Ancillary Providers General Billing Requirements

Transcription

1 Introduction... 2! Claims Settlement Practices and Provider Dispute Resolution Mechanism Regulations (Assembly Bill 1455)...2 Claim Submission Instructions... 2 Dispute Resolution Process for Contracted Providers... 3 Claim Overpayments... 5 General Billing Guidelines... 6 Billing References... 7 Claim Submission Filing Limits... 7 Hard-Copy Billing... 9 Electronic Claims Submission... 9 Introduction...9 What Is EDI?... 9 How It Works... 9 Getting Started Benefits to You Researching a Claim Common Reasons for Rejected and Returned Claims Claim Follow-Up Form Single Mailing Address for Claims Page 1

2 Introduction This section provides general billing guidelines for all service categories and specific billing requirements that are organized by service category (e.g., ambulatory surgical center, physical therapy and skilled nursing facility). To help ancillary providers reduce the number of returned claims, this section identifies the more common situations that result in processing delays due to returned or rejected claims.! Claims Settlement Practices and Provider Dispute Resolution Mechanism Regulations (Assembly Bill 1455) As required by AB 1455, the California Department of Managed Health Care (DMHC) has set forth regulations establishing certain claim settlement practices and the process for resolving provider disputes for managed care products regulated by the DMHC. This information notice is intended to inform you about your rights, responsibilities and related procedures as they relate to claim settlement practices and provider disputes for commercial Health Maintenance Organization (HMO), Point-ofservice (POS), and, where applicable, Preferred Provider Organization (PPO) products where Anthem Blue Cross (Anthem) is delegated to perform claims payment and provider dispute resolution processes. 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 about claims. See the table below for the department and phone number to call based on the type of plan. Type of Plan Service Unit Phone Number Anthem HMO Anthem PPO (Prudent Buyer) Anthem Individual Provider Care (800) Anthem Small Group Page 2

3 Type of Plan Service Unit Phone Number Anthem Federal Employees Program (FEP) Customer Service (800) BlueCard (out-of-area Blue Cross and Blue Shield members) Eligibility Line (800) Anthem POS (Anthem PLUS) Customer Service (800) Anthem HMO (CaliforniaCare) Customer Service (800) Anthem HMO Plus (CaliforniaCare Plus) Customer Service (800) EDI Claims Submission Customer Service (800) Healthy Families and Medi-Cal Health Care Professional/ Member Services (800) Optometry Network VSP Customer Service (800) Workers Compensation Managed Care Services (WCMCS) Bill Review Service (800) 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, which are located on ProviderAccess at 4. Claim receipt verification. To verify receipt of your claim, log on to ProviderAccess at You may also contact us by plan type at the phone numbers listed above. Your Explanation of Benefits (EOB) or Remittance Advice (RA) will also verify receipt of your claim. Dispute Resolution Process for Contracted Providers 1. Definition of contracted provider dispute. A contracted provider dispute is a provider s written notice to Anthem challenging, appealing or requesting reconsideration of a claim (or a multiple group of substantially similar multiple claims that are individually numbered) that has Page 3

