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Provider Operations Manual for these programs:

Medi-Cal Managed Care, Healthy Families Program, Access for Infants and Mothers, and Major Risk Medical Insurance Program

Anthem Blue Cross


Effective December 2006
Version 1.5 Updated February 2012

Provider Operations Manual

Chapter 1: Introduction Proprietary Information . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Using This Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Manual Updates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Secure eMail. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

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

The Healthy Families Program . . . . . . . . . . . . . . . . . . . . . 2


For Children Who Dont Qualify for Medi-Cal. . . . . . . . . . . . . . . 2 Who Is Eligible? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Program Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Access for Infants and Mothers . . . . . . . . . . . . . . . . . . . . . 3


AIM: Who Is Eligible? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Want to Know More About AIM?. . . . . . . . . . . . . . . . . . . . . . . . . 4 Cross-Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Major Risk Medical Insurance Programs . . . . . . . . . . . . . 4


Insuring the Uninsurable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

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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

California Childrens Services . . . . . . . . . . . . . . . . . . . . . . 6


General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Sample Services and Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Program Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 CCS Medical Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Medical Eligibility for Specific Conditions. . . . . . . . . . . . . . . . . . 12 Referral Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CCS Referral Procedures/Care Management . . . . . . . . . . . . . . . 15 Provider Paneling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

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

County and State-Linked Services . . . . . . . . . . . . . . . . . . 40


Sample of Available State Services and Programs . . . . . . . . . . . . 41 Directly Observed Therapy (DOT) for Tuberculosis . . . . . . . . . 49 Early Start Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Reportable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Waiver Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Referrals to Maternal, Child and Adolescent Health Program . . 56 Cross-Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

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 4: Member Eligibility Eligibility Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Confirm Member Identity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Ask to See Identification (ID) Cards . . . . . . . . . . . . . . . . . . . . . . . 1 Medi-Cal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Verify Member Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Medi-Cal Sample Member ID Cards . . . . . . . . . . . . . . . . . . . . . . . 4 Healthy Families Program, AIM and MRMIP Member ID Cards 5

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

Claims Processing and Payment . . . . . . . . . . . . . . . . . . . .12


Claims Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Claim Return for Additional Information . . . . . . . . . . . . . . . . . . 13 Claim Filing with Another Payor . . . . . . . . . . . . . . . . . . . . . . . . . 13 Claims Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Claims Overpayment Recovery Procedure . . . . . . . . . . . . . . . . . 14

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Claim Status Inquiry and Follow Up . . . . . . . . . . . . . . . . 14


Checking Claim Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Claim Follow-Up/Resubmission . . . . . . . . . . . . . . . . . . . . . . . . . 15 Reviewing Batch Status Reports . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Questions about Claim Status and Follow-Up . . . . . . . . . . . . . . 16

Claim Returned for Information . . . . . . . . . . . . . . . . . . . 16


Time Frame for Returning Requested Information . . . . . . . . . . 16 How to Submit Requested Additional Information . . . . . . . . . . 16 Common Reasons for Rejected and Returned Claims . . . . . . . . 17 Time frame for Filing a Dispute . . . . . . . . . . . . . . . . . . . . . . . . . . 20 How to File a Dispute. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Provider Dispute Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Plan Response to Provider Dispute Resolution (PDR) Request 20 Cross-Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

CMS-1500 Claim Form . . . . . . . . . . . . . . . . . . . . . . . . . . . 21


Who Should Use a CMS-1500 Claim Form? . . . . . . . . . . . . . . . . 21 Completing a CMS-1500 Claim Form . . . . . . . . . . . . . . . . . . . . . 21 CodingProfessional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Medi-Cal Local Codes and Modifiers. . . . . . . . . . . . . . . . . . . . . . 22 Sample Section from the CMS-1500 (08-05) Claim Form . . . . . 24 CMS-1500 (08-05) Claim Form Fields . . . . . . . . . . . . . . . . . . . . . 25

CMS-1450 (UB-04) Claim Form . . . . . . . . . . . . . . . . . . . . 27


Who Should Use the CMS-1450 Claim Form? . . . . . . . . . . . . . . 27 Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Medi-Cal Local Codes and Modifiers. . . . . . . . . . . . . . . . . . . . . . 27 Inpatient CodingInstitutional . . . . . . . . . . . . . . . . . . . . . . . . . . 28
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Outpatient CodingInstitutional . . . . . . . . . . . . . . . . . . . . . . . . 28 Sample Section from the CMS-1450 Form with Instructions . . 30 Recommended Fields for CMS-1450 . . . . . . . . . . . . . . . . . . . . . . 31

Professional Billing Requirements by Service Category. 34


California Childrens Services (CCS) . . . . . . . . . . . . . . . . . . . . . . 34 Child Health and Disability Prevention Program Services . . . . . 35 Medi-Cal, CHDP and Healthy Families Program Lab and Immunizations Comparison Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 School-Based Clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 History and Physical Examinations . . . . . . . . . . . . . . . . . . . . . . . 39 Vaccines for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Immunizations and Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Child Health and Disability Prevention Program . . . . . . . . . . . . 44 Comprehensive Perinatal Services Program . . . . . . . . . . . . . . . . 46 Maternity Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Maternity Procedure Codes for Medi-Cal Providers . . . . . . . . . . 47 Delivery Procedure Codes For All Providers . . . . . . . . . . . . . . . 49 Procedure CodesCPSP Certified Medi-Cal Managed Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Sterilization Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Durable Medical Equipment (DME) . . . . . . . . . . . . . . . . . . . . . . 51 Emergency Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Initial Health Assessments (IHA). . . . . . . . . . . . . . . . . . . . . . . . . 52 Adult Preventive Care Procedure Codes . . . . . . . . . . . . . . . . . . . 53 Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Newborns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
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Self-Referable Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Sensitive Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Additional Billing Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Hospital and Institutional Billing Requirements by Service Category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65


Maternity and Boarder Baby Care . . . . . . . . . . . . . . . . . . . . . . . . 65 Inpatient Acute Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Inpatient Sub-Acute Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Emergency Visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Urgent Care Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Outpatient Laboratory, Radiology and Diagnostic Services . . . . 71 Outpatient Surgical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Outpatient Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Outpatient Infusion Therapy Visit and Pharmaceuticals . . . . . . 73 Other Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Ancillary Billing Requirements by Service Category . . . 77


Laboratory and Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . 77 Disposable and Incontinence Medical Supplies. . . . . . . . . . . . . . 79 Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Other Service Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Additional Billing Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Capitated Group Claims Processing and Encounter Data Submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91


Encounter Data Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

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TelemedicineMedi-Cal and Healthy Families Program Members Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94


Additional Code Tables:Medi-Cal & Healthy Families Program. . 94 CPT Codes for Evaluation and Management . . . . . . . . . . . . . . . 95

Chapter 6: Utilization Management Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Role of Utilization Management. . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Decision-Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

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

Self-Referral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Second Opinions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Additional Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11


California Childrens Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

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Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Chapter 7: Care Management Care Management Overview . . . . . . . . . . . . . . . . . . . . . . . 1


Referral Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Provider Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Members Eligible for Specialized Services . . . . . . . . . . . . . . . . . . . 2 Additional Potential Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Role of the Case Manager . . . . . . . . . . . . . . . . . . . . . . . . . 3


Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Accessing Specialists: Access to Care Unit . . . . . . . . . . . . . . . . . . 3 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Chapter 8: Provider Grievances and Appeals Provider Grievances and Appeals . . . . . . . . . . . . . . . . . . . 1


How Providers File a Grievance or Appeal . . . . . . . . . . . . . . . . . . 1 When to File a Grievance or Appeal . . . . . . . . . . . . . . . . . . . . . . . 1 Receipt and Acknowledgement of a Grievance or Appeal . . . . . . 2 Requesting More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Grievance & Appeal Investigation Responsibilities . . . . . . . . . . . 2 When to Expect Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Provider Dissatisfaction with Resolution. . . . . . . . . . . . . . . . . . . . 3 Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

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Chapter 9: Member Grievances and Appeals Member Grievances and Appeals . . . . . . . . . . . . . . . . . . . 1


How Members File a Grievance or Appeal . . . . . . . . . . . . . . . . . 1 When to File a Grievance or Appeal . . . . . . . . . . . . . . . . . . . . . . . 2 Who Can File the Grievance or Appeal . . . . . . . . . . . . . . . . . . . . 2 Receipt & Acknowledgement of Standard Grievance or Appeal . 2 Receipt & Acknowledgement of Expedited Grievance or Appeal 3 Requesting More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Grievance & Appeal Investigation Responsibilities . . . . . . . . . . . 4 When to Expect Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Member Dissatisfaction Resolution . . . . . . . . . . . . . . . . . . . . . . . . 5 Independent Medical Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Confidentiality and Discrimination . . . . . . . . . . . . . . . . . . . . . . . . 7 Grievances and Complaints of Discrimination . . . . . . . . . . . . . . . 7 Medi-Cal Members Continuing Benefits During an Appeal or State Fair Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

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

Chapter 11: Provider Roles and Responsibilities


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Primary Care Physicians Scope of Responsibilities . . . . . 1


Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Initial Health Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Transitioning Members Between Facilities or to Home . . . . . . . . 3 Comprehensive Perinatal Services Program for Medi-Cal (PCPs and OB/GYNs only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Hospital Scope of Responsibilities . . . . . . . . . . . . . . . . . . 6


Notification of Admission and Services. . . . . . . . . . . . . . . . . . . . . 6

Ancillary Scope of Responsibilities . . . . . . . . . . . . . . . . . . 7 Responsibilities Applicable to All Providers . . . . . . . . . . . 8


Eligibility Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Preservice Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Interpreter Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Communication for Continuity of Care . . . . . . . . . . . . . . . . . . . . . 9 Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Obtaining Signed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Medical Records Documentation & Access to Medical Records 10 Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Mandatory Reporting of Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Notifying the Plan of Changes . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Members Rights and Responsibilities . . . . . . . . . . . . . . . . . . . . . 11 Oversight of Non-Physician Practitioners . . . . . . . . . . . . . . . . . . 12 Office Hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Licenses and Certifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Prohibited Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

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Open Clinical Dialogue/Affirmative Statement . . . . . . . . . . . . . 13 Provider Terminations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Provider Terminations from Groups . . . . . . . . . . . . . . . . . . . . . . 13 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Financial Requirements for Participating Medical Groups . . 15


State Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Financial Performance Standards . . . . . . . . . . . . . . . . . . . . . . . . . 16 Financial Audit Requirements Access to Financial Data . . . . . 17 Solvency Grading Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Claims Timeliness Regulation and Reporting Requirements . . . 19

Chapter 12: Enrollment and Marketing Rules Physician Marketing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 How Prospective Members Find Out About Us. . . . . . . . . . . . . . 3

Program Enrollment Process . . . . . . . . . . . . . . . . . . . . . . . 3


Medi-Cal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Healthy Families Program, AIM, and MRMIP . . . . . . . . . . . . . . . 4

Chapter 13: Access Standards & Access to Care Appointment Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Initial Health Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Medical Appointment Standards (All Counties Except Los Angeles) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Medical Appointment Standards (Los Angeles County Only) . . . 2 Missed Appointment Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Med-Cal Beneficiary Health Care Rights . . . . . . . . . . . . . . . . . . . . 4

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Continued Access to Care/Continuity of Care . . . . . . . . . 5


New Enrollees & Members Transitioning to Another Health Plan 6 Physician Contract Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Continuity of Care Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Emergency Department Protocol Reporting Process . . . . . . . . . . 7

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

Staying Healthy Assessment Tool . . . . . . . . . . . . . . . . . . . 3


New Medi-Cal Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Existing Medi-Cal Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 PCP Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Emergency Room Program Initiative . . . . . . . . . . . . . . . . 5 Nurse Information Line . . . . . . . . . . . . . . . . . . . . . . . . . . . 6


How the Nurse Information Line Assists Members . . . . . . . . . . . 6 How 24/7 NurseLine Assists Providers . . . . . . . . . . . . . . . . . . . . 6 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Health Education Classes and Materials . . . . . . . . . . . . . 6


No-Cost Classes Available to Members . . . . . . . . . . . . . . . . . . . . . 6
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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

Preventive Care Programs . . . . . . . . . . . . . . . . . . . . . . . . . 9


Immunization Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Well Woman Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Health Education Programs . . . . . . . . . . . . . . . . . . . . . . 10


Childhood Obesity Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Childhood Obesity Physician Tool Kit . . . . . . . . . . . . . . . . . . . . 10 Body Mass Index (BMI) Training and Promotion Program . . . . 11 Kids in Charge of Kalories (KICK) . . . . . . . . . . . . . . . . . . . . . . . 11 Tobacco Cessation Program: The Last Cigarette . . . . . . . . . . . . 12

Health Management Programs . . . . . . . . . . . . . . . . . . . . 13


Healthy Habits Count with Asthma Program . . . . . . . . . . . . . . . 13 Healthy Habits Count with Diabetes Program . . . . . . . . . . . . . . 14 Healthy Habits Count for Your Heart Program . . . . . . . . . . . . . 14 Healthy Habits Count for You and Your Baby Program . . . . . . 15 Breastfeeding Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Comprehensive Perinatal Services Program . . . . . . . . . . . . . . . . 18

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

Medical Record and Facility Site Reviews . . . . . . . . . . . . 3


Facility Site Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Medical Office Policies and Procedures. . . . . . . . . . . . . . . . . . . . . 6

Medical Record Documentation Standards . . . . . . . . . . . 6


Medical Record Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Chapter 18: Member Transfers & Disenrollment Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Member-Initiated Primary Care Physician Transfers . . . . . . . . . . 1 PCP-Initiated Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

Member Transfers and Disenrollment from the Plan . . . . 7


Member-Initiated Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 7 PCP-Initiated Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

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Chapter 19: Credentialing and Recredentialing Credentialing Policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Appeals for HDOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Chapter 20: Fraud and Abuse Fraud and Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Understanding Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Combating fraud, abuse, and waste begins with knowledge and awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Examples of Provider Fraud or Abuse . . . . . . . . . . . . . . . . . . . . . 1 Examples of Member Fraud and Abuse . . . . . . . . . . . . . . . . . . . . 1 Reporting Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Role of the Fraud and Abuse Department . . . . . . . . . . . . . . . . . . 2 False Claims Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Chapter 21: Provider Resources ProviderAccess Website . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Log in to ProviderAccess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Service Hours for Transactions (Pacific Standard Time) . . . . . . . 3 Community Resource Coordinator Staff . . . . . . . . . . . . . . . . . . . 5 Outreach for Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Local Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Services All Services are Available through the Health Plan . . . 8 Provider Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Resources Available on Our Website . . . . . . . . . . . . . . . . . . . . . . . 9 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Cultural Competency and Health and Reading Literacy 14

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Low Literacy and Its Impact on the Health Professional . . . . . . 14 Cross-Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter 22: Acronyms, Definitions and Maps Acronym List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Maps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

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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:

Shaded Blue Box

Link to other section or website Important Information to Remember

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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.

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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.

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PRIVACY AND SECURITY STATEMENT


Anthem Blue Cross latest Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant privacy and security statements can be found on our website at www.anthem.com/ca. Secure eMail We use the Secure eMail encryption tool to ensure that your clients Protected Health Information (PHI) is kept private and secure. Were doing this because we know that many people are concerned about identify theft. Secure eMail encrypts e-mails and attachments identified as potentially having PHI. Heres how it works:

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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Provider Operations Manual

CONTACT INFORMATION BY INQUIRY TYPE


We offer the following contact information for Anthem Blue Cross by Inquiry Type: Member Eligibility, Verifying PCP, Provider Questions and Interpreter Services
Resource Web Portal Phone Number/Website Hours of Availability

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

AIM and MRMIP Customer 1-877-687-0549 Care Center

TDD 24/7 NurseLine Automatic Eligibility Verification System (AEVS)

TDD: 1-888-757-6034 1-800-224-0336 1-800-456-2387

See above. 24 hours a day, 7 days a week. 24 hours a day, 7 days a week.

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Care Management Referrals


Resource Care Management Department Phone Number/Website 1-805-384-3629 Fax: 1-866-333-4827 Hours of Availability Monday to Friday: 8 a.m. to 5 p.m. 24 hours a day, 7 days a week (Response within 3 business days).

Claims Payment Issues


Resource Web portal Phone Number/Website Hours of Availability

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

See CCC for Member eligibility.

Fraud and Abuse


Resource Phone Number/Website Hours of Availability Monday to Friday: 8 a.m. to 5 p.m.

