Transcript OH ABD Update - indianamedicaid.com

Anthem Blue Cross and Blue Shield
“Serving Hoosier Healthwise”
State Sponsored Business
Managed Care Forms
October 2008
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.
Anthem Provider Forms - Overview
Forms and Tools Library
Anthem provides you with the following forms, tools, and additional resources to help you take care of our
members.
The below list is does not include all forms. You can find a more complete list by going to Anthem’s website www.anthem.com
•
•
•
•
•
Claims and Billing
• EFT/ERA
• Claims Follow up
• Claims Resubmission
Grievances and Disputes
• Provider Dispute Resolution (PDR)
• Provider/Member Grievance
• Billing Dispute External Review Process
• Fraud Referral Form
Changes and Referrals
• Case Management Referral
• Provider Request for Member Deletion
• Request for Professional Provider Information
Pregnancy and Childbirth
• Pregnancy Notification
• Newborn Enrollment Notification Report
• Pre-birth Selection
Other Forms
• Mental Health Consent Form
• Outreach Request Form
• Full Panel Add Request Form
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Provider Online Resources
3
Forms and Tools Library
4
Claims and Billing Forms
EFT/ERA Form
EFT/ERA
Enrollment Form
•
EFT: Electronic Claims Transfer
• Claims payments deposited directly into a
bank account.
• Enroll by calling EDI Services at 1-800-470-9630
Complete this form to request implementation of the Electronic Funds Transfer / Electronic Remittance Advice (EFT/ERA)
for Anthem Medicaid Managed Care program(s) claims. Please note your Billing NPI number is required to enroll in
EFT/ERA.
A separate form must be completed for each Tax Identification Number.
Provider’s legal name as it appears on W-9:
Billing NPI Number:
Tax ID Number:
Email:
•
•
ERA: Electronic Remittance Advice
• Received through the SPC: MAILBOX.
• Implementation guides are available at no
charge at www.wpc-edi.com/hipaa.
• Enrollment is required. Providers can enroll
by calling EDI Services at 1-800-470-9630.
• Electronic data transfers and claims are HIPAAcompliant and meet federal requirements for EDI
transactions, code sets, member confidentiality,
and privacy.
Completed EFT/ERA claims can be faxed or mailed
to:
Attention: Maryjo Johnson, PCDA
5151-A Camino Ruiz, Mailstop CACD01-042C
Camarillo, CA 93012
Phone: 805-384-7406
Fax:
866-652-1236
Physical Address:
City:
Contact Name:
Title:
State:
ZIP:
Phone:
I WILL BE USING ONE OF THE FOLLOWING TO TRANSLATE/PRINT THE ERA FILE (Check one box only):
INTERNAL TRANSLATOR SOFTWARE
VENDOR
By submission of this form to Anthem, I authorize implementation of the services requested above for this facility and agree
to the following:
1.
PROVIDER hereby requests Electronic Funds Transfer and Electronic Remittance Advice and ("EFT/ERA") for Anthem
claims.
2.
PROVIDER shall assign a primary contact person for EFT/ERA, with responsibilities for scheduling and implementation.
3.
If PROVIDER implements ERA capability other than directly with Anthem, PROVIDER shall authorize the Billing Service,
Electronic Media Claims (EMC) vendor or other party, in writing as the agent of PROVIDER. Said agent shall be authorized to
schedule and implement ERA for PROVIDER. PROVIDER shall further authorize in writing the release of all claims payment
data and applicable financial information to PROVIDER’s agent.
4.
PROVIDER agrees that, if PROVIDER uses an agent to implement ERA, PROVIDER shall give Anthem a letter ("Release
Letter") signed by a duly authorized representative of PROVIDER, on PROVIDER’s letterhead, stating (1) the name and
address of PROVIDER’s agent and (2) the scope of the agent’s authority and (3) that said agent is both aware of, and has
agreed to be bound by, all applicable state and federal laws and regulations with regard to patient confidentiality.
5.
