Anthem “Serving Hoosier Healthwise”

Home Health Overview

State Sponsored Business

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PRIOR AUTHORIZATION

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Home Health Care

Prior Authorization Process• All home care services must be pre-authorized. • Call or fax request before services are rendered.

Intake Line 1-866-408-7187 (or Fax 1-866-406-2803)

Effective January 12, 2009, the following changes will apply:• Prior authorization for certain specialty drugs that are covered under a member’s

medical benefits will be required. (See attached list).

• The prescribing/ordering physician is required to submit the prior authorization request for specialty drugs.

• Note: If the rendering provider is not also the prescribing/ordering physician, the rendering provider will need to ensure that prior authorization has been obtained by the prescribing/ordering physician, as prior authorization requests will be accepted from the prescribing/ordering physician only!

• Specialty Drugs Prior Authorization Fax: 1-866-545-0062• Specialty Drugs Prior Authorization: 1-888-662-0944

• General Formulary Prior Authorization 1-866-408-7103• General Formulary Prior Authorization 1-877-652-1223.

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Home Health Care

Forms and Resource Tools

available online at www.anthem.com

Providers Spotlight Anthem State Sponsored Programs IN Policies or Prior Auth

• Forms available: Request for Pre-service Review; Home Apnea Monitor; Home Oxygen; CPAP/BiPAP; Pediatric Formula; etc.

• Online Access to Medical Policies & UM Clinical Guidelines

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Home Health CareWhat to Submit with Request

• Most current 485 (signed if available)

• For services already in progress: include timesheets/records from the last 3 weeks of visits

• Any other clinical information to support the need for the requested services

• Reminder: The prescribing/ordering physician is required to submit the prior authorization request for specialty drugs.

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Home Health CareMedical Necessity Criteria Used• State Regulations – Link to IAC website:

http://www.in.gov/legislative/iac/iac_title?iact=405

See Article 5: Medicaid Services - Rule 16 (Home Health Agency) - Rule 22 (Nursing & Therapy Services)

• Medical Policy & UM Clinical Guidelines: - Admin.00004 (Medical Necessity) - CG-Rehab-04 (PT) - CG-Rehab-05 (OT) - CG-rehab-06 (Speech) - Others as applicable to request Note: All Requests that do not appear to meet criteria are sent to an Anthem physician for a medical necessity determination.

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Claims and Billing

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Home Health CareCLAIMS AND BILLING GUIDELINES

• All home health care must be pre-authorized. Contact the Plan’s UM Department for authorization prior to delivery of the service.

• When billing for a home health visit, the visit is billed on a CMS-1450 (UB-04) form.

Home Infusion Therapy• The correct way to bill for home infusion therapy is to:

• Submit all claims within the contracted filing limit

• Obtain authorization from the Plan’s Utilization Management department for all infusion therapy before the services are rendered.

• Reminder: The prescribing/ordering physician is required to submit the prior authorization request for specialty drugs.

• You must use the appropriate HCPCS codes to bill• List of Codes section in the provider manual on the Indiana FSSA• website (www.in.gov/fssa) OR IHCP’s website (www.indianamedicaid.com)

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Home Health CareCLAIMS AND BILLING GUIDELINES-CONT’D

• Synagis• The correct way to bill for Synagis is to:

• Submit CPT-4 code 90378 and the appropriate number of units; 1 unit of 90378 is equivalent to 50 mg

• Always submit the patient’s weight for the date of service being billed

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Home Health CareCLAIMS AND BILLING GUIDELINES-CONT’DNPI REQUIREMENTS

• Rendering and Billing Providers• 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.

• Claims and Billing Requirements:• CMS 1450 (UB-04) NPI should be entered in Box 56• CMS 1500- Rendering provider NPI in box 24J, rendering NPI

number, service facility NPI in 32a, and billing provider NPI in 33a• Be sure to attest all of your NPI numbers with the state of Indiana at

www.indianamedicaid.com• Use NPI number in lieu of legacy ID on paper claims

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Home Health CareCLAIMS AND BILLING GUIDELINES-CONT’D

• Claim Filing Limits• All claims must be submitted within the contracted filing limit to be

considered for payment. Anthem will deny claims that are received past the filing limit.

• Anthem is not responsible for a claim never received. Prolonged periods before resubmission may cause you to miss the filing limit.

• Determine filing limits as follows:• If Anthem is primary, use the length of time between the last date

of service on the claim and the Plan’s receipt date.

