Presentation on theme: "Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Anthem Blue Cross and Blue Shield is."— Presentation transcript:
Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Anthem “Serving Hoosier Healthwise” State Sponsored Business 2011 Updates/Provider File Changes/ And Top Claim Denials CMS-1500 Professional Providers
2 Anthem HHW Updates What’s new January 1, 2011: Anthem’s Behavioral Health will be integrated with medical HHW & HIP products will be combined PMP for HIP product will now have panel PMPs should see only assigned members MCOs will assign PMPs New Tools/Reports: · Enhanced Web Portal · My Health Advantage My Health Notes Care Alerts
3 Provider File Updates/Changes Anthem provider files must match the State’s provider information. To maintain accuracy submit your provider updates to IHCP at or contact HP at Note: For more information on this topic, please refer to the IHCP Provider Manual, Chapter 4.
4 Provider File Updates/Changes Anthem’s Health Care Management area handles the provider file updates for Anthem Medicaid, as well as our Anthem Commercial provider files. Provider Terminations, Updates, and Changes (including address, name, panel holds and/or changes): Send a letter on the provider’s letterhead providing us with the new updated information. For terminations include effective date, as well as the reason why the provider is no longer with your group or no longer will be seeing Anthem Medicaid members. Include the Tax ID, NPI, and Medicaid numbers on the letter. Adding a New Provider: Complete the State Sponsored Business Practice Information Form Forms and Resource tools available online at Providers Spotlight Anthem State Sponsored Programs IN Provider Resources Anthem Medicaid Contracting Questions: Refer to your Anthem Commercial Network Development Manager (Contract representative within your territory).
5 CMS-1500 Top Claim Denials CLAIMS AND BILLING
6 Frequent Claim Denials Pregnancy Only Services (Package B) Eligibility Duplicate Services PE/NOP Prior Authorization NPI Editing Denials Coordination of Benefits Filing Time Limit Diagnosis/Procedure Inconsistent with Patient’s Age/Gender Behavioral Health Services
7 Pregnancy Only Service Denials (Pkg. B) Pregnancy Only Services: HHW (Pkg. B) coverage includes services related to pregnancy, which includes prenatal, delivery, and post partum care, as well as conditions that complicate the pregnancy. HHW (Pkg. B) also includes coverage for family planning and transportation (must be pregnancy related) services. Pregnancy-related diagnosis code must be billed as the primary diagnosis in Box 21 on the CMS-1500 claim form. Note: Reference the IHCP manual Chapter 8, pages
8 Eligibility Denials Always verify member’s eligibility prior to rendering services. Verify eligibility through Web interChange at: https://interchange.indianamedicaid.com Member ID Card: Hoosier Healthwise ID Card Note: Always include the YRH prefix preceding the member’s 12-digit Medicaid ID/RID number in Box 1a of the CMS-1500 claim form.
9 Duplicate Claim Denials Allow for processing time: 21 days for electronic claims before resubmitting. 30 days for paper claims before resubmitting. Check claim status before resubmitting. If no record of claim – resubmit. Note: Be sure to ask the Customer Care Representative to verify if the claim is imaged in Filenet if the claim is not showing in our processing system. Do not resubmit if the claim is on file in the processing or image system.
10 Duplicate Claim Denials Claim Follow Up Form: Must use this form to submit corrected claims. Attach this completed form to the claim. Submit within 60 days to: Attn: Claims Correspondence Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN Forms and Resource tools available online at Providers spotlight Anthem State Sponsored Programs IN Provider Resources
11 PE/NOP Denials PE Claims: PE covered services include: Doctor visits, outpatient professional services, lab work, & transportation (must be pregnancy related only). Be sure to file with the appropriate PE “550” or Medicaid RID number based on eligibility for the date of service. Pregnancy-related diagnosis code must be billed as the primary diagnosis in Box 21 on the CMS-1500 claim form. Note: Reference the IHCP manual Chapter 8, pages 284–290. NOP Claims: Contact our Customer Care Center at for any NOP claims denied not on file. NOPs must be filed to the state within 5 calendar days from the date of service. The pregnant member’s gestation must not be greater than 29 weeks. Note: Be sure to include the YRH prefix with the PE “550” RID number.
