacturer Name - Model Number - Catalog Number - Completion of the Reserved for Local Use field (Box 19) on the CMS-1500
Claim Form with the total MSRP of the wheelchair, including all wheelchair accessories, modifications, or replacement parts and the name of the employed Rehabilitation and Assistive Technology of America (RESNA)-certified technician.
Providers must mark each catalog page or invoice line so it can be matched to the appropriate claim line.
For scooters, in addition to the above, the invoice must be an amount published
by the manufacturer before August 1, 2003. If the item was not available before then, providers must list the date of availability in the Reserve for Local Use field (Box 19) of the CMS-1500 Claim Form. The catalog page that initially published the item must be attached to the claim.
The suggested retail price (MSRP) from a catalog page dated before August 1, 2003. If the item was not available before August 1, 2003, the manufacturers invoice must accompany the claim. The initial date of availability must be documented in the Reserve for Local Use field (Box 19) of the CMS-1500 Claim Form.
Modifiers For a listing of DME Modifier Codes, see Appendix 1 of the HCPCS 2006 publication available from the American Medical Association (AMA) or log onto the AMA web site (www.ama-assn.org/) for online access. Other Service Types Ambulance Ambulance services, including those for municipalities, should use a CMS-1500 Form to bill for ambulance services. A Transportation Authorization Request (TAR) is required for all non-emergency ground transportation.
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In the code fields for Medi-Cal, use the Medi-Cal Local Codes.
More information about Medi-Cal requirements for Ambulance services can be found in the DHCS Operations Manual Medical Transportation -- Ground Billing Codes and Reimbursement Rates section. Click http://files.medi-cal.ca.gov/pubsdoco/publications/masters-MTP/Part2/m ctrangndcd_a05.doc
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For Healthy Families Program, use HCPCS CPT Codes. Medi-Cal HCPCS
A0380 A0390 A0430 A0431 A0432 A0433 A0434 A0435 A0436 A0800 A0998 A0999 X0010 X0012 X0014 X0016 X0018 X0020 X0022 X0030 X0032 X0034 X0036 X0200 X0202 X0204 X0206 X0208 X0210 X0212 X0214 X0216 X0218 Medi-Cal Level II National Codes BLS mileage (per mile) ALS mileage (per mile) Ambulance service, conventional air services, transport, one way (fixed wing) Ambulance service, conventional air services, transport, one way (rotary wing) Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers Advanced life support, Level 2 (ALS 2) Specialty care transport (SCT) Fixed wing air mileage, per statute mile Rotary wing air mileage, per statute mile Ambulance transport provided between the hours of 7 p.m. and 7 a.m. Ambulance Response and Treatment, No Transport Unlisted ambulance service Med trans s amb wait time ov 15 min e 15 Compressed air for infant respirators Extra attendant rn 1st hr Extra attendant rn 2nd 3rd hr ea Extra attendant rn ea additional hr Cost of IV fluids ECG in ambulance Ambulance service basic life support Med trans amb 1 pt Med trans amb mil one way per mile Med trans amb oxygen per tank Response to call-non litter case, 1 patient Response to callnon litter case, 2 patients Response to callnon litter case, 3 patients Response to callnon litter case, 4 patients Med trans nurg wheelchair use Response to call litter case Response to call litter case Waiting time over 15 min, each15 min Amb/mileage Night call 7pm to 7am
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A0390 A0420 A0422 A0424 A0425 A0426 A0427 A0428 A0429 A0430 A0431 A0432 A0433 A0434 A0435 A0436 A0800 A0888 A0999
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Dialysis All Dialysis care must be preauthorized (except where Medicare is primary payer). Contact our UM Department for authorization prior to delivery of the service. Dialysis centers and other entities which perform dialysis may use the CMS-1450 Form or the CMS-1500 Form to bill for dialysis services.
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For Medi-Cal, use the Medi-Cal Local Codes For Healthy Families Program, use HCPCS/CPT Codes
More information about Medi-Call requirements for Dialysis services can be found in the DHCS Operations Manual Dialysis Examples: UB-04 section. Click http://files.medi-cal.ca.gov/pubsdoco/publications/masters-MTP/Part2/di alexub_o03o04.doc Home Health All Home Health care must be preauthorized. Contact our UM Department. for authorization prior to delivery of the service. When billing for a Home Health visit
For Medi-Cal, use the Medi-Cal Local Codes For Healthy Families Program, use HCPCS/CPT Codes
(See the Durable Medical Equipment (DME) for billing for supplies and equipment; See Home Infusion Therapy below for billing guidelines for injections given or home infusion therapy.) Home Infusion Therapy All Home Infusion Therapy (HIT) claims are priced by an outside vendor, Ancillary Care Management (ACM). ACM prices all the services billed and converts NDC codes appropriate to the infusion codes. ACM then forwards the pricing information to us by daily EDI submission. If a claim is submitted prior to 9 p.m., it is transmitted overnight to us and appears in our system the following business afternoon. Contracted HIT providers should submit all HIT claims directly to ACM by logging onto ACMs website at www.acmcentral.com. Providers can call the ACM Help Desk at 1-800-957-9693 to get a User ID issued to access the website. The ACM User Manual is posted on the ACM website.
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Coding:
Provider should enter the appropriate HIT Codes provided by Medi-Cal Local
Codes provided to ACM or Per Diem Code in the Item ID field and also enter the National Drug Code (NDC) Number with quantity to be billed.
For Total Parenteral Nutrition (TPN), bill by entering the appropriate S Per
Diem Codes and the B Codes.
For compounded drugs, bill by entering the appropriate NDC Number. Bill by using the appropriate NDC Number and quantity of each unit or per vial.
ACM Help Desk 1-800- 957-9693 ACM Fax 1-402-220-2019 Synagis
Providers should submit CPT-4 Code 90378 and the appropriate number of units;
1 unit of 90378 is equivalent to 50 mg.
Providers should always submit the patients weight for the date of service being
billed. Hospice All hospice care must be preauthorized. Contact our Utilization Management (UM) Department for authorization prior to hospice admission. Hospices should bill for hospice services on the CMS-1450 Form.
For Medi-Cal, use the appropriate Z codes, the range is Z7100 through Z7106.
These claims are paid according to DHCS Medi-Cal Hospice rates. For Medi-Cal members, the Hospice Care section of the Department of HealthCare Services Provider Manual provides detailed billing instructions. Click http://files.medi-cal.ca.gov/pubsdoco/publications/masters-MTP/Part2/ho spic_m01i00o03o08.doc
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Physical Therapy All physical therapy must be preauthorized. Contact our Utilization Management (UM) Department for authorization prior to delivery of services.
Physical therapy is coded using national HCPCS Codes. When entering modifiers,
do not include hyphens. For Medi-Cal claims, if the requested information does not fit neatly in the Reserved For Local Use field (Box 19) of the claim, type requested information on an 8 x 11-inch sheet of paper and attach it to the claim. Skilled Nursing Facilities (SNFs) All Skilled Nursing Facility care must be preauthorized. Contact our Utilization Management (UM) Department for authorization prior to SNF admission. SNF care is billed using a CMS-1450 Form. Ambulatory Surgical Centers (ASC) Most outpatient surgery delivered in an Ambulatory Surgical Center requires preauthorization. Ambulatory Surgical Centers bill on a CMS-1450 Form. When billing for ASC:
Medi-Cal--Use the Medi-Cal Local Code for room charges. Healthy Families Program--Use Revenue Codes for room charges and
HCPCS/CPT codes for other charges.
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If the claim was a paper claim, acknowledgement must be provided by the group
within 15 business days of receipt of the claim.
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Groups must pay a clean claim, or a portion thereof, or contest or deny a claim, or a portion thereof, within 45 working days of receipt of the claim (or within contractual timeframes for the groups contracted providers which comply with the timeframes set forth in this section). The groups request for additional information must be sent to the Provider of service with a date that the requested information is due.
The date of payment or notification of denial is the postmarked date of the payment, or the notice is actually mailed to the Provider of service. The Provider of service and member, when applicable, must be notified if a claim is denied, adjusted or contested. The notification must include an understandable written explanation of the reasons for the denial, adjustment, or contested elements.
Groups must have a dispute resolution mechanism in place that allows Providers of service to file a dispute within 365 days of receipt of an RA by the Provider. All disputes must be resolved within 45 business days of the groups receipt of the dispute or as required by applicable state or federal law.
If a group determines that a claim was overpaid, the group must notify the
Provider of service in writing of the overpayment:
The written notice must identify the claim, the name of the member, the date of service and a clear explanation of the basis upon which the group believes the amount paid was in excess of the amount due, including interest and penalties. Providers of service have 30 calendar days from the receipt of the notice of the overpayment to contest or reimburse the overpayment. (See the Claims Overpayment Recovery Procedure section in this chapter.)
The responsibility for claims payment as outlined above continues until all claims have been paid/denied for services rendered pursuant to your Anthem Blue Cross State Sponsored Business Participating Group Agreement. For questions related to delegation of claims processing activities, contact your group administrator.
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Encounter Data Reporting Because data regarding an encounter is obtained by us through claims data mining, those groups delegated for claims processing must submit encounter data to us as prescribed below: Capitated groups delegated for claims processing must submit all encounter data electronically to us on a monthly basis. Encounters must be reported by the tenth (10th) of the month for all encounters for the preceding 90 days. For example, encounter data being submitted on July 10 should reflect encounters from April 1 through July 1. It is a DHCS requirement to submit encounter data on time. Encounter Data File Format Provide encounter data to us in a proprietary format, except in the instance of L.A. Care Health Plan members. Submit encounter data for L.A. Care members to us in the latest X12N37 HIPAA-compliant format. Questions about Encounter Data Reporting For questions about encounter data reporting, contact the Customer Care Center and ask to be transferred to the Data Analysis Department. Refer to Important Contact Information for the Customer Care Center.
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CPT codes are routinely updated for both additions and deletions. This list represents our best efforts to accurately reflect currently approved CPT Codes as of the date of publication of this State Sponsored Business Provider Operations Manual. Refer to the most current edition of the CPT Manual for the most current codes. Global billing is not accepted. All charges must be itemized.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
CPT Codes for Evaluation and Management Office or Other Outpatient Services, New Patient
Code 99201 99202 99203 99204 99205 Description Office or other outpatient visit for the evaluation and management of a new patient; the presenting problems are self-limited or of minor severity. Office or other outpatient visit for the evaluation and management of a new patient; the presenting problems are of low to moderate severity. Office or other outpatient visit for the evaluation and management of a new patient; the presenting problems are of moderate severity. Office or other outpatient visit for the evaluation and management of a new patient; the presenting problems are of moderate to high severity. Office or other outpatient visit for the evaluation and management of a new patient; the presenting problems are of moderate to high severity.
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Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
OVERVIEW
Our Utilization Management (UM) Program is a collaboration with providers to promote and document the appropriate use of health care resources. The program reflects the most current UM standards from the National Committee for Quality Assurance (NCQA). The UM Department takes a multi-disciplinary approach to help provide access to health care services in the setting best suited for the medical and psychosocial needs of the member based on benefit coverage, established criteria, and the community standards of care. Role of Utilization Management In conjunction with providers, UM assists in providing access to the right care to the right member at the right time in the appropriate setting. Service Reviews The UM Department provides preservice, concurrent and post-service reviews using clinical criteria based on sound clinical evidence. These criteria are available to members, physicians, and other health care providers upon request by contacting the UM Department at: Medi-Cal and Healthy Families Program: AIM/MRMIP members: Availability of UM Staff We ensure availability of UM staff at least eight hours a day on normal business days to answer UM-related calls. Member or provider UM-related calls received through the Customer Care Center (CCC) are triaged to, and handled by, UM staff. Customer Care can be reached at the following numbers: Medi-Cal (all counties except Los Angeles): Medi-Cal (Los Angeles County only): Healthy Families Program: AIM/MRMIP: 1-800-407-4627 1-888-285-7801 1-800-845-3604 1-877-687-0549 TDD: 1-888-757-6034 1-888-831-2246 1-877-273-4193
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
After normal business hours, an answering service is available to take UM-related messages. A UM staff member will return the call the next business day. Eligibility verification, benefits, and network information may be available after normal business hours through our ProviderAccess website. For after hours assistance not available on the website, call the CCC (at the contact numbers above) to be connected to an after hours support staff. Decision-Making We make UM decisions periodically in a fair, consistent, and timely manner. We do not reward practitioners and other individuals conducting utilization review for issuing denials of coverage or care. There are no financial incentives for UM decision-makers that encourage decisions that result in under-utilization. The Utilization Management Committee (UMC) meets at least every other month and supports the Quality Operations Committee (QOC) in the provision of appropriate medical services and provides recommendations for UM activities. Decision and Screening Criteria Decision and notification time frames for approval, modification, deferral, and denial are in alignment with the NCQA, contracts, and other applicable legislation. Decision and screening criteria are developed for the purpose of determining the medical necessity of an outpatient procedure, service, supply, medical device/equipment, or inpatient hospital admission/continued stay. Anthem Blue Cross clinical guidelines and medical policies are available on our website. Anthem Blue Cross also uses Milliman Care Guidelines for inpatient reviews. Providers may request a copy of our guidelines by calling our CCC. The UM Department applies the Milliman Care Guidelines and WellPoint Corporate Medical Policy and Clinical Guidelines for UM screening and decisions. UM does not rely solely on these guidelines but also gives consideration to the clinical information that is provided as well as the individual health care needs of the member. Decision criteria incorporates nationally recognized standards of care and practice from sources such as the American College of Cardiology, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, American Academy of Orthopedic Surgeons, current professional literature, and cumulative professional expertise and experience. The decision criteria used by the clinical reviewers are evidence-based and consensus-driven. We update periodically criteria as standards of practice and technology change. We also involve actively practicing physicians in the development and adoption of the review criteria.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
These criteria are available to members, physicians and other health care providers upon request by contacting the UM Department at: Medi-Cal and Healthy Families Program: AIM/MRMIP: 1-888-831-2246 1-877-273-4193
PRESERVICE REVIEW
Providers are responsible for verifying eligibility and in ensuring that our UM Department has conducted preservice reviews for elective non-emergency and scheduled services before rendering the services. Preservice review is required for elective inpatient admissions, outpatient surgeries, and diagnostic tests or treatments as specified on the Anthem Blue Cross website. Preservice review ensures that services are based on medical necessity, are a covered benefit, and are provided by the appropriate providers. Some Anthem Blue Cross members are assigned to delegated medical groups or IPAs. Providers should contact the medical group to confirm the need for authorization before elective services. Emergency services and sensitive services never require preservice review or authorization from Anthem Blue Cross or delegated groups. Services requiring preservice review include, but are not limited to:
Inpatient hospital care Selected surgical procedures (performed in an outpatient or ambulatory surgical
center)
Selected durable medical equipment (DME) Formula Home health care Speech therapy Sensory integration therapy All infusion therapies Selected MRIs and CT scans Cosmetic procedures
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP Version: 1.4 Revision Date: February 2010 Chapter 6: Page 3
Experimental and investigational services Cardiac and pulmonary rehabilitation Transplants Hospice Skilled nursing facilities Out-of-network specialist referrals Out-of-network services For a more detailed list (by CPT and HCPCS codes) of services requiring
preservice review, go to www.anthem.com/ca and select State Sponsored Plans. From the State Sponsored Plans screen, select Prior Authorization Toolkit, then select the specific program. If you do not have a User ID, click here in the dialog text to request an account and follow the instructions to request an online account. Once approved, you will receive an e-mail confirmation of your approval. If a ProviderAccess account is not approved, you will be notified by mail. What to Have Ready When Calling UM To request preservice review and report medical admission, call the UM Department at: Medi-Cal and Healthy Families Program: AIM/MRMIP: Medical groups delegated to perform UM: 1-888-831-2246 1-877-273-4193 1-888-831-2246 Fax: 1-888-232-0708 To help the process be as quick as possible, have the following information ready when calling:
Member Name and ID Number Diagnosis with the ICD-9 Code Procedure with the CPT Code
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Facility Name (if applicable) Primary Care Physician (PCP) Name Specialist or attending Physician Name Clinical justification for the request Level of care Results of lab tests, radiology and pathology results Medications Treatment plan with time frames Prognosis Psychosocial status Exceptional or special needs issues Ability to perform activities of daily living Discharge plans
Physicians, hospitals and ancillary providers are required to provide information and documentation to UM. Physicians are also encouraged to review their utilization and referral patterns. Preservice Review Time frame For routine nonurgent requests, the UM Department will complete preservice review within five business days from receipt of information reasonably necessary to make a decision, not to exceed 14 calendar days from the date of request. We will send requests that do not meet medical policy guidelines to our physician or medical director for review. We will notify providers within one business day from the receipt of the request by phone of the UM decision and will send the member and requesting provider a written notification by mail within two business days from the receipt of the request of any denial or deferral decision.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
When a reconsideration of a denial based on lack of clinical information is requested, we will make a redetermination within five days of receiving the clinical information necessary to make a medical necessity determination. We will communicate the decision to the physician by telephone and in writing within five working days of receipt of request. Requests with Insufficient Clinical Information For preservice requests with insufficient clinical information, we contact the provider with a request for the clinical information reasonably necessary to determine medical necessity. We make one or two attempts to contact the requesting provider to obtain the additional necessary clinical information. If we do not obtain a response within this time frame, we will send a deferral letter within five business days of receipt of the request. This deferral letter includes specific information that we need to make a decision. If we do not receive the information, we send a denial letter to the member and provider within 14 calendar days from the date on the deferral letter. We extend the deferral time frame for another 14 calendar days if the member or the members provider requests an extension. For urgent requests, the UM Department completes preservice review within 72 hours from receipt of the clinical information necessary to render a decision. Generally speaking, the provider is responsible for contacting us to request preservice review for both professional and institutional services. However, the Hospital or Ancillary provider should always contact us to verify preservice review status on all nonurgent services before rendering services. Emergency Medical Conditions and Services We do not require authorization for treatment of emergency medical conditions. In the event of an emergency, members can access emergency services 24 hours a day, 7 days a week. Members who call their primary care physicians office reporting a medical emergency (whether during or after office hours) should be directed to dial 911 or go directly to the nearest hospital emergency department. All non-emergent conditions should be triaged by the PCP or treating physician with appropriate care instructions given to the member.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Stabilization and Post-Stabilization The Emergency Departments treating physician determines the services necessary to stabilize the members emergency medical condition. After the members medical condition is stabilized, the Emergency Departments treating physician must contact the members PCP for authorization of further services. If the PCP does not respond within 30 minutes, the needed services will be considered authorized. The members PCP is noted on the back of the ID card. Emergency admissions do not require authorization. All continued inpatient stays are reviewed to determine whether the stay is medically necessary. The transfer process for out-of-network admissions requiring transfer to a Anthem Blue Cross-contracted facility or to a higher level of care include the following:
The attending physician is to discuss the potential transfer with the PCP. To facilitate the transfer (that is, inform the caller of the in-network Hospital for
transfer, identify the contracted specialist, and admit the member), the PCP is required to contact the treating physician within 30 minutes of the call.
The attending physician must document and sign orders stating the member is
stable for transfer.
Transfers of children require the signed permission of the parents, except in cases
of transfers to a higher level of care. The Emergency Department should send a copy of the Emergency Room record to the PCPs office within 24 hours. The PCP should file the chart copy in the members permanent medical record. The PCP should review the Emergency Room chart, contact the member, and schedule a follow-up office visit or a specialist referral, if appropriate. All providers who are involved in the treatment of a member share responsibility in communicating clinical findings, treatment plans, prognosis, and the psychosocial condition of such member with the members PCP to ensure effective coordination of care. Referrals to Specialists The UM Department is available to assist providers in identifying a network specialist or arranging for specialist care. Here are some other items to keep in mind when referring members:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Authorization from UM is required when referring to an out-of-network specialist. Authorization from UM is not required for Medi-Cal members who self-refer (see
Self-Referral) for sensitive services, even if services are rendered out-of-network.