PROVIDER is, is not  currently using a billing agent. If PROVIDER is currently using a billing agent, PROVIDER’s
Release Letter is attached and is incorporated by reference.
6.
PROVIDER understands and agrees that a new Release Letter shall be provided to ANTHEM whenever PROVIDER changes
PROVIDER’s agent, as applicable.
7.
PROVIDER hereby represents and warrants that its duly authorized representative signs this request for EFT/ERA.
The CEO or CFO or duly authorized representative of this facility must sign this form.
PRINT NAME:
SIGNATURE:
TITLE:
DATE:
PHONE:
ATTACHMENT A
Anthem Blue Cross and Blue Shield is the trade name for: In Connecticut: Anthem Blue Cross and Blue Shield Plan Administrator, LLC., In Indiana: Anthem Insurance Companies, Inc., In
Nevada: HMO Colorado, Inc., dba Anthem Blue Cross and Blue Shield Partnership Plan, In Ohio: Anthem Blue Cross Blue Shield Partnership Plan, Inc. 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.
0708 ANW0713 07/21/08
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Claims and Billing Forms (continued)
Anthem Blue Cross Blue Shield
State Sponsored Business
Claim FollowUp/Resubmission Forms
Follow-up to determine claim status if
there has been no response from
Anthem to a submitted claim after 30
business days from the date the claim
was submitted:
• Check Anthem for disposition of the claim,
• Check the Interactive Voice Response
(IVR) for disposition of the claim, or
• Contact the Customer Call Center (CCC)
• Provide a copy of the original claim
submission and all supporting
documentation (such as records and
reports) that you deem pertinent or that
has been requested by Anthem.
ClaimFollow
Follow
Form
Form
Upup
Claim
Provider Information
Sent by
Date Sent
Hospital/Facility/Physician
Phone Number
NPI Number
Provider Tax ID Number
Member Information
Patient Name
Date of Service
Member ID Number
Medicaid ID Number
INSTRUCTIONS: When submitting this form to request reconsideration of a claim, please
attach the proper documentation, including a copy of any applicable correspondence received
from Anthem Blue Cross and Blue Shield.
After completing this form, place it on top of all documentation and mail to:
Attn: Claims
Anthem Blue Cross and Blue Shield
P.O. Box 6144
Indianapolis, IN 46206-6144
A copy of the claim should not be submitted with the documentation requested, unless otherwise
denoted by an asterick (*).
For reconsideration of a returned claim, check all that apply:
COB/Medicaid Information
Corrected Billing*
EOMB/EOB of Primary Insurance Carrier
Hard Copy of Itemized Bill for a Previously Submitted Claim
Medical Records
Patient Eligibility Verified (through Customer Service, IVR, Provider Access)
Other:
To request a claim adjustment, check all that apply:
Additional Charges*
Other Action Required:
HMO Use Only: (consult your HMO Agreement if you are uncertain which choice applies)
Eligibility Guarantee Claims
Enrollment Protection Claims
Non Cap Discrepancies
Other:
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Claims and Billing Forms (continued)
Anthem Blue Cross Blue Shield
Claim Follow-Up/Resubmission
Forms (cont’d)
State Sponsored Business
Claim Resubmission Form
Claim Resubmission Form
Attach a copy of the original claim form with corrections and/or attachments and send to:
Attn: Claims
Anthem Blue Cross and Blue Shield
P.O. Box 6144
Indianapolis, IN 46206-6144
Corrections or additional information by line number is necessary to reconsider previously paid
(overpayment/underpayment) and/or denied claims listed.
Please Print or Type
Provider Name:
Address:
Tax ID Number:
Provider NPI:
Member Name:
License Number:
Client Index Number:
Claim Type (Please check one.)
Hospital/Inpatient
LTC/Hospice
DME/Med Supplies
Hospital/Outpatient
Physician
Home Care
Remarks:
This is to certify that the above information is true, accurate and complete.