4 been denied, adjusted or contested, or seeking resolution of a billing determination or other contract dispute (or multiple group of substantially similar multiple billing or other contractual disputes that are individually numbered), or disputing a request for reimbursement of an overpayment of a claim. Each contracted provider dispute must contain, at a minimum, the following information: the provider s name, the provider s identification number, the provider s contact information and: a) If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from Anthem to a contracted provider, the following must be provided: a clear identification of the disputed item, the date of service and a clear explanation of the basis on which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect; b) If the contracted provider dispute is not about a claim, a clear explanation of the issue and the provider s position on such issue; and c) If the contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the date of service and provider s position on the dispute, and an enrollee s written authorization for the provider to represent said enrollees. 2. Sending a contracted provider dispute to Anthem. Contracted provider disputes submitted to Anthem must include the information listed in Section 1. a.) above for each contracted provider dispute. The Provider Dispute Resolution Request Form is available online at or by calling the customer service number on the Anthem member s ID card. All contracted provider disputes must be sent to the following address: Anthem Blue Cross P.O. Box Los Angeles, CA Time Period for Submission of Provider Disputes a) Anthem must receive contracted provider disputes within 365 days from Anthem action that led to the dispute (or the most recent action if there are multiple actions) that led to the dispute, or b) In the case of inaction, Anthem must receive contracted provider disputes within 365 days after the provider s time for contesting or denying a claim (or the most recent claim if there are multiple claims) has expired. c) Contracted provider disputes that do not include all required information as set forth above in Section 1.a) above may be returned to the submitter for completion. An amended contracted provider dispute that includes the missing information may be submitted to Anthem within thirty (30) working days of your receipt of a returned contracted provider dispute. Page 4

5 4. Acknowledgment of contracted provider disputes. Anthem will acknowledge receipt of all contracted provider disputes as follows: a) Anthem will acknowledge receipt of contracted provider disputes that are submitted electronically within two (2) working days of Anthem date of receipt. b) Anthem will acknowledge receipt of contracted provider disputes that are submitted on paper within fifteen (15) working days of Anthem date of receipt. 5. Contact Anthem about contracted provider disputes. All inquiries about the status of a contracted provider dispute or about filing a contracted provider dispute must be directed to Anthem by plan type at the applicable phone numbers listed on the previous pages. 6. Instructions for filing substantially similar multiple contracted provider disputes. Substantially similar multiple claims, billing or contractual disputes may be filed in batches as a single dispute if you submit such disputes in the following format, or you may use the Provider Dispute Resolution Request Form, which is available online at or by calling the customer service number on the member s ID card: a) Sort provider disputes by similar issue. b) Provide cover sheet for each batch. c) Number each cover sheet. d) Provide a cover letter for the entire submission describing each provider dispute with references to the numbered cover sheets. 7. Time period for resolution and written determination of contracted provider disputes. Anthem will issue a written determination stating the pertinent facts and explaining the reasons for its determination within forty-five (45) working days after the date of receipt of the contracted provider dispute or the amended contracted provider dispute. a) Past due payments. If the contracted provider dispute or amended contracted provider dispute involves a claim and is determined in whole or in part in favor of the provider, Anthem will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five (5) working days of the issuance of the written determination. Claim Overpayments 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 clearly 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 exceeded the amount due, including interest and penalties on the claim. a) Contested Notice. If the provider contests Anthems notice of overpayment of a claim, the provider, within 30 working days of the 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 Anthems Page 5

6 Page 6 Ancillary Providers contracted provider dispute resolution process described in the Dispute Resolution Process for Contracted Providers section above. b) No contest. If the provider does not contest Anthem s notice of overpayment of a claim, the provider must reimburse Anthem within thirty (30) working days of the provider s receipt of the notice of overpayment of a claim. c) Offsets to payments. Anthem may only offset an uncontested notice of overpayment of a claim against provider s current claim submission when 1) the provider fails to reimburse Anthem within the timeframe set forth in Dispute Resolution Process for Contracted Providers section above, and 2) 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. If 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. General Billing Guidelines The following are general guidelines for billing Anthem. Any special billing requirements and guidelines can be found in the appropriate service category following this section. 1. Billing requirements per contract. Anthem s billing requirements apply to all Anthem member claims, except some services administered through Medi-Cal and other state-sponsored programs. 2. 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 likely will be returned. 3. Valid coding. For claims submitted to Anthem, valid Health Care Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT) or revenue codes are required for all line items billed, whether sent on paper or electronically. Refer to the specific service category for special coding requirements. 4. Split-year claims. For services that begin before December 2006 but extend beyond December 2007, split claims at calendar-year end. This is necessary to accurately track calendaryear deductibles and copayment maximums. 5. Type of bill code. All claims submitted on a UB-92 Form must include the appropriate type of bill code. The three-digit type of bill code provides the appropriate facility type, billing classification and frequency information. 6. Contract change during course of treatment. When the provider s reimbursement is affected by a contract change during a course of treatment, the provider must split the dates of service to be reimbursed at the new rate. 7. Medical records. Medical records for certain procedures may be requested to determine medical necessity. 8. Modifiers. Use modifiers in accordance with your specific billing instructions.

