Physician Partnership Network (PPN)Claims Submission

Transcription

1 Introduction... 3 Information for Contracting Providers Claims Settlement Practices... 3 Claim Submission Instructions... 3 Claim Overpayments... 4 General Guidelines... 4 Modifier Reimbursement Guidelines... 7 Modifiers... 7 Anesthesia Claims Types of Anesthesia Payable Anesthesia Services Non-Payable Anesthesia Service Obstetrical Anesthesia Anesthesia Time Units Multiple Surgeries Major and Minor Surgeries Physical Therapy Immunizations and Injectable Medicines Supplies Common Reasons for Rejected and Returned Claims Claim Follow-Up Electronic Claims Submission Introduction What Is EDI? How It Works Benefits To You Getting Started BlueCard Claims Administering CaliforniaKids Inpatient Care Claims Submission: Page 1

2 Point-of-Service Claims What are Point-of-Service Benefits? Hard Copy Billing Provider License Claim Submission Filing Limits Billing References Claims Submission: Page 2

3 Introduction This section provides general billing guidelines and claim submission requirements. To assist the biller in reducing the number of returned claims, the manual identifies the more common situations that result in processing delays due to returned or rejected claims. Also covered is an overview of electronic billing and whom to contact for information on Electronic Data Interchange (EDI) products and services. Information for Contracting Providers Claims Settlement Practices As required by Assembly Bill 1455, the California Department of Managed Health Care has set forth regulation establishing certain claim settlement practices and the process for resolving provider disputes for managed care products. To the extent required by the Department of Managed Health Care, the Knox-Keene Act or accompanying regulations, the following is intended to inform you of your rights, responsibilities and related procedures, as they relate to claim settlement practices for commercial HMO, POS and, where applicable, PPO products where Anthem Blue Cross (Anthem) is delegated to perform claims payment. Unless otherwise provided herein, capitalized terms have the same meaning as set forth in Sections and of Title 28 of the California Code of Regulations. Claim Submission Instructions 1. Sending Claims to Anthem. Send all hard copy claims to: Anthem Blue Cross P.O. Box Los Angeles, CA Calling Anthem Regarding Claims. Call the Customer Service phone number on the member s ID card. 3. Claim Submission Requirements. A list of commonly required claim attachments, supporting information, and documentation required by Anthem may be found in the various Anthem operations manuals. 4. Claim Receipt Verification. To verify receipt of your claim, log on to ProviderAccess at Your Explanation of Benefits (EOB) or Remittance Advice (RA) will verify receipt of your claim as well. Claims Submission: Page 3

4 Claim Overpayments 1. Notice of Overpayment of a Claim. If Anthem determines that it has overpaid a claim, Anthem will notify the provider, in writing, through a separate notice identifying the claim, the name of the patient, the date of service(s), and a clear explanation of the basis on which Anthem believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim. 2. Contested Notice. If the provider contests Anthem s notice of overpayment of a claim, the provider, within 30 working days of receipt of the notice of overpayment of a claim, must send written notice to Anthem stating the basis on which the provider believes that the claim was not overpaid. Anthem will process the contested notice in accordance with Anthem s contracted provider dispute resolution process, as described in provider operations manual under the Information for Contracting Providers - Provider Dispute Process subsection of the Physician Responsibilities section. 3. No Contest. If the provider does not contest Anthem s notice of overpayment of a claim, the provider must reimburse Anthem within 30 working days of the provider s receipt of the notice of claim overpayment. 4. Offsets to Payments. If the provider does not reimburse Anthem within 30 working days of the provider s receipt of the notice of overpayment of a claim, then, pursuant to the Physician Partnership Network Participating Physician Agreement, the provider authorizes Anthem to offset an uncontested notice of overpayment of a claim from the provider s current claim submission. Anthem may only offset an uncontested notice of overpayment of a claim against a provider s current claim submission when: (i) the provider fails to reimburse Anthem within the time frame set forth in No Contest, above, and (ii) Anthem s contract with the provider specifically authorizes Anthem to offset an uncontested notice of overpayment of a claim from the provider s current claims submissions. In the event that an overpayment of a claim or claims is offset against the provider s current claim or claims, pursuant to this section, Anthem will give the provider a detailed written explanation identifying the specific overpayment or payments that have been offset against the specific current claim or claims. 5. Balance Billing Prohibition. Except for applicable copayments and deductibles, a physician shall not invoice or balance bill a Anthem member for the difference between a physician s billed charges and the reimbursement paid by Anthem for any covered benefit. General Guidelines Anthem establishes and, from time to time, revises unit values based on observed charge patterns by CPT and HCPCS Level II codes. The presence of a code in the current CPT, HCPCS, or other procedure manuals does not necessarily indicate Anthem allows the services. Anthem retains discretion in the determination of payment structures. Claims Submission: Page 4

