Provider Manual - Anthem

1 Provider ManualMedi-Cal Managed CareMajor Risk Medical Insurance Program CABC-CD-PM-028102-23 Anthem BLUE CROSS Provider Manual The master copy of this document is available online. Hard copies are for information purposes only and are not subject to document control. ii SEPTEMBER 2023 TABLE OF CONTENTS 1 | INTRODUCTION .. 2 WELCOME .. 2 USING THIS Manual .. 2 2 | QUICK REFERENCE .. 5 WEBSITES AND COMMUNITY RESOURCES .. 5 ONLINE TOOLS FOR PROVIDERS .. 5 health EDUCATION AND CULTURAL AND LINGUISTIC NEEDS .. 6 MEDICAL APPOINTMENT STANDARDS .. 6 CONTACT INFORMATION .. 7 COVERED SERVICES GRID.

2 12 3 | MEMBER ELIGIBILITY .. 22 VERIFYING ELIGIBILITY .. 22 ENROLLMENT/DISENROLLMENT .. 24 MEMBER-INITIATED PCP CHANGES .. 24 MEMBER TRANSFERS TO OTHER PLANS .. 25 MEMBER NONDISCRIMINATION .. 25 4 | GENERAL BENEFITS .. 27 BENEFIT PROGRAMS AND POPULATIONS .. 27 BEHAVIORAL health AND SUBSTANCE ABUSE .. 28 MEMBER RECORDS, ASSESSMENT, AND TREATMENT PLANNING .. 30 MAJOR ORGAN TRANSPLANT .. 36 SENSITIVE 38 TELEHEALTH .. 38 39 5 | MEMBER SERVICES, EDUCATION, WELLNESS .. 41 WELLNESS PROGRAMS .. 41 CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES .. 46 MEMBER RIGHTS AND RESPONSIBILITIES .. 49 6 | PHARMACY.

3 53 PRIOR AUTHORIZATIONS .. 54 SPECIAL FILL PROCEDURES .. 56 PHARMACY PROGRAMS .. 56 COORDINATION OF BENEFITS .. 57 7 | SPECIAL PROGRAMS .. 58 MANAGED LONG-TERM SERVICES AND SUPPORTS .. 58 COMMUNITY-BASED ADULT SERVICES .. 60 ENHANCED care MANAGEMENT PROGRAM .. 64 COMMUNITY SUPPORTS .. 66 PALLIATIVE care PROGRAM .. 69 COMMUNITY health WORKER .. 71 DOULA .. 72 LIVEHEALTH ONLINE (LHO) .. 73 8 | Provider PROCEDURES AND RESPONSIBILITIES .. 74 HOSPITAL SCOPE OF RESPONSIBILITIES .. 76 ACCESS TO care , APPOINTMENT STANDARDS, AND AFTER-HOURS SERVICES .. 77 REQUIRED ASSESSMENTS .. 83 CALIFORNIA CHILDREN S SERVICES.

4 85 iii PREGNANCY NOTIFICATION .. 86 PREVENTIVE healthcare .. 87 9 | ADMINISTRATIVE PROCEDURES .. 91 Provider TERMINATION, LOCATION, COVERED SERVICES AND/OR POPULATION SERVED CHANGES 91 CONTRACT TERMINATION WITH health PLAN .. 92 TERMINATION OR AFFILIATION CHANGE WITH Provider GROUPS .. 92 UPDATING Provider DIRECTORIES .. 93 10 | CREDENTIALING AND RECREDENTIALING .. 95 CREDENTIALING SCOPE .. 95 INITIAL CREDENTIALING .. 96 health DELIVERY ORGANIZATIONS .. 97 CREDENTIALING PROGRAM 99 SANCTION MONITORING .. 111 APPEALS PROCESS .. 111 11 | UTILIZATION MANAGEMENT AND PRIOR AUTHORIZATION .. 113 AUTHORIZATION REQUESTS AND TIME FRAMES.

