Condition Care for Medicaid
Condition Care is based on a system of coordinated care management interventions and communications designed to assist physicians and others in managing members with chronic conditions.
Our mission
The mission of the Condition Care program is to improve the health and quality of life for our members served by encouraging member self-care efforts, coordinating healthcare education, and providing interventions along the continuum of care.
Condition Care services include:
- A holistic, member-centric approach to condition care, focusing on the needs of the member through telephonic and community-based resources
- Motivational interviewing techniques used in conjunction with member self-empowerment
- The ability to manage more than one disease to meet the changing healthcare needs of our member population
- Weight management and smoking cessation education
Who is eligible?
Members diagnosed with one or more of the conditions listed are eligible for Condition Care services:
- Asthma
- Bipolar disorder
- Chronic obstructive pulmonary disorder (COPD)
- Congestive heart failure (CHF)
- Coronary artery disease (CAD)
- Diabetes
- HIV/AIDS
- Hypertension
- Major depressive disorder — adult
- Major depressive disorder – child/adolescent
- Schizophrenia
- Substance use disorder
How can I refer a member to this program?
To refer a member to the Condition Care program, fill out our Condition Care Referral Form and email the completed form to Condition-Care-Provider-Referrals@anthem.com.
Forms
Condition Care programs are designed to:
- Address gaps in care
- Improve the understanding of disease processes
- Improve the quality of life for members
- Support collaboration to develop member-centered goals and interventions
- Support network provider relationships with members
- Increase network provider awareness of Condition Care programs
- Reduce acute episodes requiring emergent or inpatient care
- Identify social determinants of health and address by referring members to appropriate community resources
Program features include:
- Proactive population identification processes
- Program content based on evidence-based national practice guidelines
- Collaborative practice models to include physician and support service providers in treatment planning for members
- Continuous patient self-management education, including primary prevention, coaching related to healthy behaviors and compliance or monitoring, and care management for high-risk members
- Ongoing communication with primary and ancillary providers regarding patient status
Nine of our Condition Care programs are National Committee for Quality Assurance (NCQA) accredited and incorporate outreach, education, care coordination, and follow-up to improve treatment compliance and enhance self-care.
What are the benefits of collaborating with Condition Care?
Quality of care
If you have patients with one or more of the conditions listed above who could benefit from additional education or care management, we encourage you to refer them to Condition Care.
Collaborative treatment plans
Condition Care invites your input for patient treatment plans. We provide you with Condition Care information and the most up-to-date Clinical Practice Guidelines to assist you in creating an individual plan of care for your patient.
Receive feedback on your patients
Providers can access Patient360 to obtain feedback on their patients regarding their care plans and condition management while enrolled in our program.
How to access Patient360 through Availity
- From the Availity home page, select Payer Spaces from the top navigation.
- Select the health plan.
- From the Payer Spaces homepage, select the Applications tab.
- Select the Patient360 tile.
Contact Us
Email us at Condition-Care-Provider-Referrals@anthem.com or call 888-830-4300 from 8:30 a.m. to 5:30 p.m. local time. Confidential voicemail is available 24 hours a day.
Call:
888-830-4300
Email:
Provider rights and responsibilities
You have additional rights and responsibilities such as the right to:
- Obtain information about the organization’s services, staff qualifications, and any contractual relations
- Decline to participate in or work with the organization’s programs and services on behalf of their patients
- Be informed how the organization coordinates interventions with care plans for individual members
- Know how to contact the care manager responsible for managing and communicating with their patients
- Be supported by the organization when interacting with members to make decisions about their healthcare
- Receive courteous and respectful treatment from the organization’s staff
- Communicate complaints to the organization
A copy of these rights and responsibilities can also be found in the provider manual .
The Clinical Practice Guidelines (CPGs) for the chronic conditions outlined in the previous section are available on Availity Essentials , our secure provider website. CPGs can also be requested at any time.
Our Condition Care programs do not advertise, market, or promote specific products or services to members or providers and do not have any financial ownership arrangements with anyone who advertises, markets, or provides the good and services we offer.
Provider tools & resources
- Log in to Availity Essentials
- Launch Provider Learning Hub Now
- Learn about Availity
- Prior Authorization Lookup Tool
- Prior Authorization Requirements
- Claims Overview
- Member Eligibility & Pharmacy Overview
- Provider Manuals and Guides
- Provider Search Tool
- Forms
- Training Academy
- Pharmacy Information
- Electronic Data Interchange (EDI)