5 Anthem uses these guidelines for administrative purposes, such as claims processing and developing guidelines for Medical Review and Medical Policy. The allowable charge for services will be calculated using the unit values as in effect at the time of service, multiplied by the applicable conversion factors. The following are general claim submission guidelines: 1. System Edits. Edits are in place for both electronic and paper claims. Therefore, claims not submitted in accordance with requirements cannot be readily processed, and most of these will likely be returned. 2. HCPCS and CPT Codes. Current HCPCS and CPT Manuals must be used because many changes are made to these codes every year. Anthem uses only current HCPCS and CPT codes. For information about how to purchase current HCPC and CPT Manuals, see the Billing References subsection below. 3. Reimbursement for HCPCS Level II Codes a. Pharmacy (including infusion therapy drugs). Statewide maximum allowable changes are established by Anthem and takes into consideration claims and/or external data, including Average Wholesale Price (AWP). Self-injected drugs for home use and all oral prescription drugs dispensed in the physician office will be denied and the member may not be billed by the physician and/or other health care clinician. These drugs must be provided by a licensed pharmacy. Use the appropriate code that best describes the dosage being administered. To ensure appropriate allowances, include the units of occurrence in box 24G (Units-Days) of the CMS-1500 form. b. Durable Medical Equipment, Supplies (including, but not limited to, infusion therapy supplies), Prosthetics and Orthotics. The maximum allowable will be determined by Anthem based on claims data and/or external data. The maximum allowable will be based on whether the equipment is new, used, or rented as identified by the HCPCS Level II code modifier. Anthem may designate certain items as rental only or purchase only or rent to purchase. For rent to purchase items, the maximum allowable is the Anthem-determined purchase price; rental will not exceed the purchase price. Codes not identified by a modifier as purchase will be considered as rentals. DME equipment used in the physician s office is separately reimbursable. c. Other HCPCS Codes. For other HCPCS codes, the maximum allowable will be determined by Anthem using claims data and/or external data. Claims Submission: Page 5

6 4. Split Year Claims. For services that begin before December 31, but extend beyond December 31, split claims at calendar-year end. This is necessary to accurately track calendar-year deductibles and copayment maximums. 5. Modifiers. A modifier indicates that the procedure performed by the physician has been altered by some specific circumstance, but has not changed in its definition or code. The presence of a modifier in the current CPT, HCPCS, or other procedure manuals does not necessarily indicate Anthem allows the services. Anthem retains discretion in the determination of payment structures. Modifiers may be billed in accordance with the CPT and HCPCS manual to indicate the following: A service or procedure requiring a professional or technical component (Not all services are considered to have professional or technical components; some procedures are considered as professional only or global only) A service or procedure performed by more than one physician and/or in more than one location A service or procedure that increased or was reduced A service or procedure rendered more than once Partial procedure performed Adjunctive services Bilateral procedures Unusual events occurred * Effective January 1, 2001, modifier 27 is no longer accepted for technical component; use TC to indicate the technical component. AMA has designated modifier 27 for Multiple Outpatient Hospital E/M Encounters on the same date. For more information about billing with modifiers, see Modifier Reimbursement Guidelines below. 6. Cardiac Catheterization. For cardiac catheterization codes, physicians are required to bill these services with the modifier 26 to reflect the professional service. 7. Anesthesia Codes and Modifiers. To be consistent with industry guidelines, Anthem changed its anesthesia service billing procedures to conform with the practice of using only current CPT codes through when billing for anesthesia administration. Anthem does not accept the practice of billing anesthesia services using surgical codes with a modifier 23 or 30. Claims Submission: Page 6