Signature of provider or authorized representative
Date
For Anthem Blue Cross and Blue Shield Use Only
Reconsideration
Network Prv: Y
Appeal
N
Orig Claim DCN:
Records attached: Y
Prior MRU:
Y
N
Attached:
Y
N
Prior PA:
Y
N
Attached:
Y
N
N
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Grievances and Disputes
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Grievances and Disputes
Provider Dispute Resolution
Form
• Complete Provider Dispute Resolution
Request with all points of contention
itemized and explained
• Include:
•
•
A copy of the original/corrected CMS1500 or CMS-1450 claim form
Any and all supporting documentation
(such as records, reports) that you deem
pertinent or that we have requested
• Anthem sends acknowledgement of receipt
to all provider claim disputes within five
business days from the date Anthem
receives of the dispute.
• Determination is made in 45 business days
from Anthem’s receipt of dispute.
Anthem Blue Cross Blue Shield
State Sponsored Business
Provider
Dispute
FormRequest Form
Provider
Dispute
Resolution
Submission of this form constitutes agreement not to bill the patient during the dispute process.
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Please complete the form below. Fields with an asterisk ( * ) are required.
Be specific when completing the “Description of Dispute” and “Expected Outcome.”
Provide additional information to support the description of the dispute. Do not include a copy of a
claim that was previously processed.
For routine follow-up, please use the Claims Follow-Up Form.

Mail the completed form to:
Anthem Blue Cross and Blue Shield
P.O. Box 6144
Indianapolis, IN 46206-6144
Provider Name*:
National Provider Identifier(NPI) Number:
Rendering Provider NPI Number:
Tax ID Number:
Street Address:
City:
State:
Provider Type:
MD
Mental Health
DME
Rehab
Other (please specify):
ZIP code:
Hospital
Home Health
ASC
Ambulance
SNF
CLAIM INFORMATION
Single
Substantially Similar Multiple Claims (complete page 2)
Patient Name*:
Date of Birth:
Health Plan ID Number*:
Patient Account Number:
Original Claim ID Number (if multiple claims, complete page 2):
Service “From/To” Dates* (required for claim, billing, and reimbursement of overpayment disputes):
Original Claim Amount Billed:
/
Original Claim Amount Paid:
DISPUTE TYPE
Claim
Seeking Resolution of a Billing Determination
Request For Reimbursement of Overpayment
Contract Dispute
Appeal of Medical Necessity / Utilization Management Decision
Other (please specify):
Description of Dispute*:
Expected Outcome:
Contact Name (please print):
Title:
Phone Number:
Fax Number:
Signature:
Date:
Check here if additional information is attached. Please do not staple additional information.
For Health Plan Use Only:
Tracking Number:
Provider ID #:
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Grievances and Disputes (continued)
Provider Grievance Form
Anthem Blue Cross Blue Shield
State Sponsored Business
Physician/Provider
form to 1-866-408-7087.
fax the completed
Please
Grievance
Form
•
•
•
•
Providers may file a grievance in
writing or fax.
May be filed up to 60 calendar days of
the date the provider became aware
of the issue.
Anthem will send a written
acknowledgement to the provider
within 5 calendar days of receiving a
provider grievance.
Anthem sends a written resolution
letter to the provider within 30
calendar days of the receipt of the
grievance.
SCHIP (Pkg. C)
Medicaid (Pkg. A or B)
Provider Information
Date:
Primary Medical Provider Site Number:
Provider Name:
License Number:
Tax ID Number:
NPI Number:
Are you part of the Anthem network?
Phone Number:
Yes
No
ZIP Code:
State:
Address:
-
-
Fax Number:
-
-
Information about the Grievance
This information is part of the permanent record. Write clearly and legibly. Use more sheets of paper if
necessary.