CONCURRENT REVIEW
Admission and Continued Stay Reviews Providers are to notify Anthem Blue Cross and provide a clinical review within 24 hours of admission or the next business day if the member is admitted on a weekend or holiday. Anthem Blue Cross will contact hospitals and request clinical reviews within 24 hours of notification of admissions. All inpatient stays beyond the approved number of days require concurrent review. Providers are to submit ongoing reviews as requested by Anthem Blue Cross. Anthem Blue Cross performs continued stay reviews to assure the medical care rendered is medically necessary and provided at the appropriate facility and level of care. The clinical information for continued stay reviews may be provided by the Hospital or the attending physician and may be called or faxed to Anthem Blue Cross. When a continued inpatient stay or treatment is expected to exceed the number of days authorized during preservice review or when the inpatient stay or treatment did not have preservice review, the Hospital or provider must contact us for concurrent review in order to determine if the inpatient stay or treatment is medically necessary. In such case, we require clinical review of the inpatient stay or treatment for all members upon admission and during the course of the members hospitalization. We perform the review, based on clinical information provided to us by the Hospital or attending physician, to assess that the medical care rendered is medically necessary and that the facility and level of care are appropriate. We identify members admitted to the inpatient setting by:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Members or their representatives reporting admissions Claims submissions for services rendered without authorization Preservice authorization requests for inpatient care
The UM Department completes concurrent inpatient reviews within 24 hours of receipt of clinical information or sooner, consistent with the members medical condition. Review coordinators request clinical information from the Hospital on the same day they are notified of the members admission/continued stay. If the information provided meets medical necessity review criteria, we will approve the request within 24 hours from the time the information is received. We will send requests that do not meet medical policy guidelines to the physician advisor or medical director for review. We will notify providers within 24 hours of the decision. We will send a written notification to the member and requesting provider within two business days of any denial decision. Inpatient Admission Notification We identify members admitted to the impatient setting (acute care hospital, acute rehabilitation hospital, intermediate facility, or skilled nursing facility) by:
Providers reporting admissions Member or their representatives reporting admissions Preservice authorization requests for impatient care for elective admissions
Medi-Cal and Healthy Families Program: AIM/MRMIP: 1-888- 831-2246 1-877-273-4193
Evidence-based criteria are used in medical necessity and appropriate level of care determinations.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Clinical Information Facilities are required to provide clinical information within 24 hours of the admission notification in order to facilitate concurrent review, certify approved impatient days, expedite discharge planning and authorizations, and ensure proper claims payment. Decisions are made within 24 hours of the receipt of the clinical information needed to make these decisions. The review coordinator performs ongoing follow-up concurrent reviews in collaboration with Hospital UM staff and provides assistance with discharge planning, as needed, to facilitate and coordinate the timely transition of care when medically indicated. Denial of Service Only a medical or behavioral health physician who possesses an active State of California professional license or certification can deny an outpatient procedure, service, durable medical equipment (DME), inpatient hospital admission, or continued inpatient hospital stay for lack of medical necessity or of medical information. When a determination that a request is not medically necessary is made, a physician reviewer calls the requesting Provider for peer-to-peer discussion of the case. The physician reviewer also informs the provider of the opportunity for an appeal should the final determination result in denial. The UM Department has Utilization Management policies and procedures that address the availability of physician reviewers to discuss by telephone adverse determinations based on medical necessity. Providers may contact the physician clinical reviewers to discuss any UM decision by calling the UM Department at: Medi-Cal and Healthy Families Program: AIM/MRMIP: Post-Service/Retrospective Review Post-service/retrospective reviews determine the medical necessity or level of care for inpatient services or treatments that were rendered without obtaining preservice or concurrent review, and, therefore, no inpatient days or treatments were certified. For inpatient admissions or treatments where no preservice or concurrent notification was received, a copy of the medical record is required with the claim. Elective non-emergent services performed without the required preservice review will be denied since this is not a covered benefit. 1-888-831-2246 1-877-273-4193
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
SELF-REFERRAL
Members may self-refer for sensitive services, such as:
Health education and counseling Limited history and physical examinations Laboratory tests Diagnosis and treatment of sexually transmitted diseases if medically indicated HIV testing and counseling Contraceptive pills, devices/supplies Sterilization Pregnancy testing and counseling
ADDITIONAL SERVICES
California Childrens Services California Childrens Services (CCS) is a state and county-funded program that serves children under the age of 21 who have acute and chronic conditions that may benefit from specialty medical care and case management. State statutes and contracts require that CCS Program services be carved out of our Medi-Cal and Healthy Families Programs. As a result, upon suspicion or identification of a CCS-eligible condition, please refer the child to the local CCS Program or contact us to assist with the referral.
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Mental Health Services Mental health services are not covered for Medi-Cal members. We, however, cover outpatient mental health services that are within the scope of practice of the primary care physician. Certain mental health services are covered on a limited basis for the Healthy Families Program, AIM and MRMIP members as described in the members Evidence of Coverage (EOC). For a list of the covered mental health services and benefit limitations, review the benefit matrixes found in the Medical Benefits subsection under Covered and Noncovered Services. If you have questions or need assistance, call the CCC at the following numbers: Medi-Cal (All counties except Los Angeles): Medi-Cal (Los Angeles County only): Healthy Families Program: AIM/MRMIP: Authorizing Mental Health Services Medi-Cal Members Contact the local county Mental Health Department to report and obtain authorization for any inpatient admission to a participating Hospital pertaining to a mental health diagnosis. Healthy Families Program HMO and EPO Members For questions regarding benefit coverage and limitations, or for authorizations, contact Anthem Blue Cross Behavioral Health Programs at 1-800-399-2421. Vision Care Members access basic vision care and primary eye care services through Vision Service Plan (VSP) providers as outlined in the VSP Provider Operations Manual. For preservice authorization of all vision services, contact VSP at 1-800-615-1883. 1-800-407-4627 1-888-285-7801 1-800-845-3604 1-877-687-0549 TDD: 1-888-757-6034
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Dental Care Providers can use AEVS to determine the appropriate provider. Healthy Families Program members should access their contracted dental network through the Managed Risk Medical Insurance Board (MRMIB). The MRMIP and AIM Programs do not cover dental services. Cross-References
Important Contact Information California Childrens Services Mental Health Member Grievances and Appeals Provider Grievances and Appeals Pharmacy Benefits Vision Services
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Referring members who could benefit fromcare management Sharing information as soon as possible (for example, during the Initial Health
Assessment the Primary Care Physician [PCP] identifies care management needs)
Collaborating with care management staff on an ongoing basis Monitoring and updating the care plan to promote goal achievement Providing medical informations Calling Care Management if members are referred to county or state-linked
services
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Members Eligible for Specialized Services We work closely with our physician partners to ensure continuity and coordination of care for our members who are eligible for linked and carved-out services. These services include:
Regional centers Early Start/Early Intervention California Childrens Services (CCS) County mental health care
Although these agencies provide specialized services for our members, we and primary care physicians remain responsible for providing or arranging for the provisions of all necessary and preventive medical services. Whenever your office refers one of our members to any of these agencies, complete and fax the Notification of Referral/Linked and Carved-Out Services Form to our Pediatric Care Management Department at 1-866-333-4827. You may also contact the Pediatric Care Management Department at 1-866-595-0145. Additional Potential Referrals Additional referrals might be for:
Potential transplants Complex or multiple-care needs such as multiple trauma or cancer Chronic illness such as asthma, diabetes, heart failure, or end-stage renal disease High-risk pregnancies and pre-term births HIV/AIDS Frequent hospitalizations or Emergency Room utilization Members who are aged, blind, or disabled Hemophilia, sickle cell anemia, cystic fibrosis, or cerebral palsy Children or adults with special health care needs requiring coordination of care and carved-out services such as certain mental health services
Persons with developmental disabilities Individuals who may need or are receiving services from out-of-network providers
or programs
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Facilitate communication and coordination between all members of the health care
team, involving the member and family in the decision-making process in order to minimize fragmentation in the health care delivery system
Educate the member and all providers of the health care delivery team about care
management, community resources, benefits, cost factors and all related topics so that informed decisions can be made
Encourage appropriate use of medical facilities and services, improving the quality
of care and maintaining cost-effectiveness on a case-by-case basis The Care Management team includes credentialed, experienced Registered Nurses who are Certified Case Managers (CCMs) as well as Case Manager Social Workers. The Case Manager Social Workers add valuable skills that allow us to address not only the members medical needs, but also their psychological, social and financial issues. Procedures Upon identification and referral of a potential member for care management, the case manager contacts the referring Provider and member and completes an initial assessment. The case manager develops an individualized care plan based on information from the assessment and with the involvement of the member, the members representative, and the referring Provider. The case manager periodically re-assesses the care plan to monitor the following: progress toward goals, any necessary revisions, and any new issues to ensure that the member receives support and teaching to achieve care plan goals. Once goals are met or the case can no longer be impacted by care management, the case manager closes the members case. Accessing Specialists: Access to Care Unit Case managers are available to assist PCPs with accessing specialists when needed. For assistance locating a specialist, call the Customer Care Center (CCC). A Customer Service representative will assist with the referral. Cross-References
A grievance may be filed up to 180 days after the date of the incident that gave rise
to the grievance.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
A Provider appeal may be filed up to 365 days after the date of the Notice of
Action letter from the Plan advising the Provider of the adverse determination.
Member appeals may be filed up to 180 days after the date of the Notice of Action
letter advising the member of the adverse determination. For more information, refer to Chapter 9, Member Grievances and Appeals, in this manual.
Medi-Cal members may file an appeal up to 90 days after the date of the Notice of
Action letter. For claims disputes, see Chapter 5, Claims and Billing Guidelines, in this manual. Receipt and Acknowledgement of a Grievance or Appeal We send a written acknowledgement to the provider within five calendar days of receiving a grievance, nonphysician provider appeal, or member appeal. For acknowledgement time frames for claims dispute, refer to Chapter 5, Claims and Billing Guidelines, in this manual. For information on expedited grievances and appeals, refer to Chapter 9, Member Grievances and Appeals, in this manual. Requesting More Information We may request, by telephone or by fax, with a signed and dated letter, medical records or a Provider explanation of the issues raised in the grievance or appeal received by the Plan.
For grievances or appeals, Providers are expected to comply with our request for
information within 10 days of our request.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Administrative Grievances (Quality of Service) For administrative grievances, a Grievance & Appeal associate reviews the grievance and consults with the appropriate department for resolution. The Grievance & Appeal associate determines what information needs to be collected to resolve the case. Appeal A Physician Clinical Review (PCR) specialist of the same or similar specialty and who was not involved in any previous level of review in decision making reviews the Provider appeal. The PCR may not be the subordinate of any person involved in the initial determination. The PCR reviews the case and contacts the Provider as necessary to discuss possible appropriate alternatives, render a decision, and document the decision in the system. When to Expect Resolution For grievances and appeals, we send a written resolution letter to the Provider within 30 calendar days from the receipt of the grievance or appeal. The resolution letter also provides details on the Providers additional grievance and appeals rights. For claims disputes, refer to Chapter 1, Introduction and General Claims Guidelines, in this manual. According to state laws, we may not be able to disclose to Providers the final disposition of certain grievances. In cases where we have investigated a provider or in cases related to quality of care, we notify the Provider that the grievance was received and investigated and inform the Provider that the final disposition of the grievance cannot be disclosed due to peer review confidentiality laws. Provider Dissatisfaction with Resolution Providers who have exhausted our Grievance & Appeal Resolution Process and are dissatisfied with our resolution have the right to file a grievance or appeal, as applicable, with the following entities. Grievances & Provider Appeals Medi-Cal Program L.A. Care Health Plan (available for services provided to Los Angeles County members only)
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Arbitration (in accordance with the Anthem Blue Cross State Sponsored Business Participating Provider Agreement) Healthy Families Program, AIM, MRMIP Arbitration (in accordance with the Anthem Blue Cross State Sponsored Business Participating Provider Agreement) For member appeals, refer to Chapter 9, Member Grievances and Appeals, in this manual. We handle all grievances and appeals in a confidential manner and do not discriminate against a provider for filing a grievance or an appeal. Contact Information Utilization Management Medi-Cal and Healthy Families Program: 1-888-831-2246 AIM/MRMIP: Customer Care Center Medi-Cal: Medi-Cal, Los Angeles County only: Healthy Families Program: AIM/MRMIP: 1-800-407-4627 1-888-285-7801 1-800-845-3604 1-877-687-0549 TDD: 1-888-757-6034 1-877-273-4193
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Mail Grievance & Appeal forms or letters to: Attn: Appeals and Complaints Department Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
When to File a Grievance or Appeal Members have the following period of time to file:
Grievance180 days after the date of the incident that gave rise to the grievance Appeal180 days after the date of the notice of action letter notifying the member
of a denial, deferral, or modification of a request for services for AIM, Healthy Families Program and MRMIP members
Appeal90 days after the date of the notice of action letter notifying the member
of a denial, deferral, or modification of a request for services for Medi-Cal members Who Can File the Grievance or Appeal The member does not need to be the one to file a grievance or appeal. A member may choose anyone he or she wishes to represent him/her, including an attorney, relative, representative, or the members health care provider. If a member has not submitted a written consent to us, he or she may give verbal authorization. Verbal authorization is documented in the members grievance or appeal file, and a follow-up letter is sent to the member confirming the verbal authorization to designate a representative. In addition, members are required to sign an authorization for release of medical records. If a member is a minor or is incompetent or incapacitated, the parent, guardian, conservator, relative, or other designee of the member, as appropriate, may submit the grievance or appeal on the members behalf. We conform to the HIPAA policies and procedures regarding the verification of member representatives. Receipt & Acknowledgement of Standard Grievance or Appeal Members are always encouraged to first discuss their concerns with their Provider, giving the Provider the opportunity to resolve the issue. We send a written acknowledgement of the members grievance or appeal within five calendar days from the date we receive the appeal or grievance.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
If a request for an expedited review has been received, the medical director, without delay, reviews the request to determine if the request involves an imminent and serious threat to the health of the member, including, but not limited to, severe pain or potential loss of life, limb or major bodily function. If the medical director determines a request involves medical care or treatment for which the application of the standard time period is appropriate, the request will be handled and resolved in 30 calendar days from the receipt of the request. A Grievance & Appeal clinical associate immediately notifies the member by telephone if possible, of the determination and that the request will be handled as a standard grievance or appeal. In addition, a Grievance & Appeal clinical associate immediately sends an acknowledgement letter to the member which indicates the receipt of the expedited grievance or appeal request, the date of receipt, and notification that the request was reviewed for urgency but will be handled as a standard grievance or appeal. Receipt & Acknowledgement of Expedited Grievance or Appeal For expedited grievances or appeals, members may contact the Department of Managed Health Care (DMHC) at anytime to apply for DMHC review of a grievance or appeal. Members do not have to go through our Grievance & Appeals process first. If the request meets the criteria for an expedited grievance or appeal, we acknowledge the expedited grievance or appeal immediately by telephone if possible and resolve the grievance within three calendar days of receiving the request. We also notify the member as soon as possible of his or her right to contact the Department of Managed Health Care regarding the expedited grievance or appeal. Requesting More Information We may request medical records or a Providers explanation of the issues raised in the grievance or appeal by telephone or by fax with a signed and dated letter. For standard grievances or appeals, Providers are expected to comply with our request for information within 10 days of the date of the request. For expedited grievances or appeals, the Provider is expected to comply with our request for information within 24 hours of the date of the request.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Grievance & Appeal Investigation Responsibilities Clinical Grievances (Quality of Care) A medical director who was not involved in any previous level of review or decision making reviews all clinical grievances. If, upon review, a clinically urgent situation is identified, the grievance is processed as quickly as the medical condition warrants until a satisfactory resolution is reached. The medical director makes recommendations for further actions when necessary. This may include forwarding the case to the Physician Quality Improvement Committee (PQIC) for peer review. Administrative Grievances (Quality of Service) For administrative grievances, a Grievance & Appeals associate reviews the grievance and consults with the appropriate department for resolution. The Grievance & Appeals associate determines what information needs to be collected to resolve the case. Appeal A Physician Clinical Reviewer (PCR) specialist of the same or similar specialty and who was not involved in any previous level of review or decision making reviews the appeal. The PCR may not be the subordinate of any person involved in the initial determination. The PCR reviews the case and contacts the provider as necessary to discuss possible appropriate alternatives, render a decision, and document the decision in the system. When to Expect Resolution For standard grievances and appeals, we send a written resolution letter to the member within 30 calendar days from the date of the receipt of the grievance or appeal. Expedited grievances and appeals are resolved within three calendar days from the date we receive the request for an expedited grievance or appeal. The member is notified by telephone of the resolution, if possible. A written resolution is sent within three calendar days from the date we receive the expedited grievance or appeal. According to state laws, we may not be able to disclose to members the final disposition of certain grievances. In these cases where the Plan has investigated a Provider or in cases related to quality of care, we will notify the member that the grievance was received and investigated and inform the member that the final disposition cannot be disclosed due to peer review confidentiality laws.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Member Dissatisfaction Resolution Except in certain situations as discussed below, members who have exhausted our Grievance & Appeals process and who are dissatisfied with our resolution have the right to file a complaint, grievance, appeal or request a hearing or independent medical review, as applicable, with the following entities:
L.A. Care Health PlanLos Angeles County members may submit a grievance to L.A.Care Health Plan at any time. California Department of Social Services, State Hearing Division to request a state fair hearing. Members may request a state fair hearing at any time during the grievance process. The Medi-Cal Managed Care Office of the Ombudsman at the California Department of Health Care Services may submit a grievance. California Department of Managed Health Care (DMHC)members may request an Independent Medical Review (IMR), if eligible, or request an expedited review of an urgent grievance or appeal. For IMRs of Plan coverage decisions of experimental or investigational therapies or expedited reviews of an urgent grievance or appeal, the member may submit a request to the DMHC at any time during the grievance process. If a member has requested a State Fair Hearing, he or she cannot request an IMR.
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California Department of Managed Health Care (DMHC)Members may request an Independent Medical Review (IMR), if eligible, or request an expedited review of an urgent grievance or appeal. For IMRs of Plan coverage decisions of experimental or investigational therapies or expedited reviews of an urgent grievance or appeal, the member may submit a request to the DMHC at any time during the grievance process. California Managed Risk, Medical Insurance Board (MRMIB)Members may request an administrative review or administrative hearing. ArbitrationThis can take place as set forth in the members applicable Benefit Agreement.
DMHCMembers may request an IMR, if eligible, or request an expedited review of an urgent grievance or appeal. For IMRs of Plan coverage decisions of experimental or investigational therapies or expedited reviews of an urgent grievance or appeal, the member may submit a request to the DMHC at any time during the grievance process. California Managed Risk, Medical Insurance BoardMembers may request an administrative review or administrative hearing. ArbitrationThis can take place as set forth in the members applicable Benefit Agreement.
In addition, we inform all members of the availability of the DMHC to review member grievances or complaints. The following information is required by law to be included in specific member communications: The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against us, you should first call us at 1-800-427-4627 and use our grievance process before contacting the department. Using this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational
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in nature and payment disputes for emergency, or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet website http://www.hmohelp.ca.gov has complaint forms, IMR application forms, and instructions online. Independent Medical Review For eligible members, an IMR by the DMHC is provided for health care services that are denied or modified because the service is either not medically necessary or experimental or investigational. Go to http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_imr.asp for details on the DMHC IMR process. Confidentiality and Discrimination All grievances and appeals are handled in a confidential manner. We do not discriminate against a member for filing a grievance or appeal or for requesting a state fair hearing. We also notify members of the opportunity to receive information about our grievance and appeal process. Members may request a translated version of the process in a threshold language other than English. Grievances and Complaints of Discrimination We have a system in place that affords consistent and thorough evaluation and reporting of grievances of discrimination with a fair and timely resolution. We do not discriminate against any member. Members who contact us with an allegation of discrimination are immediately informed of their right to file a grievance. This also happens 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. We document and track and trend all alleged acts of discrimination. A Grievance and Appeal associate will review and trend cultural and linguistic grievances in partnership with a Cultural and Linguistic specialist. Medi-Cal Members Continuing Benefits During an Appeal or State Fair Hearing Medi-Cal members may continue benefits while the appeal or state fair hearing is pending in accordance with federal regulations (42 CFR 438.420) when all of the following criteria are met:
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The member or representative must request the appeal on or before the later of the
following: within10 days of the Plans mail date of the Adverse Action Notification or the intended effective date of the notice of the Plans proposed adverse action.
The services were ordered by an authorized provider. The original period covered by the initial authorization has not expired. The member requests an extension of benefits.
Contact Information Customer Care Center Medi-Cal: Medi-Cal, Los Angeles County only: Healthy Families Program: AIM/MRMIP: Utilization Management Medi-Cal and Healthy Families Program: 1-888-831-2246 AIM/MRMIP: Attn: Appeals and Complaints Unit Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007 1-877-273-4193 1-800-407-4627 1-888-285-7801 1-800-845-3604 1-877-687-0549 TDD: 1-888-757-6034
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To know their rights and responsibilities To know about our services, doctors and specialists To know about all our other caregivers To have access to their medical records according to state and federal laws To have a candid talk with their doctor about all treatments, regardless of their cost
or whether their benefits cover them
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To have their privacy protected by everyone in our health plan To know that we keep all information about our members confidential To be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience, or retaliation
To use these rights without affecting how we, our doctors, or the state of California
treats them Members have the right to be in charge of their health care.
To choose their primary care physician To refuse care from their primary care physician or other caregivers To help make decisions about their health care To do what they think is best for their health without anyone stopping them. They
may make health decisions without fear of their doctor or health plan retaliating against them.
To receive family planning services To be treated for sexually transmitted diseases (STDs) To access minor consent services if they are under 18 years of age To get emergency care outside of the network, according to federal law To get health care from a Federally Qualified Health Center To get health care at an Indian Health Center To receive free interpreter services including services for the hearing impaired
(such as sign language interpreters, TTY service and the California Relay Service)
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Members have the right to tell us how they would like us to change our health plan.
To tell us what they dont like about our health plan or the health care they get To appeal our decisions about their health care To tell us what they dont like about our rights and responsibilities policy To ask the Department of Social Services (DSS) for a fair hearing To ask the DSS for an expedited fair hearing when their grievance involves an
imminent and serious threat to their health. This may include, but is not limited to, when they are in severe pain or they are at risk of losing their life, limb, or major bodily function.