7 In addition, when two or more surgical procedures are performed during the same operative session, only the anesthesia procedure with the higher base unit value is allowed for reimbursement. 8. Anesthesia Time. To more accurately calculate and reimburse physicians or other health professionals for anesthesia services, Anthem requires all anesthesia services to be billed using minutes. 9. Unlisted Procedure or Service. There may be services or procedures performed by physicians that are not found in CPT; therefore, specific code numbers for reporting unlisted procedures have been designated. When an unlisted procedure code is used, Anthem needs a description of the service to calculate the appropriate reimbursement, and medical records may be requested. 10. CPT Code CPT Code (supplies and materials provided by the physician over and above those usually included with the office visit or other services) is not accepted by Anthem. Physicians and other health professionals are to use HCPCS Level II codes, which give a detailed description of the service provided. Anthem will follow Medicare guidelines and cover surgical trays only for specific surgical procedures. Surgical trays billed with all other services will be considered incidental and will not be payable separately. 11. Multiple Surgery. Multiple surgery claims are priced based on major and minor procedures. The surgical procedure with the highest Anthem unit value is considered the major procedure and is priced at 100 percent of the unit value. The minor surgeries have a lesser unit value and are reduced as follows: Procedure Position Second Procedure Third Procedure Fourth Procedure Fifth Procedure Allowance 50 percent of unit value 25 percent of unit value 25 percent of unit value 25 percent of unit value Claims submitted with more than five surgeries are referred to Medical Review for pricing determination. Modifier Reimbursement Guidelines Modifiers A modifier indicates that the procedure performed by the physician has been altered by some specific circumstance, but has not changed in its definition or code. The presence of a modifier in Claims Submission: Page 7

8 the current CPT, HCPCS or other procedural manuals does not necessarily indicate Anthem (Anthem allows the services. Anthem retains discretion in the determination of payment structures Modifiers may be billed in accordance with the CPT and HCPCS manual to indicate the following: A service or procedure requiring a professional or technical component (not all services are considered to have professional or technical components; some procedures are considered professional or global only). A service or procedure performed by more than one physician and/or in more than one location A service or procedure that increased or was reduced A service or procedure rendered more than once Partial procedure performed Adjunctive services Bilateral procedures Unusual events occurred Effective January 1, 2001, Modifier 27 was no longer accepted for technical component; use TC to indicate the technical component. The AMA has designated Modifier 27 for Multiple Outpatient Hospital E/M Encounters on the same date. Claims Submission: Page 8

9 *Below are the most commonly used modifiers that have pricing implications. Modifier & Description 22: Unusual Services Anthem Blue Cross Policy Claim routed to Medical Department for review. Documentation is required. 26: Professional Component Allows professional component of procedure value 47: Anesthesia by Surgeon Not payable 50: Bilateral Procedure Allows 150 percent of the procedure s total value 51: Multiple Procedures. Value reduction as follows: Major procedure 100 percent Second procedure 50 percent Third procedure 25 percent Fourth procedure 25 percent Fifth procedure 25 percent Refer to Multiple Procedures section 54: Surgical Care Only Allows 70 percent of the surgical procedure value 55: Postoperative Management Only Allows 30 percent of the surgical procedure value; no change if attached to an office visit. 56: Preoperative Management Only Claim reviewed by Medical Department 62: Two Surgeons Allows a 50 percent reduction of 125 percent of the procedure value 66: Surgical Team Claim reviewed by Medical Department 76: Repeat Procedure by Same Physician 77: Repeat Procedure by Another Physician 80: Assistant Surgeon 81: Minimum Assistant Surgeon Claim reviewed by Medical Department; radiological procedures report is required Claim reviewed by Medical Department Allows 20 percent of the surgical value; refer to Medical Policy Bulletin # Allows 1.1 times the surgical conversion factor dictated by the assistant surgeon s provider status Claim reviewed by Medical Department if more than one surgery per date of service. 82: Assistant Surgeon (When qualified resident surgeon not available) Allows 20 percent of the surgical procedure value (same as Assistant Surgeon modifier 80) 99: Multiple Modifiers Claim referred to senior examination for calculation Claims Submission: Page 9

