Anthem Copay

All of Anthem’s MediBlue Rx Part D plans have just $1 to $3 copays for generic tiers at preferred pharmacies (after your deductible if it applies). If you’re new to Medicare Part D plans, you can read more about prescription drug tiers and costs. Find the Anthem MediBlue Rx. Services that are not medically necessary; The difference between the actual charge and the maximum allowed amount, plus any deductible and/or copayments/coinsurance. Anthem has processes to review claims before and after payment to detect fraud, waste, abuse and other inappropriate activity.

Information from Anthem for Care Providers About COVID-19 (March 12, 2021)

Please note that the following information applies to Anthem Blue Cross’ Commercial health plans. Please review the Medicare and Medi-Cal specific sites noted below for details about these plans.

Commercial: Provider News Home

Medi-Cal: Medi-Cal Provider News & Announcements - COVID-19

Medicare: Medicare Advantage News

Information from Anthem for Care Providers about COVID-19 (March 12, 2021)

Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company (collectively “Anthem”) are closely monitoring COVID-19 developments and what it means for our customers and healthcare provider partners. Our clinical team is actively monitoring external queries and reports from the Centers for Disease Control and Prevention (CDC) to help us determine what action is necessary on our part.

To help address care providers’ questions, Anthem has developed the following updates and frequently asked questions.

Contents:

Waiver of member cost shares
Prior authorization
Telehealth and telephonic-only services
Coding, billing, and claims
Claims audits, retrospective review and policy changes
Provider credentialing
Vaccine administration
Prescription drugs
General questions

Waiver of Member Cost Shares

Will Anthem waive member cost shares related to COVID-19 including screening, testing, and treatment?

Screening & Testing: Yes, as of March 5, 2020, and until further notice, cost shares, inclusive of copays, coinsurance and deductibles for COVID-19, will be waived by Anthem or its delegated entities for screening and testing for COVID-19. Tests samples may be obtained in many settings including a physician’s office, urgent care, ER or even drive-thru testing once available. While a test sample cannot be obtained through a telehealth visit, the telehealth provider can help a member get to a provider who can do so. The waivers apply to members who have individual, employer-sponsored, Medicare and Medicaid plans.
Treatment: Yes, effective April 1, 2020, through January 31, 2021, Anthem and its delegated entities will waive cost shares for members undergoing treatment related to a COVID-19 diagnosis.

Anthem will reimburse healthcare providers according to standard reimbursement rates, depending on provider participation and benefit plan, for fully insured, individual, Medicaid and Medicare members. Anthem will continue to monitor and comply with state and federal guidelines. Self-insured plan sponsors will have the choice to participate

Prior authorization

Does Anthem require a prior authorization for screening or testing for COVID-19?

No, prior authorization is not required from Anthem or its delegated entities for screening or testing related to COVID-19 testing.

Is Anthem changing its requirements for prior-authorization?

Anthem recognizes the intense demands facing physicians, hospitals and all healthcare providers in the face of the COVID-19 pandemic. As of March 27, 2020, through February 18, 2021, Anthem and its delegated entities will suspend select prior authorization requirements, to allow healthcare providers to focus on caring for patients diagnosed with COVID-19. These adjustments apply to members of all lines of business, including self-insured plan members. The suspension of select prior authorization is inclusive of the following:

Inpatient and respiratory care

To assist the removal of administrative burden on hospitals during the COVID-19 pandemic, medical reviews are suspended for all confirmed and suspected COVID-19 inpatient cases.
Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities, home health, acute rehabilitation, long-term acute care, swing beds, or any other lower level of care. These changes are effective December 22, 2020, through February 18, 2021. These adjustments apply for our fully-insured and self-funded employer, individual, Medicare, and Medi-Cal plan members receiving care from in-network providers. While prior authorization is not required for facility transfers to lower levels of care, we continue to require notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers. Anthem encourages providers to continue to follow normal processes and obtain prior authorization and reminds providers that patient transfers should be to in-network facilities when possible.
Prior authorization requirements are suspended for patient transfers through February 18, 2021: All hospital inpatient transfers to lower levels of care (by land only). Although prior authorization is not required, Anthem requests voluntary notification via the usual channels to aid in our members’ care coordination and management.