To make an appointment with their doctor within 120 days of becoming a new
member for an initial health assessment
To give their doctors the information they need to treat them To learn as much as they can about their health To follow the treatment plans agreed upon by them and their doctors To follow their doctors advice about taking good care of themselves To use appropriate sources of care To bring their Plan ID card with them when they visit their doctor To treat their doctors and other caregivers with respect
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To know and follow the rules of their health plan To know that laws govern our health plan and regulate our services To know that we do not discriminate against members because of their age, sex,
race, national origin, culture, language needs, sexual orientation or health, economic status, or source of payment for their care Medi-Cal (L.A. Care Health Plan [L.A. Care]) Member Rights
Members have the right to have an appointment with their doctor within a
reasonable time and have their doctor listen and work with them to take care of their health care needs.
They have the right to a confidential (private) relationship with their doctor. No
one will talk about their health care unless they okay it.
They have the right to polite, kind and helpful care regardless of race, religion, sex,
age, gender, cultural or ethnic background.
They have the right to say no to medical treatment. They have the right to know and understand their medical problem and treatment
plan.
They have the right to get a copy of their medical records and have them kept
private.
They have the right to get information and to be spoken in the language that they
understand and are comfortable with. This means that they can get free 24-hour interpreter services. They do not have to use a family or a friend to interpret for them.
They have the right to file a grievance with us or L.A. Care if they do not receive
their services in the language they request.
They have the right to get information on how to file appeals grievances with us
and directly to the California Department of Health Care Services and L.A. Care. They also have a right to a State fair hearing.
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They have the right to get preventive health care services. They have the right to a second opinion. They have the right to get a timely answer to a referral.
They have the right to be informed when their doctor is no longer contracted with
us and L.A. Care. Member Responsibilities
Members are responsible for participating in their health care and the health care
of their family. This means taking care of problems before they become serious. They should follow their doctors instructions, take their medications, and participate in health programs that keep them well.
They are responsible for using the Emergency Room for emergency only. Their
Primary Care Physician (PCP) will provide most of the medical care they need.
They are responsible for being polite and helpful to people who give health care
services to them and their family.
They are responsible for making and keeping appointments for checkups and
calling their PCPs office when they need to cancel appointments.
They are responsible for participating in member satisfaction surveys. They are responsible for reporting Health Care Fraud (misuse of Medi-Cal
services). They can report it without giving us their name. Call L.A. Care toll-free at 1-800-400-4889.
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Healthy Families Program Member Rights and Responsibilities Member Rights Healthy Families Program members have the following member rights:
To be treated with respect and dignity To choose their providers from our Provider Directory To get appointments within a reasonable amount of time To participate in candid discussions and decisions about their health care needs,
including appropriate or medically necessary treatment options for their conditions, regardless of cost and of whether or not the treatment is covered by this health plan.
To have a confidential relationship with their Provider To have their records kept confidential. This means we will not share their health
care information without their written approval or unless it is permitted by law.
To voice their concerns about us or about health care services they received to the
Plan
To receive information about us, our services, and our Providers To make recommendations about their rights and responsibilities To see their medical records To get services from Providers outside of the network in an emergency To request an interpreter at no charge to them To use interpreters who are not their family members or friends To file a complaint if their linguistic needs are not met
Member Responsibilities Healthy Families Program members have the following responsibilities as health care consumers:
To give their providers and us correct information To understand their health problems and participate in developing treatment goals,
as much as possible, with their Provider
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To always present their Member Identification Card when getting services To use the emergency room only in cases of an emergency or as directed by their
Provider
To make and keep medical appointments and inform their Provider at least 24
hours in advance when an appointment must be cancelled
To ask questions about any medical condition and make certain they understand
their Providers explanations and instructions
To treat all Plan personnel and health care Providers respectfully and courteously
AIM Member Rights and Responsibilities Member Rights AIM members have the following member rights: Members have the right to be informed.
To know their rights and responsibilities To receive information about Plan services, doctors, and specialists To receive information about all their other health care Providers To be able to talk honestly with their doctors about all the appropriate treatments
for their condition, regardless of cost or whether or not their benefits cover them
To use interpreters who are not their family members or friends; the interpreter
will be provided at no charge to them.
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To be treated with respect and dignity in all situations To have their privacy protected by us, their doctors, and all their other health care
providers
To know that information about them is kept confidential and used only to treat
them Members have the right to be in charge of their health care.
To complain about us or the health care they receive To file a complaint or grievance if their cultural and linguistic needs are not met To appeal a decision from us about the health care they receive To make recommendations about their rights and responsibilities policy
Member Responsibilities AIM members have the following responsibilities as health care consumers: We want members to cooperate with us and their doctors.
To give us, their doctors, and other health care providers the information needed
to treat them to the best of their ability
To understand their condition and help their doctor set treatment goals they both
agree on to the best of their ability
To follow the plans they have agreed on with their doctors and their other health
care Providers
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To follow the guidelines for healthy living their doctor and their other health care
providers suggest
To be informed of their rights and responsibilities To receive information about Plan services, doctors, and specialists To receive information about all their other health care Providers To be able to talk honestly with their doctors about all the appropriate treatments
for their condition, regardless of cost or whether or not their benefits cover them Members have the right to be treated well.
To be treated with respect and dignity in all situations To have their privacy protected by us, their doctors, and all their other health care
Providers
To know that information about them is kept confidential and used only to treat
them Members have the right to be in charge of their health care.
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To complain about us or the health care they receive To appeal a decision from us about the health care they receive To make recommendations about our rights and responsibilities policy
Member Responsibilities Major Risk Medical Insurance Program (MRMIP) members have the following responsibilities as health care consumers: We want members to cooperate with us and their doctors.
To give us, their doctors, and other health care Providers the information needed
to treat them to the best of their ability
To understand their condition and help their doctor set treatment goals they both
agree on to the best of their ability
To follow the plans they have agreed on with their doctors and their other health
care providers
To follow the guidelines for healthy living their doctor and their other health care
Providers suggest
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Routine and preventive health care services Emergency care services Hospital services Ancillary services Specialty referrals Interpreter services EPSDT/CHDP screening services for children and adolescents Coordination with care coordinators to ensure continuity of care for members
PCPs coordinate care with clinic services, such as therapeutic, rehabilitative, or palliative services for outpatients. With the exception of nurse-midwife services, the physician furnishes clinic services. PCPs must cooperate with any court-ordered services.
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Referrals PCPs coordinate and make referrals to appropriate specialists, ancillary providers, or community services. They monitor and track all services and provide health education information, materials, and referrals. Members have the right to select an OB/GYN without referrals from their PCPs. All PCPs:
Are expected to refer members to specialists or specialty care, including the Child
Health and Disability Prevention (CHDP) Program, California Childrens Services (CCS), behavioral health care services, other carved-out services, health education classes, and community resource agencies when appropriate
Must coordinate with the Women, Infants and Children (WIC) Special
Supplemental Nutrition Program to provide medical information necessary for WIC eligibility determinations, such as height, weight, hematocrit, or hemoglobin
Must coordinate with the local tuberculosis (TB) control program to ensure that
all members with confirmed or suspected TB have a contact investigation and receive Directly Observed Therapy (DOT)
Are responsible for screening and evaluation procedures for detection and
treatment of, or referral for, any known or suspected behavioral health problems and disorders
Must document referrals, including referrals to carved-out services Are expected to help members in scheduling appointments with other providers
and health education programs
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Initial Health Assessment PCPs should review their monthly eligibility list provided by us and proactively contact their assigned membership to make an appointment for the members initial health assessment within 60120 days of enrollment. The PCPs office is responsible for making and documenting all attempts to contact assigned members. Member medical records must reflect the reason for any delays in performing the Initial Health Assessment (IHA), including any refusals by the member to the exam. For more information, refer to Initial Health Assessment in Chapter 13, Access Standards & Access to Care, or Chapter 16, Health Services and Programs, in this manual. Transitioning Members Between Facilities or to Home Subject to benefit limits, PCPs initiate or help with the discharge or transfer of:
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CPSP Services Available Case Coordination Organizing the provision of comprehensive perinatal services, including all aspects of antepartum, intrapartum, and postpartum member care. Obstetrical Services
Assessing, in written reports, the members obstetrical status Preparing an individualized care plan obstetrical component Dispensing, as medically necessary, prenatal vitamin/mineral supplements to the
member Nutrition Services
Assessing, in written reports, the members nutritional status Preparing an individualized care plan with nutritional component that addresses
prevention or resolution of nutritional problems and support and maintenance of strengths and habits oriented toward optimum nutritional status (goals to be achieved through nutritional interventions)
Are provided by university-prepared educators Include education regarding provided services Include information regarding what to do in case of an emergency
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Are provided by Licensed Clinical Social Worker (LCSW) Include written assessments of the members psychosocial status, including a
review of his or her social support system, personal adjustment to pregnancy, history of any previous pregnancies, general emotional status and history, whether the pregnancy is wanted or unwanted, acceptance of the pregnancy, substance use and abuse, housing, education, employment, and financial resources
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Notification of Decision If the Hospital has not received notice of preservice review determination at the time of a scheduled admission or service, as required by the Utilization Management (UM) Guidelines and the Hospital Agreement, the Hospital should contact us and request the determination status. Any admission or service that requires preservice review, as discussed in the Utilization Management Guidelines and the Hospital Agreement, and has not received the appropriate review, may be subject to post-service review denial. Generally, the physician is required to perform all preservice review functions with us. However, the Hospital must ensure, before services are rendered, that these have been performed or risk post-service denial. Refer to Utilization Management for preservice review time frames Hospitals must follow all Provider responsibilities as outlined in this manual.
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Elective surgery in an ambulatory surgical center or outpatient hospital setting Nonemergency hospital admissions, including surgery Out-of-network specialist referrals Custom-made medical equipment Additional treatments or procedures listed under preservice review as outlined in
Utilization Management Providers submit preservice review requests directly to our Utilization Management Department. An emergency medical service to triage and stabilize a member does not require preservice review. Collaboration The Provider shares the responsibility of giving considerate and respectful care and working collaboratively with Plan members and their families, specialist physicians, hospitals, ancillary providers, and others for the goal of providing timely, medically necessary and quality health care services. Providers must permit members to participate actively in decisions regarding medical care, except as limited by law. The Provider also facilitates interpreter services and provides information about the Comprehensive Perinatal Services Program for Medi-Cal (PCPs and OB/GYNs only).
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Interpreter Services Providers must notify members of the availability of free health plan interpreter services and strongly discourage the use of minors, friends, and family to act as interpreters. Refer to Interpreter Services and Services for the Hard of Hearing in this manual for provider responsibilities for signage, notification of interpreter services, refusal forms for interpreter services, after-hours linguistic access, and updating language capabilities with us. Providers can reach the California Relay System and Interpreter Services at the numbers listed in Important Contact Information. Communication for Continuity of Care The PCP maintains frequent communication with the specialist physician, hospital, or ancillary provider regarding continuity of care. We encourage physicians, hospitals, and providers to maintain open communication with their patients regarding appropriate treatment alternatives, regardless of their benefit coverage limitations. We do not penalize physicians, non-physician practitioners, or other health care providers for discussing medically necessary or appropriate patient care. We established comprehensive and consistent mechanisms to provide continued access to care for members when physicians terminate from the Plan. Under specified circumstances, members may finish a course of treatment with the terminating provider. For more information, refer to Continued Access to Care/Continuity of Care in this manual. Confidentiality PCPs must ensure that their members medical and behavioral health and personal information are kept confidential as required by state and federal laws. They must prepare and maintain all appropriate records in a system that permits prompt retrieval of information on members receiving covered services from the PCPs. Obtaining Signed Consent The PCPs obtain required signed consent before providing care. Consent for treatment must be given at the initial office visit by member, parent or guardian by signing a Consent to Treat patient form. This form must be maintained in the patients medical record. Before performing a human sterilization procedure, consent forms must meet the stipulations for informed consent and for waiting time frames.
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Medical Records Documentation & Access to Medical Records Providers are responsible for ensuring that member medical records are organized and complete and include documentation from specialists, hospitals, ancillary providers, carved-out services, and community services when applicable. The Provider must record the use of any and all interpreter services, including interpreter services delivered by office staff. Documentation must be signed, dated, legible, and completed in a timely manner. Medical records must be stored in a secured location. Providers must provide us with prompt access, upon demand, to medical records or information for quality management or other purposes, including utilization review, audits, reviews of complaints or appeals, Health Employer Data and Information Set (HEDIS), and other studies. Providers must provide us, its regulatory agencies or its contracted External Quality Review Organization (EQRO) with access to office sites for facility or medical records reviews upon our request. Mandated time limitations for the completion of reviews and studies require the cooperation of the provider to provide medical records expediently. Providers must have procedures in place to provide timely access to medical records in their absence. For public health communicable disease reporting, providers must provide all medical records or information as requested and within the time frame established by state and federal laws. Reporting Health care professionals agree to provide to us, on request, periodic reports that include
Patient identification Service date and type of service Diagnosis Referring physician and other related information
Mandatory Reporting of Abuse Providers ensure that office personnel have specific knowledge of local reporting requirements, agencies and procedures to make telephone and written reports of known or suspected cases of abuse. All health care professionals must immediately report actual or suspected child abuse, elder abuse, and domestic violence to the local law enforcement agency by telephone.
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Providers must submit a follow-up written report to the local law enforcement agency within the time frame required by law. The Quality Management staff explains how to document the reporting of child, adult, elder, and domestic violence abuse. The Facility Site Review is required to examine this documentation. Providers can obtain additional copies of the Safety Training Modules tool by calling a local Community Resource Coordinator. Notifying the Plan of Changes Providers must notify us of any:
Change in professional business ownership Change in business address or the location where services are provided Legal or governmental action initiated against a health care 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 health care professional to carry out the duties and obligations under the Provider Agreement
Other problem or situation that impairs the ability of the health care professional
to carry out the duties and obligations under the Provider Agreement care review and grievance resolution procedures Use the Provider Change Form to notify us of changes. You can find the form on the www.anthem.com/ca website under Forms and Tools. In the event we determine that the quality of care or services provided by a health care professional is not satisfactory, as may be evidenced by or in member satisfaction surveys, member complaints or grievances, Utilization Management data, complaints, or lawsuits alleging professional negligence, or any other quality of care indicators, we may terminate the Provider Agreement. Health care professionals agree to be bound by and comply with Plan policies, procedures and rules. Members Rights and Responsibilities All Plan PCPs actively support the Members Rights and Responsibilities Statement as written in Members Rights and Responsibilities section of this manual.
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Oversight of Non-Physician Practitioners All providers using non-physician providers must provide supervision and oversight of such non-physician providers consistent with state and federal laws. The supervising physician and the non-physician practitioner must have written guidelines for adequate supervision. All supervising providers must follow state licensing and certification requirements. Non-physician practitioners are advanced registered nurse practitioners (including certified nurse midwives) and physician assistants. These non-physician practitioners are licensed by the state and working under the supervision of a licensed physician as mandated by state and federal regulations. Office Hours To maintain continuity of care, all Providers must be available to provide services for a minimum of 24 hours each week. The Provider must be available 24 hours a day by telephone or have an on-call physician take calls. Office hours must be conspicuously posted. For specific hours of operation and after-hours requirements, refer to Chapter 13, Access Standards & Access to Care. The provider must inform members of the Providers availability at each site. Licenses and Certifications Providers must maintain all licenses, certifications, permits, accreditations, or other prerequisites required by us and federal, state, and local laws to provide medical services. Copies of the licenses, certifications, permits, evidence of accreditations or other prerequisites are in the respective Provider Agreements. Prohibited Activities All providers are prohibited from:
Billing eligible members for covered services Segregating members in any way from other persons receiving similar services,
supplies, or equipment
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Open Clinical Dialogue/Affirmative Statement Nothing within the Providers participating Provider Agreement or this Provider Operations Manual (POM) should be construed as encouraging providers to restrict medically necessary covered services or to limit clinical dialogue between the providers and their patients. Providers can communicate freely with members regarding the treatment options available to them, including medication treatment options, regardless of benefit coverage limitations. Provider Terminations When a participating provider or a participating physician group notifies the Plan that he or she intends to terminate his or her contract with the Plans provider network, the Plan notifies all members assigned to the terminating provider or physician group that the provider is terminating and will no longer be available to the member as a physician participating in the provider network. The Plan makes every effort to notify members at least 30 days prior to the termination.Providers should refer to their Anthem Blue Cross Provider Agreement for responsibilities and time frames as these relate to provider termination from the Plan. Anthem Blue Cross acts in accordance with California Health and Safety Code Sections 1373.65, 1373.95 and 1373.96 (SB 244), California law regarding continuity of care when either a physician or a physicians group OR the contract is terminated. A physician or group may choose to complete a members regimen of care following contract termination provided the physician or group accepts the previous rate of payment until the members treatment is completed (such as pregnancy chemotherapy or surgeries). Refer to the Continued Access to Care/Continuity of Care for more information. Provider Terminations from Groups Anthem Blue Cross has updated its Participating Provider Agreement and Group Addendum to reflect new policies and procedures for provider terminations. These changes affect capitated Providers who are with Participating Medical Groups (PMGs) and/or Independent Practice Associations (IPAs). When a capitated Provider decides to terminate from the Anthem Blue Cross network:
The Provider should notify all his or her affiliated PMGs/IPAs within a minimum
of 90 calendar days notice.
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The PMGs/IPAs should then notify Anthem Blue Cross. (Note: The Providers
termination is effective 90 calendar days after we receive notification from the PMGs.)
The Providers decision to terminate from the Anthem Blue Cross network could
impact participation in other Anthem Blue Cross lines of business and may prevent the Provider from participating in the future with us as a Provider. Cross-References
Eligibility Verification Utilization Management Interpreter Services and Services for the Hard of Hearing Continued Access to Care/Continuity of Care Health Services and Programs
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Medical Record and Facility Site Reviews Member Rights and Responsibilities Access Standards & Access to Care
FINANCIAL REQUIREMENTS FOR PARTICIPATING MEDICAL GROUPS
It is the policy of Anthem Blue Cross to take appropriate action to limit its exposure to unwarranted financial risks from its business relationships with its delegated Participating Medical Groups (PMGs). This responsibility begins with a screening analysis of the PMG by appropriate Anthem Blue Cross units and includes the conduct of a financial review by Health Management Organization (HMO) Finance. The review involves tracking the financial performance of the PMG, particularly those experiencing adverse financial trends. State Regulations State regulations require that health plans monitor the financial position of its capitated PMG or delegated risk-bearing organizations (RBOs) to ascertain that they demonstrate compliance with the financial solvency requirements mandated in Title 28, Section 1300.75.4 of the California Code of Regulations (CCR). The PMGs also must meet, at all times, the financial performance standards or covenants hereunder listed, which are mandated by the Medical Services Agreement. We engage in financial monitoring in order to protect Anthem Blue Cross members from Provider group insolvency that may result in the interruption of the delivery of health care services. The PMG must furnish the quarterly and annual financial information to Anthem Blue Cross, and other data as may be required by law and Anthem Blue Cross as stated under Financial Audit Requirements Access to Financial Data. Pursuant to Anthem Blue Cross Medical Services Agreement, each PMG is required to submit audited financial statements to Anthem Blue Cross no later than 150 calendar days (five months) following the end of its fiscal year. The annual financial statements shall be attested by an independent certified public account (CPA). The PMG also may be required, if necessary, to submit tax returns, along with the internally prepared financial statements and other related reports.
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In addition to the fiscal year-end financial statements, the PMG also agrees to provide Anthem Blue Cross with quarterly financial statements within 45 days after the close of each fiscal quarter, or as often as deemed necessary by Anthem Blue Cross to ensure appropriate monitoring. The financial data enables Anthem Blue Cross to assess the financial status of the PMG and/or its capacity to fulfill its financial obligations under the Medical Services Agreement. Financial Performance Standards Regulations require the financial statement to be prepared in accordance with generally accepted accounting principles (GAAP) and include a balance sheet, income statement, cash flow statement, and disclosures. In accordance with the Medical Services Agreement, the PMG is required to maintain adequate financial reserves to cover all assumed risks. The PMG is required, at all times, to comply with the solvency standards mandated by regulations, including, but not limited to, unanticipated claims for referral services that are the potential responsibility of the PMG. The PMG shall meet or exceed Anthem Blue Cross financial performance standards as follows:
Cash ratio must be at least 60 percent (cash and/or equivalents, plus marketable
securities divided by current liabilities).
Total stockholders equity is required to equal at least two percent of total revenue
or four percent of total medical expenses, whichever is higher.
The PMG must maintain a working capital ratio of at least 1.5:1. The PMG must maintain a debt-to-equity ratio (financial leverage) of not more
than 250 percent.
The PMG must provide, for incurred but not reported (IBNR) claims liability, of
at least two months of average annual claims expenses or base this on an actuarially sound formula approved per regulations.
PMGs are required to submit the financial data requirements specified in this
operations manual when requested. In the event the PMG does not meet any of the regulatory solvency and performance standards, the PMG shall, within 30 days upon request by Anthem Blue Cross, provide a Stand-by Letter of Credit, as a contingency reserve in an amount acceptable to Anthem Blue Cross, in order to mitigate risk. Pursuant to regulations, the PMG is required to submit a corrective action plan to the Department of Managed Health Care (DMHC) with a copy to Anthem Blue Cross if it fails to meet the Solvency Grading Criteria.