10 Modifier & Description AS: Physician Assistant, Nurse practitioner, or clinical nurse specialist services for assistant at surgery TC: Technical Component Anesthesia Claims Refer to Assistant Surgeon section Anthem Blue Cross Policy Allows technical component of procedure value Anesthesia is the reduction or loss of the ability to perceive pain caused by the administration of a drug or by other medical interventions. Anesthesia services include the induction of anesthesia coupled with the appropriate monitoring of body functions during surgical and select non-surgical procedures. Types of Anesthesia 1. General anesthesia - a state of unconsciousness, with the absence of pain and/or sensation, produced by anesthesia agents that affect the entire body. Drugs that produce this state are administered intravenously, rectally, intramuscularly or by inhalation. 2. Regional anesthesia - the absence of pain and/or sensation to a specific area (region) of the body, produced by introducing an agent that interrupts the sensory nerve conduction of the specific area. There are two primary types of regional anesthesia: a. Field block - introduction of a local or topical anesthetic to produce the absence of pain and/or sensation to an operative area of the body. Local anesthesia may be used in more than one area of the body and is any agent injected to produce the absence of pain and/or sensation to one or more localized areas. Topical anesthesia are local agents applied to the surface in areas, such as eyes and mucous membranes where injections are not recommended or possible. Eye drops, creams and sprays are common topical agents. b. Nerve block - introduction of an anesthetic agent close to a nerve so that conduction is cut off. Spinal, epidural and caudal anesthesia are types of nerve blocks into the spinal column. These types of anesthesia are often desired for abdominal or obstetrical surgery and affect a large area of the body. Payable Anesthesia Services The following are payable anesthesia services: Claims Submission: Page 10

11 Anesthesia, given in conjunction with a covered surgical, specified non-surgical or specified radiological procedure, where the anesthesiologist or CRNA administers anesthesia, monitors and manages life functions, manages unconsciousness, if any, and/or manages fluid therapy (regardless of where the surgery is performed). Such care includes preanesthetic evaluation, intra-anesthetic record keeping and postanesthetic follow-up. Non-Payable Anesthesia Service Non-payable anesthesia services include anesthesia given in conjunction with a non-covered surgery or non-covered medical procedure. Obstetrical Anesthesia For continuous lumbar epidural, caudal or spinal injection anesthesia, the time is calculated at one unit for every hour. The delivery anesthesia time is calculated as all other anesthesia (that is, one unit of time for each 15 minutes in increments of five minutes). Anesthesia Time Units The system calculates the Time Units for anesthesia at one unit per 15 minutes (in increments of five minutes) for the first four hours. After four hours, one unit is allowed for each 10 minutes (in increments of five minutes). Examples of how the system converts the anesthesia minutes into Time Units when pricing the claim are: 48 minutes = 3 time units 50 minutes = 4 time units 1 hour 34 minutes = 6 time units 1 hour 35 minutes = 7 time units 4 hours 20 minutes = 18 time units 5 hours 12 minutes = 23 time units Multiple Surgeries More than one surgical procedure performed on the same date of service during the same surgical session. The pricing of multiple surgeries is based on the order of procedures. The major procedure has the greatest unit value; the minor procedure(s) has/have a lesser unit value and is paid at a reduced rate. Incidental Surgery. A surgical procedure that is related to another surgery. Add On Surgeries. Surgeries outside the integumentary system that are subsequent procedures (e.g., additional segment, suture of additional nerve). Add on surgeries are always billed with another surgery. Claims Submission: Page 11

