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Second level
Third level
Fourth level
“Serving
Fifth level
Anthem
Hoosier Healthwise”
State Sponsored Business
2011 Updates/Provider File Changes/
And
Top Claim Denials
CMS-1450 (UB-04)
Institutional Providers
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.
2011 Anthem HHW /HIP Updates
What’s New January 1, 2011:
• Anthem’s Behavioral Health will be integrated with medical
• HHW & HIP products will be combined
• PMPs 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
·MyHealth Notes
·Care Alerts
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Provider File Updates/Changes
Anthem provider files must match the State’s provider
information.
• To maintain accuracy submit your provider updates to IHCP at
www.indianamedicaid.com, or contact HP at 877-707-5750.
Note: For more information on this topic, please refer to the
IHCP Provider Manual, Chapter 4.
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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 www.anthem.com
• 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).
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CMS-1450 (UB-04) Top Claim Denials
Claims and Billing
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Frequent Claim Denials
•ER Claims
•Eligibility
•COB
•Prior Authorization
•Pregnancy Only Services (Package B)
•Presumptive Eligibility
•Duplicate Services
•Filing Time Limit
•Diagnosis/Procedure Inconsistent with Patient’s Age/Gender
•Behavioral Health
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ER Claim Denials
ER Claims:
• ER claims should be billed appropriately based on the members’/patients’
medical conditions.
• Emergency services (revenue code 450).
• Nonemergent services (revenue code 451).
• Emergency services (revenue code 450) will be processed based on “Prudent
Layperson Guidelines”.
• If ER claim denies (revenue code 450):
• Complete claim follow up form
• Attach medical records
• Submit the above information within 60 calendar days from the date of the Remittance
Advice to:
Attn: Claims Correspondence
Anthem Blue Cross and Blue Shield
PO Box 6144
Indianapolis, IN 46206-6144
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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 Form
Locator 60 of the UB-04 claim form.
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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 37010
Louisville, KY 40233-7010
• Include the member’s Medicaid number along with the YRH prefix, in Form
Locator 60 on the CMS 1450 (UB-04) claim form.
• Attach the third party’s Remittance Advice or letter explaining the denial with the
CMS claim form.
• Specify the other coverage in Form Locator 58-62 on the CMS 1450 (UB-04)
claim form.
• COB Filing Limit: Based on the facility’s contract from the date of the primary
carrier’s Remittance Advice.
• Contact Customer Service for primary insurance information.
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Coordination of Benefits
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-1450 (UB-04) 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 46206-6144
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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 innetwork specialist.
• Authorization is required when referring to an out-of-network
specialist.
• Nonparticipating providers seeing Anthem’s Medicaid members
- all services require 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:
www.anthem.com
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Prior Authorization Denials
Contact Information:
Phone
FAX:
1-866-4087187
1-866-406-2803
• Forms and Resource Tools available online:
www.anthem.com
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.
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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)
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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 46206-6144
• Benefits, Eligibility, or Claim information:
Contact Customer Care at 1-866-408-6132
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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 Form Locator 67 on the CMS-1450 (UB04) claim form.
Note: Reference the IHCP manual Chapter 8, pages 97-98.
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Presumptive Eligibility (PE) 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 Form Locator 67 on the CMS-1450 claim form.
Note: Be sure to include the YRH prefix with the PE “550” RID number.
Reference the IHCP manual Chapter 8, pages 271-279. You may also
reference the IHCP Presumptive Eligibility manual.
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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.
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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 46206-6144
Forms and Resource Tools available online at www.anthem.com
Providers SpotlightAnthem State Sponsored ProgramsINProvider Resources
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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 37010
Louisville, KY 40233-7010
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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 46206-6144
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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 46206-6144
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Filing Time Limit Denials
Claim Filing Limits:
• Third Party Liability 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
PO Box 37010
Louisville, KY 40233-7010
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.
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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 8A of the
CMS 1450 (UB-04) claim form.
• Be sure the correct date of birth and sex are indicated in Box 1011 of the CMS 1450 (UB-04) claim form.
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Behavioral Health Claim Denials
Behavioral Health Services:
• Anthem Medicaid Behavioral Health 2010 services are carved
out to Magellan.
• Contact Magellan at 1-800-327-5480.
• Reference the POM, Chapter 3, pages 46-48.
Note: Effective January 1, 2011, Anthem’s Behavioral
Health will be integrated with medical.
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2011 Updates/Provider File Changes/Top
Claims Denials
Questions
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