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Financial Audit Requirements Access to Financial Data The PMG agrees to provide Anthem Blue Cross representatives or employees access to and a copy of appropriate PMG books and records upon request, and within a reasonable time frame, to allow the onsite review, analysis, or validation of the PMG financial information. Accounting books and records will include, but are not limited to, the general ledger, subsidiary ledger, journal entries (together with the appropriate backup documentation), accounts receivable aging schedules (including details of due from accounts, risk and incentive receivables, claims inventory aging schedule, IBNR claims lag schedule, specific general ledger account details, and other data related to the financial statements that Anthem Blue Cross may request from time to time). Other financial information includes, but is not limited to, the trial balance, bank statements/reconciliations, and certification of bank deposits. The PMG also agrees to submit the annual financial review questionnaire, representation or financial statement certification, statement of renewal of relevant insurance policies, and corrective action plans (if appropriate), together with pro-forma or projected financial statements with detailed assumptions and other special reports as determined by Anthem Blue Cross. It does not preclude the use of more frequent reports (if one is required). Solvency Grading Criteria The above financial requirements are needed to ensure that Anthem Blue Cross receives sufficient financial data for monitoring the PMGs financial status based on established Anthem Blue Cross financial performance covenants (performance standards) and/or solvency grading criteria mandated in Title 28, Section 1300.75.4 of the CCR. These include maintaining, at all times, a positive tangible net equity, positive working capital and the cash-to-claims ratio. It also requires that each PMG be required to estimate, accrue and document its methodology for IBNR claims liability on a monthly basis. These solvency requirements are in addition to meeting the standard for timely claims resolution mandated by Title 28, Sections 1300.71 and 1300.71.38 of the regulations (or Claims Processing and Timeliness Regulations). The PMGs failure to substantially comply with the Anthem Blue Cross performance standards and solvency regulations, including the submission of all appropriate monthly, quarterly, and annual financial report requirements, may constitute a material breach of the Medical Services Agreement. To ensure that Anthem Blue Cross can act on solvency issues accordingly, the PMG is required to inform Anthem Blue Cross HMO Finance no later than five (5) business days from discovering that is has experienced any event, which materially alters its financial condition or threatens its solvency.
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The financial (performance standards) metrics are used as guideposts in the analysis of the hospitals financial capacity. In addition to the financial metrics applicable to PMGs, the following are specifically applied in the financial review of hospitals:
Return on assets, initially set at =>1.2 percent. Return on equity, initially set at =>10 percent. Net operating income, initially set at positive. Days cash on hand, initially set at =>100 days. Viability index, initially set at max of <100 percent and preferably trending lower. Volume and length of stay indicators. Other profit measurements, such as profit per inpatient discharge, profit per
outpatient visit and operating margin. Anthem Blue Cross also obtains from the State of California relevant hospital utilization statistics and other financial data on hospital operations. Like PMGs, delegated hospitals are required contractually to provide Anthem Blue Cross with quarterly and annual financial statement (and others) to apprise Anthem Blue Cross on those experiencing severe financial difficulties or about emerging financial issues that could adversely impact their capacity to deliver the services.
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In a financial review, nonhospital revenues and nonoperating expenses are measured to ascertain the degree of relationship to the Hospitals financial condition and/or its short-term survivability as a business enterprise. Furthermore, Anthem Blue Cross would like to determine the Hospitals compliance with some current laws that require substantial cash flow adjustments or test their capacity to access external funds, such as AB394 (staff ratio) and SB1953 (seismic mandate). It is also important to analyze the value of fixed assets deployed in generating revenues on a per-licensed-bed basis. Hospitals receiving Medi-Cal SB855 funding assistance or disproportionate share payments and other government assistance programs should be evaluated as to the degree of vulnerability without such financial aid. At the front end, Anthem Blue Cross may require the Hospital to submit to Anthem Blue Cross a standby Letter of Credit amounting to $300,000 or as may be determined by HMO Finance and the Healthcare Management Department in order to mitigate financial risk. Unlike PMGs, hospitals are not subject to the DMHC solvency criteria (SB260). Section 128740 of the California Health and Safety Code and Title 22 of the CCR requires hospitals to file quarterly financial and utilization reports with the Office of Statewide Health Planning and Development (OSHPD) within 45 days after the end of the quarter. Adjusted reports reflecting changers as a result of their audited financial statements may be filed within four months of the close of the Hospitals fiscal year. Failure to file the required report would subject the Hospital to pay a civil penalty of $100 a day for each day of delay. Claims Timeliness Regulation and Reporting Requirements The PMG is required to comply with claims settlement practices and the dispute resolution mechanism (implemented under Section 1300.71 and 1300.71.38 of Title 28 of the CCR). This is to ensure that all claims and disputes from any physician, hospital, medical facility, and other health care entities are processed and resolved in an appropriate and timely manner. The PMG shall, per regulations, submit a claims report, which includes the percentage of claims that have been timely reimbursed, contested, or denied during the quarter by PMG in accordance with the requirements of Sections 1371 and 1371.35 of the California Health and Safety Code and Section 1300.71 of Title 28 of the CCR and any other applicable state and federal laws and regulations. If less than 95 percent of all complete claims have been reimbursed, contested, or denied on a timely basis, the claims report also should also describe the reasons why the PMG claims adjudication
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process is not meeting the requirements of applicable law, any actions taken to correct the deficiency, and the result of such actions. The claims report is for the purpose of monitoring the financial status of the PMG and is not intended to change or alter existing state and federal laws and regulations relating to claims payment settlement practices and timeliness. The PMG agrees to provide Anthem Blue Cross with monthly and quarterly reports of claims processing timeliness and other applicable reports required by Anthem Blue Cross and regulations. The timeliness report should be sent to Anthem Blue Cross within 15 days after the end of each month. Quarterly and annual reports on claims compliance are required based on time frames set by regulation or by the DMHC. For more information, refer to Monthly Report of Claims Processing Timeliness and Overall Percent of Denial Accuracy for Anthem Blue Cross Commercial Members. At the request of Anthem Blue Cross, the PMG will provide a claims aging schedule, including both dollars and number of claims outstanding as of a certain period. If necessary, a historical record of a particular medical providers claims (billings), as well as the record of payments/denials made by the PMG in any form, may also be required during a claims or financial audit or as often as necessary. The PMG will provide separate claims aging reports for contracted and noncontracted physicians, hospitals or other health care professionals in a format as determined by Anthem Blue Cross. The mailing address for financial requirements is: Attn: HMO Finance Department Anthem Blue Cross CAAC10-010H 21555 Oxnard St. Woodland Hills, CA 91367
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
PHYSICIAN MARKETING
Limitations Because physicians are in a unique position of trust to influence patients on the selection of a health plan, the Department of Health Care Services (DHCS) and MRMIB have created policies for marketing practices by providers for state programs. Policies prohibit network providers from making false and misleading claims that:
The Primary Care Physician (PCP) office staff are employees or representatives of
the state, county, or federal government.
The Plan is recommended or endorsed by any state agency, county agency, or any
other organization.
The state or county recommends that a prospective member enroll with a specific
health plan.
A prospective member or medical recipient will lose benefits under the Medi-Cal
Program or other welfare benefits if the prospective member does not enroll with a specific health plan. Policies prohibit network providers from:
Using any list of members for enrollment purposes obtained originally from
confidential state or county data sources or from data sources of other contractors
Using any list of Anthem Blue Cross members for enrollment purposes obtained
originally from confidential state or county data sources or from the data sources of other contractors
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Reproducing or signing an enrollment application for the member Engaging in any marketing activity on state or county premises on behalf of
Anthem Blue Cross or its affiliates or any other location not authorized in Anthem Blue Crosss Marketing Plan (event locations include, but are not limited to, health fairs and festivals, athletic organizations and events, recreational activities, and Plan-sponsored events (including grand openings and luncheons, school-based enrollment events, Back to School Nights, conferences, safety fairs, Chambers of Commerce, small businesses and other locations approved by DHCS or MRMIB) Providers and both members and prospective members may:
Help the member preliminarily find out what program he or she may qualify for:
Medi-Cal, Healthy Families Program, Access for Infants and Mothers (AIM) Program, or the Major Risk Medical Insurance Plan (MRMIP)
Direct individuals who are eligible for Medi-Cal to call our Outreach Call Center
(OCC) at 1-800-227-3238 to contact a Community Resource Coordinator (CRC).
Direct individuals who are eligible for the Healthy Families Program to call our
Outreach Call Center (OCC) at 1-800-227-3238 if they need assistance with the application
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How Prospective Members Find Out About Us The Plan and its contracted network providers may not market directly to individuals and families. Any information prospective members receive about our Plan comes from the State, from the Plan upon a specific prospective member request, from the Plans Community Resource Coordinators (for Medi-Cal members), or from marketing activities approved by DHCS. The State must also approve any marketing materials we create.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Healthy Families Program, AIM, and MRMIP A Managed Risk Medical Insurance Board (MRMIB) enrollment contractor enrolls and disenrolls Healthy Families Program, Major Risk Medical Insurance Plan (MRMIP), and AIM Program members into our Plan. Potential members must complete the application process to confirm if they qualify for the programs. MRMIB and DHCS have an application assistance program to encourage enrollment assistance through schools, community-based programs and health care providers. For additional enrollment information, use the following resources: MRMIB Website: MRMIP Enrollment Phone: AIM Website: AIM Enrollment Phone: Healthy Families Program Website: Healthy Families Program Enrollment: Outreach Call Center (OCC): www.mrmib.ca.gov 1-800-289-6574 www.aim.ca.gov 1-800-433-2611 www.healthyfamilies.ca.gov 1-800-880-5305 1-800-227-3238
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
L.A. Care Health Plan, Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MRMIB), and Other stakeholders, as required.
We are not responsible for obtaining approvals from other health plans with which you may participate as a provider of services. Anthem Blue Cross may obtain separate legal review from in-house counsel for any materials submitted for approval. Please contact your local CRC when you have materials for review. Please keep in mind as you are planning your materials that the review period can vary for a complete review and response to the provider office. Your local CRC will let you know the time line, depending on the request.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
APPOINTMENT STANDARDS
We base standards for appointment scheduling on guidelines published by the American College of Obstetricians and Gynecologists (ACOG), National Committee for Quality Assurance (NCQA); as well as L.A. Care, Department of Health Care Services (DHCS) and California Department of Managed Health Care (DMHC) contractual requirements. Primary care physicians (PCPs) and specialists must meet standards for appointment scheduling to ensure that our members have timely access to medical care and services. We monitor provider compliance with appointment access on a regular basis. Failure to comply with outlined standards may result in corrective action. Initial Health Assessments PCPs are required to perform an Initial Health Assessment (IHA), which, depending on the members age, includes a complex medical history, a head-to-toe physical examination and an assessment of health behaviors within 60 to 120 days of the new members assignment to the practice. Medical Appointment Standards (All Counties Except Los Angeles) PCP and specialists must make appointments for members from the time of request, as follows: General Appointment Scheduling
Emergency examinations: immediate, 24 hours a day, 7 days a week Urgent examinations: within 24 hours of request Nonurgent (sick) examinations: within 4872 hours of request, as clinically
indicated
Nonurgent routine examinations: within 14 days of request Consult/specialty referrals: within 21 days of request
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Children under the age of 18 months: within 60 days of enrollment (or within the American Academy of Pediatrics (AAP) guidelines, whichever is less) Children age 19 months to 20 years of age: within 120 days of enrollment
Initial Health Assessments: within 120 days of enrollment Preventive Care Visits: within 14 days of request Routine Physicals: within 30 days of request
Prenatal and Postpartum Visits
1st and 2nd trimesters: within 7 days of request 3rd trimester: within 3 days of request High-risk Pregnancy: within 3 days of identification Postpartum: between 21 and 56 days after delivery
Medical Appointment Standards (Los Angeles County Only) General Appointment Scheduling
Emergency Examination: immediate, 24 hours a day, 7 days a week Urgent (sick) Examination: within 24 hours of request Nonurgent (sick) Examination: within 48 hours of request Nonurgent Routine Examination: within 10 days of request Standing Referrals: within 3 business days of request
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Initial Health Assessments: within 120 days of enrollment EPSDT/CHDP or Preventive Care Visits: within 2 weeks of request Routine Physicals: within 30 days of request
Prenatal and Postpartum Visits
First Prenatal Visit: within 2 weeks of request High-risk Pregnancy: within 3 days of identification Postpartum: between 21 and 56 days after delivery
Missed Appointment Tracking When members miss appointments, providers must document the missed appointment in the members medical record. Providers must make at least three attempts to contact the member to determine the reason for the missed appointment. The medical record must reflect the reason for any delays in performing an examination, including any refusals by the member. Documentation of the attempts to schedule an Initial Health Assessment must be available to us or state reviewers upon request.
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Med-Cal Beneficiary Health Care Rights To ensure compliance with Medi-Cal Beneficiary Health Care Rights (CA 42 CFR Section 438.100), Anthem Blue Cross members enrolled in the Medi-Cal Program are allowed to obtain health care from Federally Qualified Health Centers (FQHCs) and Indian Health Centers. Independent Practice Associations (IPAs) are encouraged to contract with and support the traditional safety net providers. If an IPA is not contracted with an FQHC or Indian Health Center, the IPA must still allow any member assigned to one of its contracted providers to have access to these safety net clinics. The Anthem Blue Cross policy, which supports the Medi-Cal Beneficiary Health Care Rights, is that if a member assigned to an IPA-contracted provider receives covered health care services during a visit to an FQHC or Indian Health Center, then that clinic will bill the IPA at the prevailing Medi-Cal fee-for-service rate for that visit. The IPA must pay the claim as an out-of-network provider. In this way, compliance with regulations will be maintained, and these safety net providers will be kept financially whole.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
AFTER-HOURS SERVICES
Our members have access to quality, comprehensive health care services 24 hours a day, 7 days a week. Members can call their PCP with a request for medical assessment after PCP normal office hours. The PCP must have an after-hours system in place to ensure that the member can reach his or her PCP or an on-call physician with medical concerns or questions. An answering service or after-hours personnel must forward member calls directly to the PCP or on-call physician or instruct the member that the Provider will contact the member within 30 minutes for urgent situations. The answering service or after-hours personnel must ask the member if the call is an emergency. In the event of an urgent situation, after-hours personnel immediately connect the member to the PCP or an on-call physician. In an emergency, after-hours personnel direct the member to dial 911 or to proceed directly to the nearest hospital emergency room. We prefer that the PCP use a Plan-contracted in-network physician for on-call services. When that is not possible, the PCP must use best efforts to ensure that the covering, noncontracted, on-call physician abides by the terms of the Provider contract. We monitor PCP compliance with after-hours access standards on a regular basis. Failure to comply with after-hours access standards may result in corrective action. Members can also call the 24-hour 24/7 NurseLine information line to speak to a registered nurse. 24/7 NurseLine nurses provide health information regarding illness and options for accessing care, including emergency services, if appropriate. Non-English speaking members who call their Provider after hours can expect to receive language appropriate messages with appropriate care instructions. These instructions direct the member to dial 911 or to proceed directly to the nearest hospital emergency room in the event of an emergency or provide instructions on how to call the on-call provider in a nonemergency. If an answering service is used, the person at the answering service should know where to contact a telephone interpreter for the member.
They are newly enrolled. The physicians or physicians group contract terminates. They are disenrolling to another health plan.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Qualifying conditions are medical conditions that may qualify a member for continued access to care/continuity of care, such as, but not limited to:
An acute condition A serious chronic condition Pregnancy, regardless of trimester, through immediate postpartum care Terminal illness Care of a newborn child between the ages of birth and 36 months Surgery or other procedure authorized by us that is scheduled to occur within 180
days of the contracts termination or within 180 days of the effective date of coverage for a newly covered enrollee
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Only a Plan physician can deny continuity of care services. Decisions are communicated in writing and mailed to the member and to the physician within two business days of the decision. Members and physicians can appeal the decision by following the procedures in Chapter 9, Member Grievances and Appeals. Examples of reasons for continuity of care denials include, but are not limited to:
The condition is not a qualifying condition. The treating physician is currently contracted with us. The request is for change of PCP only and not for continued access to care. The member is ineligible for coverage. The course of treatment is complete. Services rendered are covered under a global fee. The services requested are not a covered benefit. Continuity of care is not available with the terminating Provider.
Emergency Department Protocol Reporting Process The Plan has implemented a system to report any difficulties experienced with the 24/7 NurseLine or our emergency care systems or protocol failures. Please contact us at the following numbers to report any failures: Medi-Cal (Outside Los Angeles County: Medi-Cal (Inside Los Angeles County: Healthy Families Program: Access for Infants and Mothers (AIM) Program: Major Risk Medical Insurance Program (MRMIP): County Medical Services Program (CMSP): 1-800-407-4627 1-888-285-7801 1-800-845-3604 1-877-687-0549 1-877-687-0549 1-800-670-6133
Corrective action plans will be requested from contracted network hospitals that have Emergency Departments that fail to meet Anthem Blue Cross contractual obligations or follow our Emergency Department/Emergency Room protocols For Medi-Cal members who present at the Emergency Department for non-emergency services, we provide Emergency Department personnel with written referral procedures (including after-hours instruction).
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Enter www.anthem.com/ca. Under the Learn More heading, select State Sponsored Plans. Under Manuals and Guidelines, choose Clinical Practice Guidelines to find
the most recommended clinical resources and references. If you do not have Internet access, you can request a hard copy of the Clinical Practice Guidelines by calling our Customer Care Center (CCC) at 1-800-407-4627. Our recommendation of these guidelines is not an authorization, certification, explanation of benefits, or a contract. Benefits and eligibility are determined in accordance with the requirements set forth by the State of California.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Enter www.anthem.com/ca. Under the Learn More heading, select State Sponsored Plans. Under Manuals and Guidelines, choose Preventive Health Care Guidelines
to find the most up-to-date resources and references. If you do not have Internet access, you can request a hard copy of the Preventive Health Care Guidelines by calling our Customer Care Center (CCC) at 1-800-407-4627. Our recommendation of these guidelines is not an authorization, certification, explanation of benefits, or a contract. Benefits and eligibility are determined in accordance with the requirements set forth by the State of California.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
INTRODUCTION
Our Health Services Department offers health education and health management programs that educate, inform, and encourage self-care. Our services are customerfocused and customer-driven, with the goal of increasing awareness and care for the early detection and treatment of disease. We offer health education programs and services to all eligible Medi-Cal and Healthy Families Program members, as appropriate. Examples of educational interventions to assist members include: The effective use of the managed care system, preventive and primary health services, health education services, and appropriate use of complimentary and alternative care Identifying and modifying personal health behaviors
Working with member primary care physicians to manage their personal health care Encouraging members to achieve and maintain healthy lifestyles Promoting positive health outcomes
Health education and health management programs help members learn about and follow self-care regimens and treatment therapies for existing medical conditions and chronic diseases or health conditions such as pregnancy, asthma, and diabetes. We first introduce new members to our health services and programs through a new member packet, with information presented in an easy-to-read format. We include preventive health guidelines and a Member Services Guide that includes information on how to access health education services by calling our Customer Care Center (CCC). We then may use a variety of methods to communicate health services information to members, for example: Have PCPs refer members to available and applicable programs. Make telephone calls (outbound and inbound). Develop and distribute written materials. Do direct mailings. Participate in health fairs and community events. Have our website available (www.anthem.com/ca).
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Hold health education classes. 24/7 NurseLine, a 24-hour health information line.
For a detailed description of any of our programs and member materials, refer to our website at www.anthem.com/ca.
