Transcript

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 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.

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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

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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.

NPI Denials

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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.

NPI Denials

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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

NPI Denials

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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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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.

Duplicate Claim Denials

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Claim Resubmission Form

• Must use this form to submit corrected claims.

• Attach this form to the claim.

• Submit within 60 days to:

Attn: Claims CorrespondenceAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, IN 46206-6144

Forms and Resource tools available online at www.anthem.comProviders Spotlight Anthem State Sponsored Programs IN Provider Resources

Duplicate Claim Denials

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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: ClaimsAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, IN 46206-6144

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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 – 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 include the YRH prefix in Form Locator 60 of the UB-04.

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Claim Filing Limits

• Initial Claim Submission:

• Based on the facility’s contract.• Submit the initial claim electronically or mail to:

ATTN: ClaimsAnthem Blue Cross and Blue ShieldPO Box 37180Louisville, KY 40233-7180

Filing Time Limit Denials

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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 CorrespondenceAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, IN 46206-6144

Filing Time Limit Denials

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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. Attach a copy of the Remittance Advice, claim, as well as other documentation to help in the review process. Submit to:

Attn: Complaints – AppealsAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, IN 46206-6144

Filing Time Limit Denials

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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: ClaimsAnthem Blue Cross and Blue ShieldPO Box 37180Louisville, KY 40233-7180

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• 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.

Prior Authorization Denials

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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.

Prior Authorization Denials

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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)

Prior Authorization Denials

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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: Utilization ManagementAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, IN 46206-9210

• Specialty injections/infusions: To start a request, the ordering physician should contact Next Rx at1-888-662-0944.

• Benefits, Eligibility, or Claim information: Contact Customer Care at 1-866-408-6132.

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• 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 37180Louisville, 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.

Coordination of Benefits (COB) Denials

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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 or letter explaining the

denial.• Send the completed form along with all documents to:

Attn: Claims Correspondence – COBAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, IN 46206-6144

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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 Anthem’s Medical Policies.

• 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 inpatient services only.

• 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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