12 Prior Authorization Denials Physician is responsible for obtaining the preservice review for both professional and institutional services. Hospital and ancillary providers should always contact us to verify preservice review status. Authorization is not required when referring a member to an in- network specialist. Authorization is required when referring to an out-of-network specialist. Nonparticipating providers seeing Anthem’s Medicaid members – all services require Prior Authorization. Check the Prior Authorization list regularly for any updates on services that require Prior Authorization. See the Prior Authorization Toolkit listed on our website:
13 Prior Authorization Denials Contact Information: Phone: FAX: Forms and Resource Tools available online: Providers Spotlight Anthem State Sponsored Programs IN Policies or Prior Auth Forms: Preservice Review Forms available, such as: Request for Preservice Review; Home Apnea Monitor; Home Oxygen; CPAP/BIPAP; Pediatric Formula; etc. See our website: Medical Policies and UM Clinical Guidelines. Note: Requests that do not appear to meet criteria are sent to an Anthem physician for medical necessity determination.
14 Prior Authorization Denials What to have ready when calling Utilization Management: Member name and ID number Diagnosis with ICD9 code Procedure with CPT code Date(s) of Service Primary Physician, Specialist, and Facility performing services Clinical information to support the request Treatment and discharge plans (if known)
15 Prior Authorization Denials Other Help Available: Retro Prior Authorization Review: If the service/care has already been performed, UM case will not be started. Send medical records in with the claim for review: Attn: Anthem Correspondence/Utilization Management Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN Benefits, Eligibility, or Claim information: Contact Customer Care at
16 NPI Denials Rendering and Billing Provider: Rendering (Type 1) Providers – Health care providers who are individuals, including physicians, dentists, specialists, chiropractors and sole proprietors. An individual is eligible for only one NPI number. Billing (Type 2) Providers – Health care providers that are organizations, including physician groups, hospitals, residential treatment centers, laboratories and group practices, and the corporation formed when an individual incorporates as legal entity.
17 NPI Denials Most Common NPI Denials: Rendering NPI (Type 1) is not indicated in Box 24J. Incorrect Rendering NPI is indicated in Box 24J. Group Billing NPI (Type 2) is not indicated in Box 33a. Incorrect Group Billing NPI is indicated in Box 33a. Rendering NPI and/or group billing NPI are unattested with the State of Indiana. NPI provider file updates not received by Anthem’s Medicaid Division. Anthem’s provider file does not match State’s provider file information.
18 NPI Denials Claims and Billing Requirements: CMS-1500 Box 24J – Rendering Provider NPI Box 32A – Service Facility NPI Box 33A – Billing Provider NPI Note: Be sure to attest all of your NPI numbers with the State of Indiana at:
19 NPI Denials Claims and Billing Requirements: The following must be used on all electronic claims. You are encouraged to submit this information on paper claims as well. Tax ID Billing NPI name and address Rendering NPI name and address Taxonomy Code (Provider Specialty Type) Provider taxonomy codes can be obtained from:
20 NPI Denials Anthem will deny the claim if the NPI is omitted from the claim, the NPI is invalid, or the NPI is unattested. The information below is the only additional provider-identifying information that should be included on your claims.
