CHAPTER 3: EXECUTIVE SUMMARY

Transcription

1 INDIANA PROVIDER MANUAL EXECUTIVE SUMMARY Indiana Family and Social Services Administration (FSSA) contracts with Anthem Insurance Companies, Inc. (dba Anthem Blue Cross and Blue Shield) for the provision of in all counties in Indiana. provides coverage pursuant to the program in the state of Indiana. is hereafter referenced in this manual as the Plan. Chapter 3: Page 1

2 Anthem Secure Provider Website Anthem's Website is available for Providers to access information regarding member's eligibility and benefits, claims status and secure messaging for claims inquiry or claims review. Log in to the Anthem secure provider website by going to click Providers. In the site box, click the down arrow and choose Indiana. Then click Enter. On the Provider Home page, select Login, type your User ID and Password, then click Submit. Member Eligibility Verification Providers must verify the member s eligibility before providing services. All providers must verify member eligibility immediately before providing services, supplies or equipment. Eligibility may change monthly so a member eligible on the last day of the month may not be eligible on the first of the following month. The Plan is not responsible for charges incurred for treating ineligible persons. Provider Inquiry Department: Customer Service: TDD: Indiana Health Coverage Program (IHCP) AVR: Confirm Member Identity To prevent fraud, providers should confirm the identity of the person presenting ID cards. Claims submitted for services rendered to non-eligible members will not be eligible for payment. Chapter 3: Page 2

3 Ask to See ID Card At each member visit, before rendering services, providers must ask to see the members ID card to verify health plan eligibility. Each member will have their own Anthem Plan ID card. Providers can verify Anthem eligibility in one of the following ways: Log in to the Indiana s MyAnthem secure website: Customer Service Phone number: TDD: Eligibility Verification Systems (EVS) will provide the following eligibility information for HIP members: The member is eligible for HIP The member s insurer and telephone contact information for member s benefits. Log in to Indiana s secure website Web interchange at Use the Indiana Health Coverage Program (IHCP) Automated Voice Response (AVR) System: or (Indianapolis area) Use the MyAnthem website to verify member eligibility at: Chapter 3: Page 3

4 Utilization Management The Plan requires precertification review for authorization of certain procedures and services to assure that services are medically necessary, are a covered benefit, and are provided by the appropriate provider. Precertification Review The Utilization Management (UM) department provides precertification, concurrent and post-service reviews using clinical criteria based on sound clinical evidence. Prior Authorization Inpatient Admission: Elective Admissions Emergency Admissions (Anthem requires Plan notification within 24 hours) Inpatient Skilled Nursing Facility (SNF) Long Term Care Facility (LTAC) Rehabilitation Facility admissions Inpatient Hospice Respite Care Bariatric Surgery Outpatient Services: Bariatric Surgery Radiology Services: **NOTE THE SEPARATE RADIOLOGY PRECERTIFICATION PHONE NUMBER Nuclear Cardiology CT Scan MRI MRA MRS PET Chapter 3: Page 4

5 Human Organ and Bone Marrow/Stem Cell Transplants (Predetermination of Benefits is Required) Inpatient Admits for ALL solid organ and bone marrow/stem cell transplants All outpatient services for the following: Stem Cell/Bone Marrow Transplant (with or without myeloablative therapy) Donor Leukocyte Infusion Out-of-Network Referrals Out-of-Network Referrals (may be preauthorized based on network availability and/or medical necessity). Out-of-Network services must be rendered by an IHCP provider. Mental Health/Substance Abuse All facility based care: Inpatient admissions Intensive outpatient program (IOP) Partial Hospitalization program (PHP) Residential Care Providers with Anthem patients can view the most current list of these services online. Go to click Providers, from the site address, click the down arrow and select Indiana and press Enter. On the Provider Home page, select Login, type your User ID and Password; then click Submit. An emergency medical service to triage and stabilize a member does not require precertification review. Call the Plan s UM department at Chapter 3: Page 5

6 After normal business hours, an answering service is available to take UM-related messages. A UM staff member will return the call the next business day. Decision Making The Plan makes UM decisions affecting the health care of members in a fair, impartial, consistent, and timely manner. The Plan does not reward practitioners and other individuals conducting utilization review for issuing denials of coverage or care. There are no financial incentives for UM decision makers that encourage decisions that result in under-utilization. Time Frame For routine non-urgent requests, the UM department completes precertification review within 14 calendar days from request. The Plan sends requests that do not meet medical policy guidelines to our physician or medical director for review. We will notify providers by phone within 14 calendar days from the receipt of the request or fax of the UM decision, and will send the member and requesting provider a written notification by mail within 14 calendar days from the receipt of the request of any denial or deferral decision. Concurrent inpatient reviews are completed within 24 hours of receipt of clinical information, or sooner. For urgent requests, the UM department completes precertification reviews within three business days (72 hours) from receipt of the clinical information necessary to render a decision. Claims and Billing The Importance of a Correct Clean Claim Submit claims with all fields completed correctly and in accordance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements. Claims submitted correctly are called clean. Providers should also submit on the correct form for the type of service provided. A clean claim is one in which all the information required for processing the claim is present. Chapter 3: Page 6

7 The Plan returns claims submitted with incomplete or invalid information, and requests that the provider correct and resubmit the claim. If providers use a clearinghouse for Electronic Data Interchange (EDI), the clearinghouse/gateway will reject claims that are incomplete or invalid. Providers are responsible for working with their EDI vendor to ensure that claims that fail to pass the EDI gateway are corrected and resubmitted. Filing Limits Providers must submit all claims within the contracted filing limit in order for the Plan to consider the claims for payment. We will deny claims that we receive past the filing limit. See the Claim Forms and Claim Filing Limits chart for standard claim filing and processing time frames. Submit claims as soon as possible following delivery of service to avoid delays in processing. Chapter 3: Page 7