12 Bilateral Surgeries. Bilateral surgeries are considered one surgery and are identified with modifier 50. Bilateral surgeries are either billed with the surgical procedure code and modifier 50 or with the surgical procedure billed without the modifier first, then the same procedure with modifier 50 billed again. The allowable is calculated by using 150 percent of the unit value times the conversion factor. A bilateral procedure billed with another procedure is priced as follows: Multiply the assigned unit value of the bilateral procedure times 150 percent. The procedure with the greatest unit value is the major surgery. The procedure with the lesser unit value is priced the minor surgery. Claims Submission: Page 12

13 Major and Minor Surgeries Major and minor surgeries are priced line-by-line based on the unit value and not the charge of the procedure on the claim. If none of the surgeries are identified as incidental procedures, then minor procedures are paid at a reduced rate. The major surgery is determined by the unit value assigned (i.e., the procedure assigned the greatest number of units is the major surgery, the procedure assigned the second greatest number of units is the second surgery, etc.). The major and minor rule applies to the services of the surgeon and assistant surgeon only and not to the anesthesiologist. The assigned unit value reduction will be applied to each applicable procedure as follows: Unit Value Reduction Position of Procedure 100 percent Major procedure 50 percent Second procedure 25 percent Third procedure 25 percent Fourth procedure 25 percent Fifth procedure Exception: Effective 1/1/95, multiple surgeries in the medical range of performed on the same day (even if billed with one other surgery in the medical range), are all reimbursed at full unit value. The multiple surgery reduction applies to surgeries in the range when billed on the same day with procedures in the range. Anthem reimburses the following ranges 1140X, 1160X, 1727X and 1728X of dermatological procedures at 100 percent, 50 percent, 50 percent, and 50 percent, etc. If any of these procedures are billed with p to four other unrelated CPT codes, the calculation, excluding the primary procedure, will remain at the 50 percent level. The unrelated CPT codes will be processed at the 25 percent level if the surgery represents the third, fourth or fifth procedure. Physical Therapy Physical medicine is the art and science of physical/corrective rehabilitation or treatment designed to improve or restore maximum functional ability, relieve pain, and prevent or minimize disability following disease, injury or loss of a body part. Physical and/or occupational therapy treatments may include functional activities, mobility training, manipulations, physical modalities, assessment, instruction, special tests and/or therapeutic exercises. Physical medicine codes are divided into four types of service: 1. Special Procedures ( ) are more complex procedures. The price of these procedures is always calculated using the full unit value. Additional procedures ( , 97139) for the same date of service are treated as subsequent procedures (Price Claims Submission: Page 13

14 using 30 percent of the unit value). Additional modalities ( , 97128) for the same date of service are treated as subsequent modalities (Price using 10 percent of the unit value). 2. Procedures ( , 97139) are more involved and are performed while the provider is in attendance the entire time. The price of the initial procedure (most expensive) is calculated using the full unit value of the procedure (unless billed on the same date of service as a Special Procedure ). The price of each subsequent procedure performed during the same session is calculated using 30 percent of the unit value of the procedure. 3. Modalities ( , 97128) require less time and skill by the provider. The price of the initial (most expensive) modality is calculated using the full unit value of the modality (unless billed on the same date of service as a Special Procedure ). The price of each subsequent modality performed during the same session is calculated using 10 percent of the unit value of the modality. 4. Tests and Measurements ( ) are evaluations and/or assessments. When calculating the price for these codes, the full unit value is always used. Tests and measurements are not considered procedures or modalities, and therefore do not affect the price of any other services performed. Immunizations and Injectable Medicines The allowable is established by Anthem and considers claims and/or external data, including Average Wholesale Price (AWP) and the actual cost of the drug (specific pricing is available to participating providers through ProviderAccess). Supplies Effective May 1, 1993, CPT code (supplies and materials provided by the physician over and above those usually included with the office visit or other services) is not accepted by Anthem. Providers were advised that HCFA Common Procedure Coding System (HCPCS) Level II codes are to be used for billing supplies, pharmaceuticals and DME, rather than CPT code The reason for this change is to allow for a more detailed description of the service provided, thereby avoiding misuse of code 99070, which does not allow for this detail. Effective September 1, 1994, HCPCS code A4550 (surgical tray) will be reimbursed only when billed with a surgical CPT code that allows reimbursement for the surgical tray. The system will identify which procedure(s) qualify for the surgical tray reimbursement and price accordingly. HCPCS code A4550 will be incidental to procedures that do not qualify for an additional allowance for the surgical tray. Claims Submission: Page 14