Policy Issue
Service Issue
Member Name:
Medical Group Issue
Quality Issue
Other
Member ID Number:
Date of Incident:
Describe What Happened:
Signature of Provider:
Date:
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Grievances and Disputes (continued)
Billing Dispute External
Review Process Form
Anthem Blue Cross Blue Shield
State Sponsored Business
Billing Dispute External Review
Process
Billing
Dispute External Review Form
Please send this completed form, and the filing fee to the Billing Dispute External Review Board,
IMEDECS (formerly known as HAYES Plus, Inc.). Attach the final appeal denial letter and supporting
documentation: Explanation of Benefits (EOB) and additional clinical information, etc.
IMEDECS
157 S. Broad Street, Lansdale, PA 19446
Phone: (215) 855-4633 / Fax: (215) 855-5318
Physician Information:
Treating Physician Name (as submitted on claim):
NPI Number:
• After exhausting internal physician
appeal process for a medical
necessity or experimental /
investigational adverse determination
• Submit a written request for an
external review of the internal
physician appeal within 60 calendar
days from the date of the notice of
our internal appeals decision
• Any decision issued pursuant to the
external review process is binding
upon the physician
Tax ID Number:
Billing Address (Street, City, State, ZIP):
Telephone Number:
Extension:
Contact Name:
Fax Number:
Contact Phone Number:
Contact E-Mail:
If Codes/Modifiers are Disputed:
A specific code set must be identified; a minimum of two codes must be entered below.
Note: To see examples of the types of disputes eligible for review, please refer to the attached Example
Billing Dispute Category List.
CPT® Code (Primary):
CPT Code® (secondary)
(and/or) Modifier
Claim Information:
If your billing dispute contains multiple claims for the same code set, please attach a separate sheet noting
the physician’s name, member’s name, member’s ID, date of service, and claim number.
Member Name:
Member ID Number:
Member Group Number (Optional):
Member Address (Street, City, State, ZIP):
Request for Physician Billing Dispute External Review:
Date of Service:
Claim Number (Indicated on Explanation of Payment):
Amount in dispute (the
additional amount you
believe you are
entitled to receive in
this dispute):
Filing fee: (Please check one.)
$50.00 Disputed amount greater than $500 and less than or equal to
$1,000.00
$50.00 + 5% of amount of dispute which exceeds $1,000.00. The fee may
not exceed 50% of the cost of the review.
No amount is enclosed because this claim is an aggregate of a deferred
$
claim for which a filing fee has previously been paid.
Amount enclosed: $
Please Make check payable to IMEDECS.
The decision of IMEDECS is final and binding on Anthem Blue Cross and Blue Shield and the physician
or physician group only with respect to the specific case under review by IMEDECS. Physicians may
access the Anthem website (www.anthem.com) or the IMEDECS website (www.IMEDECS.com) for
further information.
Comments:
I hereby acknowledge the terms of the Billing Dispute External Review Process, further certify that I am a
member of the class, and further certify the accuracy of the material and information submitted with the
request.
Signature of Physician:
Date:
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Grievances and Disputes (continued)
Fraud Referral Form
Anthem Blue Cross Blue Shield
State Sponsored Business
Fraud Referral Form
Patient Information
Name:
Any type of intentional deception or
misrepresentation made with the
knowledge that the deception could result
in some unauthorized benefit to himself
or some other person.
ID/Certificate Number:
Address:
City:
State:
Phone:
ZIP Code:
Date of Birth:
Date(s) of Incident(s):
Provider Information
Name:
Address:
City:
State:
ZIP Code:
Phone:
Tax ID Number:
License Number:
NPI Number:
Details of Suspected Fraud (Use additional paper if necessary.)
Signature:
Date:
Reporting Party:
Phone:
Reporting Party
Signature:
Date:
Note: Be sure to attach to this form any document (claims, correspondence, medical records, etc.) that you
may have.
Send complete form to:
Anthem Blue Cross and Blue Shield
PO Box 9054, Mail Stop CACC01-055D
Oxnard, CA 93031-9054
Or fax to:
1-866-454-3990
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Changes and Referrals
13
Changes and Referrals
Case Management Referral
Form
Anthem Blue Cross Blue Shield
State Sponsored Business
Case Management Referral Form
This person submitting the referral for care Management or continuity of care should
complete this form. When complete please fax to care management at 1-866-4062808. Thank you for your referral!
