Anthem Blue Cross and Blue Shield (Anthem) Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect 2017 summer updates

Transcription

1 Serving Hoosier Healthwise, Healthy Indiana Plan Anthem Blue Cross and Blue Shield (Anthem) Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect 2017 summer updates

2 Agenda Billing updates Utilization management updates Operational updates Availity online PMP Member Listing Reports 2 2

3 Billing updates Most common claim denials: Rendering NPI and/or group NPI unattested with the state of Indiana Clinical Laboratory Improvement Amendments (CLIA) denial code: GLI validate provider has CLIA certificate on file Taxonomy codes Group billing NPI not noted in box 33a Incorrect group billing NPI indicated in box 33a Note: Be sure to attest all of your NPI numbers with the state of Indiana at 3 3

4 Claims dispute resolution process Follow-up guidelines Check the claim status if you have not received payment or denial within 30 business days of submission. First, verify the claim wasn t returned by our mail room, rejected by your billing agent or the electronic data interchange clearinghouse with Anthem. Use this process to also follow up on claim adjustments resulting from provider helpline intervention, claims dispute or appeal. Allow 60 calendar days for adjustments to be processed. 4 4

5 Claims dispute resolution process (cont.) Use Availity to check claim status online. You can also call the appropriate Provider Services helpline: o Hoosier Healthwise: o Healthy Indiana Plan: I o Hoosier Care Connect: Network providers must file claims within 90 calendar days. It is the provider s responsibility to follow up in a timely manner and ensure claims are received and accepted. 5 5

6 Claims dispute resolution process (cont.) Corrected claims submission guidelines Submit a corrected claim when the claim is denied or only paid in part due to an error on the original claim submission. When submitting corrected claims, follow these guidelines: Submit the corrected claim no later than 60 calendar days from the date of our letter or remittance advice (RA). Submit the corrected claim as a paper claim through the mail, even if the original claim was sent electronically. Clearly mark the paper claim at the top with the words corrected claim and attach a Claim Follow-Up Form. 6 6

7 Claims dispute resolution process (cont.) Send paper, corrected claims to: Medicaid Corrected Claims P.O. Box Virginia Beach, VA Note: New address effective April 1, The Claim Follow-Up Form is available at > Provider Support > Forms. 7 7

8 Claims dispute resolution process (cont.) Claims dispute and appeal process There is a 60-calendar day time limit from the date on the RA to dispute any claim. Disputes and appeals that are not filed within the defined time frames will be denied without a review for merit. 8 8

9 Claims dispute resolution process (cont.) The claims dispute process is as follows: Claims dispute Must be received in writing within 60 calendar days from the date on the RA. Verbal requests must also be filed in writing within the 60-calendar day time frame. Submit a claims dispute if you disagree with full or partial claim rejection or denial, or the payment amount. Administrative claims appeal If you are not satisfied with the claims dispute resolution, you may submit an administrative claims appeal. We must receive this appeal within 33 calendar days from the date of the claims dispute resolution. Note: See the provider manual. 9 9

10 Utilization management updates Accessing the Prior Authorization Look Up Tool:

11 Utilization management updates (cont.) 11 11

12 Utilization management updates (cont.) Enter CPT/HCPCS code 12 12

13 Utilization management updates (cont.) Submit prior authorizations online with the Interactive Care Reviewer (ICR) Anthem is pleased to now offer ICR, a website providers can use to request prior authorization for Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect. ICR is accessible via Availity at no cost to providers

14 Utilization management updates (cont.) ICR was developed to give providers a convenient way to request prior authorization and receive information regarding their requests. Many Indiana providers (facilities and professionals) are already using ICR for commercial membership. ICR will accept the following types of requests for our members: o Inpatient o Outpatient o Medical/surgical o Behavioral health Note: Prior authorization is required for all procedures for out-of-network providers 14 14

15 Utilization management updates (cont.) Pharmacy prior authorizations Effective April 2, 2017: o Our Pharmacy team is now processing all prior authorizations for pharmacy items and medical drug items including all medical injectables. Phone: Fax: Attn: Pharmacy Note: To verify if a drug code requires prior authorization, please utilize the Prior Authorization Look Up Tool

16 Operational updates Member ID cards from Anthem Identification numbers have changed for some Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect members. Anthem has issued new member ID cards effective April The member ID number and the state recipient identification (RID) number can be found on the front of the card. Here is an example of a new member card

17 Operational updates (cont.) Member ID cards The member ID number listed is the member ID number. We also list the state RID on the front of the cards. Search the state website using the state RID. Search the Availity Web Portal using either the member ID number or the state RID number as long as either is preceded with the YRK or YRH prefix. o This is no change from prior

18 Operational updates (cont.) Telehealth: Anthem is offering the Telehealth program to provide Hoosier Care Connect members the tools to help manage their health. This program will monitor the following conditions: o Diabetes o Heart failure o Chronic obstructive pulmonary disease 18 18

19 Operational updates (cont.) Home health services value code update We have updated our claims system requirement for payment of home health services for Healthy Indiana Plan members. Effective April 1, 2017, providers must bill value code 80 with the amount equal to the number of days. If providers do not bill the value code 80 for Healthy Indiana Plan members, regardless of the number of days being billed, the claim will be denied. If you have any questions regarding Healthy Indiana Plan, contact your Network Relations representative

20 Operational updates (cont.) Advantages of Plus versus Basic Instead of struggling with copays ranging from $4 to $75*, Plus members pay a monthly contribution as low as $1. Extra medical benefits: dental, vision, enhanced pharmacy Value-added benefits for those who qualify: Weight Watchers, YMCA memberships and more * All Healthy Indiana Plan members pay a copay for nonemergent ER usage

21 Operational updates (cont.) Advantages of Plus versus Basic Healthy Indiana Plan Basic members can choose Plus within the first 60 days after enrollment and upon redetermination by calling Members Services at If the payment is not received within 60 days the member will be locked into Basic or removed from the program if they are over the Federal Poverty Level

22 Operational updates (cont.) POWER Account Service Estimate Effective July 2017, the POWER Account Service Estimate replaces the POWER Account Visa debit card. New tool is available through the Availity Web Portal and allows PMPs to provide Healthy Indiana Plan members with an estimate for rendered medical services. Now, providers only need choose from a simplified list of office visit and diagnosis categories instead of looking up and using detailed CPT codes

23 Operational updates (cont.) Accessing the estimator tool: Log in to Availity as usual. Confirm your Healthy Indiana Plan patient s eligibility. Click the Create POWER Account Service Estimate link. Select one of the categories. Print out for your patient

24 Operational updates (cont.) Availity online PMP Member Listing Reports PCP member: Listing_Indiana New program for provider online reporting Healthy Indiana Plan, Hoosier Care Connect and Hoosier Healthwise reports will be combined into the PMP Member Listing Report

25 Operational updates (cont.) Availity online PMP Member Listing Reports PCP member: Listing_Indiana New program for provider online reporting Program name: Member Panel Listing Description: The PMP Member Listing Report is available to providers to view and download a complete list of past and current Medicaid members that have been assigned to a specific provider or group

26 Operational updates (cont.) Member Panel Listing: Description will be added to home and program pages

27 Operational updates (cont.) Report Search 27 27

28 Operational updates (cont.) If you have any questions about the program, all inquiries can be directed through our Contact Us page

29 Provider Relations map Marvin Davis Angelique Jones Michelle Cox Randall Mills Angel Dodson Jovita Mielke Donnica Hinkle

30 Thank you for your partnership and serving our Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect members. The MDwise session starts immediately following this presentation. 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. AINPEC June