7 9. Unlisted procedures. There may be services or procedures performed by health care professionals 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 Anthem does not accept CPT code (supplies and materials provided by the health care professional over and above those usually included with the services provided). Health care professionals are to use HCPCS Level II codes, which give a detailed description of the service provided. Billing References The Anthem Blue Cross Ancillary Operations Manual, used with the following references, provides detailed instructions about uniform billing requirements. 1. CPT (current year), American Medical Association. To order, call (800) CMS Common Procedure Coding System (HCPCS), National Level II (current year). To order, call (800) UB-92 Manual, Uniform Billing Procedures, published by the California Healthcare Association. To order, call (800) Claim Submission Filing Limits Health care professionals should consult the Ancillary Agreement to verify the time limit for filing claims. Effective November 1, 2006, the filing limits apply to the original claim, as well as to any corrected billing for additional charges. For claims that involve coordinating benefits with another carrier or Medicare, the date of the other carrier s Explanation of Benefits or Medicare s EOB is used for determining the eligible submission period. Refer to the section titled Timely Filing Acceptable Forms of Proof,.on the following page for more information about acceptable proof and items to verify acceptable proof Page 7

8 Forms of Acceptable Proof: Electronic Clearinghouse report (e.g., NEIC) of acceptance by Anthem or the Anthem Blue Cross Acknowledgement of Claims Received report Ancillary Providers Timely Filing Acceptable Forms of Proof Items to Verify Acceptable Proof: Proof must be from a clearinghouse Submission dates must be included and within the filing limits from the DOS Anthem Blue Cross generated Positive Acknowledgement Report Verify that the claim was received for processing Confirm the date of submission and date of service is within the filing limits Request for additional information form (from Anthem Blue Cross) Claim denial letter or EOB from Anthem Blue Cross Verify Member Information and Dates of Service For EDI claims which could not be processed by Anthem Blue Cross Hard Copy Computer-generated claim transaction history with the Anthem name from a billing system Request for additional information form (from Anthem Blue Cross) and dated Ensure dates are within the filing limitations from DOS to Anthem letter date Confirm that response to Anthem s request is also within the filing limits Ensure EOB/Denial Letter Date is within the filing limit Anthem letter must indicate the original submission was within the filing limits; or A batch number or error report must be included to verify submission to Anthem Correct Anthem address must be indicated (on ledger or a code listing) Must include complete billing history Follow-up attempts must be made consistently and within a reasonable amount of time Detailed follow up information should include dates, names, and other pertinent details Ensure dates are within the filing limitations from DOS to Anthem letter date Confirm that response to Anthem request is also within the filing limits Verify Member Information and Dates of Service Claim denial letter or EOB from Anthem Blue Cross Ensure EOB/Denial Letter Date is within the filing limit Letter must have valid letterhead Denial letter from other insurance carrier, dated and printed Letter must be dated on letterhead Claim to Anthem must be within the filing limit starting from the date of the letter Dated EOB from other insurance carrier Proof of member billing EOB must have date within the filing limits Claim to Anthem must be within the filing limit starting from the date of the EOB Must include complete billing history Follow-up attempts must be made within the timely filing limits Page 8

