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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.
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CMS-1450 (UB-04) Top Claim Denials
CLAIMS AND BILLING
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Frequent Claim Denials
• 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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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.
NPI Denials
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Claims and Billing Requirements:
• CMS-1450 (UB-04)
• 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.
NPI Denials
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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.
• 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
NPI Denials
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NPI Denials
• 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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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.
Duplicate Claim Denials
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Claim Resubmission Form
• Must use this form to submit corrected claims.
• Attach this form to the claim.
• Submit within 60 days to:
Attn: Claims CorrespondenceAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, IN 46206-6144
Forms and Resource tools available online at www.anthem.comProviders Spotlight Anthem State Sponsored Programs IN Provider Resources
Duplicate Claim Denials
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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: ClaimsAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, 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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Claim Filing Limits
• Initial Claim Submission:
• Based on the facility’s contract.• Submit the initial claim electronically or mail to:
ATTN: ClaimsAnthem Blue Cross and Blue ShieldPO Box 37180Louisville, KY 40233-7180
Filing Time Limit Denials
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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 CorrespondenceAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, IN 46206-6144
Filing Time Limit Denials
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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 – AppealsAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, IN 46206-6144
Filing Time Limit Denials
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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: ClaimsAnthem Blue Cross and Blue ShieldPO Box 37180Louisville, KY 40233-7180
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• 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 in-network 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.
Prior Authorization Denials
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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
• 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.
Prior Authorization Denials
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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)
Prior Authorization Denials
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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 ManagementAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, IN 46206-9210
• Specialty injections/infusions: To start a request, the ordering physician should contact Next Rx at1-888-662-0944.
• Benefits, Eligibility, or Claim information: Contact Customer Care at 1-866-408-6132.
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• 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 37180Louisville, 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.
Coordination of Benefits (COB) Denials
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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 – COBAnthem Blue Cross and Blue ShieldPO Box 6144Indianapolis, 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