Medicaid
SCHIP
Other
Member Name:
Date of Birth:
Member Phone Number:
Certificate Number:
Date Referred to Care Management:
Name of Person Submitting Referral:
Phone Number of Person Submitting Referral:
Reason for Care Management Referral
High Risk Obstetrics-Gestational Age Less Than 35 Weeks
Pregnancy-induced hypertension (increase over baseline of 15 mm diastolic or 30 mm systolic >140 mm/diastolic >90 mm)
Diabetes on insulin
Previous preterm labor: gestational age <35 weeks for two or more pregnancies on tocolytics
Confirmed psychosocial issues (domestic abuse, depression) with plans to continue pregnancy
Obese with a BMI of >35
Current substance abuse (include smoking) - Type:
Incompetent cervix
Cerclage (date done):
Placenta previa/abruption
Other HROB: hyperemesis with weight loss of greater than 10 lbs. from pregnancy weight
Other (specify high-risk medical condition):
Transplant
Type:
New Referral (please check one):
Catastrophic Conditions (ADULT and PEDIATRIC)
Catastrophic/complex diagnosis requiring coordination of care, connection to services, coordination of benefits
Compounding psychosocial factors presenting actual or potential barriers to care
Chronic conditions requiring:
Three or more hospitalizations within the past 6 months
Nonhealing wound requiring active treatment for a duration greater than 3 months
Provider or member is requesting care management. Contact phone number:
HIV/AIDS
End Stage Renal Disease
HIV
Hemodialysis
AIDS
Peritoneal dialysis
Continuity of Care Services (because of physician contract terminations or member insurance changes)
Does the member have a need for continuation of services?
Acute or chronic health care condition requiring completion of service to complete a course of treatment
Pregnancy
Surgery
Terminal illness
Newborn (birth to 36 months)
Comments:
What do you think Care Management can impact with this referral?
S
P
Are medical records attached to this referral?
Yes
No
TO BE COMPLETED BY CARE MANAGER
Care management case opened
Assigned Care Manager:
Care management case NOT opened (check reason below):
Not active care management needed at this time
Member is not eligible for services
14
Changes and Referrals (continued)
Anthem Blue Cross Blue Shield
State Sponsored Business
Provider Request for Member
Deletion from PMP
Assignment Form
Provider Request for Member deletion from Primary
Medical Provider (PMP) Assignment
A primary medical provider (PMP) may request disenrollment of a member from his or her primary care
assignment if the member demonstrates serious noncompliance or disruptive behavior. Please follow all
policies for member transfers and disenrollment as stated in Chapter 19 of the Provider Operations
Manual. Anthem will perform an upper-level review to determine if the request will be approved.
Date:
Provider Information
A PMP can request a member
reassignment to another PMP by
completing and submitting the Provider
Request for Member Deletion from PMP
Assignment form
PMP Name:
PMP Phone No.:
Member Information
Member Name:
Member Date of Birth:
Member ID No.:
Member Phone No.:
Reason for Request
Excessive missed appointments (more than three unreasonable misses)
What were the dates and circumstances?
Unreasonable demands for referrals combined with documented threatening, abusive, or hostile
behavior
Have you ever seen this member?
Yes
No
What are the specific circumstances?
Abusive or disruptive behavior
Unsatisfactory doctor/patient relationship (explain below)
Other
What are the specific circumstances?
Add additional comments here:
Fax to:
Anthem Blue Cross and Blue Shield
State Sponsored Business
1-866-408-7087
or
Mail request to:
Anthem Blue Cross and Blue Shield
State Sponsored Business
P.O. Box 6144
Indianapolis, IN 46206-6144
15
Changes and Referrals (continued)
Request for Professional
Provider Practice Information
Anthem Blue Cross Blue Shield
State Sponsored Business
Request for Professional Provider Practice
Information
Request for Professional Provider Practice Information
Please TYPE or PRINT.