8 Claim Forms and Filing Limits Claim Form Service/Provider Type Claim Filing Time Limit (Refer to your Provider Agreement to verify claim filing time limits) CMS-1500 Claim Form (Formerly the HCFA-1500 Claim Form) Physician and other Health Care Practitioner Professional Services Outpatient Treatment Services including: Physical, Occupational and Speech Therapy and Outpatient Mental Health and Substance Abuse Services Non-Hospital-Owned Ancillary Services including, but not limited to: Ambulance, Durable Medical Equipment (DME), Diagnostic Imaging Centers, Hearing Aid Dispensers, Home IV Therapy, Independent Laboratories and Orthotic/Prosthetic Dispensers. Note: Hospital-Owned Ancillary Services are contracted under the Hospital Agreement and therefore should be billed on a HCFA-1450 (UB-92) Claim form. Within 180 Days from the Date of Service CMS-1450 (Formerly the UB-92 or UB- 04 Claim Form) Hospital Services Other Facility Providers including: Ambulatory Surgery Centers, Cardiac Cath Laboratories, Dialysis Centers, Home Health Services, Hospice, and In-Patrient Free-Standing Skilled Nursing Facilities, Ancillary Services Owned by a Hospital and therefore contracted through the Hospital Agreement. Within 180 Days from the Date of Service Chapter 3: Page 8

9 Claims and Inquiries Mailing Address Claims: P.O. Box Louisville, KY Inquiries: P. O. Box Louisville, KY Fax: Submitting a Claim Providers may submit claims electronically through a Plan-approved electronic billing system software vendor and/or clearinghouse. Completion of electronic claim submission requirements can speed claim processing and prevent delays. Claims that require paper attachments cannot be processed electronically at this time. Please submit claims with attachments on paper. Anthem s NPI claim filing requirements for paper and electronic claims as well as Anthem s contingency plan updates are available on the website at You are also strongly encouraged to include your unique NPI to speed up claims payment. Contact your vendor or billing service for instructions about how to ensure that the Plan Provider ID is coded as an Anthem NPI. Chapter 3: Page 9

10 Coding Commonly used codes, specific to provider type and program, can be found in the main body of the Provider Manual under the following sections: Professional Billing Requirements Hospital and Institutional Billing Requirements Ancillary Billing Requirements Claim Return for Additional Information If the Plan returns a claim to the provider for correction or additional information, we call this a mailback, or our request for additional information, from the provider before we can process the claim. For more information, refer to Claim Returned for Correction/Additional Information in the Claims and Billing Guidelines chapter. When resubmitting additional or corrected information on a claim, send only the additional requested information or the corrected claim. This avoids having the resubmission mistaken for a duplicate filing and helps it be reprocessed as quickly as possible. Read all notices in their entirety and respond in the manner noted on the correspondence. Failure to do so could result in additional denials. Claims Payment Time Line Providers should receive a response from the Plan within 30 calendar days for electronic and 45 days for paper receipt of a claim. If the claim contains all required information, we will enter the claim into our claims system for processing and send the provider a Remittance Advice (RA) at the time the claim is finalized. Chapter 3: Page 10

11 Claim Follow-Up/Resubmission Providers should initiate follow-up action to determine claim status if we have not responded to a submitted claim after 30 or 45 calendar days from the date the provider submitted the claim. To follow up on a claim, providers should: Call the Provider Inquiry Phone Number for the disposition of the claim. Check claim status online at the MyAnthem secured provider website Secure messaging is available for claims inquiry and claims reprocessing requests at the MyAnthem secured provider website Access to Care Continued Access to Care/Continuity of Care The Plan ensures continued access to care for members with qualifying conditions when any of the following are true: The members are newly enrolled The physician s contract terminates The members are disenrolling to another health plan Complete information can be found in the Continued Access to Care / Continuity of Care for Anthem Members section of the Access Standards and Access to Care chapter. Chapter 3: Page 11

12 Office Hours To maintain continuity of care, all PCPs must be available to provide services for a minimum of 24 hours each week. The PCP must be available 24 hours a day by telephone or have an on-call physician take calls. Primary Care Physicians must post their office hours at each practice location. For specific hours of operation and after-hours requirements, refer to the Access Standards and Access to Care section of the Access Standards and Access to Care chapter. The PCP must inform members of the PCP s availability at each site. Providers must accommodate their non-english proficient patients by having multilingual messages on answering machines and training their answering services and on-call personnel on how to access the Plan s interpreter services. Providers have to offer the same hours and services to HIP members as to all other Anthem members. PRIMARY CARE PHYSICIANS OFFICE APPOINTMENT AVAILABILITY Appointment Type Goal Emergency Immediate access 24/7 Urgent Within 24 hours Symptom-Related Within 72 hours Routine/Preventative Within two weeks or 10 business days Office Wait-time Not to exceed 15 minutes, on average After-Hours All members should have access to emergency medical care after hours through their Primary Care Physician through a Paging Service, Covering Physician Call Group or Answering Service. One of these options must be available when calling the PCP s office after normal business hours or on weekends Chapter 3: Page 12

13 After Hours Those providers contractually obligated to provide After Hours coverage for members shall not bill members for such coverage. Providers may only bill members for applicable Coinsurance, Copayments and Deductibles. Chapter 3: Page 13