Fraud and Abuse Department See CCC phone numbers above. Fax: 1-805-384-3102

Grievance and Appeals


Resource Grievance and Appeals Department Phone Number/Website Fax: 1-866-387-2968 Hours of Availability 24 hours a day, 7 days a week.

Hearing Impaired Services


Resource California Relay Service Phone Number/Website 1-800-735-2929 Hours of Availability 24 hours a day, 7 days a week.

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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

http://www.dhcs.ca.gov/s N/A ervices/ccs/Pages/default .aspx

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.

Utilization Management / Prior Authorization


Resource Utilization Management Department Phone Number/Website Medi-Cal, Healthy Families Program: 1-888-831-2246 Fax: 1-800-754-4708 AIM and MRMIP: 1-877-687-0549 Hours of Availability Monday to Friday: 8 a.m. to 5 p.m.

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MEDI-CAL CALIFORNIAS MEDICAID PROGRAM


What Is Medi-Cal? Anthem Blue Cross provides Medi-Cal services for the California Department of Health Care Services and the Department of Public Health in Alameda/Contra Costa, Fresno, Los Angeles (as a Plan partner with L.A. Care Health Plan), Sacramento, San Francisco, San Joaquin, Santa Clara, Stanislaus and Tulare Counties. We enhance access, emphasize prevention, improve quality of care, educate members and providers and provide first-class customer service. Medi-Cal (Californias Medicaid Program) Medi-Cal:

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.

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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

THE HEALTHY FAMILIES PROGRAM


For Children Who Dont Qualify for Medi-Cal The Healthy Families Program focuses on children without access to standard health care systems. This program:

Provides low-cost health insurance for eligible children of low-income families


with incomes too high to qualify for Medi-Cal.

Has no deductibles. Requires small copayments for specific services.


Who Is Eligible? To qualify for the Healthy Families Program, applicants must be:

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

ACCESS FOR INFANTS AND MOTHERS


The state of California created the Access for Infants and Mothers (AIM) Program for middle-income families who dont have health insurance or whose income is too high to qualify for no-cost Medi-Cal. AIM is also available to those with health insurance if their deductible or copayment for maternity services is more than $500. For eligible women, AIM:

As of the effective date in the AIM Program, coverage includes comprehensive


health care services, hospital delivery and 60 days postpartum care.

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

AIM HMO and EPO Benefits Summary


MAJOR RISK MEDICAL INSURANCE PROGRAMS
Insuring the Uninsurable For Californians with extensive health care needs but no employer-sponsored or private health insurance, Californias Major Risk Medical Insurance Program (MRMIP) can help. What Is MRMIP? Californias Major Risk Medical Insurance Program:

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.

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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

Ineligible to purchase health insurance for continuation of coverage through


COBRA or CalCOBRA

Unable to secure adequate health insurance coverage


There are three ways to document the inability to secure adequate insurance coverage within the past 12 months. Along with the completed application, an applicant must submit one of the following letters/copies of letters:

From a health insurance carrier, health plan or health maintenance organization: a


denial of individual coverage within the past 12 months (Note: An insurance denial notification received through the Internet that does not provide the reason for denial and the applicants name will not be accepted).

From a health insurance carrier, health plan, health maintenance organization or


employer: an involuntary termination of coverage for reasons other than nonpayment of premium or fraud within the past 12 months.

From a health insurance carrier, health plan or health maintenance organization:


an offer within the past 12 months of individual coverage for subscriber or dependents at a premium rate higher than the MRMIP rate.

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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

MRMIP Benefits Summary


CALIFORNIA CHILDRENS SERVICES
General Information The California Childrens Services (CCS) program is a state and county-funded program that serves children under the age of 21 who have acute and chronic conditions such as cancer, congenital anomalies and other serious medical conditions that benefit from specialty medical care and case management. State statutes and contracts require that CCS program services be carved out of Anthem Blue Cross Medi-Cal and Healthy Families Programs. As a result, upon identification of a CCS-eligible condition, providers must refer a child to the local CCS program or contact us to assist with the referral to CCS.

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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.

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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.

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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.

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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.

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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.

Congenital Heart Disease: If a heart murmur is detected on a routine physical


exam, refer the child after the primary care provider (PCP) confirms the murmur requires ongoing medical management.

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.

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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.

Lead Poisoning: A single blood level of 20 ug/dl or greater than if symptomatic.


Otherwise, two blood levels of 20 ug/dl or one of 45 ug/dl or greater than, even if asymptomatic.

Malocclusion: Refer clients with a craniofacial anomaly to a paneled Craniofacial


Center for orthodontic treatment.

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
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Services requested (include current procedural terminology [CPT] or healthcare


common procedure coding system [HCPCS] codes as appropriate) CCS also requires medical records that support the CCS-eligible diagnosis; if a Plan representative is assisting you in completing a referral to CCS, we may request medical records from your office to facilitate this process. For CCS Referral Forms when making a referral to CCS, go online to the following website for established client or new client referrals: http://www.dhcs.ca.gov/formsandpubs/Pages/default.aspx Emergency Referrals For an emergent hospital admission or treatment, notify CCS within one business day. Follow-up urgent and emergency referrals with all relevant medical reports to determine CCS medical eligibility. Notify us immediately for assistance in making an urgent or emergency referral to CCS. Outpatient Services CCS requires preauthorization for elective procedures and treatment. CCS requires information regarding the planned procedure or treatment. We can assist you in making a request or referral to CCS for outpatient services. Inpatient Referrals For elective hospital admissions, submit written requests to CCS before the scheduled date of admission. Include the following information with the referral/request for service:

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.

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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.

Through intake requests for preauthorization, the Customer Care Center or


Utilization Management identifies members who have a CCS-eligible condition.

Utilization Management uses CCS eligibility criteria to determine if a referral to


CCS is needed and also advises the provider to refer to CCS if appropriate.

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

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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

Healthy Families Program:

$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

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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

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Benzodiazepines Prescription vitamins and minerals.

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.

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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:

Insulin products Certain narrow therapeutic index medications:


Coradarone, Pacerone Tegretol, Tegretol XR, Carbatrol

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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:

Weight-loss medications, unless medically necessary, which require providers to


submit PAB

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)

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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

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Topical antibiotics Topical anti-parasites Vaginal anti-fungal preparations


For our Healthy Families Program, MRMIP and AIM members, the pharmacy benefit does not include OTC coverage except for items used in the treatment and monitoring of diabetes. For the most current list of OTC medications covered, go to www.anthem.com/ca>Learn More>Pharmacy. Injectables We cover self-injectable medications under the pharmacy benefit. Some self-injectable medications may require a PAB submission from the prescribing provider. Office-based injectables, including vaccines, are covered under the medical benefit. Carve-Outs for Medi-Cal Members Only For our Medi-Cal members only, select drugs and drug classes are carved out of the pharmacy benefit and reimbursed by Fee For Service (FFS) Medi-Cal. The Department of Health Care Services (DHCS) carve-outs for HIV, anti-psychotic medications, erectile dysfunction and heroin detox apply specifically to Medi-Cal and are reimbursable through Electronic Data Systems (EDS). Other therapeutic classes might be eligible for coverage under California Childrens Services (CCS) for Medi-Cal and Healthy Families Program. For CCS carve-outs, refer to the California Childrens Services section in this chapter for more information. Medical Devices The pharmacy benefit for our members provides coverage for diabetic supplies, spacers and peak flow meters. All other medical devices, such as nebulizers or insulin pumps, are covered under the medical benefit. Phenylketonuria (PKU) Enteral supplements are not a pharmacy-covered benefit with the exception of enteral supplements for PKU. Obtain all other supplements through the medical benefit when medically necessary.

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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

Pharmacy Contacts Prior Authorization of Benefits PAB Guidelines


Prior Authorization of Benefits Refer to the www.anthem.com/ca site for detailed information about Prior Authorization of Benefits, using these steps to access the site.

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.

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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

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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

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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

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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

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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)

COX-II Selective NSAIDs (such as Celebrex): Prescriptions for Celebrex require


an internal review by Express Scripts on behalf of the Plan to determine eligibility or medical necessity.

Nonselective NSAIDs (such as Mobic): Mobic requires an internal review by


Express Scripts on behalf of the Plan to determine medical necessity.

Nonselective NSAIDs (such as Arthrotec): Coverage for Arthrotec requires an


internal review by Express Scripts on behalf of the Plan to determine medical necessity. For a PAB Form for Celebrex, go online to http://pd.web.bluecrossca.com/wpf/forms/BCC%20Celebrex%20PAB%20% 20Form%2010_7_05.pdf For a PAB Form for Mobic, go online to http://pd.web.bluecrossca.com/wpf/forms/cox2mobic.pdf For a PAB Form for Arthrotec, go online to http://pd.web.bluecrossca.com/wpf/forms/pageneric.pdf Hepatitis C Agents (Pegasys, PEG-Intron, Rebetron, Copegus, Rebetol, Ribavirin) 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 Hepatitis C Agents, go online to http://pd.web.bluecrossca.com/wpf/forms/hepatitisc.pdf

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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

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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

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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

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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

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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:

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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

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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.

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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

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MENTAL HEALTH SERVICES


Non-Emergency Mental Health Services PCPs shall treat members with situational mental health, the most common of which are depression and anxiety disorders. For members whose mental health does not respond to treatment in a primary care setting, call the following numbers for referral and authorization information regarding assessment and ongoing services:

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:

Psychoses, involutional, depressive Schizophrenia Multiple diagnosis

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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

Symptoms require brief, specific, goal-oriented medical/psychological treatment


in an outpatient setting.

Symptoms are expected to be reduced by office-based group or individual


treatment, 13 times a week.

Member needs periodic monitoring for medication management to prevent


relapse. Day Treatment

Goals require intensive, formal program with a minimum three hours per day and
at least three days per week.

Members condition cannot be stabilized and symptoms reduced on a weekly


outpatient professional visit schedule.

Day treatment can reasonably be expected to abort an acute episode or reduce the
chances for relapse.

Member requires periodic monitoring or medication management to prevent acute


relapse. Residential Treatment

Specified treatment goals can most efficiently be achieved in a 24-hour program


with daily management and organized treatment.

Symptoms cannot be stabilized nor controlled on an outpatient basis.


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24-hour care is required to prevent acute episode or reduce chance of relapse.


Acute Inpatient

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.

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Referrals to Psychologist or Licensed Clinical Social Worker (LCSW)

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

Benefits Matrixes Utilization Management


COUNTY AND STATE-LINKED SERVICES
To ensure continuity and coordination of care for members, we enter into agreements with locally based public health programs. Providers are responsible for notifying the Care Management Department when a referral is made to one of the agencies listed below.

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Care Management Contact Numbers: Telephone: Fax: 1-805-384-3629 1-805-333-4827

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

Also see Waiver Programs: Early Start Program

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Provider Operations Manual Service or Program Description Services Provided Upon Referral A full range of health assessment services Referrals for diagnosis and treatment of suspected problems Coordination of care to assist families with medical appointment scheduling, transportation and access to diagnostic and treatment services Periodic health services to non-Medi-Cal eligible children and youth (from birth to 19 years of age) Health assessments for children enrolled in Head Start and State Preschool

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:

California Med-Cal recipients from birth to 21 years

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Provider Operations Manual Service or Program Local Mental Health Plans Description County mental health service system to provide community-based, integrated mental health services. Website: Department of Mental Health www.dmh.ca.gov Services Provided Upon Referral

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

Family Planning Services

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

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Provider Operations Manual Service or Program Confidential HIV Counseling and Testing Description A program that integrates prevention counseling with HIV testing. Website: Department of Health Care Services www.dhs.ca.gov/AIDS Services Provided Upon Referral

Confidential HIV testing, counseling Early intervention services HIV/AIDS resources

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

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Provider Operations Manual Service or Program Directly Observed Therapy (DOT) for Treatment of Tuberculosis Description Services Provided Upon Referral

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:

Those at risk for noncompliance with medical treatment for tuberculosis

Also, see Directly Observed Therapy (DOT) for Tuberculosis in this section.

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Provider Operations Manual Service or Program Women, Infants and Children Program (WIC) Description Services Provided Upon Referral

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.

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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

Service or Program Population-Based Prevention Program Refugee Health Services

Services Provided Upon Referral Community-based prevention programs For arriving refugees: medical screening and initial medical treatment until enrolled in a health plan

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Provider Operations Manual Service or Program Sexually Transmitted Disease (STD) Services Childhood Lead Screening Local Maternal, Child and Adolescent Health (MCAH) Programs Services Provided Upon Referral Local clinics provide STD screening, counseling, diagnosis and treatment services Local programs provide educational programs

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

Genetic Testing and Counseling

School-Based Clinic (SBC) Agreements

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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:

Have significant developmental delays in one or more of these areas:


Cognitive development Physical and motor development, including vision and hearing Emotional-social development Adaptive development (for example, feeding difficulties)

Have established risk conditions of known etiology or those conditions are


expected to result in significant developmental problems

Are at high risk of having a substantial developmental disability due to a


combination of risk factors

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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

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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

Recording referrals to the Early Start Program in member record files.


We are a resource for parents with questions regarding services for disabled children and the Early Start Program. If you have any direct questions, call the Customer Care Center or your local Community Resource Coordinators. Reportable Diseases By state mandate, physicians and providers must report communicable diseases and conditions to local health departments. Our physicians and providers are to comply with all state laws in the reporting of communicable diseases and conditions. Timely reporting is vital to minimize the incidence and prevalence of communicable diseases. Click Title 17, California Code of Regulations Reportable Diseases.

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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.

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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:

IHSS/chore IHSS/personal care IHSS/health care IHSS/protective supervision

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:

Case management Attendant care Homemaker services In-home skilled nursing

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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

Regional offices for the In-Home Operations Unit include:

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.

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To ensure continuity of care, the Waiver Program staff arranges home-based


assistance for the member.

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.

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Referral procedures include:

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.

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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.

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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:

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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

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(Provided only for services that are medically necessary)

Services

Diagnostic, X-Ray and Laboratory Service1 Durable Medical Equipment1

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.

Emergency Health Care Services1 Family Planning Services Health Education

Hearing Aids and Services Home Health Care Services Hospice

Hospital Services (Inpatient) Hospital Services (Outpatient) Maternity Care Mental Health Services (Inpatient)

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Provider Operations Manual Healthy Families Program HMO Benefits
(Provided only for services that are medically necessary)

Services

Mental Health Services (Outpatient)

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

Professional Services Reconstructive Surgery1

Skilled Nursing Care

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Provider Operations Manual Healthy Families Program HMO Benefits
(Provided only for services that are medically necessary)

Services

California Childrens Services (CCS)

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

Deductibles Lifetime Maximums


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.

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.

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Provider Operations Manual Healthy Families Program EPO Benefits
(Provided only for services that are medically necessary)

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

Diagnostic, X-Ray and Laboratory Service1 Durable Medical Equipment1

Emergency Health Care Services1 Family Planning Services Health Education

Hearing Aids and Services Home Health Care Services

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Provider Operations Manual Healthy Families Program EPO Benefits
(Provided only for services that are medically necessary)

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)

Mental Health Services (Outpatient)

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.

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Provider Operations Manual Healthy Families Program EPO Benefits
(Provided only for services that are medically necessary)

Services

Preventive Health Service

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;

Professional Services Reconstructive Surgery1

Skilled Nursing Care California Childrens Services (CCS)

Deductibles Lifetime Maximums

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.

