Working with Anthem Subject Specific Webinar Series

Transcription

1 Working with Anthem Subject Specific Webinar Series Provider Claim Submission and Adjustment Request Tips and Tools Access to Audio Portion of Conference: Dial-In Number: Conference Code: # Please Mute Your Phone Use the mute button or press *6 This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden.

2 Provider Claim Submission & Adjustment Requests Tips and Tools Agenda Housekeeping and Announcements Claim Submission Medical Policy and Clinical UM Guidelines Clinical Claim Edits Reimbursement Policies Claim Processing Remittance Advice Claim Adjustments Complaints and Appeals Helpful Links and Handouts 2

3 Working with Anthem Subject Specific Webinar Series Housekeeping & Announcements Navigation and Handouts Click here for handouts 1. Select items by checking the boxes 2. Select a destination on your computer 3. Press OK to download Control your view Full Screen 3

4 Claim Submission - Initial Claims should be submitted in the same manner as you would to any other payer following national correct coding guidelines Complete member ID number including alpha prefix NPI and Tax Identification Numbers required Referring provider name in box 17 with type 1 NPI box 17b Rendering provider NPI should be present in box 24j on professional claim forms Billing (Organizational/Billing Type 2) NPI should be present in box 33a 4

5 Claim Submission - Initial Claims should be submitted in the same manner as you would to any other payer following national correct coding guidelines Billing address under 5010 must be a physical location not a PO Box o Submit PO Box in the Pay To Loop on electronic claims Submit with Taxonomy codes for practitioners with dual specialties Facility claim requirements o Present on admission (POA) indicators 5

6 Claim Submission - Initial Ancillary Provider Claim Submission Reminder Independent Clinical Lab o File to the Plan whose service area where the specimen was drawn. o Determined by the zip code associated with NPI Durable/Home Medical Equipment o File to the Plan in whose service area the equipment and/or supplies were delivered, shipped to, or o the location of the retail store where the equipment and/or supplies were purchased or rented. 6

7 Claim Submission - Initial Ancillary Provider Claim Submission Reminder Specialty Pharmacy o File to Plan in service area ordering provider located (ordering physician address) o Determined by the zip code associated with NPI Applies to all Commercial and Medicare Advantage Blue Plans Does not apply to Federal Employee Program (FEP) members More Information Answers@Anthem, Ancillary Claim Filing Requirements FAQs September, 2012 link: pdf?refer=ahpprovider&state=wi 7

8 Claim Submission Medicare Crossover Claims Submitted directly to the secondary payer electronically by Medicare Indicated on the Medicare EOMB Payment made directly by the secondary payer Submitting a paper claim before or immediately upon receiving your Medicare EOMB may cause: Rejected claims Delayed payments Duplicate denials Double work for your payment posters 8

9 Claim Submission Medicare Crossover Claims continued When a Medicare claim has crossed over, providers are to wait 30 calendar days from the Medicare remittance date before submitting the claim to the local Blue Plan to avoid claim returns. Providers should continue to submit services that are covered by Medicare directly to Medicare. Even if Medicare may exhaust or has exhausted its benefits, continue to submit claims to Medicare to allow for the crossover process to occur and for the member s benefit policy to be applied. Local Blue Plans will reject provider submitted claims received within 30 calendar days of the Medicare remittance date or any claims received without a Medicare remittance date on the claim.. 9

10 Claim Submission Medicare Crossover Claims continued Submitted directly to the secondary payer electronically by Medicare Indicated on the Medicare EOMB MA18 Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them. N89 Alert: Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice Payment made directly by the secondary payer 10 10

11 Claim Submission Medicare Crossover Claims 11 11

12 Claim Submission Medicare Crossover Claims 12 12

13 Claim Submission Medicare Crossover Claims continued Anthem will reject Medicare primary provider-submitted claims with the following conditions Medicare advice remark codes MA18 or N89 that indicate Medicare crossover has occurred Received by provider s local Blue Plan within 30 calendar days of Medicare remittance date Received by provider s local Blue Plan with no Medicare remittance data 13 13