Physician Information
Last Name:
Degree (MD, DO, etc.):
EPSDT Certified?
Yes
No
Tax ID Number:
First Name:
Middle Initial:
Ethnicity (optional):
Gender:
Male
Female
Indicate how you would like to participate in our network:
Primary Care Physician/Provider (PCP1) Specialist
Both
Group (Type II) 10-Digit NPI Number2:
Date of Birth:
MO / DY / YEAR
Legal Business Name:
DBA (if different from Legal Business Name):
License Number:
Medicaid ID Number3:
CAQH ID Number*4:
Individual (Type I) 10-Digit NPI Number:
Provider Practice Information
Indicate if you are a:
Individual Practice
Group Practice
Federally Qualified Health Clinic
Tribal Health Center
Community Health Center
School-Based Health Clinic
Other
Indicate service types provided:
Medical
Dental
Vision
DEA Number:
Health Plan ID Number:5
Rural Health Clinic
Department of Health
Other:
Billing Information
Primary Billing Information (Name):
Remittance Address (for receiving payments):
City:
State:
ZIP Code:
City:
State:
ZIP Code:
Phone Number:
Fax Number:
Billing NPI Number (10-Digit):
Primary Tax ID Number:
Correspondence Address (for receiving provider communications):
Secondary Billing Information (Name – if different from Primary Billing Location):
Address:
City:
State:
Phone Number:
Fax Number:
Billing NPI Number (10-Digit):
ZIP Code:
Secondary Tax ID Number:
Current Hospital Privileges
2.
4.
1.
3.
Please complete the following page. Please attach a separate sheet for additional office locations.
1
In Indiana, Primary Medical Provider (PMP).
2
If you don’t have an NPI number, visit the Centers for Medicare & Medicaid Services website at www.cms.hhs.gov/NationalProvIdentStand or dial 1-800-465-3203.
For the most efficient application processing and the fastest receipt of NPIs, visit the National Plan and Provider Enumeration System website at www.nppes.cms.hhs.gov
and apply online.
3
Medicaid ID number is also known as the state ID. For example, in Texas - the TPI; for Indiana - the IHCP; for Kansas - the KMAP number; etc.
4
Credentialing information must be provided for each physician covered under the Medicaid Agreement. In order to streamline this process, we have included information
about joining the Council for Affordable Quality Healthcare (CAQH). CAQH is an online service that streamlines the credentialing process. To find out more about
registering for this service, please visit the website at https://caqh.geoaccess.com or call CAQH toll-free at 1-888-599-1771. If you already use CAQH, please provide
your CAQH ID Number, as indicated, and log into your CAQH account to authorize Anthem Blue Cross and Blue Shield to obtain your credentialing information.
5
If commercially contracted with us, please supply Provider ID Number.
16
Pregnancy and Childbirth
17
Pregnancy and Childbirth
Pregnancy Notification Report
Anthem Blue Cross Blue Shield
State Sponsored Business
Pregnancy Notification Report
Pregnancy Notification Report
All providers must complete this form. Please fax this form to Anthem Blue Cross and Blue Shield at 1-866-387-2840 within 30
days of assessment.
SECTION A: Patient Information
Today’s Date (MM/DD/YY):
ID Card Number/CIN Number:
Last Name:
Date of Birth (MM/DD/YY):
First Name:
Street Address:
Apt. No.:
Phone No.:
Due Date (MM/DD/YY):
Language Spoken:
English
Spanish
City:
State:
ZIP Code:
Confidential Pregnancy
Other:
SECTION B: OB Provider Information
Last Name:
First Name:
Street Address:
Suite No.:
Phone No.:
City:
State:
Tax ID No.:
ZIP Code:
Provider NPI:
SECTION C: Risk Assessment
Medical
Asthma
Diabetes
Advanced maternal age ( > 35 yrs. )
History of poor pregnancy outcome
Other
Social
Age < 16 years
Mental retardation or history of mental
problems
Illiteracy/communication problems
Other
Substance Abuse
Alcohol
Cocaine/crack
Sedatives/tranquilizers
Inhalants/glue
Medications that may affect fetal outcome
Gestational diabetes
Genetic disorder
Multifetal pregnancies
Current placental problems
Previous preterm birth (< 5 lbs.)
