Anthem Blue Cross and Blue Shield. Serving Hoosier Healthwise and Healthy Indiana Plan

Transcription

1 Anthem Blue Cross and Blue Shield Serving Hoosier Healthwise and Healthy Indiana Plan 3rd Quarter Updates

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3 NDC Denials The following elements are required for claims with NDC information J code NDC N4 qualifier Unit of Measure Anthem will deny the entire claim if all of the required elements are not on the claim. Please do not include the name of the drug in your claim submission. 3

4 Claim Updates- Newborns Anthem identified an issue where newborn claims are denying as past the filing limit when filed within the 365 filing limit days. A process is in place to review these claims prior to adjudication. di You should not see auto denied d claims for filing limit it if billed within 365 days. As a reminder: Prior Authorization is not required within the first 30 days of the newborn s life &

5 Claim Updates- NPI Denials Most Common NPI Denials: Rendering NPI (Type 1) is not indicated in Box 24J. Incorrect Rendering NPI is indicated in Box 24J. Group Billing NPI (Type 2) is not indicated in Box 33a. Incorrect Group Billing NPI is indicated in Box 33a. Rendering NPI and/or group billing NPI are unattested with the State of Indiana. NPI provider file updates not received by Anthem s Medicaid Division. Anthem s provider file does not match State s provider file information. Note: Be sure to attest all of your NPI numbers with the State of Indiana at: 55

6 Claim Updates- NPI Denials Please submit corrected claims if you know that a claim was submitted with an incorrect NPI. Corrected claims can be submitted with the Claim Follow Up Form to: Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN Contact Provider Service for assistance with specific NPI denials at HHW: HIP:

7 Home Health Date Span Denials The Anthem system is being updated to allow overhead to calculate when providers bill the occurrence date span in fields 35a-36b of the UB04. As of today, the system is not capturing the overhead. Once system has been updated, a claims sweep will be done for claim adjustments. t 77

8 ACA Increases Reimbursement for Primary Care Services in 2013 and 2014 Section 1202 of the Affordable Care Act (ACA) requires a temporary increase in Medicaid payments for qualifying primary care services provided by qualifying physicians for dates of service in calendar years 2013 and Authorized only for 2013/2014. Rates will return to existing structure after 2014 (pending no further federal action). Qualified services may be eligible for the temporary rate increase The Indiana Health Coverage Programs (IHCP) will make quarterly supplemental payments to self-attested qualifying physicians for qualifying primary care services. Payment methodology for services provided to managed care members is pending. Physicians will be notified at a later date how the temporary payment increases will be paid. IHCP Bulletin BT November 27,

9 ACA Increases Reimbursement for Primary Care Services in 2013 and 2014 Claims for Vaccines for Children (VFC) vaccines Denials For DOS January 1, 2013 through December 31, 2014, providers using VFC-provided vaccines should bill the IHCP for the VFC vaccine administration fee by billing V20.2 as the primary diagnosis, the procedure code of the specific vaccine administered with a billed amount of $0.00, 00 and the appropriate vaccine administration code with the SL modifier (see the following list of procedure codes). The allowed amount per claim for the administration of a VFC vaccine will remain at $8.00; any increase in reimbursement will be paid in a supplemental payment. All previously denied VFC claims with DOS January 1, 2013 March 31, 2013 were reprocessed in a sweep completed July 2013 If any VFC claims haven t been reprocessed please contact customer service at (866)

10 Occurrence Code 11 Denials In order to be in compliance with the IHCP manual. CH.8 Section 2: UB-04 Billing Instruction Advises for Form Field 31a-34b valid Occurrence Codes. Status Code 11 is not listed as a valid code and has been removed from the system. Please follow the claims resolution process to correct claims

11 New Consent Form Reminder Updated Consent for Sterilization form. Effective May 9, 2013, the IHCP requires the updated consent form to be used. The signature on a consent form is valid for up to 180 days, any signature obtained before May 9, 2013 would be valid for dates of service through November 4, Updated form is available on the Forms page at indianamedicaid.com id Please reference BR201314, for guidelines

12 Claim Updates- Electronic COB Anthem HHW will accept claims submitted to us as a secondary payer. Please include all of the following loops/ information: Other Subscriber Information 2330A- Other Subscriber Name 2330B- Other Payer Name Line Adjudication Information You may work with your clearinghouse/ software vendor or contact Anthem EDI ( ) to test new processes or discuss filing requirements

13 Claim Updates- Electronic COB Please note: This process is for initial claim submission only. Claims previously submitted that denied for a primary EOB must be submitted via paper to: Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN

14 Provider File Updates/ Changes Anthem s Provider Engagement & Contracting (PE&C) Department handles ALL provider file updates. This includes: Anthem Medicaid network Anthem Healthy Indiana Plan network All Anthem Commercial networks. Professional Providers Submit all provider file updates using our online Provider Maintenance Form (PMF). Go to Select the Provider tab on the left side of the screen Enter the State of Indiana The online PMF is located under Answers@Anthem tab

15 Provider File Updates/ Changes The online PMF has all the fields needed to submit your Medicaid information. Use the COMMENTS FIELD at the bottom of the PMF for any information needed to enter your provider file information appropriately. The online PMF should be used to submit any information for: Adding a new provider Terminating an existing provider within your group Address, phone, fax changes Panel changes for primary care physicians (use the COMMENTS Field) 15 15

16 Provider File Updates/ Changes Anthem Medicaid Contracting and Provider File Questions: Contact your Anthem Provider Engagement & Contracting representative for questions about any provider network agreements e and provider file information. o See the territory to list in your workshop folder. Facility and Ancillary Providers: Contact your Anthem contractor in our Provider Engagement &Contracting (PE&C) Department. Submit all changes and updates in writing to your contact 16 16

17 Provider Revalidation Please remember to provide all revalidation materials back to IHCP timely. Anthem will not revalidate for providers. Failure to revalidate could lead to a non par status with Anthem HHW/ HIP. Failure to revalidate by a PMP will result in the loss of the member panel. Providers who lose their par status due to failure to revalidate will have to be re- contracted

18 Reminder of our policy concerning the waiver of prior authorization (PA) for emergency services rendered in an emergency room. Our policy remains in effect that providers do not need to obtain PA to render emergency services in an emergency room or urgent care setting. Please remember to obtain prior authorization on services that require a prior authorization when rendered outside of an emergency room or urgent care setting. Services performed by non-participating providers in a setting outside the emergency room or urgent care setting, will require prior authorizations for all services. Effective October 14, 2013, claims requiring a prior authorization outside the emergency room or urgent care setting will deny if no authorization was obtained

19 Claims Process

20 Claims Process Timely Filing Initial Claim Submission: 90 calendar days from the date of service for Anthem contracted providers 365 calendar days for non-participating providers Submit the initial claim electronically or mail to: Attn: Claims Anthem Blue Cross and Blue Shield PO Box Atlanta, GA

21 Claims Process Timely Filing Disputing a processed claim: 63 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 Correspondence Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN

22 Claims Process Timely Filing Appealing the disputed claim decision: 33 calendar days from the date of 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 Appeals Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN

23 Claims Process Timely Filing Processing time: 21 days for clean electronic claims before resubmitting. 30 days for clean paper claims before resubmitting. Check claim status before resubmitting. If no record of claim resubmit Note: Be sure to ask the Provider Services Representative to verify if the claim is imaged in Filenet/ WCF if the claim is not showing in our processing system. *Do not resubmit if the claim is on file in the processing or image system. 23

24 Operational Responsibilities Provider Operations Manual (POM) This Manual is a comprehensive document designed to inform network physicians, hospitals, facilities, ancillary providers and other health care professionals of Anthem guidelines and requirements. Providers can learn how to verify member eligibility, submit a timely claim form, request authorization for services, and much more. 24

25 Operational Responsibilities Provider Operations Manual (POM) How to find POM: 1. Go to 2. Click on Providers in the upper left corner. 3. Select Indiana from the drop down box, click enter 4. Hover over Plans & Benefits, click on State Sponsored Business 5. Click on Indiana Hoosier Healthwise and Indiana Health Indiana Plan 6. Scroll down to Provider Communications 7. Click on Provider Operations Manual and Important Updates m&label=provider%20operations%20manual%20and%20important%20updates%20for%20hoosi er%20healthwise%20and%20healthy%20indiana%20plan&state=in&rootlevel=2 in&rootlevel

26 Important Contact Information Provider Services Hoosier Healthwise HIP Prior Authorization HHW(phone) HIP (phone) (fax) Member Services /7 NurseLine

27 Where to find presentation: This presentation has been posted on the Anthem website Provider Resources page, under the heading Health Education: Under OTHER ANTHEM WEBSITES, click on Providers 3. Under Providers Spotlight, click on State Sponsored Plans Indiana Hoosier Healthwise and Healthy Indiana Plan. 4. On the State Sponsored Plan home page, click on Indiana Hoosier Healthwise and Healthy Indiana Plan (HIP). 5. Scroll down to Health Education and click on Webinars and Presentations

28 Thank you for serving our Anthem members! 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. HEDIS is a registered mark of the National Committee for Quality Assurance (NCQA). INW3807-PP 07/16/2013 Aprimo