• If Anthem is secondary, use the length of time between the other payor’s Remittance Advice (RA) date and the Plan’s receipt date.

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Home Health Care

CLAIMS AND BILLING GUIDELINES-CONT’D

• Claims Timely Filing Limits

• In-Network Providers

• 180 days

• Out of Network Providers

• 365 days

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Home Health CareCLAIMS AND BILLING GUIDELINES-CONT’D• Coordination of Benefits

• When applicable, Anthem coordinates benefits with any other carrier or program that the member may have for coverage, including Medicare. Indicate “Other Coverage” information on the appropriate claim form.

• If there is a need to coordinate benefits, include at least one of thefollowing items from the other carrier or program when submitting a COB claim:

• Third party Remittance Advice (RA)• Third party letter explaining the denial of coverage or reimbursement

• COB claims received without these items will be mailed back to you with a request to submit to the other carrier or program first. Make sure that the information you submit explains any coding listed on the other carrier’s RA or letter.

• We cannot process your claim without this specific information. Anthem must receive COB claims within 180 days for professional and 365 days for institutional from the date on the other carrier’s or program’s RA or letter of denial of coverage.

• When submitting COB claims, specify the other coverage in:• Boxes 9a–d of the CMS-1500 claim form• Boxes 58–62 of the CMS-1450 claim form

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Home Health CareCLAIMS AND BILLING GUIDELINES-CONT’D

• Electronic Funds Transfer (EFT)• Anthem allows the EFT option for claims payment transactions. This allows

claims payments to be deposited directly into a previously selected bank account. You can enroll by calling EDI Services at 1-800-470-9630.

• Electronic Remittance Advice (ERA)• Providers contracted with the Plan can choose to receive ERAs. ERAs are

received through the SPC: MAILBOX. The SPC: MAILBOX is a mailbox setup between a provider or clearinghouse and the Plan. Use the mailbox to send and receive ERA files, which are in an ASC X 12N 835 file format.

• Implementation guides are available at no charge at www.wpc-edi.com/hipaa. There is no charge for the service but enrollment is required. Providers can enroll by calling EDI Services at 1-800-470-9630.

• Note: Electronic data transfers and claims are HIPAA-compliant and meet federal requirements for EDI transactions, code sets, member confidentiality, and privacy.

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Home Health CareCLAIMS AND BILLING GUIDELINES-CONT’D

• Claims Reconsideration• Providers may begin the reconsideration process by completing a Dispute

Resolution Request form. You can access this form and other forms and resources located on Anthem’s website www.Anthem.com

• Filing Time Frame:• Within 60 days from the date you receive the Remittance Advice

Mail Reconsideration Requests to: Anthem Blue Cross Blue Shield

   PO Box 6144  

Indianapolis, IN 46209-9210  

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Home Health CareGrievance and Appeals• The Plan provides a process for providers to file a written grievance related to

dissatisfaction or concern about another provider, the health plan or a member. We also assure the right providers have to file an appeal for denial, deferral or modification of a prior authorization request.

• Providers can also request a claim dispute appeal. Refer to the How Providers File a Grievance or Appeal section in the Provider’s Operation Manual (POM)

• As a provider, you can also request an appeal on behalf of a member for denial, deferral or modification of a prior authorization. These appeals are treated as member appeals and follow the member appeal process.

• How Providers File a Grievance or AppealProviders may file a grievance and appeal in writing or the provider can submit a grievance by fax to 1-866-387-2968.

:ATTN: Appeals and Complaints DepartmentAnthem Blue Cross and Blue ShieldP.O. Box 6144Indianapolis, IN 46206-6144

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Home Health Care

Grievance and AppealsTimelines for filing:  Grievance: 60 calendar days from the date the provider

became aware of the issue

   Appeals: 30 calendar days from the date of the notice of action letter advising of the adverse determination

Anthem’s response:

   Resolutions: Grievances within 20 business days; appeals within 30 business

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Home Health CareFor further assistance, please contact:

• Customer Care Center• Hoosier Heathwise: 1-866-408-6132

• Utilization Management• Hoosier Healthwise: 1-866-408-7187

• Local Community Resource Center

Northwest CRC51 West 79th Street

Merrillville, IN 46410

Ph. No. 866-724-6533

Southwest CRC1318 N. Green River

Evansville, IN 47715

Ph. No. 866-461-3586

Central CRC2424 N. Meridian

Indianapolis, IN 46260

Ph No. 866-795-5440