21 NPI Denials
22 Editing Denials Modifiers that help clarify services: Modifier 25: Modifier 25 is used to indicate that, on the day of a procedure or service identified by a CPT code, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service or beyond the usual preoperative and postoperative care associated with the procedure that was performed. Modifier 50 (Bilateral Procedure): Modifier 50 is used to report bilateral procedures performed in the same operative session. Identify that a second (bilateral) procedure has been performed by adding modifier 50 to the procedure code. Do not report two line items to indicate a bilateral procedure. Modifiers LT & RT: Modifiers LT and RT should only be used when the bilateral surgery rules do not apply. The bilateral surgery rules apply to procedures with a bilateral indicator of “1”. When the fee schedule has a bilateral indicator of “0” or “3”, use modifiers LT and RT to describe procedures performed on identical anatomic sites. Modifiers LT and/or RT should never be used when modifier 50 is applied to a code Modifier 57(Decision for Surgery): An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service. Modifier 59 (Distinct Procedural Service): Modifier 59 is used to indicate that a procedure was distinct or independent from other services performed on the same date. Modifier 59 may be used when procedures that are normally bundled should both be reported because of a specific unusual circumstance. Modifier 59 should never be used routinely. Modifier 59 should never be used when another modifier would describe the circumstances better. Note: Reference the Current Procedural Terminology (CPT) manual.
23 Coordination of Benefit (COB) Denials All COB claims must be submitted on paper. Do not file COB claims electronically. Submit the COB claims to: Anthem Blue Cross and Blue Shield PO Box Louisville, KY Include the member’s Medicaid number, along with the YRH prefix, in Box 1a on the CMS-1500 claim form. Attach the third party’s Remittance Advice or letter explaining the denial with the CMS claim form. Specify the other coverage in Boxes 9a-d on the CMS-1500 claim form. COB Filing Limit: 180 days from the date of the primary carrier’s Remittance Advice. Contact Customer Service for Primary insurance information.
24 Coordination of Benefit (COB) Denials Re-filing COB Claims: Always complete the Claim Follow Up Form when you re-bill a COB claim. When you receive a denial from Anthem’s Medicaid division requesting the primary carrier’s Remittance Advice, complete the Claim Follow Up Form and: Attach the CMS-1500 claim form. Attach the primary carrier’s Remittance Advice or letter explaining the denial. Send the completed form along with all documents to: Attn: Claims Correspondence – COB Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN
25 Filing Time Limit Denials Claim Filing Limits: Initial Claim Submission: 180 calendar days of the date of service Submit the initial claim electronically or mail to: Attn: Claims Anthem Blue Cross and Blue Shield PO Box Louisville, KY
26 Filing Time Limit Denials Claim Filing Limits: Disputing a processed claim: 60 calendar days from the date of the Remittance Advice. Submit the Dispute Resolution Request Form along with a copy of the EOB, as well as other documentation to help in the review process, to: Attn: Claims Correspondence Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN
27 Filing Time Limit Denials Claim Filing Limits: Appealing the disputed claim: 30 calendar days from the date of notice of action letter advising of the adverse determination. Submit the Dispute Resolution Request Form along with a letter stating that you are appealing. Attach a copy of the Remittance Advice, claim, as well as other documentation to help in the review process. Submit to: Attn: Complaints – Appeals Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN
28 Filing Time Limit Denials Claim Filing Limits: Third Party Liability Claim Filing Limits 180 days from the date of the primary carrier’s Remittance Advice. Submit the initial claim and primary carrier’s Remittance Advice, along with any claims filing supporting documentation to: Attn: Claims Anthem Blue Cross and Blue Shield PO Box Louisville, KY Note: Claim filed with wrong plan – provide documentation verifying initial timely claims filing, within 180 days of the date of the other carrier’s denial letter or Remittance Advice.
29 Diagnosis/Procedures Inconsistent with Patient’s Age/Gender Denials Use the correct Current Procedural Terminology (CPT) codes appropriate for patient’s age/gender according to the current Physician’s CPT manual. Use the correct Healthcare Common Procedure Coding System (HCPCS) codes appropriate for patient’s age/gender. Use the correct diagnosis codes appropriate for patient’s age/gender according to the current ICD9 manual. Be sure the correct patient name is indicated in Box 2 of the CMS-1500 claim form. Be sure the correct date of birth and sex are indicated in Box 3 of the CMS-1500 claim form.
30 Behavioral Health Claim Denials Behavioral Health Services: Anthem Medicaid Behavioral Health 2010 services are carved out to Magellan. Contact Magellan at Reference the POM, Chapter 3, pages Note: Effective January 1, 2011, Anthem’s Behavioral Health will be integrated with medical.