History of high-risk pregnancy
Pregnancy-induced hypertension
Noncompliant with medical directions or
appointments
Shelter, homeless, or migrant
Abuse/neglect during pregnancy
Lack of food
How often?
How often?
How often?
How often?
Narcotics/heroin
Marijuana
Amphetamines/diet pills
Tobacco/cigarettes
How often?
How often?
How often?
How often?
Other
Nutrition
Poor diet or pica
Obstetrical/medical condition requiring diet modification
Other
SECTION D: Referrals
WIC
Nutritional counseling
SECTION E: Other Information
Yes
No
N/A
Yes
No
N/A
Case management
Substance abuse treatment
Patient taking prenatal vitamins?
Toxicology completed?
Pregnancy underweight or overweight, inadequate or excessive weight
gain
Smoking cessation
Parenting/childbirth classes
Yes
No
N/A
Glucose monitor with nutrition
counseling
HIV test completed?
Provider comments or suggestions:
Signature/Title:
Date:
18
Pregnancy and Childbirth (continued)
Newborn Enrollment Form
Anthem Blue Cross Blue Shield
State Sponsored Business
Newborn
Enrollment
Notification
Report
Newborn
Enrollment
Notification
Report
Please send completed form by secure email to [email protected] or fax it to
1-877-833-5735.
PURPOSE: Use this form to report a birth to a mother who is currently eligible under Anthem Medicaid.
Completion and submission of this form will allow us to promptly add the newborn(s) to our plan.
Anthem Blue Cross and Blue Shield
Name of HMO
/
/
Mother’s Effective Date (MM/DD/YYYY)
Mother’s SSN#
Mother’s Medicaid ID# (required)
Mother’s Name (Last, First, Middle) (required)
/
/
Mother’s Date of Birth (required)
Residence County
Phone Number
Street Address
City
State
ZIP Code
Newborn’s Name (Last, First, Middle) (Required)
Newborn Medicaid ID#
Gender (required)
Twin Name (Baby 2, 3, etc.)
Newborn Medicaid ID#
Gender (required)
Newborn(s) Date of Birth (required)
Newborn(s) PMP Name
Delivery Hospital Name (required)
Phone Number
Contact Name (required)
Phone Number
Fax Number
For Internal Use Only
Entered by Member Specialist:
Contact Name
Date
19
Pregnancy and Childbirth (continued)
Pre-birth Selection Form for
Hoosier Healthwise Members
Anthem Blue Cross Blue Shield
State Sponsored Business
Prebirth Selection Form for Hoosier Healthwise Members
Hoosier Healthwise Members
Please complete all fields and fax completed form to 1-317-238-3120.
Today’s Date:
Name of Staff Completing Form:
Member Name:
Member Hoosier Healthwise RID#:
Member Social Security Number:
Member Address
Street:
City:
State:
ZIP Code:
Phone Number (where member can be reached – write “none” if no phone):
Newborn Information
Full name of Hoosier Healthwise primary medical provider (PMP) that member is
selecting for baby:
Address of PMP
Street:
City:
State:
ZIP Code:
PMP ID Number:
Mother’s Estimated Due Date:
Mother’s Signature:
Date:
If PMP panel is full, PMP must sign below authorizing the addition to his/her panel.
PMP Signature:
Date:
PMPs should contact the MCO for procedures.