14 Claim Submission Medicare Statutorily Excluded Services Providers who render statutorily excluded services should indicate these services by using GY modifier at the line level at the service line level of the claim. Providers required to submit only statutorily excluded service lines on a claim (cannot combine with other services like Medicare exhaust services or other Medicare covered services) Provider s local plan will not require Medicare EOMB If providers submit combined line claims (some lines with GY, some without) to their local plan, the provider s local plan will deny the claims, instructing provider to split the claim and resubmit. More information: August 2013 Network Update Newsletter - BCBSA initiative addresses secondary payer Medicare claims beginning on page

15 Claim Submission Claim Submission - Electronic Why submit claims electronically? No postal delays Transmit claims 24 hours a day, seven days a week Electronic claims are faster and more accurate Electronic claims are acknowledged by Anthem through notification and error reports that are placed in your electronic mailbox Accepted directly from providers (direct submitters) or through billing services, vendors and clearinghouses

16 Claim Submission Claim Submission - Electronic Submit in 5010 format Initial Claims Secondary Claims Corrected Claims Wisconsin Payer IDs: Professional Institutional (facility) Anthem EDI Help Desk Telephone: Website: Live Chat 16 16

17 Claim Submission Claim Submission An Anthem Difference Ambulatory Surgery Centers (ASC) facility services submitted on a professional claim form consistent with Medicare o Do not include a rendering physician as these charges should be submitted separately by the physician Guidelines Public provider website o Anthem Medical Policies and Clinical UM Guidelines o Clinical Claim Edits Secure Provider Portal MyAnthem SM via Availity o On Availity select MyPayer Portals Anthem Payer Portal Administrative Support\Policies & Procedures o Reimbursement Policies 17 17

18 Medical Policy & Clinical UM Guidelines Accessed through the Medical Policy, Clinical UM and Precertification Guideline router Information available for local and out-of-state Blue plans Precertification requirements Medical policies o Searchable by term and code 18 18

19 Clinical Claim Edits Accessed through the Anthem Customized Claim Edits link under Self Service and Support on the Provider Home page of our website Edits contain, the subject, the edit number, the rationale and if available the reference for the claims edit Google search by term or by code Default includes Medical Policies, Medical Coverage Guidelines and 10 results 19 19

20 Reimbursement Policies Accessed through Availity to MyAnthem Payer Portal Select Administrative Support Policies & Programs o Procedures for Professional Reimbursement o Recommended for immediate review List of Payment Policy Indicators Bundled Services and Supplies Policy 0008 Frequency Editing Policy

21 Reimbursement Policies Accessing MyAnthem via Availity To access MyAnthem, click on My Payer Portals on Availity s left navigation menu. Then click Anthem Provider Portal and I Agree to be navigated to MyAnthem without entering an additional log in and password

22 Reimbursement Policies Accessing MyAnthem via Availity 22 22

23 Claim Processing A Picture Paper Claim Received Claim Imaged Claim keyed Data submitted to Claim Processing System Is Member Local? Yes Member Eligibility & Benefits Medical Policy Clinical UM Guidelines Provider Indentification Provider Pricing Including Reimbursement Policies, Clinical Claim Edits Claim Adjudicated Electronic Claim Received No Provider Indentification Provider Pricing Including Reimbursement Policies, Clinical Claim Edits Provider Remittance Advice Data sent to member s (home) plan Member Eligibility & Benefits Medical Policy Clinical UM Guidelines Claim Adjudicated Data sent to provider s (host) plan 23 23

24 Claim Processing Status Electronically 276/277 Transactions (5010 format) Availity Multi-payer portal All lines of business Telephonically Ready Reference Guide o Found under Contact Us on the public provider website Availity is an independent company providing a wide variety of online tools that allow providers to access real-time information from multiple payers via one secure sign-on 24 24

25 Claim Processing Status Availity Inquiry Recommendations Start with Member Eligibility Inquiry Under Claims Management, select Claim Status Inquiry o Change the provider if not the same as organizational (billing) o Enter date of service range 25 25

26 Claim Processing Status Availity Inquiry Recommendations continued o Click on From-To Date of Service to expand 26 26

27 Remittance Advice Paper and Electronic Electronically 835 ERA Electronic Funds Transfer (EFT) Payments EFT and EFT+ERA Enrollment via CAQH EnrollHub ERA only Anthem EDI at On Paper In the Mail Online copies via Availity link to MyAnthem SM Hand-Out: Provider Remittance Advice Example 27 27