5 113 EMERGENCY MEDICAL CONDITIONS AND SERVICES .. 118 CONTINUED STAY 119 POST-SERVICE CLINICAL CLAIMS REVIEW .. 120 REFERRALS AND SECOND OPINIONS .. 120 TRANSITION AND DISCHARGE PLANNING .. 121 12 | care MANAGEMENT AND health PROGRAMS .. 123 CONTINUITY OF care .. 125 CONDITION care PROGRAMS .. 127 health SERVICE 128 13 | QUALITY MANAGEMENT .. 131 Provider PERFORMANCE DATA .. 133 healthcare EFFECTIVENESS DATA AND INFORMATION SET (HEDIS) .. 133 FACILITY SITE AND MEDICAL RECORDS REVIEWS .. 135 MEDICAL RECORDS REVIEW PROCESS .. 137 14 | CLAIMS AND ENCOUNTERS .. 140 REIMBURSEMENT POLICIES .. 140 OUTLIER REIMBURSEMENT AUDIT AND REVIEW PROCESS.

6 141 CLAIM SUBMISSIONS .. 152 CLAIMS CODING AND DOCUMENTATION .. 168 CLAIM PROCESSING .. 172 CLAIMS STATUS .. 174 OVERPAYMENT AND RECOVERY .. 175 ENCOUNTER DATA .. 175 15 | GRIEVANCES, APPEALS, DISPUTES .. 178 CLAIM PAYMENT DISPUTE .. 178 CLAIM INQUIRIES .. 178 Provider GRIEVANCES .. 181 ARBITRATION .. 181 MEMBER APPEALS AND GRIEVANCES .. 182 16 | COMPLIANCE AND REGULATORY REQUIREMENTS .. 186 Provider S ROLE IN COMPLIANCE, ETHICS, PRIVACY, AND HOTLINE REPORTING .. 186 MARKETING RULES .. 187 HIPAA PRIVACY, PHI, SECURITY .. 188 iv FRAUD, WASTE, AND ABUSE .. 189 DELEGATION OVERSIGHT .. 191 Provider GROUP FINANCIAL OVERSIGHT.

7 192 HOSPITAL FINANCIAL REVIEW .. 193 2 1 | INTRODUCTION WELCOME Thank you for being part of the Anthem Blue Cross family of healthcare services. Anthem Blue Cross has been selected by the California Department of health care Services (DHCS) to provide healthcare services for Medi-Cal Managed care (Medi-Cal) members in the following counties: Alameda Alpine Amador Butte Calaveras Colusa Contra Costa El Dorado Fresno Glenn Inyo Kings Madera Mariposa Mono Nevada Placer Plumas Sacramento San Benito San Francisco Santa Clara Sierra Sutter Tehama Tulare Tuolumne Yuba Anthem Blue Cross partners with care health Plan to provide healthcare services for Medi-Cal members in the following county: Los Angeles Medi-Cal provides healthcare coverage for California's most vulnerable low-income residents who lack health insurance.

8 Medi-Cal is the second largest source of healthcare coverage in California. Anthem Blue Cross has a long-standing history of providing Medi-Cal services to Californians. In fact, Anthem Blue Cross was one of the first Medi-Cal managed care organizations (MCOs). USING THIS Manual This Provider Manual is designed for Anthem Blue Cross contracted providers. Our goal is to create a useful reference guide for you and your office staff. Anthem will solicit feedback from community stakeholders in various forums that can include the Community Advisory Committee (CAC) and Medical Advisory Committee (MAC) regarding the development of this Manual and clarify new or revised policies and procedures it contains.

9 Providers contracted with an independent physician association (IPA) or other Provider organization may have separate policies and procedures. Please contact the organization s administrator for details. We recognize that managing our members health can be a complex undertaking. It requires familiarity with the rules and requirements of a system that encompasses a wide array of healthcare services and responsibilities. With that in mind, we have divided this Manual into broad sections that reflect your questions, concerns, and responsibilities before and after a member of Anthem Blue Cross walks through your doors.

10 This Manual is available to you on our website at: Select any topic in the Table of Contents and you will be automatically redirected to that topic s location within the Manual . Select any web address and you will be redirected to that site. Each chapter may also contain cross- 3 links to other chapters, important phone numbers, and our website or outside websites containing additional information. Throughout this Manual , there are instances where information is provided as a sample or example. This information is meant for illustration purposes only and is not intended to be used or relied upon in any circumstance or instance.