Anthem Blue Cross and Blue Shield (Anthem) update Spring 2018

Transcription

1 Serving Hoosier Healthwise, Healthy Indiana Plan Anthem Blue Cross and Blue Shield (Anthem) update Spring 2018

2 Objectives NPI one-to-one match Billing provider NPI Billing provider taxonomy code Billing provider ZIP code +4 Billing provider considerations Rendering provider NPI Rendering provider taxonomy code Rendering provider considerations Attending, operating, OPR providers Claim sweeps NPI crosswalk exercise Phone numbers Behavioral health provider contacts 2

3 NPI one-to-one match Anthem must be able to make a one-to-one match between the billing provider s national provider identifier (NPI) and service location address identified on the provider s IHCP (Indiana Health Coverage Programs) profile. A one-to-one match can be easily established for providers with only one enrolled service location by looking only at the billing provider s NPI. For providers with more than one enrolled service location, additional data points are required to make the match: o Taxonomy code o ZIP code +4 3

4 NPI one-to-one match (cont.) Our system utilizes the following algorithm to establish a one-to-one NPI/service location match: o Billing provider NPI only o Billing provider NPI and taxonomy code o Billing provider NPI, taxonomy code and service location ZIP code +4 Coming soon: Billing provider NPI and service location ZIP code +4, in cases where a taxonomy code is not included on the claim. At whichever step the match is established, the algorithm stops and the claim finishes processing. 4

5 Billing provider NPI Enter the billing provider s NPI required. UB-04: Field 56 CMS-1500: Field 33a 5

6 Billing provider taxonomy code Enter the billing provider s taxonomy code and qualifier. Required. UB-04: 81CCa use B3 qualifier. CMS-1500: Field 33b use ZZ or PXC qualifier. 6

7 Billing provider ZIP code +4 Enter the billing provider s physical service location address and full nine-digit ZIP (ZIP +4). Required. UB-04: Field 1 CMS-1500: Field 33 7

8 Billing provider considerations All information on the claim MUST match the IHCP provider enrollment file. o Update IHCP file if using new/different taxonomy codes. A P.O. Box or lockbox address is NOT a service location address. You MUST include the service location address. o Medicaid does not read field 32 of the claim form. o Medicaid does not use the address in field 33 to determine where to remit payment. Remit identified by the Pay To address entered on the provider s application only, not the claim. 8

9 Billing provider considerations (cont.) If you use a clearinghouse, make sure your billing software is sending the data fields to your clearinghouse, that your clearinghouse is accepting these data elements, and, most importantly, that your clearinghouse is sending these data elements to the plan, Anthem. o We have identified cases in which a clearinghouse is not sending the required elements, causing denials. 9

10 Rendering provider NPI Enter the rendering provider s NPI. Required, if applicable. CMS-1500: field 24J (bottom) UB-04: There is no field for a rendering provider on the UB-04 claim form. 10

11 Rendering provider taxonomy code Enter the rendering provider s taxonomy code. Required, if applicable (temporary). CMS-1500: field 24I (top) Enter ZZ or PXC qualifier. CMS-1500: field 24J (top) Enter taxonomy code. UB-04: There is no field for a rendering taxonomy code on the UB-04 claim form. 11

12 Rendering provider considerations Not all provider types have associated rendering providers (R). o Medical groups (G): yes Multiple doctors, physician assistants, nurse practitioners, etc., reassign their payments to the group s tax ID o Facility/entity (B): no The entity itself provides the service, and there are no other providers that reassign their payments or share the entity s tax ID Durable/home medical equipment (DME/HME) Ambulance Hospital, billing for certain supplies on a CMS-1500 Hearing aid dealer Solo practice physician/provider 12

13 Rendering provider considerations (cont.) Facilities/entities (billing providers): o Field 24I and 24J BLANK You do not have rendering providers. Groups: o Rendering information in 24I/24J (top/bottom) must match what is listed in the provider s IHCP profile. o Update Anthem is updating the system to remove the requirement for rendering provider taxonomy codes in 24I/24J (top). Should be complete sometime during Q

14 Attending, operating, OPR providers UB-04 claims require the NPI of the attending provider, operating provider and OPR when these are applicable to the case. o The NPI will be validated to ensure the provider is IHCP-enrolled. o Taxonomy codes are no longer required for these providers. o If included, the taxonomy code will not be validated against the provider s enrollment profile. 14

15 Claim sweeps Anthem has conducted several claim sweeps to reprocess NPI-related denials including: o Attending, operating, OPR not attested/enrolled o Billing provider not attested/enrolled o Rendering provider not attested/enrolled Rework continues Outreach/education 15

16 NPI crosswalk exercise The following slides show CMS-1500 claims examples for establishing a one-to-one match. For institutional (UB-04) billers: CMS 1500 UB-04 NPI Field 33a Field 56 Taxonomy Field 33b Field 81CCa ZIP code Field 33 Field 1 16

17 NPI crosswalk exercise (cont.) Billing provider s enrolled locations ABC Medical Clinic NPI: ABC Medical Clinic ABC Medical Clinic 1234 E. Medicaid St Hoosier Pl. Anthem, IN Anthem, IN Taxonomy: 207Q00000X Taxonomy: 207P00000X ABC Medical Clinic ABC Medical Clinic 4567 HIP St HCC Dr. Anthem, IN Anthem, IN Taxonomy: 207P00000X Taxonomy: 207Z00000X 17

18 NPI crosswalk exercise (cont.) Example 1: ABC Medical Clinic 1234 E Medicaid St. Anthem, IN Unable to make a one-to-one match o All four locations have the same NPI. o No taxonomy code is present to match to any of the locations. 18

19 NPI crosswalk exercise (cont.) Example 2: ABC Medical Clinic 1234 E Medicaid St. Anthem, IN Unable to make one-to-one match o All four locations have the same NPI. o Taxonomy code is present, but two locations have the same taxonomy code. o All four locations have same five-digit ZIP code. The +4 extension is not included on the claim P000000X 19

20 NPI crosswalk exercise (cont.) Example 3: ABC Medical Clinic 8910 Hoosier Pl. Anthem, IN P000000X Unable to make a one-to-one match ABC Medical Clinic PO Box 5555 St. Louis, MO P000000X o The address entered in 33 does not match any of the service location addresses/zip codes on file with IHCP; must be a physical address. o Information entered in 32 matches one location, but Indiana Medicaid does not read

21 NPI crosswalk exercise (cont.) Example 4: ABC Medical Clinic 4567 HIP St. Anthem, IN P000000X Successful one-to-one match made o All four locations share the same NPI. o Taxonomy code narrows it down to two locations. o +4 ZIP code extension matches only one location. 21

22 Phone numbers Prior Authorization/Provider Services/Appeals: Hoosier Healthwise: Healthy Indiana Plan: Hoosier Care Connect:

23 Behavioral health provider contacts 23

24 Medical provider contacts 24

25 Questions? 25