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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

Home Health Care Hospice Hospital Services (Inpatient)

Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP

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Provider Operations Manual AIM HMO and EPO Benefits Hospital Services (Outpatient) Services All outpatient services except emergency services require prior authorization

Use of emergency room All other services

Mental Health Services (Inpatient) Mental Health Services (Outpatient)

Limited to 30 days per benefit year (except SMI and SED conditions) Limited to 20 visits per benefit year (except SMI and SED conditions)

Mental health care Biofeedback

Orthotics and Prosthetics Physical, Occupational and Speech Therapy Requires prior authorization and periodic evaluations as long as therapy is provided

Inpatient and skilled nursing facility All other places of service

Pregnancy and Maternity Care Prescriptions

Prescription drugs Maintenance drugs Prescription contraceptive drugs/devices

Limited to 30-day supply Limited to 90-day supply

Preventive Care

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Provider Operations Manual AIM HMO and EPO Benefits Professional Services Services

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

Reconstructive Surgery Skilled Nursing Facilities Transplants Urgent Care

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

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Provider Operations Manual MRMIP Benefits Emergency Health Care Services1 Explanation

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

Skilled nursing care Explanation

$500 annual deductible per household effective January 1, 2009

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

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Provider Operations Manual MRMIP Benefits Lifetime Benefit Maximum Explanation Members must pay for all services received after the combined total of all benefits paid under the MRMIP reaches $750,000 in members lifetime

1. Refer to the Evidence of Coverage booklet for exact terms and conditions of coverage.

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Provider Operations Manual

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

Allergy Testing Antigen Ambulance Services

Air ambulance Dry runs Ground ambulance Nonemergent transport (from home to doctors office, dialysis, physical therapy)

Amniocentesis Anesthetics (administration of) Artificial insemination

Yes Yes Not Covered

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Provider Operations Manual Medi-Cal Managed Care Benefits/Services Audiology services Coverage 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. Not Covered Yes Yes Preauthorization required (CCS if <21 years of age) Yes Carved out to mental health Yes, with a case required for listing drug dosage and duration (CCS if <21 years of age) GMC Yes (preauthorization required) Mainstream and Los Angeles Carved out 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. Not covered (unless medically necessary)

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

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Provider Operations Manual Medi-Cal Managed Care Benefits/Services Colostomy Supplies Coverage Yes Yes Yes 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, if within 6 months of injury (limited pre-op) Yes Carved out to mental health Yes (CCS if <21 years of age) Yes (preauthorization for selected CT/MRI/PET) Yes (CCS if <21 years of age) Carved out GMC and Mainstream Yes (preauthorization required for specific equipment) Los Angeles Yes, if preauthorized Yes Yes Yes

Inpatient facility component Outpatient dispensing In conjunction with home health

Dental Services

(Accidental) injury inpatient facility component Professional component (anesthesia)

Detoxification (acute phase) Diabetic Services Diagnostic X-Ray and Lab Dialysis Directly Observed Therapy (DOT) Durable Medical Equipment

Emergency Room (in and out of area)

Outpatient Professional

Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP

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Provider Operations Manual Medi-Cal Managed Care Benefits/Services Endoscopic Studies Experimental Procedures Family Planning Services/Supplies Fetal Monitoring Genetic Testing Health Education Health Evaluations/Physicals Hearing Aids Hearing Screens Hemodialysis Chronic Renal Failures Hepatitis B Vaccine/Gamma Globulin Home Health (including meds) Hospice Hospital Base Physicians (in lieu of acute inpatient or SNF) Hospitalization Yes Not covered Yes Yes Yes if positive, carved out to genetic disease branch of DHCS Yes Yes except when requested by school, job, camp or sports program Yes, (CCS if <21 years of age, medically necessary and preauthorized) Yes (CCS if <21 years of age) Yes (CCS if <21 years of age) Yes Yes (preauthorization required) Yes (preauthorization required) Yes Coverage

Inpatient Outpatient Intensive Care Services Supplies and Testing

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

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Provider Operations Manual Medi-Cal Managed Care Benefits/Services Immunization Administration Coverage Subject to vaccines for children (VFC) Yes 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 (preauthorization required) Not covered Yes Carved-out mental health Yes Yes Yes, if preauthorized (CCS if <21 years of age) Carved out (CCS if <21 years of age) Yes Yes Yes

Immunization Vaccine (pediatrics) Immunization Vaccine (adults)

Incontinence creams and washes

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

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Provider Operations Manual Medi-Cal Managed Care Benefits/Services Mental Health Coverage Carved out Carved out

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

Nutritionist/Dietician Obstetrical/Gynecological Services

Yes (preauthorization required)

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

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CHAPTER 3: COVERED AND NONCOVERED SERVICES


Provider Operations Manual Medi-Cal Managed Care Benefits/Services Physical, Occupational and Speech Therapy Coverage

Inpatient or SNF Outpatient Professional

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.

Physician Office Visits Podiatry Services

Preadmission Testing Prosthetics and Orthotics (including artificial limbs and eye) Psychology services

Yes Yes, if preauthorized (CCS if <21 years of age)

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

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Provider Operations Manual Medi-Cal Managed Care Benefits/Services Radiology Services Coverage Yes Yes (preauthorization required for specific procedures) Yes Yes (preauthorization required) Yes (preauthorization required) Yes (except when required by job, school, camp or sports program) Yes (preauthorization required every 60 days) Yes 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 Yes (preauthorization required) Yes Yes Yes VSP VSP

Inpatient facility component Outpatient facility component Professional component

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

When medically necessary Frames Lenses

Anthem Blue Cross and Anthem Blue Cross Partnership Plan Medi-Cal / Healthy Families Program / AIM / MRMIP

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Provider Operations Manual Medi-Cal Managed Care Benefits/Services Vision Screening (refraction) VSP Coverage

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Provider Operations Manual

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).

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Provider Operations Manual

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.

Use the Automatic Eligibility Verification System (AEVS) at 1-800-456-2387.


Healthy Families Program Providers can verify Healthy Families Program 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.

Call our IVR automated telephone response system at 1-800-845-3604 to verify


member eligibility 24 hours a day, 7 days a week; you may also request a facsimile verification.

Call the Healthy Families Program eligibility line at 1-888-439-4741 Monday to


Friday, 8 a.m. to 8 p.m. and Saturday, 8 a.m. to 5 p.m.

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Provider Operations Manual

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.

Call our IVR automated telephone response system at 1-800-289-6574 to verify


member eligibility 24 hours a day, 7 days a week; you may also request a facsimile verification Cross-References

Provider Roles and Responsibilities Claims and Billing Guidelines Important Contact Information

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Provider Operations Manual

MEMBER IDENTIFICATION CARDS


Medi-Cal Sample Member ID Cards Following enrollment in our Medi-Cal Program, the member receives two cards that he or she must present at each visit to a provider:

Member ID Card Beneficiary Identification Card (BIC)


Paper Member Identification Card Our member ID card contains member information (Member Name, ID Number, Group Number, member effective date and plan codes), primary care physician (PCP) assignment, PCP address, PCP Number, Customer Service Number, 24/7 NurseLine number, Vision Plan Number, and Dental Plan Number. It also contains provider emergency service notification instructions and hospital inpatient admission instructions. Los Angeles County members will have a different card than non-Los Angeles County members.

Medi-Cal L.A. Care Card (Los Angeles County members)

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CHAPTER 4: MEMBER ELIGIBILITY


Provider Operations Manual

Medi-Cal Card (Remaining California Counties - NOT Los Angeles County)

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).

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Provider Operations Manual

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

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.

Prescription drug questions: 1-800-700-2533 Mental health referrals: 1-800-399-2421

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association.

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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.

Prescription drug questions: 1-800-700-2533 Mental health referrals: 1-800-399-2421

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association.

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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)

Pharmacy Information Claims Billing Address

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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

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INTRODUCTION AND GENERAL CLAIMS GUIDELINES


IMPORTANT EPO providers who serve State Sponsored Business EPO members in the Healthy Families Program and AIM and MRMIP Programs should refer to the Anthem Blue Cross commercial POM for claims and billing guidelines. We need your help to achieve our goal of rapid and efficient claims payment. Follow these guidelines to help the process go smoothly. The following claims and billing guidelines pertain to claims processed pursuant to an Anthem Blue Cross State Sponsored Business Participating Provider Agreement. Share this section with your staff, and, if applicable, with your billing service agent and electronic data processing service agent. It is important that everyone involved understand the guidelines for preparing and submitting claims for services to Plan members. The Importance of a Correct Clean Claim Submit claims with all fields completed as outlined in this chapter and in accordance with HIPAA requirements. Claims submitted as outlined in this chapter are called clean. This section assists you in understanding how to submit a claim to us correctly the first time, which may help avoid delays in processing.

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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.

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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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Other Filing Limits


Action Description Third Party Liability If the claim has COB or TPL and (TPL) or Coordination requires submission to a third of Benefits (COB) party before submitting to us, the filing limit starts from the date on the notice or remittance advice (RA) from the third party. Checking Claim Status Claim status may be checked any time on ProviderAccess, the provider home page or by calling the Customer Care Center IVR System. Claim Follow-Up To submit a corrected claim Form or Mailback following the Plans request for Form more information or correction to claim or to follow up a claim that has not been paid, denied or contested. Provider Dispute Providers may request a claim reconsideration in writing with a Provider Dispute Resolution Request Form Plan Response to The Plans response time to Provider Dispute investigate and make a Resolution Request determination based on guidelines Time Limit to File From the date of notice or RA from the third party, follow the applicable claims filing time limits set forth above.

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:

Electronic Data Interchange (EDI) Paper or hard copy


Electronic Claims Submit claims electronically through a Plan-approved electronic billing system software vendor or clearing-house. Completion of electronic claim submission requirements can speed claim processing and prevent delays. If you use EDI, you must include:

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:

Monitor claim status on ProviderAccess or through interactive voice response


(IVR). 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.

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.

A front-end edit process may occur at your contracted vendor or clearing-house


that can result in a vendor/clearing-house error report. In addition, there is a final edit process at the Plan.

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:

A simplified billing process since it is no longer necessary to maintain and use


legacy identifiers for each plan

The ease of administering changes for addresses and locations


Providers have only one number for electronically transacting business with any health plan with which they affiliate. How to Apply for Your NPI Providers may apply for an NPI online at the National Plan and Provider Enumeration System (NPPES) website at https://nppes.cms.hhs.gov or by obtaining a paper application by calling the NPPES at 1-800-465-3203. The Centers for Medicare and Medicaid Services (CMS) developed regulations for a batch enumeration called Electronic File Interchange, or EFI. The EFI process is available to large provider groups such as hospitals and provider practice groups. For more information on EFI, go to https://nppes.cms.hhs.gov. Although a provider may not be currently billing to Medi-Cal or other publicly funded programs, a participating provider must still apply for an NPI with CMS. According to the NPI Final Rule, we can require the NPI on paper claims for our participating providers. Entity Type 1 and Entity Type 2 Providers A health care provider who is an individual human being can apply for an Entity Type 1 NPI. This includes, but is not limited to, physicians, dentists and chiropractors. Organizations, such as hospitals, can apply for an Entity Type 2 NPI. The definition of an organization includes, but is not limited to, hospitals, residential treatment centers, laboratories and group practices.

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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.

Information is typed within the designated area of the field:

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 involving pre-certification/prior authorization/pre-determination (or


some other form of utilization review) including, but not limited to:

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 we have reason to believe involve inappropriate (including fraudulent)


billing

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

Other situations in which clinical information might routinely be requested:

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:

Third party remittance advice (RA)

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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.

CLAIM STATUS INQUIRY AND FOLLOW UP


Checking Claim Status Providers should receive a response from us within 30 business days of 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.

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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

A copy of the original/corrected CMS-1500 or CMS-1450 Claim Form.

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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.

Authorization Number Missing/Doesnt Match Services

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.

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 17

CHAPTER 5: CLAIMS AND BILLING GUIDELINES


Provider Operations Manual Problem Missed Filing Limit Explanation Resolution The time frame for submitting a claim Be sure to submit the claim for reimbursement is determined by the within: applicable Anthem Blue Cross State 180 days from date of Sponsored Business Participating service for professionals Provider Agreement and the type of (CMS-1500 Form) services provided (professional, ancillary or institutional). 180 days from date of service for institutions (CMS-1450 Form) For participating physicians who provide professional services to EPO members enrolled in the Healthy Families Program and AIM or MRMIP Programs; file a claim within 12 months from the date of service. Current HCPCS and CPT Manuals must Make sure all services are coded be used because changes are made to the with the correct codes (see lists codes quarterly or annually. Manuals provided). Check the code may be purchased at any technical book books or ask someone in your store or call the American Medical office familiar with coding. Association or the Practice Management Information Corporation to order manuals. Some procedures or services do not have We need a description of the a code associated with them, so an procedure and medical records unlisted procedure code is used. when appropriate in order to calculate reimbursement. For DME, prosthetic devices, hearing aids, or blood products, we require a manufacturers invoice. For drugs/injections we require the NDC number.

Missing Codes for Required Service Categories

Unlisted Code for Service

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 18

CHAPTER 5: CLAIMS AND BILLING GUIDELINES


Provider Operations Manual Problem By Report Code for Service Resolution We need a description of the procedure and medical records when appropriate to calculate reimbursement. For DME, prosthetic devices, hearing aids or blood products, we require a manufacturers invoice. For drugs/injections, we require the NDC number. Unreasonable Unreasonable numbers, such as 9999 Be sure to check your claim for Numbers Submitted may appear in the Service Units fields. accuracy before submitting it for processing. Submitting Batches of Stapling claims together can make the Make sure each individual claim Claims subsequent claims appear to be is clearly identified and not attachments rather than individual stapled to another claim. claims. Incorrect Return of When we request additional information, Be sure to attach records or Requested we iclde a Mailback Form is in the corrected claim to the original Information request. Mailback Form. Do not reattach a new claim copy. Send each Mailback Form in a separate envelope to be sure each is identified as an individual response. Nursing Care Nursing charges are included in the Do not submit bills for nursing hospital and outpatient care charges. charges. Nursing charges that are billed separately are considered unbundled charges and are not payable. In additional, we will not pay claims using different room rates for the same type of room to adjust for nursing care. Hospital Medicare ID A Medicare ID number is required to On the CMS-1450 Form, Missing process. Hospitals claim at their hospitals must enter their appropriate contracted rates. Medicare ID number in Box 64. Explanation Some procedures or services information is missing.

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 19

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Provider Operations Manual

PROVIDER DISPUTE RESOLUTION


If a provider does not agree with the outcome of a claim decision, the provider can file a Provider Dispute Resolution (PDR) request with us. Time frame for Filing a Dispute The request for dispute resolution must be submitted in writing to our dispute address within 365 days from the date of the providers receipt of our RA. (The provider receives an RA with every claim, whether paid or denied.) How to File a Dispute Include information that may affect the outcome of the dispute, including:

A completed Provider Dispute Resolution Request Form with all points of


contention itemized and explained. You can find the form on the www.anthem.com/ca website under Forms and Tools.

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.

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 20

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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

Provider Grievances and Appeals


CMS-1500 CLAIM FORM
Who Should Use a CMS-1500 Claim Form? All professional providers and vendors should bill us using the most current version of the CMS-1500 Form. Refer to the Sample Section from the CMS-1500 (08-05) Claim Form section for a sample. Completing a CMS-1500 Claim Form Complete all the fields for reimbursement. Refer to the CMS-1500 (08-05) Claim Form Fields section for complete instructions. CodingProfessional To be sure that claims are processed in an orderly and consistent manner, standardized code sets must be used. The Healthcare Common Procedure Coding System (HCPCS) provides codes for billing for a variety of services. These codes are sometimes called National Codes. HCPCS consists of two principal subsystems, referred to as Level 1 and Level 2 of the HCPCS.

Level 1 consists of Current Procedural Terminology (CPT) codes maintained by


the American Medical Association (AMA). CPT codes are represented by five numeric digits.

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.

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 21

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Provider Operations Manual

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:

Current Procedural Terminology Codes (CPT): Refer to the current edition of


the Physicians CPT manual, published by the American Medical Association; to order, call 1-800-621-8335.

Healthcare Common Procedure Coding System (HCPCS): Refer to the


current edition of HCPCS published by the Centers for Medicare and Medicaid Services (CMS); to order, call 1-800-633-7467.

International Classification of Diseases, 9th Revision (ICD-9 Procedure


Codes): Practice Management Information Corporation. Applicable ICD-9 procedure codes must be in Boxes 8081 of the CMS-1450 Form when the claim indicates a procedure was performed; to order, call 1-800-633-7467.

UB-04Manual, Uniform Billing Procedures, published by the California


Healthcare Association; to order, call 1-800-494-2001.

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.

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 22

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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:

Physician Assistants Nurse Practitioners Certified Nurse Midwives


Refer to the CMS-1500 (08-05) Claim Form Fields section for sample field descriptions for the CMS-1500 (08/05) Claim Form or visit the Centers for Medicare and Medicaid Services website at www.cms.hhs.gov/forms.