For new members over the age of 18 months, providers must complete an IHA within 120 days of enrollment. For members under the age of 18 months, providers must complete an IHA within 60 days following the date of enrollment or within the periodicity schedule established by the American Academy of Pediatrics for children ages two and younger, whichever is less. The provider or staff member must contact a new member to schedule an appointment for an initial health examination. Providers have access to an eligibility report online under our secure provider website, ProviderAccess. Providers who are unable to access the website can request a hard copy of the monthly new member eligibility report by calling our CCC. An IHA is not necessary if the member is new to the Plan but is an existing patient of the PCP group and has a documented IHA within the past 12 months prior to the members enrollment. Follow-up is not required if there is an established medical record that shows a baseline health status. This record must include sufficient information for the PCP to understand the members health history and to provide treatment recommendations, as needed. Transferred medical records can meet the requirements for an IHA if a completed health history is included. For children under 21 years of age, providers must complete: A physical examination A developmental history An assessment of nutritional status
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Preventive Care Forms are available on the www.anthem.com/ca website under Forms and Tools. Providers can use these forms to collect baseline data for the Initial Health Assessment. We monitor PCP provision of IHAs through different methods, such as quality management studies, medical record reviews, and facility audits. Providers should administer the Initial Health Assessment along with the Staying Healthy Assessment Tool (SHAT). The SHAT is available in English, Spanish, Vietnamese, Chinese, Lao, Hmong and Russian for the following groups: 03, 48, 911, 1217 and 18 years and older. The latter is given to patients to complete and is reviewed with the provider during an office visit. Upon moving into the next age group, the SHAT should be re-administered at the patients first scheduled health screening exam. Note: Some patients may require assistance with completing the SHAT Form. Use of both the IHA and the SHAT facilitates receiving complete behavioral and physical health histories for patients and should become a permanent part of member medical records. The translated forms are available for printing at www.anthem.com/ca in the Forms and Tools Library section. You also may contact our CCC. Cross-References
Preventive Health Care Guidelines Utilization Management Medical Record and Facility Site Reviews Medical Office Policies and Procedures Medical Record Review Access Standards & Access to Care
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP Version: 1.4 Revision Date: February 2010 Chapter 18 : Page 1
Assist in initiating and documenting focused health education interventions, referrals and follow-up The Staying Healthy Assessment Tool is a set of five age-specific questionnaires that address 11 different patient behavioral risk factors, such as alcohol use, smoking, and nutrition. Providers can find these questionnaires online at www.dhs.ca.gov/ps/ocpm/html/staying%20healthy.htm. Our Health Promotion Consultants (HPCs) or other designated Community Resource Coordinator (CRC) can provide the necessary training and materials needed to implement the SHAT in the PCP offices. New Medi-Cal Members All new Medi-Cal members need to complete the SHAT within 120 calendar days of enrollment or within 60 days for children less than 18 months of age as part of the Initial Health Assessment. Existing Medi-Cal Members All existing members need to complete the assessment at their next nonacute care visit but no later than the next scheduled health screening exam.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
PCP Responsibilities This text is adapted from the Department of Health Care Services website. To meet administrative timelines, the PCP must review the completed form with the member initially, review it again annually, and re-administer it to: Children when they start in a new age group (such as 03, 48 and 911 years) Adolescents age group 1217 years (administer the form annually)
Adults 18 years and older (review the form annually; re-administer the form every 5 years) The PCP must document health education interventions and referrals using Intervention Codes listed on the bottom of each tool and initial and date all interventions. Members can complete the SHAT questionnaires, or office staff can provide assistance utilizing age appropriate forms for each age group. Counseling points are available on the California Department of Health Care Services website to discuss important behavior risk factors for which patients may need additional health education and counseling. We monitor PCP provision of the SHAT through different methods such as quality management studies, medical record reviews and facility audits.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Outreach phone calls Care management (if appropriate) Provider interventions include: Monthly reports to PCPs. The reports are member-specific with the dates, diagnoses, and locations of the physicians assigned members who are enrolled in the ER Initiative.
Providers are to place member-specific information in the members medical record. Providers are encouraged to follow up with members regarding emergency room visits to help coordinate their care.
Providers also may request provider office training on the ER Initiative by calling our Health Services Department at 1-866-829-4547. We based this ER Program Initiative on three core principal components: Empowering members by providing education and a strong knowledge base to make informed decisions when seeking care for nonemergency events Collaborating with PCPs and encouraging them to actively provide access to care and treatment to their assigned members who are identified as high ER users
Working in partnership with members and providers to identify and reduce barriers to access
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Information on more than 300 health topics in both English and Spanish through an audio tape library with recorded information
The 24/7 NurseLine also has dedicated nurses just for teens to help them with questions about their specific health issues. This service provides confidential access to a registered nurse and referrals to local adolescent programs. Information on the 24/7 NurseLine Program is included in the new member packet. How 24/7 NurseLine Assists Providers After regular business hours, providers can call the 24/7 NurseLine at 1-800-224-0336 for: Telephone interpreters for medical visits or telephone conversations Emergency sign language interpreters
For Providers who call our CCC on holidays, weekends or between 5 p.m. to 8 a.m. on weekdays (after regular business hours), our system automatically transfers the call to our after-hours answering service. If Providers call after hours with questions on behalf of a member with an immediate medical care issue, the answering service representative will transfer the call to the 24/7 NurseLine for support. The 24/7 NurseLine gives general information only, not medical advice. If someone needs emergency health care, he or she should call 911 right away. Cross-References
Asthma Management Childbirth/Lamaze Diabetes Management Injury Prevention Nutrition Parenting/Well Child Prenatal Education Sexually Transmitted Disease Smoking Cessation/Tobacco Prevention Substance Abuse Weight Management
How to Schedule Health Education Classes Members receive information about health education classes through a variety of ways, such as enrollment materials, member newsletters, Community Resource Coordinators (CRCs), and physician offices. Members should call the CCC to schedule a health education class. When a member calls, a representative assists the member in locating an available class. Follow-Up We send an Attendance Confirmation Letter to the members PCP with the members name, ID number, and title of class attended. If a member does not show up for the registered class, we will mail a No Show Letter to the members PCP. PCPs are to file the documentation in the members record for follow-up. For more information on health education classes, members or providers can call our CCC. How to Get Health Education Materials for Your Office We supply providers with health education materials developed for our members cultural and linguistic needs. To request health education materials, go to www.anthem.com/ca and select State Sponsored Plans>Forms and Tools. You also may contact our CCC.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Document Health Education Counseling and Referrals Providers must document health education services in the members medical record. Documentation must include the education topic, materials distributed to the member, identification of person providing the education, and notation of any follow-up or recommendations. Once a member attends a class at a participating hospital or community-based organization, we send a letter to the members PCP with the members name, ID number, and title of class attended. We include this letter as documentation in the members medical record. Get Up and Get Moving! Family Workbook The Get Up and Get Moving! Family Workbook is a guide for Anthem Blue Cross members 6 to 12 years of age and their families. The focus is to empower young children and families with information about healthy eating habits and physical activity and to provide physicians with tools to educate and counsel parents of overweight children. The key educational concept of the program is that regular exercise and nutrition are the basis of a healthy family lifestyle. Family workbooks are available to parents of children ages 6 to 12 to reinforce healthy lifestyles. These are available in English, Spanish, Vietnamese, Chinese, and Russian. To order copies of the family workbook for your patients, please go to www.anthem.com/ca and select State Sponsored Plans>Forms and Tools.
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Facility Site Review Medical Record Review Self-Referral Health Education Classes and Materials
PREVENTIVE CARE PROGRAMS
We developed Preventive Care Programs to help promote and maintain good health for members. These include programs such as Immunization, Well Infant, Well Child, Well Adolescent, and Well Woman Programs that remind members about the importance of regular checkups. Providers play an important role in the following Preventive Care Programs. Immunization Program We designed the Immunization Program to increase childhood immunization rates and to increase the number of our members who are fully immunized by two years of age. By including key partners (parents and guardians, PCPs and health plan staff) as part of our multi-level intervention plan, we have succeeded in increasing childhood immunization rates. For Immunization and Screening Guidelines, log on to www.anthem.com/ca. Under Learn More, select State Sponsored Plans. Choose Preventive Health Care Guidelines to find the most up-to-date clinical resources for preventive screening, immunizations, and counseling for our members from nationally recognized sources. Scroll through age-specified sections to find links for more specific information.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
If you do not have Internet access, you can request a hard copy of the Preventive Health Care Guidelines by calling our CCC. Our recommendation of these guidelines is not an authorization, certification, explanation of benefits, or a contract. Benefits and eligibility are determined in accordance with the requirements set forth by the state. Monthly Provider Reports PCPs can use ProviderAccess, our online provider information tool, to obtain a monthly eligibility report of their patients who are 9 and 18 months old and, according to our claims history, are in need of one or more immunizations. This report assists the office in implementing a physician-based reminder system. Providers who are unable to access the website can request a hard copy of the monthly eligibility report by calling our CCC. Well Woman Program We designed our Well Woman Program to encourage members to have regular cervical and breast cancer screenings. The program reminds and encourages members to call their PCP to make an appointment for scheduled screenings. Physician Care for Women PCP responsibilities of care for female members include, but are limited to Informing and referring members for cervical and breast cancer screenings Educating members on the Preventive Care Guidelines Scheduling screening exams for members
Providers can access our Preventive Health Care Guidelines in this manual.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
We offer reference tools and materials to assist providers who care for children to initiate dialogue with families about their childs weight, nutrition, and physical activity and to enhance patient knowledge of these issues. For more information about the Childhood Obesity Initiative call 1-866-638-1865 or send an e-mail to childhoodobesity@wellpoint.com. Childhood Obesity Physician Tool Kit The Physicians Tool Kit includes: Childhood Obesity Desktop Reference Tool: The Patient Counseling Guidelines for Families with Overweight Children and Adolescents gives physicians quick access to current data from scientific literature and expert work groups relating to childhood obesity. Body Mass Index (BMI) Wheel: This tool assists physicians and clinical staff in calculating BMI percentiles of their pediatric patients and assessing if they are underweight, normal, overweight, or obese. BMI CDC Growth Charts: These charts assist physicians and clinical staff in plotting the BMI percentiles of their pediatric patients and assessing if they are underweight, normal, overweight, or obese. Parent Education Materials For more information about the Childhood Obesity Physician Tool Kit, call 1866-638-1865 or send an e-mail to childhoodobesity@wellpoint.com. Body Mass Index (BMI) Training and Promotion Program BMI screening is an important first step in identifying children who are overweight or obese. We have developed a statewide BMI training and promotion program that provides education and instruction in measuring, plotting, documenting, and tracking BMI. The training is designed for clinical staff (nurse practitioners, registered nurses, licensed vocational nurses, and medical assistants) in pediatric and family practice offices. The overall goal of the program is early identification of children who are either overweight or obese to enable timely delivery of preventive and management services to those children and their families. A tiered approach to training offers in-person workshops for groups of 40 to 75 clinical staff, a convenient web-based online module, and CD training. For more information about BMI training, call 1-866-638-1865 or send an e-mail to childhoodobesity@wellpoint.com.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP Version: 1.4 Revision Date: February 2010 Chapter 16: Page 10
Kids in Charge of Kalories (KICK) Children who are overweight or obese can be referred to the free Kids in Charge of Kalories (KICK) Program. KICK is a free, comprehensive health improvement program designed to encourage children and their families to eat healthy foods and be more active. According to the American Academy of Pediatrics, nutrition and exercise are the best ways to keep children healthy and prevent childhood obesity. Children are referred to the KICK Program through Anthem Blue Cross network physicians who provide care to young children. The KICK Program also makes outbound calls to members between the ages of 6 and 12 who have a Body Mass Index (BMI) in the obese range for age and sex (>95th percentile) and their families. The goals of the program are to: Reduce the prevalence of childhood obesity within our membership Educate and encourage members and their families to eat healthy and increase physical activity Educate physicians about childhood obesity and equip them with tools for the prevention and management of childhood obesity Develop meaningful collaborations and relationships with community-based organizations to address childhood obesity
Children are better able to lose weight and improve health when family members are involved in changes to eating and lifestyle habits. To refer members to KICK, please call 1-866-634-3435. Tobacco Cessation Program: The Last Cigarette Our Tobacco Cessation Program, The Last Cigarette (TLC), offers numerous resources and tools to assist members who want to quit smoking. This program will help members in any stage of cessation readiness and includes several resources. A TLC Quit Kit is available by calling the TLC hotline at 1-866-634-3435. We offer smoking cessation classes at no cost to members; call our CCC for more information. Nicotine Replacement Therapy (NRT) is available at no cost to members. Providers prescribing NRT to members should tell them that to receive free NRT, they need to show their pharmacy the NRT prescription and certificate of enrollment into a smoking cessation class or quit line.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Smoking cessation clinical practice guidelines are posted online at www.anthem.com/ca. Provider Assessment of Tobacco Use Assess member smoking status and offer quick advice about quitting. Use Pregnancy Notification Reports as a way to notify us of pregnant women who smoke. Women are more likely to quit smoking during pregnancy, encourage pregnant women to stop smoking, and continue this tobacco cessation after pregnancy. Offer members resources to stop smoking, including our TLC Program information. Resources to Help Members Stop Smoking California Smokers Helpline 1-800-NO-BUTTS is a free telephone program, funded by the California Department of Health, which can help members quit smoking. Callers receive a choice of services, including self-help materials, a referral list of programs, and one-to-one counseling over the phone. The program has been operational since 1992. Phone: Website: 1-800-662-8887 www.californiasmokershelpline.org
Smoking Cessation Material for Women of Childbearing Age We are pleased to make educational resources available to our members and health care partners designed to help women of childbearing age quit smoking and avoid starting again. Copies can be downloaded from the physician section of our website at www.anthem.com/ca. Anthem Blue Cross Smoking Cessation Articles Click on the links below for helpful tobacco cessation articles:
Planning to Stop Smoking? Your Physician Can Help! Smoking and Diabetes
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Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Document all referrals and treatments related to asthma in the members medical record. File the member-specific notification with the members risk stratification and utilization in the medical record. Order asthma educational materials by calling our CCC or visiting our website at www.anthem.com/ca.
Healthy Habits Count with Diabetes Program We designed our Healthy Habits Count with Diabetes Program to augment the care of members with diabetes. We adopted the clinical practice guidelines from the American Diabetes Association, available on our website, www.anthem.com/ca. Select State Sponsored Plans under Learn More. Scroll down the page and choose Health Education Resources, then select Diabetes Guidelines. Providers who do not have Internet access can request a hard copy of these clinical practice guidelines by calling our CCC. Member enrollment and participation in the Healthy Habits Count with Diabetes Program is based on either an opt-out process for high-risk members or an opt-in process available to self-referred members into the program. Identified members are automatically enrolled in the program and receive interventions according to risk stratification. A member may opt out of the program at any time by contacting the Plan. Provider Care for Diabetic Members PCPs provide each diabetic member with ongoing treatment and perform the appropriate physical and laboratory examinations following the Diabetes Care Guidelines from the American Diabetes Association. Providers are required to: Assess and treat members according to the Diabetes Care Guidelines Refer members for appropriate laboratory and screening tests Refer members to Healthy Habits Count with Diabetes Program, classes, and local community agencies by calling our CCC File the member-specific notification with the members risk stratification and the date of the last diabetic screening in the medical record Coordinate care management, pharmacy, and specialists as needed
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Document all referrals and treatments related to diabetes in the members medical record Order diabetes education materials by using the Health Education Materials Order Form for Physicians available on our website at www.anthem.com/ca. Select State Sponsored Plans under Learn More, then select Forms and Tools and Health Education
Healthy Habits Count for Your Heart Program The Healthy Habits Count for Your Heart Program consists of a multi-disciplinary approach that addresses member medical and behavioral issues through education and care management. The program helps improve member self-management skills and adherence to treatment plans for their cardiovascular conditions as well as support treating physicians in the management of their patients condition. The Healthy Habits Count for Your Heart Program encompasses the following conditions and clinical practice guidelines: Cardiovascular Disease: American Heart Association (AHA) Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: (http://circ.ahajournals.org/cgi/content/full/106/3/388) Congestive Heart Failure: Diagnosis and Management of Chronic Heart Failure in the Adult AHA: (http://circ.ahajournals.org/cgi/content/full/112/12/1825)
Member enrollment and participation in the Healthy Habits Count for Your Heart Program is based on either an opt-out process for high-risk members or an opt-in process available to self-referred members into the program. Identified members are automatically enrolled in the program and receive interventions according to risk stratification. A member may opt out of the program at any time by contacting the Plan. Provider Care for Members with Cardiovascular Conditions PCPs provide each member with a cardiovascular condition with ongoing treatment and perform the appropriate physical and laboratory examinations following the guidelines from the American Heart Association (AHA). Providers are required to: Improve quality of care in accordance with the AHA clinical practice guidelines for congestive heart failure and coronary artery disease
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Improve quality of life for members with congestive heart failure or coronary artery disease Promote a patient-physician interactive approach toward cardiovascular care by using action/goal plans, facilitating patient-physician communications, and encouraging members to take a more active role in managing their conditions Encourage member adherence to physician-prescribed treatment plans Increase member self-management and knowledge of cardiovascular disease, including early detection and management of symptoms Reduce exacerbation and secondary complications Refer members to Healthy Habits Count for Your Heart Program, classes, and local community agencies by calling our CCC
Healthy Habits Count for You and Your Baby Program The Healthy Habits Count for You and Your Baby Program provides members with a comprehensive program of prenatal and postpartum care. We designed the program to identify pregnant members, encourage early and ongoing prenatal and postpartum care, provide care management to members with high-risk pregnancies, and increase member access to perinatal information. Members enrolled in the Healthy Hearts Count for You and Your Baby Program receive the following: Educational mailings of perinatal information Care management for high-risk pregnancies Referral to community-based resources, as needed Access to Prenatal Education classes Postpartum reward incentive
We developed the program specifically for state sponsored members, focusing on their needs for additional follow-up and support to improve access to health plan services. We work together with the members obstetrician (OB) and PCP to meet the program goals. Identification of Pregnancies We identify pregnancies through communication among PCPs, obstetric providers, and the Plan. This communication takes place through two primary methods:
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Providers complete a Pregnancy Notification Report (PNR) and fax it to us at 1-877-848-0147; this report is available on our website at www.anthem.com/ca. When Providers call to request authorization for prenatal services for a member, we let them know about the Healthy Habits Count for You and Your Baby Program and encourage them to enroll the member into the program.
Components of the Healthy Habits Count for You and Your Baby Program To promote healthier pregnancies for members, we send an educational packet to participants covering each trimester. We also have arrangements with several hospitals to provide prenatal classes for pregnant members in a variety of topics. Participants may self-refer to some of the classes, including early prenatal, childbirth education, baby care, and breastfeeding classes. Members can register by calling our CCC. Physician Assessment of Pregnancy Risk The PCP or prenatal care physician should assess all pregnant members for high-risk indicators during the initial prenatal care visit. For all pregnant members, the Provider needs to: Complete and fax a Pregnancy Notification Report (PNR) to our Prenatal Program Coordinator at 1-877-848-0147 Refer members to prenatal education, childbirth education, and breastfeeding classes. Members and physicians can call our CCC to register for Health Education Classes and Materials Document all referrals in member medical records Schedule members for postpartum visits
Breastfeeding Promotion The Healthy People 2010 goal is to increase breastfeeding initiation at delivery to at least 75 percent of all mothers and achieve at least 50 percent continuation of breastfeeding for six months. The American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the American Public Health Association recognize breastfeeding as the preferred method of infant feeding. Providers should encourage breastfeeding for all pregnant women unless it is not medically appropriate. To support this goal, we ask you to: Refer pregnant and postpartum women to our Breastfeeding Support Line at 1800-231-2999 for information, support, and referrals
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Refer pregnant women to community resources that support breastfeeding such as La Leche League, WIC, and breastfeeding classes Assess all pregnant women for health risks that are contraindications to breastfeeding, for example, AIDS and active tuberculosis
Provide breastfeeding counseling and support to postpartum women immediately after delivery Assess postpartum women to determine the need for lactation durable medical equipment (DME), such as breast pumps and breast pump kits (providers may prescribe hand-held breast pumps without prior authorization; however, electric breast pumps require prior service review).
Document all referrals and treatments related to breastfeeding in the patients medical record (pediatricians should document frequency and duration of breastfeeding in babys medical record.) Refer members to breastfeeding classes prior to delivery by calling the CCC Support continued breastfeeding at the postpartum visit
Breastfeeding Support Tools and Services Lactation management aids are a covered benefit for our Medi-Cal members. Members can obtain hand-held breast pumps through a prescription without prior authorization. Electric breast pumps are available for medical necessity for members with a Provider referral and prior authorization. Contact the Utilization Management (UM) Department for information. Arrangement for the provision of human milk for newborns must be made if the mother is unable to breastfeed due to medical reasons and the infant cannot tolerate or has medical contraindications to the use of any formula, including elemental formulas. The Mothers Milk Bank of Santa Clara Valley Medical Center is the only human milk bank in the state of California. Contact the Mothers Milk Bank at 1408-998-4550.
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Comprehensive Perinatal Services Program The Comprehensive Perinatal Services Program (CPSP) is a voluntary participation program for Medi-Cal recipients. It is designed to provide comprehensive perinatal services during pregnancy and 60 days following delivery by or under the personal supervision of a physician approved by the Department of Health Care Services (DHCS) to provide CPSP services. CPSP services include care coordination, obstetrical, nutrition, health education, and psychosocial services. As a PCP or obstetrics/gynecology (OB/GYN) specialist, you are responsible for assessing the members needs and referring all pregnant members to community prenatal services (for example, Women, Infants and Children (WIC) Program, substance abuse programs, prenatal education classes, and others) as soon as pregnancy is determined. Refer all women with identified high-risk factors to a certified CPSP provider.
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Care and service provided in all health delivery settings Provider and enrollee satisfaction Provider site facilities and medical records Provider promotion of Preventive Health Programs and exams and management
of member health status
Providing access to medical records for quality improvement projects and studies Participating in the facility and medical record audit process Completing corrective action plans when applicable
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
HEDIS measures Internal Quality Improvement Projects which include focused studies that
measure quality of care and service in specified clinical and service areas We submit the results of HEDIS and quality studies annually to the California Department of Health Care Services (DHCS). HEDIS Activities We ask Providers to support and contribute to our efforts to improve HEDIS measures rates. HEDIS Training and Consultation for Office Staff The Plan provides assistance for medical office staff regarding HEDIS activities. Providers may access a presentation on key elements of HEDIS on the Plans website (HEDIS Training Link). Additionally, Providers can request a consultation. Training and consultation includes:
Information about the years selected HEDIS measures Guidelines on how data for those measures will be collected Codes associated with each measure for administrative data Tips for smooth coordination of medical record data collection
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Access to Medical Records for HEDIS Reviews The Quality Management staff will contact the Providers office to arrange for a review or to copy any medical records required for Quality Improvement (QI) studies. Office staff must give access to medical records for review and copying. Satisfaction Surveys Member Satisfaction Surveys We participate in the Consumer Assessment of Healthcare Providers and Systems (CAHPS), an annual survey of members to measure satisfaction with the service and care provided by us and our Providers. The survey measures access to care, member satisfaction with the Plan, and satisfaction with provider communication and office staff performance. We communicate the results of the survey to both members and Providers. The Provider should review results of the survey, share the results with office staff, and incorporate appropriate changes in the office. Provider Satisfaction Surveys We may conduct Provider surveys to monitor and measure Provider satisfaction with the our services and access to care and to identify areas for improvement. We inform Providers of results and plans for improvement through Provider bulletins, newsletters, and meetings, or training. Provider participation in the survey process is highly encouraged. Provider feedback is very important to us to help address areas needing improvements.
