2011 Updates/Provider File Changes/ And Top Claim Denials CMS-1450 (UB-04) Institutional Providers

1. 2011 Updates/Provider File Changes/ And Top Claim Denials CMS-1450 (UB-04) Institutional Providers Anthem“Serving Hoosier Healthwise”State Sponsored Business

2. 2011 Anthem HHW /HIP Updates • What’s New January 1, 2011: • Anthem’s Behavioral Health will be integrated with medical • HHW & HIP products will be combined • PMPs for HIP product will now have panel • PMPs should see only assigned members • MCOs will assign PMPs • New Tools/Reports: • Enhanced Web Portal • My Health Advantage ·MyHealth Notes ·Care Alerts

3. Provider File Updates/Changes • Anthem provider files must match the State’s provider information. • To maintain accuracy submit your provider updates to IHCP at www.indianamedicaid.com, or contact HP at 877-707-5750. • Note: For more information on this topic, please refer to the IHCP Provider Manual, Chapter 4.

4. Provider File Updates/Changes • Anthem’s Health Care Management area handles the provider file updates for Anthem Medicaid, as well as our Anthem Commercial provider files. • Provider Terminations, Updates, and Changes (including address, name, panel holds and/or changes): • Send a letter on the provider’s letterhead providing us with the new updated information. For terminations include effective date, as well as the reason why the provider is no longer with your group or no longer will be seeing Anthem Medicaid members. • Include the Tax ID, NPI, and Medicaid numbers on the letter. • Adding a New Provider: • Complete the State Sponsored Business Practice Information Form • Forms and Resource tools available online at www.anthem.com • Providers SpotlightAnthem State Sponsored ProgramsINProvider Resources • Anthem Medicaid Contracting Questions: • Refer to your Anthem Commercial Network Development Manager (Contract representative within your territory).

5. CMS-1450 (UB-04) Top Claim Denials • Claims and Billing

6. Frequent Claim Denials • ER Claims • Eligibility • COB • Prior Authorization • Pregnancy Only Services (Package B) • Presumptive Eligibility • Duplicate Services • Filing Time Limit • Diagnosis/Procedure Inconsistent with Patient’s Age/Gender • Behavioral Health

7. ER Claim Denials • ER Claims: • ER claims should be billed appropriately based on the members’/patients’ medical conditions. • Emergency services (revenue code 450). • Nonemergent services (revenue code 451). • Emergency services (revenue code 450) will be processed based on “Prudent Layperson Guidelines”. • If ER claim denies (revenue code 450): • Complete claim follow up form • Attach medical records • Submit the above information within 60 calendar days from the date of the Remittance Advice to: Attn: Claims Correspondence Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN 46206-6144

8. Eligibility Denials • Always verify member’s eligibility prior to rendering services. • Verify eligibility through Web interChange at: • https://interchange.indianamedicaid.com • Member ID Card: • Hoosier Healthwise ID card • Note: Always include the YRH prefix preceding the member’s 12-digit Medicaid ID/RID number in Form Locator 60 of the UB-04 claim form.

9. Coordination of Benefit (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 37010 • Louisville, KY 40233-7010 • 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 58-62 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.

10. Coordination of Benefits • Re-filing COB Claims: • Always complete the Claim Follow Up Form when you re-bill 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

11. Prior Authorization Denials • Physician is responsible for obtaining the preservice review for both professional and institutional services. • Hospital and ancillary providers should always contact us to verify preservice review status. • Authorization is 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 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

12. Prior Authorization Denials • Contact Information: • Phone 1-866-4087187 • 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: • Medical Policies and UM Clinical Guidelines. • Note: Requests that do not appear to meet criteria are sent to an Anthem physician for medical necessity determination.

13. 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 performing services • Clinical information to support the request • Treatment and discharge plans (if known)

14. 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: Anthem Correspondence/Utilization Management • Anthem Blue Cross and Blue Shield • PO Box 6144 • Indianapolis, IN 46206-6144 • Benefits, Eligibility, or Claim information: • Contact Customer Care at1-866-408-6132

15. Pregnancy Only Service Denials (Pkg. B) • Pregnancy Only Services: • HHW (Pkg. B) coverage includes services related to pregnancy, which includes prenatal, delivery, and post partum care, as well as conditions that complicate the pregnancy. • HHW (Pkg. B) also includes coverage for family planning and transportation (must be pregnancy related) services. • Pregnancy-related diagnosis code must be billed as the primary diagnosis in Form Locator 67 on the CMS-1450 (UB-04) claim form. • Note: Reference the IHCP manual Chapter 8, pages 97-98.

16. Presumptive Eligibility (PE) Denials • PE Claims: • PE covered services include: Doctor visits, outpatient professional services, lab work, & transportation (must be pregnancy related only). • Be sure to file with the appropriate PE “550” or Medicaid RID number based on eligibility for the date of service. • Pregnancy-related diagnosis code must be billed as the primary diagnosis in Form Locator 67 on the CMS-1450 claim form. • Note:Be sure to include the YRH prefix with the PE “550” RID number.Reference the IHCP manual Chapter 8, pages 271-279. You may also reference the IHCP Presumptive Eligibility manual.

17. 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 Representative to verify if the claim is imaged in Filenet 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.

18. Duplicate Claim Denials • Claim Follow Up Form: • Must use this form to submit corrected claims. • Attach this completed 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

19. Filing Time Limit Denials • Claim Filing Limits: • Initial Claim Submission: • 180 calendar days of the date of service • Submit the initial claim electronically or mail to: • Attn: Claims • Anthem Blue Cross and Blue Shield • PO Box 37010 • Louisville, KY 40233-7010

20. 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

21. Filing Time Limit Denials • Claim Filing Limits: • Appealing the disputed claim: • 30 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 46206-6144

22. Filing Time Limit Denials • Claim Filing Limits: • Third Party Liability Filing Limits: • 180 days from the date of the primary carrier’s Remittance Advice. • Submit the initial claim and primary carrier’s Remittance Advice, along with any claims filing supporting documentation to: • Attn: Claims • PO Box 37010 • Louisville, KY 40233-7010 • Note: Claim filed 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.

23. 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 10-11 of the CMS 1450 (UB-04) claim form.

24. Behavioral Health Claim Denials • Behavioral Health Services: • Anthem Medicaid Behavioral Health 2010 services are carved out to Magellan. • Contact Magellan at 1-800-327-5480. • Reference the POM, Chapter 3, pages 46-48. • Note: Effective January 1, 2011, Anthem’s Behavioral Health will be integrated with medical.

25. 2011 Updates/Provider File Changes/Top Claims Denials • Questions