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 23

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Provider Operations Manual

Sample Section from the CMS-1500 (08-05) Claim Form


HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA 1. MEDICARE (Medicare #) MEDICAID (Medicaid #) TRICARE (Sponsors SSN) CHAMPUS CHAMPVA (Member ID#) GROUP (SSN or ID) HEALTH PLAN YY FECA (SSN) BLK LUNG OTHER 1a. INSUREDS I.D. NUMBER (ID) PICA

12-digit Medicaid number

(For Program in Item 1)

Members complete name


2. PATIENTS NAME (Last Name, First Name, Middle Initial) 5. PATIENTS ADDRESS (No., Street)

MM DD Date of birth

Members sex M F
SEX Other

Members complete address


4. 7. INSUREDS ADDRESS (No., Street)

INSUREDS NAME (Last Name, First N ame, Middle Initial)

3. PATIENTS BIRTH DATE

Members street address City ( IN


TELEPHONE (Include Area Code) STATE

6. PATIENT RELATIONSHIP TO INSURED Spouse Child Self

Self or Child
Married Full-Time Student

Same is acceptable if the member is the patient


STATE

CITY

8. PATIENT STATUS Single Other

CITY

ZIP CODE

Members Zip Code

Members phone number )

ZIP CODE Employed Part-Time Student

TELEPHONE (Include Area Code)

(
a. INSUREDS DATE OF BIRTH MM DD YY M b. EMPLOYERS NAME OR SCHOOL NAME

)
SEX F

9. OTHER INSUREDS NAME (Last Name, First Name, Middle Initial)

10. IS PATIENTS CONDITION RELATED TO:

11. INSUREDS POLICY GROUP OR FECA NUMBER

a. OTHER INSUREDS POLICY OR GROUP NUMBER

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

c. INSURANCE PLAN NAME OR PROGRAM NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. RESERVED FOR LOCAL USE

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.

Members signature or Signature on ON FILE SIGNATURE


ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP)

Date
MM

File

DATE GIVE FIRST DATE DD YY

SIGNED

Members signature or Signature on S IGNATURE ON FILE

File

14. DATE OF CURRENT: MM DD YY

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

Date of first consultation


PI

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

Referring provider

17a. 17b. N

Referring providers license number

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? YES NO $ CHARGES

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 1.

Primary diagnosis

3.

Additional diagnosis (3rd) Additional diagnosis (4th)


E. DIAGNOSIS POINTER

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER

MM

DATE(S) OF SERVICE From To DD YY MM DD

YY

B. C. PLACE OF SERVICE EMG

D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER

F. $ CHARGES

G.
DAYS OR UNITS

EPSDT ID. Family Plan QUAL.

H.

I.

J. RENDERING PROVIDER ID. #

From date(s) of service

To date(s) of service Place of service

Procedure code(s)

Modifier code(s)

Diagnosis cross reference 14

Line total

Units of occurrence

PI N

NPI

Rendering providers Medicaid number

NPI

NPI

NPI

NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT? ( )
For govt. claims, see back

28. TOTAL CHARGE $

29. AMOUNT PAID

30. BALANCE DUE

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

Signature of provider certifying the claim DATE Date SIGNED

Location where services were actually rendered


a.

Providers$name, complete address, and $ INFO number & PH # 33. BILLING P ROVIDER ( ) telephone Medicaid provider number
a.

NPI

b.

NPI

b.

NUCC Instruction Manual available at: www.nucc.org

OMB APPROVAL PENDING

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 24

PHYSICIAN OR SUPPLIER INFORMATION

2. 24. A.

Secondary diagnosis

4.

Authorization information

PATIENT AND INSURED INFORMATION

CARRIER

1500

TEST VERSION NOT FOR OFFICIAL USE

CHAPTER 5: CLAIMS AND BILLING GUIDELINES


Provider Operations Manual

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

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 25

CHAPTER 5: CLAIMS AND BILLING GUIDELINES


Provider Operations Manual Field # Field 9c Field 9d Field 10 Field 10a Field 10b Field 10c Field 10d Field 11a-b Title Employers Name or School Name Insurance Plan Name or Program Name Patients Condition Related To Related to Employment? Explanation Name of other insureds employer or school. Name of Plan Carrier.

Field 14 Field 21

Field 24a

Field 24b Field 24d

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.

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 26

CHAPTER 5: CLAIMS AND BILLING GUIDELINES


Provider Operations Manual Field # Field 32 Title Explanation Provider Servicing Address Include any suite or office number. Include abbreviations for road, street, avenue, boulevard, place, or other common ending to the street name. Physicians or Suppliers Provider Identification Number (the number we Billing Name assigned to the provider)

Field 33

CMS-1450 (UB-04) CLAIM FORM


Who Should Use the CMS-1450 Claim Form? All Medicare-approved facilities should bill us using the most current version of the CMS-1450 Claim Form. Since May 23, 2008, the UB-04 version has been required. Coding To be sure that claims are processed in an orderly and consistent manner, standardized code sets must be used. The Healthcare Common Procedure Coding System (HCPCS) provides codes for billing for a variety of services. These codes are sometimes called National Codes. HCPCS consists of two principal subsystems, referred to as Level 1 and Level 2 of the HCPCS.

Level 1 consists of Current Procedural Terminology (CPT) codes maintained by


the American Medical Association (AMA). CPT codes are represented by five numeric digits.

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.

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 27

CHAPTER 5: CLAIMS AND BILLING GUIDELINES


Provider Operations Manual

Inpatient CodingInstitutional

CMS-1450 Revenue Codes: Code claim forms using appropriate CMS-1450


revenue codes; to order the current Billing Procedures Manual, call 1-800-494-2001.

ICD-9 Procedure Codes: Applicable ICD-9 procedure codes must be in Boxes


70-74e on the UB-04 Form when the claim indicates a procedure was performed; to order the current Code Book, call 1-800-633-7467.

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.

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 28

CHAPTER 5: CLAIMS AND BILLING GUIDELINES


Provider Operations Manual

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.

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 29

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Provider Operations Manual

Sample Section from the CMS-1450 Form with Instructions


1

Facility name and Address


a

Provider's Tax ID
9 PATIENT ADDRESS b a

3a PAT. CNTL # b. MED. REC. #

Member number
6 STATEMENT COVERS PERIOD FROM THR OUGH 7

TYPE OF BILL

5 FED. TAX NO.

8 PATIENT NAME b 10 BIRTHDATE

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

31 OCCURRENCE CODE DATE

Date of Birth

Sex

32 O CURRENCE CODE DATE

Admission Hour

33 OCCURRENCE CODE DATE

34 OCCURRENCE CODE DATE

35 CODE

OCCURRENCE SPAN FROM THROUGH

37

38

39 CODE

VALUE CODES AMOUNT

40 CODE

VALUE CODES AMOUNT

41 CODE

VALUE CODES AMOUNT

Occurrence Code and Date


42 REV. CD.
1 2 3

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

44 HCPCS / RATE / HIPPS CODE

Revenue Codes
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Description

Appropriate Procedure Code(s)

Service Date Unit(s) of Occurrence

Line Total Charges

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

55 EST. AMOUNT DUE

A B C

Medicaid Provider Number


58 INSUREDS NAME 59 P . REL 60 INSUREDS UNIQUE ID

Amount Due
61 GROUP NAME

A B C

62 INSURANCE GROUP NO.


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

67: B 67Primary diagnosis A


I J K a

67a diagnosis E Cq: Other D


b
b.

69 ADMIT 70 PATIENT DX REASON DX 74 PRINCIPAL PROCEDURE a. CODE DATE

c.

Principal Procedure
OTHER PROCEDURE CODE DATE

OTHER PROCEDURE CODE DATE

G Admission H diagnosis code P Q


68 73

71 PPS CODE OTHER PROCEDURE CODE DATE

d.

OTHER PR CODE DATE OCEDURE

e.

OTHER PROCEDURE CODE DATE

77 OPERATING LAST 78 OTHER

NPI

Attending Physician ID Number


FIRST QUAL FIRST QUAL

80 REMARKS 81CC a b c d UB-04 CMS-1450 APPROVED OMB NO.

Additional diagnosis

NPI

LAST 79 OTHER LAST NPI

Prescriber ID
FIRST

FIRST

QUAL

THE CERT IFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

Signature of provider certifyingNUBC the claim

National Uniform Billing Committee

LIC9213257

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 30

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Provider Operations Manual

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.
.

Field 1 2 3a 3b 4 5 6 7 8ab 9ae 10 11 12 13 14 15 16 17 1828

# 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

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Provider Operations Manual Field 29 30 3134 3536 # blank OCCURRENCE CODE OCCURRENCE DATE OCCURRENCE SPAN (CODE, FROM, AND THROUGH) blank blank VALUE CODES (CODE AND AMOUNT) R R R REV. CD. DESCRIPTION HCPCS/RATE/HIPPS CODE SERV. DATE SERV. UNITS TOTAL CHARGES NON-COVERED CHARGES blank PAYOR NAME R HEALTH PLAN ID Occurrence Code (42) and date, if applicable. Enter dates in MM/DD/YY (month, day, year) format. Leave blank. Enter the responsible party name and address, if applicable. Enter Value Codes. Revenue Code. Revenue Codes are required for all institutional claims. Description of services rendered Enter the accommodation rate per day for inpatient services or HCPCS/CPT code for outpatient services. Date of services rendered. Number/units of occurrence for each line or service being billed. Total charge for each line of service being billed Enter any non-covered charges. Leave blank. Payor Identification. Enter any third party payers. Medicare Provider ID Number/unique Provider ID Number. The billing provider number is required. Release of information certification indicator. Assignment of benefits certification indicator. Prior payments. Estimated amount due. Enter the NPI Number. Box Title ACDT STATE Description Accident State. Leave blank.

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

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Provider Operations Manual Field 57 58 59 60 R R # Box Title OTHER PRIV ID INSUREDS NAME P. REL INSUREDS UNIQUE ID Description Enter the other provider ID, if applicable. Members Name. Patients relationship to insured (N/A: Member is the insured). Insureds ID Number Certificate number on the members ID card. For newborns, use the mothers ID Number for services during the month of birth and the month following. 61 62 63 R GROUP NAME Insured Group Name enter the name of any other health plan.

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.

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Provider Operations Manual Field 74ae 75 76 77 7879 80 81ac R R R # R Box Title OTHER PROCEDURE (CODE/DATE) blank ATTENDING OPERATING OTHER REMARKS CC Description Other Procedure Codes. Leave blank. Enter the attending physicians ID Number. Enter the Provider Number if you use a surgical procedure on this form. Enter any other Provider Numbers, if applicable. Use this field to explain special situations. Enter additional or external codes, if applicable.

PROFESSIONAL BILLING REQUIREMENTS BY SERVICE CATEGORY


The following list of services is presented in alphabetical order. California Childrens Services (CCS) CCS Reimbursement CCS-approved providers are to submit claims on the appropriate form to the local CCS Program per the terms of their agreement with CCS. CCS is the primary payer for CCS-eligible diagnoses; therefore, Anthem Blue Cross does not provide authorization for those conditions. All providers, both in-network and out-of-network, are obligated to follow CCS guidelines, including:

Referring CCS eligible or potentially eligible conditions to CCS and Anthem Blue
Cross within 24 hours or the next business day.

Using CCS network physicians and hospitals. Non-CCS-paneled hospitals must


contact CCS immediately for authorization of inpatient members who are not stable for transfer to a CCS-paneled hospital.

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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

CCS-denied claims due to failure to use CCS network physicians or hospitals


We reimburse for all health care that is unrelated to the CCS-covered condition. We do not reimburse for services related to a potentially medically eligible condition or for care that is related to a condition that has been qualified by the local CCS Program. Questions about CCS Contact our Utilization Management (UM) department at 1-888-831-2246, Monday through Friday, 7 a.m. to 5 p.m. Go to California Childrens Services for other details on CCS. Child Health and Disability Prevention Program Services The Child Health and Disability Prevention Program (CHDP) is a California state program that provides preventive health services for children and youth enrolled in the Medi-Cal Program. CHDP provides care coordination to assist families with medical appointment scheduling, transportation and access to diagnostic and treatment services. Health assessments are provided by CHDP-certified providers. Billing Codes for CHDP Only CHDP-certified providers will be reimbursed for services rendered. Providers must use the CMS-1500 claim form or electronic submission to bill for services rendered. Whether you use the proper claim submission or the electronic submission for your CHDP claims, you must mail the PM-160 Informational Only forms to: Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007 School-based clinics can bill us electronically. For questions regarding electronic billing, contact Electronic Data Interchange (EDI) at 1-800-227-3983.
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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.

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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.

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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

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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

92552 86580 D1203

Clinical Laboratory Tests Use the following codes for clinical laboratory tests performed by comprehensive care providers (PCPs).

CHDP Service Codes for Clinical Laboratory Tests for PCPs

CHDP Codes 99830 81003 81007 85660 Hemoglobin or Hematocrit Urine Dipstick Urinalysis, routine, complete

Description

Sickle Cell Status (Hemoglobin Electrophoresis)

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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.
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Service Codes for Immunizations and Vaccines for PCPs


CPT Code 90632 90633 90634 90636 90645 90646 90647 90648 90649 Description Hepatitis A vaccine, adult dosage, for intramuscular use Hepatitis A vaccine, pediatric/adolescent dosage2-dose schedule, for intramuscular use Hepatitis A vaccine, pediatric/adolescent dosage3-dose schedule, for intramuscular use Hepatitis A and Hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use Haemophilus influenza b vaccine (Hib), HbOC conjugate (4-dose schedule), for intramuscular use Haemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use Haemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3-dose schedule), for intramuscular use Haemophilus influenza b vaccine (Hib), PRP-T conjugate (4-dose schedule), for intramuscular use Human Papilloma virus (HPV) vaccine, types 6,11,16, 18 (quadrivalent) 3 dose schedule, for intramuscular use. To include permissive use in males Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use H1N flu vaccine, Influenza virus vaccine, pandemic formulation effect. 9/2009. Use Modifier SK (high risk) Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, for intramuscular use Rotavirus Vaccine, (RotaTeq), oral, 3 dose Rotavirus Vaccine, oral, 2 dose schedule Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 through 6 years of age, for Intramuscular use Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP-Hib-IPV) for intramascular use, 6 months to 4 years of age Diphtheria, tetanus toxoids and acellular pertussis vaccine (DTaP), for use in individuals younger than 7 years, for intramuscular use Diphtheria, tetanus toxoids and whole cell pertussis vaccine (DTP), for intramuscular use
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90655 90657 90658 90663 90669 90680 90681 90696

90698

90700 90701

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Provider Operations Manual CPT Code 90702 Description

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

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Administration Fee Codes for VFC/CHDP Services

CPT Code 90460

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

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CPT Code 90473 90474

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.

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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.
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For plans above in which global billing is indicated:

If the entire OB care is provided by one physician or even multiple physicians


within the same practice, global billing must be used.

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.

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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

Billing Rules One time only. One time only.

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).

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Delivery Procedure Codes For All Providers


Code 59409 59514 Service Definition Vaginal delivery only. Cesarean delivery only. Billing Rules

Procedure CodesCPSP Certified Medi-Cal Managed Care Providers


Code Service Definition CPSP Combined Initial Assessments Z6500 Initial comprehensive nutrition, psychosocial, and health education assessment and development of care plan. Nutrition Individual initial nutrition assessment and development of care plan. Z6200 Z6202 Z6204 First 30 minutes Each subsequent 15 minutes Individual, follow-up antepartum nutrition assessment, treatment or intervention, 15 minutes each. Group, per patient, followup antepartum nutrition assessment, treatment or intervention, 15 minutes each. Individual, postpartum nutrition assessment, treatment or intervention including development of care plan, 15 minutes each. Prenatal vitamins, mineral supplements(30-daysupply). May be billed once per pregnancy in lieu of Z6500. Maximum of 1 hours or 6 units Maximum of 2 hours or 8 units Billing Rules BILLED ONLY ONCE PER PREGNANCY. This covers the first 30 minutes of each assessment for nutrition, psychosocial and health education. To bill this code, all 3 assessments MUST be completed within four weeks of the first pregnancy visit.

Z6206

Maximum of 3 hours or 12 units.

Z6208

Maximum of 1 hour or 4 units.

Z6210

Up to a 90-day supply at a time.

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Provider Operations Manual Code Service Definition Psychosocial Individual initial psychosocial assessment and development of care plan. Z6300 Z6302 First 30 minutes Billing Rules

May be billed once per pregnancy in lieu of Z6500.

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

Maximum of 2 hours or 8 units.

Z6410

Maximum of 4 hours or 16 units.

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Provider Operations Manual Code Z6412 Z6414 Service Definition Billing Rules Group, per patient, perinatal Maximum of 16 units/day, 72 units/pregnancy education, 15 minutes each. Individual, postpartum Maximum of 1 hour or 4 units. health education assessment, treatment or intervention including development of care plan

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.

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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).

