1. 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.

2. CMS-1450 (UB-04) Top Claim Denials
CLAIMS AND BILLING

3. 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

4. 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.

5. 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 – Other provider types NPI
Box 5 – Tax ID Number
Be sure to attest all of your NPI numbers with the State of Indiana at

6. 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

7. 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:

9. 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.

10. 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 Indianapolis, IN
Forms and Resource tools available online at
Providers Spotlight  Anthem State Sponsored Programs  IN  Provider Resources

11. 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 Indianapolis, IN

12. Eligibility Denials
ALWAYS verify member’s eligibility prior to rendering services.
Verify eligibility through Web interChange at:
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.

13. 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 Louisville, KY

14. 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 Indianapolis, IN

15. 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 Indianapolis, IN

16. 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 Louisville, KY

17. 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:

18. Prior Authorization Denials
Contact Information:
PHONE:
FAX:
Forms and Resource Tools available online:
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 a medical necessity determination.

19. 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)

20. 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 Indianapolis, IN
Specialty injections/infusions: To start a request, the ordering physician should contact Next Rx at
Benefits, Eligibility, or Claim information: Contact Customer Care at

21. 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
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.

22. 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 Indianapolis, IN

23. 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.

24. 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.

25. Dental Claim Denials Dental Services:
Dental services are carved out to the Indiana Health Coverage Program (EDS). Contact EDS at
Exception: Procedure code 41899, emergency tooth extraction is covered in a facility setting.
Procedure code requires Prior Authorization.
Reference the POM, Chapter 3, pages

26. Behavioral Health Claim Denials
Behavioral Health Services:
Anthem’s Medicaid behavioral health services are carved out to Magellan.
Contact Magellan at
Reference the POM, Chapter 3, pages 24.

27. 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 are not acceptable for outpatient services.
Submit outpatient claims with type of bill 131.

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