Transcript Slide 1

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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-1500
Professional 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.
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
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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-1500 Top Claim Denials
CLAIMS AND BILLING
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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
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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 Box 21 on the CMS-1500 claim form.
Note: Reference the IHCP manual Chapter 8, pages 304-305.
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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 Box 1a of the
CMS-1500 claim form.
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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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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 1-866-408-6132 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.
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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 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:
• FAX:
1-866-408-7187
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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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.
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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.
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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: 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
• Rendering NPI name and address
• 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.
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NPI Denials
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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.
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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 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.
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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 46206-6144
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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 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 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 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.
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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
Claim Denials
QUESTIONS
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