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Preventive Medicine Services, New Patient


Code Description

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

Preventive Medicine Services, Established Patient


Code Description

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

Adult Preventive Care Procedure Codes


Code 82270 82465 Description Fecal Occult Blood Test (lab procedure code only) Total Serum Cholesterol (lab procedure code only)

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Code 86580 90658 90732 90718 88150 76091 84153

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.

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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

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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
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Provider Operations Manual HCPCS/CPT Description Anesthesia for intraperitoneal procedures in lower abdomen including urinary 00921 tract, vasectomy, unilateral or bilateral 55250 Vasectomy 57170 Diaphragm fitting 58300 IUD insertion 58301 IUD removal only 58600 Ligation or transection of fallopian tubes, abdominal or vaginal approach, unilateral or bilateral 58615 Occlusion of fallopian tubes by device (for example, band, clip, Falope ring) vaginal or suprapubic approach *X1500 *Must be billed with description of the item. Diaphragm/Foam/Cream/Jelly/Film/Condoms/Sponge/Cervical Cap/or Basal Body Thermometer CU-7 (Copper-7), Lippes Loop IUD (Progestasert) Norplant ParaGard Description Mirena Interuterine System (IUS) Depo Provera Medroxyprogesterone Acetate/Estradiol Cypionate, inj Estrogens, Conjugated, tablets Oral contraceptives Levonorgestrel, Ethinyl Estradiol, tablets, Emergency Contraception Kit Levonorgestrel, tablets Norelgestromin/Ethinyl Estradiol, transdermal patch Etonogestrel/Ethinyl Estradiol, vaginal ring Pregnancy test Chorionic gonadotropin assay Semen analysis; complete (volume, count, motility and differential

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

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Provider Operations Manual ICD-9 031.2031.9 038.0039.9 042 046.3046.9 053.10054.9 054 070.0070.9 079.4079.99 079.53 090097 098 099.0 099.5 112.0112.9 114.0115.9 131.0131.9 616 Description HIV-related HIV-related HIV Infection with specified conditions HIV-related HIV-related Herpes Hepatitis B/C Papillomavirus, HIV, Chlamydia HIV Type 2 Syphilis Gonorrhea Chancroid Chlamydia trachomatis Candidiasis Coccidiodomycosis, Histoplasmosis Trichomoniasis PID

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

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Provider Operations Manual HCPCS/CPT 86592 86593 86631 86687 86688 86689 86694 86695 86701 86702 86703 86781 86580 87070 87081 87110 87206 87207 87270 87320 Description VDRL-RPR (Syphilis) VDRL, quantitative Chlamydia (antibody) HIV (HTLV I) HIV (HTLV II) HIV (HTLV or HIV antibody, confirmatory test; for example, Western blot) Herpes (nonspecific test) Herpes (Type I) HIV-1 HIV-2 HIV-1 and HIV-2-single assay FTA-ABS (Syphilis, confirmatory test) TB Screening (PPD) Chancroid GC Culture/Throat Culture Chlamydia (culture) Chlamydia (fluorescent antibody screen)/Herpes (direct immuno flourescent) Herpes (special stain for inclusion bodies) Chlamydia trachomatis AG IF Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semi-quantitative, multiple-step method; Chlamydia trachomatis Hepatitis B surface antigen (HbsAg) Infectious agent detection by neucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique Chlamydia trachomatis, amplified probe technique Neisseria gonorrhoeae, amplified probe technique Syphilis test; qualitative (for example, VDRL, RPR, ART) Syphilis test; quantitative Antibody; Chlamydia Antibody; Chlamydia, IgM Antibody; Hepatitis, delta agent Antibody; Herpes simplex, non-specific type test Antibody; Herpes simplex, type 2 Antibody; HIV-1 Antibody; HIV-2

87340 87490 87491 87591 86592 86593 86631 86632 86692 86694 86696 86701 86702

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Provider Operations Manual HCPCS/CPT 86703 86704 86705 86706 86707 86708 86709 86803 86804 87110 87270 87273 87281 87320 Description Antibody; HIV-1 and HIV-2, single assay Hepatitis B core antibody (HBcAb); total Hepatitis B core antibody (HBcAb); IgM antibody Hepatitis B surface antibody (HBsAb) Hepatitis Be antibody (HBeAb) Hepatitis A antibody (HAAb); total Hepatitis A antibody (HAAb); IgM antibody Hepatitis C antibody Hepatitis C antibody; confirmatory test (for example, immunoblot) Culture, chlamydia, any source Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 2 Infectious agent antigen detection by immunofluorescent technique; Pneumocystis carinii Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Hepatitis B surface antigen (HBsAg) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Hepatitis B surface antigen (HBsAg) neutralization Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Hepatitis Be antigen (HBeAg) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Hepatitis, delta agent Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-2 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique

87340

87341

87350

87380

87390 87391 87490 87491

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Provider Operations Manual HCPCS/CPT 87492 87510 87511 87512 87515 87516 87517 87520 87521 87522 87525 87526 87527 87528 87529 87530 87534 87535 87536 87537 Description Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis B virus, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis B virus, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis B virus, quantification Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis C, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis C, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis C, quantification Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis G, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis G, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis G, quantification Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique

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Provider Operations Manual HCPCS/CPT 87538 87539 87590 87591 87592 87660 87810 87850 87902 87903 Description Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, direct probe technique Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis Infectious agent detection by immunoassay with direct optical observation; Neisseria gonorrhoeae Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C virus Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV-1; first through 10 drugs tested Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV-1; each additional 1 through 5 drugs tested

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

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Provider Operations Manual HCPCS/CPT X7724 X7726 Z0336 Description RU-486 Misoprostol Medical abortion

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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.

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Additional Billing Resources This Provider Operations Manual and information from the following references, provide detailed instructions on uniform billing requirements.

Current Procedural Terminology (CPT) 2006, American Medical Association. To


order, call 1-800-621-8335.

CMS Common Procedure Coding System (HCPCS), National Level II (current


year). To order, call 1-800-633-7467.

ICD-9 CM (current edition), Volumes 1, 2, 3 (current year) Practice Management


Information Corporation. To order, call 1-800-633-7467.

HOSPITAL AND INSTITUTIONAL BILLING REQUIREMENTS BY SERVICE CATEGORY


This section provides special billing requirements applicable to each service listed below. The members benefits may not cover some of the services listed, so it is important to confirm benefit coverage. Consult your Anthem Blue Cross State Sponsored Business Participating Provider Agreement for specifics regarding billing for any of these or other services. Maternity and Boarder Baby Care The billing requirements for maternity care apply to all live and still birth deliveries and include payment for all associated services, including, but not limited to, room and board for mother (including all nursing care), nursery for baby (including all nursing care), delivery room/surgery suites, equipment, laboratory, radiology, pharmaceuticals and other services incidental to admission. The maternity rate does not apply to newborns who are admitted to an intensive care unit or who remain in the hospital as boarder babies after the mother is discharged.

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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:

No additional requirements Utilization Management approval is required for all admissions


Inpatient Sub-Acute Care The billing requirements for inpatient sub-acute care include each approved and medically necessary service day in a duly licensed and accredited facility at the appropriate level of care. Each inpatient sub-acute care admission is considered a separate admission from any preceding or subsequent acute care admission and should be billed separately. Covered services rendered during an admission include, but are not limited to, room and board (including all nursing care), equipment use, supplies, laboratory, radiology, pharmaceuticals and other services incidental to the admission. Sub-acute care includes levels of inpatient care less intensive than those required in an inpatient acute care setting. All admissions and levels of care require prior approval. A treatment plan must accompany all sub-acute care admissions, including:

Functional, reasonable, objective and measurable goals within a predictable time


frame for each skilled discipline

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

Rehabilitation services rendered by a registered occupational, speech or physical


therapist for a documented rehabilitation diagnosis, including occupational, speech or physical therapy lasting between 90 minutes and three hours per day for five or more days per week

Initiation of nasogastric, gastrostomy, and jejunostomy feedings and


administration of continuous feeding when medically necessary; total parenteral nutrition (TPN)

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)
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Continuous passive motion machines TENS/MENS units


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 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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Special billing instructions and requirements include:

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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Special billing instructions and requirements include:

Use of CPT4/HCPCS Codes for each surgical procedure in Form Locators 44


(HCPCS/RATES); Revenue Codes 036X, 0480, 0481, 0490, 070X, 071X, 075X, 076X, 079X, and 0975 are required with the appropriate CPT4/HCPCS Code. (Note: Outpatient surgery is billed with CPT4/HCPCS code according to HIPAA mandate.)

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.

Entering 13X as the type of bill field entry.

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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.

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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)

ANCILLARY BILLING REQUIREMENTS BY SERVICE CATEGORY


This section provides special billing requirements applicable to each service listed below. The members benefits may not cover some of the services listed. Be sure to confirm benefit coverage. Also, consult your Anthem Blue Cross State Sponsored Business Participating Provider Agreement for specifics regarding billing for any of these or other services. The majority of Ancillary claims submitted are for:

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.

Contract change during course of treatment: When a Providers


reimbursement is affected by a contract change during a course of treatment, the Provider is required to split the dates of service in order to be reimbursed at the new rate.

Itemization: Itemization of services is required when the from and through


service date is the same.

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.

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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.

Attach the manufacturers invoice to the claim if using a miscellaneous or unlisted


code (such as E1399).

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.

Wheelchair claims from manufacturers billing as providers must include:

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.

Use appropriate modifiers that describe the to and from locations.

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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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Provider Operations Manual Medi-Cal Level II National Codes Oxygen per tank Amb unlisted Resp to Call Ambul Ac/Ltc Trans Only Amb mil one way per mi Ac/Ltc Trans Only Respca lit pat lit van Ac Ltc Trans Only Little wheelvan mi lne way per mi Ac/Ltc Little wheelvan mi one way per mi Ac/Ltc Wheelchair use Ac/ltc Trans Only Oxygen per tank Ac/ltc Trans Only Attendant Ac/ltc Trans Only Unlisted Ac/ltc Trans Only Loaded patient miles helicopter Loaded patient miles fixed wing Night call 7pm to 7am Air ambulance waiting time per 15 min Federal excise tax Oxygen per tank Neonatal intensive care Compressed air for infant incubator Admin IV sol 1000cc incld tube and supply Admin IV sol 500 cc incld tube and supply Unlisted air transportation Portable x-ray, 2 patients per trip Portable x-ray, 3 or more patients per trip Medi-Cal Level III Local Codes X0002 Med trans amb 2 pt each pt X0006 Med trans amb emer run X0008 Neonatal intensive care incubator X0220 X0222 X0400 X0402 X0404 X0406 X0408 X0410 X0412 X0414 X0416 X0500 X0502 X0504 X0506 X0508 X0510 X0512 X0514 X0516 X0518 X0522 X0700 X0702

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Healthy Families Program


A0225 A0380 A0384 Healthy Families Program Level II National Codes Ambulance service, neonatal transport, base rate, emergency transport, one way BLS mileage, per mile BLS specialized service disposable supplies, defibrillation (used by ALS ambulances and BLS ambulances in jurisdictions where defibrillation is permitted in BLS ambulances) ALS mileage, per mile Ambulance waiting time (ALS or BLS), one-half () hour increments Ambulance (ALS or BLS) oxygen and oxygen supplies, life-sustaining situation Extra ambulance attendant, ground (ALS or BLS) or air (fixed- or rotary-winged); (requires medical review) Ground mileage, per statute mile Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS) Ambulance service, advanced life support, emergency transport, Level 1 Ambulance service, basic life support, non-emergency transport (BLS) Ambulance service, basic life support, emergency transport (BLS-emergency) 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 Advanced life support, Level 2 (ALS2) 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 7pm and 7am Uncovered ambulance mileage, per mile (for example, for miles traveled beyond closest appropriate facility) Unlisted ambulance service

A0390 A0420 A0422 A0424 A0425 A0426 A0427 A0428 A0429 A0430 A0431 A0432 A0433 A0434 A0435 A0436 A0800 A0888 A0999

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Modifiers Medi-Cal Modifiers


Medi-Cal Level III Local Modifier Z1 Additional air mileage in excess of 10% of standard airway mileage distances. (Reason for additional mileage flown must be documented on the claim) Medi-Cal Level II National Modifiers GM Multiple patients on one ambulance trip QM Ambulance service provided under arrangement by a Provider of services QN Ambulance service furnished directly by a Provider of services Medi-Cal Level III Local Modifier TP Medical transport, unloaded vehicle TQ Basic life support transport by a volunteer ambulance Ambulance Service Modifiers For ambulance services, one-letter modifiers are combined to form two-letter modifiers that identify the place of origin (first letter) and destination (second letter) D E G H I J N P R S X Diagnostic or therapeutic site Residential, custodial facility Hospital-based dialysis facility Hospital Transfer point between ambulances (helipad to vehicle) Nonhospital-based dialysis facility Skilled Nursing Facility Physician's office Residence Scene of accident Intermediate stop at physician's office on way to hospital Healthy Families Program Level II National Modifiers GM Multiple patients on one ambulance trip QM Ambulance service provided under arrangement by a Provider of services QN Ambulance service furnished directly by a Provider of services

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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When billing for dialysis:

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

Use a CMS-1450 Form.


When billing for Home Health:

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 therapists bill on a CMS-1500 Form. Rehabilitation centers bill on a


CMS-1450 or CMS-1500 Form.

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.

Indicate bill type 830X. Itemize all claims.


Additional Billing Resources The following references provide detailed instructions on uniform billing requirements:

Current Procedural Terminology (CPT), American Medical Association; to order


call 1-800-621-8335.

CMS Common Procedure Coding System (HCPCS), National Level II (current


year); to order, call 1-800-633-7467.

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ICD-9 CM (current edition), Volumes 1, 2, 3 (current year) Practice Management


Information Corporation; to order, call 1-800-633-7467.

CMS-1450 Manual, Uniform Billing Procedures, published by the California


Healthcare Association; to order, call 1-800-494-2001.

CAPITATED GROUP CLAIMS PROCESSING AND ENCOUNTER DATA SUBMISSION


When claims processing is a delegated activity, we oversee claims processing and dispute resolution activities to ensure the activities are conducted in a timely manner and in accordance with state and federal regulations and contractual agreement. Groups must have written procedures for claims processing that are available for review by us. These procedures are outlined in your Anthem Blue Cross State Sponsored Business Participating Group Agreement. These written procedures and disclosures must comply with state and federal laws and regulations and our contractual standards and requirements. Such procedures and disclosures must be made available upon request by us or a regulatory agency. If you are a member of a provider medical group delegated for claims processing, contact your group administrator for details of your responsibilities. Capitated Group (Group) Responsibilities for Delegated Claims Processes Group Claims Processing Systems must identify and track all claims activities, including claims disputes and resolutions, and be able to deliver monthly reporting to us. Groups must have processes in place and be able to identify and acknowledge the receipt of each claim, whether or not complete, and disclose the recorded date of receipt in the same manner as the claim was submitted.

If the claim was received electronically, acknowledgement must be provided by the


group within 2 business days of receipt of the claim.

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.

Payment of a clean claim or notification of a denial of a claim must be sent,


accompanied by an RA, to the Provider of service within 45 business days of the date a claim is received.

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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TELEMEDICINEMEDI-CAL AND HEALTHY FAMILIES PROGRAM MEMBERS ONLY


For information about the Telemedicine Program, go to www.anthem.com/ca/telemedicine. Additional Code Tables: Medi-Cal & Healthy Families Program The attached codes are a representative sample of the codes most frequently utilized by providers in our Medi-Cal and Healthy Families Programs. Professional judgment should always be used in billing the most appropriate code for the service rendered. The most current version of the CPT Manual should be used for full descriptions of the codes.

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.

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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.

Office or Other Outpatient Services, Established Patient


99211 99212 99213 99214 99215 Office or other outpatient visit for the evaluation and management of an established patient; the presenting problems are of minimal severity. Office or other outpatient visit for the evaluation and management of an established patient; the presenting problems are self- limited or of minor severity. Office or other outpatient visit for the evaluation and management of an established patient; the presenting problems are of low to moderate severity. Office or other outpatient visit for the evaluation and management of an established patient; the presenting problems are of moderate to high severity. Office or other outpatient visit for the evaluation and management of an established patient; the presenting problems are of moderate to high severity

Office or Other Outpatient Consultations, New Patient or Established Patient


99241 99242 99243 99244 99245 Office consultation for a new or established patient; the presenting problems are self-limited or of minor severity. Office consultation for a new or established patient; the presenting problems are of low to moderate severity. Office consultation for a new or established patient; the presenting problems are of moderate severity. Office consultation for a new or established patient; the presenting problems are of moderate to high severity. Office consultation for a new or established patient; the presenting problems are of moderate to high severity.