The 21-day inpatient requirement before transferring a patient to a long-term acute care hospital is suspended through February 18, 2021.
Extending the length of time a prior authorization issued on or before May 30, 2020 is in effect for elective inpatient and outpatient procedures an additional 180 days. This will help prevent the need for additional outreach to Anthem to adjust the date of service covered by the authorization.

Concurrent review for discharge planning will continue unless required to change by federal or state directive.
Prior authorization requirements are suspended for COVID-19 durable medical equipment through February 18, 2021, including oxygen supplies, respiratory devices and continuous positive airway pressure (CPAP) devices for patients diagnosed with COVID-19, along with the requirement for authorization to exceed quantity limits on gloves and masks.
Respiratory services for acute treatment of COVID-19 will be covered. Prior authorization requirements are suspended where previously required through February 18, 2021.

Telehealth and telephonic services

What member cost shares will be waived by Anthem for virtual care through telehealth and telephone-only?

For COVID-19 treatments via telehealth visits, Anthem and its delegated entities will cover telehealth and telephonic-only visits from in-network providers and will waive cost shares until further notice.

For in-network providers, effective March 17, 2020, through September 30, 2020, Anthem and its delegated entities waived member cost share for telehealth (video + audio) and telephone-only visits for services not related to the treatment of COVID-19 from in-network providers, including visits for behavioral health, for our fully-insured employer, individual and Medicaid plans where permissible. For Medicare plans, in-network providers, effective March 17, 2020, through December 31, 2020, Anthem and its delegated entities waived member cost share for telehealth (video + audio) and telephone-only visits for services not related to the treatment of COVID-19 from in-network providers, including visits for behavioral health.

For out-of-network providers, Anthem waived cost shares for services received from March 17, 2020, through June 14, 2020. Cost sharing will be waived for members using Anthem’s telemedicine service, LiveHealth Online, as well as care received from other providers delivering virtual care through internet video + audio services. Self-insured plan sponsors may opt out of this program.

Will Anthem cover virtual care through telehealth and telephone-only?

Effective March 17, 2020, and until further notice, for COVID-19 related services, Anthem and its delegated entities will cover telehealth and telephone-only medical and behavioral health services from in-network providers and out-of-network providers.

Effective March 17, 2020, and until further notice, for services not related to the treatment of COVID-19, Anthem and its delegated entities will cover telehealth and telephone-only medical and behavioral health services from in-network providers. For telehealth and telephonic services received from a non-contracted provider, Anthem and its delegated entities will cover such services when there is an out-of-network benefit.

Self-insured plan sponsors may opt out of this program.

Is the option to deliver services via telehealth available for all types of services?

Yes, until further notice, so long as it is medically appropriate to render the services via telehealth.

Exceptions for Medi-Cal members include chiropractic services, physical, occupational, and speech therapies. At this time, the Department of Health Care Services (DHCS) has not authorized these services for telehealth or telephone.

Does the provider have to be physically present in their office when providing services via telehealth?

No. If the provider can effectively deliver services via telehealth from another location (for example, the provider’s home), while also maintaining the patient’s privacy the services are payable.

What is the reimbursement rate for telehealth and telephonic-only services?

As required by the State of California, telehealth and telephonic services must be paid at the same rate, whether a service is provided in-person or through telehealth or telephonically, if the service is the same regardless of the modality of delivery, as determined by the provider’s description of the service on the claim.

Anthem Copay For Urgent Care

Can all contracted providers provide telehealth and telephonic-only services?

Yes. All Anthem contracted providers can provide telehealth and telephonic services if clinically appropriate.

Is Anthem’s vendor, LiveHealth Online, prepared for the number of visits that will increase to telehealth?

As there is a heightened awareness of COVID-19 and more cases are being diagnosed in the United States, LiveHealth Online is increasing physician availability and stands ready to have physicians available to see the increase in patients, while maintaining reasonable wait times.

What is the best way that providers can get information to Anthem’s members on Anthem’s alternative virtual care offerings?

Anthem.com/ca and Anthem’s COVID-19 site (https://www.anthem.com/ca/coronavirus/) are great resources for members with questions and are being updated regularly.

