Download - Anthem Blue Cross and Blue Shield (Anthem) update · Anthem Blue Cross and Blue Shield Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Rendering provider

Anthem Blue Cross and Blue Shield

Serving Hoosier Healthwise, Healthy Indiana

Plan and Hoosier Care Connect

Spring 2018

Anthem Blue Cross and Blue Shield (Anthem) update

2


Serving Hoosier Healthwise, Healthy Indiana Plan

and Hoosier Care Connect

Objectives

• NPI one-to-one match

• Billing provider NPI

• Billing provider taxonomy

code

• Billing provider ZIP code +4

• Billing provider

considerations

• Rendering provider NPI

• Rendering provider

taxonomy code

• Rendering provider

considerations

• Attending, operating, OPR

providers

• Claim sweeps

• NPI crosswalk exercise

• Phone numbers

• Behavioral health provider

contacts

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NPI one-to-one match

• Anthem must be able to make a one-to-one match between the

billing provider’s national provider identifier (NPI) and service

location address identified on the provider’s IHCP (Indiana Health

Coverage Programs) profile.

• A one-to-one match can be easily established for providers with

only one enrolled service location by looking only at the billing

provider’s NPI.

• For providers with more than one enrolled service location,

additional data points are required to make the match:

o Taxonomy code

o ZIP code +4

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NPI one-to-one match (cont.)

• Our system utilizes the following algorithm to establish a

one-to-one NPI/service location match:

o Billing provider NPI only

o Billing provider NPI and taxonomy code

o Billing provider NPI, taxonomy code and service location

ZIP code +4

• Coming soon: Billing provider NPI and service location ZIP

code +4, in cases where a taxonomy code is not included on

the claim.

• At whichever step the match is established, the algorithm stops

and the claim finishes processing.

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Billing provider NPI

Enter the billing provider’s NPI — required.

• UB-04: Field 56

• CMS-1500: Field 33a

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Billing provider taxonomy code

Enter the billing provider’s taxonomy code and

qualifier. Required.

• UB-04: 81CCa — use B3 qualifier.

• CMS-1500: Field 33b — use ZZ or PXC qualifier.

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Billing provider ZIP code +4

Enter the billing provider’s physical service location

address and full nine-digit ZIP (ZIP +4). Required.

• UB-04: Field 1

• CMS-1500: Field 33

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Billing provider considerations

• All information on the claim MUST match the IHCP provider

enrollment file.

o Update IHCP file if using new/different taxonomy codes.

• A “P.O. Box” or “lockbox” address is NOT a service location

address. You MUST include the service location address.

o Medicaid does not read field 32 of the claim form.

o Medicaid does not use the address in field 33 to

determine where to remit payment.

Remit identified by the “Pay To” address entered on

the provider’s application only, not the claim.

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Billing provider considerations (cont.)

• If you use a clearinghouse, make sure your billing

software is sending the data fields to your clearinghouse,

that your clearinghouse is accepting these data elements,

and, most importantly, that your clearinghouse is sending

these data elements to the plan, Anthem.

o We have identified cases in which a clearinghouse is

not sending the required elements, causing denials.

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Rendering provider NPI

Enter the rendering provider’s NPI. Required, if

applicable.

• CMS-1500: field 24J (bottom)

• UB-04: There is no field for a rendering provider on the

UB-04 claim form.

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Rendering provider taxonomy code

Enter the rendering provider’s taxonomy code.

Required, if applicable (temporary).

• CMS-1500: field 24I (top) — Enter ZZ or PXC qualifier.

• CMS-1500: field 24J (top) — Enter taxonomy code.

• UB-04: There is no field for a rendering taxonomy code

on the UB-04 claim form.

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Rendering provider considerations

• Not all provider types have associated rendering

providers (R).o Medical groups (G): yes — Multiple doctors, physician assistants,

nurse practitioners, etc., reassign their payments to the group’s

tax ID

o Facility/entity (B): no — The entity itself provides the service, and

there are no other providers that reassign their payments or share

the entity’s tax ID

Durable/home medical equipment (DME/HME)

Ambulance

Hospital, billing for certain supplies on a CMS-1500

Hearing aid dealer

Solo practice physician/provider

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Rendering provider considerations (cont.)