Determine the Provider offices ongoing compliance with standards for providing
and documenting health care services and with processes that maintain safety standards and practices
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Confirm Provider involvement in the continuity and coordination of care for our
members
.
DHCS and the Plan have the right to enter into the premises of Providers to inspect, monitor, audit, or otherwise evaluate the work performed. We will perform all inspections and evaluations in such a manner as not to unduly delay work (in accordance with the Provider contract). Medical Record Review and Facility Site Review survey tools are available on the Plan website at www.anthem.com/ca. These tools can be printed or downloaded into your computer. The tools indicate what elements are reviewed. Facility Site Review As required by California statute, all primary care physician sites participating in the Medi-Cal Managed Care Program statute must undergo an initial site inspection (Facility Site Review) and subsequent periodic site inspections, regardless of the status of other accreditation or certification. A Facility Site Review is completed as part of the initial credentialing process for new Providers if that site has not been previously reviewed and accepted as part of the Plans credentialing process. The Plan conducts a Facility Site Review of each PCP every three years in accordance with Plan standards. Obstetrics/Gynecology (OB/GYN) specialty sites participating in the Medi-Cal Managed Care Program (and not serving as PCPs) must undergo an initial site inspection. Site Review Collaboration We collaborate with other health plans within each Medi-Cal Managed Care county to establish systems and implement procedures for coordinating and consolidating site audits for mutually shared primary care physicians. The collaboration provides a system-wide process to minimize site review duplication and to support consistency in PCP site reviewers.
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Facility Site Review Scoring We will notify Providers of the Facility Site Review score, all cited deficiencies, and corrective action requirements at the time of a nonpassed survey. Provider office sites will complete a critical element deficiency corrective action plan within 10 days of the Facility Site Review. Facility Site Review Scheduling Process A Quality Management Specialist (QMS) will call the Provider/office to schedule an appointment date and time within 30 days before the Facility Site Review due date. The QMS will fax/send a confirmation letter with an explanation of the audit process and required documentation. During the Facility Site Review, our QMS will:
Provide a prereview conference with the Provider or office manager to review and
discuss the process of the Facility Site Review and answer any questions
Conduct a review of the facility, completing a Facility Site Review, and develop a
corrective action plan, if applicable After the Facility Site Review is completed, our QMS will meet with the Provider or office manager to:
Review and discuss the results of the Facility Site Review and explain any required
corrective actions
Provide a copy of the Facility Site Review results and the corrective action plan to
the office manager or Provider
Schedule a follow-up Facility Site Review for any corrective actions identified Educate the provider and office staff about Plan standards and policies
Provider Support of the Facility Site Review Process The Provider and office staff will:
Provide an appointment time for the Facility Site Review Be available to answer questions and to participate in the exit interview Schedule a time for follow-up Facility Site Reviews, if applicable
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Correct critical element deficiencies within 10 days following the Facility Site
Review
Complete a corrective action plan within 30 days Sign an attestation statement (a section of the facility application) that corrective
actions are complete
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Storage and Maintenance Active medical records should be stored in one central medical record area and must be inaccessible to unauthorized persons. Medical records are to be maintained in a manner that is current, detailed, and organized and permits effective patient care and quality review while maintaining confidentiality. Inactive records are to remain accessible for a period of time that meets state and federal guidelines. Availability of Medical Records The medical records system must allow for prompt retrieval of each record when the patient comes in for an encounter. Medical Record Documentation Standards Every medical record, at a minimum, is to include:
The patients name or ID Number on each page in the record Personal biographical data, including home address, employer, emergency contact
name and telephone number, home and work telephone numbers, and marital status
All entries dated with month, day, and year All entries contain the authors identification (for example, handwritten signature,
unique electronic identifier or initials) and title
Physical findings relevant to the visit including vital signs, normal and abnormal
findings, and appropriate subjective and objective information
Information on allergies and adverse reactions (or a notation that the patient has
no known allergies or history of adverse reactions)
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Past medical history, including serious accidents, operations, illnesses, and, for
patients 14 years old and older, substance abuse. For children and adolescents past medical history relates to prenatal care, birth, operations, and childhood illnesses.
Physical examinations, treatments necessary, and possible risk factors for the
member relevant to the particular treatment
Prescribed medications, including dosages and dates of initial or refill prescriptions For patients 14 years and older, appropriate notation concerning the use of
cigarettes, alcohol, and substance abuse (including anticipatory guidance and health education)
Information on the individuals to be instructed in assisting the patient Medical records, which must be legible, dated and signed by the physician,
physician assistant, nurse practitioner, or nurse midwife providing patient care
Documentation on whether an interpreter was used, and, if so, that the interpreter
was also used in follow-up. Medical Record Review We complete a medical record review every three years, according to our medical records standards. We complete medical record reviews at all primary care sites.
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Scheduling a Medical Record Review Quality Management staff will call the Providers office to schedule an appointment date and time within 30 days. On the day of the review, Quality Management staff:
Requests the number and type of medical records required Reviews the appropriate type and number of medical records per provider Completes a medical record review Meets with the provider or office manager to review and discuss the results of the
medical record review
Gives a copy of the medical record review results to the office manager or doctor Schedules follow-up reviews for any corrective actions identified
Providers must attain a score of 80 percent or greater in order to pass the medical record review.
ADVANCE DIRECTIVES
Recognizing a persons right to dignity and privacy, our members have the right to execute a living will to identify their wishes concerning health care services should they become incapacitated. Physicians or providers may be requested to assist members in procuring and completing necessary forms. For more information, refer to Anthem Blue Cross State Sponsored Business website at www.anthem.com/ca.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
TRANSFERS
Member-Initiated Primary Care Physician Transfers A member has the right to change his or her Primary Care Physician (PCP) at any time. When a member enrolls in our programs, we provide instructions to call our Customer Care Center (CCC) if he or she wants to choose another PCP. Our CCC staff considers special needs when changing a PCP and works with the member to make a new selection. We accommodate member requests for transfers of PCPs whenever possible and have policies to maintain continuity of care during the transfer process. A member may request a PCP transfer by calling our CCCs: Medi-Cal (all counties except Los Angeles): Medi-Cal (Los Angeles County only): Healthy Families Program: AIM and MRMIP: 1-800-407-4627 1-888-285-7801 1-800-845-3604 1-877-687-0549 TDD: 1-888-757-6034
The CCC Representative checks the availability status of the members choice of a
PCP. If the PCP is not available, the CCC Representative assists the member in finding an available PCP.
If the member can be assigned to the selected PCP, the CCC Representative
performs the necessary online function to assign the member. If the member advises the CCC that he or she is hospitalized, the PCP change takes effect upon discharge. We notify PCPs of member transfers through monthly enrollment reports. PCPs can find these reports online at www.anthem.com/ca through our secure ProviderAccess website or by calling our CCCs. The effective date of a PCP transfer is the first day of the following month. We may assign a member retroactively.
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PCP-Initiated Transfers A PCP can request a member reassignment to another PCP by completing and submitting the Provider Request for Member Deletion from Primary Care Physician (PCP) Assignment Form located online at www.anthem.com/ca. For continuity of care, the PCP must continue to manage the members care until we reassign the member to another PCP. The reassignment or transfer is effective 30 days from the date we receive the Provider Request for Member Deletion from Primary Care Physician (PCP) Assignment Form. The PCP can request a member transfer to another PCP for reasons that include:
The member is abusive to a Provider or to a Providers staff. The member fails to follow prescribed treatment plans.
The PCP must complete the Provider Request for Member Deletion from Primary Care Physician (PCP) Assignment Form and send or fax the request to us at the address and fax number provided on the form. In most circumstances, we make every attempt to resolve any issues between the provider and the member and document the resolution process. If these attempts fail, we either reassign the patient to another PCP or, if applicable, forward the Disenrollment Request Form to the appropriate state agency or state-contracted agency requesting member reassignment to another health plan. For more information, see the Plan-Initiated Member Disenrollment section in this chapter. If we reassign the member to another PCP, the process is as follows:
The PCP completes the Provider Request for Member Deletion from Primary
Care Physician (PCP) Assignment Form and then mails or faxes it to us at the address and fax number on the form.
We receive and complete the form and then submit it to the Grievance
Coordinator to be filed.
We microfilm and log the form into the system for tracking purposes. For continuity of care, we reassign the member to a new PCP with an effective date
30 days from the date we receive the Provider Request for Deletion from Primary Care Assignment Form and log it into the our tracking system.
We send an ID card and fulfillment material to the member indicating the new
assigned PCP name, address, and telephone number.
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We submit the original form to the Quality Assurance Coordinator, who sends a
letter to the member within five working days.
We document any abusive behavior and notify the Fraud and Abuse Department
if abusive behavior continues. We also send a warning letter to the member stating that, if the behavior continues, we will file a disenrollment request with DHCS for approval. If approval is granted by DHCS, we proceed with the disenrollment process. For more information, call our Customer Care Center number: Medi-Cal (all counties except Los Angeles): Medi-Cal L.A. Care (Los Angeles County only): 1-800-407-4627 1-888-285-7801
DISENROLLMENT FROM THE PLAN: MEDI-CAL AND L.A. CARE HEALTH PLAN
Who Can Initiate Disenrollment Several sources may initiate a disenrollment:
The member Anthem Blue Cross Partnership Plan, State Sponsored Business (the Plan) L.A. Care Health Plan (L.A. Care) or Health Care Options (HCO) on behalf of the
Department of Health Care Services (DHCS) Member-Initiated Disenrollment Members can voluntarily disenroll and choose another managed care program at any time, subject to any restricted disenrollment period. When members enroll in our program, we provide instructions on where to call or write to disenroll or to choose another managed care program. Approved disenrollments become effective no later than the first day of the second month following the month in which the member files the request. Disenrollment may result in any of the following:
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The CCC Representative will attempt to find out the reason for the request.
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If the situation is something that the CCC Representative can address and resolve,
the CCC Representative reminds the member that he or she has the right to request disenrollment but also offers to resolve the issue. The CCC Representative also asks the member if he or she wants to delay the disenrollment process pending the resolution of the issue.
If the member declines, the CCC Representative offers to transfer the member to
HCO and provides the member with the HCO toll free number 1-800-430-4263 or L.A. Cares toll free number 1-888-452-2273.
The CCC Representative informs the member that the disenrollment process will
take approximately 15 to 45 days, or, if the member is unable to wait, the member may request an expedited disenrollment under certain circumstances. We notify L.A. Care of any member initiated disenrollment request that we have knowledge of on a monthly basis. Plan-Initiated Member Disenrollment We may request disenrollment for a member who has moved out of the service area and who has not notified his or her state eligibility caseworker. If members move out of the service area, they are responsible to contact their state eligibility case worker to notify them of the members address change. DHCS or its contracted state agency, such as HCO, is notified by the state eligibility case worker and is responsible to disenroll the member from the Plan. We may recommend to DHCS the disenrollment of any member in the event of a breakdown in the Plan/Member relationship that makes it impossible for us to render services adequately to the member. Except in cases of fraud or physical abuse as set forth below, we shall make and document its efforts to resolve the problem with the member through PCP transfers, education, or referrals to other health care services. Plan-initiated member disenrollments based on the breakdown in the Plan/Member relationship shall be prior approved by DHCS and shall be considered only under the following circumstances:
The member is repeatedly verbally abusive to providers, staff, or other members. The member physically assaults a staff person, Provider, or Providers staff person
or threatens another individual with a weapon on the Plans or Providers premises. In these circumstances, the Plan or the Provider shall file a police or security agency report as applicable and file charges against the member.
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The member is disruptive to Plan operations, in general. The member habitually uses Providers not affiliated with us for nonemergency
services without obtaining the required authorizations, subjecting us to repeated Provider demands for payment or other demonstrable deterioration in the Plans relations with community providers.
The member has engaged in or allowed the fraudulent use of Medi-Cal coverage
under the Plan which includes allowing others to use the members ID card to receive services from the Plan. A members failure to follow the prescribed treatment (including failure to keep established medical appointments) is not, in and of itself, good cause for a Plan-initiated disenrollment request unless we can demonstrate to DHCS that, as a result of the failure, we or the Provider are exposed to substantially greater and unforeseeable risk than what is otherwise contemplated under our agreement with DHCS or L.A. Care, as applicable. State Agency-Initiated Member Disenrollment We receive a daily and monthly full enrollment replacement file from DHCS and statecontracted agencies, such as HCO, containing all active membership data and all incremental changes to eligibility records. We disenroll members not listed on the monthly full replacement file effective the 1st of the following month of notification with consideration of the following mandatory disenrollment reasons, that include:
Death of the member The members permanent change of residence out of the Plans service area Plan mergers or reorganizations with another company or with a parent or
subsidiary corporation
County of residence changes Loss of benefits Voluntary disenrollment requests of the member not filed during any restricted
disenrollment period for the member
Change in members eligibility status with Medi-Cal Incarceration Admission to a long-term care or intermediate care facility beyond the month of
admission and the following month
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Requirement of medical health care services not provided by the Plan (for example,
some major organ transplants, kidney dialysis)
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CREDENTIALING POLICIES
More information about credentialing and recredentialing can be found on the StateSponsored Business pages of at www.anthem.com/ca. This list names the pertinent policies for the credentialing process:
Behavioral Health Providers (nonphysicians)Education Criteria: This policy establishes eligibility criteria related to education and training for Behavioral Health providers
Initial Application: This policy establishes the elements needed in the initial
application and the attestation requirement (Credentialing Policy #5 in Credentialing Policies)
Verification of Data Elements: This policy details the sources acceptable for
verification of the various elements required to complete the credentialing process (Credentialing Policy #6 in Credentialing Policies)
Distribution of Appropriate Information Regarding Specialty: This policy outlines the process for accurate information flow regarding provider training and specialty
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Site Visits: This document relates the site visit process and comments as to which
providers it is applicable (Credentialing Policy #7 in Credentialing Policies)
Health Delivery Organizations: In this policy, the criteria and scope of the
credentials processes, relative to HDOs, are outlined (Credentialing Policy #9 in Credentialing Policies)
Appeals: This policy establishes the mechanism available to providers who want
to appeal a CCs determination (Credentialing Policy #14 in Credentialing Policies) Appeals for HDOs
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Delegation: This series of policies discuss the principles and practices governing
the delegation of any credentialing related activity.
Revocation of Delegation: Allows us to use delegate information if the revocation was for reasons other than poor performance. Providers affected by revocation retain their rights and privileges (that is, they are not subjected to a new requirement for board certification). Individual providers leaving delegated arrangements: Allows us to use delegate information if the delegate was performing credentialing appropriately. Providers affected by revocation retain their rights and privileges (that is, they are not subjected to a new requirement for board certification). Interim Assessments for Plans Not Requiring Full File Audit: URAC (Utilization Review Accreditation Commission) now requires annual policy and procedure review. This and attestation of compliance will be used during those years when file audit is not required.
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Billing for services not provided Billing for medically unnecessary tests Unbundling/upcoding Misrepresentation of diagnosis or services Underutilization and overutilization Soliciting, offering, or receiving kickbacks or bribes Billing professional services performed by untrained personnel Altering medical records
Examples of Member Fraud and Abuse These are examples of member fraud and abuse:
Making frequent emergency room visits with non-emergent diagnoses Obtaining controlled substances from multiple providers
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Violating pain management contract Using more than one physician to obtain similar treatments or medications Using providers not approved by the Primary Care Physician (PCP) Forgoing or selling prescriptions Loaning insurance ID cards Disruptive/threatening behavior Relocating out-of-service area
Reporting Fraud and Abuse There are two ways for a Provider to report allegations of fraud and abuse:
Contact our Customer Care Center at 1-800-407-4627 Complete the Fraud Referral Form and fax it to the Fraud and Abuse Unit at
1-866-454-3990. Although you may remain anonymous, we encourage you to provide as much detailed information as possible, including:
Your name and business and telephone numbers Name, address, and license or insurance ID of the provider or member Allegation Date of incident or incidents Supporting documentation
The more information you provide, the better chance we have of successfully reviewing and resolving the issue. Role of the Fraud and Abuse Department We do not tolerate acts that adversely affect our providers or members. We investigate all reports of fraud and abuse. Allegations and investigative findings are reported to the California Department of Health Care Services (DHCS) and regulatory and law enforcement agencies. In addition to reporting, we take corrective action, such as:
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Special claims review: Special claims review places payment or system edits on the
file to prevent automatic claim payment. This requires a medical reviewer evaluation.
Quality of care: We refer providers who compromise patient care to the Quality
Management Department. The Provider may be presented to the CC or Peer Review Committee for disciplinary action.
Care management: We may refer members to Care Management for access to care,
coordination of services, mental health or pain management, and community resources.
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The FCA also contains Qui Tam or Whistleblower provisions. A whistleblower is an individual who reports in good faith an act of fraud or waste to the government or files a lawsuit on behalf of the government. Whistleblowers are protected from retaliation from their employer under Qui Tam provisions in the FCA and may be entitled to a percentage of the funds recovered by the government.
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PROVIDERACCESS WEBSITE
ProviderAccess is your online connection to real-time eligibility, benefits, claims status, and other valuable resources. As we improve our website, the content is subject to change. We are working to reduce administrative issues and make it easier for you to help your patients. Using this website, you can:
Verify member eligibility Obtain status on claims and claim reporting Obtain eligibility reports and file downloads Obtain fee schedule information Access the Provider Operations Manual (POM) Obtain program news and information
ProviderAccess requires that you request and use a Personal Identification Number (PIN) and requires that your Internet Service Provider (ISP) provides a secure e-mail domain. Accounts such as Yahoo, Hotmail, Netscape, and Lycos are not acceptable domains. Log in to ProviderAccess
Go to www.anthem.com/ca
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Refer to the Login box, select Medical from the drop-down list, then click Login
This displays the ProviderAccess Login page; in the Login box, type your User ID
and Password, then click Login.
If you do not have a User ID, select Register for ProviderAccess in the dialog text to request an account and follow the instructions to request an online account. Once approved for an online account, you will receive an e-mail confirmation of your account approval. If for some reason we cannot approve a ProviderAccess account for you, we will notify you by mail.
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Service Hours for Transactions (Pacific Standard Time) ProviderAccess is available for your use during the following times: Monday: Tuesday through Friday: Saturday: Sunday: Holidays: 12:30 a.m. to midnight 1:30 a.m. to midnight 1:30 a.m. to 7 p.m. Closed 12:30 a.m. to midnight
For more information about ProviderAccess, go to ProviderAccess Website in this chapter or go directly to the ProviderAccess website.
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Remove barriers for members in accessing health care services Provide training for health care professionals and their staff on Plan enrollment,
covered benefits, and managed care operations
Provide face-to-face assistance to our members regarding benefits and value-added programs Locate immediate and long-term community services for members to access Act as a facilitator, working collaboratively to bring agencies and organizations together to focus on promoting overall health Share information among CRCs about operational, educational and administrative procedures, such as best practices for billing and program improvement
Create partnerships with local public health, social services, and community-based
organizations as well as Providers focused to address health-related issues in order to improve the overall health status and quality of life for our members
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Community Resource Coordinator Staff CRCs are managed care professionals who reside in the CRC service area and understand the nuances of the areas Medi-Cal Program, Healthy Families Program, Access for Infants and Mothers (AIM), and Major Risk Medical Insurance Program (MRMIP) delivery systems. People who are bilingual and bicultural hold many of the staff positions; they speak at least two languages, such as English and Spanish. They understand the health beliefs and practices of the demographic population they serve. The CRC focuses on the needs of all members. Staff are trained to enroll members in all Plan programs and thoroughly understand covered benefits, interpretation of policies and procedures, filling out appropriate forms, and diversity and cultural issues. Each CRC has access to the following positions:
Administrative assistants are often the first contact for network physicians,
members, community partners, and visitors to the facilities where our CRCs are located.
Senior Clinical Quality Auditors work to improve the quality of member care by
performing facility site reviews, chart reviews, and training office staff on quality management techniques.
