Ready Reference Guide UPDATE Anthem Blue Cross and Blue Shield in Ohio

Transcription

1 Ready Reference Guide UPDATE in Ohio Products (Contact f the address f returning checks) Local Products Blue Access Blue Preferred Blue Traditional Blue Access Options PPO f ERC Health 7/1/15 Blue Access Options PPO (Ohio Standard 3 Tier) 10/1/15 On Exchange - Individual: Pathway X Tiered PPO Netwk Eff 1/1/16 Pathway X HMO Netwk Off Exchange - Individual: Pathway Tiered PPO Netwk Eff 1/1/16 Pathway HMO Netwk Group and Individual Policies: * CDHP/HDHP Plans: (855) JWR JWV (855) JWT YRG, YRJ, YRL YRM, YRN, YRO, YRP, YRQ, YRT, YRB, YRY VXA XDV YFS Ohio (Local) Products Ohio On Exchange Individual Products Ohio Off Exchange Individual Products Precert: Peer to Peer: Fax: UM Appeals Fax: Predetermination of Benefits: CM: CM centregcmref@anthem.com Demographic, Admit and D/C Dates:.OhioAdmitting@anthem.com Clinical Infmation:.precert@anthem.com PT/OT - Orthonet eff 11/1/15: Phone: Fax: Via Precert: Peer to Peer: Fax: UM Appeals Fax: Predetermination of Benefits: CM: CM centregcmref@anthem.com Demographic, Admit and D/C dates:.ohioadmitting@anthem.com Clinical Infmation:.precert@anthem.com PT/OT - Orthonet eff 11/1/15: Phone: Fax: Via

2 On Exchange - Small Group: Blue Access Netwk (855) JWJ (Contact f the address f returning checks) Ohio On Exchange Small Group (SHOP) Products Off Exchange - Small Group: Blue Access Netwk (855) JWQ Ohio Off Exchange Small Group (SHOP) Products Associates (HRA/HSA) WLU Associates Precert: UM Fax: CM: Diag Imaging, Sleep Therapy, Oncology Rx: National (non-auto) Most have "AN" in 4th and 5th digits Eligibility, Claims Status, Links to National Precert: Peer to Peer: Fax: UM Appeals: UM Appeals Fax: CM: CM INDYNatlAccts- CM@wellpoint.com CM Fax: Request UM Criteria: Demographic, Admit and D/C Dates: INAdmittingNational-@anthem.com Clinical Infmation: UMNationalUnit@anthem.com

3 National (Auto) GM: Delphi: Fd: Chrysler: UAW: UGG and UFL (Medicare-MI): Facility: Eligibility and benefits Claims Professional: Eligibility and benefits Claims GM: Eligibility, Claims GHP,GIH, Status, Links to GMJ, GMH Delphi: DEH, DKP Fd: FGP, FSP Chrysler: DXP,DCH, DZW UAW: UGD,UGG, UFK,UFL, UCK,UDC (Contact f the address f returning checks) Contract issues: Blue Cross and Benefit issues: member must appeal to BCBS MI Refer to patient ID card. Preauthization: Fax mail to: Blue Cross of Michigan P.O. Box 2227 Detroit, MI Mail code 0450 GM and Chrysler Radiology precert - AIM Specialty Health: Fax GM GeoBlue QHH GeoBlue Provider Finder (BlueCard Netwk) Precert - route to Home Plan BLUE BLUE Refer to Member's ID Card BlueCard (Non-Ohio Blue Cross and Members' Plans) Infmation dependent upon availability from Blue Plan's frontend system ITS/Blue Card Dept P.O. Box Atlanta, GA Call the number on the back of the member's ID card BlueCard Provider Service Federal Employee Program (FEP) IVR: claim status, checks,, eligibility, benefits R Claim status (high level) Federal Employee Program (FEP) Non Clinical: P.O. Box Atlanta, GA PO Box Atlanta, GA Clinical: 1351 William Howard Taft Rd. Cincinnati, OH Attn: FEP Provider Appeals,, Precert: Peer to Peer: Fax: Fax - ABD: CM: Demographic, Admit, D/C and Clinical Infmation: fepe-reviews@anthem.com Federal requests f pre-determination can not be handled through e-review please refer provider to customer service number on the back of the member s card. Medicare Supplement Products YRR Seni Services Fax: No Precert f Medicare supplement plans.

