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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