Transcript OH ABD Update - Indiana Medicaid
Anthem “Serving Hoosier Healthwise”
State Sponsored Business
TOP CLAIMS 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 a nd 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.
CMS-1450 (UB-04) Top Claim Denials CLAIMS AND BILLING
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Frequent Claim Denials
• NPI • Duplicate Services • Eligibility • Filing Time Limit • Prior Authorizations • Coordination of Benefits • Noncovered Services • Diagnosis/Procedure Inconsistent with Patient’s Age/Gender • Dental, Vision and Mental Health Claims • Type of Bill Denials 3
NPI Denials
Billing Provider: • 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.
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NPI Denials
Claims and Billing Requirements: • CMS-1450 (UB-04) • Box 1 – Provider Name and Address • Box 56 – Billing NPI • Box 81(a-d) – Billing Taxonomy Codes and Qualifiers • Field 76 – Attending Physician NPI • Field 77 – Operating Physician NPI • Field 78-79 – Other provider types NPI • Box 5 – Tax ID Number • Be sure to attest all of your NPI numbers with the State of Indiana at
www.indianamedicaid.com
.
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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 • Appropriate Provider types NPI • Taxonomy Code (Provider Specialty Type) • Provider taxonomy codes can be obtained from
http://www.wpc-edi-com/content/view/793/1
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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: 7
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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 Rep to verify if the claim is imaged in the Filenet system if the claim is not showing in our processing system. • If claim is on file in the processing system or image system, do not resubmit. 9
Duplicate Claim Denials Claim Resubmission Form
• Must use this form to submit
corrected
claims.
• Attach this 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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Duplicate Claim Denials
When Anthem requests medical records: • Complete the Claim Follow Up Form.
• Attach the previously submitted/processed claim along with Anthem’s request/Remittance Advice.
• Attach the Medical Records documentation.
• Send the information to: Attn: Claims Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN 46206-6144 11
Eligibility Denials
•
ALWAYS
services.
verify member’s eligibility prior to rendering • Verify eligibility through Web interChange at:
https://interchange.indianamedicaid.com
• Member ID Card – Anthem’s Medicaid members receive two cards: • Hoosier Healthwise’s ID Card • Anthem’s Medicaid ID Card • • Anthem’s Medicaid ID card includes the three digit alpha prefix
YRH
and the 12 digit Medicaid ID/RID number.
ALWAYS
UB-04.
include the YRH prefix in Form Locator 60 of the 12
Filing Time Limit Denials
Claim Filing Limits • Initial Claim Submission: • Based on the facility’s contract.
• Submit the initial claim electronically or mail to: ATTN: Claims Anthem Blue Cross and Blue Shield PO Box 37180 Louisville, KY 40233-7180 13
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 14
Filing Time Limit Denials
Claim Filing Limits • Appealing the disputed claim: • 30 calendar days from the date of the notice of action letter advising of the adverse determination.
• Submit the Dispute Resolution Request Form
along with a letter stating that you are appealing
help in the review process. Submit to: . Attach a copy of the Remittance Advice, claim, as well as other documentation to Attn: Complaints PO Box 6144 – Appeals Anthem Blue Cross and Blue Shield Indianapolis, IN 46206-6144 15
Filing Time Limit Denials
Claim Filing Limits • Third Party Liability Claim Filing Limits • Based on the facility’s contract from the date of the primary carrier’s Remittance Advice.
• Note: Claim Filing 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.
• 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 37180 Louisville, KY 40233-7180 16
Prior Authorization Denials
• Physician is responsible for obtaining the preservice review for both professional and institutional services.
• Hospital or ancillary providers should always contact us to verify preservice review status.
• Authorization 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:
www.anthem.com
.
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Prior Authorization Denials
Contact Information: • PHONE:
1-866-408-7187
• FAX:
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:
www.anthem.com.
• • Medical Policies and UM Clinical Guidelines.
Note: Requests that do not appear to meet criteria are sent to an Anthem physician for a 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 • Clinical information to support the request • Treatment and discharge plans (if known) 19
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: Utilization Management Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN 46206-9210 • Specialty injections/infusions: To start a request, the ordering physician should contact Next Rx at
1-888-662-0944.
• Benefits, Eligibility, or Claim information: Contact Customer Care at
1-866-408-6132.
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Coordination of Benefits (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 37180 Louisville, KY 40233-7180 • 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 50A-55C 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 (COB) Denials
Re-filing COB Claims • Always complete the Claim Follow Up Form when you rebill 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 denial.
or letter explaining the • Send the completed form along with all documents to: Attn: Claims Correspondence PO Box 6144 Indianapolis, IN 46206-6144 – COB Anthem Blue Cross and Blue Shield 22
Noncovered Service Denials
• Refer to the
Provider Operations Manual (POM),
Benefits Matrix, Chapter 3 for Covered/Noncovered services and benefit limitations.
• Cosmetic services are not covered – See Anthe m’s Policies.
Medical • Experimental/Investigational services are not covered unless medically necessary – See Anthem’s Medical Policies. The following
medications
are not covered: • Weight-loss medications unless medically necessary which requires a Prior Authorization.
• Infertility drugs.
• Cosmetic and hair medications.
• Drugs not FDA approved.
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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 10-11of the CMS-1450 (UB-04) claim form.
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Dental Claim Denials
Dental Services: • Dental services are carved out to the Indiana Health Coverage Program (EDS). Contact EDS at
1-317-655-3240.
• Exception: Procedure code 41899, emergency tooth extraction is covered in a facility setting. • Procedure code 41899 requires Prior Authorization.
• Reference the POM, Chapter 3, pages 51-52.
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Behavioral Health Claim Denials
Behavioral Health Services: • Anthem’s Medicaid behavioral health services are carved out to Magellan.
• Contact Magellan at
1-800-327-5480
• Reference the POM, Chapter 3, pages 24.
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Type of Bill Denials
• Anthem accepts interim billing for Medicaid services only.
inpatient • Anthem does not accept interim billing for Medicaid outpatient services. • Interim codes 331-334 are not acceptable for outpatient services. • Submit outpatient claims with type of bill 131.
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CMS-1450 (UB-04) Top Claim Denials
Questions
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