9 Hard Copy Billing Ancillary Providers Participating health care professionals that are not set up to process claims electronically must 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 will be returned for additional information needed for processing. When submitting a claim that requires pre-authorization, attach the Authorization Form, or include the authorization number in form Locator 23 of the CMS-1500 Claim Form. When submitting a UB-04 Claim Form, check the member s ID card or ProviderAccess for the appropriate mailing address. The six-digit Medicare ID or Anthem assigned number must be submitted in form Locator 51 of the UB-04 Claim Form. When submitting a claim for an Anthem member whose policy requires pre-authorization, attach the Authorization Form, or include the authorization number in form Locator 63 of the UB-04 Claim Form. 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 submitting claims. 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 Electronic Data Interchange (EDI), call (800) , option 1. What Is EDI? Electronic Data Interchange, or EDI, is the computer-to-computer exchange of common business transactions over a telephone line or network connection using the standard ANSI-X12N4010A1 electronic format. EDI can be compared to an electronic postal service that allows health care professionals and payors to exchange vital information. How It Works A computer, modem, telephone line/network connection and Internet access can 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 will collect the data you submit and send it to us electronically. Most of these partners are also linked to hundreds of health care EDI networks. Page 9

10 Getting Started Benefits to You 1. One-address billing. All electronically submitted claims are sent to one destination, and Anthem automatically routes the claims to the proper processing site. 2. Savings. By reducing the cost of purchasing CMS-1500 Claim Forms (formerly HCFA-1500 Claim Forms), mailing envelopes and postage stamps, along with printing costs, you can easily recognize your savings. Your billing staff will also spend less time on claim payment follow-up, because electronic claims are given priority processing. 3. Rejection and acceptance reports. You will receive a Positive Acknowledgement Report (PAR) from Anthem that identifies those claims that did not pass our claim edit process, as well as all claims that were accepted for processing. If you elect to submit your claims through a clearinghouse, you will receive your reports through the clearinghouse. You should resubmit corrected claims electronically. If you have any questions or problems, call Anthem s EDI Services Department at (800) , option 1. EDI representatives can help you with your questions about electronic claim submission and other electronic services available at Anthem. Researching a Claim The easiest way to research a claim is by logging on to the Anthem Blue Cross website at Login to ProviderAccess, click Claims tab and select Claims Status Inquiry, enter the subscriber s ID number and click Go. If you cannot access the website, the following information will help you research a claim: Did you submit the claim electronically? If you are currently submitting your claims electronically, either directly to Anthem or through a clearinghouse, Anthem sends a Rejection Validation Report to the claim submitter. This report identifies those claims that did not pass our front-end claim edit process. You should resubmit corrected claims. Is the claim an out-of-state claim and, if so, did you use the following procedures? For Blue Cross and Blue Shield Plan members, use ITSPPO in the group number field when electronically submitting claims to Anthem, even if the ID card indicates a different group number. If ITSPPO is not used, claims will be misrouted and improperly processed or denied in error. Do not leave the group number blank or use 99999, because this will also cause the claim to be misrouted or denied. In addition, the three-letter alpha prefix preceding the certificate number on the member s ID card must be included when submitting claims. This alpha prefix tells Anthem which Blue Cross and Blue Shield Plan (Illinois, Texas, etc.) the claim should be transmitted to for final processing. Out-of-state professional and institutional claims are processed at the applicable PPO rate. The standard discount Page 10