20
Other Forms
21
Other Forms
Mental Health Consent Form
Consent to Release Protected Health Information (PHI)
Magellan Health Services
10101 Alliance Rd
Suite 201
Cincinnati, Ohio 45242
Protected Health Information (PHI) means information about your health. Federal and state laws protect the
privacy of your PHI. The laws say we cannot give anyone other than your doctors or your Healthplan your PHI
unless you say it is OK. By signing this paper, you give us your OK. We will only give out the PHI that you
say we can share. And, we will only give it to the people or agencies that you list. Do you have questions? We
can help. Call Magellan at 1-800-327-5480.
Part 1
Who is the patient?
Last Name
ID Number (SSN)
Address
First Name
Middle Initial
Date of Birth (MM/DD/YYYY)
Phone Number (with area code)
City
State
Zip Code
Check One
I am the patient OR
I have the legal right to act for this person. (Check one below; if “other” fill in blank)
I’m his or her:
Parent OR
Guardian, OR
Other
Part 2
Who can give
out the PHI?
Magellan may give out your PHI. Magellan manages your mental health and/or drug and alcohol treatment for
your Healthplan.
Part 3
Who can the PHI be given
to?
Name (a person, like family members who live with me, or a place of business)
Address
Part 4
Phone Number (with area code)
City, State, and Zip Code
What PHI can we share?
We will only share the PHI that you OK. This OK includes facts about your medicine. It also includes facts
about your mental health and/or your alcohol and drug treatment that are in your records. It does not cover
psychotherapy notes that are not in your medical records. Tell us the health information from your records that
can be shared. Give the date or place if you can. __________________________________________________
_____ ____________________________________________________________________________________
__________________________________________________________________________________________
If you give us your OK to share this kind of health information, tell us by checking the box.
HIV/AIDS
Part 5
Alcohol/Substance Abuse Records
Sexual/Physical/Mental Abuse
Why are you giving out this PHI?
Tell us why you want us to share your PHI?
_____________________________________________
_____ ____________________________________________________________________________________
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Other Forms (continued)
Outreach Request
Anthem Blue Cross Blue Shield
State Sponsored Business
Outreach Request Form
Outreach Request Form
Date:
If you need assistance completing the form, please contact your local Community Resource Center
(CRC):
Columbus:
Evansville:
1-877-225-0595
1-866-461-3585
Indianapolis
Merrillville
1-866-795-5440
1-866-724-6533
Please fax completed form to your nearest CRC:
Columbus (Southeast Region): 1-866-378-9820
Evansville (Southwest Region): 1-866-461-2402
Indianapolis (West Central, Central and East Central Regions): 1-866-464-9945
Merrillville (Northwest, Northeast and North Central Regions): 1-866-781-5095
Provider Information
Practice Name:
Address:
City:
Phone:
Contact Name:
State:
Fax:
ZIP Code:
Patient Information
Patient Name:
Parent/Guardian Name
Medicaid ID Number:
Phone Number:
Reason for Outreach Request
Noncompliant
Health Education Classes (list classes):
New Member Benefits Orientation
No-Show for appointment(s) (list dates):
Community Resources (list need):
CRC Outreach Notes (To be completed by Outreach Specialist.)
Outreach Specialist:
Date of Home Visit:
Patient has::
Preferred Language:
Notes:
Package A&B
Phone Number:
Number of Family Members:
Package C (SCHIP)
Date Faxed to Provider:
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Other Forms (continued)
Full Panel Add Request Form
Anthem Blue Cross Blue Shield
State Sponsored Business
Full Panel Add Request Form
Date Requested:
Contact Name:
Contact Telephone:
Member Information
Hoosier Healthwise ID Number:
Member Name:
Social Security Number:
Newborn Date of Birth:
Member Address:
City:
State:
Member (or parent/guardian signature)
Date
ZIP Code:
Provider Information
As a PMP, I agree to add the above Hoosier Healthwise member to my full panel.
Physician Name (print):
Physician Signature:
Physician Provider ID Number:
MAXIMUS Use Only
Date Received:
Date Approved:
Date Denied:
Return Code/Reason:
In Indiana: Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue
24