4 Medicare Advantage EMPLOYER GROUP eff 1/1/15 Seni Advantage HMO Medicare Preferred LPPO-Local PPO Blue Medicare Access RPPO-Regional PPO Medicare Advantage INDIVIDUAL: new plan names eff MediBlue Essential (HMO) MediBlue Plus (HMO) MediBlue Connect (HMO) (PPO) Enhanced (PPO) Ce (RPPO) (RPPO) MediBlue Dual Advantage (HMO SNP) YRA (HMO) YRE (LPPO) YRS (RPPO) JRI VOC VOD JRG (Contact f the address f returning checks) Claims, Links to Claims, Links to Attn: Seni Appeals 4361 Irwin Simpson Rd. Mason OH Attn: Seni Appeals 4361 Irwin Simpson Rd. Mason OH Precertification: Fax - Inp notifications & all Outpatient: Fax- Facility Clinical: SNF, LTAC, Inpat Rehab: Fax f SNF, LTAC, Inpat Rehab: Predetermination of Benefits: Peer to Peer: P2P crp2p@anthem.com CM: opt. 4 CM CM-concierge@ wellpoint.com anthem.ohio.medicare@anthem.com F ALL Central Zone Medicare Advantage, regardless of CZ state Precertification: Fax - Acute Inp notifications & all Outpatient: Fax - Facility Clinical: SNF, LTAC, Inpat Rehab, Inpat non-acute: Fax f SNF, LTAC, Inpat Rehab, Inpat nonacute: SNF, LTAC, Acute Rehab Initial Concurrent reviews: OHDischargeplanning@anthem.com Predetermination of Benefits: Peer to Peer: P2P crp2p@anthem.com CM: opt. 4 CM CM-concierge@wellpoint.com anthem.ohio.medicare@anthem.com F ALL Central Zone Medicare Advantage, regardless of CZ state Orthonet Phone: PT,OT Spine & Back PM, Spinal Surgery Orthonet Fax: PT,OT Spine & Back PM, Spinal Surgery Orthonet Cardiology eff 4/1/15: Phone Fax:

5 ebusiness Help Desk: Call to reset My f Provider passwd f assistance with technical difficulties Other Infmation Dental: Behavial Health Precert: CAQH: Orthonet Focused Claim Review Radiology, Cardiology, Sleep, Radiation Therapy, Cancer Care Quality Program (f those products that apply) Phone ; Hours 8:30 7:00 ET See Precertification page in provider section of AIM Precertification via: Website: Clinical guidelines here Optinet Surveys/Site Assessments Help Desk: optinetsuppt@aimspecialtyhealth.com My Provider Ptal **Commercial and Medicare Advantage Phone: Fax: Provider Solutions Nthern Ohio: Central Ohio: Southern Ohio: Availity Phone: AIM can enter cases retro 2 business days only. Eff August 22, these can be done online. After that timeframe, use the post service review/reconsideration process.* UM Services *Medicare Advantage: No retros allowed. Effective in 2015, failure to obtain a pri authization will result in an administrative denial and members cannot be balance billed. Reminder: AIM Specialty Health does not precert Radiation Therapy and Specialty Pharmacy f Medicare Advantage members. Specialty Pharmacy Precertification - Does not include Specialty RX under Pharmacy Benefit *Change site administrat by ing central.eprovider.rep@anthem.com Eligibility and Benefits, Claims,, Precertification. Fee Schedules, On-line Remittance, Reimbursement policies, MA Provider Self Service: via link out to Provider Ptal AIM Specialty Health Precertification Retrospective Precertification National: check members ID card Commercial: Aimspecialtyhealth.com via Availity Clinical Data Submission Tools available on under the Ohio Provider Page specialtymeds@anthem.com Fax Medicare Advantage: Phone option 5, Fax with General Precert Fm (anthem.com Precertification page) Medicare Advantage maspecialtypharm@anthem.com FEP: submit ABD (with clinical) to fax Request f Claim Review, Adjustment Submitting Recds PO Box Atlanta, GA Fax: Include completed Provider Adjustment Request Fm, a letter with all pertinent claim and patient details. **If you receive a recd request letter, follow the instructions on the letter f returning them. Refunding Checks If you are returning a check issued by, please mail to: Finance Dept William Howard Taft Mail-Point: CW1-262 Cincinnati, Ohio EDI Solutions Help Desk: e-solutions.suppt@anthem.com Electronic Data Interchange Infmation Available Online: (Select OH & click enter) EDI Pay IDs: Professional ; Facility is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Association. ANTHEM is a registered trademark of Insurance Companies, Inc. The Blue Cross and names and symbols are registered marks of the Blue Cross and Association.