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Outreach Specialists call and visit targeted members in their homes to assist them
in receiving preventive care and gain access to our services. They also educate families eligible for Medi-Cal, Healthy Families Program or other programs about the options available and assist them in the application process for these programs. Outreach for Members CRCs build relationships with local community resources and agencies, enabling them to assist members with referrals for:
Nonemergency transportation Translation and interpreter services Community services, such as:
Nearby pharmacies and grocery stores Public and private transportation Senior citizen centers Dentists and orthodontists Eye care specialists Public housing and assisted housing resources Weight management centers and dieticians Food services, pantries and shelters Counseling services
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In addition, the Outreach Specialist helps members make medical appointments and explains the importance of the medical home model and preventive care. The Outreach Specialist helps members understand how their programs work. Providers can complete and fax an Outreach Request Form (English) to have a assist in facilitating care and services for the member. Local Centers To learn more about CRCs and their capabilities and obtain CRC contact information, contact our Customer Care Center or one of the local area phone numbers below: Fresno Los Angeles Sacramento Stanislaus Tulare 1-559-266-0290 1-818-655-1255 1-916-325-4200 1-209-558-2762 1-800-495-6260
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Services for the Hard of Hearing: Sign language interpreters may be scheduled in
advance for use at key points of medical contact by calling the Customer Care Center. We request 24 business hours to cancel an interpreter service; TTY and California Relay Services are available 24 hours a day, 7 days a week.
Signage: The Plan has multilingual signage available for Providers to post in areas
likely to be seen by members. This signage notifies members of the availability of interpreter services that are provided by the health plan.
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Written or oral assessment of bilingual skills Documentation of the number of years of employment the individual has as an interpreter and/or translator Documentation of successful completion of a specific type of interpreter training programs (i.e., medical, legal, court, semi-technical, etc.). Other reasonable alternative documentation of interpreter capability. For a sample of the Employee Language Skills Self-assessment Tool, go to http://www.iceforhealth.org/library/documents/ICE_Booklet.pdf
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Under Learn More, select State Sponsored Plans to display the State Sponsored
Plans page with Provider Resources
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Scroll down to Forms and Tools and select Forms and Tools Library
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On the Forms and Tools Library page, scroll to Health Education for a list of
available programs
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The above services and provider responsibilities are in compliance with Title VI of the Civil Rights Act of 1964 and California Department of Health Care Services policies for linguistic services Cross-References
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Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
The above information about cultural competency assists Providers in complying with the requirements of Title VI of the Civil Rights Act of 1964 and the California Department of Health Care Services policies for delivery of culturally competent health care. Cross-Reference
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
ACRONYM LIST
Acronym AAP ACOG ADA ADD ADHD AEVS AIM AMA BIC BMI CAHPS CC CCC CCM CCR CCS CDAPP CDC CHDP CIN CM CME CMS CMSP COB CPSP CPT CRC DAW DCN DDS DHCS DHHS DME DMHC DNS DPH DOT DSS EDD EDI Definition American Academy of Pediatrics American College of Obstetricians and Gynecologists American Diabetic Association Attention Deficit Disorder Attention Deficit Hyperactivity Disorder Automatic Eligibility Verification System Access for Infants and Mothers American Medical Association Beneficiary Identification Card Body Mass Index Consumer Assessment of Health Plans Survey Credentials Committee Customer Care Center Certified Case Manager California Code of Regulations California Childrens Services California Diabetes and Pregnancy Program Center for Disease Control Child Health Disability Program Client Index Number Care Manager Continuing Medical Education Centers for Medicare and Medicaid Services County Medical Services Program Coordination of Benefits Comprehensive Perinatal Services Program Current Procedural Terminology Community Resource Coordinator Dispense As Written Document Control Number Department of Developmental Services California Department of Health Care Services Federal Department of Health and Human Services Durable Medical Equipment California Department of Managed Health Care Do Not Substitute Department of Public Health Directly Observed Therapy Department of Social Services Expected Date of Delivery Electronic Data Interchange
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Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
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DEFINITIONS
Abuse Abuse involves provider practices inconsistent with sound fiscal, business or medical practices that result in unnecessary cost to the program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. Abuse includes recipient practices that result in unnecessary cost to the program. Access for Infants and Mothers (AIM) The AIM Program is low-cost health coverage for pregnant women and their newborns. It was designed for middle-income families who dont have health insurance and whose income is too high to qualify for no-cost Medi-Cal. AIM is also available to those who have health insurance if their deductible or copayment for maternity services is more than $500. If a member qualifies for AIM, her baby is automatically eligible for enrollment in the Healthy Families Program. Active Course of Treatment Medical care in which discontinuity could cause a recurrence or worsening of the condition under treatment and interfere with anticipated outcomes. Active courses of treatment prevent this. They typically involve regular visits to the practitioner to monitor the status of an illness or disorder, provide direct treatment, prescribe medication or other treatment, or modify a treatment protocol. An active course of treatment includes prenatal care in the second or third trimester of pregnancy and postpartum care to the sixth week after delivery. Acute Care Hospital An acute care hospital is an institution which provides medical care and treatment of sick or injured persons who cannot be cared for at a lower level of care (such as at a home or skilled nursing facility). Acute Condition An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration.
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Adolescent Confidential Sensitive Services Adolescent confidential sensitive services are those services for which confidentiality is necessary. Often they are related to family planning, sexually transmitted diseases, HIV testing, abortion, pregnancy, sexual assault, drug and alcohol abuse, and mental health services. Advance Directive An advance directive is a legal document (such as health care instruction or power of attorney) used by a person to give his or her doctor instructions regarding his or her own health care if he or she cannot speak for himself or herself. Usually, the Advance Directive instructs physicians or providers to withhold or withdraw life-sustaining treatment in the event of a terminal condition or permanent unconscious condition, when the person would be unable to make his or her wishes known at that time. All health care declarations are unconditionally revocable at any time, effective immediately upon communicating the change to the attending physician or health care provider. Adverse Determination An adverse determination is a denial, modification, reduction or determination by the Plan or PCP of a request for services based on eligibility, benefit coverage or medical necessity. Claims denials are also considered adverse determinations. After-Hours Services After-hours services are those services provided outside the PCPs normal business hours. These include specialists and other ancillary providers. Ambulatory Care Ambulatory care services are those health services that are provided on an outpatient basis, in contrast to services provided while the patient is confined at home or in a hospital. Ancillary Providers Ancillary providers provide ancillary services. These are medically necessary health care services performed in the outpatient or home setting including, but not limited to, ambulance transport, medical treatments or surgeries, home health care, physical, speech or occupational therapy; and medical equipment devices or supplies.
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Anthem Blue Cross State Sponsored Business Anthem Blue Cross serves low-income and medically indigent populations. As part of this, Anthem Blue Cross began providing managed care services to Medicaid members in 1994. Anthem Blue Cross also provides care through other publicly funded programs served by Anthem Blue Cross such as the Healthy Families Program, County Medical Services Program (CMSP), Major Risk Medical Insurance Program (MRMIP), and Access for Infants and Mothers (AIM) Program. Appeal An appeal is a request for review of an adverse determination. Authorization Authorization is the approval needed for members to receive certain types of specialty care and health services. Beneficiary Identification Card (BIC) A Beneficiary Identification Card (BIC) is a permanent plastic card issued by the California Department of Health Care Services (DHCS) to identify a person as an eligible Medi-Cal program recipient. Providers use this card to verify Medi-Cal eligibility. Benefit Agreements Benefit agreements are those such as the Member Services Guide/Evidence of Coverage (EOC), which describe and explain the health care benefits that the Plan provides, indemnifies, or administers for its members. Benefit Year A Benefit Year is the period of 12 months from July 1 to June 30. Benefits Benefits are the health, dental, vision and pharmacy services set forth in the members benefit agreement.
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Binding Arbitration Binding arbitration is a process by which disputes are reviewed by a neutral, non-governmental entity. In binding arbitration, the neutral person makes a decision after reviewing all facts and hearing both sides. Cal/OSHA This is the California Occupational Safety and Health Administration Agency. Cal/OSHAs goal is to prevent workplace injuries and illnesses. It adopts and enforces state and federal standards specific to California workers. California Childrens Services (CCS) California Childrens Services (CCS) is Californias medical program for treating children with certain physically handicapping and chronic conditions. It provides specialized medical care and rehabilitation for children whose families cannot provide all or part of the care. Eligibility factors include:
Under 21 California resident Has a CCS-eligible medical condition Familys adjusted income is $40,000 or less; OR the estimated cost of care to the
family for one year is expected to exceed 20% of the familys adjusted gross income; OR the child is enrolled in the Healthy Families Program Capitation Capitation is the term for paying an organization a set amount of money in advance to provide comprehensive health care benefits for an individual. Cardiopulmonary Resuscitation (CPR) Cardiopulmonary resuscitation (CPR) is the use of artificial respiration and cardiac compressions to restart the heart beating and the lungs breathing for an individual in cardiac or respiratory arrest.
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Care Management Care Management is a collaborative process that assesses, develops, implements, coordinates, monitors and evaluates care plans designed to optimize members health care benefits and promote quality outcomes. It includes arranging, negotiating, and coordinating medically appropriate care in a more economical, cost-effective and coordinated manner during prolonged periods of intensive medical care. Carved-Out Services Carved-out services are those services the Plans Medi-Cal member is entitled to that are covered by the state of California, but are not covered under the Medi-Cal members benefit agreement. Carved-out services include, but are not limited to:
California Childrens Services (CCS) referrals Dental screening and referrals Mental health services Vision services
Categorically Needy Categorically needy refers to those people who receive Medi-Cal and who automatically qualify for one of the major public assistance programs Temporary Assistance for Needy Families (TANF) or Supplemental Security Income/State Supplemental Program (SSI/SSP). In general, categorically needy eligible persons are either single-parent families or those who are aged, blind, or disabled. Center for Disease Control (CDC) The Center for Disease Control is the federal agency responsible for protecting the health and safety of people at home and abroad. The agency establishes and publishes immunization guidelines for children and adolescents through 18 years of age. These guidelines are a requirement for Plan physicians and providers and are adopted by the Plan annually. Center for Medicare and Medicaid Services (CMS) The Center for Medicare and Medicaid Services (CMS) is the federal agency responsible for the Medicaid Health Care Program. CMS was formerly referred to as the Health Care Finance Administration (HCFA).
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Certified Application Assistant A Certified Application Assistant is a person trained to help applicants fill out health plan applications. Child Health and Disability Prevention (CHDP) Child Health and Disability Prevention (CHDP) is a state/federal program designed to help children and young adults stay healthy by providing exams. These exams include a head-to-toe physical, growth and developmental check, vision test, hearing test, teeth and gumcheck, immunizations, TB tests, lead testing, lab tests, nutrition information, and health education. CHDP coverage is free to Medi-Cal recipients from 020 years of age. If a medical problem is discovered, Medi-Cal will pay for treatment. Members may also qualify for the CHDP program if they have a low-to-moderate income and are 118 years of age. Client Index Number (CIN) A Client Index Number (CIN) is a unique number assigned by the state; it serves as an identification (ID) number found on the members Plans ID cards. Clinical Laboratory Improvement Amendments (CLIA) Clinical Laboratory Improvement Amendments (CLIA) are federal laws that establish quality standards for laboratory testing. They ensure the accuracy, reliability and timeliness of all laboratory tests regardless of where the tests are performed. Community Resource Coordinator (CRC) A Community Resource Coordinator (CRC) is a field associate who assists managed care network providers, members and community agencies with ready access to the Plans and local community resources. Many of the staff are bilingual or bicultural; they are well acquainted with the local community resources and are able to assist members with referrals. Comprehensive Perinatal Services Program (CPSP) The Comprehensive Perinatal Services Program (CPSP) is a voluntary program that provides medical services for low-income pregnant women. All Medi-Cal women are eligible. This is a voluntary program.
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Concurrent Review A concurrent review is the assessment of clinical information during the members current inpatient stay or ongoing course of medical service over a period of time. Consumer Assessment of Health Plans Survey (CAHPS) A Consumer Assessment of Health Plans Survey (CAHPS) is a random survey of members which measures satisfaction with the service and care provided by the Plan and the Plans primary care physicians (PCPs) and specialists. Continued Access to Care Continued Access to Care is the process of authorizing continuation of services with a terminating provider under specified conditions and for a limited period of time. It results in a plan of care to transition the member to a network provider. Continuity of Care Continuity of Care is the coordination of health care services encompassing the Plan, PCPs, specialist physicians, ancillary providers, and the member. Coordination of Benefits (COB) Coordinate of Benefits is the method of determining primary responsibility for payment of benefits under the terms of the applicable benefit agreement and applicable laws and regulations when more than one payor may be liable for payment of the benefits received by the member. Coordination of Health Care Services Coordination of Health Care Services is the timely coordinated exchange of patient information between health care providers to ensure delivery of an effective plan of treatment. Copayment A copayment is a payment that a member makes at the time of receiving certain services, such as doctor visits and prescription drugs.
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Corrective Action Plan (CAP) A Correction Action Plan (CAP) is a plan available in the event that issues related to compliance or potential noncompliance issues with the contract are identified. In this event, Anthem Blue Cross will submit a written notice to the provider outlining the deficiency or issue no later than ten calendar days after we become aware of the issue. If a CAP is requested, the provider will submit a CAP to Anthem Blue Cross within five working days of receipt of written notice to do so. Anthem Blue Cross will approve or request modifications to the CAP within 30 calendar days of receiving it. Coverage Coverage is the list of services for which benefits are available subject to deductibles, copayments, or limitations from a health plan. Covered Billed Charges Covered Billed Charges are the charges billed by a hospital at its normal rates for services covered by the Benefit Agreement under which a claim is submitted. Credentialing Credentialing is the process of validating professional or technical competence of providers which involves verifying licensure, board certification, education and identification of malpractice or negligence claims through the applicable state agencies and the National Practitioner Data Base (NPDB) as applicable. Cultural Competence Cultural competence is a set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups. It requires a willingness and ability to draw on community-based values, traditions and customs and to work with knowledgeable persons from the community in developing focused interventions, communications, and other supports. Cultural Diversity Cultural diversity includes differences in race, ethnicity, language, nationality or religion among various groups within a community, organization, or nation. For example, a city is said to be culturally diverse if its residents include members of different groups.
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Cultural Sensitivity Cultural sensitivity is an awareness of the nuances of ones own and other cultures. It is the awareness that differences exist and the intention to reconcile those differences. Culture A culture includes the shared values, norms, traditions, customs, arts, history, folklore and institutions of a group of people. It is a shared set of beliefs, assumptions, values and practices that determine how we interpret and interact with the world. Current Procedural Terminology (CPT) Current Procedural Terminology (CPT) is a listing of descriptive terms and identifying codes used nationwide for reporting medical, surgical and diagnostic services and procedures performed by physicians. The successor to the California Relative Value Studies (CRVS), CPT codes are updated annually in November by the American Medical Association. Customer Care Center (CCC) A Customer Care Center (CCC) is a customer service unit for members and providers. Representatives can answer questions on benefits, PCP assignments, authorizations for care, eligibility, and member information. Day of Service The Day of Service is a measure of time during which a member receives hospital services and which occurs when a member occupies a bed as of midnight or when a member is admitted and discharged within the same day, provided that such admission and discharge are not within 24 hours of a prior discharge. Deferrals Deferrals are actions taken by the Plan to:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Delegation of Credentialing Delegation of Credentialing is the assignment of responsibilities to perform the process of credentialing to another party contracted with the Plan. Denial Denial is a decision by the Plan to deny coverage of a members, members representative, or providers request for health services. Department of Health Care Services (DHCS) The Department of Health Care Services (DHCS) is the State Department responsible for administering the Medi-Cal program, California Childrens Services (CCS) Program, Genetically Handicapped Person Program (GHPP), Child Health and Disability Prevention (CHDP), and other health-related programs. Department of Managed Health Care The Department of Managed Health Care is the state agency that regulates managed health care plans and is responsible for administering the Knox-Keene Health Care Service Plan Act of 1975. Department of Public Health The Department of Public Health is the State Department responsible for the states emergency preparedness and advancing diabetes and obesity prevention, fighting chronic illnesses, and reducing medical errors. It provides access to preventive health care services, including obesity, diabetes and tobacco use and exposure to second-hand smoke, infections and other adverse events that occur in the health care setting. Department of Social Services (DSS) The Department of Social Services (DSS) is the state agency that provides referrals to families in need of medical or monetary assistance. This agency processes applications for Medi-Cal and determines an individuals eligibility in the program. Discharge Planning Discharge planning is the process of assessing the medical and psychosocial needs of members in an inpatient setting and arranging transfers, in-home support, or linkage with community resources in preparing for release from the inpatient setting or a change in the level of care.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Discrimination As used in this context, discrimination means treating a member differently from others in the provision of a health care service or accessibility to a facility on the basis of race, color, creed, religion, ancestry, marital status, sexual orientation, financial status, national origin, age, sex, physical or mental disability, diagnosis or advance directive status. Disenrollment Disenrollment is the process that occurs when a members entitlement to receive services from a health plan is terminated. Each program has its guidelines for processing disenrollments. Only a DHCS Health Care Options Contractor will process Medi-Cal disenrollments. Disproportionate Share Hospitals (DSH) Disproportionate Share Hospitals (DSH) are health facilities licensed pursuant to Chapter 2, Division 2, California Health & Safety Code which provide acute inpatient hospital services eligible to receive payment adjustments from the state pursuant to California Welfare and Institutions Code, Section 14105.98, as amended. Electronic Data Interchange (EDI) Also known as electronic billing, electronic data interchange (EDI) is the computer-to-computer transfer of business-to-business document transactions and information. Eligibility Eligibility is the determination of whether a person is a member of the Plan. Providers can check member eligibility by using ProviderAccess or the IVR, or speaking with a CCC representative. Emergency An emergency is a sudden onset of a medical or psychiatric condition manifesting itself by acute symptoms of sufficient severity (including, without limitation, severe pain or active labor) such that the member (including a pregnant woman regarding herself or her unborn child) may reasonably believe that the absence of immediate medical or psychiatric attention could reasonably result in:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Serious impairment to bodily functions Other serious medical or psychiatric consequences Serious or permanent dysfunction of any bodily organ or part
Emergency Care Emergency Care is the initiation of the emergency response system or the diagnosis or treatment of an emergency. Enrollment Enrollment is the process through which an eligible beneficiary becomes a member of the Plan. Exclusion Exclusion is a service or condition not covered by the Plan pursuant to the members benefit agreement. Expedited Appeal An expedited appeal is a request to review an adverse determination for urgent care which the member or members representative believes may jeopardize the members health, life or ability to regain maximum function if reviewed under timeframes of standard appeals. Explanation of Benefits (EOB) Explanation of Benefits (EOB) is a form sent to the member or provider after a claim for payment has been processed by the Plan that explains the action taken on that claim. The explanation may include the amount paid, the benefits available, and reasons for denying payment. Express Scripts Express Scripts is the pharmacy benefit management company responsible for administering the pharmacy benefits on behalf of the Plan. Express Scripts can answer pharmacy benefit questions, including eligibility, formulary status, PAB requests and benefit exclusions or inclusions.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Family Planning Services Family planning services are services, supplies, or medications provided to members of childbearing age to delay or temporarily or permanently prevent pregnancy. These services are provided through community-based programs, including private, non-profit agencies and county health departments. The following are NOT considered Family Planning services:
Therapeutic abortion services Routine infertility studies or procedures to promote fertility Hysterectomy for sterilization purposes only Transportation, parking or child care
Fee Schedule A fee schedule is a listing of allowed charges or established allowances for specified procedures. It represents a providers or third partys standard or maximum charges accepted or recognized for listed procedures. Fee for Service (FFS) Medi-Cal The Fee for Service (FFS) Medi-Cal Program is the Medi-Cal program that allows the beneficiary to choose any provider that is willing to accept Medi-Cal reimbursement rates. Fraud Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person; fraud includes any act that constitutes fraud under applicable federal or state laws and regulations. Generally Accepted Standards of Medical Practice Generally Accepted Standards of Medical Practice are standards based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of physicians practicing in relevant clinical areas and any other relevant factors.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Geographic Managed Care (GMC) Geographic Managed Care (GMC) is the Medi-Cal managed care program authorized pursuant to California Welfare and Institutions Code, Sections 14089-14089.8, as amended. Grievance A grievance is a written or oral expression of dissatisfaction, including quality of care concerns regarding the Plan, a provider, or a member, which includes a complaint, dispute, request for reconsideration, or appeal made by a member or the members representative. A complaint becomes a grievance if the Plan is unable to determine whether the expression of dissatisfaction is a grievance or an inquiry. Hard-of-Hearing Member Services Hard-of-hearing member services are a system of communication provided by the Plan to facilitate communication between hearing-impaired members and their PCP or the Plan. These services include a sign language interpreter service for medical appointments. If one is not available in the providers office, access is available by calling the Plans Customer Care Center. Health Care Options (HCO) Program Health Care Options (HCO) is the DHCS program contractor which provides health plan enrollment/disenrollment presentations, enrollment and disenrollment activities, and problem-resolution functions. Health Employer Data and Information Set (HEDIS) Health Employer Data and Information Set (HEDIS) are measures that include the review of administrative and chart data to determine how effective we and our physicians/providers are in providing quality care and services to adults, children, pregnant women, and persons with mental health illness. Health Insurance Portability and Accountability Act of 1996 (HIPAA) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is designed to streamline health care delivery by employing standardized, electronic transmission of administrative and financial transactions along with protection of confidential Personal Health Information (PHI).