Anthem members have access to telehealth 24/7 through LiveHealth Online. Members can access LiveHealth Online at https://livehealthonline.com/ or download the LiveHealth Online app from the App Store or Google Play.

Anthem members also can call the Anthem 24/7 NurseLine at the number listed on their Anthem ID card to speak with a registered nurse about health questions.

As of March 17, 2020, through September 30, 2020, Anthem and its delegated entities will waive any member cost share for telehealth or telephonic visits provided by in-network provider, including visits for mental health, for our fully insured employer, individual and Medicaid plans.

For Medicare plans, in-network providers, effective March 17, 2020, and December 31, 2020, Anthem and its delegated entities will waive member cost share for telehealth (video + audio) and telephone-only visits from in-network providers, including visits for behavioral health.

Cost shares will be waived for members using Anthem’s telemedicine service, LiveHealth Online, as well as care received from other telehealth providers. Self-insured plan sponsors will have the choice to participate.

Coding, billing, and claims

How should a provider bill for services delivered via telehealth or telephone during the State of Emergency, when the provider would normally deliver the services in-person?

During the COVID-19 State of Emergency, when a provider delivers a service via telehealth that the provider would normally deliver in-person, the provider should document and bill the service(s) as follows:

Thoroughly document the visit as if the visit had occurred in person.
Use the CPT code(s) for in-office visit for the particular service(s) rendered. Do not use telehealth or telephonic Current Procedural Terminology (CPT) codes.
Use Place of Service “02” to designate telehealth.
Use modifier 95 or GT for synchronous rendering of services, or GQ for asynchronous.
- Medi-Cal Exception – use modifier 95 for synchronous rendering of services, or GQ for asynchronous.

What modifier is appropriate to waive member cost sharing for COVID-19 testing and visits related to testing?

The Centers for Medicare & Medicaid Services (CMS) has provided the Medicare guideline to use the CS modifier: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-10-mlnc-se. Anthem also looks for the CS modifier to identify claims related to evaluation for COVID-19 testing. This modifier should be used for COVID-19 evaluation and testing services in any place of service.

What diagnosis codes would be appropriate to consider for a patient with known or suspected COVID-19?

The CDC has provided coding guidelines related to COVID-19:

https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

Should providers who are establishing temporary locations to provide healthcare services during the COVID-19 emergency notify Anthem of new temporary addresses?

Providers do not need to notify Anthem of temporary addresses for providing healthcare services during the COVID-19 emergency. Providers should continue to submit claims specifying the services provided using the provider’s primary service address along with their current tax ID number.

How does a provider submit a telehealth visit with an existing patient that lives in a bordering state?

For providers (for example, in bordering states) who were previously seeing members in approved locations that met state and/or CMS billing requirements, effective March 17, 2020, and until further notice, a provider may submit a telehealth claim using the primary service address where they would have normally seen the member for the face-to-face visit.

How is Anthem reimbursing participating hospitals that perform COVID-19 diagnostic testing in an emergency room or inpatient setting?

Reimbursement for COVID-19 testing performed in a participating hospital emergency room or inpatient setting is based on existing contractual rates inclusive of member cost share amounts waived by Anthem.

Claims audits, retrospective review and policy changes

Anthem will adjust the way we handle and monitor claims to ease administrative demands on providers:

Hospital claims audits requiring additional clinical documentation will be limited through June 24, 2020, though Anthem reserves the right to conduct retrospective reviews with expanded lookback recovery periods. To assist providers, Anthem can offer electronic submission of clinical documents through the provider portal.
Retrospective utilization management review will also be limited through June 24, 2020, and Anthem reserves the right to conduct retrospective utilization management review of these claims when this period ends and adjust claims as required.
Our special Investigation programs targeting provider fraud will continue, as well as other program integrity functions that ensure payment accuracy.

Anthem will continue to administer claims adjudication and payment in line with our benefit plans and state and federal regulations, including claims denials and appeals where applicable. Our timely filing requirements remain in place, but Anthem is aware of limitations and heightened demands that may hinder prompt claims submission.

Provider credentialing

Through June 24, 2020, Anthem will continue to process provider credentialing within the standard timeframe. If we are unable to verify provider application data due to disruptions to licensing boards and other agencies then we will verify this information when available.