15 Note: When two or more surgical procedure codes are billed for a date of service and at least one of the codes qualify for the surgical tray reimbursement, the system will allow the surgical tray. Claims Submission: Page 15

16 Common Reasons for Rejected and Returned Claims Many of the claims returned for further information result from common billing errors. The following is a list of some of the more common situations. 1. No Prior Authorization for services rendered. For those services that require authorization, the authorization should be obtained prior to services being rendered. 2. Alpha prefix on subscriber ID not provided for BlueCard. The three-digit alpha prefix is critical for the proper identification and routing of all paper claims (e.g., Blue Cross and Blue Shield Plans, such as the BlueCard PPO). 3. Date of injury not provided. When charges represent an injury diagnosis, provide a date of injury. 4. Other Carrier Explanation of Benefits not provided. When billing Anthem as a secondary payor, a copy of the primary carrier s explanation of benefits must be attached. 5. Duplicate billings. Overlapping dates of service for the same service(s) create a questionable duplicate bill. 6. ICD-9-CM Codes denied. Claims that are coded with a preliminary, rather than a definitive diagnosis, are mailed back for the definitive diagnosis. 7. Member ID number is incomplete. Specifically in the case of FEP (except for Anthem HMO FEP), the alpha prefix is omitted in addition to other numeric digits. The FEP ID number starts with an alpha R and is followed by eight numeric digits. Supply the nine-digit ID number for all FEP submissions. 8. Request for medical records. When returning records to Anthem, it is imperative that the records are attached to the original mailback form and that the records are returned in the return envelope provided. Do not reattach a new copy of the claim. Do not combine other mailbacks in the same envelope since it is likely that the records will not arrive in the correct department. 9. Unlisted HCPCS codes submitted without description. A full description of unlisted HCPCS codes should be included on claims. When submitting claims electronically, enter the description in the REMARKS field. 10. Unreasonable numbers submitted. Unreasonable numbers, e.g., 999 in the UNITS field. Units greater than 999 should be indicated on the claim or in the remarks section if billing electronically. Claims Submission: Page 16

17 Claim Follow-Up Anthem will reconsider rejected or returned claims, on the physician s or health care professional s request. To request such a reconsideration, attach the Claim Follow-Up Form to the top of a copy of any applicable correspondence that was received from Anthem along with any other applicable documentation. For more information concerning claims follow-up, refer to the Physician Responsibilities section of the provider operations manual. The Claim Follow-Up Form streamlines the process for physicians and other health care professionals seeking re-evaluation of their rejected claims. The form highlights the key claims information necessary for Anthem reconsideration. The form should be used for all claims needing follow-up. Providers often resubmit copies of claims that have been rejected, denied or deemed incomplete, along with the additional information requested by Anthem. Under review, these copies are regularly treated as duplicate submissions. Use of this form will help providers avoid this pitfall by providing the follow-up claims information only. The Claim Follow-Up Form identifies the common claim submission errors in order to minimize the need for explanation. The form will minimize your administrative burden and will help get the claim reprocessed as expeditiously as possible. After completing the form, place it on top of all documentation and mail it to: Anthem Blue Cross P.O. Box Los Angeles, CA Electronic Claims Submission Introduction In recent years, Anthem customers have made unprecedented demands that we reduce administrative costs. One element driving these costs up is the submission and processing of paper claims. With the increased acceptance of computer technology in general, and electronic billing technology in particular, Anthem strongly promotes using this technology for claims submission. In addition to providing the capability to more easily measure the quality of claims processing and production, electronic claims submission leads to increased productivity, efficiency, and service. For more information about EDI, call (800) Claims Submission: Page 17