11 rate is only applicable to out-of-state members who are seeking institutional services and who have feefor-service indemnity benefit agreements. If you have questions on filing out-of-state claims, call the Anthem Blue Cross National Account Customer Service Department at (800) Did you follow physician referral claim procedures? Anthem has received claims from specialty physicians and health care clinicians without the required information from the referring physician. These claims are then sent to medical review requesting a medical necessity designation for treatment. Effective January 1, 2001, medical review cannot make a determination of medical necessity for treatment without a treatment plan submitted by the referring physician, along with the member s history and a physical. When Anthem received a claim that does not have the referring physician information attached, but it meets the requirements for a medical review, a claim examiner reviews the claim s history to see if a related claim has the necessary referring physician information. If there is no related claim on file, the claim will be mailed back to the provider of treatment requesting the referring physician information, as well as the treatment plan and member s medical history. Common Reasons for Rejected and Returned Claims Many claims returned for more information result from common billing events. The following is a list of some of the more typical situations: 1. The alpha prefix in the subscriber s ID number is not provided for BlueCard. The three-digit alpha prefix is critical for properly identifying and routing all claims. When submitting claims, make sure to include ITSPPO in the Insured s Policy Group Number field (e.g., Blue Cross and Blue Shield Plans, such as BlueCard PPO). 2. The date of injury is not provided. When charges represent an injury diagnosis, provide a date of injury by completing locators 32 through 35 on the UB-04 Occurrence Code Form and locators 14 and 15 on the CMS-1500 Claim Form. If the date of injury is not provided, Anthem may not recognize any existence of an emergency, and out-of-network benefits may be applied. 3. Duplicate billings. Overlapping service dates for the same service(s) create a questionable duplicate bill. 4. The six-digit Medicare ID number or the Anthem Blue Cross assigned number is not supplied. On the UB-04 Claim Form, enter the ID number in locator The nine-digit tax ID number is missing or incomplete. On the CMS-1500 Claim Form, enter the complete tax ID number in locator 26. On the UB-04 Claim Form, enter the tax ID number in locator ICD-9-CM codes are denied. Claims coded with a preliminary, rather than a definitive, diagnosis will be sent back for the definitive diagnosis. 7. Inappropriate utilization management information. Ensure that the utilization management number is included on the claim and that the approved services match the filed services. Page 11

12 8. The member ID number is incomplete. Specifically in the case of FEP (except for Anthem Blue Cross HMO Federal Employee Program [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. 9. Referring physician. The license number is not included. 10. Request for medical records. When returning records to Anthem, the medical records must be attached to the original mail-back form and returned in the envelope provided. Do not reattach a new claim copy. Do not combine other mail-backs in the same envelope, because it is likely that the records will not arrive in the correct department. 11. Unlisted HCPCS/CPT codes submitted without a description. Include a full description of unlisted codes on claims. The referring physician s prescription must be attached. For drugs, include the National Drug Code (NDC) number and dosage. 12. Unreasonable numbers submitted. An example of an unreasonable number is 999 in the Serv. Units field. Indicate the actual unit amount of service in the Remarks field of the claim for units greater than The other carrier Explanation of Benefits is not provided. When billing Anthem Blue Cross as a secondary payor, you must attach a copy of the primary carrier s EOB. 14. Filing limit. The claim or request for additional charges is submitted after the contract filing limit. Refer to your contract for actual filing limit requirements. 15. Incomplete data is submitted. Refer to the appropriate billing section for the services you perform (e.g., alternative birthing center, ambulatory surgery center, durable medical equipment (DME), hemodialysis, home care, mental health, physical therapy, skilled nursing facility, etc.). Claim Follow-Up Form Anthem will reconsider a rejected or returned claim with one easy-to-use form. The Claim Follow-Up Form helps ensure the proper routing of documentation and streamlines the process for seeking reevaluation of a rejected or returned claim. The form highlights key claim information necessary for Anthems reconsideration and should be used as a cover page for each claim form needing follow-up. Do not attach a copy of the claim to the form; except for corrected billing and non-member donor claims, only attach the applicable documentation and any correspondence from Anthem. Use one form for each claim that needs follow-up. Single Mailing Address for Claims Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company (Anthem) have a consolidated address for Anthem claims and claims-related correspondence, as follows: Anthem Blue Cross P.O. Box Los Angeles, CA Page 12

13 For some Anthem members, claims are administered by a third-party administrator, a capitated group or other organizations outside of Anthem. These claims must still be routed directly, as previously instructed, to the address currently printed on the member s ID card. 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. Page 13