anthem “serving hoosier healthwiseâ€‌

Download Anthem  “Serving Hoosier Healthwiseâ€‌

Post on 13-Jan-2016




0 download

Embed Size (px)


Anthem “Serving Hoosier Healthwise”. State Sponsored Business. Home Health Overview. PRIOR AUTHORIZATION. Home Health Care. Prior Authorization Process All home care services must be pre-authorized. Call or fax request before services are rendered. - PowerPoint PPT Presentation


  • Anthem Serving Hoosier HealthwiseHome Health OverviewState Sponsored Business




    Home Health CarePrior Authorization ProcessAll 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 members 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: 1-866-545-0062Specialty Drugs Prior Authorization: 1-888-662-0944

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


    Home Health CareForms and Resource Tools available online at 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


    Home Health CareWhat to Submit with RequestMost 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.


    Home Health CareMedical Necessity Criteria UsedState Regulations Link to IAC website: 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.


    Claims and Billing


    Home Health CareCLAIMS AND BILLING GUIDELINESAll home health care must be pre-authorized. Contact the Plans 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 TherapyThe correct way to bill for home infusion therapy is to: Submit all claims within the contracted filing limit Obtain authorization from the Plans 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 billList of Codes section in the provider manual on the Indiana FSSAwebsite ( OR IHCPs website (



    SynagisThe 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 patients weight for the date of service being billed


    Home Health CareCLAIMS AND BILLING GUIDELINES-CONTDNPI REQUIREMENTSRendering and Billing ProvidersRendering (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 56CMS 1500- Rendering provider NPI in box 24J, rendering NPI number, service facility NPI in 32a, and billing provider NPI in 33aBe sure to attest all of your NPI numbers with the state of Indiana at www.indianamedicaid.comUse NPI number in lieu of legacy ID on paper claims


    Home Health CareCLAIMS AND BILLING GUIDELINES-CONTDClaim Filing LimitsAll 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 Plans receipt date.If Anthem is secondary, use the length of time between the other payors Remittance Advice (RA) date and the Plans receipt date.



    Claims Timely Filing LimitsIn-Network Providers180 daysOut of Network Providers365 days


    Home Health CareCLAIMS AND BILLING GUIDELINES-CONTDCoordination of BenefitsWhen 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 carriers 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 carriers or programs RA or letter of denial of coverage.When submitting COB claims, specify the other coverage in:Boxes 9ad of the CMS-1500 claim formBoxes 5862 of the CMS-1450 claim form


    Home Health CareCLAIMS AND BILLING GUIDELINES-CONTDElectronic 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 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.


    Home Health CareCLAIMS AND BILLING GUIDELINES-CONTDClaims ReconsiderationProviders may begin the reconsideration process by completing a Dispute Resolution Request form. You can access this form and other forms and resources located on Anthems website

    Filing Time Frame: Within 60 days from the date you receive the Remittance AdviceMail Reconsideration Requests to:Anthem Blue Cross Blue ShieldPO Box 6144Indianapolis, IN 46209-9210


    Home Health CareGrievance and AppealsThe 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 Providers 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


    Home Health CareGrievance 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

    Anthems response:

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


    Home Health CareFor further assistance, please contact:Customer Care CenterHoosier Heathwise: 1-866-408-6132Utilization ManagementHoosier Healthwise: 1-866-408-7187Local Community Resource Center

    Northwest CRC51 West 79th StreetMerrillville, IN 46410Ph. No. 866-724-6533

    Southwest CRC1318 N. Green RiverEvansville, IN 47715Ph. No. 866-461-3586

    Central CRC2424 N. MeridianIndianapolis, IN 46260Ph No. 866-795-5440


View more >