18 What Is EDI? Physician Partnership Network Electronic Data Interchange (EDI) is the computer-to-computer exchange of common business transactions over telephone lines using a standard electronic format. EDI can be compared to an electronic postal service; it allows physicians, other health professionals, and payors to exchange vital information. How It Works A computer, modem and telephone line enable you to send and receive vital information such as claims, encounters, eligibility and claim-status transactions, and electronic remittance advices (ERAs). Anthem partners with many software vendors, clearinghouses and billing services that collect the data you submit and send it to us electronically. Most of these partners are also linked to hundreds of healthcare EDI networks. Benefits To You One-Address Billing. With electronically submitted claims, all claims are sent to one destination, and Anthem automatically routes your claim to the proper processing site. Fewer Rejected Claims. Claims are processed quickly and accurately with fewer claim rejects because the system provides front-end editing and does not accept common errors or omission of mandatory data. This means claims are virtually error free when they enter the Anthem processing system, which results in faster payment turnaround. Savings. By reducing the cost of purchasing CMS-1500 forms, mailing envelopes, postage stamps and printing costs, you can easily recognize the savings. Your billing staff will also spend less time on claim payment follow-up because priority processing is given to electronic claims. Acceptance/Rejection Audit Trails. You receive validation of claims from Anthem, confirming that your electronic claim file was received. It also identifies those claims that did not pass our claim edit process. These claims must be corrected immediately and resubmitted electronically. Getting Started If you have any questions or problems, call Anthem s Medical EDI Services Department at (800) Our representatives are very knowledgeable and can assist you with all your questions regarding electronic billing and other electronic services that are available. Claims Submission: Page 18

19 BlueCard Claims Submit ALL your BlueCard member claims for out-of-state patients directly to Anthem. Submit your hard copy BlueCard claims to: Anthem Blue Cross P.O. Box Los Angeles, California When submitting your claims electronically for Blue Plan members, include the patient s complete identification number and use ITSPPO in the group number field, even if the identification (ID) card indicates differently. This ensures that your claims will be routed correctly and properly processed and not denied in error. Do not leave the group number blank or use 99999, as this will cause the claim to be misrouted or be denied. Administering CaliforniaKids Inpatient Care Inpatient care is not covered under CaliforniaKids. In the event a child needs hospitalization, the family spends down and qualifies for Medi-Cal. CaliforniaKids can assist the medical group in linking the hospital with the appropriate social services worker. Point-of-Service Claims What are Point-of-Service Benefits? The Anthem Point-of-Service (POS) Plan allows a member to receive services from HMO, PPO and out-of-network health care professionals. The foundation of an Anthem POS plan is the HMO plan, which is coordinated through the member s primary care physician. By choosing to opt out from the HMO network, members can receive services from Anthem PPO (Prudent Buyer) health care professionals. If members choose to opt out to a PPO or outof-network health care professional, they do not need an authorization from the HMO primary care physician. Authorization is required for non-emergency inpatient and outpatient surgery admissions and can be obtained through the review center at (800) How do I submit a claim for a member using his or her Point-of-Service benefits? Identifying that the member is using his or her Point-of-Service benefits is instrumental to accurate claims payment. By indicating Member is using Point-of-Service Benefits in the narrative or text field on an electronic submission or Box 23 of a paper claim, your bill will be processed accurately and in a timely manner. Claims Submission: Page 19