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Medi-Cal Modifier Codes for Use in Billing Medi-Cal Services Only


Modifier NU RP RR SL SK TC YR YT YU ZL ZM ZN ZS Description New equipment (purchase) Replacement and repair Rental Used for Vaccines for Children (VFC) Program recipients younger than 18 years of age Members of high-risk population Technical component Certified Nurse Midwife Service (multiple modifiers) (when billed by a physician, organized outpatient clinic or hospital outpatient department) Nurse Practitioner Service (multiple modifiers) Physician Assistant Service (multiple modifiers) Medi-Cal initial prenatal visit Supplies and drugs for surgical procedures with other than general anesthesia or no anesthesia Supplies and drugs for surgical procedures with general anesthesia Professional and technical component

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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

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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.

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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
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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

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Date of injury/date of hospital admission and third-party liability information (if


applicable)

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.

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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.

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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 determines the member is stable for transfer to a


contracted facility.

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:

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Authorization from UM is not required if referring a member to an in-network


specialist for consultation or a nonsurgical course of treatment.

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.

Members in MRMIP (Major Risk Medical Insurance Program), Healthy Families


Program EPO, and Access for Infant and Mothers (AIM) HMO may self-refer to in-network specialists. Provider responsibilities include documenting referrals in the members chart and requesting that the specialist provide updates as to the diagnosis and treatment plan.

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:

Facilities reporting admissions Providers reporting admissions

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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:

Facilities reporting admissions within 24 hours of admission or the first business


day after a weekend

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.

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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

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SELF-REFERRAL
Members may self-refer for sensitive services, such as:

Family planning services, including:


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

Annual examination with a network OB/GYN


SECOND OPINIONS
There is no cost to members for second opinions. A second opinion must be given by an appropriately qualified health care professional. When the request is regarding care from a specialist, a provider of the same specialty must give the second opinion. This specialist must be within the network and may be selected by the member. For cases in which there is no provider within the network who meets the specified qualification, we may authorize a second opinion by a qualified provider outside of the network upon request by the member.

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

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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

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CARE MANAGEMENT OVERVIEW


The Care Management Program affords both members and providers expert assistance in coordinating complex health care needs for members. We encourage our providers to make use of this effective program. 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. The case manager, through interaction with the member, member representative or providers, collects and analyzes data and information about the actual and potential care needs for the purpose of developing a care plan. Cases may be identified by disease state or condition or high utilization of services. Referral Process Providers, nurses, social workers and members or their representatives may refer members to Care Management in one of two ways: 1) by calling the Care Management Department at 1-866-595-0145; and 2) by faxing a completed Care Management Referral Form to 1-866-333-4827. A case manager will respond to the person who submitted the faxed request within three business days. Provider Responsibility It is the Providers responsibility to participate in the care management process through information sharing (such as medical records) and facilitation of the care management process by:

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

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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

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ROLE OF THE CASE MANAGER


Case managers develop a care plan and:

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

County and State-Linked Services


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PROVIDER GRIEVANCES AND APPEALS


We provide a process for Providers to file a written grievance with us that is related to dissatisfaction or concern about another Provider, the Plan or a member. We also assure the Providers right to file a provider appeal with us for denial, deferral or modification of a post-service request. Providers can also request an appeal on behalf of a member for denial, deferral, or modification of a prior authorization or request for concurrent review. These appeals are treated as member appeals and follow the member appeal process. For additional information, see Chapter 9, Member Grievances and Appeals, in this manual. Providers can also submit a claims dispute to us. For additional information on claims disputes, see Chapter 5, Claims and Billing Guidelines, in this manual. How Providers File a Grievance or Appeal Providers may file a grievance in writing to the Grievances and Appeals (G&A) Department. and submit to: Attn: Grievances & Appeals Department Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007 Providers can also submit a grievance by fax to 1-866-387-2968. Providers may file a member appeal on behalf of a member in writing to the Utilization Management (UM) Department. For additional information, refer to Chapter 9, Member Grievances and Appeals, in this manual. The provider may submit the provider or member appeal request in writing to: Attn: Grievances & Appeals Department Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007 Providers also may fax appeal requests to 1-888-716-5183. For the Physician/Provider Grievance Form, go to www.anthem.com/ca and select Forms and Tools. When to File a Grievance or Appeal

A grievance may be filed up to 180 days after the date of the incident that gave rise
to the grievance.

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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.

Refer to Chapter 1, Introduction and General Claims Guidelines, in this manual


for the time frames applicable to claims disputes. Grievance & Appeal Investigation Responsibilities Clinical Grievances (Quality of Care) A medical director 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.

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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)

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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

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MEMBER GRIEVANCES AND APPEALS


Members or their authorized representatives have the right to communicate dissatisfaction with any aspect of the Plan or its contracted Provider services by filing a member grievance or appeal, as defined in Chapter 22, Acronyms, Definitions and Maps, in this manual, by telephone, or in writing. We communicate the grievance and appeal process to all members in writing, including the right to a state fair hearing for Medi-Cal members. These disclosures are included in the members applicable Benefit Agreement. How Members File a Grievance or Appeal Members can file a grievance or appeal by calling the Customer Care Center, by sending us a letter, or by completing a Member Grievance Form. This form is available online through our website (http://anthem.com/ca) in the Forms and Tools section; it is also available at provider offices as well. We can also mail the form to the member upon request. If a member is unable to submit a form, we will help the member by documenting the members verbal request. Customer Care Center Medi-Cal (except Los Angeles County): 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

Mail Grievance & Appeal forms or letters to: Attn: Appeals and Complaints Department Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007

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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.

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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.

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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.

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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:

Medi-Cal Program members:

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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Healthy Families Program members:

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.

AIM and MRMIP Program members:

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 appeal involves the termination, suspension, or reduction of a previously


authorized course of treatment.

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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MEMBER RIGHTS AND RESPONSIBILITIES


The state of California and its contracted agencies establish and mandate member rights and responsibilities for each program (Medi-Cal, L.A. Care, Healthy Families Program, Access for Infants and Mothers, and Major Risk Medical Insurance Program). The governing body of each program establishes the language for member rights and responsibilities. We are responsible for communicating these rights and responsibilities to members and providers. We communicate these member rights and responsibilities in the new member packets we issue to members and in Provider Operations Manuals (POM) we issue to Providers. We also post this information on our website at www.anthem.com/ca. Please review these guidelines as part of your continuing assessment of your office policies and procedures. We are proud to collaborate with you to ensure access to quality health care for our members and thank you for your continued efforts in pursuit of this goal. Member Rights Members have the following member rights: Members have the right to be informed.

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

To receive member materials in audio, large print, or in a language other than


English Members have the right to be treated well.

To be treated with respect at all times

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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 make an advance directive (also known as a living will)


Members have the right to obtain a range of services.

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 ask the California Department of Managed Health Care (DMHC) for an


Independent Medical Review (IMR)

To choose to leave our health plan


Member Responsibilities Members have the following responsibilities as health care consumers: We hope members will work with their doctors as partners in their health care.

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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We want members to understand their health plan.

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.

Routine or regular- five business days Urgent24 to 48 hours Emergencysame day

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 help us maintain accurate and current medical records by providing timely


information regarding changes in address, family status, and other health care coverage

To notify us as soon as possible if a Provider bills them inappropriately or if they


have a complaint

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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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.

To be actively involved in making decisions about their health care


Members have the right to suggest changes in their health plan.

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 use the emergency room only in cases of an emergency or as directed by their


Provider MRMIP Member Rights and Responsibilities Member Rights MRMIP members have the following member rights: Members have the right to be informed.

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.

To be actively involved in making decisions about their health care

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Members have the right to suggest changes in their health plan.

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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PRIMARY CARE PHYSICIANS SCOPE OF RESPONSIBILITIES


Plan members select a contracted Primary Care Physician (PCP) as their main provider of health care services within the established time period of the effective date of enrollment. If, after the established time period of the effective date of enrollment, the member has not selected a PCP, we assign the member to a PCP. The PCPs scope of practice includes the development and oversight of the members treatment and care plan, which includes availability to health care 24 hours a day, 7 days a week. The PCP serves as the primary provider of a members health care services. We furnish each PCP with a current list of enrolled members assigned to the PCP. The PCP provides routine, preventive, and urgent services and ensures that the member receives appropriate specialty, ancillary, emergency, and hospital care as well as access to health care services 24 hours a day, 7 days a week. The PCP provides information to the member or legal representative of the member about the illness, the course of treatment, and prospects for recovery in terms he or she can understand. PCP responsibilities include providing or arranging for:

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

Are expected to track and document appointments, clinical findings, treatment


plans and care received by members referred to specialists, other health care providers, or agencies regarding continuity of care Specialty referrals to in-network providers do not require prior authorization.

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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:

Members at an inpatient facility to the appropriate level of care of facility (skilled


nursing facility, intermediate rehabilitation facility) when medically indicated or home

Members hospitalized in an out-of-network facility to an in-network facility (or to


home with home health care assistance when medically indicated). The coordination of member transfers from non-contracted out-of-network facilities to contracted in-network facilities is a priority that may require the immediate attention of the PCP. Contact our review coordinator to assist in this process. Comprehensive Perinatal Services Program for Medi-Cal (PCPs and OB/GYNs only) The Comprehensive Perinatal Services Program (CPSP) is a voluntary participation program for Medi-Cal recipients which provides comprehensive perinatal services during pregnancy and 60 days following delivery by, or under the personal supervision of, a physician approved by DHCS to provide CPSP services. See the Introduction to the Comprehensive Perinatal Services Program (CPSP) Form for members and providers. This form can be found on our website at www.anthem.com/ca under Forms and Tools. As a PCP or Obstetrics/Gynecology (OB/GYN) specialist, you are responsible for assessing member needs and referring all pregnant members to community prenatal services, the Women, Infants and Children (WIC) Program, substance abuse programs, prenatal education classes, and other appropriate sources as soon as pregnancy is determined. Refer all women with identified high-risk factors to a CPSP provider.

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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

Providing nutritional services, via a registered dietician (with re-evaluation at each


trimester), who works collaboratively with OB/GYN physician as needed when dietary complications impact pregnancy

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)

Treating and intervening to help the member understand the importance of


maintaining good nutrition during pregnancy and lactation, with referrals as appropriate

Giving postpartum reassessments and interventions, with referrals as appropriate


Health Education Services

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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Include health education assessments, including an evaluation of current health


practices, prior experience and knowledge about pregnancy, prenatal care, delivery, postpartum care, self-care, infant care and safety, clients expressed learning needs, formal education and reading level, learning methods most effective for the member, educational needs related to risk factors identified, languages spoken and written, mental/emotional/physical disabilities that affect learning, and cultural/religious influences that impact perinatal health

Include preparing an individualized care plan with health education component


that addresses health education strengths, prevention, or resolution of health education problems/needs, health promotion, and risk-reduction behaviors that can be ameliorated or resolved through education

Include health education interventions based on the members identified needs,


interests, and capabilities and directed toward assisting the member to make appropriate, well-informed decisions about her pregnancy, delivery and parenting

Include postpartum health education assessment and interventions with referrals


as appropriate Psychosocial Services

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

Include preparation of an individualized care plan that addresses psychosocial


problems and support and maintaining strong psychosocial functioning

Include treatment and intervention directed toward helping the member


understand and deal effectively with the biological, emotional and social stresses of pregnancy with referrals, as appropriate

Include postpartum reassessment and intervention


PCPs must follow all Provider responsibilities as outlined in this manual.

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SPECIALIST SCOPE OF RESPONSIBILITIES


Specialist physicians are those who are licensed with additional training and expertise in a specific field of medicine. Specialist physicians treat Plan members to supplement the care given by PCPs. Access to contracted network specialists is through the members PCP. In limited cases, such as family planning and evaluation, diagnosis, treatment and follow-up of sexually transmitted diseases (STDs) the member can self-refer. PCPs refer members to Plan-contracted network specialist physicians for conditions beyond the PCPs scope of practice that are medically necessary. Specialists diagnose and treat conditions specific to their area of expertise. Specialist care is limited to Plan benefits. Specialists must follow all Provider responsibilities as outlined in this manual. Members with disabling conditions or chronic illnesses or children with special health care needs may request that their PCPs be specialists. Specialist physicians acting as PCPs must follow all responsibilities of a PCP.

HOSPITAL SCOPE OF RESPONSIBILITIES


PCPs refer members to Plan-contracted network hospitals for conditions beyond the PCPs scope of practice that are medically necessary. Hospital care is limited to Plan benefits. Hospital professionals diagnose and treat conditions specific to their area of expertise. Hospital professionals must follow the processes of all providers unless specified otherwise. Hospital providers must provide members with an adequate supply of medications upon discharge from the Emergency Room or the inpatient setting to allow reasonable time for the member to access a pharmacy to have prescriptions filled. Notification of Admission and Services The Hospital must notify us or the review organization of an admission or service at the time the member is admitted or service is rendered. If a member is admitted or a service is rendered on a day other than a business day, the Hospital must notify us of the admission or service during the morning of the next business day following the admission or service.

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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.

ANCILLARY SCOPE OF RESPONSIBILITIES


We have a network of various participating health care professionals and facilities. Health care professionals provide medically necessary services when a licensed physician or licensed health care professional orders the services and are in accordance with the applicable benefit agreement and ancillary agreement. All services provided by the health care professional, and for which the health care professional is responsible, are listed in the ancillary agreement. PCPs refer members to Plan-contracted network ancillary professionals for conditions beyond the PCPs scope of practice that are medically necessary. Ancillary professionals diagnose and treat conditions specific to their area of expertise. Ancillary care is limited to Plan benefits. Ancillaries must follow all Provider responsibilities as outlined in this manual.

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RESPONSIBILITIES APPLICABLE TO ALL PROVIDERS


Eligibility Verification All Providers must verify member eligibility immediately before providing services, supplies, or equipment. Eligibility may change monthly, so a member eligible on the last day of the month may not be eligible on the first of the following month. We are not responsible for charges incurred by ineligible persons. Verify eligibility by using POS, ProviderAccess website or call the Customer Care Center. Refer to Important Contact Information for numbers for each respective program. Preservice Reviews Providers must obtain preservice reviews for:

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

Discriminating against Plan members

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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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HOSPITAL FINANCIAL REVIEW


Concurrent with the policy to mitigate the risk with PMGs, a set of financial metrics also has been adopted to evaluate the financial position of hospitals participating in the Anthem Blue Cross Managed Care Program. The Hospital usually is contractually required to receive monthly capitated or per diem payments from Anthem Blue Cross on behalf of enrolled members.

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

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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:

Making presentations at the physicians site or allowing Anthem Blue Cross


representatives to make marketing presentations to prospective members

Offering or giving away any form of compensation, reward, or loan to a


prospective member to induce or procure a Anthem Blue Cross member enrollment in a specific health plan

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

Marketing practices that discriminate against medical recipients based on marital


status, age, religion, sex, national origin, language, sexual orientation, ancestry, pre-existing psychiatric problem, or medical condition (such as pregnancy, disability or acquired immune deficiency syndrome) other than those specifically excluded from coverage under our contract

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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)

If a qualified prospect expresses interest in us during a medical visit, providers may


direct him or her to call one of the following applicable numbers: Anthem Blue Cross Outreach Call Center: Medi-Cal, L.A. Care (Los Angeles County): Medi-Cal, Health Care Options (HCO): Healthy Families Program: AIM: MRMIP: 1-800-227-3238 1-888-452-2273 1-800-430-4263 1-800-880-5305 1-877-687-0549 TDD: 1-888-757-6034 1-877-687-0549 TDD: 1-888-757-6034

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

File a complaint with us if you or a member objects to any member marketing


either by other physicians or our representatives; refer to Chapter 9, Member Grievances and Appeals, for more information on the complaint process.

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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.