If Anthem finds that a practitioner fails to meet our minimum criteria because of sanctions, disciplinary action etc., we will follow the normal process of sending these applications to committee review which may add to the standard timeframe. We will monitor and comply with state and federal directives regarding provider credentialing.

Vaccine administration

Copays For Blue Cross Coverage

How is Anthem reimbursing U.S. Food and Drug Administration (FDA)-approved COVID-19 vaccines?

The cost of COVID-19 FDA-approved vaccines will initially be paid for by the government.

Anthem will reimburse for the administration of COVID-19 FDA-approved vaccines in accordance with Federal and State mandates.

Recently CMS shared (https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf) that for members of Medicare Advantage plans, the COVID-19 vaccine administration should be billed to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved. This will ensure that Medicare Advantage members will not have cost sharing for the administration of the vaccine.

For members of our fully-insured employer and individual plans as well as self-funded plans, Anthem will cover the administration of COVID-19 vaccines with no cost share for in- and out-of-network providers, during the national public health emergency.

Department of Managed Health Care (DHMC) issued regulation directing financial risk to the health plans for delegated entities.

Delegated Entities – Unless covered under the Division of Financial Responsibility (DOFR), Anthem will be responsible for the vaccine administration cost and will reimburse at the applicable Prudent Buyer rate, which is the based on the Medicare national rate.
In-Network Providers – Anthem will reimburse at the contracted rate
Out of Network – Anthem will reimburse at the Medicare national rate

For members of Medicaid plans, Medicaid state-specific rules and other state regulations may apply.

Prescription drugs

Can members obtain an extra 30-day refill of a prescription drug?

Yes. We are also allowing members to obtain an extra 30-day supply of medication when medically appropriate and permitted by state and federal law. We are also encouraging that when member plans allow that they switch from 30-day home delivery to 90-day home delivery.

General questions

Does Anthem have recommendations for reporting, testing and specimen collection?

The CDC updates these recommendations frequently as the situation and testing capabilities evolve. See the latest information from the CDC: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html

Does Anthem have recommendations for COVID-19 preventive health and clinical guidance?

Refer to the latest information found on the CDC COVID-19 website: https://www.cdc.gov/coronavirus/2019-nCoV as well as information found on local County Department of Public Health websites.

In case of mass epidemic, how can you ensure that your contracted providers can still provide services?

Anthem is committed to working with and supporting its contracted providers. Our benefits already state that if members do not have appropriate access to network physicians that we will authorize coverage for out-of-network physicians as medically necessary.

In addition, Anthem’s telehealth provider, LiveHealth Online, is another safe and effective way for members to see a physician to receive health guidance related to COVID-19 from their home via mobile device or a computer with a webcam.

Are you aware of any limitations in coverage for treatment of an illness/virus/disease that is part of an epidemic?

Our standard health plan contracts do not have exclusions or limitations on coverage for services for the treatment of illnesses that result from an epidemic.

What financial assistance is available for care providers during the COVID-19 crisis?

The CARES Act provides financial relief to lessen the impact of the COVID-19 crisis. Included in the law are new resources to address the economic impact of COVID-19 on employers of all sizes. The Act expands existing federal loan programs, creates new tax credits, postpones employment tax payments, and includes additional tax relief. To help care providers navigate the resources available to them, Anthem has complied information on programs we have learned about that could provide additional financial relief during this crisis. This information can be found in the Federal Resources Available for Care Providers and Employers in the Federal CARES Actarticle in Anthem Provider News.

Does Anthem expect any slowdown with claim adjudication because of COVID-19?

We are not seeing any impacts to claims payment processing at this time.

Do these guidelines apply to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan commonly referred to as the Federal Employee Program (FEP®)?

Where permissible, these guidelines apply to FEP members. For the most up-to-date information about the changes FEP is making, go to https://www.fepblue.org/coronavirus.

Please note that the above information applies to Anthem's Commercial health plans. Please review the Medicare and Medicaid specific sites noted below for details about these plans.

Commercial: Provider News Home

Medi-Cal: Medi-Cal Provider News & Announcements - COVID-19

Medicare: Medicare Advantage News

Anthem Blue Cross Co Pays

If you have additional questions or need more information, please call the phone number on the member’s ID card.
216-0321-WP-CA

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