20 When is a member NOT using Point-of-Service benefits? Services are provided by the member s assigned Primary Care Physician. Laboratory or radiology services which do not require prior authorization and are done at a network facility. Services are provided by a network OB/GYN. Services were authorized by the Physician Partnership Network Medical Management Department. Services are provided by our capitated specialty providers, American Specialty Health Plan or San Luis Sports Therapy & Orthopedic Rehabilitation in San Luis Obispo. Hard Copy Billing Participating professional physicians and other health professionals that are not set up to process claims electronically are required to submit all hard copy claims on the CMS-1500 claim form (with scannable red dropout ink ). All applicable data element blocks must be complete. If the form is incomplete, it is returned for additional information needed for processing. Provider License Anthem requires physicians and other health professionals to include their state license number and the ZIP Code for their practice (the location where services are rendered) when submitting claims. All professional claims submitted to Anthem must include this information consistent with Section 6.9 of the Physician Partnership Network Participating Physician Agreement. If the Tax ID number is that of a medical group, the rendering physician s name and license number must also appear on the claim. All license numbers are validated against the license number file from the State Board of Consumer Affairs. On the CMS-1500 form, the license number is entered in box number 19 and the ZIP Code in box number 32. The state license number and practice ZIP Code requirements apply to optical character recognition (OCR) scannable paper claims, non-scannable CMS-1500 paper claims, and electronically submitted claims. Claims submitted without a state license number may be returned or may have processing delayed. The following providers are not required to provide Anthem with a state license number (exempt providers must include practicing ZIP Code): 1. Air ambulance 2. Blood bank 3. Christian Science nurse Claims Submission: Page 20

21 4. Christian Science practitioner 5. Donor bank 6. Group ambulance 7. Independent laboratory 8. Medical vendor (DME) 9. MRI 10. Occupational therapy 11. Optician 12. Orthotics/prosthetics 13. Pharmacy 14. Portable X-ray 15. Anthem PPO clinical laboratory 16. Anthem PPO diagnostic imaging/mri Claim Submission Filing Limits Physicians must submit claims to Anthem within 12 months from the date of service or Anthem may refuse payment. The 12-month claim filing also applies to adjustments when Anthem is the primary carrier. For claims that involve coordinating benefits with another carrier or Medicare, the date of the other carrier s Explanation of Benefits or Medicare s Explanation of Benefits is used for determining the eligible submission period. Claims that are filed beyond the timely filing period will be denied accordingly. The patient is not responsible for this amount. If it is believed that the claim was filed within the contracted timely filing guidelines, evidence of timely filing attached to the Anthem mailback or denial EOB should be submitted in a timely manner for consideration. DO NOT RESUBMIT THE ORIGINAL CLAIM. Anthem may, for example, accept the following as evidence of timely electronic submission: Clearinghouse report (e.g., NEIC) of acceptance by Anthem Request for Additional Information form (from Anthem) Anthem generated Positive Acknowledgement Report (Should you need your report recreated during the first 30 days after submission, please call (800) , option 1.) Claim denial letter or EOB from Anthem For EDI claims which could not be processed by Anthem: o Copy of Anthem dated letter to provider requesting a resubmission, or Claims Submission: Page 21

22 o Anthem Batch Number for claims (or other identifying information) or error listing Anthem may, for example, accept the following as evidence of timely hard copy submission: Computer-generated claim transaction history with the Anthem name from a billing system o If a locator code is used instead of the billing address, a list of locator codes/ corresponding addresses must be provided o Must include billing history and history of timely follow-up attempts made within contracted timely filing guidelines Dated request for additional information form (from Anthem) Claim denial letter or EOB from Anthem Anthem accepts the following as proof of submission when initially sent to another carrier: Denial letter from other insurance carrier, dated and printed on letterhead; or Dated EOB from other insurance carrier. Anthem reserves the right to use its sole discretion in determining whether the information supplied is acceptable for timely filing purposes. Billing References Current HCPCS and CPT Manuals must be used because many changes are made to these codes quarterly or annually by the designated code set owner. These manuals may be purchased at any technical book store or by writing to: Or by calling: Mail Orders American Medical Association Attention: Order Processing P.O. Box Atlanta, GA The Practice Management Information Corporation (PMIC): (800) The American Medical Association: (800) Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark. The Blue Cross name and symbol are registered marks of the Blue Cross Association 2007 Anthem Blue Cross. Claims Submission: Page 22