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

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

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.

NPI Denials 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 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 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:

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.

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

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

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.

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

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

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

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

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 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 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 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 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.

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.

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

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.

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.

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.

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.

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.

CMS-1450 (UB-04) Top Claim Denials Questions