Provider Digest | Issue 41

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CBI data due, RSV updates and more

Submit 2023 CBI data by Feb. 29

The deadline to submit your Care-Based Incentive (CBI) 2023 data is February 29, 2024. The Data Submission Tool (DST) is available on the Alliance’s Provider Portal under “Data Submissions.” This tool was created to support providers in submitting data from their electronic medical records and paper records for the CBI and Healthcare Effectiveness Data and Information Set (HEDIS) measures.

Measures you can submit data for include:

  • Body Mass Index (BMI).
  • Breast Cancer Screening (screening and mastectomies).
  • Cervical Cancer Screening (Pap and HPV screenings and hysterectomies).
  • Child and Adolescent Well-Care Visits (0-21 years).
  • Chlamydia Screening in Women.
  • Colorectal Cancer Screening.
  • Controlling High Blood Pressure (systolic and diastolic readings).
  • Developmental Screening in the First 3 Years.
  • Diabetic HbA1c Poor Control >9.0%.
  • Application of Dental Fluoride Varnish.
  • Immunizations for Children, Adolescents and Adults.
  • Initial Health Appointment (IHA).
  • Screening for Depression and Follow-Up Plan.

After you submit your data, you should receive an email confirmation within one business day.

Tips for successful submission

  • If your file was previously rejected, please review the reason for rejection, correct it and resubmit. If you have any questions about why the file was rejected, please contact your Provider Relations Representative at 800-700-3874. ext. 5504.
  • A Data Submission Tool Guide is available on the Portal. This guide provides step-by-step instructions on the information required for each measure, how to upload and how to correct rejections.

If you have questions about the Data Submission Tool, please email [email protected].

RSV updates: prior authorization and coding

RSV continues to be a dominant public health concern this winter. RSV vaccines, including Arexvy and Abrysvo, are covered by the Alliance.

There was a delay in DHCS updates on RSV agents and all claims were being pended. Please review the updates below regarding prior authorization (PA) requirements.

Prior authorizations for RSV agents

RSV Agent PA Requirements
Arexvy PA is not required if patient is 60 years of age and older and meets service restrictions.


PA is not required if member is 60 years of older or older and meets service restrictions. Exception: PA is also not required for pregnant individuals at 32 through 36 weeks’ gestation.
Beyfortus PA is not required if patient is less than 8 months old and meets service restrictions.

PA is required for patients 8 months old and older.

Synagis PA is required to determine if member meets conditions of use. To determine if a member meets conditions of use, please see the Synagis Statement of Medical Necessity.

Please submit a PA request via the Alliance Provider Portal or by fax to 831-430-5851.

Updated RSV code list

CVX Code CPT Code RSV Agent Manufacturer Unit of Sale NDC11 Unit of Use NDC11
303 90679 Arexvy GlaxoSmithKline (GSK) 58160-0848-11 58160-0723-03
305 90678 Abrysvo Pfizer 00069-0344-01
306 90380 Beyfortus Sanofi Pasteur Inc. 49281-0575-15 49281-0575-00
307 90381 Beyfortus Sanofi Pasteur Inc. 49281-0574-15 49281-0574-88

Previous RSV communications

For more details about RSV vaccines, please review previous Alliance publications:

If you have any questions, please contact your Provider Relations Representative at 800-700-3874, ext. 5504. The Alliance is here to assist you, and we appreciate your efforts in providing vaccines to our members!

Chronic pain management in elderly patients with chronic kidney disease

A recent drug utilization review by the Alliance showed that 11% of our members ages 65 and older with chronic kidney disease (CKD) had at least one prescription of non-steroidal anti-inflammatory medication (NSAIDs) in 2022. This statistic does not include members with other health coverage such as Medicare.

Pain is a common and distressing symptom among patients with (CKD). However, NSAIDs should typically be avoided in patients with CKD. Adverse effects of NSAIDs include:

  • A reduction in estimated glomerular filtration rate (eGFR) can be severe and irreversible.
  • Sodium and water retention may aggravate hypertension.
  • Hyperkalemia.

Pharmacologic treatment of mild to moderate CKD (eGFR ≥30 mL/min/1.73 m2) is similar to that of the general population without CKD. Occasionally, an NSAID may provide greater pain control and potentially fewer side effects than other medications.

In these cases, NSAIDs may be used for acute rather than chronic pain. Limit patient use to the lowest effective dose and shortest duration. However, we stress that there is no dose of NSAID that is considered “safe” for individuals with reduced eGFR.

Cautionary notes for prescribing NSAIDs to people with CKD

  • Avoid prescribing to people with GFR <30 ml/min/1.73 m2.
  • Prolonged therapy is not recommended in people with GFR <60 ml/min/1.73 m2.
  • NSAIDs should not be used in people taking lithium.
  • Avoid NSAIDs in people taking RAAS (renin-angiotensin-aldosterone system) blocking agents such as lisinopril, losartan, Aliskiren, Entresto etc.

For more information, visit the Kidney Disease: Improviding Global Outcomes website.

Catch up on state bill and All Plan Letter updates

Please review the following Assembly Bill summaries that impact Alliance providers.

You can also contact Alliance Provider Relations at 800-700-3874, ext. 5504.

AB 232: Temporary Practice Allowances

This bill applies to individuals in another jurisdiction of the United States who are license-holding:

  • Marriage and family therapists.
  • Clinical social workers.
  • Professional clinical counselors.

Until January 1, 2026, these individuals may provide services in California for a period not to exceed 30 consecutive days in any calendar year if certain conditions are met.

Conditions include:

  • License from another jurisdiction is at the highest level for independent clinical practice in the jurisdiction where it was granted.
  • Client is in California while license holder seeks to provide care in California.
  • Client is a current client of the license holder, and had an established, ongoing client-provider relationship with them at the time the client became located in California.
  • Must provide certain information to the Board of Behavioral Sciences before providing services, including the jurisdiction in which the person is licensed, and license type and number.

AB 716: Ground Medical Transportation

Existing law requires:

  • That health care service plan contracts and health insurance policies provide coverage for certain services and treatments, including medical transportation.
  • A policy or contract to provide for direct reimbursement of a covered medical transportation services provider if the provider has not received payment from another source.

This bill would:

  • Require authority to annually report the allowable maximum rates for ground ambulance transportation services in each county, including trending rates by county, as specified.
  • Delete the direct reimbursement requirement.
  • Require a health care service plan contract or a health insurance policy issued, amended or renewed on or after January 1, 2024 to require an enrollee or insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting ground ambulance provider.
  • Prohibit a noncontracting ground ambulance provider from sending a higher amount to collections.
  • Limit the amount an enrollee or insured owes a noncontracting ground ambulance provider to no more than the in-network cost-sharing amount.
  • Prohibit a ground ambulance provider from billing an uninsured or self-pay patient more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater.
  • Require a plan or insurer to directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as specified, unless it reaches another agreement with the noncontracting ground ambulance provider.