• Facilities/entities (billing providers):

o Field 24I and 24J — BLANK — You do not have rendering

providers.

• Groups:

o Rendering information in 24I/24J (top/bottom) must match

what is listed in the provider’s IHCP profile.

o Update — Anthem is updating the system to remove the

requirement for rendering provider taxonomy codes in

24I/24J (top). Should be complete sometime during Q1

2018.

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Attending, operating, OPR providers

• UB-04 claims require the NPI of the attending provider,

operating provider and OPR when these are applicable to

the case.

o The NPI will be validated to ensure the provider is

IHCP-enrolled.

o Taxonomy codes are no longer required for these

providers.

o If included, the taxonomy code will not be validated

against the provider’s enrollment profile.

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Claim sweeps

• Anthem has conducted several claim sweeps to

reprocess NPI-related denials including:

o Attending, operating, OPR not attested/enrolled

o Billing provider not attested/enrolled

o Rendering provider not attested/enrolled

• Rework continues

• Outreach/education

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NPI crosswalk exercise

• The following slides show CMS-1500 claims examples for

establishing a one-to-one match. For institutional (UB-04)

billers:

CMS 1500 UB-04

NPI Field 33a Field 56

Taxonomy Field 33b Field 81CCa

ZIP code Field 33 Field 1

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NPI crosswalk exercise (cont.)

Billing provider’s enrolled locations

ABC Medical Clinic

NPI: 1234567890

ABC Medical Clinic ABC Medical Clinic

1234 E. Medicaid St. 8910 Hoosier Pl.

Anthem, IN 46666-1111 Anthem, IN 46666-3333

Taxonomy: 207Q00000X Taxonomy: 207P00000X

ABC Medical Clinic ABC Medical Clinic

4567 HIP St. 1112 HCC Dr.

Anthem, IN 46666-2222 Anthem, IN 46666-4444

Taxonomy: 207P00000X Taxonomy: 207Z00000X

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Example 1:

• Unable to make a one-to-one match

o All four locations have the same NPI.

o No taxonomy code is present to match to any of the

locations.

ABC Medical Clinic

1234 E Medicaid St.

Anthem, IN 46666

1234567890

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Example 2:

• Unable to make one-to-one match

o All four locations have the same NPI.

o Taxonomy code is present, but two locations have the

same taxonomy code.

o All four locations have same five-digit ZIP code. The

+4 extension is not included on the claim.

ABC Medical Clinic

1234 E Medicaid St.

Anthem, IN 46666

1234567890 207P000000X

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Example 3:

• Unable to make a one-to-one match

o The address entered in 33 does not match any of the

service location addresses/ZIP codes on file with

IHCP; must be a physical address.

o Information entered in 32 matches one location, but

Indiana Medicaid does not read 32.

ABC Medical Clinic

PO Box 5555

St. Louis, MO 55555-1234

1234567890 207P000000X

ABC Medical Clinic

8910 Hoosier Pl.

Anthem, IN 46666-3333

1234567890 207P000000X

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Example 4:

• Successful one-to-one match made

o All four locations share the same NPI.

o Taxonomy code narrows it down to two locations.

o +4 ZIP code extension matches only one location.

ABC Medical Clinic

4567 HIP St.

Anthem, IN 46666-2222

1234567890 207P000000X

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Phone numbers

Prior Authorization/Provider Services/Appeals:

• Hoosier Healthwise: 1-866-408-6132

• Healthy Indiana Plan: 1-844-533-1995

• Hoosier Care Connect: 1-844-284-1798

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Behavioral health provider contacts

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Medical provider contacts

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Questions?

Download - Anthem Blue Cross and Blue Shield (Anthem) update · Anthem Blue Cross and Blue Shield Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Rendering provider

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