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Health Plan Members or Members Health plan members/members are eligible adults, adolescents, children and infants actively enrolled with the Plan. Healthy Families Program The Healthy Families Program is a low-cost insurance for children and teens. It provides health, dental and vision coverage to children who do not have insurance and do not qualify for free Medi-Cal. High-Volume Specialists High-volume specialists are physicians, other than PCPs, determined by the Plan to treat a significant number of Plan members (for example, OB/GYN physicians). Hospital Here, a hospital is a health care facility licensed by the state of California and accredited by the Joint Commission on Accreditation of Health Care Organizations as either (a) an acute care hospital; (b) a psychiatric hospital; or (c) a hospital operated primarily for the treatment of alcoholism or substance abuse. Any facility which is primarily a rest home, nursing home, home for the aged, or a distinct part skilled nursing facility portion of a hospital is not included. Hospital Services Hospital services are those acute care inpatient and hospital outpatient services which are covered by the benefit agreement. Hospital services do not include long-term non-acute care. Infection Control Infection control includes the processes used to prevent the spread of disease. Infusion Therapy Infusion therapy is the therapeutic use of drugs or other substances ordered by a physician and prepared, compounded, or administered by a qualified provider and given to the patient any way other than by mouth. It also includes all medically necessary supplies and durable medical equipment used in relation to the infusion therapy in any setting other than an acute inpatient hospital unit. This includes giving the patient medically necessary drugs or other substances intravenously.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Initial Health Assessment (IHA) An Initial Health Assessment (IHA) is a complete medical history, a head-to-toe physical examination, and an assessment of health behaviors. For children up to 20 years of age, a developmental history, assessment of nutritional status, dental evaluation, vision screening, and hearing screening are required in addition to the physical examination. Age-appropriate preventive screening is included for both adults and children. IHAs are to be completed within 120 days of enrollment for adults and children 18 months and older and within 60 days for children fewer than 18 months old. Inpatient Inpatient is the category of hospitalization in a medical or psychiatric hospital to which a patient is admitted for treatment requiring at least one overnight stay. Institutionalized Institutionalized refers to the situation in which a patient has been admitted to a correctional or rehabilitative facility involuntarily or voluntarily for the treatment of mental illness; the patient is confined or detained, under a civil or criminal statute, in this facility, which may include a mental hospital or other facility for the care and treatment of mental illness. Intermediate Rehabilitation Facility An intermediate rehabilitation facility is an institution providing an active dynamic program aimed at enabling an ill or disabled person to achieve the highest level of physical, mental, social and economic self sufficiency of which he or she is capable. Internal Quality Improvement Projects Internal Quality Improvement Projects are focused studies that measure the quality of care and service in specified clinical and service areas. The Plan is required to demonstrate statistically significant improvement for all measures. Interpreter Services Interpreter services are language services that are provided to non-English speaking members to ensure clear communication between the member and physician or health plan.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Language Assistance Program (LAP) A Language Assistance Program (LAP) is a program that complies with the requirements and standards established by Section 1367.04 of Senate Bill 853 (Language Assistance Act). Any Language Assistance Program shall be documented in written policies and procedures and shall address, at a minimum, for enrollee assessment, providing language assistance services, staff training, and compliance monitoring. Limited English Proficient (LEP) Limited English Proficient refers to the limited ability of a Plan member to speak, read, write or understand the English language at a level that permits the member to interact effectively with a health care provider or Plan employees. Licensed Clinical Social Worker (LCSW) A Licensed Clinical Social Worker (LCSW) is a mental health professional licensed by the state of California who is trained to help individuals, groups, families and organizations deal with emotional problems and assist in resolving conflicts or problems relating to others at home, at work, in school, and in society in general. Major Risk Medical Insurance Program (MRMIP) A Major Risk Medical Insurance Program (MRMIP) is a 36-month program developed to provide health insurance for Californians who are unable to obtain coverage in the individual insurance market. Managed Care Network A Managed Care Network is the network of health care providers who have entered into contracts with the Plan or one or more of its affiliates. These providers have agreed to participate in the Plan programs and provider services pursuant to the members benefit agreements. Managed Care Managed Care is an integrated clinical and administrative approach that coordinates health care services. Managed care emphasizes preventive services and the use of a PCP.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Managed Risk Medical Insurance Board (MRMIB) The Managed Risk Medical Insurance Board (MRMIB) is the state agency that administers the Healthy Families, MRMIP, and AIM programs. Medical Information Medical information is individually identifiable information in electronic or physical form, in possession of or derived from, a provider of health care. It includes a members medical history, mental or physical condition, or treatment. Medi-Cal Managed Care Program (MCMCP) The Medi-Cal Managed Care Program (MCMCP) is a direct care prepayment plan offered by the Plan to eligible Medi-Cal beneficiaries. Medical Office Equipment Requiring Calibration or Safety Checks Medical Office Equipment Requiring Calibration or Safety Checks is equipment in a provider office in which the manufacturer, state or federal agency recommends or requires routine evaluation of the functioning or readings and settings. Medical Record Review Medical Record Review is a process used to assess provider documentation of a members physical and psychosocial assessments and the medical services rendered. Medical Review A Medical Review if the process involving provider audits by which claims or procedures are evaluated for medical necessity. Medical Services Medical services are those services provided by a participating provider and covered by a members benefit agreement. Medically Indigent The medically indigent are those persons who are not in families with dependent children and who are not aged, blind or disabled, but who otherwise qualify for aid.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Medically Necessary or Medical Necessity Medically Necessary or Medical Necessity refers to how patients are treated within the various programs according to their medical status. Details of each programs treatment protocol are shown below. Medi-Cal For Medi-Cal, this refers to the reasonable and necessary services to protect life, to prevent significant illness of significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury. AIM / Healthy Families Program For AIM/Healthy Families, this refers to those health care services or products that are:
Furnished in accordance with professionally recognized standards of practice Determined by the treating doctor to be consistent with the medical condition Furnished at the most appropriate type, supply and level of service that considers
the risks, benefits and alternative treatments MRMIP For MRMIP, this refers to the procedures, supplies, equipment, or services determined to be:
Appropriate for the symptoms, diagnosis or treatment of a medical condition Provided for the diagnosis or direct care and treatment of the medical condition Within the standards of good medical practice within the organized medical
community
Not primarily for the convenience of the patients physician or other provider The most appropriate procedure, supply, equipment, or service that can be safely
provided
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Medically Needy Medically Needy is a category of public assistance. The Medically Needy are families of people who are aged, blind or disabled and whose income is too high to qualify for Temporary Assistance for Needy Families (TANF) or Supplemental Security Income/State Supplemental Program SSI/SSP. Member Complaint A member complaint is an oral or written expression of dissatisfaction that is not related to a denial of service submitted by a member or an authorized representative. Member complaints are generally resolved at the point-of-contact or when the member declines to initiate a formal investigation. Member Grievance A member grievance is a written or oral expression of dissatisfaction, including quality of care concerns regarding the Plan, a provider or member, and which includes a complaint, dispute, request for reconsideration or appeal made by a member or the members representative. If the Plan is unable to determine whether the expression of dissatisfaction is a grievance or an inquiry, it considers the complaint to be a grievance. Member Identification Card A paper member identification card provided to members by the Plan which includes the member number, provider information, and important phone numbers. Member Marketing Member marketing is any activity conducted on behalf of a health plan where information regarding the services offered by the health plan is disseminated to persuade eligible beneficiaries to enroll with that plan. Members Member are eligible Beneficiaries, either as defined in the contract between the Plan and the Department of Health Care Services, who have enrolled in the Medi-Cal Managed Care Program or as defined in the contract between the Plan and the MRMIB, who are enrolled in AIM, Healthy Families, or MRMIP programs.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Memorandum of Understanding (MOU) A Memorandum of Understanding (MOU) is a legal document that outlines the structural elements of required activities, cites the set standards, delineates operational responsibilities, establishes performance measures, specifies reporting requirements, and describes the formal evaluation processes and the consequences of non-compliance. Mental Health Services Mental health services are psychoanalysis, psychotherapy, counseling, medical management or other services most commonly provided by a psychiatrist, psychologist, licensed clinical social worker, or marriage and family therapist for diagnosis or treatment of mental or emotional disorders or the mental or emotional problems associated with an illness, injury, or any other condition. Mid-Level Practitioners Mid-level practitioners are advanced registered nurse practitioners (including certified nurse midwives), and physician assistants licensed by the state and working under the supervision of a licensed physician as mandated by state and federal regulations. National Committee for Quality Assurance (NCQA) The National Committee for Quality Assurance (NCQA) is an independent, non-profit organization whose mission is to improve the health care quality of the nations managed care plans through their accreditation and performance measurement programs. This is accomplished through quality oversight and improvement initiatives at all levels of the health care system. Nonformulary Drug A nonformulary drug is a drug that is not listed on the Plans Formulary and requires an authorization from the Plan or its designee in order to be covered. Occupational Safety and Health Administration (OSHA) The Occupational Safety and Health Administration (OSHA) is a federal agency which is responsible for enforcing safety and health legislation. Ombudsman An ombudsman is a Medi-Cal member advocate provided by the state of California to act as a liaison between the member and the healthcare Plan.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP Version: 1.4 Revision Date: February 2010 Chapter 22: Page 25
Outpatient Outpatient is the category of treatment in which medical services are provided at a free-standing facility, provider office, or at hospital site where a member receives care and is discharged the same day. Participating Hospital A participating hospital is one that has agreed with the Plan to be a participating provider in providing hospital services. Participating Physician A participating physician is one who has entered into an agreement with the Plan to provide medical services as a participating provider and who is a licensee as that term is defined in California Business and Professions Code Section 2041, as amended. Participating Provider A participating provider is a hospital, other health facility, physician or other health professional who has entered into an agreement with the Plan to provide hospital or medical services to members. Per Diem Per diem is a measure of fixed payment for a day of service. Pharmacy Benefit Pharmacy benefit includes the outpatient drugs obtainable through a retail or mail order pharmacy. Post-service Request A post-service request is a request for a service or procedure after the service or procedure has taken place. Preservice Request A preservice request is a request for a service or procedure in advance of the date the requested service or procedure is to occur.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Preventive Health Care Preventive health care includes the health screenings, immunizations, and programs that help members prevent the development of certain diseases. Primary Care Physician or Primary Care Provider (PCP) A Primary Care Physician or Provider (PCP) is a pediatrician, general practitioner, family practitioner, internist, or sometimes an obstetrician/gynecologist or other provider who has contracted with the Plan to provide primary care services to members and to refer, authorize, supervise and coordinate the provision of benefits to members in accordance with the members benefit agreement. Primary Care Site A primary care site is the PCPs office or facility where primary care services are provided. Prior Authorization of Benefits (PAB) Prior authorization of benefits (PAB) is a written request for authorization of medications by the prescribing provider. Product Consultants Product consultants are those Community Resource Coordinators who conduct provider training in provider offices or hospital settings. Provider Grievance A provider grievance is a written request for a formal investigation into an issue or concern unrelated to a denial of service (or denial of an authorization request). A provider grievance may involve clinical quality or administrative issues. Examples of possible issues for review as provider grievances are:
Clinical Quality Issues: Any actual, possible, or potential adverse outcome in the
members health status which result from a Plan providers care or possible inappropriateness of a Plan providers behavior
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Provider Operations Manual (POM) This State Sponsored Business Provider Operations Manual (POM) is a comprehensive document designed to inform managed care network providers of the Plans guidelines and requirements. The POM offers tools and information to assist providers in caring for our members. Provider Satisfaction Survey A Provider Satisfaction Survey is a series of questions asked of the provider to measure satisfaction with the Plans services. Prudent Layperson A Prudent Layperson is a person who possesses an average knowledge of health and medicine. Qualifying Condition A Qualifying Condition is a medical condition that qualifies for continued access to care. It includes, but is not limited to:
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Quality Specialists Quality specialists are CRC registered nurses who perform participating provider site reviews and medical record reviews and trains office staff on quality management techniques. Quantity Supply Limit Quantity Supply Limit refers to the maximum quantity dispensed per prescription. If the quantity prescribed exceeds the quantity limit, the balance of the prescription can be obtained as a refill once 75 percent of the medication has been used. Receipt of Request Receipt of Request refers to the date the Plan receives an appeal or grievance from a member or provider. Recredentialing Recredentialing is the process that takes place every three years in which Anthem Blue Cross considers renewing provider participation in the Plans managed care network. Each provider is reviewed again at that time to determine eligibility for continued participation. Retrospective Review A retrospective review is a review of clinical information after the requested service has been rendered. It is conducted for the purpose of determining member satisfaction with the service provided. Safety Net Providers Safety Net Providers are those providers of comprehensive primary care or acute hospital inpatient services who, in providing these services, include a significant total number of Medi-Cal and charity or medically indigent patients relative to the total number of patients the provider serves. Examples of Safety Net Providers are governmentally operated health systems, community health centers, rural facilities, the DHCS, and public, university, rural and childrens hospitals. Self-Referral Self-referral means that a member may refer himself or herself for special services that do not require preservice review by the Plan or the PCP.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Sensitive Services Sensitive services are those which include medical care for adolescents who are between the ages of 12 and 18 and which do not require parental consent in California for:
Pregnancy Family Planning Sexual Assault Sexually Transmitted Diseases (STD) Drug and Alcohol Abuse Outpatient mental health services for sexual or physical abuse or harmful behavior
to themselves or others Serious Chronic Condition A Serious Chronic Condition is a medical condition that has occurred due to a disease, illness, or other medical problem or medical disorder that is serious in nature; if it persists without full cure or worsens over an extended period of time, it may require ongoing treatment to maintain remission or prevent deterioration. Service Area A service area is the area in which a provider serves Plan members. For PCPs who see members who are enrolled with Anthem Blue Cross outside of Los Angeles County, a members service area is the geographical area within 30 minutes travel time or 10 miles of where the member lives or works. For PCPs who see members who are enrolled inside Los Angeles County, a member is assigned preferentially to a PCP within a five-mile radius of his or her residence. If there is not an available PCP located within five miles of a member, the member is assigned to a PCP within a ten-mile radius or to the next closest available PCP. An eligible member or beneficiary may voluntarily choose to receive services from a PCP or plan service site with a travel time or distance that exceeds the requirements identified above. We strive to ensure theres at least one hospital in our contracted network within 15 miles or 30 minutes travel time of where the member lives or works.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Skilled Nursing Facility (SNF) A Skilled Nursing Facility (SNF) is a facility licensed by the California Department of Health Care Services as a skilled nursing facility to provide a level of non-acute inpatient nursing care. Specialist Physician A Specialist Physician is a Plan physician who provides services to a member within the range of his or her designated specialty area of practice. Specialist physicians treat Plan members to supplement the care given by PCPs, who refer them. State Fair Hearing A State Fair Hearing is an administrative hearing offered by the California Department of Health Care Services for Medi-Cal beneficiaries to resolve issues regarding the provision of Medi-Cal benefits. All Medi-Cal members have the right to request a state fair hearing before, during, or after initiating the Plans member grievance process. Staying Healthy Assessment Tool (SHAT) The Staying Health Assessment Tool (SHAT) is a short questionnaire designed by the California DHCS and managed care plans in California which is used to assist the PCPs to identify and track Medi-Cal members health risks and behaviors and provide targeted health education interventions, referral, and follow-up. The SHAT is a set of five age-specific questionnaires that address 11 different patient behavioral risk factors, such as alcohol use, smoking and nutrition. Sterilization Sterilization is any medical treatment, procedure, or operation performed on a person (male or female) that permanently prevents, or is intended to permanently prevent, the person from being able to reproduce permanently.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Temporary Assistance to Needy Families (TANF) Temporary Assistance to Needy Families (TANF) is the federally funded program that provides assistance and work opportunities to needy families by granting states the federal funds and wide flexibility to develop and implement their own welfare programs. The federal program replaces the Aid to Families with Dependent Children (AFDC) and the Job Opportunities and Basic Skills (JOBs) training programs. The California welfare program is called the California Work Opportunities and Responsibility to Kids program (CalWORKS). The Plan The Plan is the shorthand name for Anthem Blue Cross Partnership Plan, Inc. and Anthem Blue Cross. Anthem Blue Cross Partnership Plan, Inc. and Anthem Blue Cross are referred to jointly in this manual as the Plan. The California Department of Health Care Services contracts with Anthem Blue Cross for the provision of Medi-Cal in certain counties in California. Anthem Blue Cross provides coverage pursuant to the Managed Risk Medical Insurance Board for the Healthy Families Program, the Major Risk Medical Insurance Program (MRMIP), and the Access for Infants and Mothers (AIM) Program in the state of California. Threshold Languages Threshold Languages are those languages which are required to be translated as determined by DHCS based on member populations meeting a numeric threshold of 3,000 members residing in its service area. These languages may also be required to be translated if the member concentration meets the standards of 1,000 members in a single ZIP code or 1,500 members in two contiguous ZIP codes. Universal Precautions Universal Precautions, or the process of universal blood and body precautions, was developed by the Centers for Disease Control (CDC) to address concerns regarding transmission of Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), Hepatitis C and other blood-borne diseases. The concept assumes all patients under treatment are potentially infectious for these and all blood-borne diseases. Urgent Care Urgent Care includes the types of services and treatments needed without delay to prevent serious deterioration of a members health resulting from unforeseen illness or injury.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Urgent Examination An urgent examination is one that is performed by a physician for a member with a non-life-threatening condition that could lead to a potentially harmful outcome if not treated within 24 hours. Utilization Management (UM) Utilization Management (UM) is the process of ascertaining that health care services are medically necessary, provided in the appropriate setting, and provided by the appropriate provider. It encompasses reviewing utilization patterns to identify members for disease state-management programs, provider referral patterns for underutilization or overutilization, and hospital or emergency room access for referrals to case management. Utilization Review Utilization Review is a function performed by an organization or entity acting as an agent of the Plan and selected by the Plan to review and determine whether health care services provided or proposed are medically necessary. Women, Infants and Children (WIC) Program Women, Infants and Children (WIC) Program is a supplemental food and nutrition program for low-income, pregnant, breast feeding and postpartum women and children under age five who are at nutritional risk. WIC provides nutrition education, breastfeeding promotion, medical care referrals and specific supplemental nutritious foods that are high in protein or iron. Some of the specific nutritious foods provided to participants include peanut butter, beans, milk, cheese, eggs, iron-fortified cereal, iron-fortified infant formula and juices. Working Day A working day is any day of the typical work week, Monday through Friday. Legal holidays are excluded.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
MAPS
Maps can be found on the following pages.
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
California Healthy Families Program ServiceAND Counties CHAPTER 22: ACRONYMS, DEFINITIONS MAPS Provider Operations Manual 07/01/09 - 06/30/10
HM O C ounty
Kern Los Angeles Orange Riverside San Bernardino San Diego Santa Clara
Trinity Humboldt
Shasta Lassen
EP O County
Alpine Amador Butte Calaveras Colusa Del Norte El Dorado Glenn Humboldt Imperial Inyo Kings Lake Lassen Madera Marin Mariposa Mendocino Merced Modoc Mono Napa Nevada Placer Plumas San Benito San Joaquin San Luis Obispo Santa Cruz Shasta Sierra Siskiyou Sonoma Sutter Tehama Trinity Tulare Tuolumne Ventura Yuba
Tehama
Plumas
Mendocino
Glenn
Butte
Sierra Nevada
Lake
Colusa
Yuba
Placer
Sonoma Napa
Yolo
No n- Anthem C o unty
Solano Marin San Francisco San Mateo Santa Cruz Contra Costa Alameda Santa Clara San Joaquin
Stanislaus Merced
Monterey
Kern
50
100 Miles
Santa Barbara Ventura
San Bernardino
Los Angeles
Orange
Riverside
San Diego
by Miguel Grajeda Plan Anthem Blue Cross and Anthem BluePrepared Cross Partnership C:\Map Requests\Healthy Families\ Medi-Cal / Healthy Families Program042009 / AIM / Service MRMIP HF Counties\ 042009_hf_service_counties.mxd April 20, 2009
Imperial
Anthem Blue Cross CHAPTER ACRONYMS, DEFINITIONS AND MAPS Med 22: i-Cal Serv ice Co unties January 2009 Provider Operations Manual
Del Norte Siskiyou Modoc
CALIFORNIA
Two-Plan Model
Commercial
Humboldt
Trinity
Shasta Lassen
Local Initiative
Glenn
State Facts
Population: 36,553,215 Counties: 58
Alpine
El Dorado Amador
Napa
Solano Marin San Francisco San Mateo Santa Cruz Calaveras Contra Costa Alameda Santa Clara San Joaquin Stanislaus Tuolumne Mono Mariposa
Monterey
Kings
Kern
50 Miles
100
Santa Barbara Ventura
San Bernardino
Los Angeles
Orange
Riverside
San Diego
Imperial
Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP
Version: 1.4 Prepared by Miguel Grajeda C:\Map2010 Requests\California Medicaid\ Revision Date: February 011409 ABC Medi-Cal Counties\ 011409_abc_MediCal_counties.mxd Chapter 22: Page 36 January 14, 2009
Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc. Independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. WellPoint NextRx, NextRx and PrecisionRx are registered trademarks of WellPoint, Inc. and are used under license by Express Scripts, Inc. 24/7 NurseLine is administered by Health Management Corporation, a separate company. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS is a registered trademark of the Agency for Healthcare Research and Quality. 2010 WellPoint, Inc. 0409 CA0014967 2/12