PROGRAM ENROLLMENT PROCESS


Medi-Cal Enrollment in our Medi-Cal Program occurs through L.A. Care for Los Angeles County members or through Health Care Options (HCO) for mainstream counties. These DHCS-contracted enrollment companies present health plan options to individuals and families eligible for Medi-Cal or other programs. These individuals and families then enroll into the managed care plan of their choice. The enrollment company informs us of any new member enrollment and notifies us after enrollment of any changes in member eligibility, status, or member information (such as change of address). Medi-Cal recipients receive a pre-enrollment packet that includes a Medi-Cal Enrollment Form and the Plans provider directory. If not assigned to a Managed Medi-Cal Plan, Medi-Cal recipients must complete and return the signed Enrollment Form to HCO within 45 days. This includes the selection of a health plan and a Primary Care Provider (PCP). If the member does not choose a plan or a PCP within that time frame, the State assigns the member to a Managed Medi-Cal plan and then submits the member information to the Plan. The Plan then assigns a PCP for the member. For more enrollment information, use the following resources: DHCS Medi-Cal Website: L.A. Care (Los Angeles County): HCO (all counties except Los Angeles County): www.medi-cal.ca.gov 1-888-452-2273 1-800-430-4263

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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

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PHYSICIANS ROLE IN MEDI-CAL MARKETING AND ENROLLMENT


Members may enroll in the Medi-Cal Program through L.A. Care Health Plan for Los Angeles County members or through Health Care Options (HCO) for other Medi-Cal counties. Healthy Families Program, AIM Program, and MRMIP enrollees should contact those programs for enrollment. Go to Program Enrollment Process in this chapter for more information. As a network provider, you may not provide prospective members with an Enrollment Form. You may assist members (who are patients) in completing the Enrollment Form. If a prospect expresses interest in the Plan during a medical visit, you may help the member preliminarily find out what program he or she may qualify for, then provide him or her with resources for more information. As a provider caring for Medi-Cal and other State Sponsored Business members, you are required to obtain approvals prior to using patient-focused marketing materials that you create. Before distributing materials to your Medi-Cal patients, submit your materials to us. We will review and seek approval from the following agencies, as appropriate:

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.

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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

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Services for Members Under the Age of 21 Years

Initial Health Assessments (IHAs)

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

Preventive Care Visits: within 14 days of request


Services for Members 21 Years of Age and Older

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

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Services for Members Under the Age of 18 Months

Initial Health Assessments: within 60 days of enrollment (or within American


Academy of Pediatrics (AAP) guidelines, for ages two or younger, whichever is less)

Early and Periodic Screening Diagnostic and Treatment (EPSDT) Services/Child


Health and Disability Prevention (CHDP) or Preventive Care Visits: within 2 weeks of request Services for Members 18 Months of Age or Older

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.

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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.

CONTINUED ACCESS TO CARE/CONTINUITY OF CARE


In compliance with California Health and Safety Code Sections 1373.65, 1373.95 and 1373.96 (SB244) California law regarding continuity of care, we ensure continued access to care for members with qualifying conditions when

They are newly enrolled. The physicians or physicians group contract terminates. They are disenrolling to another health plan.

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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

Degenerative and disabling conditions (a condition or disease caused by a


congenital or acquired injury or illness that requires a specialized rehabilitation program or a high level of care, service, resources, or continued coordination of care in the community) New Enrollees & Members Transitioning to Another Health Plan All new enrollees receive Evidence of Coverage (EOC) membership information in their enrollment packets. The EOC provides information regarding the members rights to request continuity of care if the member transitions to another health plan. Physician Contract Termination A terminated physician or Provider or Provider group who actively treats members must continue to treat members until their date of termination. After we receive a physicians/Providers or physicians group notice to terminate a contract, we notify members impacted by the termination of a physician/Provider or Provider group. We send a letter to inform the affected members of the termination. The Plan makes every effort to notify members at least 30 days prior to the termination. Continuity of Care Process Care management nurses review member and Provider requests for continuity of care. If continuity of care is appropriate, facilitate continuation with the current physician until short-term regimen of care is completed or the member transitions to a new practitioner.

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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).

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CLINICAL PRACTICE GUIDELINES


Anthem Blue Cross and Anthem Blue Cross Partnership Plan supports physicians in following nationally-accepted clinical practice guidelines to improve the health of our members. Several national organizations produce guidelines for asthma, diabetes, hypertension, and other conditions. We have reviewed and recommend these clinical practice guidelines. Providers can access the most up-to-date clinical practice guidelines from nationally recognized sources through the Internet by going to the following links:

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.

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PREVENTIVE HEALTH CARE GUIDELINES


Good health begins with good lifestyle habits and regular exams. Preventive health care guidelines help providers keep members on track with necessary screenings and exams based on age and gender. Several national organizations produce guidelines for preventive screening, immunizations, and counseling. We have reviewed and recommend these preventive health care guidelines. Providers can access the most up-to-date preventive healthcare guidelines from nationally recognized sources through the Internet by going to the following links and scrolling through age-related sections for more specific information:

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.

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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).

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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.

INITIAL HEALTH ASSESSMENT


Primary care physicians (PCPs) must perform an Initial Health Assessment (IHA) with new members. The IHA consists of: A history and physical examination A developmental assessment A health education behavioral assessment that enables the provider to comprehensively assess the members current acute, chronic, and preventive health needs

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

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A dental evaluation A vision screening A hearing screening

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
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Provider Roles and Responsibilities


STAYING HEALTHY ASSESSMENT TOOL
Providers must use the Staying Healthy Assessment Tool (SHAT), also known as the Individual Health Education Behavioral Assessment (IHEBA), with all new MediCal members (does not apply to Healthy Families Program, Access for Infants and Mothers (AIM), and Major Risk Medical Insurance Program (MRMIP) members). The Office of Clinical Preventive Medicine (OCPM), the Medi-Cal Managed Care Division (MMCD), and Medi-Cal Managed Care Health Plans developed this assessment over the past several years to: Identify health risk behaviors Provide health education counseling Assist in prioritizing individual health education needs related to lifestyle, behavior, environment and cultural linguistic background

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.

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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.

EMERGENCY ROOM PROGRAM INITIATIVE


We designed the Emergency Room (ER) Program Initiative to increase member knowledge and skills related to self-care management and decision-making about appropriate resources (for example, self-care, PCP or 24/7 NurseLine) when a nonemergency event occurs. Ultimately, the goal of this program is to help members establish a medical home in a primary care setting. This program utilizes a multi-faceted approach to inform members about appropriate utilization of resources. To promote continuity of care and access to a PCP, this initiative is comprised of targeted member and physician interventions based on the members frequency of ER visits within a 12-month rolling period. Member interventions include: Dissemination of self-care books, letters, or ER member packets Educational materials

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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

NURSE INFORMATION LINE


How the Nurse Information Line Assists Members 24/7 NurseLine, a 24-hour health information line staffed by specially trained registered nurses, is available to all members 24 hours a day, 7 days a week. 24/7 NurseLine nurses can help members with health-related questions and also can help them determine whether or not an emergency room visit is necessary. The 24/7 NurseLine phone number is 1-800-224-0336. Members can contact 24/7 NurseLine for: Assistance with self-care information Referrals to community resources

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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

Member Eligibility Important Contact Information


HEALTH EDUCATION CLASSES AND MATERIALS
No-Cost Classes Available to Members We offer health education services and programs to meet the specific health needs of our members to promote healthy lifestyles and to improve the health status of those living with chronic diseases. Health education classes take place at hospitals or community-based organizations that have expertise in providing health education services. Classes are available at no charge to the member and are accessible upon self-referral or referral by contracted providers. Classes vary from county to county. Examples of some of the classes that we provide include:
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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.

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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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HEALTH EDUCATION AUDITS


We will assess Provider activities, including health education documentation, during a facility/medical records audit. This audit will review the provision of preventive health services and health education services available to members. The audit will also assess readiness of Provider health education materials and Planspecific resource information, applicable materials to the members served, and availability of materials in languages identified for that county or area of site location. Cross-References

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.

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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.

HEALTH EDUCATION PROGRAMS


To help members improve and manage their health, we developed several health education programs to address member health status and condition. Childhood Obesity Initiative Given the public health nature of the childhood obesity epidemic, we have developed a multi-pronged initiative to assist and equip physicians and health care providers to screen members who are overweight or obese, focus on preventive efforts, institute appropriate management, and empower members to lead healthier lifestyles.

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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.
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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.

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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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Tobacco Use On the Rise for Teens


HEALTH MANAGEMENT PROGRAMS
We seek to improve the health and overall well-being of members by offering health management programs that educate, inform, and encourage self-care. We designed the following programs to assist members in learning and following selfcare regimens and treatment therapies for existing medical conditions, chronic diseases, or health conditions. Healthy Habits Count with Asthma Program Our Healthy Habits Count with Asthma Program is designed to increase identification of members with asthma, ensure that they receive appropriate treatment, and develop Asthma Action Plans to improve their self-management skills. The program is based on the National Institute of Health (NIH) and National Heart, Lung, and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma (www.nhlbi.nih.gov/guidelines/asthma). We work collaboratively with providers in the identifying and managing treatment of members with asthma. Member enrollment and participation in the Healthy Habits Count with Asthma Program is based on either an opt-out process for high-risk members or an opt-in process available to self-referred members in 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 us. Provider Care for Asthmatic Members PCPs provide each asthmatic member with ongoing treatment and prescribe medication following the NIH/NHLBI Guidelines for the Diagnosis and Management of Asthma. PCPs should: Assess members for asthma using the NIH risk categories when medically appropriate. Provide each member diagnosed with asthma with a written Asthma Action Plan that describes medication dosage and level of care needed based on peakflow readings. Refer members to the Healthy Habits Count with Asthma Program education classes and local community agencies by calling our CCC. Coordinate care with care management, pharmacy, and specialists as needed.

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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

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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

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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

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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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QUALITY IMPROVEMENT (QI) PROGRAM STRUCTURE


Under federal and state guidelines, managed care organizations must have an organized Quality Improvement (QI) Program. Our commitment to quality improvement is not based on legal requirements alone. We are committed to working with providers to provide quality, cost-effective care and have a systematic process for monitoring and evaluating the quality and appropriateness of care and service to our members. Quality Improvement (QI) Program Scope The Quality Improvement (QI) Program includes developing and implementing standards for clinical care and service, measuring conformity to those standards, and taking action to improve performance. The scope of the QI Program includes, but is not limited to, monitoring and evaluating the following:

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

Internal health plan organizational performance


Quality Improvement (QI) Program Work Plan and Annual Evaluation The Plan develops an annual work plan of activities based on the results of the previous years QI Program evaluation. We review, evaluate, and revise the Quality (QI) Programs effectiveness annually. The evaluation is a written description of the ability of the Plan to implement the QI Program, to meet program objectives, and to develop and implement plans to improve the quality of care and service to members. What Providers Can Do to Support the Plans Quality Improvement (QI) Program Providers support the activities of the Quality Improvement (QI) Program by:

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

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Responding in a timely manner to requests for written information and


documentation if a quality of care or grievance issue has been filed

Utilizing preventive health and clinical practice guidelines in member care


Quality Improvement (QI) Studies and Projects The Health Employer Data and Information Set (HEDIS) is a core set of performance measures that gauges the effectiveness of the Plan and its providers in ensuring quality of care and services to adults and children. The Plan measures the effectiveness of our care and services through:

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.

MEDICAL RECORD AND FACILITY SITE REVIEWS


We conduct medical record reviews and Facility Site Reviews to:

Determine the Provider offices ongoing compliance with standards for providing
and documenting health care services and with processes that maintain safety standards and practices

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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

Submit a completed corrective action plan, supporting documents, and signed


attestation statement to our Quality Management Analyst Medical Office Policies and Procedures Sample Medical Office Policies and Procedures can be found on our secure ProviderAccess Provider website.

MEDICAL RECORD DOCUMENTATION STANDARDS


We established medical record standards that require Providers to maintain medical records in a manner that is current and organized and permits effective and confidential member care and quality review. We perform medical record reviews upon signing of a contract and, at a minimum, every three years thereafter to assure that network Providers are in compliance with the standards. Medical records are stored and retrieved in a manner that protects patient information according to the Confidentiality of Medical Information Act. This act prohibits a provider of health care from disclosing any individually identifiable information regarding a patients medical history, mental, and physical condition or treatment without the patients or legal representatives consent or specific legal authority. Records required through a legal instrument may be released without patient or patient representative consent. Providers must be familiar with the security requirements of the Health Insurance Portability and Accountability Act (HIPAA) and be in compliance. Security The medical record must be secure and inaccessible to unauthorized access in order to prevent loss, tampering, disclosure of information, or alteration or destruction of the record. Information must be accessible only to authorized personnel within the Providers office, the Plan, the Department of Managed Health Care (DMHC), the DHCS, or to persons authorized through a legal instrument. Records must be made available to the Plan for purposes of quality review, HEDIS, and other studies.

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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

Identification of all providers participating in the members care and information


on services furnished by these providers

A problem list, including significant illnesses and medical and psychological


conditions

Presenting complaints, diagnoses and treatment plans, including the services to be


delivered

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)

Information on advance directives

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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

An immunization record for children that is up-to-date or an appropriate history


is in the medical record for adults. Documentation attempts to provide immunizations. If the member refuses the immunization, proof of voluntary refusal of the immunization in the form of a signed statement by the member or guardian of the member shall be documented in the members medical record. Evidence of preventive screening and services in accordance with the Plans preventive health practice guidelines:

Documentation of referrals, consultations, test results, and inpatient records.


Notations of information the patient of test results should be included.

Notations of patient appointment cancellations or No Shows and the attempts


to contact the patient to reschedule

No evidence that the patient is placed at inappropriate risk by a diagnostic or


therapeutic procedure

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.

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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

When a member calls to request a PCP change:

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:

Enrollment with another plan Termination of eligibility with the Plan

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Return to traditional or original fee-for-service Medi-Cal for continuity of care if


the members benefits fall into a voluntary aid code If a member asks a provider how to disenroll from the Plan, the Provider can direct the member to call the CCC phone number on the back of the members ID card. Medi-Cal: Health Care Options Medi-Cal members who want to disenroll from the Plan can call Health Care Options (HCO) at 1-800-430-4263 to request a Request for Disenrollment Form. When members call our CCC requesting disenrollment, we refer them to the HCO phone number. The member must complete the Request for Disenrollment Form and mail it to: Health Care Options P.O. Box 989009 West Sacramento, CA 95798-9850 Medi-Cal: L.A. Care (Los Angeles County Only) L.A. Care Medi-Cal members who want to disenroll from the Plan may call L.A. Care at 1-888-452-2273 to request a Plan Partner Change Form. L.A. Care may refer the member to HCO. If members call the CCC requesting disenrollment, we will refer them to the L.A. Care phone number. L.A. Care determines L.A. Care Health Plan membership eligibility. L.A. Cares mailing address is: L.A. Care Health Plan 555 West Fifth Street Los Angeles, CA 90013 The Plans Response to Member Disenrollment Calls When the CCC receives a call from a member who wants to disenroll from the Plan, our CCC follows the following procedures:

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 a member agrees to allow us to attempt resolution, the CCC Representative


initiates the process that would properly address the situation (such as Grievance, Physician Service 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)

Has other nongovernment or government-sponsored health coverage


MEMBER TRANSFERS AND DISENROLLMENT FROM THE PLAN
Member-Initiated Disenrollment For information about member-initiated disenrollment for the Healthy Families Program, the Access for Infants and Mothers (AIM) Program, and the Managed Risk Medical Insurance Program (MRMIP), call the following numbers: Healthy Families Program: AIM: MRMIP: PCP-Initiated Transfers For information regarding PCP-initiated transfers of members to another PCP, call the Customer Care Center for the applicable program: Healthy Families Program: AIM and MRMIP: 1-800-845-3604 1-877-687-0549 TDD: 1-888-757-6034 1-800-880-5305 1-877-687-0549 TDD: 1-888-757-6034 1-877-687-0549 TDD: 1-888-757-6034

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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:

Credentialing Program Structure: This policy describes the WellPoint National


Credentials Committee, composed of brand medical directors and chaired by the VP of Medical Policy, Technology Assessment and Credentialing. This group has oversight of matters relating to the policies used in the Credentialing Program and is the authorizing body for the enterprise-wide Credentialing Policies (Credentialing Policy #1)

Credentialing Program Scope: This policy specifically details which providers


fall within the scope of the Credentialing Program (Credentialing Policy #2 in Credentialing Policies)

Credentials Committee (Geographic): This committee describes the


geographic composition of the Credentials Committees that perform individual peer review of all applicants for initial and continued network participation; the policy also relates the operational rules for the committees (Credentialing Policy #3 in Credentialing Policies)

Professional Competence and Conduct Criteria: This policy outlines the


various standards of conduct and competence, and the data elements required for network participation. This policy deals with issues most central to the entire credentialing process (Credentialing Policy #4 in Credentialing Policies).