28 Remittance Advice Paper and Electronic Availity link to MyAnthem SM 28 28

29 Remittance Advice MyAnthem SM 29 29

30 Remittance Advice MyAnthem SM Anthem Remittance Inquiry Tool Selections 30 30

31 Remittance Advice MyAnthem SM 31 31

32 Remittance Advice MyAnthem SM Opens a PDF file of the actual remit File can be: Searched Printed Saved to disk 32 32

33 Remittance Advice Healthcare Exchange Members Grace Period Grace period for individual health plans purchased on Exchange that are eligible for a governmental premium subsidy. 3 month grace period applies after the individual has paid at least one month s premium Premium non-payment Anthem will process claims for services received during the first month Anthem will pend claims for services received during the second and third months of the grace period, until the full premium is received After the third month, if the premium is not received, the member s health plan will be terminated and the claims for services received during the second and third month will be denied Providers will be notified of denied claims on their remittance advice The member will be responsible for payment of services 33 33

34 Remittance Advice Healthcare Exchange Members Grace Period Grace period for individual health plans purchased on Exchange that are eligible for a governmental premium subsidy. Premium non-payment continued Providers notified on their remittance advice that the claim cannot be paid until the premium is received Members displayed with a status of "Health Insurance Exchange - HIX GRACE PERIOD." on Availity and ICR Providers notified on 271 transactions (enhanced detail) Health Exchange Information Page Link 34 34

35 Remittance Advice Healthcare Exchange Members Grace Period 271 Eligibility Transactional Response Enhanced Detail 2100C/D DTP: DTP01 ="343" (Premium Paid to Date End) DTP03 = This message provides the date for which the premium is paid through (the last day of coverage for which a premium payment has been received).this is the last day of the month before the beginning of the grace period. 2110C/D DTP (1 st iteration): DTP01 = "193" (Period Start) DTP03 = This message provides the date that represents the first day of the first month of the grace period. 2110C/D DTP (2 nd iteration): DTP01 = "194" (Period End) DTP03 = This message provides the date that is the last day of the third month of the grace period. 2110C/D MSG: MSG01 = "Health Insurance Exchange - HIX GRACE PERIOD." This message indicates that a member is in the second or third month of a grace period, and that claims for this member will pend until premium is paid

36 Remittance Advice Healthcare Exchange Members Grace Period Grace period for individual health plans purchased on Exchange that are eligible for a governmental premium subsidy Premium non-payment continued After the third month, if the premium is not received, the member s health plan will be terminated and the claims for services received during the second and third months will be denied. Providers will be notified of denied claims on their remittance advice The members will be responsible for payment of services 36 36

37 Remittance Advice Healthcare Exchange Members Grace Period Grace period for individual health plans purchased on Exchange that are eligible for a governmental premium subsidy Premium non-payment continued ANSI 835 Codes passed on 835 Electronic Remittance Advice o Claim Adjustment Reason Code (CARC) 133 The disposition of the claim service is pending further review (Use only with Group Code OA) Start: 02/28/1997 Last modified : 01/20/2013 o Remittance Advice Remark Code (RARC) N617 This enrollee is in the second or third month of the advanced premium tax credit grace period Start: 07/15/2013 Paper Remittance Advice remark code information o See our Grace period for individual health plans purchased on the Exchange article on our Health Exchange Information Page 37 37

38 Claim Adjustments Appeal vs. Complaint Guide to Provider Complaints and Appeals accessed under o Appeal A formal request to change a decision upheld through the complaint process or reverse an adverse Utilization Management decision. o Complaint any expression of dissatisfaction submitted by a provider concerning claim payments or member benefits Link: Guide to Provider Complaints and Appeals 38 38

39 Claim Adjustments Complaints Administrative or operational in nature Your local Anthem plan is responsible for these decision o Claim processing, benefit interpretation and reimbursement o Not related to medical necessary, experimental or investigational or precertification decisions Send a Provider Adjustment Request Form o Under Answers@Anthem, choose Provider Forms, Provider Adjustment Request Form Send a Secure Message 39 39

