Transcript OH ABD Update - Indiana Medicaid

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.
CMS-1450 (UB-04) Top Claim Denials
CLAIMS AND BILLING
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Frequent Claim Denials
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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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NPI Denials
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.
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NPI Denials
Claims and Billing Requirements:
• CMS-1450 (UB-04)
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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.
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NPI Denials
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.
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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
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NPI Denials
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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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Duplicate Claim Denials
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.
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Duplicate Claim Denials
Claim Resubmission Form
• Must use this form to submit corrected claims.
• Attach this form to the claim.
• Submit within 60 days to:
Attn: Claims Correspondence
Anthem Blue Cross and Blue Shield
PO Box 6144
Indianapolis, IN 46206-6144
Forms and Resource tools available online at www.anthem.com
Providers Spotlight  Anthem State Sponsored Programs  IN  Provider Resources
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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: Claims
Anthem Blue Cross and Blue Shield
PO Box 6144
Indianapolis, 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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Filing Time Limit Denials
Claim Filing Limits
• Initial Claim Submission:
• Based on the facility’s contract.
• Submit the initial claim electronically or mail to:
ATTN: Claims
Anthem Blue Cross and Blue Shield
PO Box 37180
Louisville, KY 40233-7180
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Filing Time Limit Denials
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 Correspondence
Anthem Blue Cross and Blue Shield
PO Box 6144
Indianapolis, IN 46206-6144
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Filing Time Limit Denials
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 – Appeals
Anthem Blue Cross and Blue Shield
PO Box 6144
Indianapolis, IN 46206-6144
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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: Claims
Anthem Blue Cross and Blue Shield
PO Box 37180
Louisville, KY 40233-7180
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Prior Authorization Denials
• 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 innetwork 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.
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Prior Authorization Denials
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
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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.
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Prior Authorization Denials
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)
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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 Management
Anthem Blue Cross and Blue Shield
PO Box 6144
Indianapolis, IN 46206-9210
• Specialty injections/infusions: To start a request, the
ordering physician should contact Next Rx at
1-888-662-0944.
• Benefits, Eligibility, or Claim information: Contact Customer
Care at 1-866-408-6132.
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Coordination of Benefits (COB) Denials
• 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 37180
Louisville, 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.
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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 – COB
Anthem Blue Cross and Blue Shield
PO Box 6144
Indianapolis, 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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