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)

Criteria for Selecting Practitioner Leveling and Committee Presentations:


This policy provides the specific criteria that dictate applicants for both initial and continued participation will be presented for individual review by the CC; it also outlines the process for off-cycle review (Credentialing Policy #8 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)

Recredentialing: Recredentialing issues, including requirements, frequency and


the decision-making processes, are relayed in this document (Credentialing Policy #10 in Credentialing Policies)

Termination and Immediate Termination: This policy discusses the process


for termination and immediate termination (Credentialing Policy #11 in Credentialing Policies)

Reporting of Adverse Actions: This policy describes the mechanisms for


compliance with regulatory requirements for reporting to appropriate agencies (Credentialing Policy #12 in Credentialing Policies)

Continuous Monitoring: In order to support the maintenance of standards of


professional conduct and competence, ongoing, continuous monitoring of sanctions and complaints occurs; the principles and mechanisms governing this activity are described in this policy (Credentialing Policy #13 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

Reapplication After Adverse Determination (Denial or Termination): This


operational policy outlines the time frames when provider may reapply

Practitioner Physical and Mental health Conditions and Impairments: This


policy provides a framework for use in assessing providers with potential impairments.

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Credentialing of Nurse Practitioners, Nurse Midwives and Physicians


Assistants: this policy is invoked when there is a specific request by the business unit to use these provider types and to list them in the directories. Requirements for each type of provider are detailed. These provider types are to be credentialed only at the specific request of the business unit.

Credentialing of Resident Physicians: This policy outlines the requirements


and processes for the credentialing of physicians in residency programs. This policy is invoked when there is a specific request by the business unit.

Specialty Designations: This policy describes the framework for recognized


training programs and requirements for various specialty and subspecialty designations

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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FRAUD AND ABUSE


We are committed to protecting the integrity of the programs we offer and the efficiency of our operations by preventing, detecting, and investigating fraud and abuse. Understanding Fraud and Abuse Combating fraud, abuse, and waste begins with knowledge and awareness. Fraud is any type of intentional deception or misrepresentation made when a person knows that the deception could result in some unauthorized benefit to himself or herself or some other person. The attempt itself is fraud, regardless of whether or not it is successful. Abuse is any practice that is inconsistent with sound fiscal, business, or medical practices and results in an unnecessary cost to the program. Examples of Provider Fraud or Abuse These are typical examples of provider fraud and abuse:

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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Written warning or education: We send certified letters to the Provider or member


documenting the issues and the need for improvement. Letters may include education and requests for recoveries or advice of further correction action.

Medical record audit: We may review medical records to substantiate allegations or


validate claims submission.

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.

Recovery: We recover overpayments directly from the provider within 30 days.


Failure of the Provider to send the overpayment may result in reduced payment of future claims or further legal action.

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.

Provider termination: Failure to comply with program policy and procedures or


any violation of the contract results in termination from the Plan.

Member disenrollment: Fraud, threatening behavior, or failure to correct issues


may result in involuntary disenrollment form our health plan (with state approval). See Plan-Initiated Member Disenrollment.

Referral to law enforcement: We refer criminal activity to the appropriate local or


regulatory enforcement agency. False Claims Act We are committed to complying with all applicable federal and state laws including the Federal False Claims Act (FCA). The FCA is a federal law that provides the federal government with the means to recover money stolen through fraud by government contractors. Under the FCA, anyone who knowingly submits or causes another person or entity to submit false claims for payment of government funds is liable for three times the damages, or loss, to the government plus civil penalties of $5,500 to $11,000 per false claim.

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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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COMMUNITY RESOURCE COORDINATORS


Community Resource Coordinators (CRCs) are staff who are geographically located in the community to assist network physicians, members, and community agencies with direct access to our resources. CRCs do the following:

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

Implement health promotion programs and campaigns targeted to chronic


diseases such as asthma, diabetes, or prenatal care

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

Partner with community-based organizations to build a network of social and


health services and resources for our members and families

Increase community awareness of the Plan and its services


The CRCs help to bridge the gap between plan requirements and the realities of the local health care delivery systems. CRCs are responsive to the needs of both network providers and members and are always available to help with operations and access to health care services. We recommend that providers and office staff attend Provider-training sessions conducted by CRCs for valuable and critical information for managing their practices.

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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:

Managers oversee CRCs and manage relationships among staff, providers,


members, community-based organizations, local government entities, and state agencies.

Administrative assistants are often the first contact for network physicians,
members, community partners, and visitors to the facilities where our CRCs are located.

Network Management Analysts, located throughout the state, identify Provider


network gaps--they are our contract negotiators in the field.

Network Education Representatives conduct training sessions in Provider offices


and hospital settings; this training fosters successful operating procedures and ensures understanding of the various state-sponsored programs, including program policies and program requirements, billing procedures, and electronic billing. Network Education Representatives also serve as local contacts to answer questions and resolve problems for Providers.

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.

Health Promotion Consultants provide member support services, including health


education referrals, event coordination, and coordination of cultural and linguistic services. Health Promotion Specialists refer members and coordinate access to community health education resources for breast feeding, smoking cessation, diabetes, asthma, and other necessary resources.

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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

Government agencies such as Social Security Administration


Each CRC has access to the services of an outreach specialist, whose primary responsibility is to call and visit members in their homes. Providers can request an outreach specialist for members who need help in accessing health care services. Home visits are a proven strategy to reduce or eliminate barriers how members experience accessing care. Outreach Specialists conduct home visits for members who have missed multiple appointments, need assistance with nonemergency transportation to medical appointments, or are hard to reach by telephone.

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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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INTERPRETER SERVICES AND SERVICES FOR THE HARD OF HEARING


We appreciate the need for good communication between providers, patients, and the Plan and offer the linguistic tools needed for satisfying and effective medical encounters. Following is a list of interpreter services. Services All Services are Available through the Health Plan

Telephone Interpreters: Available 24 hours a day, 7 days a week by calling the


Customer Care Center during business hours and 24/7 NurseLine after-hours

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.

Assistance for the Visually Impaired: Visually-impaired members can request


verbal assistance or alternative formats for assistance with printed materials.

Face-to-Face Interpreters: Interpreters may be used at key points of medical


contact by calling the Customer Care Center 72 business hours in advance to schedule an interpreter. We request 24 business hours to cancel an interpreter service. Provider Responsibilities Providers who have delegated responsibilities, such as Utilization Management, should include Anthem Blue Cross State Sponsored Business Language Assistance Notice with benefit-related communications to members. The notice is available on the SSB provider website in the Forms and Tools Library at http://www.anthem.com/wps/portal/ca/provider?content_path=provider/f 3/s1/t4/pw_a112606.htm&label=Forms%20%5E%20Tools%20Library&rootL evel=3 Additional cultural and linguistic resources for Providers are available on our website at http://www.anthem.com/wps/portal/ca/provider?content_path=provider/f 4/s2/t0/pw_a120290.htm&label=Cultural%20and%20Linguistic%20Provider %20Resources&rootLevel=3

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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Notification: Providers must notify members of the availability of health plan


interpreter services and strongly discourage that minors, friends, and family act as interpreters.

Documentation of Notification: If the member chooses to use a friend, family


member or minor as an interpreter after being notified of the availability of free interpreter services, the Provider must document this choice in a prominent place in the members medical record.

Request/Refusal Forms for Interpretive Services: Electronic PDF copies of these


forms are available on the www.anthem.com/ca website.

After-Hours Linguistic Access: We encourage Providers to accommodate


non-English proficient members by having multi-lingual messages on answering machines and training their answering services and on-call personnel on how to access interpreter services.

Provider Directory Updates: Providers are required to maintain a system to


monitor the language capability listed in the Provider Directory - the language which they and their staff speak. Providers are required to notify us of changes in the language capability of medical and administrative staff. The website Provider Directory is updated as changes are received; printed copies of the Directory are updated twice a year. Providers must document a process for assessing interpreter capabilities of staff who speak the language, as listed in the directory. Key points include:

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

Providers must supply Anthem Blue Cross with documentation of assessment


upon request. Resources Available on Our Website To find a list of resources on our website go to www.anthem.com/ca.

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Follow these steps to navigate to interpreter information the website:

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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Click Health Education Resources for a variety of health topic brochures in


English and Spanish

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

Member Rights and Responsibilities

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CULTURAL COMPETENCY AND HEALTH AND READING LITERACY


We acknowledge the diversity of our membership and Provider network. We appreciate the challenges Providers may encounter integrating appropriate culturally diverse behaviors, values, norms, practices, attitudes and beliefs about the causes of disease, prevention, and treatment in the delivery of health care. In addition, consideration of members health and reading literacy levels also may add to the complexity of cultural competence. Although medical advances and increased efforts regarding preventive medicine have contributed to increased life expectancies and improved general health for many Americans, health disparities are still very evident in the African American, Hispanic, Asian/Pacific Islander, and American Indian/Alaskan Native, and other populations. We are eager to assist your office with increasing your cultural competence and decreasing health disparities. We also recognize that such competence is a process that evolves over time and that you and your office staff may be at various levels of awareness, knowledge and skills. We encourage you to increase your cultural sensitivity by using the cultural and linguistics resources included on our website. Go online to www.anthem.com/ca and select State Sponsored Plans>Forms and Tools Library. Scroll down to Health Education and select the link for more information. As you know, it is important to assess the individual health beliefs and practices of your members and to consider the role of culture and ethnicity. In doing so, your assessment efforts should uncover a members certain cultural health beliefs, attitudes and traditions. Although some beliefs may be associated with various groups of people, there may be a great deal of diversity within cultural groups. Categorizing groups of people according to their cultural or ethnic backgrounds when addressing their health care needs may lead to misunderstandings and possible transfer of misinformation. Low Literacy and Its Impact on the Health Professional Accurately assessing members reading and health literacy helps to improve communication between Providers and members. As a health professional, you need to make sure members understand their medical conditions and health instructions. Tips to assist you in determining a members health and reading literacy levels and successfully educating your members may be found online by going to www.anthem.com/ca. Select State Sponsored Plans.Health Education. Scroll down to Health Education and select Free Interpreting Services for more information.Please also see the Cultural and Linguistics Toolkit on our website.

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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

Interpreter Services and Services for the Hard of Hearing

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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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Provider Operations Manual Acronym EDS EPSDT EOB EOC EPO ER ERA FDA FFS FTE HCBS HCO HCPCS HEDIS HIPAA HIV HMO HPS ICD-9 ID IHA IHEBA IHMC IHSS IMR ISP IVR KICK LAP LCSW LEP LHD LMP LOS MCAH MCH MCWP MMCD MOU MRI MRMIB MRMIP MSSP NCQA Definition Electronic Data Systems Early and Periodic Screening Diagnostic and Treatment Services Explanation of Benefits Evidence of Coverage Exclusive Provider Organization Emergency Room Electronic Remittance Advice Food and Drug Administration Fee For Service Full-Time Equivalent Home and Community-Based Services Health Care Options Healthcare Common Procedure Coding System Health Employer Data and Information Set Health Insurance Portability and Accountability Act of 1996 Human Immunodeficiency Virus Health Maintenance Organization Health Promotion Specialists International Classification of Diseases, 9th Revision Identification Initial Health Assessment Individual Health Education Behavioral Assessment In-Home Medicare Waiver Program In-Home Supportive Services Independent Medical Review Internet Service Provider Interactive Voice Response Kids in Charge of Kalories Language Assistance Program Licensed Clinical Social Worker Limited English Proficient Local Health Department Last Menstrual Period Length of Stay Maternal, Child and Adolescent Health Maternal and Child Health Medi-Cal Waiver Program Medi-Cal Managed Care Division Memorandum of Understanding Magnetic Resonance Imaging Managed Risk Medical Insurance Board Major Risk Medical Insurance Program Multipurpose Senior Service Program National Committee for Quality Assurance

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Provider Operations Manual Acronym NDC NHLBI NIH NRT OB OB/GYN OCPM OCC OS OTC PAB PCP PCR PDP PDR PIN PMG PNR POS PPI PPO PQRC QI QIC QIP QM QMA QMRN QMS RA RTIE SBC SED SHAT SNF SSB STD TB TIPS TLC TPL TPN TTD TTY Definition National Drug Code National Heart, Lung and Blood Institute National Institute of Health Nicotine Replacement Therapy Obstetrician Obstetrics/Gynecology Office of Clinical Preventive Medicine Outreach Call Center Outreach Specialist Over the Counter Prior Authorization of Benefits Primary Care Physician or Primary Care Provider Physician Clinical Review Prescription Drug Plan Provider Dispute Resolution Personal Identification Number Provider Medical Group Pregnancy Notification Report Point of Service Proton Pump Inhibitor Preferred Provider Organization Physician Quality Review Committee Quality Improvement Quality Improvement Committee Quality Improvement Program Quality Management Quality Management Analyst Quality Management Registered Nurse Quality Management Specialist Remittance Advice Real Time Internet Eligibility School-Based Clinic Serious Emotional Disturbance Staying Healthy Assessment Tool Skilled Nursing Facility State Sponsored Business Sexually Transmitted Disease Tuberculosis CDCs Tobacco Information and Prevention Sources The Last Cigarette Third Party Liability Total Parenteral Nutrition Telecommunication Device for the Deaf Text Telephone (Teletype)

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Provider Operations Manual Acronym UM VFC VSP WIC WPM Definition Utilization Management Vaccines for Children Vision Service Plan Women, Infants and Children Program WellPoint Pharmacy Management

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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:

Delay a decision to approve, modify, or deny a request for authorization of a


covered service to receive additional documentation from the requesting provider

Determine if other medical coverage exists that is primary to the Plan

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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.

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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:

Placing the patients health in serious jeopardy

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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.

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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.

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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).

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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.

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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.

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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.

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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.

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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

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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.

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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.
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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.

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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

Administrative Issues: Denial of benefits (such as when a provider refuses to


treat one of our members, has the inability to maintain a satisfactory patient/provider relationship, or has problems with the Plans staff or other contracted providers)

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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:

Second or third trimester of pregnancy through at least six weeks of postpartum


evaluation

Terminal illness A series of chronic conditions


Quality Assessment and Improvement Program (QAIP) The Quality Assessment and Improvement Program (QAIP) is a written description of the quality programs goals, objectives and structure. It details the role, function and reporting relationships of the Quality Improvement Committee (QIC) and the participation of practitioners and Plan medical directors. This document serves as an outline of the Plans efforts to monitor and improve the quality of service and care to members. Quality Improvement System for Managed Care (QISMC) Quality Improvement System for Managed Care (QISMC) is a set of Centers for Medicare and Medicaid Services (CMS) standards that measure an organizations performance against standardized quality measures.

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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.

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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

Version: 1.4 Revision Date: February 2010 Chapter 22: Page 30

CHAPTER 22: ACRONYMS, DEFINITIONS AND MAPS


Provider Operations Manual

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

Version: 1.4 Revision Date: February 2010 Chapter 22: Page 31

CHAPTER 22: ACRONYMS, DEFINITIONS AND MAPS


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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

Version: 1.4 Revision Date: February 2010 Chapter 22: Page 32

CHAPTER 22: ACRONYMS, DEFINITIONS AND MAPS


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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

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CHAPTER 22: ACRONYMS, DEFINITIONS AND MAPS


Provider Operations Manual

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

Version: 1.4 Revision Date: February 2010 Chapter 22: Page 34

California Healthy Families Program ServiceAND Counties CHAPTER 22: ACRONYMS, DEFINITIONS MAPS Provider Operations Manual 07/01/09 - 06/30/10

Del Norte Siskiyou Modoc

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

El Dorado Sacramento Amador Alpine

No n- Anthem C o unty

Solano Marin San Francisco San Mateo Santa Cruz Contra Costa Alameda Santa Clara San Joaquin

Calaveras Tuolumne Mono Mariposa

Stanislaus Merced

Madera San Benito Fresno Inyo Tulare Kings

Monterey

San Luis Obispo

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

Version: 1.4 Revision Date: February 2010 Chapter 22: Page 35

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

Geographic Managed Care


Tehama Plumas Mendocino Butte Sierra Nevada Placer*

Total Medi-Cal Enrollment


787,478

Glenn

Colusa Lake Sonoma Yolo Sac.

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

Merced Madera San Benito

Fresno Inyo Tulare

Monterey

Kings

San Luis Obispo

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

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