40 Claim Adjustments Complaints Administrative or operational in nature o Provider Requests for Adjustment Local, BlueCard, Anthem Medicare Advantage PPO & FEP PO Box , Atlanta, GA

41 Claim Adjustments Complaints Secure Message via Availity o Under Claims Management Select Secure Messaging o From Claim Status Inquiry Select Send a Secure Message 41 41

42 Claim Adjustments Complaints and Appeals Complaints Secure Message via Availity o Immediate confirmation that inquiry was delivered successfully o Sent to Anthem Customer Service based on line of business o Tracking in Anthem Customer Service Call System o Response sent to your Secure Message Mail box o Average Response Time FEP 10 days Local (Facets) 3 days National (Nasco) 3 days BlueCard 30 days 42 42

43 Claim Adjustments Complaints and Appeals Complaints Telephonic Service o Call the service numbers indicated on the Ready Reference Guide or printed on your remittance advice. o If you do not feel your question or issue was adequately addressed Ask to speak to a supervisor If this does not resolve your issue Contact your Network Relations Consultant Provide the call reference numbers given by the telephonic service associates you spoke with 43 43

44 Claim Adjustments Complaints and Appeals Issue Escalation Secure Messaging o If you do not feel your question or issue was adequately addressed send another secure message requesting escalation to a supervisor Telephonic Service o If you do not feel your question or issue was adequately addressed, ask to speak to a supervisor Network Relations o If supervisor escalation does not resolve your issue Contact your Network Relations Consultant Provide the call reference numbers given by the telephonic service associates you spoke with 44 44

45 Claim Adjustments Complaints and Appeals Appeals Requests to change clinical decisions based on whether a service or supplies are medically necessary or experimental or investigational Always submitted secondarily to a reconsideration request or complaint. Applicable to o Local Anthem Members o BlueCard Members o Other Programs Federal Employee Program (FEP) Medicare Advantage 45 45

46 Claim Adjustments Complaints and Appeals Appeals Local Anthem Members Submit a complaint first Submit appeals in writing with a copy of our response to your complaint Use the Provider Appeal Checklist to ensure all information needed is included Mail the information to: Anthem Blue Cross and Blue Shield Attn: Appeals Department PO Box Atlanta, GA For additional information see the Provider Complaints and Appeals Process under the Answers@Anthem menu 46 46

47 Claim Adjustments Appeals BlueCard Program Members Clinical and benefit decisions are made by the members Home plan Your local Wisconsin plan is your single point of contact Use the Provider Adjustment Request Form Send to the local claims and correspondence address Anthem Blue Cross and Blue Shield Attn: Appeals Department PO Box Atlanta, GA Your local plan will facilitate the process with the on your behalf 47 47

48 Claim Adjustments Appeals Other Program Members Federal Employee Plan (FEP) o o o o o Follow specified directions Submit a verbal or written complaint first Submit appeals in writing within 180-days of initial adverse action Use the Provider Adjustment Request Form Send to the local claims and correspondence address Anthem Blue Cross and Blue Shield Attn: Appeals Department PO Box Atlanta, GA o Appeals routed directly to FEP who will respond o Questions Contact FEP in Wisconsin at

49 Claim Adjustments Appeals Other Program Members Anthem Medicare Advantage o Requirements and Process defined by Medicare o Access at o Includes all Anthem Medicare Advantage plans Information found in the Medicare Advantage HMO and PPO Provider Guidebook Provider Service Anthem Medicare Advantage Appeals* Fax: Mail Information to: Medicare Advantage Appeals and Grievance 4361 Irwin Simpson Road Mason, OH

50 Links and Handouts Guide to Provider Complaints and Appeals Contact Us Page Provider Forms EDI Solutions EDI Registration-Forms CAQH EnrollHub Handout - Provider Remittance Advice Example Handout - Anthem EFT ERA Brochure 50 50

51 Provider Claim Submission & Adjustment Requests Tips and Tools 51 51

52 Working with Anthem Subject Specific Webinar Series Please complete the Webinar Evaluation Survey Individuals completing the evaluation survey within 2 business days will be eligible for a Blue Prize package. Winner will be notified by within 3 business days Thank you for attending Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees 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